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close this bookCommunity-Based Longitudinal Nutrition and Health Studies: Classical Examples from Guatemala, Haiti and Mexico (INFDC, 1995, 184 p.)
close this folder5. A prospective study of community health and nutrition in rural Haiti from 1968 to 1993
View the document(introduction...)
View the documentIntroduction
View the documentBackground on Haiti
View the documentMaterials and methods
View the documentResults
View the documentDiscussion
View the documentAcknowledgements
View the documentReferences
View the documentBibliography
View the documentNotes

(introduction...)

Gretchen Berggren,1 Henri Menager,2 Eddy Genece,3 and Calixte Clerisme3

Introduction

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 Hal 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 Inte Santt 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 SantPVS) 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.

Background on Haiti

Haiti, the western half of the island of Hispaniola, covers 27,700 km2, much of it hilly and heavily forested when first discovered. Slaves were brought from Africa as early as 1510; slave ships continued to arrive over the next two centuries, bringing agricultural labor necessary for French colonial plantations of rice, cotton, tobacco, and sugarcane. The rich forest was cut for lumber to build towns as well as for export; mahogany was exported to France by the ton (Rawson and Berggren, 1973).

A brave and independent people took over their own country from the French in 1804, and became the first Black republic. The turbulent first years were characterized by efforts at establishing some kind of economy based on various types of land grants. In the north, these were large, plantation-size holdings. In the rest of the country, the grants were made outright and varied in size according to the status of the recipient (Rawson and Berggren, 1973). Today peasant farmers have many small landholdings, growing ever smaller as they are divided among daughters and sons.

Since independence, Haiti has been besieged with a series of governments that were often dictatorships with little interest in bettering conditions for the common people, and until the election of President Aristide, little democratic process emerged. As a result of this and of degradation of the environment, Haiti's population of more than six million people suffer the worst or nearly the worst health and environmental conditions in the Western Hemisphere (UNICEF, 1993). Due to deforestation, Haiti's once rich soil washes into the sea, choking with silt the coral reefs that were home to an abundance of fish. Less than one-third of the land is arable, and it is now divided into very small farms occupied by peasants who own their land but are 70% illiterate.


FIGURE 1 Map of the DesChapelles Valley, Haiti Showing Impact Areas Described

Name and Location of Study Area

Approximate Population

HAS census tract (original)

10,000

HAS Plassac and Bastien census tracts

20,000 ea

PISP (Petit Goave area)

32,000

Comparison cluster sample area

9,000

SCF (Save the Children/Maissade)

40,000

PVS (Projet Veye Santange)

30,000

The Haitian sense of community and of family stability may still be suffering from the breakdown of institutional structures imposed by slavery. Unstable conjugal unions, child-sharing practices, serial polygamy, and a propensity for women over 35 years of age to become single-parent heads of households characterize rural Haitian families (Paisible and Berggren, 1984; Rawson and Berggren, 1973). One-fifth to one-third of women over 39 years of age can expect to live in a separated or divorced state, according to recent studies (Cayemittes and Chahnazarian, 1989).

Haiti's culture is considered neo-African by anthropologists. The "whys" and "hows" of family building hark back to the whole history of the slave trade, which broke up thousands of families initially and then continued the transfer of slaves without regard for conjugal unions.

Today Haiti does not produce enough rice or other cereals to meet its own needs. Cocoa, sugar, and coffee production have been interrupted and damaged by a trade embargo imposed by the international community in an attempt to restore the democratic process from 1991 to 1993. Planting hillside crops of corn, millet, cassava, beans, and peanuts enables rural farmers to survive on small parcels of land. In some areas, such as the Artibonite Valley, irrigated crops include rice and sugarcane. Recent breakdowns in water management have put even these crops at risk.

Health indicators for Haiti reveal a maternal mortality ratio of 345/ 100,000 live births (Theodore, 1992) and an infant mortality rate at or near 100/1,000 live births/year (Cayemittes and Chahnazarian, 1989). About 159 children/1,000 (16%) can expect to die before their fifth birthday (Cayemittes and Chahnazarian, 1989). Diarrhea is blamed for nearly one-fourth of the deaths, followed by respiratory illness; however, these are usually superimposed on malnutrition which is the underlying cause of death (Cayemittes and Chahnazarian, 1989).

Malnutrition has long been a serious problem. Jelliffe and Jelliffe (1961) found that 7% of Haitian children under five suffered nutritional edema. A national nutrition survey found half that rate in 1978 (Graitcher et al., 1980). Nevertheless, nearly one-third of children continued to suffer moderate to severe malnutrition by Waterlow standards (Graitcher et al., 1980). The average daily calorie intake according to various surveys in the 1970s was about 1,500 kcal (6,300 kJ)(G Berggren et al., 1985).

Recent studies reveal a possible worsening of the nutrition situation. In the Northwest, a famine-prone area, in communities where food was being distributed, 5% to 10% of children had arm circumference measurements consistent with severe malnutrition (CARE, 1993). On Ile la Gonave,6% of children were acutely malnourished and 24% were chronically malnourished by Waterlow classification (World Vision, 1992). HAS experience in the Artibonite Valley showed that around 20% of children suffer second-degree malnutrition, and 2% to 3% of children continue to suffer Gomez third-degree malnutrition, despite an intervention program. A USAID-funded monitoring system continues to report that third-degree malnutrition affects 3% to 4% of children in most parts of Haiti (USAID 1992, 1993).

NGOs and private voluntary organizations continue to deliver much of the primary health care services in Haiti, often in concert with poorly equipped government institutions nearby. The Haitian Government's Ministry of Health (Minist de Santt de Population) works on a slim budget, paying and equipping its staff minimally to run its hospitals and dispensaries. WHO advisors estimated that in 1992 it spent 93% of its budget on salaries in the face of the international sanctions. Although malnutrition is a number one problem, no national nutrition program exists.

Materials and methods

All projects found that rural Haitian families respond well to the use of resident home-health visitors and their volunteer assistants, who are often women. The latter have helped to report vital events and assisted their neighbors to go to neighborhood posts-de-rassemblement (assembly points or rally posts) for immunization, growth monitoring/counseling, and family planning. Outreach teams from nearby health centers provide technical support to back up village workers who help carry out a census and/or enroll families in the community health program. After door-to-door registration of families, the resident home visitors derived rosters of children under five and of women in the reproductive age group for follow-up. Vital event reporting permitted the use of indicators such as birth rates, age-specific fertility rates, and age-specific, cause-specific death rates, as well as certain morbidity indicators.

