Challenges in Obtaining Informed Consent in Qualitative Research and Suggestions to Improve It- A Descriptive Qualitative Study

Introduction: The dynamic and flexible nature of qualitative studies is expected to impose new challenges upon the researchers in obtaining informed consent. The study objectives were to explore the challenges per-ceived by the researchers in obtaining informed consent in qualitative research and their suggestions to im-prove it. Material and Methods: It was a descriptive qualitative study in which In-depth interviews were conducted among ten qualitative researchers purposively selected from one medical college in Puducherry. Transcripts prepared from the audio recordings were thematically analyzed manually. Results: The challenges identified were inadequate knowledge of the researcher in designing qualitative con-sent form, reluctance to sign consent document by participant, ensuring confidentiality and risk benefit com-munication. The main suggestions provided by the participants were to use of multimedia tools to improve their understanding and creating a rapport to enhance their trust to participate in the study. Conclusions: Since most of the challenges were related to the reluctance of participants to provide consent due to various reasons and lack of adequate knowledge of the researcher, creating a good rapport with the participants and providing simple information through multimedia approaches and ethical training of qualita-tive researchers will aid us to overcome majority of these challenges.

Why tuberculosis patients under revised national tuberculosis control programme delay in health-care seeking? A mixed-methods research from Wardha District, Maharashtra

Background: Timely treatment of tuberculosis is imperative for its control. This can get delayed due to delay in care seeking, diagnosis or treatment initiation. Objectives: The study aims to find out the magnitude of delays in care seeking, diagnosis or treatment initiation, and understand the reasons behind these delays in Wardha district of Maharashtra, India. Methods: A mixed methods study was conducted among 275 patients selected from those enrolled under Revised National Tuberculosis Control Programme in 2014. We collected information regarding the duration of delays and generated a free list of reasons for delays in care seeking and diagnosis. The free list items were then subjected to pile sorting. Two-dimensional scaling and hierarchical clustering analysis were performed to identify the various domains of reasons for delays. Results: The median delay in initial care seeking and diagnosis was 10 days each, and that for treatment initiation was 2 days. The domains identified for delay in care seeking were negligence toward health, health conditions, facility-related issues, and household and social reasons. The domains identified for delay in diagnosis were system-related reasons; and patient-related reasons, each of them further having two subdomains. Conclusions: Interventions for reducing the knowledge gap and stigma, increasing the accessibility of services, active case finding; capacity building of providers, quality assured sputum microscopy, and communication skills will help reduce these delays.

Childhood morbidity, household practices and health care seeking for sick children in a tribal district of Maharashtra, India.

Objectives: To find out the magnitude of childhood morbidities, health care seeking behavior and explore the status of 'some desired practices' at household level during episodes of illness in two tribal blocks of Chandrapur district. Materials and Methods: The present explanatory mixed-method design of quantitative (survey) and qualitative (focus group discussions, FGDs )methods was undertaken in nine Primary health centers of Warora and Bhadrawati blocks in Chandrapur district. The information of 2,700 under-five children on morbidity, health care seeking behavior and some desired practices at household level was collected by paying home visits and using pre-designed and pre-tested questionnaire. The data was entered and analyzed by using SPSS 12.0.1 and C sample program of epi_info (version 6.04d) software package. The conventional content analysis of FGD data was undertaken. Results: The prevalence of morbidities was high among newborns and children. About 1,811 (67%) children had at least one of the morbidities. Private health care providers and village level faith healers were preferred for seeking treatment of newborn danger sings and childhood morbidities. The status of some desired household practices such as frequent feeding and giving extra fluid to drink during episodes of illness was poor. Conclusions: In conclusion, considering high prevalence of child morbidities and poor status of some desired household practices of caregivers at household level for sick children, household and community IMNCI strategy needs to be implemented to promote child health and nutrition. Apart from this, health care delivery at village level should be strengthened.

Acute childhood morbidities in rural Wardha : Some epidemiological correlates and health care seeking.

