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A community volunteer programme was initiated in rural Jamaica in May 1990. The main aim of the programme was to monitor the growth of children less than 36 months of age through community health volunteers (CHVs) and improve their nutritional status. At the end of the second year the programme was evaluated to determine its effectiveness. The results of the evaluation indicated that almost all (95.6%) of the children were covered by the CHVs. In addition the participation rate was high (78.5%). However, only 50% of the children were adequately covered. Nonetheless, 81% of them gained adequate weight. Indeed, malnutrition levels declined by 34.5%. The annual cost per child per year for the total programme was fairly moderate (US$14.5) with growth monitoring accounting for nearly half (42.7). The results suggest that CHVs can play an important role in primary health care programmes in developing countries.

PIP: In May 1990 in Jamaica, a nutrition program was established in the isolated and low economic level community of Freemans Hall (population, about 1400; altitude, 1000-1300 m; rainfall, 2000-2000 mm) in Southern Trelawny parish. Community health volunteers (CHVs) monitored the growth of children younger than 36 months. A committee of representatives from the local health team and parent- teachers' association selected four CHVs. One CHV covered about 22 children. Two public health nurses and two nutritionists conducted a one-week training course for the CHVs. Topics included malnutrition, young child feeding and weaning, nutrition during pregnancy, management of diarrhea, family planning, immunization, community weighing and growth monitoring, organization of a health district, and home visiting. The CHVs weighed and measured the height of all children under 36 months old monthly, provided nutritional advice to mothers, and referred malnourished children to a nutrition clinic. They received US$150 as an incentive, which they used to set up income-generating projects (e.g., goat rearing). An evaluation of the process and outcome of the CHV nutrition program during May 1990-April 1992 was conducted. None of the CHVs had stopped their duties. 95.6% of eligible children were registered in the program. 78.5% of the children participated. 50% of the children received adequate coverage. 85.7% of identified malnourished children were adequately covered. The CHVs referred all of the malnourished children to the nutrition clinic. The total cost of the program (nutrition clinics and food supplements) was US$2740. Overall cost/child was US$31.1. The cost for growth monitoring only was US$6.2. Growth monitoring accounted for 42.7% of annual costs. Malnutrition decreased from 17.1% to 11.2% (a 34.5% reduction). 81% of all children gained adequate weight. These findings show that CHVs can contribute significantly to primary health care programs in developing countries.

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Risk factors associated with malnutrition were examined in rural Jamaica. Socioeconomic data were obtained on 63 well-nourished and 14 malnourished children. Risk factors associated with malnutrition were birth weight less than 2.5 kg (P < 0.01), maternal age equal to or greater than 25 years (P < 0.05) and landlessness (P < 0.05). Interventions aimed at reducing these factors can go a long way in reducing the malnutrition problem in developing countries.

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This article describes the development of a school environment questionnaire to assess students' perception of their school environment. The dimensions and internal consistency reliability were examined utilizing various statistical methods-factor analysis and alpha coefficient. The sample consisted of 705 students from two high schools with ages ranging from ten to nineteen years. Results showed that the students perceived their school as having various aspects, rather than a global point of view. Factor analysis identified seven dimensions in the school environment: external characteristics of the environment, aesthetic and functional elements of the classroom, students' bathroom, the canteen and staffroom, the aesthetic and functional elements of the school as a whole and sanitation. Overall the internal reliability of the factors was high. Implications for school health programs are addressed.

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There is an urgent need for a quick inexpensive and reliable method for identifying groups and individuals most in need of primary health care. The Rapid Rural Appraisal (RRA) is the most appropriate approach. It is a method by which resources can be quickly deployed to alleviate the problems of the poor. If properly used it can play a major role in identifying community health needs thereby aiding the health planning process and improving the health of the people. Nevertheless, RRA techniques should not be regarded as separate and apart from other research methodologies but complementary to them.

