Social integration and health behavioral change in San Luis, Honduras.

This study explores the effects of social integration on behavioral change in the course of an intensive, community-based public health intervention. The intervention trained volunteers and mobilized local organizations to promote 16 key family health practices in rural San Luis, Honduras, during 2004 to 2006. A mixed methods approach is used. Standard household sample surveys were performed in 22 villages before and after the intervention. Eight villages were then resurveyed. A household survey, focus groups, and key informant interviews measured health behaviors and several social structural and psychosocial variables. The villages were then ranked on their mean behavioral and social integration scores. The quantitative and qualitative rankings were in close agreement (Kendall's coefficient of concordance = .707, p < .001). Behaviors changed most markedly in the villages where respondents participated in local organizations, observed that others performed those behaviors, and depended on their neighbors for support. The results show that social integration conditions health behavioral change. Health interventions can be made more effective by analyzing these features a priori.

The health benefits of social mobilization: experiences with community-based Integrated Management of Childhood Illness in Chao, Peru and San Luis, Honduras.

This article reviews the implementation of the community component of the Integrated Management of Childhood Illness (IMCI) strategy in Chao, Peru (2001 to 2004) and San Luis, Honduras (2003 to 2005). An evaluation was conducted in 2005 and included a project documentation review, key-informant interviews, and a household level baseline and follow-up survey of the WHO/UNICEF key family practices in each intervention site. The promotion of the key family practices in Chao and San Luís demonstrated measurable success. In comparison with the initial survey in 2002, the percentage of participant mothers ( N = 78) in Chao in 2004 who knew that they should breastfeed exclusively for at least six months increased from 33% to 94%; the presentation of complete vaccination records for one-year-old children increased by 19%; the recognition of danger signs for pneumonia increased 18% and for diarrhea by 8%; and the percentage of mothers who received four or more prenatal check-ups increased by 25%. A dramatic reduction in malaria cases was also attributed to the intervention in Chao. In San Luis, a quasi-experimental, random household sample ( N = 300) showed that the incidence of diarrheal disease among children under five years old declined by 18% between survey rounds (from 44% in August 2004 to 26% in December 2005). Social mobilization has promoted inter-sector consensus-building around community health issues, especially those related to maternal and child health. The promotion of the participation of representatives from various organizations via the community IMCI social-actor methodology has led to increased civic cooperation. Positive changes in health behaviors have been documented through an increase in preventive health practices, greater demand for primary health care services, and concrete community actions to improve public health.

The health benefits of social mobilization: experiences with community-based Integrated Management of Childhood Iliness in Chao, Peru and San Luis, Honduras

This article reviews the implementation of the community component of the Integrated Management of Childhood Illness (IMCI) strategy in Chao, Peru (2001 to 2004) and San Luis, Honduras (2003 to 2005). An evaluation was conducted in 2005 and included a project documentation review, key informant interviews, and a household level baseline and follow up survey of the WHO UNICEF key family practices in each intervention site. The promotion of the key family practices in Chao and San Lu is demonstrated measurable success. In comparison with the initial survey in 2002, the percentage of participant mothers (N equal 78) in Chao in 2004 who knew that they should breastfeed exclusively for at least six months increased from 33 percent to 94 percent; the presentation of complete vaccination records for one year old children increased by 19 percent; the recognition of danger signs for pneumonia increased 18 percent and for diarrhea by 8 percent; and the percentage of mothers who received four or more prenatal check-ups increased by 25 percent. A dramatic reduction in malaria cases was also attributed to the intervention in Chao. In San Luis, a quasi experimental, random household sample (N equal 300) showed that the incidence of diarrheal disease among children under five years old declined by 18 percent between survey rounds (from 44 percent in August 2004 to 26 percent in December 2005). Social mobilization has promoted inter sector consensus building around community health issues, especially those related to maternal and child health. The promotion of the participation of representatives from various organizations via the community IMCI social actor methodology has led to increased civic cooperation. Positive changes in health behaviors have been documented through an increase in preventive health practices, greater demand for primary health care services, and concrete community actions to improve public health. (AU)

Expandiendo la atención integrada de las enfermedades prevalentes de la infancia a nivel nacional: logros y retos en el Perú / Scaling up integrated management of childhood illness to national level: achievements and challenges in Peru

Este artículo presenta el primer reporte publicado de un esfuerzo nacional de implementación de la atención integrada a las enfermedades prevalentes de la infancia (Aiepi) en gran escala. Es el primer reporte publicado de un esfuerzo nacional de implementación de la atención integrada a las enfermedades prevalentes de la infancia (Aiepi) en gran escala. Aiepi fue introducido en el Perú a finales de 1996; la fase de implementación inicial empezó en 1997 y la de expansión en 1998. Comunicamos aquí los resultados de una evaluación retrospectiva diseñada para describir y analizar el proceso de captación de Aiepi a nivel nacional en el Perú, evaluación conducida como parte de los cinco estudios de la evaluación multipaís de la efectividad, costo e impacto de Aiepi (EMP), coordinada por la Organización Mundial de la Salud. Supervisores capacitados visitaron las 34 direcciones de salud (Disas) del Perú, entrevistaron al personal de las Disas y revisaron los registros existentes. Los resultados muestran que Aiepi no fue institucionalizado en el Perú; fue implementado paralelamente a los programas existentes de control de infecciones respiratorias agudas y diarrea, compartiendo con ellos presupuesto y personal. El número de personal de salud capacitado en Aiepi aumentó hasta 1999 y luego disminuyó en el 2000 y el 2001, con una cobertura para médicos y enfermeras estimada en 10,3 por ciento . La implementación del componente comunitario de Aiepi empezó el año 2000 con la capacitación de agentes comunitarios de salud, pero no se efectivizaron las sinergias esperadas entre las intervenciones en los establecimientos de salud y las intervenciones comunitarias, pues las Disas en los que la capacitación clínica fue más intensa no fueron las mismas en las que la capacitación en Aiepi comunitario fueron las más fuertes. Se presenta las limitaciones encontradas para la expansión nacional de Aepi y las implicancias políticas de los hallazgos. Hubo pocos documentos de monitoreo...

