- Email: [email protected]
Partners for improved nutrition and health—An innovative collaborative project
PROGRAM RESPONSES REPORT
Partners for Improved Nutrition and HealthAn Innovative Collaborative Project AGNES
w.
HINTON/ ALFIO RAUSA,2 TERESA LINGAFELTER,3 AND ROBERT LINGAFELTER
INutrition Services, Mississippi State Department of Health, Jackson, Mississippi 39215-1700; Health District, Greenwood, Mississippi; and 3PINAH, P.O. Box 531, Greenwood, Mississippi 38930
2
3
Delta Hills Public
to serve as an incubator of innovative health promotion initiatives, to encourage local self-help activities that yield sustained improvements in the nutrition and health of low income residents, and to establish models for self-help nutrition and health improvement suitable for replication in other parts of the rural South. PINAH consists of two projects: The Community Health Advisor (CHA) Network, which is being implemented in Humphreys County by the MSDH, and Partners for Life, which is being conducted in Leflore County by the MCES (not described in this report due to space constraints). The FFHF has responsibility for the overall coordination of the development, implementation and evaluation of the PINAH program. The Foundation has established a contract with Dr. Eugenia Eng, School of Public Health, University of North Carolina (UNC) for a complete evaluation of the Humphreys County project. A state level Committee of Advisors (COA) was established to guide both components of the program. The COA's charge was to offer advice and assistance to PINAH staff regarding project design and implementation and evaluation of project suitability for expansion through both group and individual meetings. Objectives of the Humphreys County CHA project include strengthening inter-agency coordination; strengthening leadership within low income communities; and building partnerships between county agency personnel and informal leaders of the low income communities. The Community Health Advisor program follows and expands on international and domestic experience with Village Health Worker and Lay Health Advisor Programs (3-10). It is based on the assumption that in every human community there exists a capacity for self-help, embodied at least in part in a group of persons known to their neighbors to be reliable sources of advice, help and leadership ("Natural Helpers" or "Informal Leaders"). The purpose
INTRODUCTION The Freedom From Hunger Foundation (FFHF) of Davis, California, is committed to helping the hungry and poor help themselves to eliminate the root causes of malnutrition and hunger. The Foundation's programs are founded on strategies to develop, test, and refine creative and innovative self-help strategies, with an emphasis on community-based self-help and mutual help solutions that enhance self-reliance and preserve dignity (1). With a forty-year history of conducting international relief programs, the Foundation in 1986 conducted a study on poverty in the United States (2). The study identified three states, Arkansas, Georgia and Mississippi, as areas with relatively large increases in the number of rural poor since the early 1980s. The Mississippi Delta was identified as the area with the greatest concentration of high poverty counties with related hunger and health problems. Following several extensive site visits, Foundation officials selected the state of Mississippi for further activities, not only because of obvious need, but also because of the willingness of state and local leaders to explore new ways of doing business, new modes of interagency collaboration, and new partnerships with the communities that they serve. Discussions with the Mississippi Cooperative Extension Service (MCES) and the Mississippi State Department of Health (MSDH) resulted in a Memorandum of Understanding between the two agencies and FFHF, which formed Partners for Improved Nutrition and Health (PINAH) in late 1987. PINAH was established Address for correspondence: Agnes W. Hinton, R.D., M.S., Director, Nutrition SelVices, Mississippi State Department of Health, P.O. Box 1700, Jackson, MS 39215-1700; (601) 960-7476. 0022-318219212401-067S$03.00/0 © 1992 SOCIETY FOR NUTRITION EDUCATION 67S
68S
Hinton et al. ! PINAH
of the program is to collaborate with this natural and informal group in Humphreys County neighborhoods to conduct and evaluate an innovative community nutrition and health education and promotion effort (11).
