4. Chapitre 4 : Contribution des relais communautaires au suivi de la croissance des enfants de moins de cinq ans en milieu rural du Sud Kivu (R.D.Congo).
Introduction
Après avoir participé activement au processus d’identification des populations et de leur catégorisation par groupe cible tel que décrit dans le chapitre 3, ce chapitre évalue la capacité des relais communautaires à contribuer au suivi de la croissance des enfants de moins de cinq dans leurs milieux respectifs.
Nutritional monitoring of preschool-age children by community volunteers during armed conflict in the Democratic Republic of the Congo.
Ghislain Bisimwa, Thierry Mambo, Prudence Mitangala, Carole Schirvel, Denis Porignon, Michèle Dramaix and Philippe Donnen.
Article publié dans Food and Nutrition Bulletin, 2009. Vol.30, no.2:120-7.
Abstract
Background. The coverage of preschool preventive medical visits in developing countries is still low. Consequently, very few children benefit from continuous monitoring during the first 5 years of life.
Objective. To assess community volunteers' effectiveness in monitoring the growth of preschool-age children in a context of endemic malnutrition and armed conflict.
Methods. Community volunteers were selected by village committees and trained to monitor children's growth in their respective villages. Community volunteers monitored 5,479 children under 5 years of age in the Lwiro Health Sector of the Democratic Republic of the Congo from January 2004 to December 2005 under the supervision of the district health office. Children's weight was interpreted according to weight-for-age curves drawn on the growth sheet proposed by the World Health Organization and adopted by the Democratic Republic of the Congo.
Results. During the 2-year program, the volunteers weighed children under 5 years of age
monthly. The median percentage of children weighed per village varied between 80% and 90%
for children of 12-59 months, and 80% and 100% for children of less than 12 months even during the conflict period. The median percentage of children between 12 and 59 months of age per village ranked as highly susceptible to malnutrition by the volunteers decreased from 4.2% (range, 0% to 35.3%) in 2004 to 2.8% (range, 0.0% to 18.9%) in 2005.
Conclusions. The decentralization of weighing of children to the community level could be an alternative for improving growth monitoring of preschool-age children in situations of armed conflict or political instability. This option also offers an opportunity to involve the community in malnutrition care and can be an entry point for other public health activities.
Key words: Armed conflict, community, growth monitoring, malnutrition, volunteers
BACKGROUND
In 2005, the World Health Organization (WHO) estimated that 11 million children under 5 years of age die each year, the majority in developing countries. Four million of these deaths occur within 28 days after birth, and 53% of all deaths are directly or indirectly associated with malnutrition [1-3]. In January 2008, Black et al. [4] revised the estimate of the proportion of malnutrition-associated deaths to 35%. Reduction of child mortality depends on improvement of child care during the first years of life. Special care should be devoted to nutrition monitoring. To reach this goal, several policies have been implemented, such as monitoring of child growth, pregnancy, and delivery [5,6].
The coverage of preventive activities is still low in developing countries, especially preschool-age medical visits. Consequently, very few children benefit from continuous nutritional monitoring during the first 5 years of life [7]. In the Democratic Republic of the Congo, a recent survey found that less than 30% of children 0 to 59 months of age are weighed at least once every 3 months by adequate medical services. In South Kivu, however, the percentage is even lower, at 18.5% [8]. The attendance rate at preschool medical visits is usually higher for children under 1 year of age. In some health areas the
rate reaches 70% to 90%. Attendance at medical visits dramatically diminishes after administration of the measles vaccine at 9 months.
Yet it is generally agreed that at this age the risk of malnutrition increases. In the Democratic Republic of the Congo, the prevalence of severe malnutrition peaks at 12 to 24 months of age and remains high until 5 years of age [8-10].
A study published in 2005 showed that the Democratic Republic of the Congo is among the countries with a high rate of child mortality. It was ranked ninth in the world in child mortality, with a rate of 205 deaths per 1,000 live births per year, and fifth in the absolute number of child deaths [2]. A Multiple Indicator Cluster Survey (MICS II) conducted in 2005 by the Ministry of Planning of the Democratic Republic of the Congo and UNICEF corroborated this finding and showed a higher rate of child mortality (210 deaths per 1,000 live births per year). The same survey showed that the South Kivu District had the highest rates of acute malnutrition according to weight-for-height scores (16.5%) and child mortality (247 deaths per 1,000 live births per year) [8].
