Efectividad de los trabajadores comunitarios en medidas preventivas para salud maternal e infantil en países de bajos y medianos ingresos: revisión sistemática de la literatura / Effectiveness of community workers on preventive measures to maternal and child health in low and middle income countries: systematic review of the literature

Objetivo: Evaluar y sintetizar la evidencia científica que presente información sobre la efectividad de las intervenciones preventivas realizadas por los trabajadores comunitarios en salud materna y salud infantil a nivel hogar. Metodología: Se realizó una revisión sistemática de la literatura. La búsqueda se realizó desde 1966 a 2014 en las diferentes bases de datos: Medline, Embase, Lilacs, Cochrane, CINHAL, OMS series y google schollar. Se incluyeron estudios tipo experimental o cuasi experimentales que abordaran la incorporación de trabajadores comunitarios en intervenciones de prevención primaria para salud materna e infantil. Se realizó una síntesis narrativa de los resultados. Resultados: se identificó un total de 12 560 referencias; de estas se tamizaron 6234. Se incluyeron en esta revisión, posterior a una evaluación de calidad metodológica, 19 estudios. De estos se identificaron diseños como ensayos clínicos controlados, ensayos por conglomerados, estudios de antes y después, estudios observacionales analíticos tipo casos y controles y estudios de corte transversal. Se identificaron actividades de promoción y prevención para malaria, adherencia a la lactancia materna, cuidados del recién nacido, cuidados y soporte para el momento del parto. En todos los escenarios se demostró efectividad de la inclusión del trabajador comunitario en los desenlaces de adherencia y reducción de mortalidad materna e infantil. Conclusiones: La inclusión de los trabajadores comunitarios es efectiva en la reducción de la mortalidad materna e infantil en países de bajos y medianos ingresos. Además de ello, mejora el acceso y la cobertura a los servicios de salud de poblaciones vulnerables.

Objective: To evaluate and synthesize scientific evidence that reports on the effectiveness of preventive interventions by community workers in maternal and child health at the household level. Methods: A systematic literature review was conducted. The search was conducted from 1966-2014 in different databases: Medline, Embase, Lilacs, Cochrane, CINAHL, WHO and google Schollar series. Experimental or quasi-experimental studies that addressed the incorporation of community workers in primary prevention interventions for maternal and child health were included. A narrative summary of the results was performed. Results: A total of 12 560 references were identified, of these 6234 references were screened. They were included in this review, after an assessment of methodological quality, 19 studies. Of these 19 studies designs as controlled clinical trials, cluster tests, before and after studies, analytical observational case-control studies and cross-sectional studies we were identified. Advocacy and malaria prevention, adherence to breastfeeding, newborn care, care and support during childbirth were identified. In all scenarios, including the effectiveness of Community worker in the outcomes of adherence and reduction of maternal and infant mortality it was demonstrated. Conclusions: Inclusion of community workers is effective in reducing maternal and infant mortality in low- and middle-income. Moreover it is improving access and coverage of health services to vulnerable populations.

Percepción sobre condiciones de trabajo y salud de la población inmigrante Colombiana en Alicante, España / A group of Colombian immigrants' self-perception regarding working conditions and health in Alicante, Spain

Objetivo: Explorar la autopercepción sobre condiciones laborales y salud en inmigrantes colombianos en Alicante, España. Material y método Estudio cualitativo descriptivo mediante 11 entrevistas y 2 grupos de discusión en trabajadores con y sin permiso de trabajo y residencia de más de 6 meses en la provincia de Alicante (España), durante los meses de noviembre de 2006 a enero de 2007. Se realizó análisis narrativo de contenido y se obtuvieron categorías mixtas de acuerdo y disenso. Resultados: La inmigración es entendida como un proyecto para mejorar las condiciones socioeconómicas del trabajador inmigrante y su familia. El reconocimiento social y laboral puede evitar la aparición de fenómenos de exclusión y discriminación. Las personas entrevistadas asociaron sus problemas de salud con sus condiciones de vida, manifestando que constituyen limitaciones para la realización de actividades cotidianas. Conclusiones: La situación laboral y de salud es considerada desde una perspectiva multidimensional, asociada a condiciones biológicas y socioculturales. Sería necesaria una mayor acción política para mejorar la situación económica, laboral y de salud de la población inmigrante.

