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.     

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%).     

Defining the Role of the Community Health Worker within a Federal Healthy Start Care Coordination Team

Introduction Federal and state policies often require utilization of evidence-based home visiting programs. Measurement of specified interventions is important for tracking program implementation and achieving program outcomes. Thus, the Strong Beginnings program worked to define community health worker (CHW) interventions, a core service of the program to improve maternal and child health. Methods A workgroup consisting of CHWs, supervisors and other program staff was created in order to develop and define specific CHW interventions within a nurse or social worker care team. Basic interventions were first compared to the nurse or social worker care coordinator home visiting interventions by risk topic. The evaluator then grouped each CHW intervention into categories per risk domain using thematic analysis and assigned a CHW core function or role based on literature review findings. The workgroup confirmed the results. The workgroup then continued discussions to further enhance CHW interventions per risk domain once the general structure was created. Results The workgroup identified seven core functions and 28 maternal and child health risk topics to be addressed by the CHW. The process resulted in a detailed document of program interventions that the CHWs use to guide care. Conclusions The process helped CHWs feel more valued with their role in team care. The specified interventions will help others understand the CHW role within the care team, ensure consistent interventions are delivered across program partners, provide a foundation to better understand how specific CHW contributions are related to health outcomes, and support program sustainability.     

Expanding immunization coverage in rural India: A review of evidence for the role of community health workers

Poor routine immunization coverage in India has led to a large burden of vaccine-preventable diseases borne by children under 5 years of age. Despite efforts to strengthen infrastructure and service delivery in the past decade, immunization coverage rates have reached a plateau. To meet the formidable needs of India's growing population and address the shortcomings of health services for rural populations, the country is now turning toward a new national community health worker (CHW) plan. This article reviews the effectiveness of CHWs in expanding immunization coverage in developing countries and examines the potential contribution of CHWs toward strengthening immunization services in rural India. While the limited number and quality of available studies make it difficult to directly compare CHW interventions to other strategies for improving immunization coverage, it is clear that CHWs make diverse contributions toward strengthening immunization programs. Incorporation of evidence-based strategies for CHW selection, retention, and training is critical for success of India's immunization program. In addition, there is growing need to develop efficient mechanisms for monitoring children's vaccination status to generate actionable feedback and identify cost-effective strategies.     

北京市郊区农村基层医疗卫生服务能力现状及问题分析

目的分析北京市郊区村巡诊和村卫生室建设现状,为完善农村基层医疗卫生服务体系建设提供参考。方法对北京市郊7个区中119个行政村进行实地观察,并对652名相关研究对象进行半结构化访谈,包括对巡诊和卫生室的满意度、基层医疗机构的服务质量等。结果村巡诊服务效率不高,不能满足居民实际医疗服务需求;村卫生室医疗人员短缺,基本药物配备不全,报销途径不畅通,村民就医行为更倾向于选择乡镇卫生院和县医院。结论为更好落实卫生领域重要民生项目,切实提升农村居民就医体验,应进一步落实和丰富村巡诊内容,加强基层全科医生培养力度,提升卫生费用投资的针对性和有效性,把村卫生健康服务情况纳入村干部工作考核指标,优化基本药物目录,扩大新农合定点报销覆盖范围等。     

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.     

A successful, preventive-oriented village health worker program in Hebron, the West Bank, 1985-1996.

Village health rooms (VHRs) were established in villages with no on-site health facilities in the Hebron District of the West Bank, beginning in 1985. By 1991, the program served a total population of 40,000 in 49 VHRs and by the end of 1996 covered 69 villages in Hebron and 20 in other districts that were previously served by visiting vaccination teams and nearby clinics. The VHRs provide close contact with the population of mothers for well child and pregnancy care, health education and provide visiting doctor/nurse teams for backup services and supervision. Data on coverage, utilization, costs, and outcome measures are presented. The program is accepted and grows despite adverse social and political conditions.     

Barriers to universal child immunization in rural Senegal 5 years after the accelerated Expanded Programme on Immunization.

