Bringing together viewpoints of mothers and health workers to enhance monitoring and promotion of growth and development of children: a case study from the Republic of Congo

In 1996, the Government of the Republic of Congo launched a pilot project to improve the child growth and development component of primary healthcare. The present study was carried out (i) to explore perceptions and practices of mothers and health workers regarding child growth, health, and development, and (ii) to design culturally-appropriate tools to enhance their monitoring and promotion. The study was carried out in two randomly-selected health centres in Brazzaville. Qualitative data collected included 16 focus-group discussions with 174 mothers, two focus-group discussions with 18 health workers, and 20 individual interviews with paediatricians or psychologists. The health workers reported that the main indicator of child growth was weight, while the mothers used broader concepts for evaluating growth and development of their toddlers. A strategy encompassing anthropometrics, developmental milestones, and acquisition of social skills was elaborated to enhance communication between health workers and mothers. A new growth chart was designed, and a new calendar of systematic visits, including key tasks and messages, was established. However, these new tools derived from the formative research still need to be carefully tested.     

Application of multiple methods to study the immunization programme in an urban area of Guinea

During 1988-89, studies were conducted to evaluate the immunization system in Conakry, Guinea. The first, a health facility survey, found that health staff screened the vaccination status of only 30% of children who presented for curative care. A sterile syringe and needle were used for less than half of the injections. In the second survey, key informant interviews with vaccinators and health centre chiefs showed that there were minimal lines of communication between health workers and the community, but that health workers did not perceive this to be a problem. Focus group discussions in the community revealed a high level of general knowledge about vaccine-preventable diseases. However, mothers did not know how many vaccinations their children should receive or by what age they should be completed. They complained of long waiting times in health centres, the high costs of vaccination, poor rapport with health workers, and the occurrence of abscesses after vaccination. The final study, a "knowledge, attitudes, and practice" community survey, showed that missed immunization opportunities and inappropriately timed vaccinations reduced potential vaccine coverage by almost 30% among children with vaccination cards. Higher socioeconomic status, delivery in hospital, and whether mothers perceived the vaccinations to be affordable affected whether the child began the immunization series. Once a child had entered the immunization system, completion of the series was determined by the mother's education level, employment status, and experience with vaccination services.     

Immunization: full coverage the aim.

In November 1988, nursing students at Khon Kaen University in northeast Thailand conducted a baseline survey in 16 villages before a retraining program for village health workers began. It consisted of a 1-week intensive training program and meetings between officers and village health workers. The goal was to achieve full immunization coverage for children under 5. After retraining, the workers implemented their health education and immunization recruitment programs with a refresher course 4 months later. The nursing students conducted a follow-up survey in June 1989 so researchers could compare the effects of the 8 intervention villages with data collected in the 8 control villages. The intervention indeed brought about improvement in immunization coverage, mother's and health worker's knowledge, and health worker participation in program planning and coordination in the case villages. For example, full immunization coverage among children under 1 increased from 65% to 89% while in the control villages it remained at 56%. It also increased among children over 5 (30-81%) but in the control villages it only rose slightly (23-31%). The percentage of mothers who were very knowledgeable about infectious diseases increased from 1% to 8% yet in the control villages it decreased from 2% to 0. Mothers with high level of knowledge about immunization was higher in the 2nd survey in both groups, but the increase was greater in the intervention villages (12-33% vs. 14-21%). High level of knowledge about infectious diseases among health workers grew considerably (3-72%) in the case villages but in the control villages it decreased from 10% to 2%. In addition, health workers in the case villages improved their contact with health officers but not those in the control villages (47-64% vs. 70-36%). Program participation increased in the intervention villages (11-36%) but fell in the control villages (22-13%).     

Assessment of the nutritional status of Nigerian rural children and mothers'' perceptions of quality of life

One hundred and fourteen preschool school children and their 30 mothers from three selected villages in Ile-Ife, Nigeria were assessed for nutritional status using selected and sensitive anthropometric techniques. The mothers' dietary patterns, their perceptions as to components of a good quality of life, infants' immunization status and major cause of infant death were also examined. Approximately 56% of the children and 80% of the women were identified to be suffering from mild to moderate malnutrition. The major cause of infant death as reported by the mothers was high fever and convulsion. Practically all the children under 3 years had not received any form of immunization. Ability to have plenty of children, good health and money, were highly perceived as measures of essential components of quality of life by all the mothers, while 20% listed good feeding, housing, clothing, and only 7% listed potable water. The need for effective health services, regular home visits, supplementary feeding programmes for school children and an effective health education campaign on the importance of immunization and nutrition for rural people are discussed. The training of agricultural extension workers in the use of simple anthropometric techniques to identify covert malnutrition is also highlighted.     