Objective: Exploring the self-perceptions of a group of migrants from Colombia living in Alicante , Spain , regarding their working conditions and health. Material and methods This was a qualitative and descriptive research was conducted on a group of Colombian workers (with and without legal permission to work) having lived in Alicante ( Spain ) for more than 6 months. 11 interviews were carried out, plus 2 focal groups, from November 2006 to January 2007. The interviews were recorded and transcribed. A narrative analysis of the contents was carried out, a mixture of categories being obtained from different viewpoints. Results: Immigration was understood as being an action for improving an immigrant worker and family's socioeconomic conditions. Work and social recognition should lead to avoiding exclusion and discrimination. The people interviewed had associated their health problems with their living conditions. Such problems were considered to be a limitation on carrying out their daily activities. Conclusions: Working and health situations were perceived from a multi-dimensional perspective associated with biological and socio-cultural conditions. More political action should be taken for improving immigrant people's economic, work and health conditions.

The looming threat of AIDS and HIV in Latin America.

PIP: A conference, organized by the International HIV/AIDS Alliance and Glaxo Wellcome's Positive Action Program, was held in Ecuador to address the growing number of HIV cases in Latin America. It recognized the high prevalence rates of HIV infections in Brazil and Mexico, and the potential increase in HIV infections in Ecuador due to its changing demographics and lack of government action. Community workers from Ecuador were eager to listen to how Brazil and Mexico had dealt with the AIDS issue. The HIV/AIDS situation in Ecuador is further worsened by its economic crisis. Several speakers in the conference also asked for more HIV positive counselors that will work with other infected individuals and to complement the role of doctors and nurses. In addition, details of numerous projects, including that of an HIV program in a Quito young offenders' institution, were discussed.^ieng

Urban women educate their community on HIV / STDs, family planning and reproductive health.

PIP: To broaden the context of HIV/AIDS prevention interventions in an urban slum in Rio de Janeiro, Brazil, a model program was developed that involved training 12 low-income women to serve as paid community health agents. The 4-month training course covered the health education topics of reproduction, HIV/AIDS, family planning (FP), and reproductive health and was guided by the belief that women's vulnerability to HIV/AIDS is embedded in gender relations and that health education should be bolstered with promotion of individual autonomy among trainees. Trainees also conducted simple research to analyze the needs of their community and assessed and produced the health education materials they would use in the community. The HIV/AIDS intervention model developed by the women takes the form of three community meetings on 1) gender relations, 2) sexuality and HIV/AIDS prevention, and 3) AIDS. Women who attend the meetings are given cards that simplify their acceptance as FP clients at local health centers. The training empowered the 12 women and led to positive improvements in their lives. Because their community is controlled by drug dealers, the women had to overcome restrictions on their interactions with their neighbors. The training gave the women the courage to do this and to be recognized and accepted in their communities. While the paid project is completed, the women have continued offering educational sessions. Currently, the project staff is seeking funding to find ways to replicate this intervention model at a lower cost.^ieng

Funding women's health work -- no easy answers.

PIP: This article discusses a community's solution to improving women's health in Guatemala. Indigenous women from the highland community of Cajola formed the Asociacion Pro-Bienestar de la Mujer Mam (APBMM). The APBMM identified a need for women health promoters and good, low-cost medicines. The Instituto de Educacion Integral para la Salud y el Desarrollo (IDEI) helped train 16 women as health communicators or promoters in 1996. The health communicators learned about setting up community medicine distribution. The mayor bypassed APBMM's efforts to set up medicine distribution and set up a community pharmacy himself. Someone else opened a private pharmacy. The 200-member group was frustrated and redirected their energies to making natural herbal medicines, such as eucalyptus rub. The group set up a community medicine chest in the IDEI medical clinic and sold modern medicine, homemade vapor rubs, and syrups. The group was joined by midwives and other volunteers and began educating mothers about treatment of diarrhea and respiratory diseases. The Drogueria Estatal, which distributes medicines nationally to nongovernmental groups, agreed to sell high quality, low cost medicine to the medicine chest, which was renamed Venta Social de Medicamentos (VSM). The health communicators are working on three potential income generation projects: VSM, the production and sale of traditional medicines and educational materials, and an experimental greenhouse to grow medicinal plants and research other crops that can be grown in the highlands.^ieng

Steaming ahead in Guatemala.