IMPLEMENTATION The first phase of the project has the following objectives: to get to know both the strengths and weaknesses of the community; to secure local input from the onset into the design, planning and implementation of the project; and to make the broad community aware of the program as it evolves. Beginning in 1988, this phase involved three major activities in Humphreys County. The first was collaboration with the Humphreys County Interagency Council, composed of representatives of public and private agencies providing services in the county who meet monthly to share program and resource information. As local sponsors for the project, they provide technical assistance and support for the Health Advisors' activities. During the early stages of the project, PINAH staff engaged them in project development through a number of workshops, including the process of identifying Natural Helpers, establishing priority topics for Health Advisor training, identifYing major community health issues, and identifYing and describing neighborhoods in the County. In addition, PINAH staff worked with the Interagency Council to produce a Community Services Directory. Staff and Interagency Council members interviewed approximately 50 agencies, organizations and service providers to gather information on available community resources, examples of previous community experience with local self-help initiatives, and perceived community health problems. The names of other people knowledgeable about community affairs were also gathered, along with an initial list of Natural Helpers. In addition to collecting information for the Services Directory, these interviews accomplished three things: 1) provided an understanding of how things got done in the community and how health problems were perceived at the agency level; 2) provided an opportunity for large numbers of agency personnel to become familiar with the program in an interactive and personal setting; and 3) produced an initial list of Natural Helpers. Finally, PINAH staff conducted an informal survey to determine community perceptions concerning major health problems. Two hundred and fifty people completed the survey form, including 100 health department patients, 100 members of community organizations, and 50 school teachers. There was a strong concurrence between community perceptions and the leading causes of death as reported by the Mississippi State Department of Health. The fact that heart disease, cancer and high blood pressure were mentioned most often indicated a significant awareness in the community about major health problems. Recent media focus on the relation between diet and chronic
disease has raised awareness of the need to change traditional eating habits, but few people know what changes are truly important or how to go about making them. It was determined that a training program covering these problems would attract interest. On the other hand, prenatal care and infant care, which represent a top public health priority due to the high incidence of low birth weight and high rate of infant mortality in the county, were rated as major problems by less than 20% of respondents, reflecting an incomplete picture of county health problems. The recognition by community residents of poor hOUSing as a community health-related problem indicated an awareness and concern over the interrelationship of economic problems and health problems. This suggested combining basic nutrition and health education with training in the skills of community-building and problem-solving. In the process of identifying Natural Helpers within the community, the following two questions were asked to approximately 200 agency and community organization staff and church leaders: 1) Who is it that people go to when they need help or advice or when they have a problem? and 2) Who else is knowledgeable about the community that we should also talk to? Names were tabulated using index cards, and about 60 names emerged as people who were named by several sources as being Natural Helpers. The PINAH staff approached these people and explained that training was being offered to enhance their already existing skills as volunteers. The only requirements for the training were that participants agree to attend all 10 training sessions, and that they agree to share on a voluntary basis what they learn with their neighbors. Of the 60 persons, 22 agreed to participate in the initial training program. The graduate Health Advisors now help identity new volunteer candidates for training, but the basic method of identification is similar. It has proven to be important to visit each identified "helper" personally, to explain how they were identified, to explain the program, and to invite them to participate. Based on Health Advisor profile data collected during the training, " ... a 'typical' Health Advisor can be described as a black woman in her 40's with 13 years of formal education, who has lived in Humphreys County for 35 years. In her household are four people earning a total family income of $1100-$1950 per month. Compared to statistics for the county, Health Advisors are slightly better educated and more financially secure than the average resident. Health Advisors also belong to an average of three community organizations. All Health Advisors are members of at least one church and 12 report membership in a second church (most likely the spouse's church). Affiliation with a civic, social, or professional organization is also common. Thus, it appears that those recruited to be Health Advisors are actively involved with a wide range of speCial interest groups connecting them to individuals and other groups important to the life of their communities .... " (12)
JanuarylFebruary Supplement 1992
J. of Nutr. Educ. Vol. 24, No.1
TRAINING Based on conversations with identified natural helpers and local agency personnel, a 10-week skills-based training program was developed, combining nutrition and health promotion with community development methods. The training covers health promotion topiCS such as good nutrition, chronic disease, accident prevention, pregnancy and family planning, and community development skills such as conducting problem-solving workshops, maximizing participation and partnerships, and skills for giving advice. The health and nutrition portion of the curriculum is facilitated by professionals who live and work in the community. This lays the foundation for an ongOing relationship between the Health Advisors and local service organizations. The final session is an "action-planning" workshop in which Health Advisors build a three to six month plan for launching their own health promotion initiatives. The training is seen as having two additional objectives: first, to build a partner relationship between Health Advisors and local professionals, and second, to build a sense of solidarity and mutual support among the Health Advisors themselves. Both of these partnerships are essential for the long-range effectiveness of the Health Advisors' work. By June 1990, the training had been conducted four times, with a total of 52 Health Advisors graduating.
