Community health workers in Sergipe, Brazil : implications for their future role in maternal and child health

Abstract

Every year six million children die worldwide due to diseases that are easily preventable or curable. Interventions to reduce the number of deaths are offered by health facilities, yet many children continue to die at home without receiving any type of health care. Expansion of the strategy for the Integrated Management of Childhood Illness (IMCI), promoted by WHO and UNICEF, provides a unique opportunity to improve health care for young children at the household level. This thesis examines the potential role for community health workers (CHWs) in extending the IMCI strategy from health facilities to the community. A review of the literature on CHWs and IMCI is followed by a description of two state-wide questionnaire surveys and a qualitative study carried out in Sergipe, Northeastern Brazil, aimed at evaluating child health care with particular emphasis on the role ofCHWs. In the first survey, children less than five years of age were investigated regarding morbidity patterns, utilization of health services, socioeconomic and household conditions. A two-stage process led to a representative sample of caretakers of 1,785 children (response rate of 98%). About one third of the families with children were living below the poverty line and under unfavourable environmental conditions. Of all the children studied, 39% had been ill in the two weeks preceding the survey, mostly with acute lower respiratory infections which is the main reason for medical consultations and hospital admissions in the State. Co-morbidity was frequent and 85% of all reported illness episodes were covered by the IMCI strategy. Nine out of 10 children were fully immunized, and 69% had had their growth monitored in the last month. Almost all children who sought care were seen by a health worker. Despite high access to health care, essential drugs were often unavailable in health facilities. Overprescribing was also common with two thirds of children, seen by a doctor, having received an antibiotic. The median duration of total and exclusive breastfeeding were very short at 5.4 months and 2.1 months, respectively. Complementary feeding was also inappropriate with a median number of three meals in the previous 24 hours when, at least, five meals are recommended. There is therefore a potentially significant role for IMCI in improving the quality of care and nutritional management of children under five years of age. CHWs were regularly visiting 81% of all children under five years of age in the State. There was a clear trend towards higher coverage among the poor. Coverage was highest among children living in municipalities in the interior of the State (86.9% against 58.1% in the capital) and in rural areas (88.5% against 76.3% in urban areas). CHWs were also more 8 likely to visit children whose mothers did not attend school (86.3% against 69.3% with nine years or more of schooling) and those belonging to families earning less than one minimum wage (89.2% against 69.4% of families receiving four minimum wages or more). This suggests that CHWs are contributing to reducing inequities in access to basic health care and may explain the high coverage of immunization and growth monitoring activities as CHWs playa major role in delivering these activities. In the second representative survey, 311 CHWs were asked about their knowledge on child survival issues as well as about the support and supervision they received from their local health teams. Again, a two-stage sampling process (municipalities and CHWs) was used with a response rate of 96%. CHWs from Sergipe state were usually female, young and married. Their educational level was substantially higher than that of mothers of young children. Yet, CHWs were inadequately trained, supervised and supported. They were overloaded having to deliver 26 different tasks and usually worked alone in the community. In addition, their professional standing was negatively affected by low salaries, a lack of job security and few fringe benefits. A comparison of families who were regularly visited by CHWs and those that were not, showed a positive effect on maternal knowledge about oral rehydration therapy, breastfeeding and kind of delivery. Children who were visited were also more likely to receive vitamin A and be weighed regularly. The positive impact of CHW visits remained after adjustment for confounding variables. These findings suggest that CHWs are already effective in improving maternal knowledge as well as in providing several interventions that are part of the IMCI strategy. In order to investigate perceptions and beliefs regarding health care, the qualitative study included expert interviews with doctors, nurses and heads of municipal departments of health as well as in-depth interviews with a sample of CHWs. Mothers of children under five years old were enrolled in the qualitative study through focus groups discussions. A total of 90 qualitative interviews and six focus groups were carried out by the author of this thesis and an anthropologist. These data showed that the relationships between facility workers, CHWs and community mothers were often conflicting. Facility workers did not take part in community activities and, in tum, mothers did not participate in group activities in the health facilities. As a result, integration was poor or non-existent. Mothers, especially those from rural areas, wanted a greater availability of doctors and nurses. Most facility workers, in contrast, judged mothers to be highly demanding, making excessive use of health services by seeking health care for mild illnesses, and making inappropriate demands because they 9 lacked knowledge about the roles of the different cadres of health workers. The role of CHWs in the health team was unclear and their tasks were not properly defined. Their relationship with facility workers, especially doctors, was often conflicting. They also did not relate well to urban mothers, who wanted direct access to doctors and who did not feel that CHWs had greater knowledge than themselves. Rural mothers had a generally positive view of CHWs. Currently the main task of CHWs is to act as messengers between the community and the health facility. While this is a positive role per se, CHWs could have a greater impact if their roles in urban and rural areas were more specialized. In urban areas, they should be better trained to deliver educational messages, whereas in rural areas they should also be allowed to perform simple curative tasks to improve their professional standing as well as to deliver key interventions in areas with poor access to health facilities. Almost all respondents stated that extending the activities related to IMCI - such as identifying pneumonia and dysentery at household level through CHWs - would be highly appropriate and desirable. However, to effectively extend IMCI to the community through CHWs, substantial changes would have to occur in their selection, training, supervision, support and professional standing. Several policy recommendations for improving child health in Sergipe are presented. These include improving the performance and professional standing of CHWs and redefining their tasks in the light of the IMCI strategy. Recommendations are also given for improving the integration between communities, facility-based health workers and CHWs, and on how to extend IMCI more effectively to the community through an enhanced role for CHWs.