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Wahl B, Nama N, Pandey RR, Garg T, Mishra AM, Srivastava S, Ali S, Verma SK, Erchick DJ, Sauer M, Venkatesh U, Koparkar A, Kishore S. Neonatal, Infant, and Child Mortality in India: Progress and Future Directions. Indian J Pediatr 2023; 90:1-9. [PMID: 37695418 DOI: 10.1007/s12098-023-04834-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023]
Abstract
In India, considerable progress has been made in reducing child mortality rates. Despite this achievement, wide disparities persist across and socio-economic strata, and persistent challenges, such as malnutrition, poor sanitation, and lack of clean water. This paper provides a comprehensive review of the state of child health in India, examining key risk factors and causes of child mortality, assessing the coverage of child health interventions, and highlighting critical public health programs and policies. The authors also discuss future directions and recommendations for bolstering ongoing efforts to improve child health. These include state- and region-specific interventions, prioritizing social determinants of health, strengthening data systems, leveraging existing programs like the National Health Mission (NHM) and Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), and the proposed Public Health Management Cadre (PHMC). The authors argue that reducing child mortality requires not only scaled-up interventions but a comprehensive approach that addresses all dimensions of health, from social determinants to system strengthening.
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Affiliation(s)
- Brian Wahl
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
- Johns Hopkins India, Lucknow, Uttar Pradesh, India.
| | - Norah Nama
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Raghukul Ratan Pandey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Johns Hopkins India, Lucknow, Uttar Pradesh, India
- Department of Microbiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Tushar Garg
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Johns Hopkins India, Lucknow, Uttar Pradesh, India
| | - Aman Mohan Mishra
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Johns Hopkins India, Lucknow, Uttar Pradesh, India
| | - Swati Srivastava
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Johns Hopkins India, Lucknow, Uttar Pradesh, India
| | - Sana Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Johns Hopkins India, Lucknow, Uttar Pradesh, India
| | - Shival Kishore Verma
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Johns Hopkins India, Lucknow, Uttar Pradesh, India
| | - Daniel J Erchick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Molly Sauer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - U Venkatesh
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Gorakhpur, India
| | - Anil Koparkar
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Gorakhpur, India
| | - Surekha Kishore
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Gorakhpur, India
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Nelson HJ, Angus B, Munns A, Ong S, Burns S. Models, theoretical design and formal evaluation of integrated specialist community health service provision for the first 2000 days: a scoping review. BMJ Open 2023; 13:e070042. [PMID: 37225272 DOI: 10.1136/bmjopen-2022-070042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE This scoping review identifies evidence for design, models and evaluation of integrated care service provision for families and children in the first 2000 days, in the context of community-based specialised health, education and welfare services. DESIGN Scoping review following the Joanna Briggs scoping review method. DATA SOURCES Medline, CINAHL, Cochrane and PsycINFO. Grey literature used a manual search of original articles, and snowball technique to identify government and policy documents relevant to Australia. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Inclusion criteria were 'population' of prebirth to age 5; 'concept' of design, models and delivery of integrated specialist care for children and families; and 'context' of community-based specialised health, education and welfare services. Medical Subject Heading (MeSH) and free text searches were conducted in electronic database sources. Limits January 2010 to October 2022, full text, English language, human. DATA EXTRACTION AND SYNTHESIS Data were extracted independently by two authors using a piloted data extraction table and presented in table and narrative form. RESULTS Full text of 11 articles were reviewed, domains were coded using four domains of a framework identified in one reviewed article to maintain consistency of reporting; 'governance,' 'leadership,' 'organisational culture and ethos,' and 'front-line interdisciplinary practice.' A fifth domain was identified, 'access.' CONCLUSIONS Services providing integrated care for families in the early years will ideally be based on values generated through codesign with families and the community. Considerations include sound governance and leadership, shared vision, and commitment to providing accessible and culturally safe family-centred care.