SUPPORTING HEALTH ADVISOR INITIATIVES Health Advisors use their neighborhood, church and workrelated networks to provide counselling and sound, basic advice based on their training. They provide assistance, particularly in the form of referrals to appropriate community services and resources. When a neighborhood or community-wide health issue is encountered, they work with local groups and agencies to organize short and long-term community action efforts to address these problems. "Initial findings indicate that Health Advisors are reaching out to people in need instead of waiting to be asked to help"(12). Health Advisors are often asked for advice about medications, family problems and school-related issues. They prOvide the emotional support and encouragement that enables people to think through a problem and arrive at their own decision about a solution. In addition, they often provide direct assistance. They give people rides to clinics and grocery stores, they run errands and cook meals for people who are ill, or they may loan or give money. They also make many referrals to existing organizations and social service agencies. They help people negotiate the system by assisting with forms , making appointments, and providing information on eligibility requirements. Health Advisors find that a large portion of their counselling has to do with diet and the medications related to diabetes and hypertenSion. They find it is necessary to have frequent contact with elderly neighbors who suffer from
69S
these diseases and to repeat their advice often. At the other end of the spectrum, Health Advisors report helping young mothers design adequate meals using Food Stamps and WIC foods. Their work in the county exposed the need for a source of emergency food. As a result, they established an Emergency Food Pantry, which not only distributes foods , but also works with reCipients to determine the root causes of hunger in the county. When organizing action, Health Advisors work to form partnerships with other community groups. They work at the neighborhood level, as in door-to-door information campaigns; at the town level, as in organizing communitywide clean ups; or at the county level, as in establishing an emergency food pantry. Health Advisors engage in an annual planning session, during which they identify priority arenas of need and outline action strategies to meet those needs. For example, a workshop focused on the causes of chronic malnutrition in the Delta, and specific ways to address those problems. The linkage to agencies provided during the training not only enhances the effectiveness of referrals, but also insures access to on-going training opportunities and resources outside the community. An early evaluation study showed each Health Advisor making an average of 3.6 helping contacts per week providing assistance to 4.9 individuals. Recent surveys show that the number of contacts is Significantly increasing. At this rate, even allOwing for multiple contacts with the same individual(s), Health Advisors are reaching approXimately one half of the total low income population of the county once every six months. Those assisted are friends (37%), acquaintances (23%) , neighbors (14%), fellow church members (12%). Most are black (95%), women (86%), and unemployed but not retired. Thirty-one percent are teens, and 21% are 60-69 years old. Fourteen percent of the contacts are made in the Health Advisors home, 25% by phone, 45% in someone else's home, and 17% at church and meetings. CONCLUSIONS PINAH's activities are being evaluated by county residents and collaborating agencies with technical assistance from public health researchers at the UNC. While it is too early to interpret final results, early indications are promising: " .. . the project has successfully recruited the more active and visible members of communities ... "; " ... training is enhancing (Health Advisor) knowledge of health risks and benefits so that they can take appropriate action . . ."; Health Advisors are" . .. reaching out to individuals through their pre-existing, non-kin social networks ... "; and" ... it appears that the scope of response from Health Advisors is widening in terms of problems and types of support ... "(12). As part of the evaluation conducted by UNC, agency officials are asked to sample the number of interagency referrals they make and to report annually on
70S
Hinton et al. / PINAH