Underlying Concepts

Common to the projects reviewed here are underlying concepts; the most important is that the family is the key primary health care provider or enabler, and health workers are their trainers.
Other common concepts were:

a. Equitable distribution of preventive health services (through community registration of families or households; no one is left out);

b. Community involvement with services offered through locally recruited and trained resident home visitors (RHVs), or family workers;

c. The need for ongoing health and nutrition surveillance activities and preventive services at the community level (for example, community-based distribution of contraceptives in the PISP project; periodic deworming and vitamin A distribution in others);

d. Use of vital event reporting and reporting on nutritional status of children as a part of an emerging "management information system" (for example, data such as birth rates and age-specific, cause-specific death rates were used for community diagnosis and for decision making);

e. The need for continuing community participation in the primary health care system, with feedback to the community from the information system;

f. Use of an itinerant technical support team to assist community workers in the delivery of key preventive services, such as immunization, and growth monitoring as close to homes of villagers as possible;

g. The need for education of families and traditional birth attendants in appropriate early referral for illness or complications of childbirth.

Both HAS and the PVS/Cange programs have the advantage of an excellent curative institution nearby. The PISP project relied on an under equipped government hospital with erratic services at the time (for example, lack of 24-hour-a-day coverage for emergency illnesses or conditions). Reliable services for early referral of ill persons emerged as a key concept for the more successful of the projects.

Strategy

Paid full-time or part-time community health workers or RHVs, often called Agents de SantI> in Haiti, acted as family educators and as reporters, assisted by local volunteer community health assistants and/or women's groups or their supervisors. These workers were recruited, trained, and supervised locally by technical support teams of health professionals at nearby institutions.

Through their home visits and work with community leaders, the RHVs were able to implement community-based health rallies where preventive activities could occur. Attendance at the monthly or bimonthly community-based sessions was enhanced by offering services near the homes of mothers, who rarely will walk more than one hour for preventive services (Alvarez et al., 1993). Other enhancements included the addition of simple first aid or beginning curative care for ill children, the provision of free worm medicine, and the availability of vitamin A supplements.

In addition to vital event reporting and nutrition surveillance, RHVs focused on training families in the following activities:

a. Use of oral rehydration therapy (ORT);

b. Seeing that children are breast-fed, immunized, and attending nutrition monitoring/counseling (including vitamin A supplementation in more recent programs);

c. Finding contraceptive services;

d. Finding primary health care facilities in cases of respiratory infections or febrile illness.

Mothers under surveillance were asked to participate in growth monitoring/counseling; to prolong breast-feeding; to use trained birth attendants; to take advantage of maternal health services such as family planning, antenatal care, and postnatal care; to use project-trained traditional birth attendants; and to adopt behaviors to prevent AIDS.

The overall strategy differs little among programs. The following steps, or modifications of them, were considered necessary by all of them:

1. Map out defined communities to be served, with community participation in planning for house numbering and door-to-door registration of families so that no family is left out (a concern for equity);

2. Identify, recruit, and train community health workers, ideally RHVs and local assistant workers (including volunteers) who will participate in activities such as teaching mothers and inviting mothers and children to assembly points or "rally posts" for preventive services and some curative services;

3. Implement an information system with appropriate indicators so that impact evaluation is possible:

a. Derive rosters from the family register or "census" instruments, for example, community-based rosters of names of children under five or under three years old (one roster for every 20-30 families) so that health workers (one worker for every 30-100 families) can record serially the weight/age and immunization status for each child he or she follows through assembly post activities;

b. Create and test or adopt report forms (for example, government immunization report forms, and pregnancy, birth, and death report forms for the local program);

c. Create, test, or adapt home-based, hand-held record forms to be carried by mothers (such as vaccination cards), Road-to-Health weight/age growth monitoring graphs, and maternal health records;

d. Train health workers in the use of these appropriate instruments;

e. Train supervisors in the use and creation of instruments for aggregation of data for feedback to communities and for reporting onward those data needed by program or project managers.

4. Train health workers at all levels to help set up "stations" for assembly posts at the community level (a station for immunizations and vitamin A distribution, a station for weighing children, a separate station for counseling the mother with participatory interpretation of the Road-to-Health weight/age graph, one for family planning counseling, etc.);

5. Train itinerant technical support teams to arrive monthly, bimonthly, or quarterly at the village level to carry out primary health care and nutrition monitoring activities according to a respected appointed schedule with an early-in-the-day arrival (rural Haitians arise at dawn or before, and prefer community-based activities very early or late in the day);

6. Inform community leaders and mothers of the purpose of the program and the date, time, and place of assembly points, often by a personal home visit on the eve of the activity;

7. Plan for absentee follow-up, sometimes during the activity or immediately thereafter (volunteers often did this);

8. Implement immediate vital event reporting in at least one defined project area to provide impact indicators. The absence of a supervised civil registration system in Haiti and the need to report vital events on a carefully defined local population necessitated this activity.

To explore whether good results could be expected if this kind of community health approach were to be undertaken by a government institution, the Haitian Ministry of Health Division of Family Hygiene in the PISP project, replicated and improved child survival and fertility control activities in defined communities near Petit Goave in 1974- 1978. Assisted by the Department of Population Sciences of the Harvard School of Public Health and the Haitian Institute of Statistics, prospective longitudinal reporting of pregnancies, births, and deaths was carried out in three "census tracts"; a nonintervened population was studied for comparison purposes.

In the PISP and HAS projects, all data on migrations were coded and computerized for further analysis and interpretation. Types of data available included a record of demographic variables and reasons for migration for all persons classified as immigrants, emigrants, or transfers within the census tract.

Rupture of the nuclear family during a move was a special concern to the investigators because of health and nutrition consequences. In the first HAS study all migrants and transfers were classified as "moving alone" or moving as a part of a family group. Reasons for migration as well as new and old addresses were also noted. The PISP study also noted whether any conjugal union had dissolved and whether any children under five had been separated from their biologic mothers as a result of the move.

Nutrition Monitoring and intervention

Rural Haitians tend to appear thin, reflecting their scant diets of rice, corn, cassava, or millet with a few beans, served once or twice daily. Most families can afford animal protein once a week at best; some have meat only once a month. The average daily calorie intake has been estimated as between 1,200 and 1,700 calories per day, with carbohydrates forming 72% of the daily intake (Haiti Bureau of Nutrition, 1979). Children suffer most, especially toddlers who cannot be expected to consume their daily calorie requirement at one sitting. Once weaned from the breast, however uneducated mothers will expect a child to do so (Beghin et al., 1970).