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Affiliation(s)
| | - Bethany Angus
- Carey Community Resources, Harrisdale, Western Australia, Australia
| | - Ailsa Munns
- School of Nursing, Curtin University, Perth, Western Australia, Australia
| | - Sarah Ong
- Child and Adolescent Community Health Service, Nedlands, Western Australia, Australia
| | - Sharyn Burns
- School of Population Health, Collaboration for Evidence, Research and Impact in Public Health, Curtin University, Perth, Western Australia, Australia
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Abstract
Despite several efforts by the Government of India, the national burden of anaemia remains high and its growing prevalence (between 2015-2016 and 2019-2021) is concerning to India's public health system. This article reviews existing food-based and clinical strategies to mitigate the anaemia burden and why they are premature and insufficient. In a context where multiple anaemia control programmes are in play, this article proposes a threefold strategy for consideration. First, except the Comprehensive National Nutrition Survey, 2016-2018, which measured Hb concentration among children and adolescents aged 1-19 years using venous blood samples, all national surveys use capillary blood samples to determine Hb levels, which could be erroneous. The Indian government should prioritise conducting a nationwide survey for estimating the burden of anaemia and its clinical determinants for all age groups using venous blood samples. Second, without deciding the appropriate dose of Fe needed for an individual, food fortification programmes that are often compounded with layering of other micronutrients could be harmful and further research on this issue is needed. Same is true for the pharmacological intervention of Fe tablet or syrup supplementation programmes, which is given to individuals without assessing its need. In addition, there is a dire need for robust research to understand both the long-term benefit and side effects of Fe supplementation programmes. Third and final, the WHO is in process of reviewing the Hb threshold for defining anaemia, therefore the introduction of new anaemia control programmes should be restrained.
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Lansford JE, Betancourt TS, Boller K, Popp J, Altafim ERP, Attanasio O, Raghavan C. The Future of Parenting Programs: II Implementation. PARENTING, SCIENCE AND PRACTICE 2022; 22:235-257. [PMID: 36439707 PMCID: PMC9683038 DOI: 10.1080/15295192.2022.2086807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Jennifer E Lansford
- Center for Child and Family Policy, Duke University, Box 90545, Durham, NC 27708, USA
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S. K R. What matters most for early childhood development? Evidence from Malda district, India. PLoS One 2022; 17:e0268985. [PMID: 35657789 PMCID: PMC9165910 DOI: 10.1371/journal.pone.0268985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background The early period of a child’s life is considered to be the most important developmental stage throughout the lifespan. Around 250 million children of age below five years in low-and middle- income countries (LMICs) are at risk of not attaining their developmental potential. A cross-sectional case study was conducted to assess the early childhood developmental (ECD) status and to investigate the factors influencing the same in Malda, India. Methods Information on 731 pre-school children aged 36 to 59 months was collected in 2018 using a structured questionnaire following a multi-stage, stratified simple random sampling procedure. ECD was measured following the UNICEF’s Multiple Indicator Cluster Survey, which monitors early child development in LMICs. A path analysis using structural equation modelling was carried out to examine the relationship between possible associated factors and ECD status. Results It has been found that only about 25% of children are developmentally on track of literacy-numeracy domain of ECD. Although, in the other domains, the situation is better. Results of the path analysis revealed that there are certain proximal factors, i.e., home environment, mother’s time for care, having home tuition and attending private pre-school, which are influenced by certain distal factors and subsequently affecting ECD. The total effects revealed that place of residence (urban or rural) affects ECD mostly (Coef. -0.87, p = <0.001) directly or via mothers’ time for stimulating activities, home environment and having home tuition for children. Further, it revealed that private pre-schools (Coef. 0.76, p = <0.001) and home tuition (Coef. 0.43, p = <0.001) also play a significant role in ECD. Conclusion Urgent attention from policymakers or other stakeholders is needed to promote ECD for the betterment of children and society of Malda district. In addition to that, special attention needs to be given to the children who belong to Muslim families, socially deprived communities and living in rural areas.
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Affiliation(s)
- Rayhan S. K
- Centre for the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University, New Delhi, India
- * E-mail:
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Kumar K, Saikia N, Diamond-smith N. Performance barriers of Civil Registration System in Bihar: An exploratory study. PLoS One 2022; 17:e0268832. [PMID: 35648782 PMCID: PMC9159592 DOI: 10.1371/journal.pone.0268832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 05/10/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives
Vital statistics generated by the Civil Registration System (CRS) are essential for developing healthcare interventions at all administrative levels. Bihar had one of the lowest levels of mortality registration among India’s states. This study investigates CRS’s performance barriers from the perspective of CRS staff and community members in Bihar.