There is a current debate about the necessity of strengthening growth monitoring of preschool-age children. Most experts agree on the necessity of implementing integrated policies allowing the control of all risk factors affecting young children in developing countries (undernourishment, infectious diseases, and environmental exposure) [11].
Other authors go further and propose that communities should be involved in health- care issues such as malnutrition [12]. This option is enticing, and experts in nutrition have been trying to study the possibility of involving the community in malnutrition screening and caring. So far, most health care approaches in communities have been carried out by health professionals rather by the community itself [13].
This study was carried out to assess the effectiveness of monitoring the growth of preschool-age children by community volunteers through village nutrition committees in a context of endemic malnutrition and armed conflict in South Kivu.
METHODS Study area
The study was carried out in Katana Health District precisely in Lwiro health sector who includes two health areas, Buhandahanda and Lwiro. It is located in the South Kivu Province, Eastern Democratic Republic of the Congo between 1,500 and 2,000 m altitude, bordered on the east by Lake Kivu in Rwanda and on the west by the Kahuzi Biega National Park. The climate is temperate, with two rainy seasons (April to June and October to January). The economy of the region is mainly based on small-scale agriculture. The main food products are sweet potatoes, beans, cassava, and food of animal origin is scarce. Malnutrition is endemic in South Kivu, with the highest child mortality rate found in the study area [7,8,14].
Study plan
A nutrition program based in the community was conducted in the Lwiro Health Sector.
This sector has an estimated population of 30,000 in 31 villages distributed in two health areas (Buhandahanda and Lwiro). The nutrition program was conducted for 32 months (from April 2003 to December 2005) and included a population awareness campaign, recruitment and training of community volunteers, and organization of community weighing sessions.
After the awareness campaign, the inhabitants of each village appointed five representatives to the village nutrition committee. The criteria were personal moti- vation, devotion to community, integrity, good morality, known employment or occupation, and ability to read and write. Priority was given to women. Village committees composed of five members from different professions were constituted in each village and were given the responsibility to follow up children's growth in their respective villages.
Community volunteers agreed to work for free. However, to guarantee their motivation, the Health District Office agreed to employ them whenever there was a paid activity (survey, vitamin A supplementation campaign, polio campaign).
Community volunteers received training during three successive mornings on the following themes: 3A approach (appreciate the problem, analyze the problem, and take appropriate actions), growth surveillance of under- five children, feeding of children and key nutrition practices, techniques for weighing children and malnutrition screening, food security at the family level, and family resource management. A presurvey was done in April 2003 by community volunteers. The objective of the survey was to take a rigorous census of the population.
Community weighing sessions were conducted monthly from January 2004 in all villages, and monthly sheets for data collection were given to the village committees.
All data were collected by community volunteers within their village. The village committees were supervised by the senior nursing staff and the health district frame team (the physician as leader of district health and his collaborators). The program also received support from a physician specialist in public health and nutrition, a nutritionist, a technician in rural development and two extension workers. This protocol was approved by the district ethics committee in charge of health, and prior approval of parents whose children were involved in this study was sought.
Organization of community weighing and collection of anthropometric data
Each village committee planned two community weighing sessions monthly (one main session and one session for children who were absent from the main session).
For each village committee, the first session was organized in the presence of a nurse or health agent who was involved in weighing activities at the health area level.
Meeting places were determined according to local availability (school, church, community day nursery, or nutritional supplementation center). A total of 5,479
children under 5 years of age living in the Lwiro Health Sector were included in the survey between January 2004 and December 2005.
