Empower parents, enable breastfeeding: a behavioral change communication exercise conducted at a community health centre of Haryana

In India, only 41.6% of the children are breastfed within 1 hour and 54.9% of the children are exclusively breastfed till 6 months. In order to promote breastfeeding, the first week of August is being observed as World Breastfeeding week. We organized a brainstorming session followed by an Interactive, audio-visual health education event on breastfeeding for the pregnant women and their household members at a Community Health Centre (CHC) in Haryana, during that week. A behavior change communication (BCC) session was held on 1st August 2019 at the Antenatal clinic of the CHC. Target population was the pregnant, lactating mothers and their household members. Needs assessment was done to assess their current knowledge, attitude and needs about the breastfeeding and breast milk, by interacting with them and posing questions. Based on the above needs assessment exercise, we delivered a health education session. The household members were enlightened about their role in breastfeeding. The behavior change communication exercise, tailored to local population and conducted by us would have improved the knowledge, attitude of the pregnant women and their family members towards breastfeeding, and in turn will improve the practice in near future. The exercise is replicable in other settings, by tailoring it according to the local needs.

Public health activism: success story of overcoming barriers to health care faced by a migrant family.

This is a case study from a village in Haryana. A migrant family from another state was working in poultry farm. Family had six children. Youngest was girl infant with grade IV malnutrition and unimmunised. This family was denied immunisation, registration to Anganwari centre, and there were issues of child labour. With public health activism, all these problems were solved. This case study demonstrates that if there is strong commitment and confidence among public health practitioners, they can overcome most of the barriers. Such Public Health Activism should be promoted.

Inequity in dental care utilisation: what gets delivered gets known - evidence from Chandigarh and Haryana.

Background: Studies till date have focussed on the prevalence of dental disorders and the related health seeking behaviour. Inequity in seeking dental health care is debated based on age, wealth and education. This study focussed on geographical inequity in awareness and treatment seeking for dental health care. Methods: Paper compares awareness for dental problems and related treatment practices of rural population of a district in Haryana with rural area of adjoining union territory Chandigarh. Results: In rural Chandigarh, more than 90% knew about dental caries and dentures, whereas, in rural Haryana only 50% knew about dental caries and 70% about dentures. Knowledge about gum problems, mal-alignment, and growth of plaque was low. Knowledge about scaling, and root canal treatment was low in both rural areas. Majority of subjects (66.7%) attending health camp in rural Haryana never underwent a dental check-up, compared to 41% in rural Chandigarh. In rural Haryana, commonly available dental services are extractions and filling, whereas, Chandigarh has wider spectrum of services available. Conclusions: Poor awareness of dental morbidity, treatment practices and treatment seeking is possibly linked to the availability of the services. Overall, penetration of newer treatments for dental health care in the community has been slower and more so in the rural areas.

Impact of referral transport system on institutional deliveries in Haryana, India.

Background & objectives: Creation of a strong referral transport network across the country is necessary for improving physical access to public sector health facilities. In this study we evaluated the referral transport services in Haryana, i.e. Haryana Swasthya Vaahan Sewa (HSVS), now known as National Ambulance Service (NAS), to assess the extent and pattern of utilization, and to ascertain its effect on public sector institutional deliveries. Methods: Secondary data on 116,562 patients transported during April to July 2011 in Haryana state were analysed to assess extent and pattern of NAS utilization. Exit interviews were conducted with 270 consecutively selected users and non- users of referral services respectively in Ambala (High NAS utilization), Hisar (medium utilization) and Narnaul (low utilization) districts. Month-wise data on institutional deliveries in public facilities during 2005-2012 were collected in these three districts, and analysed using interrupted time series analysis to assess the impact of NAS on institutional deliveries. Results: Female gender (OR = 77.7), rural place of residence (OR = 5.96) and poor socio-economic status (poorest wealth quintile OR = 2.64) were significantly associated with NAS ambulance service usage. Institutional deliveries in Haryana rose significantly after the introduction of NAS service in Ambala (OR=137.4, 95% CI=22.4-252.4) and Hisar (OR=215, 95% CI=88.5-341.3) districts. No significant increase was observed in Narnaul (OR=4.5, 95% CI= -137.4 to 146.4) district. Interpretation & conclusions: The findings of the present study showed a positive effect of referral transport service on increasing institutional deliveries. However, this needs to be backed up with adequate supply of basic and emergency obstetric care at hospitals and health centres.

Pharmacotherapy in patients with drug-induced parkinsonism: A case series.

