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Published on February 25, 2008

Author: Simeone

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Slide1:  Research to Support Household and Community IMCI Summary of the Meeting January 24-26, 2001 Baltimore, Maryland Slide2:  Research to Support Household and Community IMCI January 22-24, 2001 Baltimore, Maryland USAID’s Child Health Research Project: WHO-CAH, Boston University, INCLEN, ICDDR,B, and Johns Hopkins School of Public Health USAID’s BASICS II, and The CORE Group Sponsored by: Slide3:  Research to Support Household and Community IMCI January 22-24, 2001 Baltimore, Maryland To review the results of recent research on child health and nutrition interventions implemented at the household and community levels; To examine which interventions to improve child health and nutrition are both feasible and of proven effectiveness, and which should be incorporated into programs, and   To determine research needs in relation to the integrated implementation of child health and nutrition interventions at the household and community levels. Slide4:  Research to Support Household and Community IMCI January 22-24, 2001 Baltimore, Maryland Nutritional interventions Vector control Community care seeking and illness management Compliance with treatments and referrals Integrated interventions in the community Roles of community health workers Costing of community IMCI Slide5:  Improving Infant and Child Nutrition A study in Bangladesh has shown that exclusive breastfeeding rates increased to 84% with community promotion. Research in Peru and India has shown that it is possible to improve infant feeding with nutritional counseling in the health services. AIN: a community-based, preventive health and nutrition program (which uses IMCI) reduced malnutrition in Honduras by 26% in less than one year. The positive-deviance model reduced severe malnutrition in Vietnam from 26% to 4% in two years. Slide6:  Research and Programs to Improve Nutrition Operations research is needed to understand how to promote exclusive breastfeeding at the national level. Further complementary feeding studies are needed to maximize coverage, and find ways to motivate counseling activities in private practitioners. Studies are also needed to adapt the positive deviance approach to IMCI, including identifying how to modify it to improve pre-pregnancy or pregnancy nutrition. Slide7:  Vector Control In Peru, mosquitoes bite from underneath 86% of all beds, most exposure (to Anopheles darlingi) is during early evening activities out of doors, and bednet use is high, but nets are washed every few weeks and never retreated with protective chemicals. Netmark research in Nigeria, Senegal, Uganda, and Zambia has shown inadequate net use by pregnant women and young children, general distrust of foreign chemicals, and high market segmentation (nets sold in one place, chemicals in another). Slide8:  Research and Programs to Aid Vector Control Research is needed on ways to promote insecticide-treated materials (ITMs) use and must build on existing positive perceptions of ITMs, counter the perception of nets as luxury items, and direct significant effort toward reassuring the public about their safety and efficacy. The greatest additional reduction of disease in Peru will be gained from reducing exposure to mosquitoes in the early evening and early morning when people are outside of the nets. Slide9:  Community Care Seeking and Illness Management In Bangladesh, only 11% of care is given by the formal health sector; traditional healers provided 53% of care outside the home. In Zambia only 7% of mothers knew the correct dose of chloroquine for children. In Ethiopia, trials teaching home treatment of malaria reduced deaths in children to 29 per 1000 from 50/1000 in control communities. In India a package of essential newborn care practices reduced sepsis mortality by 76% and neonatal mortality declined by 62%. Slide10:  Research to Improve Community Care Seeking and Illness Management Studies are needed to understand how to motivate care seeking from formal health providers and facilities. What signs and symptoms are best for health workers to identify neonates with serious illness, and which organisms cause infections in the community. Further research on how get families to use anti-malarial drugs at home. How to provide community treatment of malaria in areas of high chloroquine resistance. Slide11:  Compliance with Recommended Treatments and Referrals Studies in Uganda have shown that most IMCI counseling by health providers is good, and that IMCI counseling guidelines are effective in improving drug counseling quality and treatment compliance. Research in Ecuador has shown the primary barriers of referral compliance are: not receiving a referral slip; not being told to go to the hospital immediately; not being able to afford transportation; mother not being the primary decision-maker; needing to spend the night away from home to take the child to hospital, and having an infant less than three months old. Slide12:  Research and Programs to Improve Treatment and Referral Compliance Research to improve drug use must target private practitioners, address consumer practices & household decision-making dynamics. Studies are needed to determine how to expand IMCI counseling in clinics by clinical officers, nurses and midwives. Referral compliance may be improved if health workers were trained to use referral slips and assess each child’s individual risk of not being taken to hospital – such as age, or if the caregiver needs to be away from home. Slide13:  Integrated Community Interventions IMCI-trained health providers relative to non-trained health staff asked if sick infants could: drink or breastfeed 58% vs 26% of the time; checked respiratory rates 76% vs 19%; checked for dehydration in children reporting diarrhea 70% vs 24% of the time, and checked children’s weight against growth cards 82% vs 38% percent of the time. Lesson’s from UNICEF’s Bamako Initiative (revolving drug-funds, fee-for-service and health insurance plans) can be applied to implementation of community IMCI. Slide14:  Research & Programs to Support Integrated Community Interventions Work is urgently needed to introduce IMCI guidelines into private practice. Research and programs are necessary to better implement prescribing guidelines for drug sales through education and negotiation. Referral of sick children must be improved and funds be available to offset the high costs of transportation. Immunization rates must be increased. Slide15:  Roles of Community Health Workers In India, anganwadi workers (CHWs) can effectively use IMCI guidelines for diagnosis and management of illness. Using a modified form of the IMCI guidelines in Kenya, CHWs have reduced child mortality by 49%; and increased DPT vaccinations to 84%. In Nepal, CHWs can correctly diagnose and treat pneumonia, and over 80% retain knowledge of danger signs and antibiotic dosages for several years after training. In El Salvador, CHWs have increased exclusive breastfeeding from 17% to 43%, and tetanus immunization from 21% to 54%. Slide16:  Research to Better Utilize Community Health Workers Research is needed to improve IMCI training methods for CHWs to raise the sensitivity and specificity of their diagnoses relative to a physician’s gold standard. Improving support and supervision of CHWs would extend their reach in the community; better salaries and benefits would increase job tenure. Local health teams (CHWs, doctors and nurses) need to participate more in community activities to build acceptance and use of health services. Slide17:  Costing of Community IMCI Using predictive costing techniques, investments in health centers, rural hospitals and CHWs were found to be more cost-effective for reducing maternal mortality than trained traditional birth attendants (TBAs). When developing a cost estimate for community IMCI, one must include the costs of meetings; consultancies; workshops; communications campaigns, and surveys and assessments, as well as delivery of services. In addition to establishing “start-up” costs, the IMCI costing tool also establishes the recurrent costs of the program in the introduction and expansion phases. Slide18:  Research Needed to Develop Costing of Community IMCI More rigorous cost-effectiveness studies of community interventions are needed to help with promoting community-based health care and planning for additional interventions. There is a need to classify interventions based on similarity in cost structures, and summarize cost by focus or objective, in order to plan for community IMCI. Slide19:  Priorities for Programs and Applied Research Introduce IMCI guidelines into private practice; Better utilize the skills of community health workers; Raise exclusive breastfeeding rates, and reduce growth faltering with adequate complementary feeding; Increase the use of insecticide-treated materials; Improve recognition of illness with simple danger signs and improve care seeking and referral for severely ill infants and neonates, and Improve prescription and use of anti-malarial and antibiotic drugs. Improve the referral process. Slide20:  Further success in reducing childhood mortality will depend upon adequate nutrition, preventing malaria, care seeking, and diagnosis and treatment of illness in the household and community

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