Integrating Home Health Care into Your It Strategy

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					Health Systems
                                                University of the Western Cape
Research Unit

    Integrating care into IMCI: Scaling up care in child health

                 Dr Mickey Chopra and Dr Mark Tomlinson
                     Health Systems Research Unit
                        Medical Research Council
                              South Africa
•   … the care that children receive has powerful effects on their
    survival, growth and development.
•   … care refers to the behaviours and practices of
    caregivers (mothers, siblings, fathers and child care providers)
    to provide the food, health care, stimulation and emotional
    support necessary for children’s healthy survival, growth and

•    … Not only the practices themselves, but also the way they
    are performed – in terms of affection and responsiveness
    to the child – are critical to a child’s survival, growth and
                                                         Engle (1999)

1997          An advisory group: how should WHO support
              child development?

1997-1999     Review interventions to improve physical growth
              and psychological development A Critical Link,
              and apply them to the development of the
              intervention Care for Development

1999          Conduct a field test in Brazil: counselling
              mothers on Care recommendations

1999-2000     Incorporate Care into the generic IMCI training
              materials: IMCI Counsel the Mother, with video

2000-2001     Conduct 2 additional field tests: IMCI training
              with Care (South Africa), IMCI adaptation with
              Care (Syria)

2001-present Build the capacity to introduce Care for
Recommendations from

                A Critical Link
Recommendations for the design of programmes
from   A Critical Link

For the greatest impact on the child’s healthy physical
  and psychosocial development:

• Focus on children most at risk

   – Undernourished
   – Impoverished

• Focus on young children (the critical window)
• Combine interventions to

   – Improve nutrition (breastfeeding and complementary
   – Improve mother-child interactions
   – Stimulate psychosocial development
   – Improve health

• Scaffold interventions – adapt as the child develops

• Involve parents and other caregivers
Looking at the Evidence
       for the Care Intervention
Reversing the developmental effects
associated with stunting
(low height for age)

• 40% of children                  under 5 years of age in developing
   countries are stunted        (Onis et al. 1993, Bundy, 1996)

• Stunting is associated with
  – Poor developmental attainment in young
       children   (Lasky et al., 1981; Powell & Graham-McGregor, 1985)

    – Poor school achievement and intelligence
      levels in older children (Jamison, 1977, Moock & Leslie, 1986).
The Jamaica Study
Graham-McGregor, et al. , 1991

•   Looked at the effects of nutritional supplementation and
    psychological stimulation on stunted children aged 9-24 months
•   An experimental intervention study
•   129 children from poor neighboorhoods were randomly assigned to
    four groups:
     – Control
     – Supplemented only
     – Stimulated only
     – Supplemented plus stimulated
•   And a matched comparison group of non-stunted children
  Jamaica Project:
  Effects of supplementation and stimulation on the mean development
  quotient of stunted groups compared with non-stunted groups
                                                                                                 Supplemented and

       95                                                                                        Supplemented

       90                                                                                        Control

       Baseline            6             12             18             24
Source: S.M. Grantham-McGregor, et al. (1991). Nutritional supplementation, psychosocial stimulation, and mental
development of stunted children: the Jamaican Study, in The Lancet, 338,1-5.
Bogotá Project:
Effects of supplementation and stimulation
on growth and weight (results at age 7)

  compared to controlgroup

    % increase of mean



                                                                Maternal tutoring

                             1%                                 Both
                                  height   weight

Van der Gaag, J. School Performance and Physical Growth of Underprivileged Children:
Results of the Bogotá Project at Seven Years. (1993). World Bank, Washington D.C.
Bogotá study (continued)

• Children who had received supplementation and
  stimulation (at age 7 years)

   – Physical growth: Less than 20% were stunted,
     compared to 50% in the control group
   – Development:
      • Better reading readiness scores
      • Better mathematics scores and basic
        knowledge (preschool achievement test scores)
      • Results especially strong for chidren of
        fathers of low to moderate levels of
        education and literacy
Documenting the evidence

   A Critical Link: Interventions for physical growth
 and psychological development

   Caregiver-Child Interactions for the Survival and
 Healthy Development of Young Children

   Care for Development: Promoting Child
 Development for Low-Income,Nutritionally At-Risk
 Care for Development
and the IMCI Strategy
An opportunity: Link psychosocial           interventions
to the IMCI strategy

• IMCI combines and integrates interventions for
  health and growth
   –Prevention of illness (e.g. promotes immunization)

   –Case management of illness (assessment and treatment,
   counselling on home care)

   –Home care of illness – treatment, when to seek care

   –Health promotion (e.g. nutrition counselling)