PIP: In cooperation with local nongovernmental organizations (NGOs), the JOICFP Integrated Project in Solola State, where it is implemented by the Family Welfare Association of Guatemala (APROFAM), has been refocused on reproductive health (RH) and family planning (FP) within the predominately Mayan communities of Panajachel, San Pedro la Laguna, and San Lucas Toliman. Emphasis has been placed on sensitivity to cultural and gender issues. Mayan professionals, including a Mayan doctor who provides 2 days of service to clinics on a rotational basis, are employed. A clinic has been added in San Pedro la Laguna and another in Panajachel; the latter serves as the project's headquarters. Training of traditional birth attendants (TBAs) and of community-based distribution agents (CBDs) has been increased in order to broaden project coverage. 31 CBDs have been recruited from project communities to counsel and to educate clients in the local language, to provide referrals, and to sell low-cost contraceptives. A Japanese public health nurse serves as a Japanese Overseas Cooperation Volunteer at the APROFAM clinic in Solola. Six TBAs have received follow-up training in natural and modern FP. The project's Mayan doctor works closely with these health personnel. 28 CBDs have been trained to provide Depo-Provera; acceptance of this method has increased by 42%. Contraceptive acceptance between January and June of this year is greater than the total for all of 1996. Two UN Population Fund (UNFPA) representatives, Dr. Sergio de Leon (program officer) and Dr. Ruben Gonzalez (national coordinator of the project to reduce maternal mortality), visited during a monitoring/technical support mission in July and August.^ieng

Using lot quality assurance sampling to assess measurements for growth monitoring in a developing country's primary health care system.

BACKGROUND: Local supervisors used lot quality assurance sampling (LQAS) during routine household visits to assess the technical quality of Costa Rican community-based health workers (CHW): measuring and recording weights of children, interpreting their growth trend and providing nutrition education to mothers. METHOD: Supervisors sampled 10 households in each of 12 Health Areas (4-8 hours per area). No more than two performance errors were allowed for each CHW. This LQAS decision rule resulted in judgments with a sensitivity and specificity of about 95 percent. RESULTS: Three categories of results are reported: (1) CHW adequately weighed children, calculated ages, identified children requiring nutritional services, and used the growth chart. (2) They needed to improve referral, education, and documentation skills. (3) The lack of system support to regularly provide growth cards, supplementary feeding to identified malnourished children, and other essential materials may have discouraged some CHW resulting in them not applying their skills. CONCLUSIONS: Supervisors regularly using LQAS should, by the sixth round of supervision, identify at least 90 percent of inadequately performing CHW. This paper demonstrates the strength of LQAS, namely, to be used easily by low level local health workers to identify poorly functioning components of growth monitoring and promotion.

PIP: Nurses and rural health supervisors used the Lot Quality Assurance Sampling (LQAS) technique to assess the quality of growth monitoring and promotion (GMP) conducted by community health workers (CHWs) in 12 health areas in Costa Rica. Each supervisor made 10 routine household visits and spent 4-8 hours in each area. The study allowed no more than two performance errors per CHW. CHWs could correctly identify children in need of the nutritional services of the primary health care (PHC) system. Yet they were weak in their referral, education, and documentation skills. The supply system and the documentation system that support growth monitoring did not work well. Perhaps the inadequate support system may have contributed to the CHWs' inferior use of their skills. The finding that there were inadequate supplies and poor documentation of required GMP data suggest that CHWs did not regularly conduct growth monitoring, perhaps due to a lack of scales and growth charts. The PHC system did not follow children with nutritional deficiencies, suggesting that health facilities did not keep a register and refer these children systematically. This would explain why CHWs did not refer malnourished children to health facilities. CHWs had significant time constraints that influenced their ability to perform regular growth monitoring. The evaluation team required 4-8 hours to observe growth monitoring in 10 households. The PHC system expects each CHW to conduct about 10 complete household visits/day, which includes growth monitoring, vaccinations, pre- and post-natal care, oral rehydration therapy training, and monitoring blood pressure. With each subsequent supervision visit, the misclassification error of substandard CHW (i.e., the probability of identifying an inadequate performer) decreases. By the sixth visit, supervisors could identify almost all CHWs with a performance quality of 80% or less. These findings suggest that supervisors use LQAS methods to regularly identify GMP problems.

Growth monitoring: the role of community health volunteers.

