Community Level Health Workers Research Articles

Impact of market-based home fortification with micronutrient powder on childhood anemia in Bangladesh: a modified stepped wedge design.

Anemia poses a significant public health problem, affecting 1.6 billion people and contributing to the loss of 68.4 million disability-adjusted life years. We assessed the impact of a market-based home fortification program with micronutrient powder (MNP) called Pushtikona-5 implemented by Bangladesh Rural Advancement Committee (BRAC) on the prevalence of anemia among children aged 6-59 months in Bangladesh. We used a modified stepped wedged design and conducted three baseline, two midline, and three endline surveys to evaluate the Pushtikona-5 program implemented through three BRAC program platforms. We interviewed children's caregivers, and collected finger-prick blood samples from children to measure hemoglobin concentration. We also collected data on coverage of Pushtikona-5 and infant and young child feeding (IYCF) practices. We performed bivariate and multivariable analysis and calculated adjusted risk ratios (ARRs) to assess the effect of program outcomes. A total of 16,936 households were surveyed. The prevalence of anemia was 46.6% at baseline, dropping to 32.1% at midline and 31.2% at endline. These represented adjusted relative reductions of 34% at midline (RR 0.66, 95%CI 0.62 to 0.71, value of p <0.001) and 32% at endline (RR 0.68, 95%CI 0.64 to 0.71, value of p <0.001) relative to baseline. Regarding MNP coverage, at baseline, 43.5% of caregivers surveyed had heard about MNP; 24.3% of children had ever consumed food with MNP, and only 1.8% had consumed three or more sachets in the 7 days preceding the survey. These increased to 63.0, 36.9, and 4.6%, respectively, at midline and 90.6, 68.9, and 11.5%, respectively, at endline. These results show evidence of a reduction in the prevalence of anemia and an improvement in coverage. This study provides important evidence of the feasibility and potential for impact of linking market-based MNP distribution with IYCF promotion through community level health workers.

Tools for assessing child and adolescent stunting: Lookup tables, growth charts and a novel appropriate-technology "MEIRU" wallchart - a diagnostic accuracy study.

Stunting affects 149 million children worldwide and is a form of chronic malnutrition defined by low height-for-age. Surveys and intervention programmes depend on effective assessment and identification of affected individuals. Gold standard assessment is based on height-for-age Z-score (HAZ): HAZ <-2 defines stunting; HAZ <-3 defines severe stunting. However, a major problem for field-based programmes is that Z-scores can be time-intensive and challenging to calculate. We thus developed a novel wallchart that we have coined 'MEIRU wallchart' to easily and accurately identify stunted children and adolescents. Our study aim was to evaluate its performance and acceptability against other methods used in current clinical/field practice. We undertook a non-interventional diagnostic accuracy study in Malawi. We recruited 244 participants aged 8-19 years and determined each individual's stunting status using, in varying order: the MEIRU wallchart, traditional lookup tables, and traditional growth charts. All were compared against 'gold standard' HAZ, calculated using AnthroPlus WHO software. Local community healthcare workers performed all the assessments. The wallchart method was strongly preferred by both participants and staff. It had an overall accuracy of 95.5%(kappa = 0.91) and was faster than lookup tables by an average of 62.5%(41.4sec; p<0.001) per measurement. Lookup tables and growth charts had overall agreements of 59.4%(kappa = 0.36) and 61.9%(kappa = 0.31) respectively. At the HAZ-2 cut-off, the wallchart had a sensitivity of 97.6%(95%CI: 91.5-99.7) and specificity of 96.3%(95%CI: 92.1-98.6). We conclude that the MEIRU wallchart performs well and is acceptable for screening and identification of stunted children/adolescents by community-level health workers. It fulfils key criteria that justify a role in future screening programmes: easy to perform and interpret; acceptable; accurate; sensitive and specific. Potential future uses include: conducting rapid stunting prevalence surveys; identifying affected individuals for interventions. Current field methods, lookup tables and growth charts performed poorly and should be used with caution.