Methods
We conducted a primary qualitative survey in the two districts of Bihar during February-March 2020 with CRS staff (n = 15) and community members (n = 90). We purposively selected the Patna and Vaishali districts of Bihar for the survey. Thematic analysis was done to identify the pattern across the data using the Atlas-ti software.
Results
Most participants showed a good understanding of registration procedures and birth and death registration benefits. The perceived need for death registration is lower than birth registration. Birth registration was higher among female children than male children. We found that most participants did not report children or adult female death due to lack of financial or property-related benefits. Most participants faced challenges in reporting birth and death due to poor delivery of services at the registration centres, higher indirect opportunity cost, and demand of bribes by the CRS staff for providing certificates. We found a lack of adequate investment, shortage of dedicated staff, and limited computer and internet services at the registration centres.
Conclusions
Poor data on birth and death registration could lead decision-makers to target health services inappropriately. Strengthening health institutions’ linkage with the registration centres, mobile registration in far-flung areas and regular CRS staff training could increase death registration levels. An adequate awareness campaign on the benefits of birth and death registration is required to increase the reporting of vital events.
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Affiliation(s)
- Krishna Kumar
- Centre for the Study of Regional Development, School of Social Sciences III, Jawaharlal Nehru University, New Delhi, India
| | - Nandita Saikia
- Department of Public Health and Mortality Studies, International Institute for Population Sciences, Deonar, Mumbai, India
- * E-mail:
| | - Nadia Diamond-smith
- Epidemiology and Biostatistics Department, University of California, San Francisco, CA, United States of America
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Nutritional Status of Under-five Siblings of Severely Wasted Children in Bhopal. Indian Pediatr 2022. [DOI: 10.1007/s13312-022-2441-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ramani S, Sridhar R, Shende S, Manjarekar S, Patil S, Pantvaidya S, Fernandez A, Jayaraman A. Implementing a "convergent" framework of action against childhood malnutrition in urban informal settlements of Mumbai: Frontline perspectives. J Family Med Prim Care 2021; 10:3600-3605. [PMID: 34934653 PMCID: PMC8653499 DOI: 10.4103/jfmpc.jfmpc_2526_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 06/15/2021] [Accepted: 06/20/2021] [Indexed: 11/21/2022] Open
Abstract
Context: The National Nutrition Mission (POSHAN Abhiyaan) intends to “converge” nutrition-related program components across sectors (nutrition, health, water, and sanitation). In this study, we have examined the perspectives of Anganwadi workers (AWWs), the frontline workers of the Integrated Child Development Services, on working in convergence with the public health sector. Methods: This exploratory qualitative study was done between June 2018 and June 2019 in two urban informal settlements in Mumbai. We conducted in-depth interviews with 26 AWWs and their supervisors, purposively sampled and diversified in terms of age, education, and years of experience. We used the software NVivo version 12 to aid analysis. Results: Most AWWs acknowledged that a convergent framework of action between “nutrition” and “health” was likely to be beneficial to the community. However, they also shared that cross-sector convergence was currently limited due to technical unfamiliarity with “health-sector” issues in the frontline, discomfort with data sharing, and lack of meaningful incentives for joint work. Broader organizational challenges such as poor infrastructure and lack of supervision, as well as challenges in the urban context (migration and cultural barriers) further hindered joint activities. Conclusions: The findings indicate that critical structural gaps in the urban setup of ICDS need to be addressed and AWWs need to be better familiarized with the changing roles expected from them under POSHAN Abhiyaan. To work better with the health sector, the work timings of AWWs need to be aligned with those of the health sector and meaningful financial incentives need to be put in place for cross-sector activities.
