[Trained stroke helpers : Voluntary care model in outpatient stroke aftercare]. / Geschulte Schlaganfall-Helferinnen und Schlaganfall-Helfer : Ehrenamtliches Versorgungsmodell in der ambulanten Schlaganfallnachsorge.

The rehabilitation of people after suffering a stroke is a long-term process, in which patients, their families and friends are reliant on social support and assistance. Therefore, the individual promotion of available resources and autonomy of those affected represents an important task. The College for Health in Bochum and the German Stroke Help Foundation have developed the volunteer-supported model "Trained stroke helpers-a partnership-based model for local care (GeSa)" that educates stroke helpers as experts for individual local support of stroke patients and their relatives. The stroke helpers offer a patient-oriented care and individual assistance in the daily routine and therefore make a contribution to improvement of the health-related quality of life of those affected and their relatives. A training curriculum was developed and successfully tested and evaluated in a course with 21 stroke helpers. Up to summer 2020 a total of 480 stroke helpers have been trained at 16 locations in 37 courses. The experiences with the project have so far been consistently positive, which was confirmed by two scientific studies. The inclusion of cooperation partners for the coordination of the volunteers, which was already implemented in the model project, has been shown to be the most important success factor for the sustainability of the project. This article presents the results of the pilot study and the standardized process on implementation of a regional stroke helper project and describes the experiences with the previous course of the project.

Expanding Roles of Accredited Social Health Activists (ASHAs) in the 2019 Hepatitis E Outbreak in a Peri-urban Slum, Nagpur, India.

OBJECTIVE: Due to constraints in the dedicated health work force, outbreaks in peri-urban slums are often reported late. This study explores the feasibility of deploying Accredited Social Health Activists (ASHAs) in outbreak investigation and understand the extent to which this activity gives a balanced platform to fulfil their roles during public health emergencies to reduce its impact and improve mitigation measures. METHODS: Activities of ASHAs involved in the hepatitis E outbreak were reviewed from various registers maintained at the subcenter. Also, various challenges perceived by ASHAs were explored through focus group discussion (FGD). During March to May 2019, 13 ASHAs involved in the hepatitis outbreak investigation and control efforts in a peri-urban slum of Nagpur with population of around 9000. In total, 192 suspected hepatitis E cases reported. RESULTS: During the outbreak, ASHAs performed multiple roles comprising house-to-house search of suspected cases, escorting suspects to confirm diagnosis and referral, community mobilization for out-reach investigation camps, risk communication to vulnerable, etc. During the activity, ASHAs faced challenges such as constraints in the logistics, compromise in other health-related activities, and challenges in sustaining behavior of the community. CONCLUSIONS: It is feasible to implement the investigation of outbreaks through ASHAs. Despite challenges, they are willing to participate in these activities as it gave them an opportunity to fulfil the role as an activist, link worker, as well as a community interface.

Community acceptance, satisfaction, and support for case management of malaria of various degrees in selected rural communities in Ibadan, Oyo-State.

Objectives: This study aimed to assess communities' perception and adoption of the evidenced-based malaria diagnosis and case management intervention targeted at under-five children. The effectiveness of trained Volunteer Community Health Workers (VCHWs) to diagnose malaria among under-five children using rapid diagnostic testing kit, provide treatment using Artemisinin Combination Therapy and rectal Artesunate were assessed. Design: A qualitative evaluation study was conducted in October 2015. Setting: Communities in the 6 rural wards in Ona-Ara Local Government Area, Oyo State Nigeria. Participants: Caregivers of under-five children, community-based frontline health workers, and community leaders selected using purposively sampling. Methods: Nine Focus Group Discussions and 15 Key Informant Interviews were conducted using a pre-tested guide. Data were subjected to thematic analysis. Results: It was disclosed that VCHWs promoted people's access to prompt and appropriate malaria treatment. The communities accepted the VCHWs; the reasons given for this included the following: effectiveness of VCHWs in case management of malaria; good inter-personal relationship with caregivers; and the positive health outcomes associated with services provided by them. In addition, community members expressed satisfaction with the VCHWs and provided them with all the support needed to function throughout the malaria case management intervention. The VCHWs considered the support as a great source of encouragement. Conclusions: The use of VCHWs to treat malaria was adjudged to be effective and considered acceptable to the communities. The adoption of the intervention and its integration into the primary health system by the government is advocated for in medically underserved rural communities. Funding: This work was supported by UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland (project ID: A80550 [Nigeria] through funds made available by the European Commission (FP7) for research to improve community access to health interventions in Africa.

