Antenatal influenza vaccination in urban Pune, India: clinician and community stakeholders' awareness, priorities, and practices.

The World Health Organization (WHO) recommends antenatal influenza vaccination (AIV) for pregnant women at any stage of pregnancy. This study assessed fundamental aspects of AIV acceptance and demand among key stakeholders in urban Pune, India. Semi-structured interviews for rapid ethnographic assessment of AIV-related awareness, priorities, and practices were used to study clinicians and their communities of practice. A qualitative survey was conducted among 16 private clinicians providing antenatal care (ANC) in slum and middle-class areas of Pune. Following the survey, clinicians were informed about authoritative AIV recommendations. A qualitative community survey was also conducted with 60 women aged 20-35 years and 30 spouses from the same slum and middle-class practice areas of the ANC providers. Subsequently, a second clinician survey was conducted to assess changes in clinicians' awareness, priority, and vaccination practice. After this interview, clinicians were informed of community survey findings. Most community respondents were unaware of AIV, in contrast with well-known and widely used antenatal tetanus vaccination. They expressed confidence in vaccines and trust in the clinicians. Clinicians' advice was reportedly the most important determinant of community vaccine acceptance. Clinicians were confident of the safety of AIV and they anticipated patients' acceptance if recommended. The second clinician interview showed increased awareness of AIV policy, but clinicians were more skeptical about the severity of maternal influenza in their practice. Our findings indicate community acceptance though not demand for AIV. We recommend five essential elements for vaccination program strategies to improve coverage with AIV and other ANC vaccines.

Building capacities of Auxiliary Nurse Midwives (ANMs) through a complementary mix of directed and self-directed skill-based learning-A case study in Pune District, Western India.

Auxiliary nurse midwives (ANMs) play a pivotal role in provision of maternal and newborn health at primary level in India. Effective in-service training is crucial for upgrading their knowledge and skills for providing appropriate healthcare services. This paper aims at assessing the effectiveness of a complementary mix of directed and self-directed learning approaches for building essential maternal and newborn health-related skills of ANMs in rural Pune District, India. METHODS: During directed learning, the master trainers trained ANMs through interactive lectures and skill demonstrations. Improvement and retention of knowledge and skills and feedback were assessed quantitatively using descriptive statistics. Significant differences at the 0.05 level using the Kruskal-Wallis test were analysed to compare improvement across age, years of experience, and previous training received. The self-directed learning approach fulfilled their learning needs through skills mall, exposure visits, newsletter, and participation in conference. Qualitative data were analysed thematically for perspectives and experiences of stakeholders. The Kirkpatrick model was used for evaluating the results. RESULTS: Directed and self-directed learning was availed by 348 and 125 rural ANMs, respectively. Through the directed learning, ANMs improved their clinical skills like maternal and newborn resuscitation and eclampsia management. Less work experience showed relatively higher improvement in skills, but not in knowledge. 56.6% ANMs either improved or retained their immediate post-training scores after 3 months. Self-directed learning helped them for experience sharing, problem-solving, active engagement through skill demonstrations, and formal presentations. The conducive learning environment helped in reinforcement of knowledge and skills and in building confidence. This intervention could evaluate application of skills into practice to a limited extent. CONCLUSIONS: In India, there are some ongoing initiatives for building skills of the ANMs like skilled birth attendance and training in skills lab. However, such a complementary mix of skill-based 'directed' and 'self-directed' learning approaches could be a plausible model for building capacities of health workforce. In view of the transforming healthcare delivery system in India and the significant responsibility that rests on the shoulder of ANMs, a transponder mechanism to implement skill building exercises at regular intervals through such innovative approaches should be a priority.

Factors governing the performance of Auxiliary Nurse Midwives in India: A study in Pune district.