A community volunteer programme was initiated in rural Jamaica in May 1990. The main aim of the programme was to monitor the growth of children less than 36 months of age through community health volunteers (CHVs) and improve their nutritional status. At the end of the second year the programme was evaluated to determine its effectiveness. The results of the evaluation indicated that almost all (95.6%) of the children were covered by the CHVs. In addition the participation rate was high (78.5%). However, only 50% of the children were adequately covered. Nonetheless, 81% of them gained adequate weight. Indeed, malnutrition levels declined by 34.5%. The annual cost per child per year for the total programme was fairly moderate (US$14.5) with growth monitoring accounting for nearly half (42.7). The results suggest that CHVs can play an important role in primary health care programmes in developing countries.

PIP: In May 1990 in Jamaica, a nutrition program was established in the isolated and low economic level community of Freemans Hall (population, about 1400; altitude, 1000-1300 m; rainfall, 2000-2000 mm) in Southern Trelawny parish. Community health volunteers (CHVs) monitored the growth of children younger than 36 months. A committee of representatives from the local health team and parent- teachers' association selected four CHVs. One CHV covered about 22 children. Two public health nurses and two nutritionists conducted a one-week training course for the CHVs. Topics included malnutrition, young child feeding and weaning, nutrition during pregnancy, management of diarrhea, family planning, immunization, community weighing and growth monitoring, organization of a health district, and home visiting. The CHVs weighed and measured the height of all children under 36 months old monthly, provided nutritional advice to mothers, and referred malnourished children to a nutrition clinic. They received US$150 as an incentive, which they used to set up income-generating projects (e.g., goat rearing). An evaluation of the process and outcome of the CHV nutrition program during May 1990-April 1992 was conducted. None of the CHVs had stopped their duties. 95.6% of eligible children were registered in the program. 78.5% of the children participated. 50% of the children received adequate coverage. 85.7% of identified malnourished children were adequately covered. The CHVs referred all of the malnourished children to the nutrition clinic. The total cost of the program (nutrition clinics and food supplements) was US$2740. Overall cost/child was US$31.1. The cost for growth monitoring only was US$6.2. Growth monitoring accounted for 42.7% of annual costs. Malnutrition decreased from 17.1% to 11.2% (a 34.5% reduction). 81% of all children gained adequate weight. These findings show that CHVs can contribute significantly to primary health care programs in developing countries.

Hobby or job? Mexican female health workers.

A critical analysis of the role and status of female health workers in the primary health care service (PHC) of the Secretary of Health in the Federal District of Mexico is presented. Women are key workers in the health service; however, since the creation of the PHC service, women appear to have been kept in low-pay, low-status jobs. Data from questionnaires and in-depth interviews with female health workers in the Federal District illustrate the situation. Female health workers' status is determined by the structure and operation of the PHC system; by family and personal needs; by the cultural context of Mexican society; and by the fact that some female health workers view their job as a hobby, placing family considerations above career enhancement.

PIP: The position of the female health worker in Mexican public health services has been marginalized by her perceptions, her lack of power and authority, and the decline in institutional conditions. The success of primary health care strategies may be dependent on the role women play in improving the system. Women have chosen a career because of the flexible work practices that allow for accommodating personal and family needs; a health workers may value flexibility equally with adequate wages, recognition as a professional, and job stability and mobility. However, health planners and administrators may not view the value of health workers as vital. Instead women health workers are low paid, low status employees. Data is obtained from 391 respondents from 54 primary health care (PHC) centers and in-depth interviews with female health workers on the structure and operation of the PHC system, family and personal needs, the cultural context, and the job definition as hobby rather than career opportunity. Women's role in heath care has been traditionally compatible with the view of women as caregiver and "natural" skills throughout the world and history. Women participate in health systems at the household level, community level, and within informal and formal health systems. Comprehensive PHC systems involve community participation, while selective systems emphasize use of professional workers. The Mexican Federal District system serves the need of about 30% of the population, while social security, private practices, traditional healers, and philanthropic organizations fulfill other health demands. The District system primarily serves the urban poor in PHC centers of various sizes in close proximity to marginal populations. 57% of health workers in the District system were women in 1987; positions involved all occupations at all levels. Staff shortages are common, but jobs provide no easily obtainable permanency. A review of wages from questionnaires reveals even physicians are paid less than the government minimum salary. Salaries vary between districts and the poorest paid physicians are in Iztalcalco and Venustiano Carranza. Tlahuac nurses are paid over the minimum wage. Most wages constitute 50% to 100% of household income. PHC jobs are chosen because of the need to serve people, be of some help to the community, and be close to home.

CHWs trained in ARI management.