Nationwide survey on volunteers' training in hospice and palliative care in Poland.

BACKGROUND: Volunteers working in hospice and palliative care facilities in Poland undertake various activities which are performed in accordance with legal regulations and the individual policies of each hospice. The aim of this study was to explore the roles and training of volunteers working in hospice and palliative care settings. METHODS: A cross-sectional survey was carried out that investigated the services performed by volunteers and their preparation for work within residential hospices. Questionnaires were distributed to volunteers and hospice representatives, and the responses obtained underwent statistical analysis. PARTICIPANTS: A total of 180 volunteers and 28 hospice representatives from 29 residential hospices participated in this survey. RESULTS: All hospices surveyed were supported by volunteers. 79% of volunteers worked alongside patients and performed the following services: accompanying patients (76%), feeding patients (61%), cleaning rooms (48%), dressing and bathing (42%) and organising leisure time (40%). Fewer volunteers were involved in activities outside of patient support-for example, charity work and fundraising (34%), cleaning hospice buildings (23%) as well as providing information and education (22%). According to volunteers, prior to undertaking their duties, 64% participated in theoretical training and 37% took part in a practical course. The majority attended courses relating to general knowledge of hospice and palliative care (64%) and volunteer rights and duties (55%). CONCLUSIONS: Overall, proper training was an essential requirement needed to be fulfilled by volunteers, particularly when involved in direct patient support. Most volunteers were simultaneously involved in various areas of service; therefore, their training should be comprehensive.

Veterans Health Administration's Disaster Emergency Medical Personnel System (DEMPS) Training Evaluation: Potential Implications for Disaster Health Care Volunteers.

OBJECTIVE: The US Veterans Health Administration's Disaster Emergency Medical Personnel System (DEMPS) is a team of employee disaster response volunteers who provide clinical and non-clinical staffing assistance when local systems are overwhelmed. This study evaluated attitudes and recommendations of the DEMPS program to understand the impact of multi-modal training on volunteer perceptions. METHODS: DEMPS volunteers completed an electronic survey in 2012 (n=2120). Three training modes were evaluated: online, field exercise, and face-to-face. Measures included: "Training Satisfaction," "Attitudes about Training," "Continued Engagement in DEMPS." Data were analyzed using χ2 and logistic regression. Open-ended questions were evaluated in a manner consistent with grounded theory methodology. RESULTS: Most respondents participated in DEMPS training (80%). Volunteers with multi-modal training who completed all 3 modes (14%) were significantly more likely to have positive attitudes about training, plan to continue as volunteers, and would recommend DEMPS to others (P-value<0.001). Some respondents requested additional interactive activities and suggested increased availability of training may improve volunteer engagement. CONCLUSIONS: A blended learning environment using multi-modal training methods, could enhance satisfaction and attitudes and possibly encourage continued engagement in DEMPS or similar programs. DEMPS training program modifications in 2015 expanded this blended learning approach through new interactive online learning opportunities. (Disaster Med Public Health Preparedness. 2018;12:744-751).

A Community-Led Medical Response Effort in the Wake of Hurricane Sandy.

On October 29, 2012, Hurricane Sandy made landfall in the neighborhood of Red Hook in Brooklyn, New York. The massive tidal surge generated by the storm submerged the coastal area, home to a population over 11,000 individuals, including the largest public housing development in Brooklyn. The infrastructure devastation was profound: the storm rendered electricity, heat, water, Internet, and phone services inoperative, whereas local ambulatory medical services including clinics, pharmacies, home health agencies, and other resources were damaged beyond functionality. Lacking these services or lines of communication, medically fragile individuals became isolated from the hospital and 911-emergency systems without a preexisting mechanism to identify or treat them. Medically fragile individuals primarily included those with chronic medical conditions dependent on frequent and consistent monitoring and treatments. In response, the Red Hook community established an ad hoc volunteer medical relief effort in the wake of the storm, filling a major gap that continues to exist in disaster medicine for low-income urban environments. Here we describe this effort, including an analysis of the medically vulnerable in this community, and recommend disaster risk reduction strategies and resilience measures for future disaster events.

Volunteer activity in specialist paediatric palliative care: a national survey.

