Integrating Community-based Strategies into Existing Health Systems_ Judy Lewis_5.6.14


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  • In 2000, 40,183 children under five were diagnosed as having pneumonia. Of these, 2,987 (7.4%) died. 5 3 14
  • Dr. Jeremiah Lowney, FounderUCHC and University Board of TrusteesHHF BEGAN with public healthHealth and development
  • A one-page pictorial home-care set of instructions was developedthat included important activities such as keeping the child warm, increasing foods andfluids, giving the medicine as prescribed, clearing the nose, and returning to the clinicfor care if symptoms persisted or worsened. The CHW reviewed each action photowith the caregiver and suggested posting the pictorial where everyone could see it asa reminder of these important home-based activities.
  • 6 organizations included HAS, big system, to small NGOsFeedbackTimers were not good qualityFiches Techniques shortage???All found training useful and appropriate (many wished for one more field day)Used HHF songs and mobilization techniques and community response positive4/6 fully implemented program (1 CBP because referred to own hospital)No Family Left Behind: The Example of Community-Based Pneumonia Care in Haiti Journal of Health Care for the Poor and Underserved, Volume 20, Number 4, November 2009 Supplement, pp. 22-30 (Article) Published by The Johns Hopkins University PressHAS I knowSADA I knowBut what about AEADMA,   A PRIVATE ORGANIZATION IN DAME MARIE (RURAL)Claire Heureuse      A HAITIAN ORGANIZATION CANNOT REMEMBER WHERECDS    I CANNOT REMEMBER WHAT IT STANDS FOR.  AN ORGANIZATION IN THE NORTH AND WAS IN CITE SOLEILCBP  PIGNON   IN THE NORTH. GUY THEODORE HAS A HOSPITAL AND A PUBLIC HEALTH PROGRAM (RURAL)
  • Think have reduced disease specific mortality by more than half again…January 2013 pentavalent includeshflu (pneumonia), hepb,dip, per, tetanus same schedule as dpt, have to get before one year of age (maybe not give after one because of shortages, etc.) 1.5 months all except bcg3 doses before 12 mos agestockouts because volume is one vial per child, can’t physically store as many vialsAdded rotavirus for diarrhea 1.5 months 5months onlyOnly booster is polio, everything else not given after age 1Measles and german measles? Newborn pneumonia is different/sepsisHaemophilusinfluenzae type b (Hib) disease is a serious disease caused by bacteria.
  • Integrating Community-based Strategies into Existing Health Systems_ Judy Lewis_5.6.14

    2. 2.  Pneumonia still leading cause of death <5  PAHO 1995:  In 2000, 40,000 children <5 diagnosed  Almost 3000 died (7.4%) PEDIATRIC PNEUMONIA IN HAITI Mortality Rate (Children Under 5 Years) 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 Haiti Dominican Republic United States of America Deathsper100,000livebirths ARI Mortality Rate (1994) Total Mortality Rate (1994)
    3. 3. Population based primary health care HHF initial program 1986 Public Health Program 1987 200,000 population  Village Health Committees  Community Selected Village Health Workers  Mobile Health Teams  Registered Population  Family Data System  Epidemiological Profile HAITIAN HEALTH FOUNDATION
    4. 4. DATA DRIVEN PARTICIPATORY PROGRAM IMPROVEMENT Assessment Communities Providers Researchers Feedback Planning Implementation Data Collection Information System
    6. 6.  Method: scenarios, video interpretation, card sorts of symptoms and causal relationships  Results:  Rapid breathing and inter-costal retraction believed to be parasites  Bwonch (pneumonia) vs grip (flu-like)  Bwonch caused by bathing too late in the day or in cold water, or an untreated cold  Knowledge of symptoms low and only 26% identified rapid infant breathing video as pneumonia  Everyone knew at least one child who died of pneumonia Information used by PAHO to launch national pneumonia program in 1993 1990 WHO ETHNOGRAPHIC STUDY
    7. 7.  WHO treatment algorithms and training modules  Translation to Haitian Creole by JSI 1994  USAID sponsored pilot implementation  Tools: battery-operated timer that emitted a sound at 30 and 60 seconds to assess breathing  Two sequential recordings of rate above age group norm  Questions and observation to help classify  Two week training  Doctors and nurses  Community health workers – had to demonstrate competence  Treatment documentation  Ongoing supervision PNEUMONIA TREATMENT AND TRAINING
    8. 8.  HHF has regular meetings with community leaders, healers and members  Community participation given equal weight in staff training  seminars for community-based organizations  creating songs about recognizing and treating pneumonia  public demonstrations on the use of the timer, counting respiratory rates  medicine (cotrimoxazole), cost, first dose, length of rx and home care  Treatment  5 days for 5 Haitian gourdes (US$.04)  Now 8 days for 10 gourdes (WHO) COMMUNITY MOBILIZATION
    9. 9. Refrain Mothers there is an illness that is called pneumonia That kills children. If you see a child with rapid breathing or coughing, go to the dispensary. I. Pneumonia is a severe illness. If you wait to see you will lose your child. If you see the child gets worse after going to the dispensary you need to return quickly to the dispensary. Refrain II. Fathers with children, help the mothers! Its not only mothers who seek care for children When they have pneumonia or another illness, if they are not treated they will die more easily. PNEUMONIA SONG
    10. 10.  1997 CDC program impact evaluation  17,000 cases treated in first 3 years  CDC concluded:  HHF ARI program is an important model for Haiti  Reduction of baseline pneumonia-specific mortality from 6.2/1000/year to 3.1  CHWs with brief formal training, intensive supervision and regular continuing education can effectively diagnose and treat ARI in Haiti  1998 CDC case control study of children with multiple episodes of pneumonia*  Wheezing was found to be the significant contributor CDC EVALUATION/RESEARCH *Heffelfinger JD, Davis TE, Gebrian B, et al. Evaluation of children with recurrent pneumonia diagnosed by World Health Organization criteria. Pediatr Infect Dis J. 2002 Feb;21(2):108–12.
    11. 11.  In 1993 CHWs in Haiti not allowed to dispense antibiotics  USAID got MSPP approval for HHF CHWs  Careful documentation of medication distribution and outcomes  Based on evidence and discussions with HHF, MSPP approved CHW cotrimoxazole distribution in USAID sponsored NGOs  After HHF’s further advocacy and documentation  Community based treatment of ARI became part of Haiti national IMCI policy in 2005  HHF collaborated with Haitian Pediatric Society 2011 World Pneumonia Day GOVERNMENT POLICY
    12. 12.  2002 HHF began training other organizations  FOCAS child survival grant wanted to incorporate community treatment for pneumonia  2005 USAID designated HHF as a field training site for community based treatment of pediatric pneumonia  6 Haitian NGOs came for one week of training  Teams of physicians, nurse managers and CHWs—teamwork critical component  HHF Community Based ALRI Treatment Manual revised based on feedback  Follow up with NGOs found that most had implemented—major obstacle was timers  5 additional NGO trainings after USAID  2 publications and 4 graduate student research projects DISSEMINATION AND TRAINING
    13. 13.  Continue to track pneumonia episodes and treatment—93,000 episodes through 2013  January 2013 pentavalent vaccine became Haiti protocol  Problems with stock outs  Lack of storage space for so many individual vials  HHF will be able to demonstrate impact of having Hib vaccination on pneumonia rates and outcomes  Healthy children determining their future! PRESENT AND FUTURE