• Good nutrition and less severe and frequent illness
  support the healthy development of the child’s brain,
  exploration and learning, psychosocial development (Bundy,
•   IMCI focuses on children in the critical window:

     – Children age less than 5 years

     – Special interventions for
        • All children up to age 2 years
        • All undernourished children age up to 5 years

•   IMCI focuses on children most at risk

     – Sick, often with multiple conditions, often malnourished

•   IMCI strengthens the skills of parents to provide good nutrition
    and care for the sick child at home
With IMCI, a strategy for   taking support for child
development to scale

•   IMCI has tools to implement three components, to improve:

    – Health worker skills
       • technical guidelines, training

    – Health system supports for care
       • improving capacity for planning and monitoring
       • availability of supplies
       • division of work
       • follow-up supervision

    – Family and community practices for child health
      for working through the health system and community
The   IMCI Approach
      to Supporting Child Development
Programme approaches to supporting child   development

• Main approaches to supporting psychosocial development
  in existing programmes implemented through health

   – Monitoring developmental achievements or milestones

   – Screening for developmental delays

   – Counselling on care: helping the mother or other
     caregiver to support the child’s healthy development
Monitoring developmental achievements or milestones

   What the healthy child should be able to do at various ages or
     stages (e.g. on the MCH card)

   Problems include:

   – Focus on what the child is (or is not) doing, little help for

   – Little support for behaviour change in the child’s care,
     although some success in improving awareness of child’s
  Assessing (or testing) children to identify those in need of
    special help

  Problems include:
  – Difficult to develop, teach use of tools, for large scale

  – Lack of time, poor conditions for testing during visit

  – Poor reliability in very young children

  – Limited resources to provide special care for children

  – Lifelong consequences of misclassifying children
Ages at which 90% of children
achieved gross-motor tasks on the Denver Scale
Developmental item on                   Denver Scale                    Madinah,
the Denver Scale                          standard                 Saudi Arabia result
Pulls to sit, no head lag                6.2 months                     4.3 months
Stands holding on                       8.5 months                       12.1 months
Pulls self to stand                     9.7 months                       12.1 months

Kicks ball forward                       23.2 months                   17.6 months
Balances on one foot                      48 months                      42 months
                                          (4.0 years)                   (3.5 years)
                                                  Salih Saad Al-Ansari and Hassan Bella. (2000).
  Normal developmental milestones: Variations between Denver and Madinah children, Saudi Arabia.
                                                                   International Pediatrics,15:1.
IMCI Care for Development
uses a counselling approach


•   Focuses on improving interactions of mother (or other caregiver)
    with child, on what mother can do

•   Scaffolds the advice for activities to help move the child (and
    caregiver) to the next step

•   Helps solve problems in giving care

•   Where further assessment and care is possible, refers children
    in need

•   Based on the tested model for nutritional counselling in IMCI
                                                     (Santos et al. 2001)
•   Counselling on Care - special elements

     – Focus is on strengthening emotional ties between caregiver
       and child and sensitive, responsive interactions

     – Recommendations include activities that are:
         •   Appropriate for the child’s age and skills
         •   Designed to be done with caregiver
         •   Able to use simple items available in the home as ‘toys’
         •   Demonstrated, before spoken

     – Caregiver and child try-out the recommendation before

     – Praise reinforces interaction and responsiveness, e.g.
         • See how your child smiles at you and copies your sounds
         • See how you are able to help your child learn to count
         • Your child is enjoying playing with you
The intervention: IMCI Care for Development

•   Starts with improving the
    skills of first-level health
    workers: adds Care for
    Development to the IMCI
    guidelines and training on

•   Provides tools for follow-up

•   Links facility-based
    interventions to community
    interventions for greater
A   Field Test
               for the IMCI Care
Improved Assessment and Counseling

• UWC conducted field trial in Western Cape to see if the
  addition of care compromises outcomes
• 20 randomly selected health workers
• Observations of consultations and exit interviews before,
  during and four weeks after IMCI training
Improved Assessment

                                            Assessment of feeding
                                                                                     Before Training (n=14)
                                                                                     Supervisor's visit (n=19)
               100                                                                   Final Visit (n=19)

  pe r ce nt

                      Asks if     How many How many          About       Who/how
                     breastfed   breastfeeds times others serving size   feeds the
                                 in 24 hours     foods                     child
Improved Counselling


   80                                                                           Before training

   60                                                                           After training



        Compares feeding   Praises mother      Discusses      Checks mother's
              with                          recommendations    understanding
Improved caretaker’s recall of recommendations


                                                                        Before training
                                                                        After training


        Recommended foods   How often to feed   How to help child eat
                                  child                 well
Acknowledgement: Dr Jane Lucas and
CAH/WHO for the use of background slides

                  brings it all together

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