Each child was weighed naked or with light underpants with a Salter scale, and the weight was recorded on a growth sheet. Children's weight was interpreted in relation to different weight-for-age (WFA) curves drawn on the growth sheet. The proposed WHO monitoring growth sheet adopted by the Ministry of Health of the Democratic Republic of the Congo was used in this study. The green strip represents the space above -2 SD including the 50th percentile curve, the yellow strip represents the space between -2 SD and -3 SD, and the red strip represents the space below-3 SD. Each child was located on the sheet depending on his or her weight and age. Children located exactly on the separating line (between two strips) were ranked as belonging to the lower strip. A child presenting with edema was considered in danger and transferred to the pediatric hospital. Other children who ranked in the red strip but did not have edema were con- sidered to have severe malnutrition. These children were transferred to the health center for diagnosis of malnutrition according to weight-for-height (WFH) criteria.
Children who ranked in the green strip with an ascending WFA were considered to have a good nutritional status, and their parents were congratulated. Children who ranked in the green strip with a descending or stationary curve for 3 months and those in the yellow strip were considered to be in the "alert" phase, and were checked to assure a good nutritional followup. A community discussion was held on children in the danger phase (red strip) or the alert phase (yellow strip or green strip decreasing or stationary) to analyze the possible causes of this situation. Home visits were organized to support the mothers of these children and to help them intensify their feeding. Health center nursing staff were associated with that program. All children in need of vaccine were transferred to health centers according to the vaccine calendar in use in the Democratic Republic of the Congo. Children presenting with signs of morbidity from home or during the weighing process (fever, diarrhea, coughing for more than 3 days, dyspnea) were also referred to the health center for a curative medical visit. Children under 6 months
of age were particularly monitored; their mothers were advised to practice exclusive breastfeeding up to 6 months of age.
In addition to community weighing, each village committee met once a week to assess the level of progress and study the possibility of strengthening population mobilization for the benefit of nutrition. Community meetings were organized monthly in each village to assess reports of activities. Reports of community weighing (number of children weighed and proportion of children classified as malnourished) were regularly analyzed by the senior nurse and the technical team of the health district.
Data control and management
Supervising missions were set up in different villages to attend community weighing sessions and community discussions. Each village committee was supervised at least once every 2 months. At the end of the month, the health area village committee met with the health center senior nurse to validate reports from different villages before sending them to the Health District Office and to the technical team. Dialogue meetings between the Health District Office and the joint commission were organized to validate reports made by community volunteers.
All reports with aberrant values were excluded from the analysis. Agreement between the number of children examined and the number of children ranked for nutritional status was checked, and a margin of error of 5% or less was considered acceptable. The statistical analysis was conducted on 616 reports, 87.6% of the 703 reports received (87 reports were excluded because of aberrant values). In 2004, 311 reports were received, and in 2005, 305 reports were received.
Statistical methods
Data were encoded in ACCESS software and analyzed by SPSS 12.0 software. The percentages of children weighed within each age category and each village were expressed as medians, followed by minimums and maximums as a measurement of
dispersal. The Mann-Whitney test was used to compare the proportions of children with WFA < -3 SD within the 2-year program. Graphics were produced by SPSS 12.0 software.
RESULTS
From January 2004, each village committee was responsible for monitoring the growth of children under 5 years of age in its village. Each village submitted monthly activity reports. A total of 744 (31 x 24) reports were expected for the 2-year study. A total of 703 reports that were complete and validated by the central office health district were considered in this study. This represents a completeness rate of 94.5% for the 2-year period (98.4% for 2004 and 90.6% for 2005).
The median percentage of children under 12 months of age weighed monthly during the 2 years varied between 80% and 100%. The percentage decreased from 2004 to 2005 (figure 4.1). The median percentage of children between 12 and 59 months of age weighed monthly during the 2 years varied between 80% and 90% (figure 4.2). The proportion of children between 12 and 59 months of age whose WFA ratio was less than -3 SD declined during the second year of monitoring. In general we observed an improvement in nutritional status in the second year (p < 0.001, figure 4.3 and table 4.1).
Figure 4.1. Median percentage of children under 0-11 mo old weighed monthly per village in 2004-2005.
The percentage varied between 80% and 100%.
FIG. 4.2. Median percentage of children between 12 and 59 months of age weighed monthly per village in 2004 and 2005.
The percentage varied between 80% and 90%.
