The Ruli District Hospital Community Nutrition Program:Evaluation and Recommendations for Improvement Presented by Sean Morris and Uwacu Theophila August 3, 2011
Project Introduction1. Evaluation of Community Nutrition Worker program a. Surveys of CNWs at monthly meetings b. Observation of village screening activities c. Interviews with program supervisors2. Understanding the community nutrition situation a. Surveys of community members b. Observation of nutrition education c. Home visit assessment
Project Introduction3. Health center teaching gardens a. Nyange HC teaching garden b. Ruli Sustainable Agriculture Manual c. Assessment of existing situation4. Establishment of farming cooperatives a. Understand existing village associations b. Identification of potential stakeholders c. Initiation of Nyange PLWHA pilot farming coop.
Project IntroductionMethodology …• 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
Community SituationWho 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 SituationDistance 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 SituationHousehold 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 SituationEstimated Monthly Household Income of • Majority of community Community Members members have very little money to spend on food & health insurance. • Consistent with observations 0-5000Rwf of screening participants’, 5001-10000Rwf and home visit situations. Thought question… 10001-15000Rwf • What is the best way to 15001Rwf+ combat malnutrition in a No Response poor population that has access to limited cultivating space?
No Space for the Poor Bar Chart Bar Chart 10 If f4.1, how large is the Has your child ever area of land that you been to the cultivate? malnutrition center for Small area 12.5 treatmet? Medium area Yes 8 Large area No 10.0 6Count Count 7.5 4 5.0 2 2.5 0 0.0 0 0<x<5000 5000<x<10000 10000<x<15000 +15000 0 0<x<5000 5000<x<10000 10000<x<15000 +15000 What is your estimated monthly household income? What is your estimated monthly household income?
Agriculture SituationAvailable 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 Seasonality of Malnutrition Incidence and Cultivating Challenges 60 50 40% of Respondents 30 Months of Highest Malnutrition Incidence 20 Most Difficult Month to Cultivate 10 0
Let’s Work Together! Opportunities for Farming Cooperative Formation 80 70 60% of Respondents 50 40 Work Alone Work Together 30 Both 20 10 0 Total Village Screening Nyange PLWHA VCT Mothers Nutrition Center Mothers
Need for Diversity Village Level Crop Production 87 68 61 Beans Maize 37 Tubers 34 Coffee 9 Vegetables 9 Soya Bananas 5 Fruit 4 Wheat 3 Sorghum0 10 20 30 40 50 60 70 80 90 100 % of Villages Growing...
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 SituationWho 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 SituationSatisfaction …• 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 NeedsGreatest 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 NeedsBarriers 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 KnowledgePerceptions 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 Community Member Needs for More Information about Nutrition Improvement of Nutrition Situation 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 Planning0 5 10 15 20 25 30 35 40 No Ideas % of Respondents
CNW Improvements 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 Livestock0 10 20 30 40 50 60 % of Respondents
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!
Recommendations① Training and Informational Assistance i. Formal training at program entry ii. Increase involvement of village husbands iii. Printed instruction for CHW diagnosis and referral② Materials and Monthly Screening Improvement i. Indoor kitchen and supplies for each village ii. Central, enclosed meeting space for IEC③ 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 CHWs④ 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 Health CenterFormal Training High High CHW LeadersInclude Village CHWs, Health Medium Very HighHusbands in IEC Centers, Hospital Printed instruction for The Ihangane High High CHW referral Project protocols
2. Materials and Screening Objective Responsibility Feasibility Priority Indoor kitchen The Ihangane Medium Mediumfor each village Project, CHWs Enclosed The Ihanganemeeting space Low Medium Project, CHWs for IEC
3. Agriculture and Food Security Objective Responsibility Feasibility Priority Objective Inclusion of Ruli Responsibility Feasibility Priority The Ihangane Project, Hospital Inclusion of Ruli High High Ruli Hospital The Ihangane Project, Agronomist Hospital High High Ruli Hospital Farming Coop. Agronomist CHWs, Ruli Hospital The High Very High Formation Farming Coop. Ihangane Project CHWs, Ruli Hospital High Very HighWorking Teaching The Ihangane Project Formation Ruli Agronomist, CHWs, Gardens at Each Supervised High High Health Centers Health CenterKitchen Garden CHWs, Health Centers Medium Very HighSupervised Kitchen Installation CHWs, Health Centers Medium Very HighGarden Installation
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”
4. Integration of Nutrition and HIV Programs Objective Responsibility Feasibility PriorityOpt-In HIV Register Ruli Hospital, Health High High for Each Village Centers, CHWs Kitchen Demo. and Nutrition Ruli Hospital, NutritionEducation for VCT Center, The High High mothers at the Ihangane Project Nutrition Center
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 referral② Materials and Monthly Screening Improvement i. Indoor kitchen and supplies for each village ii. Central, enclosed meeting space for IEC③ 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 CHWs④ Integration of Nutrition and HIV Programs i. Opt-in HIV register for each village ii. Kitchen demonstrations and nutrition education for HIV+ mothers