the number and quality of referrals between agencies and between agencies and the community. They report an increase in interagency referrals and a significant increase in the number of referrals from and to individuals and informal groups in the community. These agencies also report referring people in need to their neighborhood Health Advisor, particularly when the need falls outside the agency's range of services. The PINAH experience in the Delta is a continual learning experience. Low income residents have a strong desire and capacity to take charge of their lives and their health, and will volunteer their time and resources to help others. Local participation in planning, implementing and evaluating development efforts is possible, feasible and essential to real and lasting progress. Public agencies and private organizations alike must learn "new ways of doing business" if they are to become truly responsive to local initiatives. Perhaps the most important lesson learned in Humphreys County is that public health nutrition issues do not exist in isolation. Health issues intertwine with poverty, hunger, education, economic and social problems in ways that frustrate abstract and piecemeal solutions. Comprehensive, in-depth responses and lasting solutions will require a tremendous investment in the human resource that is the Delta's rural population. The keys to the resolution of chronic poor health can be found in the development of new partnerships with the people themselves, partnerships that are dedicated to the vitality and well-being of neighborhoods and communities. In the words of one Community Health Advisor: "We want you to know that you are not alone . . . in this struggle. There are people in every community in this nation who are concerned about the health of their community, and looking for a way to do something about it. We are ready
to join you, the health profeSSionals and agencies, as partners for a healthy nation through healthy neighborhoods. It is important for policy-makers to understand that local initiatives to the problems of poor health and poverty have the best chance of producing lasting solutions"(13). REFERENCES 1 Freedom From Hunger Foundation. 1987 annual report. Davis, California, 1987. 2 Douglas, G., E. Dolber-Smith, and C. Dunford. A geography of American poverty. Davis, CA: Freedom From Hunger Foundation, 1986. 3 Service, C. and E.J. Salber. Community health education: The lay advisor approach. Duke University, Durham, NC: Community Health Education Program, 1977. 4 Hatch, J. and H. Barr. The General Baptist State Convention Health and Human Services Project. Contact 77:1-17, 1984. 5 Uphoff, N. T., J. M. Cohen, and A. A. Goldsmith. Feasibility and application of rural development participation: A state-of the-art paper. Monograph Series. Cornell UniverSity, Ithaca NY: Rural Development Committee, Center for International Studies, 1979. 6 Frate, D., T. L. Whitehead, and S. A. Johnson. The selection, training and utilization of health counselors in the management of high blood pressure. Urban Health 12:52-54, 1983. 7 Wilson, S. E. CHAP manual: Community health advocacy program. East Carolina University School of Medicine, Greenville, NC: Center for Health Services Research and Development, 1987. 8 Pratt, B. and J. Boyden, eds. The field directors handbook: An Oxfam manual for developing workers. Oxford, England: Oxford University Press, 1985. 9 Stinson, W., M. Favin, and B. Bradford. Training community health workers. Washington, D.C.: World Federation of Public Health Association, 1983. 10 Eng, E., J. Hatch, and A. Collan. Institutionalizing social support into the community. Health Education Quarterly 12(1):81-92, Spring, 1985. 11 Dunford, C. Mississippi applied nutrition program. Davis, CA: Freedom From Hunger Foundation, 1987. 12 Eng, E. PINAH evaluation progress report, 1988-1989. University of North Carolina, Chapel Hill, 1989. 13 Chambers, H., Community Health Advisor. Testimony before the Committee on Labor and Human Resources, United States Senate, April 20, 1990.
ABSTRACT OF INTEREST
Overcoming hunger in the 1990s. Kasperson, JX and R.W. Kates, eds. Food Policy 15(4):274358,1990. This special issue contains eight papers that look at the possibilities of overcoming hunger in the 1990s. A review of world hunger is presented; opportunities for the 1990s to halve world hunger are described; the additional flows of money and food aid required are estimated; coping mechanisms and efforts to overcome hunger at the village and grass root level are assessed through case studies; obstacles thwarting the potential of biotechnology to alleviate Third World hunger are reviewed; and the need to strengthen the political force of interest groups to ensure that the airing of the hunger issue is contained at the highest levels is stated. Three important declarations with regard to solving the hunger problem are presented in full: the Cairo Declaration, the Bangkok Affirmation, and the Bellagio Declaration. It is argued that it is possible to reduce the toll of hunger within a decade, perhaps by as much as half.
