|Community-Based Longitudinal Nutrition and Health Studies : Classical Examples from Guatemala, Haiti and Mexico (International Nutrition Foundation for Developing Countries - INFDC, 1995, 184 pages)|
|5. A prospective study of community health and nutrition in rural Haiti from 1968 to 1993|
Nongovernmental organizations (NGOs) play a key role in the development of community-oriented primary health care (COPHC), and now provide more than half of all primary health care services in Haiti (Augustin, 1993). One of these, the Hôpital Albert Schweitzer (HAS) Community Health Department, has a population-based, community-oriented health project in rural Haiti which has produced relevant country-specific research since 1968. It has contributed to the fund of knowledge about COHPC, community epidemiology, and research. In an article entitled "Surveillance for equity in primary health care: policy implications from international experience," Taylor (1992) cites the HAS study for its documentation of reduction of early childhood mortality to one-quarter of its earlier levels in less than five years, due first of all to a reduction in tetanus of the newborn, and also to a village-level health and nutrition surveillance program which impacted on malnutrition, diarrhea, and tuberculosis.
Although the project cost less than $ 1.60 per capita per year in the early 1970s (W Berggren et al., 1981; Taylor, 1992), it was thought not to be replicable under the conditions in most Haitian government rural health services. This idea was disproven in a special study of the project by the Ministry of Health and Population of Haiti, the Division d'Hygiene Familiale, the Projet Intégré de Santé et de Population (PISP) under Dr. Ary Bordes (Clerisme, 1979; PISP, 1982; Paisible and Berggren, 1984).
Recent findings from a follow-up study of the original census tract and two others within the HAS catchment area, published here for the first time, reveal that the reduction has been maintained despite worsening economic conditions in Haiti. This chapter reviews key results from the HAS study as well as some similar findings from three other prospective longitudinal studies in rural Haiti, each benefiting from lessons learned in the HAS study. They include the PISP project (see above), the Save the Children/USA project in Maissade (SCF/Maissade), and the Projet Veye Santé (PVS) in the Cange area, supported by Zanmi Lasante, Port-au-Prince, Haiti, and Partners in Health, Cambridge, MA, USA.
In all projects, defined communities were mapped, followed by community participation in house numbering and family registration. Rosters of children under five and of women in the reproductive age group derived from the family registers enabled workers to keep track of children and mothers needing immunizations, family planning, vitamin A distribution, and other services, such as education in the prevention of sexually transmitted diseases, including AIDS. Home-based, hand-held records such as immunization cards and the "Road-to-Health Weight-Age" chart for children under five were distributed, carried, and rarely lost by Haitian mothers trained in their use and interpretation.
Elements of the first project, ongoing since 1967 in villages served by HAS near Deschapelles, now reach the entire catchment area of 180,000 people. Although longitudinal reporting was gradually dropped after the first five years of the project at HAS, a 25-year follow-up study carried out in 1992 showed that the reduction in childhood mortality rates in the original census tract had held despite worsening economic conditions. The 1992 study at HAS, using World Fertility Survey techniques, studied two other census tracts for comparison purposes: one in the mountains around Bastien, and one known as Plassac, separated from HAS by an often impassable river. In the latter, local volunteer women's health workers (animatrices) serve as liaisons to villages. Significant trends in the reduction of childhood mortality rates were documented in all three census tracts, with rates in villages nearest HAS being lowest. Little reduction in fertility rates was noted, despite ready access to family planning services.
In the initial studies, itinerant Centres de Rehabilitation et Education Nutritionelle (CERNS) were shown not only to prevent deaths but to be cost-effective in rehabilitating malnourished children and reducing hospital admissions for kwashiorkor and marasmus (WL Berggren, 1971). The Haitian government's PISP team modified the CERNS to reach mothers with a two-week, village-level workshop (Foyer de Demonstration en Nutrition) with lower cost and good results in training mothers so that they not only rehabilitated their own malnourished children with locally available foods but prevented malnutrition and death in younger siblings (G Berggren et al., 1984).
Such methods and lessons learned from the HAS project and the Haitian government's PISP project have now been applied in at least two other projects, reaching defined populations of more than 40,000 each, and in a current project at HAS. The SCF and PVC projects are now performing longitudinal "small area studies" as they work out least-cost methods of primary health care delivery and document impact. Their defined populations were initially registered, often as part of a baseline survey, and then followed with vital event reporting as community health activities were instituted. The PISP project, however, was the only one to study a "comparison area" at midpoint as well as carrying on an annual census to double-check on vital events. A map with census data is shown in Figure 1.
The prospective longitudinal community-based studies described in this chapter serves to:
a. show how community-oriented primary health care (COPHC), when carried out in defined populations served by locally recruited, trained, and supervised resident home health visitors, has a measurable impact on poor Haitian communities;
b. review the determinants and consequences of high fertility, mortality, and morbidity rates in rural Haiti as revealed by these studies;
c. present lessons learned from these studies in developing practical methods to combat infectious disease and malnutrition in rural Haiti.