Drug-induced Parkinsonism develops in a number of patients with schizophrenia or schizo-affective disorders. Conventionally, anti-parkinsonism drugs, such as levodopa and dopamine agonists have been avoided due to their potential to result in an increase in psychotic symptoms, hallucinations and behavioral disturbance. We present ten cases series of drug-induced Parkinsonism in whom a trial of antiparkinsonism medications administered commenced with good effect. In particular, there was no deterioration in psychotic symptoms. A number of cases had asymmetrical signs, suggesting that these patients had a component of idiopathic Parkinson’s disease in addition to long standing drug-induced Parkinsonism. The diagnosis of idiopathic Parkinson’s disease on clinical grounds is often difficult in patients who have been on or are currently on an anti-psychotic drug. A trial of levodopa or a dopamine agonist is worth considering, albeit cautiously. In our series of cases a relapse or exacerbation of psychotic symptoms did not occur after commencing levodopa and dopamine agonists.

Cost & efficiency evaluation of a publicly financed & publicly delivered referral transport service model in three districts of Haryana State, India.

Background & objectives: Various models of referral transport services have been introduced in different States in India with an aim to reduce maternal and infant mortality. Most of the research on referral transport has focussed on coverage, quality and timeliness of the service with not much information on cost and efficiency. This study was undertaken to analyze the cost of a publicly financed and managed referral transport service model in three districts of Haryana State, and to assess its cost and technical efficiency. Methods: Data on all resources spent for delivering referral transport service, during 2010, were collected from three districts of Haryana State. Costs incurred at State level were apportioned using appropriate methods. Data Envelopment Analysis (DEA) technique was used to assess the technical efficiency of ambulances. To estimate the efficient scale of operation for ambulance service, the average cost was regressed on kilometres travelled for each ambulance station using a quadratic regression equation. Results: The cost of referral transport per year varied from `5.2 million in Narnaul to `9.8 million in Ambala. Salaries (36-50%) constituted the major cost. Referral transport was found to be operating at an average efficiency level of 76.8 per cent. Operating an ambulance with a patient load of 137 per month was found to reduce unit costs from an average ` 15.5 per km to ` 9.57 per km. Interpretation & conclusions: Our results showed that the publicly delivered referral transport services in Haryana were operating at an efficient level. Increasing the demand for referral transport services among the target population represents an opportunity for further improving the efficiency of the underutilized ambulances.

User charges in health care: Evidence of effect on service utilization & equity from north India.

Background & objectives: User charges have been advocated on efficiency grounds despite the widespread criticism about their adverse effect on equity. We assessed the effect of user charges on inpatient hospitalizations rate and equity in Haryana State. Methods: The inpatient department (IPD) statistics of the public sector facilities in Yamuna Nagar district where user charges had been introduced were analysed and compared with Rohtak district which did not have user charge between 2000 and 2006. National Sample Survey data of Haryana for the 2004-2005 period were analyzed to compare utilization of public sector facilities for hospitalization, cost of hospitalization, and prevalence of catastrophic out-of-pocket (OOP) expenditure by income quintiles in three districts which had user charges and 17 districts of Haryana which did not levy user charges. Results: During 2000 and 2006, hospital admissions declined by 23.8 per cent in Yamuna Nagar district where user charges had been introduced compared to an almost static hospitalization rate in Rohtak district which did not have user charges (P<0.01). Public sector hospital utilization for inpatient services had a pro-rich (concentration index 0.144) distribution in the three districts with user charges and pro-poor (concentration index -0.047) in the 17 districts without user charges. Significantly higher prevalence of catastrophic health expenditure was observed in public sector institutions with user charges (48%) compared to those without user charges (35.4%) (P<0.001). Interpretation & conclusions: The findings of our study showed that user charges had a negative influence on hospitalizations in Haryana especially among the poor. Public policies for revenue generation should avoid user charges.

Access to public dental care facilities in Chandigarh.

Objectives: The objective of the study was to determine the level of dental health care access and associated factors, at various public health facilities in the Union Territory (UT) of Chandigarh. Materials and Methods: A study was done using a multistage random sampling technique, to interview adult respondents at their homes and to interview the dentists in the public dental clinics and hospitals. Results: The mean composite access score was 59.2 (SD 18.9) in urban areas and 60.5 (SD 20.9) in rural areas (P=0.64) on a scale of 100. The mean score for the self-perceived condition of their oral health was 6.47 (95% CI 6.17 - 6.76). Thirty-four percent of the respondents did not contact a dentist despite having a problem in the last year, primarily because dental problems were not important for them (45%), they lacked time (22%), and took self-medication (16%). Overall 58% of the respondents suggested government clinics and 44% liked private dentists for treatment of dental cavities. The government setup was preferred because the facilities were cheaper and affordable. Conclusions: Dental health care access and only limited dental facilities were available in most of the dental clinics in Chandigarh. Self-reported dental problem was low, and people ignored their dental problems.