Background: In India, common morbidities among children under 3 years of age are fever, acute respiratory infections, diarrhea. Effective early management at the home level and health care-seeking behavior in case of appearance of danger signs are key strategies to prevent the occurrence of severe and life-threatening complications. Objectives: To find out the prevalence of acute child morbidities, their determinants and health-seeking behavior of the mothers of these children. Setting and Design: The cross-sectional study was carried out in Wardha district of central India. 0 Material and Methods: We interviewed 990 mothers of children below 3 years of age using 30-cluster sampling method. Nutritional status was defined by National Center for Health Statistics (NCHS) reference. Composite index of anthropometric failure (CIAF) was constructed. Hemoglobin concentration in each child was estimated using the 'filter paper cyanm ethemoglobin method.' Using World Health Organization guidelines, anemia was defined as hemoglobin concentration less than 110 g/L. Post-survey focus group discussions (FGDs) were undertaken to bridge gaps in information obtained from the survey. Statistical Analysis: The data was analyzed by using SPSS 12.0.1 software package. Chi-square was used to test the association, while odds ratios were calculated to measure the strength of association. Multiple logistic regression analysis was applied to derive the final model. Results: Anemia was detected in 80.3% of children, and 59.6% of children were undernourished as indicated by CIAF. The overall prevalence of acute morbidity was 59.9%. Children with mild anemia, moderate anemia and severe anemia had 1.52, 1.61 and 9.21 times higher risk of being morbid, respectively. Similarly, children with single, 2 and 3 anthropometric failures had 1.16, 1.29 and 2.27 times higher risk of being morbid, respectively. Out of 594 (60%) children with at least one of the acute morbidities, 520 (87.5%) sought health care, where majority (66.1%) received treatment from private clinics. The final model suggested that anemia and mother's poor educational status are predictors of childhood morbidity. Conclusions: Nutritional anemia and mother's poor educational status are the most important risk factors of acute childhood morbidity. There is need to revitalize existing health care delivery and child health programs in rural India with emphasis on immediate correction of nutritional anemia.

Perceptions and health care seeking about newborn danger signs among mothers in rural Wardha.

OBJECTIVE: To know mothers' knowledge and explore their perceptions about newborn danger signs and health care seeking behaviors. METHODS: A cross-sectional study was undertaken in three of the 27 primary health centres of Wardha district with a population of 88187. Out of 1675 expected mothers, 1160 mothers in the area were interviewed by house-to-house visits. Data was entered and analyzed in SPSS 12.0.1. In order to explore mothers' perception of danger signs and actions taken, a triangulation of formative research methods like chapatti diagram and Focus Group Discussion (FGD) was undertaken. The analysis of free list and pile sort data obtained was undertaken using Anthropac 4.98.1/X software. RESULTS: About 67.2 % mothers knew at least one newborn danger sign. Majority of mothers (87.4%) responded that the sick child should be immediately taken to the doctor but only 41.8% of such sick newborns got treatment either from government hospital (21.8%) or from private hospital (20%) and 46.1% of sick babies received no treatment. As told by mothers, the reasons for not taking actions even in presence of danger signs/symptoms were ignorance of parents, lack of money, faith in supernatural causes, non availability of transport, home remedy, non availability of doctor and absence of responsible person at home. For almost all the danger signs/symptoms supernatural causes were suspected and remedy was sought from traditional faith healer (vaidu) followed by doctor of primary health centre and private doctor. CONCLUSION: The present study found gap between mothers' knowledge and their health seeking behavior for sick newborn and explored their deep perceptions, constraints and various traditional treatments. Comprehensive intervention strategies are required to change behavior of caregivers along with improvement in capacity of Government health care services and National Health Programs to ensure newborn survival in rural area.

Newly developed WHO growth standards: implications for demographic surveys and child health programs.

OBJECTIVE: To compare estimates of undernutrition based on the World Health Organization (WHO) Child Growth Standards ('WHO standards') and the National Center for Health Statistics NCHS/ WHO international growth reference ('NCHS reference') and discuss implications for child health programs and reporting of prevalence of underweight in demographic surveys. METHODS: A cross-sectional study was carried out in 20 Anganwadi centers under Primary Health Centre, Anji. Total of 1491 under-six year children attending the Anganwadi centers were studied for nutritional status. Nutritional status was analyzed by NCHS standards by using EPI_INFO 6.04 software package and also by newly introduced WHO Child Growth Standards by Anthro 2005 software package. Chi-square test was used to compare the results. RESULTS: According to WHO standards, the prevalence of underweight and severe underweight for children 0-6 year was 47.4% and 16.9% respectively. By NCHS reference, the overall prevalence of underweight and severe underweight for children 0-6 years was 53% and 15% respectively. The prevalence of underweight as assessed by WHO standards was significantly lower when compared with the assessment based on NCHS reference (p< 0.01). But, WHO standards gave higher prevalence of severe underweight than NCHS reference though the difference was not statistically significant (p>0.05). CONCLUSION: In the light of newly developed WHO Child growth standards, all the nutrition-related indicators in demographic surveys like NFHS should now be derived using the WHO standards. There is need to reanalyze NFHS - I and NFHS - II data using WHO standards and findings should be made available so that it becomes comparable and trends over the years can be studied.