A mixed methods evaluation of an integrated training package for skin neglected tropical diseases in Kaduna and Ogun, Nigeria.

The overall burden of neglected tropical diseases (NTDs) affecting the skin is undetermined. Skin conditions are among the top 10 causes of disability worldwide. Affected persons seek treatment at advanced stages of the disease, resulting in morbidity and disability. We developed and evaluated an integrated training intervention for early case detection, referral and management of skin NTDs in two states in Nigeria. This was a mixed-methods study using participatory approaches to develop specific skin algorithms and training packages for community and primary level health workers. This supported the identification, referral and clinical diagnosis of suspected cases. We used Kirkpatrick's model to evaluate the training package. Participants' knowledge improved after the 2-months intervention. Across both states, knowledge retention appeared more robust for cadres at all levels: state, local government area and primary healthcare. All (100%) participants mentioned that the training assisted them in detecting, referring and managing skin NTDs. Training was understood by participants and training materials were easy to understand. Materials were also effective in educating community members about the symptoms of NTDs and supported referral to facilities for appropriate management. Community implementers can be trained and supervised to detect people affected by skin NTDs and support appropriate management within the existing patient care pathway.

Detection Of Treatment Adherence, Disease Control and Its Predictors in Asthma Patients by Rural Community Level Health Workers

Background: Despite the availability of effective therapy, disease control in Asthma remains suboptimal with high morbidity.&#x0D; Objectives: To assess treatment adherence, asthma control and its influencing factors.&#x0D; Methodology: A prospective, observational study was conducted among 152 adult asthma patients reporting consecutively to a BPHC for twelve months. Patients were followed up by trained healthcare workers to assess their treatment adherence and disease control using a predesigned, pretested and validated questionnaire.&#x0D; Results: Mean age was 49.6 years (SD = +14.0), males reported more cases (73.7%), addiction to tobacco was high (48.7%). 40.8% patients had high treatment adherence. Only 37.5% patients reported good asthma control of which 68.4% showed high adherence. The mean Asthma Control Test (ACT) score was 18.75 ± 4.8 SD. Increasing age (aOR=0.96, 95% CI= 0.93-0.99), tobacco smoking (aOR=2.90, 95% CI=1.20-6.99), dust allergy (aOR= 7.92, CI =3.15-19.91) and low treatment adherence (aOR=5.33, 95% CI=2.22-12.82) were found to be significant predictors of poor disease control.&#x0D; Conclusions: Non adherence to treatment and poor disease control were high among rural asthma patients. Patient education for tobacco cessation and treatment compliance along with periodic monitoring undertaken by trained health workers can be an effective strategy to reduce disease burden in the community.

Innovative, enhanced community management of non-hypoxaemic chest-indrawing pneumonia in 2–59-month-old children: a cluster-randomised trial in Africa and Asia

IntroductionThe WHO recommends oral amoxicillin for 2–59-month-old children with chest-indrawing pneumonia presenting at the health facility. Community-level health workers (CLHWs) are not allowed to treat these children when presented at...

Cut-off Points of Treatment Delay to Predict Poor Outcomes Among New Pulmonary Tuberculosis Cases in Dalian, China: A Cohort Study.

PurposeDespite increasing literature on the association between treatment delay and outcomes, cut-off point (1 month or median) selection in almost all studies for treatment delay is too subjective. This study explored more scientific cut-off points of treatment delay for poor treatment outcomes and death at the clinical level.Patients and MethodsA total of 18,100 newly confirmed pulmonary tuberculosis (TB) cases in Dalian, China were used in the final analysis. A 3-knotted restricted cubic spline (RCS) fitted for Cox proportional hazard regression models is used to analyse the effects of cut-off points of treatment delay on incident poor treatment outcomes. To explore the moderating effects of age, gender and diabetes, we added the interaction terms of these moderating variables and treatment delay to Cox proportional hazard regression models.ResultsThe median time of treatment initiation was 30 days (IQR: 14–59 days). The risk of incident poor treatment outcomes increased when the time was greater than cut-off point 1 (53 days; adjusted HR: 1.26; 95% CI: 1.00–1.60) of treatment delay, and the risk of incident death events increased when the time was greater than cut-off point 2 (103 days; adjusted HR: 1.56; 95% CI: 1.00–2.44) of delay. In addition, treatment delay was associated with an increased risk of incident poor treatment outcomes and death, and older age, male sex, and diabetes may increase the risk of treatment delay for poor outcomes.ConclusionThis study is the first to identify scientific cut-off points of treatment delay for poor treatment outcomes and death, and this method of exploration should be popularized. In addition, the knowledge of tuberculosis must be spread to every adult. Moreover, the tuberculosis diagnosis level of community level health workers should be enhanced.

