Cnw hospital presentationreduced
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Transcript of Cnw hospital presentationreduced
Presented by Sean Morris and Uwacu Theophila
August 3, 2011
The Ruli District Hospital Community Nutrition Program:
Evaluation and Recommendations for Improvement
Project Introduction
1. Evaluation of Community Nutrition Worker program
a. Surveys of CNWs at monthly meetings
b. Observation of village screening activities
c. Interviews with program supervisors
2. Understanding the community nutrition situation
a. Surveys of community members
b. Observation of nutrition education
c. Home visit assessment
3. Health center teaching gardens
a. Nyange HC teaching garden
b. Ruli Sustainable Agriculture Manual
c. Assessment of existing situation
4. Establishment of farming cooperatives
a. Understand existing village associations
b. Identification of potential stakeholders
c. Initiation of Nyange PLWHA pilot farming coop.
Project Introduction
Methodology …
• Chose 4 of Ruli’s 7 Health Centers at random
• Used clustered method to select survey participants
• Guidance and No Guidance surveys
• Rwankuba pilot survey
• Community members: Nutrition center, village
screenings, Nyange PLWHA, and VCT mothers
• Many villages and health centers represented
Project Introduction
Community Situation
Who is represented …
• 8 health centers [2 from other Hospital’s catchment]
• 25 cells
• 44 villages
• 5 males, 62 females
• 73.2% Married; 14.9% Single; 11.9% Widowed
• Educational achievement: 85% Primary; 6% Ordinary
Level; 1.5% Secondary; 4.5% CERAI, Familial, Technical
• Religion: 40.3% Catholic; 16.4% Protestant; 8.9%
Pentecostal; 10.4% Adventist; 24% No religion specified
Community Situation
Distance from Home to Health Center
• Combined Average, 1 hr. 38 min.
• Village Screenings, 2 hr. 10 min.
• Nyange PLWHA, 58 min.
• VCT Mothers, 1 hr. 26 min.
• Nutrition Center, 1 hr. 26 min.
Community Situation
Distance from Home to Screening Site
• Combined Group Average, 25
min.
• Village Screenings, 16 min.
• Nyange PLWHA, 36 min.
• VCT Mothers, 25 min.
• Nutrition Center, 28 min.
Community Situation
Household Circumstances:
• Average size, 5 people (ranging between 3 & 12)
• 85% of total sample have children <5 years
• 70% own land; 18% rent land; 12% live with extended family
• 85% farmers; 11.9% coltan miners; 10% artisans; 7.5% public
institution workers; 4.5% carpenters; 1% unemployed
Economic Situation
Estimated Monthly Household Income of
Community Members
0-5000Rwf
5001-10000Rwf
10001-15000Rwf
15001Rwf+
No Response
• Majority of community
members have very little
money to spend on food &
health insurance.
• Consistent with observations
of screening participants’,
and home visit situations.
Thought question…
• What is the best way to
combat malnutrition in a
poor population that has
access to limited cultivating
space?
No Space for the Poor
What is your estimated monthly household income?
+1500010000<x<150005000<x<100000<x<50000
Co
un
t
10
8
6
4
2
0
Bar Chart
Large area
Medium area
Small area
If f4.1, how large is the area of land that you
cultivate?
What is your estimated monthly household income?
+1500010000<x<150005000<x<100000<x<50000
Co
un
t
12.5
10.0
7.5
5.0
2.5
0.0
Bar Chart
No
Yes
Has your child ever been to the
malnutrition center for treatmet?
Agriculture Situation
Available Land …
• 15% of CNW villages report a “large area to farm”
• Consistent with community member surveys…
• 58.9% have small area
• 37.5% have medium area
• 3.6% have large area
• 67% of VCT mothers, and 70% of Nutrition Center mothers
report having a “small” area to farm…
Agriculture & Malnutrition
0
10
20
30
40
50
60
% o
f R
esp
on
de
nts
Seasonality of Malnutrition Incidence and Cultivating Challenges
Months of Highest Malnutrition Incidence
Most Difficult Month to Cultivate
Let’s Work Together!
0
10
20
30
40
50
60
70
80
Total Village Screening Nyange PLWHA VCT Mothers Nutrition Center
Mothers
% o
f R
esp
on
de
nts
Opportunities for Farming Cooperative Formation
Work Alone
Work Together
Both
Need for Diversity
3
4
5
9
9
34
37
61
68
87
0 10 20 30 40 50 60 70 80 90 100
% of Villages Growing...