Partners for Improved Nutrition and HealthAn Innovative Collaborative Project AGNES
w.
HINTON/ ALFIO RAUSA,2 TERESA LINGAFELTER,3 AND ROBERT LINGAFELTER
INutrition Services, Mississippi State Department of Health, Jackson, Mississippi 39215-1700; Health District, Greenwood, Mississippi; and 3PINAH, P.O. Box 531, Greenwood, Mississippi 38930
2
3
Delta Hills Public
to serve as an incubator of innovative health promotion initiatives, to encourage local self-help activities that yield sustained improvements in the nutrition and health of low income residents, and to establish models for self-help nutrition and health improvement suitable for replication in other parts of the rural South. PINAH consists of two projects: The Community Health Advisor (CHA) Network, which is being implemented in Humphreys County by the MSDH, and Partners for Life, which is being conducted in Leflore County by the MCES (not described in this report due to space constraints). The FFHF has responsibility for the overall coordination of the development, implementation and evaluation of the PINAH program. The Foundation has established a contract with Dr. Eugenia Eng, School of Public Health, University of North Carolina (UNC) for a complete evaluation of the Humphreys County project. A state level Committee of Advisors (COA) was established to guide both components of the program. The COA's charge was to offer advice and assistance to PINAH staff regarding project design and implementation and evaluation of project suitability for expansion through both group and individual meetings. Objectives of the Humphreys County CHA project include strengthening inter-agency coordination; strengthening leadership within low income communities; and building partnerships between county agency personnel and informal leaders of the low income communities. The Community Health Advisor program follows and expands on international and domestic experience with Village Health Worker and Lay Health Advisor Programs (3-10). It is based on the assumption that in every human community there exists a capacity for self-help, embodied at least in part in a group of persons known to their neighbors to be reliable sources of advice, help and leadership ("Natural Helpers" or "Informal Leaders"). The purpose
INTRODUCTION The Freedom From Hunger Foundation (FFHF) of Davis, California, is committed to helping the hungry and poor help themselves to eliminate the root causes of malnutrition and hunger. The Foundation's programs are founded on strategies to develop, test, and refine creative and innovative self-help strategies, with an emphasis on community-based self-help and mutual help solutions that enhance self-reliance and preserve dignity (1). With a forty-year history of conducting international relief programs, the Foundation in 1986 conducted a study on poverty in the United States (2). The study identified three states, Arkansas, Georgia and Mississippi, as areas with relatively large increases in the number of rural poor since the early 1980s. The Mississippi Delta was identified as the area with the greatest concentration of high poverty counties with related hunger and health problems. Following several extensive site visits, Foundation officials selected the state of Mississippi for further activities, not only because of obvious need, but also because of the willingness of state and local leaders to explore new ways of doing business, new modes of interagency collaboration, and new partnerships with the communities that they serve. Discussions with the Mississippi Cooperative Extension Service (MCES) and the Mississippi State Department of Health (MSDH) resulted in a Memorandum of Understanding between the two agencies and FFHF, which formed Partners for Improved Nutrition and Health (PINAH) in late 1987. PINAH was established Address for correspondence: Agnes W. Hinton, R.D., M.S., Director, Nutrition SelVices, Mississippi State Department of Health, P.O. Box 1700, Jackson, MS 39215-1700; (601) 960-7476. 0022-318219212401-067S$03.00/0 © 1992 SOCIETY FOR NUTRITION EDUCATION 67S
68S
Hinton et al. ! PINAH
of the program is to collaborate with this natural and informal group in Humphreys County neighborhoods to conduct and evaluate an innovative community nutrition and health education and promotion effort (11).