Factors influencing mass drug administration adherence and community drug distributor opportunity costs in Liberia: a mixed-methods approach

BackgroundPreventive chemotherapy delivered via mass drug administration (MDA) is essential for the control of neglected tropical diseases (NTDs), including lymphatic filariasis (LF), schistosomiasis and onchocerciasis. Successful MDA relies heavily on community drug distributor (CDD) volunteers as the interface between households and the health system. This study sought to document and analyse demand-side (households) and supply-side (health system) factors that affect MDA delivery in Liberia.MethodsWorking in two purposively selected counties, we conducted a household MDA access and adherence survey; a CDD survey to obtain information on direct and opportunity costs associated with MDA work; an observational survey of CDDs; and key informant surveys (KIS) with community-level health workers. Data from the CDD survey and Liberian minimum wage rates were used to calculate the opportunity cost of CDD participation per MDA round. The observational data were used to calculate the time spent on individual household-level tasks and CDD time costs per house visited. KIS data on the organisation and management of the MDA in the communities, and researcher reflections of open-ended survey responses were thematically analysed to identify key demand- and supply-side challenges.ResultsMore respondents were aware of MDA than NTD in both counties. In Bong, 39% (103/261) of respondents reported taking the MDA tablet in the last round, with “not being informed” as the most important reason for non-adherence. In Maryland, 56% (147/263) reported taking MDA with “being absent” at the time of distribution being important for non-adherence. The mean cost per CDD of participating in the MDA round was −$11.90 (median $5.04, range −$169.62 to $30.00), and the mean time per household visited was 17.14 min which equates to a mean opportunity cost of $0.03 to $0.05 per household visited. Thematic analysis identified challenges, including shortages of and delays in medicine availability; CDD frustration over costs; reporting challenges; and household concerns about drug side effects.ConclusionsImproved adherence to MDA and subsequent elimination of NTDs in Liberia would be supported by an improved medicine supply chain, financial compensation for CDDs, improved training, healthcare workforce strengthening, greater community involvement, capacity building, and community awareness.Graphical

Community-based amoxicillin treatment for fast breathing pneumonia in young infants 7–59 days old: a cluster randomised trial in rural Bangladesh, Ethiopia, India and Malawi

IntroductionYoung infants 7–59 days old with fast breathing pneumonia presented to a primary level health facility receive a 7-day course of amoxicillin as per the WHO guideline. However, community-level health...

Assessment of surveillance core and support functions regarding neglected tropical diseases in Kenya

