Presented by Sean Morris and Uwacu Theophila

August 3, 2011

The Ruli District Hospital Community Nutrition Program:

Evaluation and Recommendations for Improvement

Project Introduction

1. Evaluation of Community Nutrition Worker program

a. Surveys of CNWs at monthly meetings

b. Observation of village screening activities

c. Interviews with program supervisors

2. Understanding the community nutrition situation

a. Surveys of community members

b. Observation of nutrition education

c. Home visit assessment

3. Health center teaching gardens

a. Nyange HC teaching garden

b. Ruli Sustainable Agriculture Manual

c. Assessment of existing situation

4. Establishment of farming cooperatives

a. Understand existing village associations

b. Identification of potential stakeholders

c. Initiation of Nyange PLWHA pilot farming coop.

Project Introduction

Methodology …

• Chose 4 of Ruli’s 7 Health Centers at random

• Used clustered method to select survey participants

• Guidance and No Guidance surveys

• Rwankuba pilot survey

• Community members: Nutrition center, village

screenings, Nyange PLWHA, and VCT mothers

• Many villages and health centers represented

Project Introduction

Community Situation

Who is represented …

• 8 health centers [2 from other Hospital’s catchment]

• 25 cells

• 44 villages

• 5 males, 62 females

• 73.2% Married; 14.9% Single; 11.9% Widowed

• Educational achievement: 85% Primary; 6% Ordinary

Level; 1.5% Secondary; 4.5% CERAI, Familial, Technical

• Religion: 40.3% Catholic; 16.4% Protestant; 8.9%

Pentecostal; 10.4% Adventist; 24% No religion specified

Community Situation

Distance from Home to Health Center

• Combined Average, 1 hr. 38 min.

• Village Screenings, 2 hr. 10 min.

• Nyange PLWHA, 58 min.

• VCT Mothers, 1 hr. 26 min.

• Nutrition Center, 1 hr. 26 min.

Community Situation

Distance from Home to Screening Site

• Combined Group Average, 25

min.

• Village Screenings, 16 min.

• Nyange PLWHA, 36 min.

• VCT Mothers, 25 min.

• Nutrition Center, 28 min.

Community Situation

Household Circumstances:

• Average size, 5 people (ranging between 3 & 12)

• 85% of total sample have children <5 years

• 70% own land; 18% rent land; 12% live with extended family

• 85% farmers; 11.9% coltan miners; 10% artisans; 7.5% public

institution workers; 4.5% carpenters; 1% unemployed

Economic Situation

Estimated Monthly Household Income of

Community Members

0-5000Rwf

5001-10000Rwf

10001-15000Rwf

15001Rwf+

No Response

• Majority of community

members have very little

money to spend on food &

health insurance.

• Consistent with observations

of screening

participants’, and home visit

situations.

Thought question…

• What is the best way to

combat malnutrition in a

poor population that has

access to limited cultivating

space?

No Space for the Poor

What is your estimated monthly household income?

+1500010000<x<150005000<x<100000<x<50000

Co

un

t

10

8

6

4

2

0

Bar Chart

Large area

Medium area

Small area

If f4.1, how large is the area of land that you

cultivate?

What is your estimated monthly household income?

+1500010000<x<150005000<x<100000<x<50000

Co

un

t

12.5

10.0

7.5

5.0

2.5

0.0

Bar Chart

No

Yes

Has your child ever been to the

malnutrition center for treatmet?

Agriculture Situation

Available Land …

• 15% of CNW villages report a “large area to farm”

• Consistent with community member surveys…

• 58.9% have small area

• 37.5% have medium area

• 3.6% have large area

• 67% of VCT mothers, and 70% of Nutrition Center mothers

report having a “small” area to farm…

Agriculture & Malnutrition

0

10

20

30

40

50

60

% o

f R

esp

on

de

nts

Seasonality of Malnutrition Incidence and Cultivating Challenges

Months of Highest Malnutrition Incidence

Most Difficult Month to Cultivate

Let’s Work Together!

0

10

20

30

40

50

60

70

80

Total Village Screening Nyange PLWHA VCT Mothers Nutrition Center

Mothers

% o

f R

esp

on

de

nts

Opportunities for Farming Cooperative Formation

Work Alone

Work Together

Both

Need for Diversity

3

4

5

9

9

34

37

61

68

87

0 10 20 30 40 50 60 70 80 90 100

% of Villages Growing...