Knowledge and skills of primary health care workers trained on integrated management of neonatal and childhood illness: Follow-up assessment 3 years after the training.

Background: The primary health care workers of a district in northern India were trained in the year 2006 for Integrated Management of Neonatal and Childhood Illness (IMNCI) using two different training methods: conventional 8-day training and new interrupted 5-day training. Knowledge and skills may decline over a period of time. Rate of decline may be associated with the type of training. A study was thus conducted to see the retention of knowledge and skills in the two training groups, 3 years after the initial training. Materials and Methods: This study was done in the Panchkula district of Haryana state in northern India. In the year 2006, 50 primary health care workers were given new interrupted 5-day training and another 35 workers were given conventional 8-day training on IMNCI. Knowledge and skills of the same workers were evaluated in the year 2009, using the same methodology and tools as were used in the year 2006. Data analysis was done to see the extent of decline in knowledge and skills in these 3 years and whether decline was more in any particular training group. Results: Compared to post-training score in the year 2006, composite knowledge and skill scores for Auxilliary Nurse Midwives (ANMs) and Anganwari workers (AWWs) together declined significantly in the year 2009 from 74.6 to 58.0 in 8-day training group and from 73.2 to 57.0 in 5-day training group (P < 0.001). Follow-up composite scores in the two training groups were similar. Whereas the decline was more for knowledge scores in 8-day training group and for skill score in 5-day training group, the pattern of decline was inconsistent for different health conditions and among ANMs and AWWs. Conclusion: Long-term retention of knowledge and skills in 5-day group was equivalent to that in 8-day training group. Refresher trainings may boost up the decline in the knowledge and skills.

Persistence of goitre in the post-iodization phase: micronutrient deficiency or thyroid autoimmunity.

Background & objectives: Despite years of salt iodization, goitre continues to be a major public health problem worldwide. We examined the prevalence of goitre in the post-iodization phase and the relationship of goitre with micronutrient status and thyroid autoimmunity in school children of Chandigarh, north India. Methods: Two phase study; in the first phase, 2148 children of 6 to 16 yr were screened for goitre by two independent observers as per the WHO grading system. In the second phase, a case-control study, 191 children with goitre and 165 children without goitre were compared with respect to urinary iodine, iodine content of salt, serum levels of T3, T4, TSH, anti-TPO (thyroid peroxidase) antibody, haemoglobin, ferritin and selenium. Results: Prevalence of goitre in the studied subjects was 15.1 per cent (13.9% in 6 to 12 yr and 17.7% in 13 to 16 yr age group, P= 0.03). Median urinary iodine excretion in both the groups was sufficient and comparable (137 and 130 µg/l). 3.2 per cent children with goitre and 2.4 per cent without goitre had hypothyroidism (subclinical and clinical) and only one child with goitre had subclinical hyperthyroidism. Nine (4.9%) children in the goitre group and 3 (1.9%) in control group had anti-TPO antibody positivity. The median serum selenium levels were not different in both the groups (181.9 and 193.5 µg/l). Seventy one (37.4%) of the goitrous children had anaemia (haemoglobin <12 g/dl) as compared to 41 (24.8%) of the control group (P <0.01). More number of goitrous children (39, 20.6%) were depleted of tissue iron stores (serum ferritin <12 µg/l) as compared to controls (11, 6.4%; P<0.001). Serum ferritin level negatively correlated with the presence of goitre (r = - 0.22, P =0.008) and had an OR of 2.8 (CI 1.20 - 6.37, P =0.017). Interpretation & conclusions: There was a high prevalence of goitre in young children despite iodine repletion and low thyroid autoimmunity. The concurrent iron deficiency correlated with the presence of goiter. However, the cause and effect relationship between iron deficiency state and goitre requires further elucidation.

A community-based study on nasal carriage of Staphylococcus aureus.

Background & objectives: Community acquired methicillin resistant Staphylococcus aureus (CA-MRSA) is a major global problem. Colonization rates of MRSA in the community have been reported to range from 0 to 9.2 per cent. The present study was conducted to detect S. aureus nasal colonization and prevalence of MRSA in children (5 to 15 yr) in an Indian community setting of rural, urban and semiurban slums, as also evaluation of an in-house PCR to detect MRSA. Methods: Nasal swabs from children were cultured and S. aureus isolates were processed for antibiotic susceptibility. mecA gene was studied by polymerase chain reaction (PCR) on S. aureus isolates and directly from enrichment broth aliquots inoculated with nasal swabs, at sequential time intervals. Results: The overall prevalence of S. aureus nasal colonization was 52.3 per cent and that of MRSA 3.89 per cent. CA-MRSA nasal carriage was 3.16 per cent in children without prior exposure to health care settings. PCR detection directly on nasal swabs and enrichment broth had a poor sensitivity of 60.42 per cent. Interpretation & conclusions: There was a high rate of S. aureus nasal colonization in the 5-15 yr age group and an alarming rate (3.89%) of community acquired methicillin resistant S. aureus nasal colonization in the community. PCR as a method of direct detection of MRSA from nasal samples needs further fine tuning.