BackgroundEffective surveillance and response systems are vital to achievement of disease control and elimination goals. Kenya adopted the revised guidelines of the integrated disease surveillance and response system in 2012. Previous assessments of surveillance system core and support functions in Africa are limited to notifiable diseases with minimal attention given to neglected tropical diseases amenable to preventive chemotherapy (PC-NTDs). The study aimed to assess surveillance system core and support functions relating to PC-NTDs in Kenya.MethodsA mixed method cross-sectional survey was adapted involving 192 health facility workers, 50 community-level health workers and 44 sub-national level health personnel. Data was collected using modified World Health Organization generic questionnaires, observation checklists and interview schedules. Descriptive summaries, tests of associations using Pearson’s Chi-square or Fisher’s exact tests and mixed effects regression models were used to analyse quantitative data. Qualitative data derived from interviews with study participants were coded and analysed thematically.ResultsSurveillance core and support functions in relation to PC-NTDs were assessed in comparison to an indicator performance target of 80%. Optimal performance reported on specimen handling (84%; 100%), reports submission (100%; 100%) and data analysis (84%; 80%) at the sub-county and county levels respectively. Facilities achieved the threshold on reports submission (84%), reporting deadlines (88%) and feedback (80%). However, low performance reported on case definitions availability (60%), case registers (19%), functional laboratories (52%) and data analysis (58%). Having well-equipped laboratories (3.07, 95% CI: 1.36, 6.94), PC-NTDs provision in reporting forms (3.20, 95% CI: 1.44, 7.10) and surveillance training (4.15, 95% CI: 2.30, 7.48) were associated with higher odds of functional surveillance systems. Challenges facing surveillance activities implementation revealed through qualitative data were in relation to surveillance guidelines and reporting tools, data analysis, feedback, supervisory activities, training and resource provision.ConclusionThere was evidence of low-performing surveillance functions regarding PC-NTDs especially at the peripheral surveillance levels. Case detection, registration and confirmation, reporting, data analysis and feedback performed sub-optimally at the facility and community levels. Additionally, support functions including standards and guidelines, supervision, training and resources were particularly weak at the sub-national level. Improved PC-NTDs surveillance performance sub-nationally requires strengthened capacities.

Community Empowerment in Health: An Exploratory Study in Rural Community of a District of West Bengal

Background: Community empowerment is the process and outcome where community itself is able to identify, prioritize health problems and address them. It has been considered as the key strategy for scalability and sustainability of health services.&#x0D; Objectives: To explore the status of community empowerment in health in rural areas in West Bengal, India and the interplay of different stakeholders.&#x0D; Methods: A cross-sectional, qualitative study was conducted in 2017 – 2018 among the people residing in rural areas of Birbhum district in West Bengal, India who utilized the public health system (lay informants), formal and informal leaders of the community, community level health workers and peripheral health staff (key informants). Three community blocks, two sub-centers from each block and one village from each sub-center were selected randomly. In-depth interviews were conducted among 36 lay and 36 key informants using Laverack’s nine dimension model of community empowerment. Framework analysis was done to summarize data.&#x0D; Results: Participation of people was restricted to awareness and utilization of existing health services. Unmet aspiration for greater participation was noted among a small section of the community. They were mostly fitted to the role of beneficiaries. Functioning of village level organization to promote communitization as envisaged in national health programmes was largely deficient. The community health workers acted as the most peripheral appendages of formal health system rather than the health activists to empower community regarding community’s health.&#x0D; Conclusion: Although, every national health programme advocated community empowerment, the current status and the process of empowerment in health is in nascent stage.

Framework for strengthening primary health care and community networks to mitigate the long-term psychosocial impact of floods in Kerala

Individuals who encounter disasters experience negative consequences across physical, mental and psychosocial domains. Impacts on mental health and psychosocial domains are more common, and last longer than physical health problems. In August 2018, the state of Kerala, India witnessed unprecedented floods that resulted in 483 deaths and significant loss of property and livelihood. Project “PARIRAKSHA” was implemented by the Government of Kerala, to mitigate the long-term psychosocial impact of the disaster. It has been one of the largest comprehensive post-disaster psychosocial project in India till date, aimed to benefit approximately 2 million people across 93 panchayats which experienced severe flooding and loss of life.This paper describes the detailed methodology of this project. In addition, the supplementary material includes the technical manuals that were prepared, and is freely accessible to personnel in disaster affected zones.Counsellors were newly appointed in all the primary health centres in affected panchayats to provide mental health and psychosocial support. Accredited Social Health Activists (community level health workers) undertook home-visits to ensure early case-detection. Medical officers’ in affected areas received booster training regarding pharmacological management of mental health issues. Multi-disciplinary mobile mental health teams were constituted to ensure availability of specialised mental health inputs locally.The project integrated additional mental health resource personnel, into the existing health care system. Existing health care personnel received training to improve competency in dealing with post-disaster psychosocial issues. This framework is expected to ensure early detection and intervention, thus facilitating timely psychosocial recovery of communities impacted by the floods.