Because Haitian children under five have been and remain the most malnourished in the Western Hemisphere (UNICEF, 1990), special nutrition activities characterize these projects. During the 1970s and into the 1980s, rural nutrition surveys revealed that 3% to 6% of preschool children suffered Gomez third-degree malnutrition, that is, with weight/ age measurements less than 60% of the international standard median (Haiti Bureau of Nutrition, 1979). By 1992, data for sentinel surveillance areas set up by USAID still showed that 3% of Haitian children fell into the category of third-degree malnutrition (USAID, 1992, 1993).

Growth monitoring and reporting on nutrition status was a part of the nutrition surveillance system for all children in the HAS program and the PISP project. At HAS this included weight/height/age measurements monthly on more than 80% of census tract children. The Road-to-Health weight/age growth record was used to educate mothers in all projects at monthly, bimonthly, or (in the case of the PISP project) quarterly assembly posts, where immunizations, family planning, and health education were carried out.

Growth monitoring and nutrition surveillance and intervention activities were based on the following premises:

a. Rural Haitian mothers, although illiterate, can and will retain and interpret home-based growth charts on their children;

b. Nutrition demonstration-education involving the mother in food preparation and in feeding and rehabilitating her child is superior to counseling alone;

c. Continuing surveillance activities with periodic deworming and vitamin A distribution are appreciated by rural families, who will continue to participate as long as there is an outreach program that provides simple services within easy walking distance of their homes.

In 1968 the HAS community health program adopted a plan for nutrition intervention based on the experience of the Haitian Bureau of Nutrition, a part of the Ministry of Health of Haiti at the time. This was the use of village-level "centers" (temporarily rented homes) where a trained nutrition aide would teach mothers to rehabilitate their own malnourished tots using locally available, inexpensive foods. These nutrition rehabilitation and education centers or "mothercraft centers" lasted three months for each "promotion" of about 20 to 30 children and their mothers from a nearby neighborhood. The women nutrition aides, known as monitrices, moved with their center equipment in an itinerant manner across the HAS district, targeting those communities where the data from the growth monitoring indicated an acute need. Local farmers and their wives cooperated in making a home available for the demonstration and in observing the changes in the malnourished children. For the first time, mothers were shown the recuperation of children from kwashiorkor and marasmus by the use of inexpensive foods rather than treatment by medications received in hospital or clinic settings. Teaching emphasized the use of an inexpensive, locally available mixture known as akamil (one-third beans and two-thirds corn), which had an excellent amino acid ratio (King, 1964).

For HAS, this was a contrast to the traditional approach in which children were hospitalized, tube fed, and rehabilitated with imported products in a setting where cross-infection rates were high. Using the mothercraft centers in an itinerant manner across the HAS catchment area resulted in a significant decrease in the number of children requiring hospitalization for severe marasmus or kwashiorkor and was cost-effective (King et al. 1978). The PISP project in the Petit Goave area developed a less expensive modification of the mothercraft centers known as Foyers de Demonstration en Nutrition or nutrition demonstration centers, introduced in the context of the nutrition monitoring program, in which each mother was trained to follow the growth of her child on a home-based weight/age graph. The foyers lasted only two weeks in a village and took place in the borrowed kitchen or foyer of a volunteer mother who was a participant in the training exercise, whether or not her own child was malnourished. In this modification, the malnourished child was not completely rehabilitated but only began the process. The monitrice who conducted the training sessions met with villagers before, during, and after the demonstration to encourage completion of the rehabilitation process for each child in question.

The adverse nutritional consequences to children in unstable family situations were documented. Fostering of nonbiologic children is not uncommon in rural Haiti, especially in the face of dissolving conjugal unions. Children who were moved from one family to another in child-sharing practices typical of rural Haiti were followed prospectively to detect changes in nutritional status and survival.

Family Planning and Community-Based Distribution of Contraceptives

Although HAS was one of the first institutions in Haiti to introduce family planning, the program remained hospital- or dispensary-based until the recent AIDS epidemic (G Berggren et al, 1974). By contrast, door-to-door community-based distribution of contraceptives was an active part of the PISP project in the Petit Goave area as a part of its activities under Haiti's Division de Hygiene Familiale. The success of this approach was a harbinger of the community-based distribution projects introduced more widely in Haiti and elsewhere. The door-to-door activities of local volunteers (collaborateurs volontaires) who were part of the surveillance system enabled contraceptives to be made available at the community level. Over a three-year period, a crude birth rate of over 40/1,000/year came down to 37/1,000 with a concomitant high acceptance rate of condoms and pills. Many women also expressed their interest in the possibility of an injectable contraceptive (Paisible and Berggren, 1984).

The SCF/Maissade project, serving a very conservative rural population, has seen less success with community-based distribution activities but has found an apparently increasing interest and use of progestational implants (Norplant).

Tuberculosis and AIDS

Longitudinal death reporting revealed that tuberculosis was among the 10 leading causes of death in the HAS census tract in 1968; HAS studies in the Artibonite Valley in 1969 included a tuberculosis survey of the total population living in 23 villages near Deschapelles (see Results). Community-based activities included home visits, distribution of medication, and follow-up for compliance. A study carried out by PVS showed 2.4% active tuberculosis in the Cange census tract, including pediatric cases (Farmer et al., 1991). The PVS project included free tuberculosis drugs with or without financial aid.

Funding did not permit such a study by the PISP personnel in the Petit Goave area. However, tuberculosis emerged as a major cause of death in adults and therefore became a concern. All deaths were reported by cause using verbal autopsy methods. Those thought to be caused by tuberculosis were investigated by physicians who had access to the records of a tuberculosis treatment project in the area, funded in part by the International Child Care Foundation and Grace Children's Hospital for tuberculosis in Haiti.

Evolution of the Information System

All vital events were reported by RHVs, who discovered the vital event through home visits, "roll calls" of children under five or mothers at rally posts, or annual census updates. In the HAS studies, all deaths were investigated by physicians or their trained assistants; often an accompanying clinic or hospital record revealed the most likely cause of death. If not, physicians carried out informal verbal autopsies. At HAS they examined the cadaver, and in some cases convinced families to bring the body to the hospital morgue for autopsy in order better to determine the cause of death. Births were recorded by the RHVs, who contacted trained traditional birth attendants in each neighborhood.

