Growth Faltering Among Discharged Babies from Inpatient Newborn Care Facilities: Learnings from Two Districts of Himachal Pradesh

Objective: To determine the burden of early growth faltering and understand the care practices for small and sick babies discharged from newborn units in the district. Study design: Observational and follow-up study. Participants: 512 babies discharged from two Special Newborn Care Units (SNCUs) and four Newborn Stabilization Units (NBSUs) in two districts of Himachal Pradesh. Methods: Anthropometric assessments, interview of mothers and Accredited Social Health Activists (ASHAs) conducted between August, 2018 and March, 2019. Change in weight-forage z-score (?WAZ) of <-0.67SD between birth and assessment was used to define growth faltering. Outcomes: Proportion of growth faltering (or catch-down growth) in small and sick babies discharged from SNCUs and NBSUs, and infant care practices. Results: Growth faltering was observed in a significant proportion of both term (30%) and preterm (52.6%) babies between 1 to 4 months of age. Among babies with growth faltering (n=180), 73.9% received a home visit by ASHA, and only 36.7% received a follow-up visit at a facility. There were 71.3% mothers counselled at discharge (mostly informed about breast feeding). Most (96.7%) mothers did not perceive inadequate weight gain in their babies post-discharge. During home visits, ASHAs weighed 61.6% of the infants with growth faltering. Amongst infants who had growth faltering, only 49.6% of mothers had been provided information about their infant’s growth and 57.1% mothers had received breastfeeding counselling. Conclusion: Small and sick newborn infants (both term and preterm babies) discharged from special care newborn units are at increased risk of early growth faltering. Follow-up care provided to these infants is inadequate. There is a need to strengthen both facility-based and home-based follow up of small and sick newborn infants discharged from newborn care facilities.

Barriers to the Delivery and Uptake of Water Sanitation and Hygiene (WASH) Promotion and Infant Diarrhea Prevention Services: A Case Study in Rural Tribal Banswara, Rajasthan

Objective: We aimed to identify key barriers to Water Sanitation and Hygiene (WASH) promotion and infant diarrhea prevention services delivered by Accredited Social Health Activists (ASHAs) in rural India. Methods: A case-study was conducted across nine tribal villages in Banswara district (Rajasthan), where in-depth observational and qualitative data was collected from frontline health workers and infant caregivers. Results: ASHAs’ prioritization of their incentive-based link-worker tasks over their health activist roles, limited community mobilization, and lack of monitoring of such activities hindered the delivery of WASH promotion and infant diarrhea prevention services. Caregivers’ lack of trust in ASHA’s health knowledge and preference for private providers and traditional healers also hindered the uptake of ASHA’s health promotion services. Conclusions: Strengthening ASHAs’ health activism roles and building trust on frontline health workers’ knowledge among tribal communities will be the key to address the determinants of child malnutrition and stunting and accelerate progress towards the national development agenda.

An Uphill Task for POSHAN Abhiyan: Examining the Missing Link of ‘Convergence’

The Participatory Approach for Nutrition in Children: Strengthening Health, Education, Engineering and Environment Linkages(PANChSHEEEL) project is a collaboration between University College London, Save the Children India, Jawaharlal Nehru Universityand Indian Institute of Technology Delhi to develop a socio-culturally appropriate, tailored, integrated and interdisciplinary intervention inrural India and test its acceptability for delivery through Anganwadi Centre (AWCs) and schools. Recognizing the socio-ecologicaldeterminants of under-nutrition, the POSHAN Abhiyan (POSHAN Mission) adopts a multi-sectoral approach to achieve five goals, ofwhich two are directly related to children. The POSHAN Abhiyan resonates with the conceptual framework of the PANChSHEEEL study inits interdisciplinary scope and focus on local linka ges. This paper draws upon empirical evidence from the PANChSHEEEL Project inBanswara (one of the POSHAN mission districts), Rajasthan to help understand linkages between policy and practice, specifically thechallenges of operationalizing ‘convergence’, the core strategy of the Abhiyan.