OBJECTIVE: To assess the involvement of volunteers with direct patient/family contact in UK palliative care services for children and young people. METHOD: Cross-sectional survey using a web-based questionnaire. SETTING: UK specialist paediatric palliative care services. PARTICIPANTS: Volunteer managers/coordinators from all UK hospice providers (n=37) and one National Health Service palliative care service involving volunteers (covering 53 services in total). MAIN OUTCOMES: Service characteristics, number of volunteers, extent of volunteer involvement in care services, use of volunteers' professional skills and volunteer activities by setting. RESULTS: A total of 21 providers covering 31 hospices/palliative care services responded (30 evaluable responses). Referral age limit was 16-19 years in 23 services and 23-35 years in seven services; three services were Hospice at Home or home care only. Per service, there was a median of 25 volunteers with direct patient/family contact. Services providing only home care involved fewer volunteers than hospices with beds. Volunteers entirely ran some services, notably complementary therapy and pastoral/faith-based care. Complementary therapists, school teachers and spiritual care workers most commonly volunteered their professional skills. Volunteers undertook a wide range of activities including emotional support and recreational activities with children and siblings. CONCLUSIONS: This is the most detailed national survey of volunteer activity in palliative care services for children and young people to date. It highlights the range and depth of volunteers' contribution to specialist paediatric palliative care services and will help to provide a basis for future research, which could inform expansion of volunteers' roles.

HIV risk behavior among Peace Corps Volunteers.

OBJECTIVE: To describe HIV risk behaviors among Peace Corps Volunteers (PCV) and to examine correlates of sexual risk behaviors. METHOD: Cross-sectional data were collected from 1242 randomly selected PCV serving in 28 countries in 1991. PCV reported the frequency of specific risk behaviors in self-administered questionnaires, which were completed anonymously and returned to the Centers for Disease Control and Prevention. RESULTS: Non-sexual HIV risk behaviors were rarely reported by PCV. Sixty-one per cent of the 1080 PCV who answered questions about sexual behavior during their Peace Corps service reported having at least one sex partner. Sixty per cent of PCV had another PCV partner, 39% had a host-country national partner, and 29% had a non-PCV expatriate partner. Overall, less than one-third (32%) of unmarried PCV used condoms during every episode of sexual intercourse; more frequent use was reported in relationships with non-steady and (for male PCV) host-country national partners. Among male PCV, condom use was positively related to lower alcohol use and the belief that HIV was a problem in the host country. Female PCV reporting more condom use with male partners were younger and had fewer partners than those reporting less use. CONCLUSION: These data indicate that PCV are at risk for acquiring HIV through unprotected vaginal intercourse. All persons who become sexually active with new partners while travelling or living abroad should be encouraged to use condoms consistently.

PIP: At least 10 former Peace Corps volunteers are believed to have acquired human immunodeficiency virus (HIV) during their time of service. To assess HIV risk behavior among current Peace Corps volunteers, cross-sectional data were collected from 1242 randomly selected volunteers in 28 countries in 1991. 474 (38%) were stationed in sub-Saharan Africa. Non-sexual HIV-related risk activities included injection from local health facilities (209) and ears or body parts pierced (59). Of the 1018 volunteers who were unmarried or not living with a spouse, 61% of men and 60% of women indicated they had at least one sexual partner during their time of service; 30% and 20%, respectively, had three or more partners. Only 17 men and 12 women reported having a same-sex partner. 52% of sexually active Peace Corps volunteers stationed in Eastern Europe, 43% of those in Central or South America, 36% in sub-Saharan Africa, and 32% in Asia and the Pacific had a sexual partner from the host country. 32% of these volunteers used condoms on every occasion with partners from the host country, 49% used condoms some of the time, and 19% never used them. For male volunteers, consistent condom use was negatively associated with alcohol use and positively related to the perception that HIV was a problem in the host country; for female volunteers, younger age and fewer partners were the significant correlates of condom use. The inconsistent use of condoms in countries where HIV is widespread suggests a need for Peace Corps leaders to educate volunteers about local seroprevalence rates, cultural differences in sexual negotiation, and the importance of condom use.

Childhood mortality among users and non-users of primary health care in a rural west African community.