The mobility of rural Haitian families posed a special problem, not only from the point of view of documenting vital rates, but also for follow-up purposes. Haitian conjugal unions are very unstable (Williams et al., 1975; Allman and May, 1979; ); their dissolution is often followed by in- or out-migration from a given census tract. The HAS definition of a resident was a person who resided at least six continuous months in the census tract, with intent to stay. The PISP project required that a resident be present four months or more with intent to stay before their vital event could be counted. Thus, vital events of visitors and transients were eliminated from the final analyses.

Results

Evolution of Community Health in the Defined Population at the Hal Albert Schweitzer

In the HAS experience, communities can be mobilized to combat the most common killing and disabling diseases once they participate in the community "diagnosis" and understand appropriate action in concert with a health team. Community volunteers (about one per 100 families) helped the technical service outreach team to set up "rally posts" where quarterly preventive activities could take place. During the 1970s, this included immunization, training in ORT and family planning, growth monitoring/counseling, and nutrition intervention in the form of temporary targeted supplementary feeding for children with growth faltering. Because tuberculosis emerged as a major problem, the outreach teams also collected sputum specimens and made smears which were brought back to HAS for laboratory diagnosis.

Community health workers and professional consultants recommended that primary health care services be made geographically closer to the communities served. Therefore during the 1980s, HAS recruited, trained, and supervised medical auxiliaries who manned six outlying dispensaries and developed liaisons with other private voluntary organizations (PVOs) who also had dispensaries. These proved valuable in bringing curative aspects of primary health care closer to needy villagers, while at the same time reducing the case load at the hospital. The total number of outpatient consultations doubled; by 1992, HAS was seeing 6,000 outpatients per month, with an equal number being seen at outlying dispensaries. Thus, in the sense of providing earlier diagnosis and treatment, the dispensaries brought improvement. But dispensaries proved disappointing as an answer to preventive aspects of primary health care; medical auxiliaries were instead overwhelmed with curative care.

Immunization, growth monitoring coverage, and village-level nutrition intervention dropped during the 1980s because of the reasons described above and also because HAS redefined its RHVs as paid Agents de SantI> in keeping with government norms. Community volunteers were forgotten; Agents de SantI> were not required to be residents of the communities they serviced. The Agent de SantI> was supposed to cover a population of 2,000-3,000, or about 500 families, beginning with family enrollment and followed by home visits. They were supposed to set up "rally posts" for immunization and growth monitoring/counseling without community volunteers, but with the help of a technical backup team for immunizations. The new approach resulted in a decrease in preventive coverage in the 1980s.

The lesson learned was that the volunteer RHV, chosen by his or her own community to act as a liaison to health services, is essential. In HAS experience, women volunteers have been found to be an essential ingredient in the process, as are paid community health worker/supervisors and technical support outreach teams. A new model in the Plassac region is under way. Here the community health department mobilized women volunteers (1:15 families) to reach their own neighborhoods. Several of them cooperate to help the Agent de SantI> set up assembly posts in their own neighborhood for immunization, growth monitoring/counseling, and mini-antenatal and family planning consultations. The nearby dispensary auxiliary assists in some consultations. Prescribed medications are then provided by community pharmacies maintained by the community health committee who help finance the venture.

Neither outlying dispensaries nor paid community health workers (Agents de SantI>) work well without community mobilization and (in Haiti's case) women volunteers. There are young mothers in most rural communities who can and will give some time and effort to help create "rally posts" or "under-five" clinics at the neighborhood level. With such input, immunization and growth monitoring/promotion activities are far more likely to reach the majority of families. This experience is not unique. A World Vision project on Haiti's Ile de la Gonave, serving an extremely poor population of 80,000, recently completely immunized 80% of children under two through the use of community volunteers and the assistance of local churches (World Vision, 1993).

In rural Haiti, volunteers are also essential to vital event reporting, especially that related to pregnancy outcome. Newborns who survive only a few hours or days as well as other births and deaths are usually noted by local neighborhood women who, even though illiterate, can and will report them to paid health workers. Without this level of reporting, HAS had no data with which to calculate age-specific cause-specific death rates or birth rates for the 1 980s, which impairs community diagnosis. This necessitated a retrospective study to fill in the gap during the past 20 years.

The results discussed here are first and foremost those of the HAS study near Deschapelles, a unique study with 25-year follow-up results. Other studies will be brought into the Results section whenever pertinent.

Population Growth

In 1980, estimated overall population density exceeded 540 per square kilometer, with 390 per square kilometer of arable land (Institut Haitien de Statistiques, 1980). The HAS census tract of 23 villages did not double as expected over the intervening 22-year period; but an overall population growth of 47% was documented. Upland villages, however, more than doubled, increasing by 105% (see Table 1). Lowland villages are closer to public transportation; the communities are less traditional and more mobile. Here out-migration played a role, since the rate of natural increase would be expected to be greater than 2% per year. In the PISP project near Petit Goave, the natural rate of growth fluctuated slightly, but overall growth was around 2% per year. The population did not increase at this rate, due to net out-migration (Paisible and Berggren, 1984).

TABLE 1 Evolution of the Population of 23 Rural Villages Near Deschapelles Over the Period 1968-1990 Preliminary Data Based on Census Update by Community Health "Agents de Sant/B>

Year

1968

1972

1976

1990

Growth rate (over 22 years)

Upland Villages






Subtotal

1,957

2,264

2,558

4,023

105%

Lowland Villages






Subtotal

7,096

7,419

7,826

9,294

31%

Total

9,053

9,863

10,384

13,317

47%

Over a four-year period (1968-1972), the HAS census tract documented a crude out-migration rate of 97.6/1,000 which was almost balanced by an immigration rate of 92.0/1,000, giving a net migration rate of -5.6/1,000 over a four-year period of observation. A year of food shortage (1970) greatly increased the propensity to migrate. In the subsequent year, over one-third (34%) of males aged 20 to 24 were involved in migration. The rate for females in the same age group was about half as much; many females in this age group were burdened with children and tended to remain behind (G Berggren et al., 1980).

Mobile Children, Dissolving Conjugal Unions, and Child Health

The HAS and PISP studies provide insights into the determinants and consequences of high mobility and its relationship to family building in rural Haiti. Dissolving Haitian conjugal unions are a cause of mobility from one household or one village to another; there is a propensity to displace children from their biologic mothers in the process. Even children under the age of two were separated from their biologic mothers. Some such children appeared to be unwanted when the mother moved in order to enter into a new union. Others were simply left behind with relatives, usually a grandparent, when the mother moved to gain financial advantage.