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Affiliation(s)
- Sudha Ramani
- SNEHA (Society for Nutrition, Education and Health Action), Mumbai, Maharashtra, India
| | - Rama Sridhar
- SNEHA (Society for Nutrition, Education and Health Action), Mumbai, Maharashtra, India
| | - Sushma Shende
- SNEHA (Society for Nutrition, Education and Health Action), Mumbai, Maharashtra, India
| | - Shreya Manjarekar
- SNEHA (Society for Nutrition, Education and Health Action), Mumbai, Maharashtra, India
| | - Sonali Patil
- SNEHA (Society for Nutrition, Education and Health Action), Mumbai, Maharashtra, India
| | - Shanti Pantvaidya
- SNEHA (Society for Nutrition, Education and Health Action), Mumbai, Maharashtra, India
| | - Armida Fernandez
- SNEHA (Society for Nutrition, Education and Health Action), Mumbai, Maharashtra, India
| | - Anuja Jayaraman
- SNEHA (Society for Nutrition, Education and Health Action), Mumbai, Maharashtra, India
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Gopalakrishnan L, Diamond-Smith N, Avula R, Menon P, Fernald L, Walker D, Patil S. Association between supportive supervision and performance of community health workers in India: a longitudinal multi-level analysis. HUMAN RESOURCES FOR HEALTH 2021; 19:145. [PMID: 34838060 PMCID: PMC8627081 DOI: 10.1186/s12960-021-00689-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 11/13/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services. OBJECTIVES We examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge. METHODS We used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong. RESULTS Among 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge. CONCLUSION Higher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes. TRIAL REGISTRATION Trial registration number: https://doi.org/10.1186/ISRCTN83902145.
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Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute, Washington, DC, USA
| | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, USA
| | - Lia Fernald
- University of California Berkeley, Berkeley, USA
| | - Dilys Walker
- University of California San Francisco, San Francisco, USA
| | - Sumeet Patil
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
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Sethi V, Choedon T, Chowdhury R, Bhatia N, Dinachandra K, Murira Z, Bhanot A, Baswal D, de Wagt A, Bhargava M, Meshram II, Babu GR, Kulkarni B, Divakar H, Jacob CM, Killeen SL, McAuliffe F, Vergehese M, Ghosh S, Hanson M. Screening and management options for severe thinness during pregnancy in India. Int J Gynaecol Obstet 2021; 155:357-379. [PMID: 34724206 DOI: 10.1002/ijgo.13939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 11/08/2022]
Abstract
This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources.
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Affiliation(s)
- Vani Sethi
- Nutrition Section, United Nations Children's Fund, New Delhi, India
| | | | - Ranadip Chowdhury
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Neena Bhatia
- NITI Aayog, Government of India, New Delhi, India
| | | | - Zivai Murira
- Regional Office for South Asia, UNICEF, Kathmandu, Nepal
| | | | - Dinesh Baswal
- Programmes, Mamta Health Institute for Mother and Child, New Delhi, India
| | - Arjan de Wagt
- Nutrition Section, United Nations Children's Fund, New Delhi, India
| | - Madhavi Bhargava
- Department of Community Medicine, Yenepoya Medical College, Mangalore, Karnataka, India
| | | | - Giridhara R Babu
- Department of Epidemiology, Indian Institute of Public Health, Bengaluru, India
| | - Bharati Kulkarni
- Indian Council of Medical Research, National Institute of Nutrition, Telangana, India
| | | | - Chandni Maria Jacob
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK.,Institute of Developmental Sciences, University of Southampton, Southampton, UK
| | - Sarah Louise Killeen
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Fionnuala McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | | | | | - Mark Hanson
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK.,Institute of Developmental Sciences, University of Southampton, Southampton, UK
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11
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Prado EL. Children Staying Smaller but Growing Smarter Beyond the First 1000 Days. J Nutr 2021; 151:1684-1685. [PMID: 34036311 DOI: 10.1093/jn/nxab136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Elizabeth L Prado
- Department of Nutrition and Institute for Global Nutrition, University of California Davis, Davis, CA, USA
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12