To evaluate the effectiveness of primary health care (PHC) interventions implemented through the Pahou PHC Project, the utilization of PHC by 74 children aged 4 to 35 months who died in 1986 or 1987 was compared to that of 230 controls who survived and were individually matched by date of birth, sex and place of residence. The crude death rate was 35.9/1000/year. Measles vaccination before the first birthday significantly reduced the risk of mortality (Relative Risk/RR = 0.4). Children with less than 75% weight for age early in 1986 had an increased risk (RR = 4.3). Children who died had had significantly fewer contacts with the village health worker (VHW) in the last six months prior to death (RR = 0.3). A similar association was not observed for periods more than six months prior to death. Children who had more regular contact with the VHW throughout life were better protected than children for whom contact had been less systematic. We conclude that VHWs contribute to a better survival of young children through regular personal contact with the household.

PIP: Researchers analyzed the relationship between use of primary health care services and child mortality in 16 villages in the communes of Pahou and Avlekete on the Atlantic coast of Benin. The case control study included 74 4-35 month old children who died in 1986-1987 and 230 controls who survived. Overall child mortality stood at 35.9/1000/year. Fever and convulsions, presumably malaria, were the most likely cause of the majority of deaths (38 cases). No protective effect of a village health worker (VHW) visit in the 6 months before death occurred between fever and convulsion cases and other causes of death cases, however. VHWs had visited considerably more controls than cases in the 6 months prior to death (RR ..3; p.05). Indeed the greatest protective effect occurred in children who has been seen by VHWs had visited 71% of all children for a median of 4 visits each. Poor children were only slightly more likely to die than nonpoor children. Children whose weight for age was 75% of the standard for their age has a 4.26 relative risk (RR) of mortality (p.05). Further, when the researchers excluded cases who died within 3 months of the weight measurement, the RR remained high (2.9) and the association significant (p=.08). Measles vaccination between 9-12 months old significantly protected children against mortality (RR .36; p.05). On the other hand, diphtheria, tetanus, and pertussis vaccination did not have a significant protective effect. In conclusion, personal and household contact with a VHW and measles vaccination between 9-12 months improves child survival for 4-35 month old children.

National community health worker programs: how can they be strengthened?

This article is based on a collaborative research study of policy and practice in national community health worker (CHW) programs in developing countries. The study involved a review of the relevant literature, case studies in Botswana, Colombia and Sri Lanka, and an international workshop where the future of such programs was discussed. The findings of this research are discussed under four headings: unrealistic expectations, poor initial planning, problems of sustainability, and the difficulties of maintaining quality. It is clear that existing national community health worker programs have suffered from conceptual and implementation problems. However, given the interest and political will, governments can address these problems by adopting more flexible approaches within their CHW programs, by planning for them within the context of all health sector activities rather than as a separate activity, and by immediately addressing weaknesses in task allocation, training and supervision. CHWs represent an important health resource, whose potential in extending coverage and providing a reasonable level of care to otherwise underserved populations must be fully tapped.

PIP: A collaborative research study of policy and practice in large, national community health worker (CHW) programs in developing countries was conducted. The report was based on a review of the literature, case studies in Botswana, Colombia and Sri Lanka, and an international workshop on the future of CHW programs. The objective of the study was to reexamine the implementation of national CHW programs, looking at policy, planning and management implications to suggest improvements. The chief findings were poor initial planning, unrealistic expectations of the workers, difficulties in maintaining quality and problems of sustainability. National CHW programs have suffered from conceptual and implementation problems. With political will, however, governments can adopt more flexible approaches by planning CHW programs within the context of overall health sector activities, rather than as a separate activity. Weaknesses in training, task allocation and supervision need to addressed immediately. CHWs represent an important health resource whose potential in providing and extending a reasonable level of health care to undeserved populations must be fully tapped.

Passage House as model for AIDS education of street children.