40 50 60 70 80 90 100
Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec
Median percentage
Month
Median percentage of children under 1 year of age weighed monthly per village
2004 2005
70 75 80 85 90 95 100
Median percentage
Month
Median percentage of children12-59 mo-old weighed monthly
2004 2005
Figure 4.3. Percentage of children between 12 and 59 months of age weighed and ranked as malnourished according to weight-for-age (WFA)
Percentage of children between 12-59 mo weighed and ranked as malnourished according to WFA (<-3SD). This percentage shows a tendency to decline during the second monitoring year.
Table 4.1. Nutritional status of children between 12 and 59 months of age according to month and yeara
Goodb Alertb Dangerb
Month 2004 2005 2004 2005 2004 2005
Jan 79.4 (30.1) 85.6 (16.3) 17.1 (23.1) 9.1 (10.8) 4.2 (6.3) 3.3 (5.1) Feb 83.1 (20.7) 87.6 (13.2) 14.4 (14.4) 9.7 (7.8) 5.6 (5.4) 2.1 (4.0) Mar 80.8 (17.0) 83.3 (15.6) 13.9 (12.2) 12.2 (15.2) 4.4 (6.0) 3.5 (4.4) Apr 85.7 (14.6) 84.8 (13.8) 12.2 (9.4) 12.1 (8.2) 4.0 (3.0) 2.8 (3.5) May 80.5 (29.6) 86.4 (11.0) 12.5 (16.9) 10.3 (9.2) 5.0 (8.3) 2.3 (4.1) Jun 84.5 (17.5) 89.6 (17.2) 10.4 (9.4) 8.3 (8.5) 4.0 (6.1) 2.7 (5.4) Jul 86.6 (19.7) 89.6 (11.7) 12.6 (13.2) 7.4 (10.3) 3.6 (5.5) 2.5 (4.9) Aug 83.3 (28.0) 89.4 (11.8) 1l.2 (17.9) 8.7 (9.4) 5.0 (5.9) 2.9 (4.8) Sep 82.4( 20.2) 83.3 (2l.5) 10.7 (10.9) 11.0(17.2) 5.3 (4.6) 4.9 (6.9) Oct 83.3 (20.7) 84.2 (14.3) 11.5 (19.0) 13.0 (10.0) 4.6 (5.3) 3.2 (4.9) Nov 83.7 (13.1) 89.0 (18.1) 12.1 (12.7) 8.5 (12.3) 3.2 (5.0) 2.9 (5.3) Dec 90.0 (12.4) 86.7 (15.4) 7.6 (6.3) 8.5 (10.9) 2.3 (5.4) 2.8 (5.8)
(a) The numbers are the median percentages of children (interquartile range); (b) WFA criteria was used:
Good (WFA above - 2SD), Alert (WFA between - 2 SD and - 3 SD) and Danger (WFA < - 3 SD).
0 1 2 3 4 5 6
Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec
Median percentage
Month
Percentage of children 12-59 mo-old weighed and ranked as malnourished according to WFA
2004 2005
DISCUSSION
Community involvement in monitoring the growth of preschool-age children in Kivu District through community volunteers resulted in a good performance in monitoring of children under 1 year of age and an exceptional achievement in monitoring of children aged 12 to 59 months, who are not usually monitored in health centers. The program also demonstrated the effectiveness of community volunteers in caring for preschool- age children in the context of armed conflict and instability.
Monitoring the growth of children under 1 year of age
During the 2-year community-based nutrition program, the median percentage of children under 1 year of age weighed monthly was 94.1 % (range, 13.6% to 100%) in 2004 and 84.6% (range, 23.5% to 100%) in 2005 (fig. 4.1). This result remains encouraging for a community program, but some health districts with good health coverage and good accessibility regularly weigh 70% to 80% of children under 1 year of age without a community-based nutrition strategy [8]. This performance is often attributed to the fact that parents are sufficiently motivated to bring children in that age group for vaccination. Nutritional monitoring is carried out when the mother brings the child for vaccination, and monitoring is usually stopped between the 9th and 10th months, when the child has received the last vaccine according to the vaccine program in use in the Democratic Republic of the Congo [15]. The task of the community volunteers, particularity in relation to that age category, consists in assuring regular monthly monitoring, probably because weighing sessions are performed at the village level and community volunteers conduct a door-to-door awareness campaign. This regular contact with community volunteers can guarantee, in addition to growth monitoring, the promotion of some key practices, such as exclusive breastfeeding and early access to health-care services in case of illness. The duration of exclusive breastfeeding is prolonged in these children in settings where the rate of exclusive breastfeeding is very low [16].
