Josh Report

Josh Back spent a year in San Jose, taking time off between his third and fourth year of medical school.  He was very busy furthering our ongoing projects.  Additionally, Josh performed a home survey, reaching 57 of 60 identified homes.  Below is a google earth map of the locations he visited, and a copy of the final report. 

Map below shows the location of each house surveyed.  The terrain is very mountainous, so the amount of work involved in this survey is huge!

 

Link to full report

Summary of Report

 

San Jose Partners:

Eight Year Follow-Up to the Baseline Household Survey

Summary

I.      Purpose

·         To define current and trending socioeconomic and health status.

·         To determine the penetration and sustainability of existing interventions.

·         To evaluate the currently employed model of development.

II.      Methods

·         Baseline survey (BQ) sampled approximately 10% of houses in the San Jose township using a quasi-randomized convenience sampling method (N=38). 

·         Follow-up (FQ) survey sampled 15% of each village (N=56) using randomized census lists.

·         Limitations

o   Variation in design and execution between BQ and FQ

       Different sampling methodology within villages and a proportionally larger recruitment from the wealthier village of El Horno in the BQ.

       Three quarters in BQ were administered at end of rainy season while all in FQ were administered prior to the rainy season.

o   Some metrics were underpowered due to reduced sample size in some survey components.

o   Participant desire to appease the interviewer, language and cultural nuances, and mistrust are likely to have influenced the data.

III.      Data Highlights

·         Educational achievement (FQ only)

o   98% reported primary school attendance (grades 1-6). 

o   42% reported middle school attendance (grades 7-9).

o   5% reported high school attendance (grades 10-12).

·         Self reported health status

o   Rated “very good” or “excellent” for 39% in BQ compared to 55% in FQ (Not statistically significant, “NS”).

·         Income sources (FQ only)

o   80% unskilled day labor (earning $2.50-$3.50 per day and without guarantee of daily work).

o   69% of households send at least one member to the coffee harvest in another department.

·         Maternal and Child Health

o   Weight for age ≤2 std. dev. below the WHO median in 25% of BQ and 10% of FQ (NS).

o   Immunizations

       Full immunization for Polio, DPT and measles before 13 months of age in 26% of BQ and 100% FQ (p=0.087).

       93% in FQ completely immunized according to expanded Honduran national guidelines.

o   Institutional births in 22% of BQ compared to 59% of FQ (p=0.002).

o   Traditional midwifes attending 69% of BQ and 79% of FQ home births (NS).

o   Childhood illness – Parental recall of diarrheal, cough or febrile episodes in the past two weeks was not statistically significantly different between BQ and FQ.

·         Reproductive health (FQ only)

o   73% could name a single method of contraception; 23% of those could name a LARC.

o   41% currently using a method of contraception, of which 12 of 14 is tubal ligation.

·         Water, sanitation and home smoke exposure

o   Drinking water source is surface water in 86% of BQ and 91% of FQ (NS).

o   Open defecation in 61% of BQ compared to 37% of FQ (p=0.006).

o   Improved cook stove (reduced smoke exposure and improved fuel efficiency) in 16% of BQ and 72% of FQ (p=<0.001).

·         Project penetration and sustainability (FQ only)

o   Improved cook stoves in 39 (72%) of households; 88% still being used.

       56% supported by San Jose Partners, of which 85% were built in or before 2010

o   Latrines in 37 (69%) of households; 88% still being used.

       35% supported by San Jose Partners, of which 42% were built in or before 2010

o   Ceramic Water Filters in 15 (28%) of households

       11 (21%) had previously purchased a water filter, but are not using them due to a broken component.

       20 (51%) report alternative “acceptable” method of purifying water, of which only 13% passed a brief screening test for correct use.

o   Barriers to intervention penetration include household inability to afford price, inability to perform required labor, lack of awareness and lack of initiative.

IV.      Insights, conclusions and further questions

·         Projects should be most heavily promoted when households experience a relative increase in reserve funds, at the end of the coffee harvest in March and April.

·         There is near universal attendance of primary school, improved middle school attendance and very poor high school attendance.  Does this represent cohort bias (ie. changes that have allowed increased primary and middle school attendance will be reflected in increased high school attendance as these younger students grow older) or does it demonstrate an unchanging barrier to job training level education?

·         Dramatic improvement in both institutional births and immunization rates are most likely due to improved community health outreach since Shoulder to Shoulder assumed responsibility for healthcare in San Marcos de la Sierra.

·         Traditional midwives are still attending many births and need continued training and the provision of hygienic birth kits.

·         There is inadequate promotion of LARC forms of birth control, which are offered for free in government clinics and are especially important in this region due to difficulty of follow-up and male partner resistance to “visible” methods.

·         Other point of consumption water purification methods are not being used correctly, reinforcing the importance of ceramic water filters.

·         A supply line for replacement of ceramic water filter components needs to be maintained.

·         The pace of public health project distribution has slowed. 

o   The most able community members have already received interventions, village based leadership is less active and further intervention penetration to the more marginalized households is limited by the barriers mentioned above. 

o   Can this inertia be overcome by creative changes to distribution rules and changes in local project leadership or, without a permanent on the ground presence, has San Jose Partners reached a point of diminishing marginal returns for its public health promotion efforts in the township of San Jose?