A Landscape Analysis of Human Milk Banks in India

Objective: To evaluate the existing status of human milk banks in India with reference toinfrastructure, human resources, funding mechanisms, operating procedures and qualityassurance. Methods: A pretested questionnaire was administered to 16 out of 22 human milkbanks across India, operational for more than one year prior to commencing the study.Results: 11 (69%) milk banks were in government or charitable hospitals; only 2 (12.5%)were established with government funding. 8 (50%) had a dedicated technician and only1(6%) had more than five lactation counsellors. Milk was collected predominantly frommothers of sick babies and in postnatal care wards followed by pediatric outpatientdepartments, camps, satellite centers, and homes. 10 (63%) reported gaps between donormilk demand and supply. 12 (75%) used shaker water bath pasteurizer and cooled the milkmanually without monitoring temperature, and 4 (25%) pooled milk under the laminar airflow.10 (63%) tracked donor to recipient and almost all did not collect data on early initiation,exclusive breastfeeding or human milk feeding. Conclusion: Our study reports the gaps ofmilk banking practices in India, which need to be addressed for strengthening them. Gapsinclude suboptimal financial support from the government, shortage of key human resources,processes and data gaps, and demand supply gap of donor human milk.

Programmatic Approaches for Nutritional Care in India: Addressing the Continuum of Care Perspectives

Child health and nutrition is nested within a larger gamut of child care and development, functioning through the health care system.Malnutrition is multidimensional and rooted in poor early childhood care and development that is shaped by environmental, social andeconomic factors. Current nutrition care interventions are marked by a piecemeal approach, focusing on treating malnutrition butoverlooking the need for rehabilitation and care support. Continuum of care (CoC) as an approach aims for a seamless and need-basedcare, bearing an impact on improved care output, beneficiary participation, care experience and access to care. CoC in nutrition care shallcontribute to integration of nutrition and health care services, addressing distal and proximal causes of undernutrition through a gamut ofpreventive, promotive, treatment and rehabilitative care.

The Slippery Slope of Child Feeding Practices in India

National Family Health Survey 4 (NFHS-4) data shows a ten percentage point decline in timely complementary feeding rates in the backdrop of increases in breastfeeding indicators. There is large-scale decline in this indicator across all regions and states. An understanding of social determinants is critical for generating transformative ideas to address these challenges.

Rapid Survey of Wasting and Stunting in Children: What’s New, What’s Old and What’s the Buzz.

Nationwide Rapid Survey on Children (RSoC), conducted by the Ministry of Women and Child Development and UNICEF in 2013-14 showed a marked improvement in the status of the child malnutrition over the third National Family Health Survey (NFHS-3) that was conducted in 2005-06. Despite some impressive gains in the anthropometric indicators of malnutrition, the absolute levels remain high, and of concern. Despite these gains, the feeding indicators remain stagnant. The programmatic responses need to adopt a multi-sectoral comprehensive approach with regular and comprehensive nutrition surveillance and recognize the epidemiological diversity.

Programmatic Response to Malnutrition in India: Room for More Than One Elephant.

Programming platforms need to recognize the diversity of malnutrition epidemiology in India and choose appropriate implementation designs. With severe chronic malnutrition as the dominant epidemiologic entity, the net needs to be cast wide, focusing on: food security, health care, agriculture, water and sanitation, livelihoods and women’s empowerment. Community-based malnutrition treatment and prevention programs need to collaborate to complement treatment with socioeconomic and preventive interventions. Expansion of nutrition rehabilitation centers should be limited to areas/districts with high wasting. Pediatric services with nested nutrition services (including counseling) requires urgent strengthening. Continuum of Care is a weak link and requires strengthening to make both hospital and community-based models meaningful.

Can Nutrition Rehabilitation Centers Address Severe Malnutrition in India.

Madhya Pradesh has made remarkable progress in facility based management of severe acute malnutrition, and has developed a model that is being replicated in many states. India has uniquely high prevalence of both stunting and wasting, implying that both severe acute malnutrition and severe chronic malnutrition co-exist. This study sought to explore design issues of nutritional rehabilitation centers in order to inform its effectiveness in settings where the prevalence of chronic poverty and malnutrition is high. Our analysis attributes the limited success (marked by poor cure rates and high non-responder rates) to high prevalence of chronic malnutrition, particularly in nutritional rehabilitation centers located in pheripheral areas. There is a failure to recognize severe chronic malnutrition as an epidemiological entity and gear wide-ranging programmatic and social interventions.

Screening for SAM in the Community: Is MUAC a ‘Simple Tool.

Anthropometric data from our survey of 1,879 children in Madhya Pradesh revealed low sensitivity (17.5%) and positive predictive value (30.4%) of Mid-Upper Arm Circumference (MUAC) at the recommended cut-off of 115 mm for identifying Severe Acute Malnutrition (SAM). This led us to question the reliability of MUAC as a screening tool to identify SAM at the community level, especially in the context of very high levels of stunting.