PIP: Rapid Rural Appraisal (RRA) is an approach used for identifying quickly, inexpensively, and reliably groups and individuals most in need of primary health care. The method has been used primarily in agricultural research. Techniques may involve review of existing records, key informant interviews, focus group interviews, direct observation, wealth ranking, flow diagrams, and games and role plays, depending on available resources and objectives. A team of no more than 6 people should perform the review, including a social scientist, a health specialist, and an experienced team leader. The time frame for data collection and analysis is expected to be no more than 1 month. Useful sources of background information are previous survey final reports and monthly and annual health department reports. Key informant interviews are in-depth discussions of a single topic of interest with individuals with pertinent knowledge. The informants should reflect a diversity of opinion. Topics should be preselected and interviews conducted by trained personnel. A typical sample would involve 20-30 persons for 30-90 minutes each, in a quiet location. The least controversial questions should be introduced first. Focus group interviews with 6-10 individuals, who do not know each other, should be conducted by a facilitator for 60-90 minutes in a quiet and comfortable location. Notes should be taken and the discussion taped. The facilitator explains the purpose of the session and directs the topics of conversation. Important themes should be summarized near the end of the session and final comments asked for. Focus groups can be used to pretest education materials; to assess attitudes, behaviors, and concerns; and for program planning or formative evaluation of community projects. Direct observation of a particular phenomenon is systematic, guided by checklist, and usually takes 3-4 weeks. Wealth ranking is helpful in determining the basic needs of the community and special groups. The main advantages of RRA are its holistic approach, short duration, flexibility, and low cost. Limitations are the lack of precise or comprehensive data, and the potential for misunderstanding sensitive and complex community issues.

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PIP: Infant mortality rate (IMR) is an important indicator of a country's socioeconomic development. While IMR has declined among most developing countries over the past 3 decades, under-registration of infant deaths remains a serious problem. In the case of Jamaica, IMR declined from 102/1000 in 1945 to 32/1000 in 1970 to 13/1000 by 1984. This 1984 rate is comparable to those enjoyed in the US, Austria, UK, Spain, and Australia. Significant under-registration of infant births and deaths, however, render suspect the validity of Jamaica's IMR of 13/1000. One study found 34% of infant deaths to be unregistered, while another found 9.0% of 10,249 live births to be also be unregistered. Under-registration of this magnitude is the result of faulty hospital procedures and recording systems, a lack of standardization of related terminology, and the under-registration of live births. Inaccurate IMR adversely affects development and health planning. Efforts should therefore be made with the active support of the Ministry of Health to strengthen the registration system by increasing the numbers of registrars of births and deaths and training all personnel involved in registration.^ieng

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A study was carried out in St. Elizabeth during the period July to December 1991 to evaluate the effectiveness of two communication channels on mothers' knowledge, attitudes and practices regarding food and nutrition. Five communities with high levels of malnutrition and similar socioeconomic and geographical characteristics were selected for the study and assigned to three experimental conditions: a group that was not exposed to any communication channel (group 1); another group that was exposed to group discussion and facilitator (group 2); and a third group that was exposed to facilitator only (group 3). In all, fifteen mothers were assigned to group 1, another fifteen to group 2, and nineteen to group 3. The results showed that positive changes in mothers' knowledge, attitudes and practices occurred in all three groups during the period between the baseline and the end of survey evaluation. However, these changes were more substantial in groups 2 and 3, particularly group 2. Although all groups showed improvement in nutritional status the facilitator-only group made the most improvement. Consideration should therefore be given to both communication channels when planning nutrition education programs, especially for underweight children. The type of facilitator may be critical in terms of outcome (nutritional status).

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A study of the elderly was carried out in 2 Cornwall County parishes (Hanover and Westmoreland) from June to August, 1987. The health status and general situation of the elderly attending Government Medical Clinics was studied to obtain information to design nutrition education services that met their needs. Four Health Centres (two Type II and two Type III) were selected by stratified random sampling for the study. The results indicated that more elderly women (71%) than men (29%) used the Primary Health Care Services. Obesity was more common among women (29%) than men (0%). More men (30%) were underweight than women (9%). Food stamps appeared to be the most regular source of income for the elderly. Most of the elderly (92%) felt that they were not in good health. Although they generally had 2 to 3 meals per day, their food intake, particularly of fruits and peas, appeared to be inadequate. The results point clearly to a need to strengthen the nutrition education services offered to the elderly attending Government Medical Clinics in Cornwall County, Jamaica.