In the PISP study, 38% of women in the reproductive age group stated that their male consort had fathered children elsewhere, often in what appeared to be a pattern of serial placage. One woman proudly pointed to the four stepchildren she had raised, each from a different placage union of the one man who had been her male consort. In each case, she had taken over a child left behind when the biologic mother moved. The risk of child displacement and some of its consequences to the child were explored (W Berggren et al., 1981).

The PISP study used a multiple decrement life table to study the risk of a child under two being "orphaned" by being separated from his or her biologic mother. In each year of the study, cohorts of children were followed to calculate such risk. In the first year of the study, by the time a child survived to 24 months of age, he or she had a 20% risk of being separated from the biologic mother either from being orphaned or from being left behind by a move or a dissolving union. In the second year of the study, the risk dropped slightly for unexplained reasons. The reason for this separation was rarely death of the mother; usually the child was left behind with other relatives or another wife in the process of a dissolving union. Such children fared poorly; for children under one, 13.5% died within the first six months of the separation from the mother (Paisible and Berggren, 1984, p. 1-13).

An anthropologist studied the determinants and consequences of child relocation in the census tract of HAS. His preliminary analysis of residence patterns showed that 17.5% of children under 10 years of age did not live with one or both natural parents. He conducted an in-depth analysis in one village. Concentrating on children under 12, he found that of 165 such children born to the couples in that community, 26 had residency established outside the community at the time of the study. However, another group of 26 children had migrated into the community. He studied the circumstances of 35 children who had left their natal households and one or both parents. Twenty-four of the 35 had left disrupted conjugal unions, accompanying one or the other parent at the time of the breakup. Children accompanying a parent were usually of the same sex as the parent (Rawson and Berggren, 1973). Eleven relocated children who had not left a dissolving conjugal union had been moved by their parents into the homes of close relatives. Nine lived with grandparents and two with an aunt or uncle. More than two-thirds of the latter were from homes with four or more surviving children, leading the anthropologist to conclude that overcrowding in small Haitian homes is a factor in child relocation.

A significant finding of this study was the poor nutritional status of displaced or relocated children. Of such children under the age of six, more than one-half had already been screened into nutrition rehabilitation centers, indicating that the HAS nutrition surveillance program had discovered their growth faltering. Half of these malnourished tots were living with only one parent or with another relative. Further analysis revealed a statistically significant association between malnutrition and child-parent separation in this community. The finding was no surprise to the itinerant technical support team who helped weigh and measure the children monthly. Their questions to the caretakers of growth-faltering children often revealed that well-meaning parents had displaced a child into another household, usually with the idea of better providing for such a child. Most children not nutritionally deficient lived within a complete nuclear family (Rawson and Berggren, 1973). Such families were often smaller and the parents were less burdened.

In the HAS census tract, migration rates for girls 10 to 14 years old exceeded those for boys, with a doubling of the out-migration rate for girls (158/1,000) compared to boys (86/1,000) in 1971. The surprise was how often such children were migrating alone, separated from one or both biologic parents. Children born to polygamous common-law unions may be passed from one wife to another or left behind with relatives when a couple separates or moves on; this is especially true for young girls, who are seen as babysitters and as carriers of water and wood. Young girls recorded as migrating alone were usually found on investigation to have moved to "take care of" someone. The move was related to the unpaid labor they could provide. Several parents confessed that someone from the capital, not necessarily a relative, had come and collected the child, promising to take care of her but in fact inducting her into long hours of arduous labor. In at least three instances, such children returned home in poor physical condition; one died in Port-au-Prince, apparently from tuberculosis. Interviews with families revealed that they had falsely hoped their children would have the chance for schooling in Port-au-Prince in return for their labor.

Major Findings in Mortality Reduction

Infant mortality rates

Retrospective reproductive histories revealed an infant mortality rate of 126/1,000 live births in the HAS catchment area just before the initiation of the community health activities described above. Infant mortality rates in the community health impact areas of all the longitudinal studies appeared to have been cut by two-thirds in the first three to five years of the projects (see Table 2). Yet national estimates for the same time period show that the infant mortality rate for Haiti was 100 or more. In 1972, for example, when HAS documented an infant mortality rate of 34, the national estimate was 150 (Allman and May, 1979). The Institut Haitien de l'Enfance in 1987 estimated the national infant mortality rate at or slightly below 100/1,000 live births/year (Cayemittes and Chahnazarian, 1989).

Given the high infant mortality rates of Haiti (at or near 100 or more), the reductions in Table 2 are statistically significant (Reinke et al., 1993). Although there has been a slow decline in national infant mortality rates (Cayemittes and Chahnazarian, 1989), all the programs reviewed here achieved declines much more rapidly than expected. The most salient feature in accompanying deaths-by-cause studies was the disappearance of tetanus of the newborn. Deaths from diarrhea were also reduced (W Berggren et al., 1981; Paisible and Berggren, 1984).

Reduction of death rates due to tetanus of the newborn following immunization of all women is a finding in all the projects. Retrospective fertility histories in the Artibonite Valley revealed a neonatal tetanus fatality rate of 136.9/1,000 live births prior to immunization of mothers against tetanus during 1956-1962 (W Berggren et al., 1981). This rate was reduced to 78.9 with immunization of pregnant women and finally dropped to zero in the census tract by 1971, when all women had completed an immunization schedule of three doses of tetanus toxoid. By 1991, there were no reported cases of neonatal tetanus in the entire resident population of 180,000 served by the hospital. In the PISP project, prospective reporting of deaths by cause and the use of verbal autopsy methods documented neonatal tetanus death rates of 32.9/1,000 during the first six months of the project in Trou Chouchou where activities began. After an immunization campaign in which 85% of women had received three or more doses of tetanus toxoid, the death rate due to tetanus was reduced to 1/1,000 live births (Paisible and Berggren, 1984).

TABLE 2 Reduction in Infant Mortality Rates in Four Defined Rural Haitian Populations with Census-Based, Community-Oriented Health Services

Name of Study:

HASa

PISPb

SCFc

PVSd

Location:

Artibonite

Petit Goave

Maissade

Cange

Years Covered:

1967-1992

1974-1978

1989-1992

1983-1992

Infant Mortality Rates





Baseline or Year I

110e

140e

138

112

Year 3

-

90

30


Year 5

34

-

-

-

Year 7

-

-

-

27

Year 25

33'




(follow-up study)





% reduction in first 5 - 7 years

70%f

50%f

78%f

76f

References:

aW Berggren et al., 1981, 1993; bPaisible and Berggren, 1984; cMenager and Tamari, 1990;
Berggren et al., 1993; dFarmer, 1992; Harvard Center for Population and Development Studies,
1993.

e From retrospective fertility histories using World Fertility Survey methods to determine vital rates in preceding years.

f These declines are statistically significant using the formula of Reinke (Johns Hopkins University School of Public Health) for longitudinal small area studies, as follows (Reinke, 1993).