PIP: The Casa de Passagem is a comprehensive project which reaches out to aid street girls in Recife, Brazil. Driven by the basic human needs of food, clothing, and shelter for daily survival, many of these youths prostitute themselves at great risk of HIV infection. Street educators work on streets frequented by prospective clients, and constitute the 1st phase of a 3-level approach. If workers succeed in making inroads with these girls, interested girls are then encouraged to partake of services offered at the Casa de Passagem. There, they are able to receive counseling, therapy, education, meals, showers, medical attention, and affection from 7 A.M. to 7 P.M. Where time permits, program staff work with the girls to develop income generation projects. In the 3rd and final phase of the program, street girls either rejoin their parents or move into 1 of 4 community houses run by the projects. There, they assume responsibility for themselves and live on their own. In addition to these program activities, the Casa de Passagem holds workshops and supports local initiatives to strengthen and unite the neighborhood. Where HIV infection and AIDS are particularly concerned, the girls' need to prostitute for daily survival makes AIDS education and behavioral change difficult. To help girls believe that HIV is real, program workers have used microscopes to reveal the existence of objects of microscopic proportions. Further measures include teaching street girls that the shrewd among them take precautions against HIV infection, counselling and providing condoms where possible, training former street girls to serve as peer educators, and holding peer group meetings to think of preventive steps.^ieng

An investigation into the quality of service provided by telephone hotlines for family planning services.

PIP: A study was conducted to assess the ability of two birth control telephone information services in Toronto, Ontario to transmit information of value to the client. There were 3 sets of methods which had to be developed. The initial task was to prepare the simulated cases and train actors to present them. Then, the actors' rating instruments were adapated for this study. Finally, a rating system was designed for the independent judges. A pilot test run a few weeks before experiment was the basis for revisions to the instruments, retraining of the callers and raters to ensure reliability and consistency and refinements to the phoning and taping procedures. The calls were placed at different hours over a 2 week period. Random assignment of cases to the actors, the time frame of the experiment, and the general nature of the question were designed to avoid recognition by counselors as well as any effects on the results due to order, timing or individual contacted. Each agency received half of the total of 50 separate calls. Regarding the quality of concern shown the callers and the accuracy of information provided, the ratings for the counselors in the public and voluntary agencies were uniformly high. The volunteers, as a group, had limited training in family planning counseling and experiences on the hotline services in comparison to the staff of Family Planning Services. The evaluation of the 2 services indicated the volunteer and staff counselors were generally effective. Volunteers were perceived as friendlier while fulltime staff provided a better bridge to community services. There was a tendency for counselors in both the agencies to appear rather professional, disinterested, and too anxious to instruct. An important implication of the study findings is that volunteer agencies can offer services similar to the governments' but more economically since staff costs are not included. A number of considerations in the establishment and operation of telephone answering services are listed.^ieng

Health personnel training in the Nicaraguan health system.

The "Unified National Health System" of Nicaragua was established in 1979, in an attempt to transform some of Latin America's worst health indices. This system, based on the stated principles of planning, regionalization, public participation, and primary care, has prioritized the development of health professions training programs appropriate to its special needs and principles. Public Health and Epidemiology training was inaugurated in 1982. A new campus of the School of Medicine was opened in 1981, increasing the number of medical students by a factor of five. Formal residency training (never before available within the country) in primary care specialties has been established. Training for allied health personnel has been formalized in several fields, with the establishment of the Polytechnical Institute of Health. The rapid increase in number and size of training programs has created a tremendous need for educational resources both human and material. This article reviews the status of health personnel training in Nicaragua today, the integration of these programs into planning for the health system, and problems arising from their rapid appearance.

PIP: This article explores the policies and early experiences of the extensive changes in the preparation of health personnel in Nicaragua; massive changes in the health care system were launched after the victory of the Sandinista Revolution in 1979. It reviews the status of health personnel training in the country today, the integration of these programs into planning for the health system, and problems arising their rapid appearance. The Unified National Health System was established in 1979 in an attempt to transform some of Latin America's worst health indices. This system is based on the stated principles of planning, regionalization, public participation, and primary care. To implement these policies, high priority has been given to the development of health professions training programs appropriate to the system's special needs and principles. Public Health and Epidemiology training was inaugurated in 1982. A new campus of the School of Medicine was opened in 1981, increasing the number of meidcal students by a factor of 5. Formal residency training in primary care specialties has been established. Training for allied health professions has been formalized in several fields, with the establishment of the Polytechnical Institute of Health. The rapid increase in number and size of training programs has created a trmendous need for educational resources, both human and material. The greatest constraint in expanding medical education was the lack of qualified teachers. As a solution, the new health system has made public sector employment much more available and attractive; most Nicaraguan physicians today divide their time between public and private practice, and the pressures on voluntary teaching time are heavy. The Health Ministry has developed strategies for making clinical teaching more attractive and prestigious in compensation. Medical curriculum reform since 1979 is designed to turn out doctors capable along 4 lines: clinical service, teaching, administration and research. Special importance is placed on integrated teaching and service. These multiple objectives are built into the teaching program from the very beginning. To date there are 6 schools of nursing in the country (4 before 1979), with 5 times the pre-1979 enrollment. Nicaragua has made a deliberate decision not to train mid-level medical workers. However, volunteer health personnel, the Brigadistas, have played a definite role in Nicaraguan communities. They concentrate on public education and mobilize the people for immunization and sanitation campaigns. Additionally, traditional birth attendants in rural areas have been recognised by the Health Ministry and been given training to upgrade their performance. Much in the new System has emulated policies of Cuba, especially the emphasis on public education, models for personnel training and community-oriented primary care.