Village Level Crop Production

Beans

Maize

Tubers

Coffee

Vegetables

Soya

Bananas

Fruit

Wheat

Sorghum

Community Food

Security Summary

• Average Consumption-to-Sale Ratio = 90:10 (76% at 100:0)

• Vast majority of community members are working alone!

• Overall lack of crop diversity nutrient diversity

• Those who are poor, and at greatest risk of malnutrition have

marginal land access

• Malnutrition is temporal; therefore predictable and beatable!

CNW Situation

Who is represented …

• 4 health centers [Ruli, Rwankuba, Muhondo, & Coko]

• 23 cells

• 85 villages

• 44 males, 56 females

• 92% Married; 2% Single; 6% Widowed

• Educational achievement: 75% Primary; 8% Ordinary

Level; 5% Secondary; 12% CERAI, Familial, Technical

• Average CNW age – 38.9 years

• Average tenure as CNW – 6.1 years

CNW Situation

Satisfaction …

• Average satisfaction (from 1 to 10) – 8.05

• “How has being a CNW improved your life?”

• 62% report improved diet and nutrition knowledge

• 59% report improved capacity to care for family

• 98% see reduced malnutrition since beginning their work

• 94% report good attendance at each screening

• Only 26% claim to have adequate resources to perform

their duties…

Village Screenings

Growth Monitoring

• Weight of each child

under 5 years of age

• Record weight

• Referral based on

growth chart status

• Growth chart also

includes vitamin and

immunization history

Village Screenings

Information, Education, Co

mmunication (IEC)

• Convey relevant

nutrition, infectious

disease, or lifestyle

information to the

community

• MOH Guidebooks –

rarely used…

• Sometimes

planned, often

impromptu

Village Screenings

Kitchen Demonstration

• Demonstrate

hygienic, balanced meal

preparation

• Explain the importance of

a balanced diet

• Give practical suggestions

for preparing food

specifically for the child

CNW Needs

Greatest needs to improve service from CNWs to community …

• Additional training – 81%

• Training is currently informal, on the job training

• Indoor meeting space – 70%

• Most village screenings observed took place outdoors

• Cooking supplies – 42%

• Currently, supplies are often borrowed from community

• Nutrition education materials – 41%

• They should have MOH IEC guidebook in each village

CNW Needs

Barriers to providing adequate service to the community …

• Lack of Materials – 46%

• This includes kitchen, education, and record keeping

• Evil ideologies of parents – 41%

• Discouraging screening attendance; belief in traditional

healing; failure to “buy into” nutrition education

• 86% give instruction in agriculture to their village, BUT 99% desire

more sustainable agriculture training opportunities

CNW Knowledge

Perceptions of malnutrition …

• Only 15.7% believe that the children of HIV+ mothers are more susceptible to malnutrition!!!

• BUT … 100% know that nutrition is especially important for HIV+ individuals

• 91% know the number of months that an HIV+ mother should exclusively breastfeed (6 months)

• ~70% perceive a problem of malnutrition in Rwanda … only 27% see malnutrition as a problem in their own village. Denial?

• Only 26% of CNWs check for all signs of malnutrition [swollen cheeks/legs, large belly, hair discoloration, signs of anemia]

CNW Improvements

0 5 10 15 20 25 30 35 40

% of Respondents

Community Member Needs for

Improvement of Nutrition Situation

More Information about Nutrition

More Training/Education of Parents

Support for Creating Agriculture Coop

Care/Hygiene of Children

Having a Kitchen Garden

More HC Supervision of Child

Increased Food Access for <5 Children

Respect Decisions of Health Leaders

More Access to Land

Family Planning

No Ideas

CNW Improvements

0 10 20 30 40 50 60

% of Respondents

Community Member Suggestions for CHW Program

Better Education and Communication

to Parents

More Home Visits

Increased CHW Training

Take a Greater Stake in Child Growth

No Suggestions

Improved Information About Livestock

CNW Situation Summary

• Desire for more training opportunities to better serve village

• Nutrition, Agriculture, Counseling for parents, etc.

• Lack of kitchen materials and indoor meeting space

• Most problematic during the rainy season – this is also the

time of greatest malnutrition (slide 12)

• Need for improved information about HIV and nutrition

• Need encouragement in dealing with parent ideologies, and

reminding that the fight against malnutrition is not over!

