Honduras: Integrated Care of the Child (AIN)

For many years, the Manoff Group (as part of the BASICS project) provided technical assistance to the AIN program in Honduras. The program has evolved into a model for community IMCI in Latin America and beyond. The program approach features community volunteers who weigh, counsel, and refer all children under age two. The program combined and strengthened health and nutrition actions to prevent and help reduce the prevalence of malnutrition and illness in young children. AIN has also improved the prevention and early detection of illness as well as promoted adequate growth for young children under age two.

An important element of the program is that communities have to request and support the program work. Trained community volunteers, supported and supervised by local and regional health staff, weigh all children under age two monthly. The weight of the child is recorded and monitored to ensure that each month the child maintains or gains weight. The community health volunteers use counseling cards with caregivers to discuss possible reasons for lack of growth. Specific advice is given for improving home care, feeding practices and related health behaviors. Before returning home, the health monitor and mother negotiate and agree on specific actions that the family will try to eat and remain healthy. The health volunteers use these monthly weighing sessions to reinforce good feeding and care practices and to identify growth faltering early so it can be addressed.

In addition, volunteers make household visits to follow up on children who have not attended the monthly weighing session or who are ill, lacking appetite or are losing weight. This home visit assures that the children in the community are seen and weighed each month. Children who are severely ill are referred to the appropriate health services by the volunteers. Collaboration with the health center personnel has increased vaccination coverage and encouraged early attention to illness.

The volunteers and nurses report to the community several times a year on how the young children of the community are doing. This reporting engages the entire community in analysis of the growth of its children and how to improve growth and health through collective action. The program also has facilitated the formation of support groups for mothers in the community to address common problems.

The Manoff Group technical assistance focused on two areas: community action and training.

Community action

Training in integrated community health programming was emphasized so that health staff could meet with community leaders and families to determine their interest in supporting a growth monitoring and promotion program. Once the program is accepted, the community selects the health volunteers. Health staff and volunteers learn to utilize tools, such as bar graphs, to present weight and health results to the community. To encourage local problem solving, communities carry out their own analysis of the reasons children might be having problems. The community may undertake activities to improve conditions such as encouraging community-based immunizations or cleaning up a contaminated source of water.

Competency-based training

Both health staff and volunteers needed support and training on weighing and counseling. Volunteers were inexperienced in health care so they had to be trained in all phases of weighing, health evaluation and recording data.

A series of 20 counseling cards were developed with situation and age specific guidance for the volunteers to use in negotiating feeding and care changes with the parents. The cards cover feeding practices, health maintenance and illness prevention and household management of illness. The cards are based on qualitative research on feeding practices carried out using Trials of Improved Practices (TIPs). TIPs enabled local mothers to help define appropriate practices they could utilize.

A simple volunteer's manual provides guidelines for carrying out tasks. The manual contains specific tools such as a Table of Expected Weight Gain and a Guide for Action that assist volunteers with the selection of the appropriate counseling cards.

Two training curricula were developed to systematize the training of volunteers, as well as the health staff that train, support and supervise them. The training and manual emphasize process, while the technical information is delivered separately.

The volunteers were trained in counseling techniques that are non-threatening to parents and encourage open, participatory discussion. The idea of negotiating behavioral changes surrounding the nutrition and health of the young child has been an effective tool for encouraging better health, as has the monthly weighing, recording of weight and community involvement.

Proven Results

A presentation on "Communications Strategies of the AIN-C Health and Nutrition Programme" at the 2009 International Congress of Nutrition highlighted the program's achievements. A 2004 evaluation found that in AIN communities, participation is widespread and consistent: in the three months prior to the 2004 survey, 83% of AIN children were weighed two or more times. Enrolled infants less than six months of age were significantly more likely to be exclusively breastfed than their non-enrolled counterparts. Enrolled children 6 through 23 months of age were 1.6 times more likely to be adequately fed for their age than non-enrolled children. Enrolled children were significantly more likely to receive rehydrating fluids (home fluids, breast milk, Litrosol [ORS]) for their diarrhea. Enrolled children with ARI were taken to a trained provider for care sooner than are non-enrolled children.

Among AIN children, increased participation is strongly associated with improved height-for-age, weight-for-age and weight-for-height. When controlled for caregiver and socio-economic variables, enrolled children who fully participated were 435 grams heavier than counterparts who were not participating each month. Indicators for immunization and vitamin A were significantly higher in AIN communities.