Maternal health training priorities for nursing and allied professions in Haiti.

ABSTRACTObjectives.This study summarizes the findings of a training needs and priority assessment completed in Haiti. Its objective is to describe the characteristics of nursing and allied professions providing first level maternal health care and identify training needs and priorities to inform planning of Human Resources for Health interventions.Methods.A cross-sectional survey was completed between October 2016 and March 2017 by the Pan American Health Organization/World Health Organization Haiti office in collaboration with national health authorities. Participants reached consensus to submit one finalized version of the survey. Data were collected on composition, capacities, and training needs and priorities of traditional birth attendants, community health workers, registered nurses, professional midwives, and auxiliary nurses.Results.Haiti relies heavily on community level workers including community health workers, auxiliary nurses, and traditional birth attendants. Traditional birth attendants attend the majority of Haiti’s births, despite having low education levels and not being regulated by the Ministry of Public Health and Population. All professional categories prioritize preventive capacities such as timely identification of complications, while none are trained to manage postpartum hemorrhage, preeclampsia, or eclampsia. Management of obstetric emergencies is a training priority for Haiti but is not part of the scope of work of the nursing and allied health professions included in this study.Conclusions.Community level health workers are key in providing preventive care and referral of complicated pregnancies, but lack of access to providers qualified to treat obstetric complications remains a challenge to reducing maternal mortality.

Community case management of chest indrawing pneumonia in children aged 2 to 59 months by community health workers: study protocol for a multi-country cluster randomized open label non-inferiority trial.

Background:The World Health Organization (WHO) integrated management of childhood illness (IMCI) protocol recommends treatment of chest indrawing in 2–59 months old children with oral amoxicillin by trained health facility workers. Whereas, the WHO/UNICEF integrated community case management (iCCM) protocol recommends referral by community level health workers (CLHWs) to a health facility. This study aims to evaluate whether CLHWs can treat chest indrawing pneumonia effectively and safely.Methods:This multi-centre cluster randomized controlled open label, non-inferiority trial will be conducted in Bangladesh, Ethiopia, India and Malawi. All sites will use a common protocol with the same study design, participants, intervention, control and outcomes. CLHWs will identify 2–59 months old children with chest indrawing. Study supervisors, trained in the iCCM protocol, will confirm CLHWs’ findings. Pulse oximetry will be used to identify hypoxaemic children. In the intervention group, enrolled children will be treated with oral amoxicillin for 5 days, and in the control group they will be referred to a health facility, after providing first dose of oral amoxicillin. An independent outcome assessor will visit each enrolled child on days 6 and 14 of enrolment, to assess study outcomes.Conclusions:If CLHWs can effectively and safely treat chest indrawing pneumonia in 2–59 months old children, it will increase access to pneumonia treatment substantially, as in many settings, health facilities and trained health workers are not easily accessible. Moreover, this evidence will contribute towards the review of the current iCCM protocol and its harmonization with the IMCI protocol.Trial Registration:The trial is registered at AZNCTR International Trial Registry as ACTRN12617000857303.

Management of fast breathing pneumonia in young infants aged 7 to 59 days by community level health workers: protocol for a multi-centre cluster randomized controlled trial.