Recommendations

① Training and Informational Assistance

i. Formal training at program entry

ii. Increase involvement of village husbands

iii. Printed instruction for CHW diagnosis and referral

② Materials and Monthly Screening Improvement

i. Indoor kitchen and supplies for each village

ii. Central, enclosed meeting space for IEC

③ Agriculture and Food Security Assistance

i. Inclusion of agronomist into Ruli Nutrition Program

ii. Working teaching gardens at every health center

iii. Farming cooperative formation – SOSOMA and Food Security

iv. Supervised installation of kitchen gardens by CHWs

④ Integration of Nutrition and HIV Programs

i. Opt-in HIV register for each village

ii. Kitchen demonstrations and nutrition education for HIV+ mothers

1. Training and Information

Objective Responsibility Feasibility Priority

Formal TrainingHealth Center

CHW LeadersHigh High

Include Village

Husbands in IEC

CHWs, Health

Centers, HospitalMedium Very High

Printed

instruction for

CHW referral

protocols

The Ihangane

ProjectHigh High

2. Materials and Screening

Objective Responsibility Feasibility Priority

Indoor kitchen

for each village

The Ihangane

Project, CHWsMedium Medium

Enclosed

meeting space

for IEC

The Ihangane

Project, CHWsLow Medium

3. Agriculture and

Food Security

Objective Responsibility Feasibility Priority

Inclusion of Ruli

Hospital

Agronomist

The Ihangane Project,

Ruli HospitalHigh High

Farming Coop.

Formation

CHWs, Ruli Hospital

The Ihangane ProjectHigh Very High

Supervised

Kitchen Garden

Installation

CHWs, Health Centers Medium Very High

Objective Responsibility Feasibility Priority

Inclusion of Ruli

Hospital

Agronomist

The Ihangane Project,

Ruli HospitalHigh High

Farming Coop.

Formation

CHWs, Ruli Hospital The

Ihangane ProjectHigh Very High

Working Teaching

Gardens at Each

Health Center

Ruli Agronomist, CHWs,

Health CentersHigh High

Supervised Kitchen

Garden InstallationCHWs, Health Centers Medium Very High

3. Agriculture and

Food Security – Farming Coop.

Nyange PLWHA Farming Cooperative

3. Agriculture and

Food Security - SOSOMA

0

10

20

30

40

50

60

70

80

Maize Soya Sorghum None

% o

f R

esp

on

de

nts

SOSOMA Constituent Production

Total

Village Screening

Nyange PLWHA

VCT Mothers

Nutrition Center Mothers

Kitchen Garden

Theory… …PracticeVs.

Sustainable Agriculture

• Raised or Double-Dug beds – Increase land area; deep root

penetration; increased water retention

• Compost Pile Construction – Improve soil fertility; reduce

unnecessary purchase of chemical fertilizer that harms soil

• Inter-planting & Close Spacing – Reduce pest pressure;

improve yields; increased water retention

• Crop Rotation and Planning – Improved soil fertility;

preparation for months of difficult cultivation

“Ruli Hospital Sustainable Agriculture Manual”

Sustainable Agriculture

4. Integration of Nutrition

and HIV Programs

Objective Responsibility Feasibility Priority

Opt-In HIV Register

for Each Village

Ruli Hospital, Health

Centers, CHWsHigh High

Kitchen Demo.

and Nutrition

Education for VCT

mothers at the

Nutrition Center

Ruli Hospital, Nutrition

Center, The

Ihangane Project

High High

Thank you! … Questions?

① Training and Informational Assistance

i. Formal training at program entry

ii. Increase involvement of village husbands

iii. Printed instruction for CHW diagnosis and referral

② Materials and Monthly Screening Improvement

i. Indoor kitchen and supplies for each village

ii. Central, enclosed meeting space for IEC

③ Agriculture and Food Security Assistance

i. Inclusion of agronomist into Ruli Nutrition Program

ii. Working teaching gardens at every health center

iii. Farming cooperative formation – SOSOMA and Food Security

iv. Supervised installation of kitchen gardens by CHWs

④ Integration of Nutrition and HIV Programs

i. Opt-in HIV register for each village

ii. Kitchen demonstrations and nutrition education for HIV+ mothers