IMPLEMENTATION The first phase of the project has the following objectives: to get to know both the strengths and weaknesses of the community; to secure local input from the onset into the design, planning and implementation of the project; and to make the broad community aware of the program as it evolves. Beginning in 1988, this phase involved three major activities in Humphreys County. The first was collaboration with the Humphreys County Interagency Council, composed of representatives of public and private agencies providing services in the county who meet monthly to share program and resource information. As local sponsors for the project, they provide technical assistance and support for the Health Advisors' activities. During the early stages of the project, PINAH staff engaged them in project development through a number of workshops, including the process of identifying Natural Helpers, establishing priority topics for Health Advisor training, identifYing major community health issues, and identifYing and describing neighborhoods in the County. In addition, PINAH staff worked with the Interagency Council to produce a Community Services Directory. Staff and Interagency Council members interviewed approximately 50 agencies, organizations and service providers to gather information on available community resources, examples of previous community experience with local self-help initiatives, and perceived community health problems. The names of other people knowledgeable about community affairs were also gathered, along with an initial list of Natural Helpers. In addition to collecting information for the Services Directory, these interviews accomplished three things: 1) provided an understanding of how things got done in the community and how health problems were perceived at the agency level; 2) provided an opportunity for large numbers of agency personnel to become familiar with the program in an interactive and personal setting; and 3) produced an initial list of Natural Helpers. Finally, PINAH staff conducted an informal survey to determine community perceptions concerning major health problems. Two hundred and fifty people completed the survey form, including 100 health department patients, 100 members of community organizations, and 50 school teachers. There was a strong concurrence between community perceptions and the leading causes of death as reported by the Mississippi State Department of Health. The fact that heart disease, cancer and high blood pressure were mentioned most often indicated a significant awareness in the community about major health problems. Recent media focus on the relation between diet and chronic
disease has raised awareness of the need to change traditional eating habits, but few people know what changes are truly important or how to go about making them. It was determined that a training program covering these problems would attract interest. On the other hand, prenatal care and infant care, which represent a top public health priority due to the high incidence of low birth weight and high rate of infant mortality in the county, were rated as major problems by less than 20% of respondents, reflecting an incomplete picture of county health problems. The recognition by community residents of poor hOUSing as a community health-related problem indicated an awareness and concern over the interrelationship of economic problems and health problems. This suggested combining basic nutrition and health education with training in the skills of community-building and problem-solving. In the process of identifying Natural Helpers within the community, the following two questions were asked to approximately 200 agency and community organization staff and church leaders: 1) Who is it that people go to when they need help or advice or when they have a problem? and 2) Who else is knowledgeable about the community that we should also talk to? Names were tabulated using index cards, and about 60 names emerged as people who were named by several sources as being Natural Helpers. The PINAH staff approached these people and explained that training was being offered to enhance their already existing skills as volunteers. The only requirements for the training were that participants agree to attend all 10 training sessions, and that they agree to share on a voluntary basis what they learn with their neighbors. Of the 60 persons, 22 agreed to participate in the initial training program. The graduate Health Advisors now help identity new volunteer candidates for training, but the basic method of identification is similar. It has proven to be important to visit each identified "helper" personally, to explain how they were identified, to explain the program, and to invite them to participate. Based on Health Advisor profile data collected during the training, " ... a 'typical' Health Advisor can be described as a black woman in her 40's with 13 years of formal education, who has lived in Humphreys County for 35 years. In her household are four people earning a total family income of $1100-$1950 per month. Compared to statistics for the county, Health Advisors are slightly better educated and more financially secure than the average resident. Health Advisors also belong to an average of three community organizations. All Health Advisors are members of at least one church and 12 report membership in a second church (most likely the spouse's church). Affiliation with a civic, social, or professional organization is also common. Thus, it appears that those recruited to be Health Advisors are actively involved with a wide range of speCial interest groups connecting them to individuals and other groups important to the life of their communities .... " (12)
JanuarylFebruary Supplement 1992
J. of Nutr. Educ. Vol. 24, No.1
TRAINING Based on conversations with identified natural helpers and local agency personnel, a 10-week skills-based training program was developed, combining nutrition and health promotion with community development methods. The training covers health promotion topiCS such as good nutrition, chronic disease, accident prevention, pregnancy and family planning, and community development skills such as conducting problem-solving workshops, maximizing participation and partnerships, and skills for giving advice. The health and nutrition portion of the curriculum is facilitated by professionals who live and work in the community. This lays the foundation for an ongOing relationship between the Health Advisors and local service organizations. The final session is an "action-planning" workshop in which Health Advisors build a three to six month plan for launching their own health promotion initiatives. The training is seen as having two additional objectives: first, to build a partner relationship between Health Advisors and local professionals, and second, to build a sense of solidarity and mutual support among the Health Advisors themselves. Both of these partnerships are essential for the long-range effectiveness of the Health Advisors' work. By June 1990, the training had been conducted four times, with a total of 52 Health Advisors graduating.