A comparison of HIV/AIDS awareness between self-help group leaders and other women in the villages of Primary Health Centre, Anji.

A Cross-sectional study was undertaken to compare the level of awareness about HIV/AIDS between women's self-help group leaders and other women in the villages of primary health centre area, Anji. 82 leaders of women's self-help groups i.e. president and secretary of each 41 women's self-help groups promoted by Kasturba Rural Health Training Centre, Anji in area Primary Health Centre, Anji and 98 women other than leaders of self-help group from the same villages were selected for the study. Both the groups were in reproductive age groups. The leaders of Self-help groups had better level of education and awareness about HIV/AIDS than other women in the village. Considering the significant high level of awareness regarding HIV/AIDS, the leaders of women's self-help groups could act as potential resource persons for the delivery of health education about prevention of HIV/AIDS to other women in the villages of Primary Health Centre, Anji.

Relationship of anthropometric indicators with blood pressure levels in rural Wardha.

BACKGROUND AND OBJECTIVES: Overweight and obesity are important determinants of health leading to adverse metabolic changes, including increase in blood pressure. Being overweight is associated with two- to six-fold increase in the risk of developing hypertension. Studies in urban Indian population showed strong relationship between different anthropometric indicators and blood pressure levels. Surprisingly, little is known about these relationships in rural population of India. The present study was carried out to examine the relationship between different anthropometric indicators and blood pressure levels in rural population of Wardha district in central India. METHODS: This cross-sectional study was carried out in the areas of two Rural Health Training Centres (RHTC) of Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Sewagram; namely Bhidi and Anji through house-to-house visits. Two stage sampling method (30 cluster followed by systematic random) was used to reach the respondents' households. Partial correlation coefficients were used for continuous variables. Linear regression analysis was used to assess the influence of different anthropometric indicators on the systolic and diastolic blood pressure. ROC analysis was done to identify optimal cut-off values while likelihood ratios were calculated to identify the odds of having hypertension in comparison to those with lower values of anthropometric indicators. RESULTS: The mean systolic blood pressures were 120.2 and 118.4 mmHg while the mean diastolic blood pressures were 77.7 and 76.3 mmHg in men and women respectively. There was a significant positive correlation of obesity indicators with both systolic and diastolic blood pressure. For SBP, the correlation coefficient was 0.23 with BMI, 0.23 with waist circumference, 0.11 with WHR and 0.22 with WHtR. For DBP, it was 0.13 with BMI, 0.12 with WC, 0.04 with WHR and 0.11 with WHtR. Step-wise linear regression suggested that BMI and WC were important predictors of hypertension. The suggested cut-off values for BMI were 21.7 for men and 21.2 for women; for waist circumference, the cut-offs were 72.5 for men and 65.5 for women. INTERPRETATION AND CONCLUSION: BMI and WC had strong correlation with systolic and diastolic blood pressure. The suggested lower cut-off values of the anthropometric indicators will cover maximum of the population with higher odds of having hypertension and may help in reducing the mean population blood pressure levels.

Nutritional status of adolescents in rural Wardha.

OBJECTIVE: The objective of the study was to study the nutritional status of adolescents in rural area of Wardha. METHODS: The cross-sectional study was carried out in two PHC areas of Wardha district with two stage sampling method. In the first stage, cluster-sampling method was used to identify 30-clusters in each Rural Health Training Centre (RHTC) area separately. In the second stage, systematic random sampling method was used to identify 10 households per cluster. All adolescents in the household thus selected were included in the study. The mean body mass index (BMI) for age was used for classifying the nutritional status with CDC 2000 reference. Data thus generated was entered and analyzed using epi_info 2000. RESULTS: Overall, 53.8% of the adolescents were thin, 44% were normal and 2.2% were overweight. The mean body mass index (BMI) for boys and girls was 16.88 and 15.54 respectively. The difference was statistically significant (p<0.05). The prevalence of thinness was significantly (p<0.05) higher in early adolescence, girls, lower education (<8th standard) and lower economic status. CONCLUSION: Majority (53.8%) of the adolescents in this study area are thin and only 2.2% were overweight.