BACKGROUND: The Auxiliary nurse midwife (ANM) cadre was created to focus on maternal and child health. ANMs are respected members of their communities and established providers of maternal and child health care within the community and at the facility level. Over time, additional roles and responsibilities have been added. Despite the importance of ANMs in the primary healthcare system in India, studies that consider factors governing the performance of ANMs in their workplaces are limited. We aimed to study factors governing performance of ANMs in Pune district, India. METHODS: Semi-structured interviews were conducted with 13 purposely selected key informants at facility, district, state, and national levels. Focus group discussions were conducted with 41 ANMs and 25 members of the community. Non-participatory observations with eight ANMs provided information to expand on and scrutinise findings that emerged from the other lines of inquiry. A realist lens was applied to identify ANMs' performance as a result of "mechanisms" (training, supervision, accountability mechanisms) within the given "context" (regulatory system, infrastructure and resources, ANMs' expanded scope of work, gender roles and norms). RESULTS: Weak enforcement of regulatory system led to poor standardisation of training quality among training institutions. Challenges in internal accountability mechanisms governing ANMs within the health system hierarchy made it difficult to ensure individual accountability. Training and supervision received were inadequate to address current responsibilities. The supervisory approach focused on comparing information in periodic reports against expected outputs. Clinical support in workplaces was insufficient, with very little problem identification and solving. CONCLUSION: Focusing on the tasks of ANMs with technical inputs alone is insufficient to achieve the full potential of ANMs in a changing context. Systematic efforts tackling factors governing ANMs in their workplaces can produce a useful cadre, that can play an important role in achieving universal health coverage in India.

Influenza vaccination of pregnant women: Engaging clinicians to reduce missed opportunities for vaccination.

BACKGROUND: Antenatal influenza vaccination (AIV) is an effective intervention for protecting pregnant women and their newborns against influenza. Although the World Health Organization recommends AIV at any stage of pregnancy, in low- and middle-income countries, including India, it is rarely provided. Research suggests that antenatal care (ANC) provider practices explain much of this limited coverage. Our study in urban Pune, India, assessed the feasibility of a two-stage clinician-engagement strategy to reduce missed opportunities for AIV in urban private-practice ANC clinics. METHODS: Clinicians were randomized to intervention and control groups in slum and middle-class study sites. Intervention-group clinicians (active clinicians) were assessed on vaccination-related views and practices, and were presented with authoritative AIV recommendations from global, academic and professional medical organizations. In a second meeting after a community survey, findings concerning vaccination-related views and experiences were explained to active clinicians. Assessments of community vaccination views were not provided to control-group clinicians. Both groups maintained logs of ANC clinic visit vaccination status throughout the 11-month study period to enable identification of missed and taken opportunities for vaccination. Analyses were restricted to visits of women in their third trimester without previous AIV in the current pregnancy. RESULTS: Overall, 30 clinicians participated. After first and second interactions, active clinicians in middle-class communities vaccinated at 12.2% and 37.8%, respectively. Middle-class control clinicians vaccinated at <0.2% throughout the study. This difference in AIV taken opportunities between middle-class active and control clinics was statistically significant (p < 0.05) after first and second interactions. In slum-community sites, active clinicians' AIV activity was minimal throughout. CONCLUSIONS: Our approach for engaging clinicians effectively reduced missed opportunities for AIV in urban middle-class settings of Pune. It may also improve maternal vaccination for other conditions. The absence of any similar effect in slum-based clinics likely reflects critical limitations of vaccine access.

Public Health Policy and Experience of the 2009 H1N1 Influenza Pandemic in Pune, India.

BACKGROUND: Prior experience and the persisting threat of influenza pandemic indicate the need for global and local preparedness and public health response capacity. The pandemic of 2009 highlighted the importance of such planning and the value of prior efforts at all levels. Our review of the public health response to this pandemic in Pune, India, considers the challenges of integrating global and national strategies in local programmes and lessons learned for influenza pandemic preparedness. METHODS: Global, national and local pandemic preparedness and response plans have been reviewed. In-depth interviews were undertaken with district health policy-makers and administrators who coordinated the pandemic response in Pune. RESULTS: In the absence of a comprehensive district-level pandemic preparedness plan, the response had to be improvised. Media reporting of the influenza pandemic and inaccurate information that was reported at times contributed to anxiety in the general public and to widespread fear and panic. Additional challenges included inadequate public health services and reluctance of private healthcare providers to treat people with flu-like symptoms. Policy-makers developed a response strategy that they referred to as the Pune plan, which relied on powers sanctioned by the Epidemic Act of 1897 and resources made available by the union health ministry, state health department and a government diagnostic laboratory in Pune. CONCLUSION: The World Health Organization's (WHO's) global strategy for pandemic control focuses on national planning, but state-level and local experience in a large nation like India shows how national planning may be adapted and implemented. The priority of local experience and requirements does not negate the need for higher level planning. It does, however, indicate the importance of local adaptability as an essential feature of the planning process. Experience and the implicit Pune plan that emerged are relevant for pandemic preparedness and other public health emergencies.