SUPPORTING HEALTH ADVISOR INITIATIVES Health Advisors use their neighborhood, church and workrelated networks to provide counselling and sound, basic advice based on their training. They provide assistance, particularly in the form of referrals to appropriate community services and resources. When a neighborhood or community-wide health issue is encountered, they work with local groups and agencies to organize short and long-term community action efforts to address these problems. "Initial findings indicate that Health Advisors are reaching out to people in need instead of waiting to be asked to help"(12). Health Advisors are often asked for advice about medications, family problems and school-related issues. They prOvide the emotional support and encouragement that enables people to think through a problem and arrive at their own decision about a solution. In addition, they often provide direct assistance. They give people rides to clinics and grocery stores, they run errands and cook meals for people who are ill, or they may loan or give money. They also make many referrals to existing organizations and social service agencies. They help people negotiate the system by assisting with forms , making appointments, and providing information on eligibility requirements. Health Advisors find that a large portion of their counselling has to do with diet and the medications related to diabetes and hypertenSion. They find it is necessary to have frequent contact with elderly neighbors who suffer from
69S
these diseases and to repeat their advice often. At the other end of the spectrum, Health Advisors report helping young mothers design adequate meals using Food Stamps and WIC foods. Their work in the county exposed the need for a source of emergency food. As a result, they established an Emergency Food Pantry, which not only distributes foods , but also works with reCipients to determine the root causes of hunger in the county. When organizing action, Health Advisors work to form partnerships with other community groups. They work at the neighborhood level, as in door-to-door information campaigns; at the town level, as in organizing communitywide clean ups; or at the county level, as in establishing an emergency food pantry. Health Advisors engage in an annual planning session, during which they identify priority arenas of need and outline action strategies to meet those needs. For example, a workshop focused on the causes of chronic malnutrition in the Delta, and specific ways to address those problems. The linkage to agencies provided during the training not only enhances the effectiveness of referrals, but also insures access to on-going training opportunities and resources outside the community. An early evaluation study showed each Health Advisor making an average of 3.6 helping contacts per week providing assistance to 4.9 individuals. Recent surveys show that the number of contacts is Significantly increasing. At this rate, even allOwing for multiple contacts with the same individual(s), Health Advisors are reaching approXimately one half of the total low income population of the county once every six months. Those assisted are friends (37%), acquaintances (23%) , neighbors (14%), fellow church members (12%). Most are black (95%), women (86%), and unemployed but not retired. Thirty-one percent are teens, and 21% are 60-69 years old. Fourteen percent of the contacts are made in the Health Advisors home, 25% by phone, 45% in someone else's home, and 17% at church and meetings. CONCLUSIONS PINAH's activities are being evaluated by county residents and collaborating agencies with technical assistance from public health researchers at the UNC. While it is too early to interpret final results, early indications are promising: " .. . the project has successfully recruited the more active and visible members of communities ... "; " ... training is enhancing (Health Advisor) knowledge of health risks and benefits so that they can take appropriate action . . ."; Health Advisors are" . .. reaching out to individuals through their pre-existing, non-kin social networks ... "; and" ... it appears that the scope of response from Health Advisors is widening in terms of problems and types of support ... "(12). As part of the evaluation conducted by UNC, agency officials are asked to sample the number of interagency referrals they make and to report annually on
70S
Hinton et al. / PINAH