Background:WHO does not recommend community-level health workers (CLHWs) using integrated community case management (iCCM) to treat 7–59 days old infants with fast breathing with oral amoxicillin, whereas World Health Organization (WHO) integrated management of childhood illness (IMCI) recommends it. We want to collect evidence to help harmonization of both protocols.Methods:A cluster, randomized, open-label trial will be conducted in Africa and Asia (Ethiopia, Malawi, Bangladesh and India) using a common protocol with the same study design, inclusion criteria, intervention, comparison, and outcomes to contribute to the overall sample size. This trial will also identify hypoxaemia in young infants with fast breathing. CLHWs will assess infants for fast breathing, which will be confirmed by a study supervisor. Enrolled infants in the intervention clusters will be treated with oral amoxicillin, whereas in the control clusters they will be managed as per existing iCCM protocol. An independent outcome assessor will assess all enrolled infants on days 6 and 14 of enrolment for the study outcomes in both intervention and control clusters. Primary outcome will be clinical treatment failure by day 6. This trial will obtain approval from the WHO and site institutional ethics committees.Conclusions:If the research shows that CLHWs can effectively and safely treat fast breathing pneumonia in 7–59 days old young infants, it will increase access to pneumonia treatment substantially for infants living in communities with poor access to health facilities. Additionally, this evidence will contribute towards the review of the current iCCM protocol and its harmonization with IMCI protocol.Trial Registration:The trial is registered at AZNCTR International Trial Registry as ACTRN12617000857303.

Assessment of 5-year risk of cardiovascular events among adults residing in an urban underprivileged area of Bangalore city: A community-based cross-sectional study

Background: Cardiovascular disease (CVD) is the major cause of premature morbidity and mortality in India and is undergoing an epidemiological transition, now affecting the urban poor. It is important to assess patients for CVD risk and mitigate risk factors as a primary mode of prevention of CVD accordingly. Objective: The objective of the study was to assess the 5-year risk of cardiovascular events and the prevalence of CVD risk factors in an underprivileged area of Bangalore City. Methods: Community-based house-to-house survey of all adults aged 30 years and above, using an interview schedule on Epicollect mobile application, capturing sociodemographic details and CVD risk factors based on the INTERHEART risk assessment which included dietary risk factors, smoking and alcohol, physical activity, and central obesity. Blood pressure, random blood sugar, height, weight, and waist circumference measurement were done. The National Health and Nutrition Examination Survey CVD risk assessment charts were used to calculate the 5-year risk of a cardiovascular event. Results: Of 1184 study participants, 23% had moderate risk (10%–20%) and 30% had high risk (>20%) of a cardiovascular event in the next 5 years. Factors such as being not currently married, belonging to a religious minority, lower education, not being gainfully employed, belonging to a joint family, and salty food consumption were significantly associated with higher CVD risk. Conclusion: Urban underprivileged areas with undermined social determinants of health have significantly high burden of CVD risk and hence require a holistic approach to CVD risk assessment and noncommunicable diseases care starting with easy to use CVD risk assessment charts by community level health workers. Cardiovascular diseases risk assessment, diabetes, hypertension, noncommunicable diseases, urban health

Newborn Care Practices in Rural Communities of Nawalparasi District, Nepal

Most of the new born deaths in the developing countries occur due to lack of access to care, as majority of the deliveries occur at home. Even deliveries conducted in health facilities are prone to suffering from traditional care practice after discharge from health facilities. Most of these deaths could be avoided with changes in antenatal, delivery and newborn care practices. This study was conducted to explore the newborn care practices related to cord care, thermal care and breast feeding in rural setting and to identify socio-demographic, antenatal and delivery care factors associated with these practices. A cross sectional study in rural setting of Nawalparasi district included 296 women who had delivered live baby at home or discharged within 24 hours of delivery from hospital proceeding four months of data collection. Chi squire test was applied to compare sociodemographic, antenatal and delivery care factors associated with cord care, thermal care and breast feeding practices. Of the total 296 mother interviewed, only 65.54% have completed ANC visit at least 4 times and 29.05% have received counselling on newborn care during pregnancy. More than half deliveries (53.38%) were home deliveries and Clean Home Delivery Kit was used only one third (39.91%) of these deliveries. Of the three selected newborn care practices, clean cord keeping practice was found in only one fourth (25.70%) of deliveries. However early initiation of breast feeding and delayed bathing practice was found in about half of the deliveries (51.35% and 58.45% respectively). There is strong need to implement the community-based interventions to improve the new born care practices in community level and to reduce the high-risk newborn care practices like unsafe cord care, delayed breast feeding, early bathing, prelacteal feeding and discarding colostrum need through the community level health workers and volunteers.&#x0D; Key words: Newborn care, Safe cord care, Early breast feeding, Thermal care, Delayed bathing.

