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Success in reducing childhood mortality will not be achieved solely through the availability of health services with well-trained personnel. Success also depends on what families provide - adequate nutrition and care, appropriate responses to illness, including seeking medical care when children need it, and the correct implementation of prescribed treatment. Expanding on experiences in ARI and CDD programmes, CHD is increasing its efforts to strengthen the ability of families and their communities to raise healthy children.
Improving family practices through the sick child visit
Face-to-face communication between health workers and caretakers who bring a sick child to a health facility provides an important opportunity for promoting child health in the home. Home care advice is an integral part of case management and during sick child visits, health workers instruct mothers on how to give home treatments. During such visits health workers also assess feeding practices, including breastfeeding and giving complementary foods, and help mothers solve feeding problems. An evaluation of nutritional counselling is being conducted to identify how to improve this important component of the sick child visit. Health workers also provide advice about signs to enable caretakers to recognize when they need to bring the sick child back. To ensure that caretakers can remember instructions, health workers select the most important messages, verify the caretaker's understanding of what they should do by asking checking questions and observing as the caretaker demonstrates how to give prescribed treatments.
Communication skills are, therefore, emphasized throughout the IMCI course for first-level health workers. Using local terms and phrases that are common in the community increases the ability of health workers to communicate effectively with caretakers. Using a locally adapted counselling card also facilitates communication. The Adaptation Guide for IMCI training materials provides instructions on how to make the counselling card more appropriate to the communities in which IMCI is implemented. In particular it suggests how to identify local terms to communicate important signs of illness, especially those used to advise mothers on when to seek care, and how to identify feeding recommendations that are culturally acceptable in the community, as well as nutritionally adequate. In some countries mothers will be able to take the cards home to remind them about these important messages.
Improving breastfeeding practices through early interventions with mothers
Good nutrition is critical for healthy growth and reducing mortality from disease. IMCI recommendations support good nutrition through the promotion of exclusive breastfeeding initiated immediately after birth and extending for four to six months. Mothers are encouraged to continue breastfeeding as the infant matures, while adding nutritionally appropriate complementary foods.
In addition to the IMCI training course for first-level health workers, CHD has developed the Breastfeeding Counselling: A Training Course for maternity staff and other health workers. The course trains health workers to assist mothers in initiating breastfeeding and improving their skills in feeding the child. It stresses the importance of support groups as a means of providing ongoing help to breastfeeding mothers in the community. Health workers also learn how to help mothers be more responsive in general to the needs of their new infants and develop the skills to provide better care through the early years of the child's growth and development. An evaluation of the course has demonstrated its ability to achieve lasting improvements in the knowledge and practices of breastfeeding counsellors.
Other methods of improving family practices
IMCI includes other interventions to help families provide better care. During the planning process, family needs and resources are considered in the development of guidelines. For example, availability and cost are reviewed when selecting drugs, in addition to their effectiveness in treating illness. Where it is possible to choose and provide paediatric formulations, it is easier for families to give correct doses.
In planning and implementing IMCI, communication materials (e.g. radio messages and written materials) in current use need to be reviewed to ensure that they are consistent with the messages delivered through the sick child visit. As new messages are developed, they can be strengthened by using information available from IMCI activities, including local feeding recommendations and the terms understood by mothers. Existing CDD and ARI tools for collecting information and designing communication interventions can be used in IMCI activities when countries have identified a need for specific actions with respect to household management of diarrhoeal diseases or acute respiratory infections.
Helping countries to develop community interventions
Expanding the implementation of IMCI will mean working with the communities, as well as through the health facilities, to reach more families. Many children who need care are not brought to a health facility and the caretakers of those who are may only have brief contact with the health worker. New channels for promoting child health, therefore, are required.
To assist countries to expand IMCI activities beyond health facilities,
CHD is developing a guide, Selecting and Designing Interventions to Improve
Family Practices, which describes a systematic process for choosing effective
interventions and implementing them at community level.
This practical guide indicates how countries can organise local information from a variety of sources and use this information to identify current family practices related to a range of potential health risks and the factors that influence them. It then shows how this information can be used to select and design specific interventions. Facilitated by a trained person, the guide can be used by members of a planning team with diverse experiences, in implementing health programmes (e.g. programme managers, health workers, and communication specialists), in conducting research (e.g. nutritionists and social scientists), and in working in communities (e.g. from NGOs and schools). The guide will also direct the planning team to the use of technical manuals that provide assistance with planning, testing, carrying out and evaluating the specific interventions selected by the team. To produce messages and use mass communication channels for example, planning teams can use the WHO/UNICEF/USAID Radio Guide. Technical manuals will be gathered from a variety of sources and will cover a range of activities, for example, provision of health education, counselling family members, and improving the design of products, packaging, and communication materials. CHD will also work on the development of new manuals for interventions for which there are no existing materials, and it is anticipated that a technical manual will be produced based on the results of a current project on careseeking (see below).
Improving specific family practices
Work began in 1996 to examine the rationale and feasibility of initiating intervention research aimed at improving careseeking for acute illness in infants and young children. As a first step in this potentially important area for household behaviour change, CHD reviewed the evidence concerning the following questions:
1. What is the nature and extent of problems in careseeking, and what is the evidence that family behaviours with respect to careseeking contribute significantly to infant and young child mortality and morbidity?
2. Is there sufficient knowledge about the determinants of careseeking to allow interventions aimed explicitly at this behaviour to be designed?
3. Is there evidence that careseeking behaviours can be changed?
The findings showed that:
1. Scientific documentation of the extent to which initial delays in careseeking affect mortality is very limited, but there is considerable evidence that families do not always make the best decisions with respect to the utilization of health care services.
2. In general, the determinants of careseeking have been well described, although there is greater knowledge about household decisions on where to seek care than about initial decisions concerning when to seek help.
3. Interventions aimed specifically at improving careseeking for sick children have not been rigorously evaluated, but changing patterns of health service utilization indicate that these behaviours can be changed.
CHD is currently undertaking a project to develop and evaluate culturally appropriate interventions to improve family care-seeking. Research on family and community practices will also continue to evaluate current activities and identify additional ways to improve home care. For example, evaluation studies in China and Viet Nam have shown that using local illness terms improves caretakers' recall and understanding of the importance of signs that the child needs medical attention. The results of a recently completed review on child growth and development will be used in the design of an approach to interventions to promote physical and psychological growth, and research on community-based nutrition interventions will strengthen IMCI nutrition counselling efforts.