the number and quality of referrals between agencies and between agencies and the community. They report an increase in interagency referrals and a significant increase in the number of referrals from and to individuals and informal groups in the community. These agencies also report referring people in need to their neighborhood Health Advisor, particularly when the need falls outside the agency's range of services. The PINAH experience in the Delta is a continual learning experience. Low income residents have a strong desire and capacity to take charge of their lives and their health, and will volunteer their time and resources to help others. Local participation in planning, implementing and evaluating development efforts is possible, feasible and essential to real and lasting progress. Public agencies and private organizations alike must learn "new ways of doing business" if they are to become truly responsive to local initiatives. Perhaps the most important lesson learned in Humphreys County is that public health nutrition issues do not exist in isolation. Health issues intertwine with poverty, hunger, education, economic and social problems in ways that frustrate abstract and piecemeal solutions. Comprehensive, in-depth responses and lasting solutions will require a tremendous investment in the human resource that is the Delta's rural population. The keys to the resolution of chronic poor health can be found in the development of new partnerships with the people themselves, partnerships that are dedicated to the vitality and well-being of neighborhoods and communities. In the words of one Community Health Advisor: "We want you to know that you are not alone . . . in this struggle. There are people in every community in this nation who are concerned about the health of their community, and looking for a way to do something about it. We are ready
to join you, the health profeSSionals and agencies, as partners for a healthy nation through healthy neighborhoods. It is important for policy-makers to understand that local initiatives to the problems of poor health and poverty have the best chance of producing lasting solutions"(13). REFERENCES 1 Freedom From Hunger Foundation. 1987 annual report. Davis, California, 1987. 2 Douglas, G., E. Dolber-Smith, and C. Dunford. A geography of American poverty. Davis, CA: Freedom From Hunger Foundation, 1986. 3 Service, C. and E.J. Salber. Community health education: The lay advisor approach. Duke University, Durham, NC: Community Health Education Program, 1977. 4 Hatch, J. and H. Barr. The General Baptist State Convention Health and Human Services Project. Contact 77:1-17, 1984. 5 Uphoff, N. T., J. M. Cohen, and A. A. Goldsmith. Feasibility and application of rural development participation: A state-of the-art paper. Monograph Series. Cornell UniverSity, Ithaca NY: Rural Development Committee, Center for International Studies, 1979. 6 Frate, D., T. L. Whitehead, and S. A. Johnson. The selection, training and utilization of health counselors in the management of high blood pressure. Urban Health 12:52-54, 1983. 7 Wilson, S. E. CHAP manual: Community health advocacy program. East Carolina University School of Medicine, Greenville, NC: Center for Health Services Research and Development, 1987. 8 Pratt, B. and J. Boyden, eds. The field directors handbook: An Oxfam manual for developing workers. Oxford, England: Oxford University Press, 1985. 9 Stinson, W., M. Favin, and B. Bradford. Training community health workers. Washington, D.C.: World Federation of Public Health Association, 1983. 10 Eng, E., J. Hatch, and A. Collan. Institutionalizing social support into the community. Health Education Quarterly 12(1):81-92, Spring, 1985. 11 Dunford, C. Mississippi applied nutrition program. Davis, CA: Freedom From Hunger Foundation, 1987. 12 Eng, E. PINAH evaluation progress report, 1988-1989. University of North Carolina, Chapel Hill, 1989. 13 Chambers, H., Community Health Advisor. Testimony before the Committee on Labor and Human Resources, United States Senate, April 20, 1990.
ABSTRACT OF INTEREST
Overcoming hunger in the 1990s. Kasperson, JX and R.W. Kates, eds. Food Policy 15(4):274358,1990. This special issue contains eight papers that look at the possibilities of overcoming hunger in the 1990s. A review of world hunger is presented; opportunities for the 1990s to halve world hunger are described; the additional flows of money and food aid required are estimated; coping mechanisms and efforts to overcome hunger at the village and grass root level are assessed through case studies; obstacles thwarting the potential of biotechnology to alleviate Third World hunger are reviewed; and the need to strengthen the political force of interest groups to ensure that the airing of the hunger issue is contained at the highest levels is stated. Three important declarations with regard to solving the hunger problem are presented in full: the Cairo Declaration, the Bangkok Affirmation, and the Bellagio Declaration. It is argued that it is possible to reduce the toll of hunger within a decade, perhaps by as much as half.