Although the Expanded Programme on Immunization (EPI) has been a worldwide success, weak points remain, particularly in Africa. In Senegal, for example, immunization coverage was low in 1990 (60%), in part because of poor results in rural areas. In order to identify obstacles to EPI in such areas, we carried out an immunization survey in Bandafassi, a rural area of Senegal, where 6078 inhabitants lived in 23 small villages. Only 41% of children aged 1-10 years were completely vaccinated in February 1992, with considerable variations in coverage from one village to another, according to their geographical location: 71% of children were completely vaccinated in villages less than 10 km from the health centre, whereas in remote villages only 10% of children had been completely vaccinated. There was no variation according to ethnic group. From 1987 to 1992, the gap in immunization coverage between the remote villages and those located close to the health centre has steadily increased. There is a need to improve the performance of the mobile teams in the remote villages and to increase awareness about the importance of immunization.     

Community health care and hospital attendance: a case study in rural Ghana

This study assesses the influence of coverage with a network of PHC clinics as well as private clinics in Dormaa District, Ghana on, hospital attendance. This influence is measured by analysing hospital attendance among inhabitants during 6 months in 1984 and 1986. Several conditioning factors are analysed: the type of modern health care present in the community and the experience of the community health worker (CHW); the distance between community and hospital; the time factor (1984 and 1986); the sex and age of the attendants; the diagnosis made at the hospital. It appears that fewer people attend the hospital if a community participates in the PHC programme and if the CHW is experienced. When people from these communities attend the hospital they do so less unnecessarily than those from other communities. Simple analysis of routine hospital data may contribute to any PHC assessment programme set up around the hospital.     

社区流动儿童计划免疫服务干预模式效果评估

目的探讨“村公共卫生服务员管理”模式对社区流动儿童计划免疫服务综合干预的效果。方法随机抽取本社区6个村中暂住时间〉3个月的1～6周岁流动儿童为干预对象。选择葑村、红光等4个村的流动儿童作为试验组，实施“村公共卫生服务员管理”计划免疫服务模式干预2年，另选五星、三星村作为对照组。结果于2005（干预前）、2006（干预1年）和2007年（干预2年）在试验组分别调查流动儿童212、230和248名，调查对象在3个年份间的预防接种建证率差异有统计学意义（P〈0．05），五苗接种率差异也有统计学意义（P〈0．01）。结论建立“村公共卫生服务员管理”模式，有助于提高社区流动儿童免疫建证及接种率。     

The immunization programme in Bangladesh: impressive gains in coverage, but gaps remain.

The paper reviews the achievements in tetanus immunization coverage and child immunization in Bangladesh. It uses data from the 1993-94 Bangladesh Demographic and Health Survey to identify and examine the programmatic and non-programmatic factors that influence the coverage of tetanus (TT) immunization during pregnancy, and full immunization among children 12-23 months old in rural Bangladesh. The purpose of this analysis is to identify the areas that need further programme attention. The logistic regression results show that the coverage of TT immunization was significantly associated with proximity to outreach clinics and the presence of a health worker in the community. Home visits by health/family planning fieldworkers and the proximity to outreach clinics had larger influences on TT coverage of poorer households compared to those better-off. The effect of distance to static clinics varied by regions. Among children, full immunization coverage (coverage of all of BCG, DPT1, DPT2, DPT3, Polio1 Polio2, Polio3) was significantly associated with distance to outreach clinics, the greater the distance to the clinics, the less the likelihood of immunization.     

Understanding the success of promotoras in increasing chronic diseases screening

The purpose of this qualitative study was to elicit information on why a promotora (or, community health worker (CHW)) increased adherence to chronic disease screening among women along the U.S.-Mexico border. After completion of the intervention, women and clinic staff who participated in the promotora phase of a randomized, controlled study answered structured, open-ended questionnaires. Clinicians from two non-participating clinics were also interviewed. Content analysis found that the promotora's roles included health education and the facilitation of routine and follow-up care. Clients appreciated the promotora's socio-cultural characteristics, as well as her personal skills and qualities, and described her as a trained, natural helper whose personalized support removed barriers to health care and helped women to take care of themselves. Most clinicians recommended working with a CHW to increase adherence to chronic disease prevention practices. A CHW can play a crucial role on a health care team and interventions should tap into this resource.     