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Wilhelm J, Mahapatra T, Das A, Sonthalia S, Srikantiah S, Galavotti C, Shah H, Creanga AA. From direct engagement to technical support: a programmatic evolution to improve large community health worker programs in Bihar, India. BMJ Glob Health 2021; 6:bmjgh-2020-004389. [PMID: 33853844 PMCID: PMC8054080 DOI: 10.1136/bmjgh-2020-004389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/02/2021] [Accepted: 03/20/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In 2011, through a multipartner Integrated Family Health Initiative (IFHI), CARE started supporting maternal and neonatal health (MNH) improvement goals in 8 of 38 districts in Bihar, India. The programme included a frontline health worker (FHW) component offering health advice through household visits and benefited from CARE's direct engagement during IFHI, which then evolved into statewide Technical Support Unit (TSU) to the Government of Bihar in 2014. METHODS Using eight rounds of state-representative household surveys with mothers of infants aged 0-2 months (N=73 093) linked with two facility assessments conducted during 2012-2017, we assessed changes in FHW visit coverage, intensity and quality between IFHI and TSU phases. Using logistic regression models, we ascertained associations between FHW outputs and three MNH core practices: ≥3 antenatal care check-ups (ANC3+), institutional delivery and early breastfeeding initiation. RESULTS Women's receipt of 1+ FHW visits declined from 60.2% (IFHI phase) to 46.3% (TSU phase) in the eight IFHI districts, being below 40% statewide during the TSU phase. Despite a parallel decline in FHW visit quality measured as the number of health advice received, all three outcomes improved during the TSU versus IFHI phase in IFHI districts. We found significant positive associations between all three outcomes and receipt of 1+ FHW visits and programme phase (TSU vs IFHI) in the eight IFHI districts. During the TSU phase, receipt of 2+ FHW visits in the third trimester increased the odds of women receiving ANC3+ (adjusted OR (aOR)=1.21; 95% CI: 1.13 to 1.31), delivering in a facility (aOR=1.64; 95% CI: 1.51 to 1.77) and initiating breast feeding early (aOR=1.18; 95% CI: 1.05 to 1.18). Independent of the number and timing of FHW visits, we also found positive associations between women reporting higher than lower quality of FHW interactions and receiving outcome-specific advice and all three MNH outcomes. CONCLUSION Implementation of large community-based interventions under the technical support model should be continuously and strategically evaluated and adapted.
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Affiliation(s)
- Jess Wilhelm
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India.,CARE USA, Atlanta, Georgia, USA
| | - Sunil Sonthalia
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | | | - Hemant Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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13
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Jain A, Rodgers J, Li Z, Kim R, Subramanian SV. Multilevel analysis of geographic variation among correlates of child undernutrition in India. MATERNAL AND CHILD NUTRITION 2021; 17:e13197. [PMID: 33960621 PMCID: PMC8189194 DOI: 10.1111/mcn.13197] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/01/2021] [Accepted: 04/07/2021] [Indexed: 12/18/2022]
Abstract
Prior research has identified a number of risk factors ranging from inadequate household sanitation to maternal characteristics as important determinants of child malnutrition and health in India. What is less known is the extent to which these individual‐level risk factors are geographically distributed. Assessing the geographic distribution, especially at multiple levels, matters as it can inform where, and at what level, interventions should be targeted. The three levels of significance in the Indian context are villages, districts, and states. Thus, the purpose of this paper was to (a) examine what proportion of the variation in 21 risk factors is attributable to villages, districts, and states in India and (b) elucidate the specific states where these risk factors are clustered within India. Using the fourth National Family Health Survey dataset, from 2015 to 2016, we found that the proportion of variation attributable to villages ranged from 14% to 63%, 10% to 29% for districts and 17% to 62% for states. Furthermore, we found that Bihar, Jharkhand, Madhya Pradesh, and Uttar Pradesh were in the highest risk quintile for more than 10 of the risk factors included in our study. This is an indication of geographic clustering of risk factors. The risk factors that are clustered in states such as Bihar, Jharkhand, Madhya Pradesh and Uttar Pradesh underscore the need for policies and interventions that address a broader set of child malnutrition determinants beyond those that are nutrition specific.