Prevalence of anti-cysticercus antibodies in slum, rural and urban populations in and around Union territory, Chandigarh.

A comparative analysis for the prevalence of anti-cysticercus antibodies was carried out in urban, rural and slum population in & around Union territory of Chandigarh. Prevalence of anti-cysticercus antibodies in different population groups was found to be 17.3% with highest prevalence (24%) reported from slum areas followed by that of rural areas (20%) and least in the urban organized sectors (8%). Only 8% of the seropositive individuals had history suggestive of neurocysticercosis. Overall, females showed the highest anti-cysticercus response of 20.4%.

Comparative analysis of intestinal parasitic infections in slum, rural and urban populations in and around union Territory, Chandigarh.

A study was conducted in and around the union Territory, Chandigarh, India to estimate the prevalence of intestinal parasitic infections in different population groups. The stool samples from a total of 600 subjects selected by cluster sampling technique were examined by direct microscopy. The prevalence of intestinal parasitic infections was found to be 14.6% with highest prevalence of 19% from the slum area. Children were the most commonly affected group (18%) with those from slums showing the highest prevalence (24.6%). The most common parasite was Giardia (5.5%) followed by H. nana and Ascaris (2.8% and 2.7% respectively).

Reproductive health education intervention trial.

OBJECTIVE: To measure the effectiveness of a reproductive health education package in improving the knowledge of adolescent girls aged 15-19 years in Chandigarh (India). METHODS: A reproductive health education package, developed in consultation with parents, teachers and adolescents, was delivered to randomly sampled classes of two senior secondary schools and one school was selected as control. In one school, a nurse conducted 15 sessions for 94 students in three batches using conventional education approach. In another school she conducted sessions for a selected group of 20 adolescents who later disseminated the messages informally to their 84 classmates (peer education). Using a 70-item structured questionnaire the knowledge of 95 adolescents from conventional, 84 from peer, and 94 from control school were assessed before and one month after the last session. Change in the score in intervention and control groups was tested by ANOVA taking age and socio-economic status as covariates. RESULTS: Teachers, parents and students overwhelmingly (88%, 95.5% and 93% respectively) favoured reproductive health education program. Five percent of the respondents reported that someone in their class is having sexual relations, and 13% of the girls approved of pre-marital sexual relations. Reproductive health knowledge scores improved significantly after intervention in conventional education (27.28) and peer education group (20.77) in comparison to the controls (3.64). Post-test scores were not significantly different between peer education group and conventional education group (43.65 and 40.52 respectively) though the time consumed in delivering the peer education intervention was almost one third of the time taken to implement conventional education. CONCLUSION: Peer education and conventional education strategies were effective in improving the reproductive health knowledge of adolescent girls but peer strategy was less time consuming.

Knowledge of men and women about reproductive tract infections and AIDS in a rural area of north India: impact of a community-based intervention.

This study of a community-level health-education intervention on reproductive tract infections/sexually transmitted diseases (RTIs/STDs) was conducted in three villages of Haryana in north India. The study was aimed at increasing awareness among men and women of reproductive age about the prevention and treatment of RTIs, modes of HIV/AIDS transmission, and methods of prevention. Health education was imparted through one-to-one interactions with men and women during home visits, at village-based clinics and health camps, and through health-education talks with men and women. Cumulative effects of the intervention were examined at the end of the survey by comparing the change in knowledge from the baseline. Records of clinic attendance were examined to assess the probable impact of the intervention on clinic attendance. Baseline and follow-up evaluations revealed that there was an improvement in the median total knowledge score of women from 0 to 6, whereas it remained at 5 for men both at baseline and follow-up. Knowledge about RTI/STIs increased among both men and women from the median score of 0 to 2 and from 0 to 3 respectively. The median knowledge score on HIV/AIDS declined among men from 4 to 2 but increased from 0 to 3 among women. Clinic attendance for RTI/STI cases, referred to the Naraingarh hospital, showed an eight-fold rise from an average of four cases per month in 1998-1999 to an average of 35 cases per month in 1999-2000. The findings of the study suggest that health-education strategy through home visits, RTI case management and counselling, and organizing a weekly clinic and occasional camps and health-education talks can increase the level of awareness about RTIs/STIs among both men and women and improve clinic attendance.