河南省艾滋病定点救治村卫生室及服务提供能力现状调查

目的:了解艾滋病定点救治村卫生室及其服务提供能力。方法:对河南省4个县的33所艾滋病定点救治村卫生室及其工作人员进行问卷调查。结果 :被调查地区艾滋病重点村卫生室平均拥有防治人员4.73人,中专及以上学历者占92.95%,高于全国平均水平;村卫生室艾滋病健康教育、预防、治疗、咨询和护理工作开展率为100%,艾滋病防治知识宣传覆盖率为88.04%。结论 :艾滋病重点村卫生室要加强基础医疗设备标准化配置,适当放宽政策,推动乡村医生执业化进程,改进培训形式和内容,改善村级艾滋病防治人员待遇,最大程度发挥艾滋病定点村卫生室的防治能力。     

农村地区建立传染病症状监测系统的可行性——以江西省2县为例

目的：从村卫生室服务能力入手,探索在农村地区建立传染病症状监测系统的可行性。方法：通过问卷调查和小组访谈分析江西省2个县15个乡镇155家村卫生室的资源配置以及253名村医开展传染病症状监测的能力,以及相应的期望和建议。结果：“一村一所”管理模式下的村卫生室门诊量大,病人集中,更适合症状监测的开展;网络直报是症状监测数据报告的首选方式,但有12．5％的村卫生室负责人不会使用电脑;村医接触最多的五种传染性疾病是上感、其他感染性腹泻、流行性腮腺炎、水痘和痢疾,分别有84．6％和71．5％的村医能够通过临床症状诊断流行性腮腺炎和水痘;75．9％的村医发现传染病人后会立即报告乡镇卫生院,77．1％的村医参与过传染病的调查核实。结论：依托村卫生室构建传染病症状监测系统具有可行性,但需完善村卫生室管理模式,提高卫生服务可及性;明确目标监测疾病,促进资源的有效利用;充分利用信息网络技术,搭建症状监测报告平台;大力推进乡村一体化管理,完善监测信号响应机制。     

Preventing Waterborne Diseases: Analysis of a Community Health Worker Program in Rural Tamil Nadu, India

Community health worker (CHW) programs have become popular tools in reducing the burden of childhood illnesses. However, the efficacy of CHWs in facilitating behavior change, as a means of preventing waterborne diseases, remains unclear. Using a household survey (n = 225),in rural Tamil Nadu, South India, we assessed the effects of a CHW program on knowledge, attitudes and practices related to diarrheal illness through comparison with a control population that was not enrolled in the program. The CHW program in the experimental village entailed behavior change aimed at preventing diarrheal illness through home visits, community events and health education. Correlates of four key variables on knowledge of drinking water contamination and behavior change were examined by using logistic regression models. We found that while the program was effective in raising awareness of drinking water contamination, it did not significantly increase hygiene and water sanitation practices in the village community in comparison to the control population. Furthermore, villagers enrolled in the CHW program were unable to recognize the connections between contaminated drinking water and disease. The results of our survey indicated the CHW program did not significantly affect behavior in the experimental village. Possible shortcomings in the program are discussed.     

Health programme effects upon acceptance of immunisation in northeast Thailand

As every year 5 million children die in developing countries because of infectious diseases, the government of Thailand in 1976 initiated an expanded program for immunization. Although vaccine coverage of the under 1 year of age population with BCG, diphtheria, pertussis, and tetanus is over 80%, the dropout rates are high and over 40% are without complete immunization. The availability and accessibility of immunization and the efficacy of health care delivery is analyzed. Group sessions were carried out with mothers of children under 4, with village health communications (VHCs) and village health volunteers (VHVs). 2 provinces with the highest immunization coverage and 2 with the lowest were selected. 608 women from 16 villages provided the sample as well as a total of 128 VHVs and VHCs. Distance to health center showed a significant relationship with completion of immunization (in contrast to travel time). The rate of complete immunization was higher for those who received regular information from VHVs and VHCs and who themselves contacted this personal than for those who never contacted the VHVs and VHCs. The most important factor of completion of immunization was the VHV/VHC contact. High immunization areas were highly correlated with high level of VHV/VHC knowledge about infectious diseases. The frequency of VHV/VHC reporting to subdistrict health officers also increased immunization coverage. Household visits were utilized by 54.6% of VHVs and VHCs in high immunization areas and by 15/7% only in low average areas. In high coverage areas, 13% of them were not instructed about dissemination of information as compared with 27.4% of them in low immunization areas. The 2nd phase of the study will consist of the measurement of intervention impact on immunization acceptance.     