Health for all and rural Medicare.

PIP: The goals of the "Health for All" (HFA) by the year 2000 remain unfulfilled, as preschool child mortality is almost 10 to 20 times higher than developed countries. 75% of the population of Indian still lives in villages and 70% of farmers are landless. The Community Health Volunteer (CHV) scheme was launched in 1977 to implement the health policy formulated by the Bhore Committee calling for extension of primary health centers and rural hospitals with 50 beds. Although CHV was changed to community health worker (CHW), and later to village health guide (VHG), this Indian version of the Chinese barefoot doctor scheme never took root. The population coverage of primary health centers was reduced from 100,000 to 30,000 and that of a subcenters to just 3,000 to 5,000. The Bhore panel proposed to set up 7,200, 30-bed community health centers (CHC's) in the rural areas by 2000 calling for 90% of all beds to be at the village, taluk or district levels with 40% set aside for maternal and child health. In 40 years of health planning, the government has been able to create only 30,000 medical jobs to serve 600 million people living in the rural areas, while there are more 90,000 jobs for 200 million urban people. Only 750 (20%) of about 3800 posts of specialists have been sanctioned for the CHC's established in the rural areas by March 1987. It is necessary to provide primary care through a network of specially trained voluntary workers. It is incumbent on the government to establish more than 3 lakh hospital beds in the next 13 years to meet the target of 1 bed for 1,000 people in concordance with the objectives of the Bhore Committee. In addition, it is advisable to implement the recommendations of the National Workshop on Child Health & Manpower: 2000 A.D.^ieng

Beyond survival: promoting healthy growth.

PIP: Growth monitoring and nutritional assessment, as means to detect malnutrition, are 2 different types of programs in terms of conception, purposes, and execution. Growth monitoring starts as detection of malnutrition, then acts through prevention by communication to mothers, and finally utilizes community participation in total primary care. Nutritional assessment is a tool used to measure undernutrition. mainly in children. Emphasis is on curative or supplemental measures. Those children that are malnourished due to infections, low quality diet, poor breastfeeding, or maternal high fertility tend to have markedly stunted physical growth. Growth promotion, as a preventative strategy, relies on the cooperation of the mother to monitor and communicate stunting of her children. Growth Monitoring and Promotion (GMP) has recently been well defined at an Indian national meeting. GMP is preventative, promotive, and preemptive; it focuses on behavioral change; it works with the child's complete environment; and it affords responsibility to the mothers. GMP starts when a child is very young, before nutritional assessments determine the existence of malnutrition, and it creates an interactive community pertaining to health care.^ieng

Child growth as a community-surveillance indicator.

PIP: Growth monitoring has unique potential for the ability to correct malnutrition and other health problems at an early age. Monitoring must be a 2-stage process of screening and intervention. Field studies of individuals and communities need to be conducted in order to determine technological and program problems, casual factors, and epidemiology of the problems. Growth monitoring objectives include education, early detection, women's participation, and promotion of community awareness and organization. Workers must decide the priorities of program policy -- including questions of individual growth monitoring vs. monitoring of a population. Pilot programs tend to be more successful than mass implementation because they are more flexible and more open to learning. Field studies that are locally appropriate need to be conducted. These should survey and test the following areas: community situation analysis; objective and priority planning; community intervention; management of primary health care; political administration and public support; locally relevant training of personnel; and self-evaluation of the program. The individual and community-based approaches should be synthesized into 1 cohesive program. Eventually, the sequence of events within any growth monitoring program should be screening of babies, analysis of casual factors, definition of controls, and implementation of the most cost effective controls.^ieng

Growth monitoring as entry point for primary health care.

