Contributing Factors for Objectives Not Fully Achieved. Immediate causes of malnutrition include inadequate food intake coupled with a high prevalence of infectious diseases, particularly diarrheal disease and respiratory infections, with two-week prevalence rates of 43% and 48% respectively (KPC 2001). Contributing causes include: insufficient food; inadequate food distribution practices within the home; a lack of time to prepare frequent meals for children; poor access to health services; lack of potable water and sanitation; insufficient education and information; and inadequate breastfeeding and complementary feeding practices. Due to socio-economic factors, changes in nutritional status may require long-term integrated development with coordinated efforts among municipal governments, health, education, the agriculture sector, and the NGO community. Constraints to meeting the objectives for micronutrients are lack of supplies, late detection of pregnant women, and limited orientation to mothers regarding the importance of the supplements. Often incomplete records are kept, making it difficult to assess coverage and to implement adequate follow-up for second doses. Health personnel require capacity building in technical aspects of nutrition, including psychomotor development, and in the implementation of behavior change strategies. Such behavior change strategies should insure that mothers understand the meaning of children’s nutritional status, that mothers recognize their nutritional risks during pregnancy, and that they are motivated to take the required actions. Another area that needs improvement is follow-up of children who are not gaining weight, based on verification of child growth cards. In particular, CSRA supervisors need to insure that registers in the community correspond to those at health centers. The child health cards, which include both immunization and growth information, are kept in duplicate at both the home and the health center or post. If the results of growth monitoring or vaccinations are recorded during the home visit, but not on the duplicate cards at the health center, health personnel has difficulty programming home visits for timely follow-up. The DIP indicated that more female health personnel would be hired to better interface with mothers, however this was achieved to a very limited extent. Most of the ANs and health volunteers are men. Although the Hearth methodology was included as a project strategy in the DIP, it was not implemented. Project staff indicated that the time required for meetings of mothers in the communities was a barrier to the establishment of peer education activities. As mentioned in section on CDD (iii), time is precious to altiplano mothers who must complete many daily tasks necessary for sheer survival. Only when mothers give high priority to an activity will they lay aside these tasks to participate. It is important to note that CSRA undertook two pilot tests of the Hearth methodology in the Altiplano, conducted by CS Coordinator ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ and CSRA nutritionist, ▇▇▇▇▇▇▇ ▇▇▇▇▇▇, prior to the initiation of CS XIII. Neither of these tests was successful. There were several reasons for this lack of success. First, population density in the area was low, resulting in the need to combine women of several nearby communities into one group. This required even more time to get to and from the meetings, and women of one village were frequently at odds with those from other villages. Second, women did not feel that they had the time for this time- intensive effort. Next, sponsoring hearth mothers, despite explanations to the contrary prior to project startup, demanded compensation of some kind in order to continue their support. Fourth, some mothers complained that despite very low costs of the complementary foods, they still could not afford to buy the ingredients for the recipe. Finally, there was a strong cultural bias toward taking a passive, wait and see approach for early childhood malnutrition. Parents, especially fathers, usually were unwilling to invest scarce family resources into its resolution, and generally were not supportive. Another activity mentioned in the DIP was a study to determine the relationship between parasite infections and anemia. Although this did not take place, health personnel recommend that children receive anti-parasite medications as part of routine child health care activities. Constraints at the community level include: 1) families are not accustomed to diversifying their diets, 2) Community authorities are not integrated in health activities nor do they participate in the analysis of nutritional information at the monthly CAI meetings, and 3) mothers are reluctant to put into practice the guidance provided by the AN or the HV.
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Sources: Cooperative Agreement, Cooperative Agreement