Village Level Crop Production
Beans
Maize
Tubers
Coffee
Vegetables
Soya
Bananas
Fruit
Wheat
Sorghum
Community Food
Security Summary
• Average Consumption-to-Sale Ratio = 90:10 (76% at 100:0)
• Vast majority of community members are working alone!
• Overall lack of crop diversity nutrient diversity
• Those who are poor, and at greatest risk of malnutrition have
marginal land access
• Malnutrition is temporal; therefore predictable and beatable!
CNW Situation
Who is represented …
• 4 health centers [Ruli, Rwankuba, Muhondo, & Coko]
• 23 cells
• 85 villages
• 44 males, 56 females
• 92% Married; 2% Single; 6% Widowed
• Educational achievement: 75% Primary; 8% Ordinary
Level; 5% Secondary; 12% CERAI, Familial, Technical
• Average CNW age – 38.9 years
• Average tenure as CNW – 6.1 years
CNW Situation
Satisfaction …
• Average satisfaction (from 1 to 10) – 8.05
• “How has being a CNW improved your life?”
• 62% report improved diet and nutrition knowledge
• 59% report improved capacity to care for family
• 98% see reduced malnutrition since beginning their work
• 94% report good attendance at each screening
• Only 26% claim to have adequate resources to perform
their duties…
Village Screenings
Growth Monitoring
• Weight of each child
under 5 years of age
• Record weight
• Referral based on
growth chart status
• Growth chart also
includes vitamin and
immunization history
Village Screenings
Information, Education, Co
mmunication (IEC)
• Convey relevant
nutrition, infectious
disease, or lifestyle
information to the
community
• MOH Guidebooks –
rarely used…
• Sometimes
planned, often
impromptu
Village Screenings
Kitchen Demonstration
• Demonstrate
hygienic, balanced meal
preparation
• Explain the importance of
a balanced diet
• Give practical suggestions
for preparing food
specifically for the child
CNW Needs
Greatest needs to improve service from CNWs to community …
• Additional training – 81%
• Training is currently informal, on the job training
• Indoor meeting space – 70%
• Most village screenings observed took place outdoors
• Cooking supplies – 42%
• Currently, supplies are often borrowed from community
• Nutrition education materials – 41%
• They should have MOH IEC guidebook in each village
CNW Needs
Barriers to providing adequate service to the community …
• Lack of Materials – 46%
• This includes kitchen, education, and record keeping
• Evil ideologies of parents – 41%
• Discouraging screening attendance; belief in traditional
healing; failure to “buy into” nutrition education
• 86% give instruction in agriculture to their village, BUT 99% desire
more sustainable agriculture training opportunities
CNW Knowledge
Perceptions of malnutrition …
• Only 15.7% believe that the children of HIV+ mothers are more susceptible to malnutrition!!!
• BUT … 100% know that nutrition is especially important for HIV+ individuals
• 91% know the number of months that an HIV+ mother should exclusively breastfeed (6 months)
• ~70% perceive a problem of malnutrition in Rwanda … only 27% see malnutrition as a problem in their own village. Denial?
• Only 26% of CNWs check for all signs of malnutrition [swollen cheeks/legs, large belly, hair discoloration, signs of anemia]
CNW Improvements
0 5 10 15 20 25 30 35 40
% of Respondents
Community Member Needs for
Improvement of Nutrition Situation
More Information about Nutrition
More Training/Education of Parents
Support for Creating Agriculture Coop
Care/Hygiene of Children
Having a Kitchen Garden
More HC Supervision of Child
Increased Food Access for <5 Children
Respect Decisions of Health Leaders
More Access to Land
Family Planning
No Ideas
CNW Improvements
0 10 20 30 40 50 60
% of Respondents
Community Member Suggestions for CHW Program
Better Education and Communication
to Parents
More Home Visits
Increased CHW Training
Take a Greater Stake in Child Growth
No Suggestions
Improved Information About Livestock
CNW Situation Summary
• Desire for more training opportunities to better serve village
• Nutrition, Agriculture, Counseling for parents, etc.
• Lack of kitchen materials and indoor meeting space
• Most problematic during the rainy season – this is also the
time of greatest malnutrition (slide 12)
• Need for improved information about HIV and nutrition
• Need encouragement in dealing with parent ideologies, and
reminding that the fight against malnutrition is not over!