Regular supervision and refresher trainings were the key to the success of a CHW (community health worker) training program in rural Bolivia. Since 1988, with the support of PLAN International, volunteer CHWs have been trained in 115 villages in Sucre, a rural health area lacking adequate health centers. CHWs educate the community, diagnose and treat pneumonia and refer severe cases to health centers or hospitals. CHWs who were already working on diarrheal disease control were chosen for the acute respiratory infection (ARI) case management training. A 3-day training program was organized for individual CHWs in their own homes and communities. The course included practicing on real ARI cases under the trainer's supervision. Since the program started, community respect for CHWs has risen. In one remote village, community leaders reported a marked improvement in child survival. Factors which explain the positive effects of CHWs include: a limited number of clearly defined tasks, provision of one-on-one appropriate training, periodic refresher courses, and continuous supervision. The main problems have been a lack of constant supply of essential drugs and some CHWs over-diagnosing pneumonia. However, once diagnosis is made, CHWs are careful about giving the correct antibiotic doses and instructions to mothers. Refresher training and supervision have helped to correct these initial problems. PLAN International and the Ministry of Health have organized supervision and training meetings every 2 months. The CHWs bring to these meetings reports of children treated and referred. Case management is analyzed, resupply of essential medicines is arranged and those with special problems are scheduled for a supervisory visit.

Community health workers and primary health care in Honduras.

Community participation and utilization of community health workers (CHWs) are essential components of the primary health care model. The success of CHWs is dependent on their training and subsequent community support. Community-prepared nurses are ideal CHW educators. A training program for CHWs was implemented in Honduras emphasizing the principles of adult learning and problem-based learning. Following a 4-month program of training a primary health care clinic was opened and managed by CHWs for a population over 10,000. Approximately 80% of local health problems were managed by the CHWs proving that well-trained CHWs can have a significant impact on the delivery of health care.

PIP: In 1986, a nurse practitioner was in San Pedro Sula in northern Honduras as a Catholic lay missionary. She conducted a community assessment of various semiurban areas called colonias to learn their health care needs. Next, she arranged for teaching sessions on community health in the homes of several local women. Based on the assessment and the sessions, the lay missionary and local women set up a mobile health clinic. During January-May, 1987, the lay missionary designed and taught a community health worker (CHW) training class for 3 local women. Its curriculum covered common illnesses, communicable diseases, first aid, ear and eye problems, maternal and child health, medicines, nutrition, sanitation, and skin problems. The learning methodologies were popular, adult, and problem-based learning theories. The training culminated in a primary health care clinic in the colonia San Jose, which began in May, 1987. CHWs ran the clinic. In September, 1987, they added a nutrition program, because more than 25% of the less than 5-year-old children were severely malnourished. In early 1988, a pharmacy joined the clinic. A formal laboratory later joined the clinic. New recruits graduated from CHW training in 1989. The CHWs provided curative and preventive care and health education, trained other health team members, collaborated with other health and community development sectors, and conducted self-assessments. The clinic staff charged 2 lempiras ($1) for each consultation. People who could not afford the fee were treated free of charge. The clinic reached financial self-sustaining status by May, 1989. Despite earnest attempts, the CHWs were unable to motivate patients to attend health teaching sessions, perhaps because the patients suffered from intense poverty. Otherwise, the clinic was successful, because the CHWs were committed and dedicated and had received adequate training and support.

What is child survival? Child-focused strategy forms key element of PLAN's health policy.

PIP: PLAN in Bolivia and the Dominican Republic has directed interventions to increase child survival. In Bolivia in August 1991, an 18 month infant with rapid breathing and cough was brought to a health center because the mother had remembered the warning symptoms provided by a community health worker. This child's life was saved by the contact with the health worker, the mother's action to bring the child to the health center, and the timely, appropriate use of antibiotics. Follow-up by a community worker revealed a return to health for the child; a child death was averted. The case of a measles epidemic in Santo Domingo, Dominican Republic in February 1992 was described, where health workers had targeted a slum area for house to house immunization and thus child deaths were averted when the measles epidemic struck. PLAN's child survival programs, funded by USAID and PLAN, have been innovative and successful in tailoring approaches to local needs and priorities. The Santo Domingo Field Office prioritized efforts in immunization, oral rehydration therapy, and child nutrition. Findings in 1992 showed that Child Survival participants had 50% less malnutrition than other neighboring community children aged 12-23 months. Bolivia's Field Office in Sucre stressed acute respiratory infections, immunizations, and oral rehydration therapy. Findings have shown that Child Survival families were four times more likely to use health facilities for respiratory infections. Success has been attributed to a focus on high risk populations, use of technical interventions, emphasis on selected key behavioral change objectives, a community based approach, cooperative relationships with other local health providers, and "community ownership" of interventions. Individual health taking behavior was changed.^ieng

Meeting the needs of disabled village children.