PIP: In Haiti, more than 755 of the children under 5 are malnourished, the infant mortality rate is about 125/1000. In the 70's, the medical community devised centers d'Education et de rehabilitation nutritionelle (CERNs) which focused on nutritional rehabilitation by education of the mothers. CERNS were very expensive and not very effective because mothers rarely returned for follow-up care and because they treated children who were already malnourished. In the mid-70's, Petit Guave attempted to set up an outreach program similar to the one that the Hospital Albert Schweitzer created. This program included preventative care, nutrition, and family planning services. Workers visited individual families to educate them in health care. Petit Guave paid special attention to children under 5 by keeping growth monitoring records. Infant mortality rates fell by almost 25% and child mortality was halved in this time. Growth monitoring was performed monthly. A lack of supervision caused the initially successful program activities to decline severely. In Bell Anse, volunteers monitored villagers weekly by operating rally posts. This program features extensive participation by the mother and nutritional education discussions. Children were immunized at the rallies. After 12 months, death rates decreased and growth rates increased significantly. Further operational research is needed in the form of supervision, community control, effectiveness of workers, and values of the incentives of the program.^ieng

A comprehensive approach to community welfare: growth monitoring and the role of women in Jamkhed.

PIP: The Comprehensive Rural Health Care Project at Jamkhed services 175 villages with a total population of almost 200,000. The program actively encourages community participation, self-help, and integration of solutions to all types of problems within the community. The project started as a mobile clinic which periodically visited each village. Villagers participated in weighing and nutritionally assessing the children. Drought hit the area in 1972 and the lack of weight gain in children caused communities to establish special feeding programs for the poor children. Growth monitoring has helped villagers to understand growth-development relationships and has been an important tool for diagnosing illnesses in children with no apparent malnourishment problems. A comparison of mean weights between children in 1975 and 1985 was performed. In 1985 less than 6% of the children were moderately or severely malnourished whereas in 1975, 30% were considered malnourished. Women villagers were strongly opposed to the cessation of this program. The most difficult problem has been to facilitate the realization among health workers that growth monitoring is an important tool. Also difficult was the introduction of weighing scales into a superstitious community. When given the responsibility of growth monitoring, however, communities rise to the challenge and participate fully.^ieng

Field level health worker's skill in detection of growth retardation and faltering in young children.

PIP: 25 out of 100 Anganwadis in Baroda city, India were studied to assess 4 components of the current growth monitoring program: reliable and accurate weighing of children, accurate recording of the weight, proper interpretation of the growth line, and appropriate allotment of advice to the mothers. Trained nutritionists visited 5 slum centers within 48 hours of the completion of the monthly weighing of the children. The AWW's in these centers were requested to reweigh 25 children. The nutritionists then weighed the children and compared the numbers to those recorded. 477 children (infant to 72 months) participated in the study. Nutritionists then tested the ability of AWW's to interpret growth charts. Accuracy of weighing and of placing the dots on the chart were highly reliable (error rate of weighing = 2%). All AWW's were able to interpret growth curves, except for a stationary weight (flat) growth curve. AWW's offered advice to mothers only after malnutrition caused obvious effects, e.g. if the child lost weight for 3-4 consecutive months. The AWW's examined in this study were amazingly competent, however they still need to be trained in early detection of growth faltering and interpretation of stationary growth curves so that they will be able to detect moderate cases of undernourishment.^ieng

Growth monitoring--lessons from India.

PIP: Growth monitoring of individuals and growth surveillance of populations are 2 very different tools and need to be distinguished from one another. Individual monitoring is an invaluable tool for the detection of early undernourishment, since malnutrition is not readily visible without an objective measurement. It is important to catch malnutrition at an early stage and to prevent further harm. It is also important for the mothers to understand the value of growth monitoring and of nutrition. In the 70's, the Safdarjung Hospital in New Delhi followed the weights and illnesses of children under 5. Currently, there are a few programs in India which utilize growth monitoring: The Integrated Child Development Services (ICDS); the Tamil Nadu Integrated Nutrition Project (TINP), and the Child in Need Institute (CINI). Successful growth monitoring must include a growth card, comprehension of the growth card by the mother, an active and motivated health worker, weighing scales that are accurate, durable, and easy to repair, adequate training for the health workers, supportive and educative supervision, back-up health care support, and active community participation.^ieng