Sociocultural determinants of anticipated acceptance of pandemic influenza vaccine in Pune, India: a community survey using mixed-methods.

OBJECTIVES: To investigate community priority and determinants of pandemic influenza vaccine acceptance in Pune, India. Community willingness to accept vaccines is often neglected in pandemic preparedness. Despite an acknowledged need, few such studies have been done in lower income countries. METHODS: A cross-sectional, mixed-methods study used semi-structured explanatory model interviews to assess anticipated acceptance of nasal and injectable vaccines at different prices among 436 urban and rural residents. Logistic regression models identified sociocultural determinants of vaccine acceptance. RESULTS: Over 93 % anticipated acceptance at no-cost; 87.8 % for INR 150 nasal vaccine; 74.1 % for INR 500 and 61.7 % for INR 1000 injectable vaccines. Some respondents preferred low-cost over free vaccines. Illness-related concerns about social isolation, contaminants identified as perceived causes, private-hospital or traditional-healer help seeking, and income were positively associated with anticipated acceptance. Humoral imbalances as perceived cause, home remedies for help-seeking and age were negatively associated. CONCLUSIONS: High acceptability of pandemic influenza vaccines indicates good prospects for mass vaccination. It appeared that confidence was higher in the vaccines than in the health systems delivering them. Vaccination programmes should consider sociocultural determinants influencing vaccine acceptance.

Community awareness, use and preference for pandemic influenza vaccines in Pune, India.

Vaccination is a cornerstone of influenza prevention, but limited vaccine uptake was a problem worldwide during the 2009-2010 pandemic. Community acceptance of a vaccine is a critical determinant of its effectiveness, but studies have been confined to high-income countries. We conducted a cross-sectional, mixed-method study in urban and rural Pune, India in 2012-2013. Semi-structured explanatory model interviews were administered to community residents (n = 436) to study awareness, experience and preference between available vaccines for pandemic influenza. Focus group discussions and in-depth interviews complemented the survey. Awareness of pandemic influenza vaccines was low (25%). Some respondents did not consider vaccines relevant for adults, but nearly all (94.7%), when asked, believed that a vaccine would prevent swine flu. Reported vaccine uptake however was 8.3%. Main themes identified as reasons for uptake were having heard of a death from swine flu, health care provider recommendation or affiliation with the health system, influence of peers and information from media. Reasons for non-use were low perceived personal risk, problems with access and cost, inadequate information and a perceived lack of a government mandate endorsing influenza vaccines. A majority indicated a preference for injectable over nasal vaccines, especially in remote rural areas. Hesitancy from a lack of confidence in pandemic influenza vaccines appears to have been less of an issue than access, complacency and other sociocultural considerations. Recent influenza outbreaks in 2015 highlight a need to reconsider policy for routine influenza vaccination while paying attention to sociocultural factors and community preferences for effective vaccine action.

Cultural epidemiology of pandemic influenza in urban and rural Pune, India: a cross-sectional, mixed-methods study.

OBJECTIVE: To identify and compare sociocultural features of pandemic influenza with reference to illness-related experience, meaning and behaviour in urban and rural areas of India. DESIGN: Cross-sectional, mixed-methods, cultural epidemiological survey with vignette-based interviews. Semistructured explanatory model interviews were used to study community ideas of the 2009 influenza pandemic. In-depth interviews elaborated respondents' experience during the pandemic. SETTING: Urban and rural communities, Pune district, western India. PARTICIPANTS: Survey of urban (n=215) and rural (n=221) residents aged between 18 and 65 years. In-depth interviews of respondents with a history of 2009 pandemic influenza (n=6). RESULTS: More urban (36.7%) than rural respondents (16.3%, p<0.001) identified the illness in the vignette as 'swine flu'. Over half (56.7%) believed the illness would be fatal without treatment, but with treatment 96% predicted full recovery. Worry ('tension') about the illness was reported as more troubling than somatic symptoms. The most common perceived causes-'exposure to a dirty environment' and 'cough or sneeze of an infected person'-were more prominent in the urban group. Among rural respondents, climatic conditions, drinking contaminated water, tension and cultural ideas on humoral imbalance from heat-producing or cold-producing foods were more prominent. The most widely reported home treatment was herbal remedies; more rural respondents suggested reliance on prayer, and symptom relief was more of a priority for urban respondents. Government health services were preferred in the urban communities, and rural residents relied more than urban residents on private facilities. The important preventive measures emphasised were cleanliness, wholesome lifestyle and vaccines, and more urban respondents reported the use of masks. In-depth interviews indicated treatment delays during the 2009 pandemic, especially among rural patients. CONCLUSIONS: Although the term was well known, better recognition of pandemic influenza cases is needed, especially in rural areas. Improved awareness, access to treatment and timely referrals by private practitioners are also required to reduce treatment delays.