Organising for immunization

In the late 1960s, health workers from a mission hospital in rural Zambia began registering children under 14 years old within 30 miles of the hospital (about 3000 children) by incorporating the cooperation of community leaders. They wanted to give every 0-4 year old child a Road to Health card and every 5-14 year old a vaccine record card and to promote the significance of immunization to parents and community leaders. The mission hospital established mobile health units to conduct regular visits in the center of villages. Staff hugh scales from a tree and borrowed a table to conduct the clinic. They kept a good relationship and communication with the community, leading successful education and communication activities. By 1988, many younger mothers were unfamiliar with a measles or whooping cough epidemic so they tended to not have their infants immunized. Epidemics began killing children nationwide, frightening these mothers so they brought their children for immunizations. The medical mission achieved an 85-90% vaccination coverage rate with immunization clinic attendance climbing quickly. 1 mother even walked 30 miles to have her infant injected with the DPT vaccine, but 10 years earlier, she did not bring her children. Further, measles had not reached her area because the immunization level was so high that it stopped the epidemic.     

A household survey on morbidity and treatment of acute respiratory infections in communities in Vietnam

Objective To ascertain the extent of under-utilization and insufficiency or inappropriateness in provision of health services as one of the possible causes of high mortality from pediatric pneumonia in pilot areas in Vietnam. Method The household survey on morbidity and treatment of acute respiratory infections, simple cough, and cold and pneumonia, was conducted in two communities with 10% sampling of the child population. Results Both under-treatment of “fast breathing”, a proxy for pneumonia, and over-treatment of simple cough and cold with antimicrobials by health workers, mothers, and private practitioners were common. Conclusions A household survey on morbidity and treatment was found to be useful to clarify actual practices in the treatment of acute respiratory infections in the community, which cannot be obtained by mere interview with health workers or mothers. Since a change of knowledge did not automatically lead to change of practice, the training of health workers, health education of mothers and provision of antimicrobials at village health stations would not guarantee improved practice of health workers and mothers. Therefore, constant supervision for health workers, continued health education of mothers and involvement of private practitioners are needed to improve the situation.     

Risk-sharing in rural health care.

Kasturba Hospital in Sevagram, India, has helped to initiate an outreach health program for nearby villages. A health insurance scheme has evolved where the community contributes sorghum for a fund and participates in decision-making and the supervision of village health workers. Contributors are entitled to free primary care and subsidized referral care. Only villages where at least 75% of the poor community agreed to enroll in the health insurance scheme were adopted by the hospital. The hospital offers insured persons free inpatient treatment for unexpected illness and a 75% subsidy for care during normal pregnancy or with cataract and hernia operations. The mobile health team, comprising auxiliary nurse-midwife, social worker, and village health worker, provides maternal and child health services in the localities. The village health workers provide symptomatic drug treatment, exercise a preventive role with the help of visiting health team members, and refer patients to hospital. The auxiliary nurse-midwife and social workers organize visits for vaccination and provide maternal and child health care. The doctor in charge treats patients in the hospital and trains village health workers. More than 75% of the villages in the area have enrolled in the scheme over the last 10 years. No vaccine-preventable illness (measles, poliomyelitis, diphtheria, whooping cough, tetanus) was reported in children or mothers after mass immunization was instituted, no maternal deaths have occurred during the past 10 years, and perinatal mortality has fallen steeply. The village health teams are now regarded as counselors on health-related matters, among them drinking-water supplies, irrigation, and programs for income generation. It is necessary to regulate the private health sector, including professionals, the drug industry, and investors. If outpatient services are opened up to the private sector, a system of universal medical insurance, financed by local government, should operate.     

Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country

Background   Programmes that promote early psychological development of children in the developed world have been found to be beneficial. However, such programmes are rare in underprivileged parts of the developing world. We adapted one such parent-based programme (Learning Through Play) for a rural Pakistani population and aimed to study if: (1) it was acceptable to community health workers; (2) the programme led to an improvement, after a period of 6 months, in mothers' knowledge and attitudes about early infant development; (3) it led to a reduction in the levels of maternal mental distress in the post-natal period.
Methods   Using a cluster randomized design with villages as unit of randomization, 163 mothers from 24 villages in a rural sub-district of Rawalpindi, Pakistan, received the 'Learning Through Play' programme, whereas 146 mothers from 24 villages acted as controls. Twenty-four community health workers were trained to carry out the programme. Assessments were conducted using a specially developed 15-item Infant Development Questionnaire and the 20-item Self-Reporting Questionnaire (SRQ).
Results   Over 80% of the community health workers trained found the programme to be relevant and were able to integrate it into their routine work. There was a significant increase in mothers' knowledge and positive attitudes about infant development in the intervention group, compared with the control group. Women in the intervention group answered correctly 4.3 (95% CI 3.7–14.9, P  < 0.001) more questions than the control group. There was no difference in levels of mental distress measured by the SRQ.
Conclusions   The 'Learning Through Play' programme was successfully integrated into the existing health system and accepted by community health workers. The programme succeeded in improving the knowledge and attitudes of mothers about infant development.     

Participatory learning materials for health promotion in Ghana-a case study

This paper reports on operational research carried out by the Kumasi Health Education Project in Ghana to study the utilisation of participatory/empowerment learning methods for health promotion. The Project used community-based workshops to develop an extensive range of participatory materials on child health and followed these up with in-service training of 367 teachers and 157 public health workers (nurses and environmental health officers). A simple random sample of about half (262) of the participants was taken 6 months later and these personnel were asked to complete a self-reporting questionnaire to evaluate the format, content and usefulness of the materials. Results were compared with focus-group discussions with mothers attending well baby clinics, at home, in market-places and with pupils at school. The field agents reported a high degree of satisfaction with the training and claimed to be utilising the methods. However, this contrasted with the interviews with target groups who reported a low level of exposure to the materials. Those who had been exposed to materials reported a high level of satisfaction and recall of messages. Further focus-group discussions were carried out with field agents and their managers, and four sets of reasons for low utilisation emerged: the quality of participatory learning materials; personal attributes of the users and the impact of training; situational factors including the location and timing of educational sessions; and the support from peers/supervisors. The experiences in Kumasi are critically assessed and indicate that uptake of participatory/empowerment methods for health promotion depends on the quality of the materials and the selection, training and support provided to field staff.     

Evaluation of the home-based maternal record: a WHO collaborative study.

Thirteen centres in eight countries (Egypt, India, Pakistan, Philippines, Senegal, Sri Lanka, Democratic Yemen and Zambia) participated in the WHO collaborative study to evaluate the home-based maternal record (HBMR). The evaluation showed that use of the HBMR had a favourable impact on utilization of health care services and continuity of the health care of women during their reproductive period. When adapted to local risk conditions, their cut-off points and the available resources, the HBMR succeeded in promoting self-care by mothers and their families and in enhancing the timely identification of at-risk cases that needed referral and special care. The introduction of the HBMR increased the diagnosis and referral of at-risk pregnant women and newborn infants, improved family planning and health education, led to an increase in tetanus toxoid immunization, and provided a means of collecting health information in the community. The HBMR was liked by mothers, community health workers and other health care personnel because, by using it, the mothers became more involved in looking after their own health and that of their babies. Apart from local adaptation of the HBMR, the training and involvement of health personnel (including those at the second and tertiary levels) from the start of the HBMR scheme influenced its success in promoting maternal and child health care. It also improved the collection of community-based data and the linking of referral networks.     

Mothers' perspectives on the quality of postpartum care in Central Shanghai, China.