E = PBDY (1)


(2)

P = Population size
B = Crude birth rate
D = Infant mortality rate
Y = Years of experience (data)
E = Expected (baseline) infant deaths
S = Observed % reduction in D needed for significance

In 1991-1992, however, Haiti experienced a measles epidemic which affected children under the age of one, and it is expected that 1992 data may reflect an upturn in infant mortality rates due to measles and to an increasing number of children born to mothers who may have AIDS.

One- to Four-Year Mortality Rates

Mortality rates in children one to four years old have been documented only by the HAS, PISP, and SCF/Maissade projects (see Table 3). HAS baseline data revealed a one- to four-year age-specific mortality rate of 14/ 1,000 before preventive, community-based interventions. This rate dropped to half of what it had been and remained at around 7/1,000/year or below during the next 15 years, according to the follow-up study. During this time, the national rate was estimated by the Haitian Institute of Statistics at 23 to 26/1,000 (W Berggren et al., 1981).

TABLE 3 One- to Four-Year-Old Age-Specific Death Rates in Rural Haiti Longitudinal Studies of Community-Based Primary Health Care

Name of Study:

HASa

PlSPb

SCFc

Location:

Artibonite

Petit Goave

Maissade

Years Covered:

1967-1992

1974-1978

1989-1992

Baseline or Year 1

14

26.7

26


(natl. 26)

(natl. 26)


Year 3

9

14.6

30

Year 5

6

-

-


(natl. 23)



Year 7

4

-

27

Year 25

4

-

-

(follow-up study)




% reduction in first 5-7 years

70%

50%

77%

References:

aW Berggren et al.,1981, 1993; bPaisible and Berggren, 1984; cMenager and Tamari, 1990; Harvard Center for Population and Development Studies, 1993.

In the PISP project, the one- to four-year-old mortality rate remained at 26/1,000/year in a nonintervened comparison (control) area, whereas in an area that had received intervention with health surveillance and child survival activities only, it dropped to 14/1,000/year.

The SCF/Maissade project has seen similar results, but has had an excess of deaths in the most recent year due to a measles epidemic (Harvard Center for Population and Development Studies, 1993).

What can explain the drop in death rates for the one- to four-year-old age group other than immunization, ORT, and earlier diagnosis and referral? It must be noted that nutrition interventions have been a salient feature of the projects described above. Over the time periods covered, as many as 6% of toddlers suffer Gomez third-degree malnutrition, many with the edema typical of kwashiorkor (that is, they weigh less than 60% of the international standard median weight for age). In the HAS, PISP, and SCF/Maissade projects, mothers assisted in rehabilitating their own children using locally available, inexpensive weaning foods. Underlying malnutrition has been shown to be a predictor of mortality in a number of studies and no doubt plays a role here (Scrimshaw and Hurtado, 1987).

It is important to note the relationship between being separated from one's biologic mother and the risk of death in rural Haitian children. The PISP project documented this risk (Paisible and Berggren, 1984), as shown in Table 4. Table 4 has strong implications for health education in community-based health projects in rural Haiti. Little is said to warn parents about separating children from their mothers, a not uncommon practice and one that is growing as the socioeconomic situation worsens.

Fertility Reduction

The HAS retrospective study showed that age-specific fertility rates have changed very little over the past 25 years, despite the continuing availability of intrauterine devices, pills, and condoms at the hospital and its outlying dispensaries (see Table 5). Reasons for resistance to family planning were studied in the 1970s by HAS investigators who noted that the "child-survival hypothesis" as a predecessor to family planning acceptance did not seem to hold for rural Haitians in the Artibonite. However, researchers noted that the crude birth rate in the HAS catchment area was only 36/1,000/year, lower than other developing countries during the 1970s. Brakes on fertility studied in the PISP and HAS projects included prolonged interpregnancy intervals due to breast-feeding (average of 18 months), frequent dissolution of conjugal unions, and a delayed age at first childbearing, documented at an average of 21 years in the PISP project area and 21.3 years in the HAS studies (Paisible and Berggren, 1984; Harvard School of Public Health, 1993). The age at onset of menses was also delayed, averaging about 15.5 years in the PISP project areas (Paisible and Berggren, 1984).

TABLE 4 Percentage of Rural Haitian Children Separating From Their Biologic Mothers in the First 24 Months of Life*

Risk of being separated from mother for all who survive to that month:


Area

Month of Life

Trou Chouchou

Grand Goave

Meilleur

6

10%

9%

5%

12

14%

16%

8%

18

19%

17%

11%

24

20%

19%

13%

Risk of Death,:




Percent dying within 6 months of separation

7.1%

16.7%

18.2%

* From: Projet Inte Santt de Population, Prospective Longitudinal Studies in Three Defined Populations Near Petit Goave, Haiti, 1974-1978
Source: Multiple Decrement Life Table using person-months of follow-up for all children followed in three census tracts (Paisible and Berggren, 1984).

TABLE 5 Age-Specific Fertility Rates by Period (per 1,000) in the Artibonite Valley of Rural Haiti HAS Census Tracts, 1993 Retrospective Study


Time period

Age group

1967-1976

1977-1986

1987-1991

15-19

49

71

59

20-24

184

227

206

25-29

237

260

264

30-34

252

233

254

35-39

-

167

215

40-44

-

124

114

45-49

-

-

49

In this study, the total fertility rate for 1977- 1991 varied by census tract from 4.5 in the villages nearest the HAS to 6.8 and 6.1 in the two more remote census tracts.

Mobility affected fertility rates. Reasons for in-migration given by adult females induded "contiguity" (21%), that is, the woman moved to stay with a migrating household. Only 17% of moves were made to form a union, and another 24% were made to join a relative, most often in the process of a dissolving union.

As women grow older, they are more likely to live without a male consort in residence, so that more than half of women over 40 are in this situation, often burdened with grandchildren. The situation of being "husbandless" is not new to them; on census day, in both studies, one-third of women who had ever entered into a union were found to be without a male consort.