Syndromic management of vaginal discharge and pelvic inflammatory disease among women in a rural community of Haryana, India: agreement of symptoms enquiry with clinical diagnosis.

World Health Organisation (1984) advocated syndromic approach for management of reproductive tract infections/sexually transmitted diseases. Some investigators have cautioned against using this approach to diagnose and treat vaginal discharge and pelvic inflammatory disease. The prevalence of RTIs in rural areas of Haryana is high and availability of per-speculum examination facility is scarce. The scope for laboratory diagnosis of RTI in rural areas is remote in near future. A community-based study was conducted to assess the agreement of symptoms enquiry with the syndromic diagnosis of RTIs/STDs (based upon per speculum examination). A total of 812 women were interviewed by ANMs and were examined by a lady doctor. History based ANM's diagnosis was found to be having high sensitivity (80.5%) and high positive predictive value (81.3%). However it had low specificity (48.6%) and low negative predictive value (47.5%) compared to clinical diagnosis. Level of agreement was found to be fair (Kappa = 0.28, 95% CI = 0.20-0.36). The chances of over treatment for vaginal discharge and pelvic inflammatory disease were only 16% and 15% respectively. However, history based syndromic protocols need revision. Proposed protocol is discussed in this paper.

Are primary health workers skilled enough to assess the severity of illness among young infants?

OBJECTIVE: To evaluate the skills of health workers in assessing the severity of illness among young infants. DESIGN: Cross sectional. SETTING: Five different health institutions viz, subcenter, primary health center, community health center, sub-divisional hospital, district hospital. METHODS: 110 young infants aged <2 months who attended the selected health institutions on specific week days were assessed by a physician. Subsequently 10 female health workers assessed these babies. Physician and health workers used same symptom and sign based guidelines for classification of the illness. Level of agreement between the physician and the health workers were assessed using kappa statistics. RESULTS: Physician classified 37.3% infants as not sick or mildly sick, 42.7% as moderately sick and 20% as severely sick. In comparison to the physician, the sensitivity and specificity of the health workers' assessment of severe illness was 77% and 76% respectively. Of 22 babies classified as severely sick by the physician, female health workers classified 5 as not sick or mildly sick, 8 as moderately sick and 9 as severely sick. On the other hand health workers classified one not sick or mildly sick and 9 moderately sick infants as severely sick. Level of agreement between the physician and health workers was poor (Kappa value = 0.39, 95% CI = 0.26, 0.52). Health workers misclassified illness mainly due to 'not counting the respiratory rate and 'not looking for chest retractions, purulent discharge and jaundice'. CONCLUSION: Trained health workers' skills were not satisfactory for assessment of illness severity among young infants. During training, importance of these signs needs to be emphasized.

A community-based rheumatic fever/rheumatic heart disease cohort: twelve-year experience.

BACKGROUND: A pilot rheumatic fever and rheumatic heart disease control porject was started in 1988 in blocks of district Ambala (Haryana) to test the feasibility of early detection, treatment and secondary prophylaxis for rheumatic fever/rheumatic heart disease cases. School teachers, students and health workers were trained to identify and refer suspected cases of rheumatic fever/rheumatic heart disease to the community health center where physicians examined the suspected cases and monthly secondary prophylaxis was provided to the confirmed cases. METHODS AND RESULTS: A survey of registered cases was done in 1999 to determine the compliance rate of secondary prophylaxis and to describe clinical and epidemiologic features of the registered cohort of rheumatic fever/rheumatic heart disease patients. A total of 257 patients had been registered till the end of 1999 with 1263 person-years of follow-up. Out of these registered patients, 132 were receiving secondary prophylaxis, 52 had died, 17 had migrated, 8 were lost to follow-up, 18 had stopped prophylaxis and 30 completed the prophylaxis course. The mean age at registration was 18 years. Half of the cases were in the 6-15 years age group at registration. Over half of the patients were registered with a history of rheumatic fever. Fever was the most common symptom (75.9%). Carditis was more common among cases with recurrent attacks of rheumatic fever than after a first attack. The mortality in rheumatic fever/rheumatic heart cases was 32.5/1000 person-years. The mean age at death was 24.4 years. Compliance with secondary prophylaxis was 92% during the past 12 years. CONCLUSIONS: A rheumatic fever/rheumatic heart disease control program can be sustained within the primary health care system and the case registry can be utilized not only for monitoring the program but also to gain insight into the epidemiology of the disease.