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Replication of the activities described has not always been successful. Rural Haitian informants pointed out that teams often arrive late, in the heat of the day, and may abruptly cancel a session with little or no explanation. Furthermore, no shady area for seating the mothers was provided as might have been the case had the villagers participated in the planning of the sessions.
Haitian families today are more mobile than ever, and this effect is felt especially in the United States and Canada. Of 336,394 Haitians legally entering the United Sates between 1956 and 1972, about 230,000 were known to have remained. It was estimated that equally as many may have entered illegally.
High mobility may be blamed on the phenomenon of "overpopulation, extreme poverty, and one repressive regime after another" in Haiti. But other reasons underlie this instability. The system of small landholding involves owning land on dispersed plots; the sale or inheritance of land often requires migration (G Berggren et al., 1980) and demographic changes that affect household and family structure (G Berggren et al., 1980). What emerges is a stepwise movement from household to household, from village to village, and finally from villages to towns and onwards.
Comments on Strategy
The use of an itinerant technical support team to supplement the activities of village-based workers at regular (at least quarterly) intervals is necessary in rural Haiti in order to provide immunizations, growth-monitoring services, and other modalities (such as materials for a mini antenatal clinic). Rural Haitian mothers do not carry their babies on their backs or in a sling, and therefore the distance they are willing to travel for immunizations must be taken into account. Services must be within a one-hour walk of their homes for rural Haitian mothers to begin to come regularly to surveillance or immunization services (Alvarez et al., 1993). Rural community leaders are willing to participate and, in the case of the HAS under-fives clinic, have assessed themselves to help cover costs.
While the above activities began in a systematic way at HAS with the purpose, in part, of providing the basis for a prospective longitudinal study, it was realized that the systematic registration and follow-up of all family members in each nuclear family in every village in a defined census tract also brought the element of equity to the primary health care system. In Bangladesh, where the methodology is being replicated by Save the Children, health workers justified the approach as the "No Child Shall Be Left Out" system.
The HAS family registration system proved so valuable that by 1992 it covered the HAS district of 180,000 people in rural Haiti. Major changes evolved over the 25-year intervention period in order to improve primary health care, surveillance, and equity. These included the use of outlying dispensaries and the identification, recruitment, and training of community-level women volunteers known as animatrices, each of whom reaches 10 to 15 families, acts as a liaison to health services, and helps to organize village-based under-fives clinics.
Rural Haitian informants point out that communities lose faith with teams that often arrive late, in the heat of day, or with the news that a session is abruptly canceled or lacks supplies. Furthermore, villagers need to have participated in the planning of the project and in its appointed sessions. They will see, for example, that shaded areas and seats or mats for waiting mothers are available.
Conjugal union status was a confusing subject and one of special interest, since it was key to the understanding of household structure and child relocation in rural Haiti. At the time of family registration, interviewers found that up to one-third of women who had been in at least one conjugal union were without a male consort. RHVs who served as census takers consistently gathered more information than was asked for, and often information essential to the understanding of union formation and dissolution. The World Fertility Survey later piloted their questionnaire in the PISP project and developed a questionnaire that allowed for the history of unions to be correlated with the prolonged interpregnancy intervals that often occurred between unions.
The general instability of the Haitian population, in terms of both conjugal unions and high migration rates, was to some degree a reflection of the economic circumstances, as their reasons for in-migration betrayed. Nearly 20% of in-migrant males aged 15 to 44 gave "nonagricultural employment" as their reason for migrating, and another 18% gave simply "unemployed, unsettled" as a reason. Another 20% gave "to join a relative" as a reason, most often also because such a migration would improve their economic circumstances.
In these studies, one sees at once a reflection of the cultural factors described and, at the same time, adverse consequences, at least in nutritional terms, for relocating children. Child relocation can be seen as a strength carried over from the African cultural setting or as a detrimental consequence of highly unstable conjugal unions and family mobility in Haiti, where both phenomena occur under adverse economic conditions. In dealing with these families, the authors found that once displaced, a child was also apt to be displaced again, and that malnutrition often ensued (Rawson and Berggren, 1973). The PISP longitudinal studies found that up to 20% of children under two were separated from their biologic mothers, and that 13% died in the first six months thereafter. Therefore, as protective as "child sharing" might be in the African cultural setting, in this culture its effects are generally adverse for the child.
Rapid assessment procedures including the use of focus groups are beginning to add understanding to the situation of women who head single-parent families and whose common complaint is "My mister abandoned me." These insights are important for those who set targets for family planning: women outside of unions do not wish to give-up the "fertility card" they feel may be necessary to gain a new male consort. Evolution of the projects has included the adaptation of rapid assessment techniques from the behavioral sciences for development of education tools, monitoring, and evaluation.
Practical Implications for Health Programs
a. These studies imply the desirability of home-based health records for every age group, since rural Haitians are highly mobile and are unlikely to continue to attend the same health center for long. Haitian mothers in both studies proved they do not lose home-based personal health records if health providers are faithful in their insistence on their being presented and interpreted, and they will use them as educational tools.
b. The information system that made the studies possible began in all cases with door-to-door registration of all families living in defined communities, with follow-up thereafter from RHVs (1:100 families) who acted as liaisons to the health services and reported all pregnancies, births, deaths, migrations, and nutrition status of children.
c. Resistance to family planning can be expected from women whose union status is in fluctuation. More educated Haitian women may feel that between unions it is in their own interest to continue the use of contraception, or to have contraceptives always available. However, until this philosophy or belief is shared by their less well-off sisters, up to one-third of women will be unlikely to use family planning because of instability of unions.
d. The adverse consequences of child relocation are not realized by Haitian families, who mean to provide better for their children by relocating them. Education about family building and the importance of bonding in child development could be included in the outreach programs of many institutions in Haiti. Nutrition education, for example, need not dwell exclusively on scientific facts about what a child needs to eat and how often. Haitian families care for their children and deserve a better chance to understand the value of family stability for both mothers and children.
e. Rawson's conclusions from his anthropological study of child relocation are relevant for health programs:Child relocation is an important underlying cause of malnutrition. If recognized early enough, the ensuing malnutrition is susceptible to simple preventive measures.
Child spacing and smaller family size would reduce the risk of relocating a child; hence family planning could contribute positively.
In addition, the health staff should identify relocated children promptly and then institute action to protect them.
In conclusion, population-based community health programs have produced longitudinal data in Haiti to confirm that low-cost, simple interventions can lower mortality rates in children. A 25-year follow-up study at HAS proved that the rates were sustained in that setting, where primary health care and referral facilities remained constant.
This review was made possible through the Community Health Department of the Hospital Albert Schweitzer of Haiti and its supporting agency, the Grant Foundation of Pittsburgh, PA, and the Pew Charitable Trusts. The projects described were funded in part through grants from the Rockefeller Foundation, the Williams and Waterman Foundation, the Canadian International Development Research Center, Bread for the World of Germany, and the United Nations Fund for Population Activities (UNFPA) through the Division d'Hygiene Familiale of the Canadian Government.
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1 Formerly with the Albert Schweitzer Hospital in Deschapelles, Haiti and the Harvard School of Public Health in Boston, MA, USA.
2 Albert Schweitzer Hospital, Deschapelles, Haiti.
3 Formerly with the Integrated Project of Health and Population, Division of Family Hygiene in Petit Goave, Haiti.
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