Nutrition Results

HAS studies showed that rural children fall behind in growth at about the sixth month of life, suffering wasting and stunting to the degree that their 50th centile is almost identical with the US (Boston standard) third centile. Where nutrition intervention occurred in the form of demonstration-education for mothers who rehabilitated their own malnourished children, stunting was prevented in the lower 10th centile, and admissions for severe forms of malnutrition dropped (King et al., 1978).

The HAS studies showed that nutrition intervention apparently prevented stunting (G Berggren et al., 1985). Weight-for-height and height-for-age date were compared for preschool-age Haitian children enrolled in the HAS nutrition intervention program and children measured in the Haiti National Nutrition Survey in 1978. Cross sections of the longitudinal data of the intervention program corresponding to the season when the national survey was conducted (May to September) were chosen for the three years of available program data (1969,1970, and 1971). Significantly less stunting was found in the children in the 1970 and 1971 intervention groups than in the children covered by the national survey. Tests of trends also showed that the height status of children in the intervention group improved from 1969 to 1971. Wasting, or low weight status, was in general not significantly different in any of the comparisons. Nevertheless, the data were more favorable for children in the intervention program even in 1970, a year of food shortages.

However, the reasons the HAS success were not immediately accepted by the Haitian Bureau of Nutrition included the following:

1. Demonstration-education and rehabilitation units are best accomplished in the context of growth monitoring/counseling systems where mothers can weigh their children nearby and are allowed to hand carry and keep at home the Road-to-Health weight-age graph.

2. HAS nutrition rehabilitation centers were kept temporary and itinerant across a zone, thus avoiding the absenteeism occurring in those of the Bureau of Nutrition, where mothers had to come from farther and farther away as new "promotions" were identified.

3. HAS professionals used ongoing aggregate data from the village-level growth monitoring system to focus on those communities with highest rates of severe malnutrition.

Government Bureau of Nutrition units instead tended to become fixed "day care centers" with high rates of absenteeism among participating mothers. The "fixed center" catchment area grew ever wider to accommodate mothers with children at risk, with the result that distances for some mothers became burdensome, as did their required contribution (mothers were expected to help with wood, water, and fresh greens for the nutrition education sessions). Thus, Haiti's Bureau of Nutrition mothercraft centers appeared to be costly and ineffective, and funding for them ceased during the 1970s.

The PISP studies showed that mothers who had been through nutrition demonstration education and who had rehabilitated a child were able to prevent death significantly more often in the younger siblings of children who had been malnourished (G Berggren et al., 1984). These mothers were taught to feed children more frequently with a more calorie-dense diet, using locally available, inexpensive foods. Demonstration education lowered the mortality rate of malnourished children to 68% of the mortality rate experienced by those whose mothers had growth monitoring and counseling services but did not receive the benefits of demonstration education. Younger siblings of malnourished children were less apt to become malnourished and had significantly lower death rates than did the younger siblings of malnourished children whose mothers had not participated in demonstration education.

Emerging evidence from current information systems reveals the vulnerability of the poorest families to malnutrition, tuberculosis, and HIV. These facts lend new impetus to link economic assistance, improvement in economic conditions, and income-generating projects to the needed nutrition and health interventions (Farmer et al., 1991).

Tuberculosis Results

Tuberculosis was a major cause of death in the HAS, PISP, and Cange projects. All deaths suspected to be caused by tuberculosis were reviewed by physicians. At HAS, hospital records or autopsy confirmed the diagnosis; in the PISP project, a local tuberculosis treatment project had records on most cases. Of particular interest is the fact that prospective death reporting revealed that tuberculosis outstripped maternal causes as a major killer of women in their reproductive years. Those women had an overall mortality rate of about 80/10,000 in the first year of the project. In the PISP project, the women's age-specific, cause-specific death rate for tuberculosis was 17/10,000, whereas death from maternal causes accounted for 13/10,000 in Trou Chouchou, 4/10,000 in Grand Goave, and 6.7/10,000 in Meilleur.

The initial HAS census tract survey (N=7,369) showed that 2.3% of the population suffered active tuberculosis, as determined by repeated chest X-rays after skin testing. Half of these were pediatric cases in which sputum examination was difficult. A follow-up study was carried out in 1972 on all patients who were originally diagnosed and treated as having tuberculosis (255 cases). Of these, 183 were confirmed by X-ray and/or sputum examination, all cases followed and treated by qualified pediatricians and internists at HAS. The investigators concluded that 2.1 % of the originally surveyed population had tuberculosis (Casey et al., 1971). Findings compared well to a study carried out in the Jeremie area of Haiti during the same decade, in which 2.3% of that population were thought to have active tuberculosis.

Age-specific, cause-specific death rates from tuberculosis dropped continually over the five-year period when health surveillance activities were continuously followed and documented at HAS.

Farmer's prospective, population-based study at Cange showed that giving free tuberculosis medications plus financial aid to buy food resulted in significantly higher cure rates among rural Haitian (non-HIV-positive) tuberculosis patients. Case fatality and morbidity rates were significantly higher in a group that received free tuberculosis medications without financial aid.

It is doubtful that tuberculosis statistics have improved since the advent of AIDS in Haiti beginning in 1981. A current survey for HIV positivity in the Artibonite Valley is being carried out. Preliminary results reveal that as many as 6% of the rural population taking advantage of HAS services may be HIV positive. Estimates for HIV are lower for the PVS/Cange area, where rates are likely to be around 1% (Farmer et al., 1991).

Discussion

Replication of the activities described has not always been successful. Rural Haitian informants pointed out that teams often arrive late, in the heat of the day, and may abruptly cancel a session with little or no explanation. Furthermore, no shady area for seating the mothers was provided as might have been the case had the villagers participated in the planning of the sessions.

Haitian families today are more mobile than ever, and this effect is felt especially in the United States and Canada. Of 336,394 Haitians legally entering the United Sates between 1956 and 1972, about 230,000 were known to have remained. It was estimated that equally as many may have entered illegally.

High mobility may be blamed on the phenomenon of "overpopulation, extreme poverty, and one repressive regime after another" in Haiti. But other reasons underlie this instability. The system of small landholding involves owning land on dispersed plots; the sale or inheritance of land often requires migration (G Berggren et al., 1980) and demographic changes that affect household and family structure (G Berggren et al., 1980). What emerges is a stepwise movement from household to household, from village to village, and finally from villages to towns and onwards.