PIP: Villagers have operated a primary health care program in western Mexico called Project Piaxtla for almost 30 years. The project often selects disabled persons to be village health workers, sine they are not in involved in hard physical farm work and thus are most available. They have excelled as village health workers and eventually started the Programme of Rehabilitation Organized by Disabled Youth of Western Mexico (PROJIMO) to address the needs of disabled children. The disables workers are more sensitive to the needs of disabled children than others are. They involve the children in meeting their own needs. The disabled adult leaders and artisans in a community program provide role models for the disabled children and their families. In fact, the program lets parents see that they do not need to overprotect their disables children or to do everything for them. PROJIMO has built a rehabilitation playground where disabled and nondisabled youth play together. All the equipment is made from local materials. Disabled and nondisabled children make toys and sometimes rehabilitation aids (e.g., a walker) in a small workshop. PROJIMO uses various child-to-child activities to promote understanding between disabled and nondisabled children. For example, the fastest runner in the class ties a pole around his/her leg. All the children run the race or play a tag. Later, all the children talk to the pseudo-disabled child to learn what she/he experienced. Disabled technicians at PROJIMO fabricate modem resin-and-fiberglass prosthetics for amputees. They also make orthopedic braces (modem thermoplastics). PROJIMO works not just with children with congenital disabilities but also those who suffer from accident- and violence-related disabilities.^ieng

Partnership for community health development.

A programme of community health development is reported from two villages in Haiti. It involves close cooperation between a district hospital, a local dispensary, and, most importantly, the inhabitants themselves. The programme is simple, financially realistic, adapted to local conditions, and linked to activities designed to meet basic requirements, such as those of food production and water supply.

PIP: The Albert Schweitzer Hospital in the Artibonite Valley of central Haiti was founded by William Larimer Mellon in 1956 to serve about 175,000 people. Early in 1977, the hospital decided to create a community health department and provide curative, preventive, and promotive health programs through 7 dispensaries. A mobile immunization team was established. In 1988, 2 villages with a total population of 1459, in the catchment area of the Plassac dispensary, were selected for a research and development project with a comprehensive baseline survey. Among children aged up to 5 years, 36% were of normal nutritional status, while 41%, 18%, and 4% suffered from first-, second- and third-degree malnutrition, respectively. Of these children, only 31% were completely immunized. 21% of the children had tuberculosis, malaria, and upper respiratory tract infections. The illiteracy rate was around 85%. A village development committee was elected by the community. Voluntary health workers, elected or selected among mothers, were trained in health promotional activities, and each was made responsible for 15-20 families. These workers, with the dispensary's health agents, delivered a minimum health care package, comprising maternal and child care, family planning, immunization, treatment of simple diseases, health and nutrition education, and environmental sanitation. In less than 2 years, there was a strong indication of declining mortality and malnutrition among children aged 1 to 3 years. No more cases of third-degree malnutrition were seen in the dispensary, and some 90% of children were fully immunized. Changes were evident in the health knowledge, attitudes, and practices of the population. It is expected that during 1993 the whole catchment area of the Plassac dispensary, with around 20,000 people, will be covered. The dispensary had to be upgraded to a community health center with 2 or 3 beds for emergency cases.

Community health worker competency in managing acute respiratory infections of childhood in Bolivia.

A competency-based training and evaluation method was developed to improve and assess the management of acute respiratory infections (ARI) in young children by community health workers (CHWs) in Bolivia. This method was used to evaluate three groups of Bolivian CHWs, provide them with a one-day refresher course in ARI management, and assess the effects of the course. The results showed the CHWs capable of acquiring the skills needed to effectively manage ARI cases in accordance with the World Health Organization's ARI case management strategy. It was found important, however, that their training emphasize how to count the respirations of children with tachypnea and how to identify chest indrawing. In general, the competency-based methods appeared to be effective in training and evaluating CHWs in the area of ARI case management; it is expected that these methods will prove useful in other community-based health interventions.