OBJECTIVES: To investigate mothers' perspectives on the quality of postpartum care services in central Shanghai, China. DESIGN: Semi-structured interviews. SETTING: Two maternal and child health posts in two subdistricts in LW District, Central Shanghai, China. STUDY PARTICIPANTS: Fifty postpartum mothers who attended the maternal and child health posts in the two subdistricts in LW District, Central Shanghai, China. MAIN OUTCOME MEASURES: Mothers' perceived quality and adequacy of postpartum services. RESULTS: A majority of the mothers (90%; n = 45) were primiparas (first time mothers). Half did not consider the postpartum services to be of high quality. They defined high quality as 'full satisfaction of the mother and the child'. Their perception of quality was influenced by their concern about child care, an area in which they expressed the need for further improvement. CONCLUSION: Mothers indicated that to improve quality of services further, greater emphasis should be placed on: (1) health education on childcare; (2) more time allocation for discussion with health workers during their postpartum home visits so their questions and concerns could be addressed effectively; (3) access to health workers in times of need rather than during officially prescribed home visits; and (4) provision of continuous training for maternal and child health workers with respect to childcare. The findings will be relevant to health workers and policy makers involved in planning and implementation of maternal and child health services in similar urban settings in developing countries.     

The health promoting school: progress and future challenges in Welsh secondary schools

Data were obtained from a random sample of 87 secondary schoolsin Wales (UK) about the organization and provision of healtheducation teaching, the implementation of health related policies,and the involvement of outside agencies and professionals inthe planning and delivery of health education programmes. Theresults suggest that schools have made progress in curriculumdevelopment. However, if the concept of the health promotingschool is to be translated into practice, greater attentionwill need to be given us the development of broadly based policiesfor health covering both pupils and staff and the better integrationof school programmes with community resources. Greater understandingof the health promoting school concept by teaching staff andthe development of examples of good practice in embedding healtheducation into national curriculum subjects, are also advocated.     

Mothers' perceptions of childhood immunizations in First Nations communities of the Sioux Lookout Zone

OBJECTIVE: Low uptake of childhood immunizations is a problem in many First Nations communities. This article describes the results of a study that examined mothers' perceptions of childhood immunizations and the factors that influence uptake. METHOD: Person-centred interviews focussing on childhood immunizations and child health were conducted with 28 mothers of young children in two First Nations communities in the Sioux Lookout Zone. Content analysis was applied to the interview data and patterns and themes were developed. RESULTS: Data analysis identified four key factors as negatively influencing immunization uptake: knowledge barriers, the influence of others, vaccine barriers, and missed opportunities. CONCLUSIONS: Further research with Elders and community members along with culturally sensitive education initiatives are required to address low immunization uptake. Changes in health professionals' behaviours may serve to reduce missed opportunities.     

Risk assessment practices among home visiting nurses and child protection caseworkers in Colorado,United States: A qualitative investigation

Nurses and caseworkers engage in assessments with the families they serve. Nurse home visitors from Nurse–Family Partnership (NFP) improve maternal–child health outcomes with first‐time low‐income mothers through care, education and support. In the United States, Child Protective Services (CPS) are state‐level governmental agencies that protect children, including responding to reports of child maltreatment. This paper aimed to characterise similarities and differences in risk assessment practices between NFP nurses and CPS caseworkers in Colorado, United States. Using a grounded theory approach, we conducted in‐depth qualitative interviews with 112 NFP and CPS workers from seven Colorado NFP sites from 2013 to 2015. Study sites were purposefully selected based on size, structure, geography and degree of collaboration with CPS. We conducted interviews first with NFP sites and used snowball sampling to recruit CPS workers. Interviews were recorded, transcribed, validated and then coded in NVivo 10. Memo writing was conducted to organise and link concepts within the theme of risk assessment. NFP and CPS workers emphasised the importance of risk assessment in their respective practices. Although there were similarities in the types of risks assessed, we found variations in work processes, operational definitions and methods of risk assessment between the two organisations that impacted inter‐organisational collaboration to serve high‐risk mothers and their children. NFP and CPS workers may have different roles and responsibilities but their underlying goals are the same – to keep children and their families safe and healthy. By understanding these similarities and differences in practice, there lies potential to improve collaboration between home visiting programmes and child welfare to provide integrated service delivery of high‐risk families and prevention of future child maltreatment.     