Monitoring growth of children between 12 and 59 months
The median percentage of children aged 12 to 59 months in each village who were weighed monthly by the community volunteers was 89.9% (range, 9.3% to 100.0%) in 2004 and 85.6% (range, 15.0% to 100.0%) in 2005 (fig. 4.2). These results are interesting because, in most health districts, children over 1 year of age are far less likely to attend preschool medical visits. In the Democratic Republic of the Congo, the national strategy consists in ensuring that all children between 12 and 59 months are weighed four times per year. However, the most recent survey results show that only one out of four (24%) of children of this age were weighed at least once a term [7]. This low rate of attendance at preschool medical visits is due to various factors, including poor health coverage resulting in geographic inaccessibility, logistic problems, staff shortage and work overload, and lack of interest by parents in the context of poverty and high birth rates. Often the mother has two or three children under 5 years of age and may also be pregnant again. As she is unable to bring all the children to the health center, she gives priority to bringing the youngest child for vaccination or a child showing signs of illness.
Bringing a child to a preschool medical visit requires a great sacrifice for the mother, who must leave her other children and lose an entire day at home, with consequences for the family economy [17].
Results observed in children between 12 and 59 months growth monitoring appears to be exceptional in relation to field realities. Thus, the coverage of growth monitoring that we observed appears to be remarkable in this context. These results are interesting as when we know that children in this age group are not generally monitored, although the risk of malnutrition is highest among these children [9,18].
The effectiveness of the community volunteers can be attributed to several factors. The children were weighed close to their homes, so that the parents did not have to walk a long distance to the health center. The community volunteers lived in the same area as the parents and performed weighing in a friendly family context that did not require
effective, so that the community became aware that malnutrition is an important issue.
The community volunteers agreed to work for free. However, the District Health Office agreed to employ the volunteers whenever there was a paid activity (surveys, vitamin A supplementation campaign, polio campaign).
The involvement of the community volunteers in nutritional monitoring offers several advantages that contribute to greatly improving the growth-monitoring policy. The proportion of children weighed monthly remained high compared with other similar health centers in the same district where children above 12 months of age were not weighed [19]. The use of volunteers ensures that children will be monitored without involving extra work for the health center staff. The volunteers are able to select children needing medical treatment so that the health center staff can focus on these children and on those needing vaccination.
The village committees also monitored children over 5 years of age who were at high risk for illness because they came from families considered vulnerable. Some cases of kwashiorkor were detected among children in this group. We believe that this approach can contribute to early detection of malnutrition, which is aggravated when kwashiorkor is also present in older children [20].
Parents participated in community discussions about their children's growth, which could not be conducted in the health centers because parents do not have much time to spend outside their villages. The discussions helped draw the parents' attention to the impact of malnutrition on child mortality and consequently to the need to assure good nutritional monitoring in order to improve children's health. In the course of the discus- sions, some practices were identified as being detrimental to the nutritional status of children: long absence of mothers because of the distance from the hospital, long hospital stays, death of one parent, polygamy, insecurity, relocation, and poverty. Our analysis is supported by the study of Engle et al. in 1977 cited by Victorine Damienne Agueh who worked with a similar approach in Benin [21]. It is a conceptual framework on child survival, growth, and development who documented the fundamental causes
of malnutrition. This study has been inspired by UNICEF and other international organizations.
Tonglet et al. [22] criticized preschool medical visits in Africa, stating that excessive workloads made the staff unable to examine children correctly. Tonglet et al. suggested that preschool medical visits should be focused on some indicators that are more appropriate to assess and that are associated with the risk of morbidty of children in the region.