Using community health workers for malaria control: experience in Zaire.

The potential for using community health workers (CHW) for administering timely and effective treatment for presumptive malaria attacks was evaluated in the Katana health zone in Zaire. In each of the 12 villages of an intervention area (area A) with 13000 inhabitants, a CHW was trained in the use of a simple fever management algorithm. The CHWs performed their services under the supervision of the nurse in charge of the area''s health centre (HC). Malaria morbidity and mortality trends were monitored during 2 years in area A and in an ecologically comparable control area (area B), where malaria treatment continued to be available at the HC only. Health care behaviour changed dramatically in the intervention area, and by the end of the observation period 65% of malaria episodes were treated at the community level. Malaria morbidity declined 50% in area A but remained stable in the control area. Parasitological indices showed similar trends. Malaria-specific mortality rates remained, however, at essentially the same levels in both areas. The non-comprehensiveness of the CHWs'' care and their ambiguous position in the health care system created problems that compromise the sustainability of the intervention.     

嘉兴市儿童常规免疫接种率调查及接种门诊管理质量分析

目的了解嘉兴市儿童计划免疫现状,接种率及影响管理质量有关因素。方法通过接种门诊金苗系统数据和现场儿童调查进行统计分析。结果嘉兴市满2周岁儿童五苗基础全程接种率为98.98%。满7周岁儿童加强免疫接种率除A+C流脑2外(本地儿童95.28%,流动儿童74.25%),其余均在97%以上;现场调查儿童建证率99.84%;在册建卡率97.58%;全市有79家接种门诊信息经电话核实为可信,7家不可信;接种门诊管理临时儿童质量较好的有61家(占70.93%),中等有15家(占17.44%),管理差的有10家(占11.63%)。结论通过优化免疫预防服务,健康宣传新模式,适宜本地流动儿童管理机制等综合措施,有效提高我市儿童接种率和接种门诊管理水平,促进现代化预防接种门诊建设的可持续发展。     

Measles outbreak in a northern Pakistani village: epidemiology and vaccine effectiveness

In the spring of 1990, local community health workers reported a measles outbreak in several partially vaccinated villages in the Punial Valley in northern Pakistan. The authors conducted an investigation in one of these villages to assess vaccine coverage and vaccine efficacy and to describe the patterns of measles outbreaks that prevailed in this community. The results of a survey of the entire village revealed two major gaps in vaccine coverage: the small minority Sunni community and children over 3 years of age. Vaccine efficacy was estimated to range from 73 to 90% but was markedly reduced in children who were vaccinated under 12 months of age. The occurrence of an outbreak in a community in which a relatively new vaccination program is primarily directed at younger children has been predicted by theoretical models of measles dynamics and is consistent with the experience of other vaccination programs in the developing world. These observations suggest that, in some areas of the developing world, the age groups targeted to receive measles vaccinations may need to be broadened to ensure adequate coverage to prevent recurrent outbreaks.     

Health department clinics as pediatric immunization providers: a national survey

OBJECTIVE: To describe a national sample of health department immunization clinics in terms of populations served, patient volume trends, services offered, and immunization practices. METHODS: Telephone survey conducted with health departments sampled from a national database, using probability proportional to population size. RESULTS: All (100%) 166 sampled and eligible clinics completed the survey. The majority of pediatric patients were uninsured (42%) or enrolled in Medicaid (34%). Most children (69%) and adolescents (70%) were referred to the health department, with only 12% using these clinics as a medical home. A number of clinics (72%) reported recent increases in adolescents served. Less than 25% of clinics offered comprehensive care, 47% conducted semiannual coverage assessments, and 76% and 38% operated recall systems for children and adolescents. Storage of records in an electronic database was common (83%). CONCLUSIONS: Although the majority of these clinics do not provide comprehensive care, they continue to serve vulnerable children, including adolescents, Medicaid enrollees, and the uninsured, and may represent the main contact with the healthcare system for such patients. Because assuring the immunization of these children is essential to their health and the health of our nation as a whole, this immunization safety net must be preserved. Experience implementing key recommendations such as coverage assessment and feedback as well as reminder or recall may enable health department staff to assist private provider colleagues. Further research is needed to investigate how patient populations, services offered, and immunization practices vary by different clinic characteristics.