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Affiliation(s)
- Anoop Jain
- Global Health & Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin Rodgers
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts, USA
| | - Zhihui Li
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts, USA
| | - Rockli Kim
- Division of Health Policy & Management, College of Health Science, Korea University, Seoul, South Korea.,Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, South Korea
| | - S V Subramanian
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts, USA.,Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts, USA
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Jain A, Walker DM, Avula R, Diamond-Smith N, Gopalakrishnan L, Menon P, Nimmagadda S, Patil SR, Fernald LCH. Anganwadi worker time use in Madhya Pradesh, India: a cross-sectional study. BMC Health Serv Res 2020; 20:1130. [PMID: 33287800 PMCID: PMC7722292 DOI: 10.1186/s12913-020-05857-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 10/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anganwadi Workers (AWWs) are a group of 1.4 million community health workers that operate throughout rural India as a part of the Integrated Child Development Services program. AWWs are responsible for disseminating key health information regarding nutrition, family planning, and immunizations to the women and children in their catchment area, while maintaining detailed registers that track key beneficiary data, updates on health status, and supply inventory beneficiaries. There is a need to understand how AWWs spend their time on all of these activities given all of their responsibilities, and the factors that are associated with their time use. METHODS This cross-sectional study conducted in Madhya Pradesh, collected time use data from AWWs using a standard approach in which we asked participants how much time they spent on various activities. Additionally, we estimated a logistic regression model to elucidate what AWW characteristics are associated with time use. RESULTS We found that AWWs spend substantial amounts of time on administrative tasks, such as filling out their paper registers. Additionally, we explored the associations between various AWW characteristics and their likelihood of spending the expected amount of time on preschool work, filling out their registers, feeding children, and conducting home visits. We found a positive significant association between AWW education and their likelihood of filling out their registers. CONCLUSIONS AWWs spend substantial amounts of time on administrative tasks, which could take away from their ability to spend time on providing direct care. Additionally, future research should explore why AWW characteristics matter and how such factors can be addressed to improve AWWs' performance and should explore the associations between Anganwadi Center characteristics and AWW time use.
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Affiliation(s)
| | - Dilys M Walker
- University of California San Francisco, San Francisco, USA
| | - Rasmi Avula
- International Food Policy Research Institute, Washington, DC, USA
| | | | | | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, USA
| | - Sneha Nimmagadda
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
| | - Sumeet R Patil
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
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15
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Kachwaha S, Nguyen PH, DeFreese M, Avula R, Cyriac S, Girard A, Menon P. Assessing the Economic Feasibility of Assuring Nutritionally Adequate Diets for Vulnerable Populations in Uttar Pradesh, India: Findings from a "Cost of the Diet" Analysis. Curr Dev Nutr 2020; 4:nzaa169. [PMID: 33313474 PMCID: PMC7721462 DOI: 10.1093/cdn/nzaa169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/10/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Healthy diets can help reduce undernutrition, morbidity, and mortality. However, evidence on the accessibility and affordability of recommended diets is limited, particularly in poor-resource settings including India. OBJECTIVES This study examined: 1) the minimum cost of different types of household diets; 2) how economic constraints can prevent households from accessing a nutritious diet; and 3) how home production and social protection can improve access to nutritious diets. METHODS We conducted 24 market and 125 household surveys in Uttar Pradesh, India, to obtain food prices and consumption patterns. Cost of Diet, a linear programming software, was used to assess the minimum cost of different diets, estimate affordability of nutritious diets, and model scenarios of home production and social protection interventions to improve affordability. RESULTS The minimum-cost nutritious diet that met all recommended nutrient requirements [904 US dollars (US$)/y] was over twice as expensive as the diet that only met energy requirements (US$393/y). The nutritious diet was unaffordable for 75% of households given current income levels, consumption patterns, and food prices. Household income and dietary preferences, rather than food availability, were the key barriers to obtain nutritious diets. Home production had potential to reduce the cost of nutritious diets by 35%, subsidized grains by 19%, and supplementary food by 10%. The poorest households could only afford recommended nutritious diets with access to multiple interventions. CONCLUSIONS Practical, habitual, diet-related behavior change communication to middle- and high-income households and additional social protection for poorer households could enable individuals to achieve optimal nutrient intakes.