Maternal nutrition intervention and maternal complications in 4 districts of Bangladesh: A nested cross-sectional study.

BackgroundMaternal morbidity is common in Bangladesh, where the maternal mortality rate has plateaued over the last 6 years. Maternal undernutrition and micronutrient deficiencies contribute to morbidity, but few interventions have measured maternal outcomes. We compared reported prevalence of antepartum, intrapartum, and postpartum complications among recently delivered women between maternal nutrition intervention and control areas in Bangladesh.Methods and findingsWe conducted a cross-sectional assessment nested within a population-based cluster-randomized trial comparing a nutrition counseling and micronutrient supplement intervention integrated within a structured home-based maternal, newborn, and child health (MNCH) program to the MNCH program alone in 10 sub-districts each across 4 Bangladesh districts. Eligible consenting women, delivering within 42–60 days of enrollment and identified by community-level health workers, completed an interviewer-administered questionnaire detailing the index pregnancy and delivery and allowed review of their home-based care register. We compared pooled and specific reported antepartum, intrapartum, and postpartum complications between study groups using hierarchical logistic regression. There were 594 women in the intervention group and 506 in the control group; overall, mean age was 24 years, 31% were primiparas, and 39% reported facility-based delivery, with no significant difference by study group. There were no significant differences between the intervention and control groups in household-level characteristics, including reported mean monthly income (intervention, 6,552 taka, versus control, 6,017 taka; p = 0.48), having electricity (69.6% versus 71.4%, p = 0.84), and television ownership (41.1% versus 38.7%, p = 0.81). Women in the intervention group had higher recorded iron and folic acid and calcium supplement consumption and mean dietary diversity scores, but reported anemia rates were similar between the 2 groups (5.7%, intervention; 6.5%, control; p = 0.83). Reported antepartum (69.4%, intervention; 79.2%, control; p = 0.12) and intrapartum (41.4%, intervention; 48.5%, control; p = 0.18) complication rates were high and not significantly different between groups. Reported postpartum complications were significantly lower among women in the intervention group than the control group (33.5% versus 48.2%, p = 0.02), and this difference persisted in adjusted analysis (adjusted odds ratio [AOR] = 0.51, 95% CI 0.32–0.82; p < 0.001). For specific conditions, odds of retained placenta (AOR = 0.35, 95% CI 0.19–0.67; p = 0.001), postpartum bleeding (AOR = 0.37, 95% CI 0.15–0.92; p = 0.033), and postpartum fever/infection (AOR = 0.27, 95% CI 0.11–0.65; p = 0.001) were significantly lower in the intervention group in adjusted analysis. There were no significant differences in reported hospitalization for antepartum (49.8% versus 45.1%, p = 0.37), intrapartum (69.9% versus 59.8%, p = 0.18), or postpartum (36.1% versus 29.9%, p = 0.49) complications between the intervention and control groups. The main limitations of this study are outcome measures based on participant report, non-probabilistic selection of community-level workers’ catchment areas for sampling, some missing data for variables derived from secondary sources (e.g., dietary diversity score), and possible recall bias for reported dietary intake and supplement use.ConclusionsReported overall postpartum and specific intrapartum and postpartum complications were significantly lower for women in intervention areas than control areas, despite similar rates of facility-based delivery and hospitalization for reported complications, in this exploratory analysis. Maternal nutrition interventions providing intensive counseling and micronutrient supplements may reduce some pregnancy complications or impact women’s ability to accurately recognize complications, but more rigorous evaluation is needed for these outcomes.

Coverage survey of Measles-Rubella mass vaccination campaign in a rural area in Tamil Nadu.

