Contributing Factors for Objectives Not Fully Achieved. There has been improvement in the nutrition indicators as compared to the baseline, except in the case of families who have food in the house after marketing on Saturday. The percentage of families that had no food on Saturday afternoon increased from 8% to 14%, indicating that in spite of the CS Project interventions, the situation of poverty and food insecurity has increased in the municipality of Matalgapa. Many of the coffee growing municipalities have been hard hit by the drop in international coffee prices— from $US 75 per 100 pound bag to $35 in the year 2000. Princes have not improved during the last two years, causing many rural families to move to the larger towns and seek work in the informal sector or as day laborers. Following are some areas that could be improved regarding the food security component, that were discussed during the Final Evaluation analysis workshop. ❑ Agriculture Promoters did not have enough educational materials regarding poultry production, pest management, and technical aspects of fruit and vegetable production. ❑ There was a lack of technical assistance for pest management. ❑ Mothers mentioned becoming discouraged with home food and poultry activities after having all their produce or chickens stolen by xxxxx neighborhood thieves. ❑ Families did not receive support to make chicken coops, which may have prevented theft in some cases. ❑ Some of the families thought that seeds, plants and poultry were free of charge and therefore did not manage revolving funds. ❑ Limited access to water resulted in a lack of sufficient irrigation for home gardens. ❑ A diagnosis was not done to determine which families and which areas would have the most success with food security interventions. ❑ New emergency projects enter the communities and start giving things for free, and this erodes the empowerment focus developed during the past 4 years by the CS Project.
Contributing Factors for Objectives Not Fully Achieved. One of the factors that has influenced early discontinuance of breastfeeding is Nicaraguan health insurance that provides formula to men whose wives have recently given birth. There is a large water system project in Matagalpa and several factories in the area that employ men. Each family is entitled to several cans of formula for newborns. In addition to the availability of baby formula, poor women in Nicaragua tend to copy the practices of upper and middle classes in regard to bottle-feeding, as mentioned in the DIP. Local beliefs may also be a factor in limited breastfeeding. In Matagalpa many women have superstitions regarding breastfeeding, entertaining the belief that if the mother is upset or has been in the sun too much, her milk is no longer suitable for the baby.
Contributing Factors for Objectives Not Fully Achieved. MOH posts are often out of essential medicines, a key factor in treatment of pneumonia. The CS Project initially planned to promote Community Medicine Chests (CMCs), however the strategy was thwarted by the MOH. In spite of this, four CMCs were established in coordination with a local organization (PROSALUD). CARE provided start-up funds for the CMCs and PROSALUD provided the training, certification and monitoring of CMC management.
Contributing Factors for Objectives Not Fully Achieved. The community census methodology is up and running in all the communities in Carabuco and Ancoraimes. In Ambana, 69% of communities have been censused, while in Puerto Xxxxxx only 16% have been censused to date. The lack of census data makes it more difficult to track individual children. Although the cold chain is well equipped in Puerto Xxxxxx, there are health facilities in Carabuco, Ambana and Ancoraimes without refrigerators. In such cases, vaccines cannot be provided to children or women who visit the health post. The factor analysis approach for tailoring educational messages was not implemented during the project. Although use of “cartillas” is a good strategy for individual or small group education, materials are not available for new staff, especially volunteers. The formation of groups to learn about CS interventions has been successful in some areas, however in Ambana only 2 groups were formed during the life of the project, hence limiting educational opportunities. Quality control using checklists has not been fully implemented. There is great resistance to tetanus toxoid vaccination. Some women complain of swelling and pain in the arm, and others believe that the vaccine will cause sterilization. There is a general mistrust of modern medicine on behalf of the Aymara population. Another factor for low reporting of coverage rates may be attributed to poor previous record keeping. Some women claim to have already had 4-5 vaccinations and therefore refuse additional immunization.
Contributing Factors for Objectives Not Fully Achieved. The three objectives for the CDD intervention were not met, and though there was progress in knowledge of ORT and administration of more liquids during diarrhea episodes, only 12% of mothers could recognize at least one danger sign of dehydration. The IMCI approach, which emphasizes 16 key family practices, including care-seeking, should be a priority for integrated behavior change strategies at the community level. “Caretakers need to recognize a sick infant or child and need to know when to take the infant or child to a health worker or health facility”.4 A key constraint to the success of all project interventions, including CDD, is the difficulty in developing strong linkages between health facilities and communities. Some limitations include: mistrust of modern medicine, a low priority given to health by community members, a reluctance to pay for health care and to spend time seeking care, and the low value placed on the life of a 4 See “Community IMCI: Reaching Communities for Child Health and Nutrition”, CORE, BASICS, USAID, CSTS, April 2001. child under the age of one year. Time used in care-seeking takes women away from tasks that are viewed as essential for survival (i.e. grazing animals, planting, harvesting, etc.). In addition, most health centers are distant from rural villages and require effort and time to reach. Some MOH health staff, many of who are doing their obligatory rural service, or have been hired as directors of Area Health Centers do not speak the native language and unintentionally “mistreat” patients due to a lack of cultural sensitivity. With the new-shared management model, not all staff is selected by CSRA, and a few of the MOH employees have an ingrained prejudice towards the indigenous people. An additional constraint is a poor understanding of the seriousness of diarrhea, a condition that project area families consider to be “normal” among infants and young children.