The study found that the median percentage of children between 12 and 59 months of age per village found to be in danger and in need of clinical and anthropometric screening for confirmation of the diagnosis was 4.2% (range, 0% to 35.3%) in 2004 and 2.8% (range, 0% to 18.9%) in 2005 (fig. 4.3 and table 4.1). Using WFH criteria, the nutritional survey carried out in Katana Health District in 2004 found a rate of acute malnutrition of 5.5% among children 6 to 59 months of age [23].
Between 2004 and 2005, there was an increase in the proportion of children with good nutritional status and a decrease in the proportion of those with "danger" or "alert"
status (fig. 4.3 and table 4.1). These changes cannot be attributed only to the action of the community volunteers because other events could have contributed to the improvement of children's nutritional status during this period. However, the intensive nutritional monitoring and the mobilization of the communities performed by the volunteers probably contributed to the improvement in children's nutritional status.
Although the efficacy of nutrition education for the enhancement of child growth is debated by different authors, a study carried out in the South Kivu region showed that weekly monitoring of children with moderate malnutrition enhanced their growth [24].
The improvement in growth with weekly monitoring was equivalent to that achieved by administration of a daily local porridge supplement. Thus, family and community involvement could contribute to protecting children from less economically developed countries against risk factors to which they have been exposed to since early childhood,
nutritional care in hospital settings in Kivu reduced the death rate among children. Hen- nart [26] and Donnen [27] found that the nutritional status of preschool-age children and of pairs of mothers and breastfed children in this region showed seasonal variations.
Monitoring growth of children between 12 and 24 months of age
During the 2-year community-based nutrition program, the median percentage of children between 12 and 24 months of age weighed monthly per village was 89.8%
(range, 11,1% to 100%) in 2004 and 86.2% (range, 17.6% to 100%) in 2005. For the category of children between 12 and 24 months of age, the median percentage of children per village ranked as in "danger" and in need of clinical and anthropometric screening for confirmation of the diagnosis was 3.2% (range, 0% to 35.7%) in 2004 and 1,5% (range, 0% to 33.3%) in 2005, a statistically significant reduction (p < .001, Mann- Whitney test). This reduction between 2004 and 2005 can be attributed to the general activities carried out by the volunteers, mainly nutritional monitoring and mobilization of the communities.
Seasonal changes
The malnutrition rate for all three categories (children under one year of age, children 12-24 months, and children 12-59 months) varies with the seasons, decreasing during the periods from February to April and from August to October. These periods correspond with the sowing periods. This change has also been documented by other studies [14,26,27].
Instability of the study area
Katana Health District is located in South Kivu Province, which has been unstable for more than 10 years. This zone is characterized by armed conflicts, as defined by the
“Centre de Recherche en Epidémiologie de Desastres” (CRED) in 2001 [28]. In our study, the median percentage of children weighed monthly initially stabilized between 90%
and 95% for the first 6 months of the program, declined in July, and continued with
oscillations between 80% and 85%, but without going below 80%. This fall in the percentage of children weighed monthly corresponds to the period when South Kivu, including the Katana Health District, was the location of a large military operation necessitating military intervention by the “Mission d'Observation des Nations Unies au Congo” (MONUC). Other health districts either interrupted all health activities or limited them to urgent curative activities [8,19].
We could also consider that the health and village committee can continue to operate even when the health center is closed during crisis and armed conflict [28-30].
CONCLUSION
The study has shown that the community volunteers constituted by village committees with recruitment based on village membership can offer valuable support to the health system. They can help in implementing and developing growth monitoring of preschool- age children, emphasizing particularly nutritional indicators.
Coordination between the activities of community volunteers and those of health-care center professional staff is a good way to decentralize nutritional monitoring at the community level. This model for community-based nutritional monitoring remains effective even in situations of armed conflict or acute instability. However, involvement of the community as well as support by community leaders is a prerequisite to achieve these results.
A more thorough investigation of the issue is worth carrying out. We suggest two approaches. First, an analysis of factors determining the motivation of community volunteers, followed by suggestions for various incentives to enhance volunteers' medium- and long-term commitment and motivation. Next, an analysis of methods of improving the quality of community-based weighing for an effective diagnosis of malnutrition in early stages and for community involvement in the care of acute malnutrition. This could constitute a great opportunity to strengthen an integrated strategy for the care of children's illness at the community level.
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