Implementation of the Integrated Management of Childhood Illness strategy in Peru and its association with health indicators: an ecological analysis.

The Multi-Country Evaluation of Integrated Management of Childhood Illness (IMCI) Effectiveness, Cost and Impact (MCE) was launched to assess the global effectiveness of this strategy. Impact evaluations were started in five countries. The objectives of the Peru MCE were: (1) to document trends in IMCI implementation in the 24 departments of Peru from 1996 to 2000; (2) to document trends in indicators of health services coverage and impact (mortality and nutritional status) for the same period; (3) to correlate changes in these two sets of indicators, and (4) to attempt to rule out contextual factors that may affect the observed trends and correlations. An ecological analysis was performed in which the units of study were the 24 departments. By 2000, 10.2% of clinical health workers were trained in IMCI, but some districts showed considerably higher rates. There were no significant associations between clinical IMCI training coverage and indicators of outpatient utilization, vaccine coverage, mortality or malnutrition. The lack of association persisted after adjustment for several contextual factors including socioeconomic and environmental indicators and the presence of other child health projects. Community health workers were also trained in IMCI, and training coverage was not associated with any of the process or impact indicators, except for a significant positive correlation with mean height for age. According to the MCE impact model, IMCI implementation must be sufficiently strong to lead to an impact on health and nutrition. Health systems support for IMCI implementation in Peru was far from adequate. This finding, along with low training coverage level and a relatively low child mortality rate, may explain why the expected impact was not documented. Nevertheless, even districts with high levels of training coverage failed to show an impact. Further national effectiveness studies of IMCI and other child interventions are warranted as these interventions are scaled up.

Expansión de la atención integrada a las enfermedades prevalentes de la infancia en el Perú / Implementation of the integrated management of chilhood illnesses strategy in Peru and its association with health indicators: an ecological analysis

Objetivos: 1) Documentar las tendencias en la implementación de la atención integrada a las enfermedades prevalentes de la infancia (Aiepi) en los 24 departamentos del país, de 1996 al 2000. 2) Documentar las tendencias en los indicadores de cobertura de servicios de salud y en los de impacto (mortalidad y estado nutricional) para el mismo período. 3) Correlacionar los cambios en estos dos grupos de indicadores. Y, 4) intentar descartar factores contextuales que puedan afectar las tendencias y las correlaciones observadas. Materiales y Métodos: Se realizó un análisis ecológico en el que las unidades de estudio fueron los 24 departamentos. Resultados: Para el 2000, 10,2 por ciento de trabajadores clínicos (médicos y enfermeras) fueron capacitados en Aiepi, pero solo algunos departamentos mostraron tasas considerablemente mayores. No hubo asociaciones significativas entre la cobertura de capacitación clínica en Aiepi y los indicadores de utilización de consultas externas, cobertura de vacunas, mortalidad o desnutrición. La falta de asociación persistió luego de haber realizado el ajuste de varios factores contextuales incluyendo indicadores socioeconómicos y ambientales y la presencia de otros proyectos de salud del niño. Los agentes comunitarios de salud también fueron capacitados en Aiepi y la cobertura de capacitación no estuvo asociada con ninguno de los indicadores de proceso o de impacto, excepto una correlación positiva y significativa con el promedio de talla para edad. De acuerdo al modelo de impacto de la Evaluación Multi-País del Impacto, Costo y Efectividad de Aiepi (EMP), la implementación de Aiepi debe ser lo suficientemente fuerte para llevar a un impacto en la salud y la nutrición. Conclusiones: El soporte de los sistemas de salud para la implementación de Aiepi en el Perú estuvo lejos de ser adecuada, y esto, así como coberturas de capacitación relativamente bajas, pueden explicar porqué no se documentó el impacto esperado. Sin embargo, inclus...

Scaling up integrated management of childhood illness to the national level: achievements and challenges in Peru.

This paper presents the first published report of a national-level effort to implement the Integrated Management of Childhood Illness (IMCI) strategy at scale. IMCI was introduced in Peru in late 1996, the early implementation phase started in 1997, with the expansion phase starting in 1998. Here we report on a retrospective evaluation designed to describe and analyze the process of taking IMCI to scale in Peru, conducted as one of five studies within the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE) coordinated by the World Health Organization. Trained surveyors visited each of Peru's 34 districts, interviewed district health staff and reviewed district records. Findings show that IMCI was not institutionalized in Peru: it was implemented parallel to existing programmes to address acute respiratory infections and diarrhoea, sharing budget lines and management staff. The number of health workers trained in IMCI case management increased until 1999 and then decreased in 2000 and 2001, with overall coverage levels among doctors and nurses calculated to be 10.3%. Efforts to implement the community component of IMCI began with the training of community health workers in 2000, but expected synergies between health facility and community interventions were not realized because districts where clinical training was most intense were not those where community IMCI training was strongest. We summarize the constraints to scaling up IMCI, and examine both the methodological and policy implications of the findings. Few monitoring data were available to document IMCI implementation in Peru, limiting the potential of retrospective evaluations to contribute to programme improvement. Even basic indicators recommended for national monitoring could not be calculated at either district or national levels. The findings document weaknesses in the policy and programme supports for IMCI that would cripple any intervention delivered through the health service delivery system. The Ministry of Health in Peru is now working to address these weaknesses; other countries working to achieve high and equitable coverage with essential child survival interventions can learn from their experience.