State of globe: mitigating measles menace in era of MMR/V

In non vaccination ancient era, multiple epidemics of measles/german measles/variola used to occur in the cyclical trend of two to three years during spring months. Outbreaks in Faroe Islands in 1846 and in Fizi Island in 1875 are examples of this type of transmission where virgin epidemics took the highest mortality toll. According to WHO report, in the absence of immunization, 90% of the persons can be expected to develop clinical measles sometimes in their life time as noted in Greenland in 1951 epidemic and german measles in 2012 in Kangra. But the epidemiology of communicable diseases underwent tremendous change not only in the developed countries, viz America and European countries but also in the developing countries like India, Pakistan and African countries with the introduction of vaccination and thereby mortality and morbidity on account of vaccine preventable diseases in all the age groups around the world nose dived. This provided a big relief to the suffering humanity across the world. Different countries have various sets of immunization programme running in the countries; be it single dose of measles at the age of 270 days or second shot of measles or other vaccinations. Round the globe, MMR or MMRV or pentavalent vaccination with their pluses or minuses, still is the right choice to mitigate the menace of measles

Good epidemiology, good ethics: empirical and ethical dimensions of global public health.

This paper examines the following ethically and epidemiologically relevant challenges, as yet neglected in public health ethics: how to distribute resources and health risks and benefits, how to define evidentiary criteria that justify public health interventions, and how to define terms in which programme goals, successes, and failures will be assessed and monitored. We illuminate critical intersections of empirical and ethical dimensions of public health work, drawing upon three global public health interventions—inclusion of the Hepatitis B vaccine in the Universal Immunisation Programme, Universal Salt Iodisation, and the Global Polio Eradication Initiative—and suggest strategies for addressing and responding to them.

Determinants of utilization of services under MMJSSA scheme in Jharkhand 'Client Perspective': A qualitative study in a low performing state of India.

Preventing maternal death associated with pregnancy and child birth is one of the greatest challenges for India. Approximately 55,000 women die in India due to pregnancy- and childbirth- related conditions each year. Increasing the coverage of maternal and newborn interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. With a view to accelerate the reduction in maternal and neonatal mortality through institutional deliveries, Government of India initiated a scheme in 2005 called Janani Suraksha Yojna (JSY) under its National Rural Health Mission (NRHM). In Jharkhand the scheme is called the Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA). This paper focuses on community perspectives, for indentifying key areas that require improvement for proper implementation of the MMJSSA in Jharkhand. Qualitative research method was used to collect data through in-depth interviews (IDIs) and focus group discussions (FGDs) in six districts of Jharkhand- Gumla, West Singhbhum, Koderma, Deoghar, Garhwa, and Ranchi. Total 300 IDIs (24 IDIs each from mother given birth at home and institution respectively; two IDIs each with members of Village Health and Sanitation Committees (VHSC) / Rogi Kalyan Samitis (RKS) from each district) and 24 FGDs (four FGDs were conducted from pools of husbands, mothers-in-law and fathers-in-law in each district) were conducted. Although people indicated willingness for institutional deliveries (generally perceived to be safe deliveries), several barriers emerged as critical obstacles. These included poor infrastructure, lack of quality of care, difficulties while availing incentives, corruption in disbursement of incentives, behavior of the healthcare personnel and lack of information about MMJSSA. Poor (and expensive) transport facilities and difficult terrain made geographical access difficult. The level of utilization of maternal healthcare among women in Jharkhand is low. There was an overwhelming demand for energizing sub-centers (including for deliveries) in order to increase access to maternal and child health services. Having second ANMs will go a long way in achieving this end. The MMJSSA scheme will thus have to re-invent itself within the overall framework of the NRHM.

Non-health determinants of health and healthcare in Delhi.

With only 0.05% of the total area of the country, Delhi is home to 1.34% of India’s population. This creates enormous pressure on natural and man-made resources, and generates situations in which non-health determinants may take precedence over the conventional determinants directly associated with health and healthcare. With the rising advocacy on social determinants of health, several of these factors may rightly seem to be part of the broader territory of healthrelated variables, and in that context, they may be designated as conventional non-medical determinants. We discuss some more visible domains, such as demography, migration and floating population; the physical and biological environment; economic determinants; social determinants; legislation and enforcement, and underscore some less explored yet critical domains of the determinants related to culture, governance and politics. What emerges as a compelling reality is a wide differential in physical environment, urban planning and access to infrastructural inputs between the privileged and marginalized areas of Delhi. Inequities in physical quality of life are so gross that even a value-neutral, official narrative betrays them helplessly. We propose actionable areas to address some of the pressing non-health determinants of health and healthcare.