Recommendations
① Training and Informational Assistance
i. Formal training at program entry
ii. Increase involvement of village husbands
iii. Printed instruction for CHW diagnosis and referral
② Materials and Monthly Screening Improvement
i. Indoor kitchen and supplies for each village
ii. Central, enclosed meeting space for IEC
③ Agriculture and Food Security Assistance
i. Inclusion of agronomist into Ruli Nutrition Program
ii. Working teaching gardens at every health center
iii. Farming cooperative formation – SOSOMA and Food Security
iv. Supervised installation of kitchen gardens by CHWs
④ Integration of Nutrition and HIV Programs
i. Opt-in HIV register for each village
ii. Kitchen demonstrations and nutrition education for HIV+ mothers
1. Training and Information
Objective Responsibility Feasibility Priority
Formal TrainingHealth Center
CHW LeadersHigh High
Include Village
Husbands in IEC
CHWs, Health
Centers, HospitalMedium Very High
Printed
instruction for
CHW referral
protocols
The Ihangane
ProjectHigh High
2. Materials and Screening
Objective Responsibility Feasibility Priority
Indoor kitchen
for each village
The Ihangane
Project, CHWsMedium Medium
Enclosed
meeting space
for IEC
The Ihangane
Project, CHWsLow Medium
3. Agriculture and
Food Security
Objective Responsibility Feasibility Priority
Inclusion of Ruli
Hospital
Agronomist
The Ihangane Project,
Ruli HospitalHigh High
Farming Coop.
Formation
CHWs, Ruli Hospital
The Ihangane ProjectHigh Very High
Supervised
Kitchen Garden
Installation
CHWs, Health Centers Medium Very High
Objective Responsibility Feasibility Priority
Inclusion of Ruli
Hospital
Agronomist
The Ihangane Project,
Ruli HospitalHigh High
Farming Coop.
Formation
CHWs, Ruli Hospital The
Ihangane ProjectHigh Very High
Working Teaching
Gardens at Each
Health Center
Ruli Agronomist, CHWs,
Health CentersHigh High
Supervised Kitchen
Garden InstallationCHWs, Health Centers Medium Very High
3. Agriculture and
Food Security – Farming Coop.
Nyange PLWHA Farming Cooperative
3. Agriculture and
Food Security - SOSOMA
0
10
20
30
40
50
60
70
80
Maize Soya Sorghum None
% o
f R
esp
on
de
nts
SOSOMA Constituent Production
Total
Village Screening
Nyange PLWHA
VCT Mothers
Nutrition Center Mothers
Kitchen Garden
Theory… …PracticeVs.
Sustainable Agriculture
• Raised or Double-Dug beds – Increase land area; deep root
penetration; increased water retention
• Compost Pile Construction – Improve soil fertility; reduce
unnecessary purchase of chemical fertilizer that harms soil
• Inter-planting & Close Spacing – Reduce pest pressure;
improve yields; increased water retention
• Crop Rotation and Planning – Improved soil fertility;
preparation for months of difficult cultivation
“Ruli Hospital Sustainable Agriculture Manual”
Sustainable Agriculture
4. Integration of Nutrition
and HIV Programs
Objective Responsibility Feasibility Priority
Opt-In HIV Register
for Each Village
Ruli Hospital, Health
Centers, CHWsHigh High
Kitchen Demo.
and Nutrition
Education for VCT
mothers at the
Nutrition Center
Ruli Hospital, Nutrition
Center, The
Ihangane Project
High High
Thank you! … Questions?
① Training and Informational Assistance
i. Formal training at program entry
ii. Increase involvement of village husbands
iii. Printed instruction for CHW diagnosis and referral
② Materials and Monthly Screening Improvement
i. Indoor kitchen and supplies for each village
ii. Central, enclosed meeting space for IEC
③ Agriculture and Food Security Assistance
i. Inclusion of agronomist into Ruli Nutrition Program
ii. Working teaching gardens at every health center
iii. Farming cooperative formation – SOSOMA and Food Security
iv. Supervised installation of kitchen gardens by CHWs
④ Integration of Nutrition and HIV Programs
i. Opt-in HIV register for each village
ii. Kitchen demonstrations and nutrition education for HIV+ mothers