PIP: Acute respiratory infections (ARI) are a leading cause of child mortality in developing countries. With under-5 mortality due to ARI in Bolivia estimated at 172/1000 live births, these infections are the second largest cause of child mortality in the country. The World Health Organization (WHO) has developed a strategy for managing cases of child ARI with respect to treatment and community health worker (CHW) tasks. Bolivia adheres to these guidelines with some exceptions regarding the tasks of CHWs. This paper reports on the development and implementation and assess the management of ARI in young children by CHWs in Bolivia. 3 groups of Bolivian CHWs were evaluated, given a 1-day refresher course in ARI management, then reevaluated to assess the effects of the course. The short duration of the program and its focus on essential tasks had a significant impact on its participants. The CHWs were found to be capable of acquiring the skills needed to effectively manage ARI cases in accordance with the WHO ARI case management strategy. It was also found important that training emphasize how to count the respirations of children with tachypnea and how to identify chest indrawing. These competency-based methods should prove useful in other community-based health interventions.

Risk indicators of childhood undernutrition in Kingston, Jamaica.

In Jamaica, early childhood undernutrition remains a problem; however, the health of all children cannot be monitored due to limited resources. Therefore, there is a need for the early identification of children at risk of undernutrition. A simple screening instrument for use by paraprofessionals in the primary health care system was developed. We conducted a case-control study using 649 children, aged 6 to 48 months. The cases were undernourished (weight-for-age less than 80% of the reference) and identified from a survey. The children's guardians were given a questionnaire comprising 31 variables thought to be associated with undernutrition and which were present from 6 weeks of age. Nine variables were significantly associated with undernutrition. Multiple logistic regression analysis indicated that low birth weight, short birth spacing, being born at home, poor ante-natal and post-natal clinic attendance, overcrowding and a lack of house-hold possessions were independent predictors of undernutrition. Using these variables, a simple scoring system was developed to identify high risk children. It had a sensitivity and specificity of 56% and 76% respectively and a positive predictive values of 31%. This simple screening instrument should be easy to use in the primary health care system. However, its low sensitivity indicates that it is difficult to identify children who are at risk of undernutrition from 6 weeks of age. Subsequent high morbidity and poor child care which were not measured may account for some of the missed cases.

Organizing a project with community-based health agents recruited from prostitutes in Rio de Janeiro.

PIP: In Brazil, the Prostitution and Civil Rights Program works to fight against stigma and violence against sex workers and to foster self-esteem, self-determination, and greater access to civil rights. It sponsors the Brazilian Prostitutes' Network. In 1988, the Ministry of Health asked the program to join the Ministry to produce sexually transmitted disease/AIDS prevention materials. The materials were ready for distribution in early 1991 when the program began recruiting prostitutes and transvestites for its Health Education Project. The aforementioned groups and the Brazilian chapter of International Planned Parenthood Federation are working together on this project. By mid-1992, the project recruited 17 community-based health agents (15 female and 2 male prostitutes) from different prostitution areas and through a network of contacts from these areas of Rio de Janeiro. After informal training in April or June 1991, they went into their communities to inform people of their health agent role, distributed free condoms and AIDS education material, and promoted the project. Health agents maintain a weekly report of condom and education material distribution. This allows them to monitor their progress. Health agents now meet with their peers to discuss sex and health issues. The communities have opened their doors to the groups. The project is also geographically mapping the sex trade to target health care and other resources in each area. It is pursuing a reference/counterreference relationship within the existing public health system in Rio de Janeiro. Involvement of sex workers in all phases contributes to the success of the project so far. Future research is needed to determine whether the project is reducing risk of HIV transmission, however.^ieng

"Comuniquemonos, Ya]": strengthening interpersonal communication and health through video.

PIP: The Nutrition Communication Project has overseen production of a training video interpersonal communication for health workers involved in growth monitoring and promotion (GMP) programs in Latin America entitled Comuniquemonos, Ya] Producers used the following questions as their guidelines: Who is the audience?, Why is the training needed?, and What are the objectives and advantages of using video? Communication specialists, anthropologists, educators, and nutritionists worked together to write the script. Then video camera specialists taped the video in Bolivia and Guatemala. A facilitator's guide complete with an outline of an entire workshop comes with the video. The guide encourages trainees to participate in various situations. Trainees are able to compare their interpersonal skills with those of the health workers on the video. Further they can determine cause and effect. The video has 2 scenes to demonstrate poor and good communication skills using the same health worker in both situations. Other scenes highlight 6 communication skills: developing a warm environment, asking questions, sharing results, listening, observing, and doing demonstration. All types of health workers ranging from physicians to community health workers as well as health workers from various countries (Guatemala, Honduras, Bolivia, and Ecuador) approve of the video. Some trainers have used the video without using the guide and comment that it began a debate on communication 's role in GMP efforts.^ieng

Tuberculosis, poverty, and "compliance": lessons from rural Haiti.