Contributing Factors for Objectives Not Fully Achieved. Although the results of the KPC for recognition of danger signs and care seeking exceed baseline levels (46% and 53% respectively), there is still a large proportion of mothers who have no knowledge regarding home practices and timely treatment of pneumonia in young children. Although child death due to pneumonia dropped from 13 cases to 6 between 1998 and 2001, pneumonia continues to be the leading cause of death in the Bolivian Altiplano. Contributing factors include the cultural barriers mentioned in the discussion of CDD above, and the difficulties regarding transport and access. An infant with pneumonia may easily die if not treated with antibiotics promptly, and by the time a mother realizes the child needs treatment, there may be no means of transport from isolated communities. Although the CS Project has established a procedure for transportation by motorcycle or ambulance for emergencies, geographic factors (such as a lack of access roads in certain areas) and communication difficulties continue to be barriers to prompt care. Not all health centers have a sufficient number of motorcycles and ambulances, and some of the health posts do not have access to radio communication. Regarding quality in pneumonia case management (PCM), the checklists originally planned in the DIP were only partially implemented. The Pneumonia ToolBox mentioned in the DIP was not used. Quality in PCM has been addressed through the IMCI approach, which has been implemented during the past two years as part of the MOH strategy.
Contributing Factors for Objectives Not Fully Achieved. Immediate causes of malnutrition include inadequate food intake coupled with a high prevalence of infectious diseases, particularly diarrheal disease and respiratory infections, with two-week prevalence rates of 43% and 48% respectively (KPC 2001). Contributing causes include: insufficient food; inadequate food distribution practices within the home; a lack of time to prepare frequent meals for children; poor access to health services; lack of potable water and sanitation; insufficient education and information; and inadequate breastfeeding and complementary feeding practices. Due to socio-economic factors, changes in nutritional status may require long-term integrated development with coordinated efforts among municipal governments, health, education, the agriculture sector, and the NGO community. Constraints to meeting the objectives for micronutrients are lack of supplies, late detection of pregnant women, and limited orientation to mothers regarding the importance of the supplements. Often incomplete records are kept, making it difficult to assess coverage and to implement adequate follow-up for second doses. Health personnel require capacity building in technical aspects of nutrition, including psychomotor development, and in the implementation of behavior change strategies. Such behavior change strategies should insure that mothers understand the meaning of children’s nutritional status, that mothers recognize their nutritional risks during pregnancy, and that they are motivated to take the required actions. Another area that needs improvement is follow-up of children who are not gaining weight, based on verification of child growth cards. In particular, CSRA supervisors need to insure that registers in the community correspond to those at health centers. The child health cards, which include both immunization and growth information, are kept in duplicate at both the home and the health center or post. If the results of growth monitoring or vaccinations are recorded during the home visit, but not on the duplicate cards at the health center, health personnel has difficulty programming home visits for timely follow-up. The DIP indicated that more female health personnel would be hired to better interface with mothers, however this was achieved to a very limited extent. Most of the ANs and health volunteers are men. Although the Hearth methodology was included as a project strategy in the DIP, it was not implemented. Project staff indicated that the tim...
Contributing Factors for Objectives Not Fully Achieved. Cultural barriers between the Aymara people and health personnel are a constraint to adoption of behavior change in reproductive health practices. In order to improve inter-cultural relationships and to bridge the gap between the indigenous population and modern medical practitioners, CSRA sponsored an ethnographic study to determine how to better reach Aymara women and men with reproductive health interventions. The local population generally is wary of strangers and often feels mistreated at health centers and hospitals. When an obstetric emergency occurs there is usually a long process of decision-making that includes the mother and/or mother-in-law, the traditional healer and the husband. If the case is not resolved, the patient may seek care at a health center as a last resort. The decision to seek modern medical treatment may be too late, and if a mother dies at a health facility the gap between traditional and modern medicine widens. As CSRA/MOH facilities implement new ways of service provision taking into account cultural differences, the use of modern medical services is increasing.
Contributing Factors for Objectives Not Fully Achieved. During the final evaluation interviews some health posts and centers mentioned stock-outs of contraceptives. Since contraceptive distribution is done by the MOH, CSRA has limited capacity to influence this situation. An emergency stock was obtained by CSRA, but this was not sufficient to provide supplies on an on-going basis. A lack of Depo Provera, the most popular method, has resulted in unplanned pregnancies among women in the project area. Several individuals who were trained in contraceptive technology are no longer working with the CS Project, therefore know-how regarding supply management has not been passed on to other staff. There was a lack of educational materials for group education activities on family planning. Quality checklists also have not been fully implemented.