Socioeconomic, cultural and behavioural features of prior and anticipated influenza vaccine uptake in urban and rural Pune district, India: a mixed-methods case study.

INTRODUCTION: Ensuring production capacity of efficacious vaccines for pandemic preparedness alone may not be sufficient for effective influenza control. Community willingness to accept the vaccine is also critical. Population acceptance must therefore be recognised as a major determinant of vaccine effectiveness, and the social, cultural and economic determinants of population acceptance require study for effective policy and action. Pune is a focus of pandemic influenza in India. The experience of the 2009/2010 pandemic in Pune, capacity for vaccine production and experience with vaccine use provide a unique opportunity to address key questions about an effective vaccine intervention strategy for influenza control in India. This study will examine the socioeconomic, cultural and behavioural determinants of anticipated acceptance of influenza vaccines among the urban and rural populations of Pune district. Additionally, community ideas about seasonal influenza and its distinction from pandemic influenza will be investigated. Proposed research also considers the influence of health professionals, policy makers and media professionals on the awareness, preference and use of influenza vaccines. METHODS AND ANALYSIS: This is a mixed-methods study including urban and rural community surveys, in-depth interviews with health professionals, case studies at two hospitals where suspected influenza cases were referred during the pandemic and in-depth interviews with media professionals and public health policy makers. ETHICS AND DISSEMINATION: This protocol was approved by the ethics review committees of the Maharashtra Association of Anthropological Sciences and the WHO, and by the Ethics Commission of Basel, Switzerland. The proposed research will provide a better understanding of communication and education needs for vaccine action for influenza control in India and other low-income and middle-income countries. The findings and the approach for health social science research will have implications for containment of pandemic influenza in other settings and for effective vaccine action planning for other vaccines.

Caring for caregivers of people living with HIV in the family: a response to the HIV pandemic from two urban slum communities in Pune, India.

INTRODUCTION: In low resource settings, the vast majority of 'Person/people Living with HIV' (PLHIV/s) and inadequate healthcare delivery systems to meet their treatment and care needs, caregivers play a vital role. Home based caregivers are often unrecognized with limited AIDS policies and programs focusing on them. We explored the perceptions and norms regarding care being provided by family caregivers of PLHIVs in India. METHODOLOGY: A community based qualitative study to understand the issues pertaining to home based care for PLHIV was conducted in urban settings of Pune city, in Maharashtra, India. Eight Focus Group Discussions (FGDs) among men, women and peer educators were carried out. A total of 44 in-depth Interviews (IDIs) with PLHIVs (20) and their caregivers (24), were conducted using separate guides respectively. Data was analyzed thematically. RESULTS: Home based care was perceived as economically viable option available for PLHIVs. 'Care' comprised of emotional, adherence, nursing and financial support to PLHIV. Home based care was preferred over hospital based care as it ensured confidentiality and patient care without hampering routine work at home. Women emerged as more vital primary caregivers compared to men. Home based care for men was almost unconditional while women had no such support. The natal family of women also abandoned. Their marital families seemed to provide support. Caregivers voiced the need for respite care and training. DISCUSSION: Gender related stigma and discrimination existed irrespective of women being the primary family caregivers. The support from marital families indicates a need to explore care and support issues at natal and marital homes of the women living with HIV respectively. Home based care training and respite care for the caregivers is recommended. Gender sensitive interventions addressing gender inequity and HIV related stigma should be modeled while designing interventions for PLHIVs and their family caregivers.