Tuberculosis (TB) is the leading cause of death among rural Haitian adults, and TB control in Haiti is widely acknowledged to be a failure. The causes of both the endemicity of TB and the failure of attempts to address it are briefly reviewed before data from a study conducted in rural, central Haiti are presented. Members of one group of patients with active TB were given free medical care; members of a second group were given free care as well as financial aid, incentives to attend a monthly clinic, and aggressive home follow-up by trained village health workers. Comparing the two groups shows significant differences in mortality, sputum positivity after 6 months of treatment, persistent pulmonary symptoms after 1 year of treatment, average amount of weight gained, ability to return to work, and cure rate. The roles of human immunodeficiency virus and cultural factors are also examined. When adequate nutrition and access to free care were assured, drug-dependent and patient-dependent factors were shown to be of secondary importance in determining treatment outcome. Based on these data from a small, community-based TB-control project, the authors conclude that high cure rates can be achieved if the primacy of economic causes of TB is acknowledged and addressed.

PIP: Between February 1989 and June 1990, village health workers with the Proje Veye Sante community health program in the central plateau of Haiti enrolled 30 adults with tuberculosis (TB) living around the reservoir in the Peligre basin (sector 1) and 30 TB patients living in villages and towns next to sector 1 (sector 2) to compare 2 TB treatment approaches. The cases (sector 1 patients) received free medical care, home visits, US$30/month for the 1st 3 months (financial aid), nutritional supplements, monthly reminders to visit the clinic, and travel expenses. The controls (sector 2 patients) received only free medical care. 1 case (3.3%) and 2 controls (6.7%) tested positive for HIV. By June 1991, all 30 cases were cured of TB compared with only 56.7% of controls. None of the cases died but 10% of controls died. None of the cases exhibited sputum positivity for acid fast bacilli 6 months after diagnosis yet 13.3% of controls did. 1 year after treatment only 2 cases (6.7%) still had pulmonary symptoms compared with 13 (43.3%) controls. Cases gained more weight on average than controls (10.4 lbs. vs. 1.7 lbs). All but 2 cases (93.3%) were able to return to work after 1 year of treatment while only 14 controls (46.7%) could. Cases made more trips to the clinic and experienced more home visits than the controls (11.4 vs. 5.8 and 37.9 vs. 1.1, respectively). 25 cases (83.3%) and 26 controls (86.7%) did not deny that sorcery may have been responsible for their illness. The results demonstrated that high cure rates can occur under extremely impoverished conditions where hospitals do not exist. The top priority under these conditions should be identification and treatment of patients with active pulmonary TB. TB programs should address nutrition and providing TB patients easy access to drugs. Direct financial aid provides an incentive for TB patients to follow through with treatment which the free treatment alone does not do.

Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study.

There is little unequivocal evidence that nutritional supplementation of undernourished children has a beneficial effect on their mental development. The effects of nutritional supplementation, with or without psychosocial stimulation, of growth-retarded (stunted) children aged 9-24 months were assessed in a study in Kingston, Jamaica. 129 children from poor neighbourhoods were randomly assigned to four groups--control, supplemented only, stimulated only, and supplemented plus stimulated. A group of matched non-stunted children (n = 32) was also included. The supplement comprised 1 kg milk-based formula per week for 2 years, and the stimulation weekly play sessions at home with a community health aide. The children's development (DQ) was assessed on the Griffiths mental development scales. Initially the stunted groups' DQs were lower than those of the non-stunted group, and those of the control group declined during the study, increasing their deficit. Stimulation and supplementation had significant independent beneficial effects on the children's development. Estimates of the supplementation effect ranged from 2.2 (95% confidence limits-1.4, 5.7) for the hand and eye subscale to 12.4 (5.4, 19.5) for the locomotor subscale and those for the stimulation effect from 6.4 (2.8, 10.0) for hand and eye to 10.3 (3.3, 17.3) for locomotor. The treatment effects were additive, and combined interventions were significantly more effective than either alone. These findings suggest that poor mental development in stunted children is at least partly attributable to undernutrition.