Background:In Tamil Nadu, where health indicators are above the national average and routine immunization coverage is >95%, the tepid response to Measles-Rubella (MR) mass vaccination campaign was unexpected. Several parents refused MR vaccine for their children, due to false news claiming inefficiency and adverse effects due to the vaccine.Aim:This study was conducted to assess the Measles-Rubella (MR) mass vaccination coverage and to know the motivating factors and barriers for vaccination.Methods:A cross-sectional study was conducted in a rural area immediately following the mass vaccination campaign. Using a pre-tested structured questionnaire, data was collected on awareness of MR vaccination campaign, MR vaccination status, motivating factors and reasons for non-acceptance of the vaccine.Results:Vaccine coverage among the 616 children surveyed was 80.2%. Factors that motivated acceptance of vaccine among the immunized participants were easy access to immunization (85%), support and motivation from school teachers (41.1%) and community level health workers (25.5%). Barriers reported among the unimmunized participants were rumours of adverse effects (47.5%), fear of adverse effects (53.3%), and no faith in immunization (18.9%). Risk factors for vaccine refusal included female child (OR = 1.7, 95%CI = 1.1-2.6), Children not attending school (OR = 3.32, 95%CI = 2.1-5.1), Mothers with higher education (OR = 4.3, 95%CI = 1.2-15.2).Conclusion:An effective communication strategy addressing the needs and concerns of the public/parents should be in place and started early on before initiation of the mass vaccination programme.

Grassroot Level Health Workers: Have They Taken Root in India?

The WHO constitution, 1948 recognized right to health as a fundamental principle which was later reaffirmed in the Alma Ata declaration in 1978. However, this concept could not gain momentum at the grassroot level settings. In the recent past, stress on the Sustainable Development Goals (SDGs) and the Universal Health Coverage (UHC) has given a boost to the right to health principle in a renewed and purposeful sense. Human health workforce is the most important component of delivery of health care especially for achieving Sustainable Development Goals and for ensuring Universal Health Coverage. The Bhore committee given its progressive vision of providing health care at the doorstep of the people paved the way for primary health care workers and this vision got strengthened in the light of Alma Ata Declaration. The need for need for grassroot level workers who would be the point of contact for the public health care delivery system was highlighted by all these documents. Many initiatives have been implemented, of which, the Community Health Workers/ Volunteers (CHVs), and the latest Accredited Social Health Activists (ASHA) need prime mention because they have a voluntary status. Such initiatives helped in placing people’s health people’s hands. T he broad group of Community-level Health Workers such as Auxiliary Nurses and Midwives (ANMs), Male Health Workers also are also important links with the community. The work of these primary care workers has been challenging mainly due to overload, comparatively low compensation and inadequate infrastructure facilities. But in a country like India where doctor population ratio is not up to the required level, use of such voluntary workers such as ASHAs and other health workers for health care delivery has helped to sustain primary health care. We conclude that by improving the quality of grassroot level health workers and volunteers would certainly help in rich dividends as far as ensuring Universal Health Coverage and achieving SDGs. The considerable experience of India with innovations in the grassroot level workers indicate that if the culture of primary care has to take root and need to be sustained, then such workers are the key players.

Postpartum and Newborn Care - A Qualitative study

Community-based postpartum care of mothers and newborns is vital to achieve mortality reduction. This qualitative study explored cultural beliefs and practices regarding postpartum care of mothers and newborns in rural Karnataka. Focus group discussions with newly delivered mothers and their caregivers in a rural maternity hospital, and in-depth interviews with community level health workers revealed cessation of the practice of withholding colostrum and the barbaric practice of branding, but found persisting harmful cultural beliefs and practices like withholding nutritious foods considered “hot” or “cold”, inadequate postpartum ambulation, separating husband and wife for up to a year or more after the birth, application of various substances to the umbilical stump and eyes of the newborn and giving pre-lacteal feeds. Antenatal and postpartum mothers, their caregivers, including elders in the family should be targeted by community level health workers for counseling and behavior change.