'As every good mother should'. Childhood immunization in New Zealand: a qualitative study

Immunization coverage is a cause for concern in both developed and developing countries. In New Zealand immunization uptake rates have been estimated at less than 60% for children under the age of 2 years old. A qualitative exploration of knowledge, experiences and concerns appeared necessary to supplement the quantitative data and offer some explanations for low uptake. Focus groups and individual interviews were held with primary child caregivers in Auckland, a major multi-cultural metropolis of New Zealand. A total of 67 parents took part of whom 97% were mothers. Discussion focused on identifying the knowledge and experiences participants had of childhood diseases and immunizations, and on their concerns. Interview data were analysed following construction of role ordered and conceptually clustered matrices. The results demonstrated limited knowledge and a lack of experience regarding childhood diseases. Some mothers conceptualized immunization using a metaphor of ‘protection’. Others perceived immunization as socio-politically driven and were distrustful of immunization campaigns. Many mothers faced a dilemma about immunization and were highly anxious. There was a greater concern about the side effects of immunization than about the side effects of childhood diseases. This may reflect a ‘developed world’ view with a difference between the concerns of white middle class mothers, and those mothers from the Pacific Islands, where common childhood diseases are more endemic. Predominantly the onus for immunization lay with mothers and this was not considered to be sufficiently recognized by health service providers. Personalized programmes designed to meet the needs of mothers are required to complement existing population oriented immunization programmes.     

An assessment of a rural health programme on child and maternal care: the Ogbomoso Community Health Care Programme (CHCP), Oyo State, Nigeria

Village health workers (VHW) in Ogbomoso have been trained by the nearby Baptist Medical Centre to accept responsibility for the health and health education of the rural populace. They assume particular care in respect of child and maternal services. This analysis is based on over 800 interviews with women to compare villages with and without VHWs, and it attempts to quantify such measures as the percentage partaking in specific services (e.g. immunization and family planning). The survey emphasizes difficulties currently faced by VHWs including competition from commercial 'quacks' as well as unenthusiasm from persons of other religions and from women who prefer not to be advised by male VHWs. Knowledge of criticism should, however, be of value in upgrading the approaches offered by the VHW programme.     

Promoting primary health in Belize

This article describes a 2-year project aimed at promoting primary health in a rural area of Belize with little access to health services. 27 mobile clinics were scheduled every 6 weeks. Services focused on immunization, development of a health education program, prenatal and postnatal care, and child health. A correlation was noted between the facilities available in each community (e.g. water supply) and the state of that community's health. Although family planning could not be promoted because of the government's pronatalist policy, birth spacing and breastfeeding were advocated. Project activities in the village of Santa Familia provide an example of community participation in health programs. A local lay midwife was given a traditional birth attenders course and trained to lead health education courses in the village. A community health council was established to initiate 3 projects: preschool nursery, cleaning up of the village, and latrine construction. As part of a campaign against hookworm, schoolchildren are required to wear shoes. The goal of these projects was to ensure that the villages would continue to take an interest in personal and community welfare after the departure of the health workers.     

Using Positive Deviance to Understand the Uptake of Optimal Infant and Young Child Feeding Practices by Mothers in an Urban Slum of Mumbai

Objectives Positive deviance research seeks out well-nourished children living in disadvantaged contexts to understand local growth-promoting behaviors. This study explored the factors that influence the uptake of infant and young child feeding behaviors among mothers. Methods Children with a height-for-age z-score (HAZ) > 0 (n = 10) or a HAZ < ?2.0 (n = 12) were purposefully selected from households enrolled in a community management of acute malnutrition (CMAM) program in an urban slum of Mumbai, India. Qualitative methods were employed by means of semi-structured key informant interviews with positive and non-positive deviant mothers. Eligibility was restricted to households with limited resources and more than one child. A 24-h dietary recall and anthropometric measurements were taken for the index child. An observation checklist assessed household hygiene. Data analysis was based on the Grounded Theory of qualitative research. Results Positive deviant mothers (those with children with a HAZ > 0) largely exhibited optimal infant and young child feeding practices explained by maternal information seeking behaviors; mothers acknowledging the importance of maternal health; and social support. The relationship between mother and health worker seemed to influence how well they listened to the health workers’ recommendations. Across all households, the daily consumption of high-energy, processed foods was apparent. Conclusions Practical considerations include exploring how to tailor CMAM programs to include social support and counseling training for health workers to engage more closely with mothers; exploring the feasibility of a women’s social group for mothers to share information on child rearing; and teaching mothers about healthy eating and the link between nutrition and health.