Comments on Strategy

The use of an itinerant technical support team to supplement the activities of village-based workers at regular (at least quarterly) intervals is necessary in rural Haiti in order to provide immunizations, growth-monitoring services, and other modalities (such as materials for a mini antenatal clinic). Rural Haitian mothers do not carry their babies on their backs or in a sling, and therefore the distance they are willing to travel for immunizations must be taken into account. Services must be within a one-hour walk of their homes for rural Haitian mothers to begin to come regularly to surveillance or immunization services (Alvarez et al., 1993). Rural community leaders are willing to participate and, in the case of the HAS under-fives clinic, have assessed themselves to help cover costs.

While the above activities began in a systematic way at HAS with the purpose, in part, of providing the basis for a prospective longitudinal study, it was realized that the systematic registration and follow-up of all family members in each nuclear family in every village in a defined census tract also brought the element of equity to the primary health care system. In Bangladesh, where the methodology is being replicated by Save the Children, health workers justified the approach as the "No Child Shall Be Left Out" system.

The HAS family registration system proved so valuable that by 1992 it covered the HAS district of 180,000 people in rural Haiti. Major changes evolved over the 25-year intervention period in order to improve primary health care, surveillance, and equity. These included the use of outlying dispensaries and the identification, recruitment, and training of community-level women volunteers known as animatrices, each of whom reaches 10 to 15 families, acts as a liaison to health services, and helps to organize village-based under-fives clinics.

Cultural Insights

Rural Haitian informants point out that communities lose faith with teams that often arrive late, in the heat of day, or with the news that a session is abruptly canceled or lacks supplies. Furthermore, villagers need to have participated in the planning of the project and in its appointed sessions. They will see, for example, that shaded areas and seats or mats for waiting mothers are available.

Conjugal union status was a confusing subject and one of special interest, since it was key to the understanding of household structure and child relocation in rural Haiti. At the time of family registration, interviewers found that up to one-third of women who had been in at least one conjugal union were without a male consort. RHVs who served as census takers consistently gathered more information than was asked for, and often information essential to the understanding of union formation and dissolution. The World Fertility Survey later piloted their questionnaire in the PISP project and developed a questionnaire that allowed for the history of unions to be correlated with the prolonged interpregnancy intervals that often occurred between unions.

The general instability of the Haitian population, in terms of both conjugal unions and high migration rates, was to some degree a reflection of the economic circumstances, as their reasons for in-migration betrayed. Nearly 20% of in-migrant males aged 15 to 44 gave "nonagricultural employment" as their reason for migrating, and another 18% gave simply "unemployed, unsettled" as a reason. Another 20% gave "to join a relative" as a reason, most often also because such a migration would improve their economic circumstances.

In these studies, one sees at once a reflection of the cultural factors described and, at the same time, adverse consequences, at least in nutritional terms, for relocating children. Child relocation can be seen as a strength carried over from the African cultural setting or as a detrimental consequence of highly unstable conjugal unions and family mobility in Haiti, where both phenomena occur under adverse economic conditions. In dealing with these families, the authors found that once displaced, a child was also apt to be displaced again, and that malnutrition often ensued (Rawson and Berggren, 1973). The PISP longitudinal studies found that up to 20% of children under two were separated from their biologic mothers, and that 13% died in the first six months thereafter. Therefore, as protective as "child sharing" might be in the African cultural setting, in this culture its effects are generally adverse for the child.

Rapid assessment procedures including the use of focus groups are beginning to add understanding to the situation of women who head single-parent families and whose common complaint is "My mister abandoned me." These insights are important for those who set targets for family planning: women outside of unions do not wish to give-up the "fertility card" they feel may be necessary to gain a new male consort. Evolution of the projects has included the adaptation of rapid assessment techniques from the behavioral sciences for development of education tools, monitoring, and evaluation.

Practical Implications for Health Programs

a. These studies imply the desirability of home-based health records for every age group, since rural Haitians are highly mobile and are unlikely to continue to attend the same health center for long. Haitian mothers in both studies proved they do not lose home-based personal health records if health providers are faithful in their insistence on their being presented and interpreted, and they will use them as educational tools.

b. The information system that made the studies possible began in all cases with door-to-door registration of all families living in defined communities, with follow-up thereafter from RHVs (1:100 families) who acted as liaisons to the health services and reported all pregnancies, births, deaths, migrations, and nutrition status of children.

c. Resistance to family planning can be expected from women whose union status is in fluctuation. More educated Haitian women may feel that between unions it is in their own interest to continue the use of contraception, or to have contraceptives always available. However, until this philosophy or belief is shared by their less well-off sisters, up to one-third of women will be unlikely to use family planning because of instability of unions.

d. The adverse consequences of child relocation are not realized by Haitian families, who mean to provide better for their children by relocating them. Education about family building and the importance of bonding in child development could be included in the outreach programs of many institutions in Haiti. Nutrition education, for example, need not dwell exclusively on scientific facts about what a child needs to eat and how often. Haitian families care for their children and deserve a better chance to understand the value of family stability for both mothers and children.

e. Rawson's conclusions from his anthropological study of child relocation are relevant for health programs:

· Child relocation is an important underlying cause of malnutrition. If recognized early enough, the ensuing malnutrition is susceptible to simple preventive measures.

· Child spacing and smaller family size would reduce the risk of relocating a child; hence family planning could contribute positively.

· In addition, the health staff should identify relocated children promptly and then institute action to protect them.

In conclusion, population-based community health programs have produced longitudinal data in Haiti to confirm that low-cost, simple interventions can lower mortality rates in children. A 25-year follow-up study at HAS proved that the rates were sustained in that setting, where primary health care and referral facilities remained constant.

Acknowledgements

This review was made possible through the Community Health Department of the Hospital Albert Schweitzer of Haiti and its supporting agency, the Grant Foundation of Pittsburgh, PA, and the Pew Charitable Trusts. The projects described were funded in part through grants from the Rockefeller Foundation, the Williams and Waterman Foundation, the Canadian International Development Research Center, Bread for the World of Germany, and the United Nations Fund for Population Activities (UNFPA) through the Division d'Hygiene Familiale of the Canadian Government.

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Notes

1 Formerly with the Albert Schweitzer Hospital in Deschapelles, Haiti and the Harvard School of Public Health in Boston, MA, USA.
2 Albert Schweitzer Hospital, Deschapelles, Haiti.
3 Formerly with the Integrated Project of Health and Population, Division of Family Hygiene in Petit Goave, Haiti.