Vitamin A deficiency (VAD) is a common problem among preschool children and is associated with high mortality and morbidity. VAD has profound effects on the health of children including impaired immunity (leading to severity of infections such as measles and diarrhea), poor growth and development, visual impairment as well as iron deficiency anemia.
In Kenya, 30% of children aged 6-59 months received a vitamin A supplement in the six months preceding the Kenya Demographic Health survey of 2008-2009. The Kenya Guidelines for Vitamin A supplementation (VAS) through Early Childhood Development Centers (ECD) recommends twice yearly supplementation of this age group. In the past VAD was primarily done at health facilities with peak times during the child health and nutrition weeks (Malezi Bora). However children in ECDs were not reached through this approach.
Njiru Dispensary is located in Njiru district; one of the nine districts in the Nairobi province. The dispensary opened in 2009 and has been working with community health workers and community based organizations to provide vitamin A supplementation to children. One such organization is Njiru Organic Farming Integrated (NOFI), which started as an organization providing simple organic farming solutions to the community but has now diversified its mandate to include health care. Its activities now include supporting the community to access HIV/AIDS care and treatment as well as a focus on maternal and child health. They also support 680 OVC to access improved health, food & nutrition support, shelter & care, child protection, education, psychosocial support, and household economic strengthening services. In January 2011, only a paltry 39 children between 12 to 59 months of age received vitamin A supplementation (according to the district health information system) through Njiru dispensary despite this strategy.
In June 2011, the chairperson of the Njiru Organic Farming Integrated (NOFI) group attended a 5-day quality improvement (QI) coaches training together with two district government officials. The QI training was based on the Orphans and Vulnerable Children (OVC) QI service standards for Kenya using a QI approach known as Improvement Collaborative. The training was a joint initiative of APHIAplusNairobi-Coast and Health Care Improvement Project, both USAID funded. Following the quality improvement coaches training, NOFI trained and set up a 20 member quality improvement team made up of representatives of OVC, caregivers, key community and religious leaders, teachers and community health workers (CHWs). In line with the quality improvement guidelines they selected three key areas that were the most challenging in their community; education, health, shelter and care. Three teams were created to take care of these areas. The education team had members who were CHWs attached to Njiru dispensary and were aware of the challenge that the neighboring Njiru dispensary was facing with the distribution of vitamin A supplementation. They encouraged the health facility to work through the school system in order to reach the children. The CHWs, health facility management team and head teachers decided to work together targeting private and public schools. The four teachers in the QI team helped in mapping and selection of 13 schools that had the highest number of under fives.
All children under five were registered using the normal school registers. Subsequently, a day was set aside for a health worker to come and administer vitamin A. Once a child is provided with the supplement, their name is checked off in the register and a note is handed to them to take to their parent indicating that the child received the supplement. In addition to this, the child receives a small ink mark on their little finger. Caregivers have prior knowledge of what the mark signifies. Those children who are not reached through the school are reached through door to door intervention and Sunday schools in churches. At the facility level, vitamin A tally sheets were used for the exercise as well as the children’s health cards. All the 13 ECDs are maintaining the VAD register. Results
There has been an improvement in the numbers of children receiving vitamin A supplementation since this program began last year. In December 2011, through the schools, a total of 2655 children were reached including 124 OVCs supported by NOFI. This is a significant improvement from the 39 recorded in January 2011.
In addition to providing vitamin A, the school system can be used to carry out deworming as well as participate in national immunization campaigns for polio and measles. The last national campaign for polio was carried out in December 2011 also reaching the same number of children under five within the thirteen schools.
Involving key members of the community in promoting their own healthcare is an effective model for creating impact through targeting health services to those who need them most.
This model of engagement is also the cornerstone of the community strategy. The community strategy works best if different partners at community level maintain commitment to community based health and undertake initiatives that enrich or complement day to day tasks of the community health worker. It is essential that CHWs are fully involved in such initiatives.
Before NOFI set up the quality improvement team, it was impossible to penetrate the school system (especially private schools) for such activities. However, after engaging the teachers, key community and religious elders in the team, they have been able to work through the schools and to a smaller level the households and churches.
A well planned strategy leads to the unveiling of gaps that if addressed collectively benefits many and especially those who need to be targeted. Efforts to improve the quality of service provided to the OVC were able to reveal underlying challenges and when these challenges were addressed a large number of children aged 12 months – 59 months benefited from VAS.