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A study of the elderly was carried out in 2 Cornwall County parishes (Hanover and Westmoreland) from June to August, 1987. the health status and general situation of the elderly attending Government Medical Clinics was studied to obrain information to design nutrition education services that met their need. four Health Centres (two Type II and two Type III) were selected by stratified random sampling for the study. The results indicted that more elderly women (71%) than men (29%) used the Primary Health Care Services. Obesity was more common among women (29%) than men (0%). More men (30%) were underweight than women (9%). Food stamps appeared to be the most regular source of income for the elederly. Most of the elderly (92%) felt that they were not in good health. Although they generally had 2 to 3 meals per day, their food intake, particularly of fruits and peas, appeared to be inadequate. The results point clearly to a need to strengthen the education services offered to the elderly attending Government Medical Clinics in Cornwall County, Jamaica

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PIP: This paper address the institutionalization of the primary health care program in Cornwall County Jamaica, supervised by the Ministry of Health. Under this program, 59 new health centers were constructed and 28 existing ones remodelled. The primary health centers were decentralized and an administrative unit of a hierarchy of health centers was established and classified as type 1 through type 4. Type 1 health center was the smallest and the simplest health unit, and both type 2 and 3 health unit functioned as referral units for patients from type 1 health center. The type 4 health center had an additional administrative block for senior staff of the parish. The implications of this health system to Cornwall county in 1976 were 1) a decline in community health aides per health center, 2) additional child welfare, prenatal family planning, and medical clinics were held, 3) the number of rural families utilizing health care increased, 4) community health workers made significantly fewer home visits as a result of additional clinic units and in turn child health care declined significantly, 5) health workers carried out more curative activities and fewer preventive duties, 6) an increase in data collection through defaults in the system lead to non-utilization of the data for policy planning purposes, 7) shortage of staff to support the increased patient load and duties at health centers. Consequently, the health system could not cope with this well intentioned policy change which emphasized shifting from community outreach to health center-based activities.^ieng

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PIP: An infant feeding survey was carried out in 3 parishes in Cornwall county, Jamaica, from March to August, 1984, in an attempt to determine the feeding patterns of infants and beliefs of mothers in Western Jamaica. 41 Enumeration districts (EDs), were randomly selected from 2 strata, urban and rural, in proportion to the population distribution. 614 households with children under 36 months of age were selected from 41 EDs. The results showed that the presence of breastfeeding was 98%. Despite the high frequency of breastfeeding, infant formula was introduced very early, and only about 1/2 of the mothers introduced semi-solids and solids within a month of the recommended time. The most popular foods, identified as good foods, were also popular weaning foods. There is need for adequate training of both primary and 2ndary health-care staff, and reinforcement of nutrition messages by frontline health workers. The collection of adequate baseline data in evaluating the effectiveness of nutrition education programs is also important.^ieng

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An infant feeding survey was carried out in three parishes in Cornwall County, Jamaica, from March to August, 1984, in an attempt to determine the feeding practices of infants and beliefs of mothers in Western Jamica Forty-one Enumeration Districts (EDs were randomly selected from two strata. urban and rural, in proportion to the population distribution. Six hundred and fourteen households with children under 36 months of age were selected from 41 EDs. The results showed that prevalence of breastfeeding was 98.0%. Despite the high frequency of breastfeeding, infant formula was introduced very early, and only about half of the mothers introduced semi-solids and solids within one month of the recommended time. The most popular foods, identified as good foods, were also popular weaning foods. It is concluded that there is need for adequate rraining of both primary and secondary health-care staff, and reinforcemen of nutrition messages by frontline health workers. The collection of adequate baseline data in evaluating the effectiveness of nutrition education programmes is also important

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PIP: The infant mortality rate is a sensitive index of health. However, in recent years, perhaps due to underregistration of deaths, the infant mortality rates for Jamaica, and particularly for certain parishes, have been so low as to make their accuracy questionable. This study sought to establish the infant mortality rates for the parishes of St. James, Hanover and Trelawny during 1980. Information on infant deaths in 1980 was sought from a variety of sources, as was information on live births in the same year. The infant mortality rate (1980) for the combined parishes of St. James, Hanover and Trelawny was estimated to be 27/1000 live births. It was estimated that only 31% of infant deaths in 1980 were registered. Health personnel were much more aware of infant deaths than were the Registrars of Births and Deaths, and hence, the Registrar General. Possible reasons for underregistration of infant deaths are suggested, but the topic requires further research. Attempts should be made to improve the registration of infant deaths.^ieng

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