Smallpox and polio eradication in India: comparative histories and lessons for contemporary policy / Erradicação da varíola e da pólio na Índia: histórias comparativas e lições para políticas contemporâneas

O artigo argumenta que um exame detalhado dos fatores que contribuíram para o desenvolvimento de estruturas e estratégias complexas para a erradicação da varíola no Sul da Ásia nos anos 70 pode fornecer indicações proveitosas para a reformulação dos capítulos nacionais do programa global de erradicação da pólio nesta região. Existe um impressionante arquivo nos escritórios da OMS em Genebra que detalha como os ataques para a erradicação da varíola foram localizados e então contidos em cidades, pequenas vilas e áreas rurais remotas desta região, por equipes de profissionais internacionais trabalhando em conjunto com as autoridades locais. Uma avaliação sistemática dos esforços globais de erradicação da varíola indicam paralelos entre os estágios iniciais do programa global de erradicação da varíola e a atual situação da campanha contra a pólio. Como veremos aqui, o artigo também pode fornecer indicadores úteis para ações futuras no Sul da Ásia e em outros locais.

This article argues that a detailed examination of factors contributing to the development of complex structures and strategies for smallpox eradication in South Asia in the 1970s can provide fruitful indications for the reformulation of the national chapters of the global polio eradication programme in this region. There is a magnificent archive in the WHO's Geneva offices, which details how smallpox eradication outbreaks were located and then contained in cities, small towns and remote rural areas in this region, by teams of international workers working closely with local officials. A systematic assessment of the global smallpox eradication efforts indicates parallels between the early stages of the global smallpox eradication programme and the present situation of the polio campaign; as we will see here, it can also provide useful indicators for future action in South Asia and beyond.

Evidence-based National Vaccine Policy.

India has over a century old tradition of development and production of vaccines. The Government rightly adopted self-sufficiency in vaccine production and self-reliance in vaccine technology as its policy objectives in 1986. However, in the absence of a full-fledged vaccine policy, there have been concerns related to demand and supply, manufacture vs. import, role of public and private sectors, choice of vaccines, new and combination vaccines, universal vs. selective vaccination, routine immunization vs. special drives, cost-benefit aspects, regulatory issues, logistics etc. The need for a comprehensive and evidence based vaccine policy that enables informed decisions on all these aspects from the public health point of view brought together doctors, scientists, policy analysts, lawyers and civil society representatives to formulate this policy paper for the consideration of the Government. This paper evolved out of the first ever ICMR-NISTADS national brainstorming workshop on vaccine policy held during 4-5 June, 2009 in New Delhi, and subsequent discussions over email for several weeks, before being adopted unanimously in the present form.

Deconstructing social resistance to pulse polio campaign in two north indian districts.

Objective: To gain an insight into the phenomenon of social resistance and rumors against pulse polio campaign. Design: Qualitative, community-based investigation, mapping perceptions of various stakeholders through in-depth interviews (IDIs), focus group discussions (FGDs), non-formal interactions and observations. Setting: Moradabad and JP Nagar districts of Uttar Pradesh. Subjects: IDIs (providers 33, mothers 33, community leaders 10); FGDs (providers 4, mothers 8) and non-formal interactions (156) with community leaders, parents, businessmen, journalists (Hindi and Urdu media), mobilizers, vaccinators and supervisors. Results: A distinct machination of social resistance and rumors against oral polio vaccine during supplementary immunization activities (SIA) was observed in some minority dominated areas. The pattern can be understood through a model that emerged through qualitative evidence. Inspite of all this, most parents in minority areas supported the SIAs. Only a few clusters from extremely marginalized sections continued to evade SIAs, with an endemic pattern. Through social osmosis, these rumors reached majority community as well and some parents were affected. However, in such cases, the resistance was sporadic and transient. Conclusion: While the program’s focus was on microbiological issues, the obstacles to polio eradication lie in the endemicity of social (and/or cultural) resistance in some pockets, leading to clustering of perpetually unimmunized children - inspite of good coverage of SIAs at macro level. This may sustain low levels of wild poliovirus transmission, and there can be exceptions to the robustness of the pulse approach. A micro level involvement of volunteers from marginalized pockets of minorities might be able to minimize or eliminate this resistance.