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Affiliation(s)
- Shivani Kachwaha
- International Food Policy Research Institute, Washington, DC, USA
| | | | | | - Rasmi Avula
- International Food Policy Research Institute, Washington, DC, USA
| | - Shruthi Cyriac
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - Amy Girard
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, USA
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16
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Public health interventions to improve maternal nutrition during pregnancy: a nationally representative study of iron and folic acid consumption and food supplements in India. Public Health Nutr 2020; 23:2671-2686. [PMID: 32605672 DOI: 10.1017/s1368980020001007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Despite a reduction in maternal mortality in recent years, a high rate of anaemia and other nutrient inadequacies during pregnancy pose a serious threat to mothers and their children in the Global South. Using the framework of the WHO-Commission on Social Determinants of Health, this study examines the socioeconomic, programmatic and contextual factors associated with the consumption of iron and folic acid (IFA) tablets/syrup for at least 100 d (IFA100) and receiving supplementary food (SF) by pregnant women in India. DESIGN We analysed a nationally representative cross-sectional survey of over 190 898 ever-married women aged 15-49 years who were interviewed as part of the National Family Health Survey (NFHS) conducted during 2015-16, who had at least one live birth preceding 5 years of the survey. SETTING All twenty-nine states and seven union territories of India. PARTICIPANTS Ever-married women aged 15-49 years. RESULTS Less than one-third of women were found to be consuming IFA100, and a little over half received SF during their last pregnancy. The consumption of IFA100 was likely to improve with women's education, household wealth, early and more prenatal visits, and in a community with high pregnancy registration. Higher parity, early and more prenatal visits, contact with community health workers during pregnancy, belonging to a poor household and living in an aggregated poor community and rural area positively determine whether a woman might receive SF during pregnancy. CONCLUSIONS Continuous monitoring and evaluation of provisioning IFA and SF in targeted groups and communities is a key to expanding the coverage and reducing the burden of undernutrition during pregnancy.
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17
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Gupta M, Zwi AB, Jagnoor J. Opportunities for the development of drowning interventions in West Bengal, India: a review of policy and government programs. BMC Public Health 2020; 20:704. [PMID: 32414356 PMCID: PMC7229618 DOI: 10.1186/s12889-020-08868-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/07/2020] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Four million people living in the Indian Sundarbans region in the state of West Bengal face a particularly high risk of drowning due to rurality, presence of open water, lack of accessible health systems and poor infrastructure. Although the World Health Organization has identified several interventions that may prevent drowning in rural low-and middle-income country contexts, none are currently implemented in this region. This study aims to conduct contextual policy analysis for the development of a drowning program. Implementation of a drowning program should consider leveraging existing structures and resources, as interventions that build on policy targets or government programs are more likely to be sustainable and scalable. METHODS A detailed content review of national and state policy (West Bengal) was conducted to identify policy principles and/or specific government programs that may be leveraged for drowning interventions. The enablers and barriers of these programs as well as their implementation reach were assessed through a systematic literature review. Identified policies and programs were also assessed to understand how they catered for underserved groups and their implications for equity. RESULTS Three programs were identified that may be leveraged for the implementation of drowning interventions such as supervised childcare, provision of home-based barriers, swim and rescue skills training and community first responder training: the Integrated Child Development Scheme (ICDS), Self-Help Group (SHG) and Accredited Social Health Activist (ASHA) programs. All three had high coverage in West Bengal and considered underserved groups such as women and rural populations. Possible barriers to using these programs were poor government monitoring, inadequate resource provision and overburdening of community-based workers. CONCLUSIONS This is the first systematic analysis of both policy content and execution of government programs to provide comprehensive insights into possible implementation strategies for a health intervention, in this case drowning. Programs targeting specific health outcomes should consider interventions outside of the health sector that address social determinants of health. This may enable the program to better align with relevant government agendas and increase sustainability.
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Affiliation(s)
- M Gupta
- The George Institute for Global Health, University of New South Wales, Level 5/1 King St, Newtown, NSW, 2042, Australia.
| | - A B Zwi
- Health, Rights and Development (HEARD@UNSW), School of Social Sciences, Faculty of Arts and Social Sciences, UNSW Australia, Morven Brown Building, Kensington, 2052, Australia
| | - J Jagnoor
- Injury Division, The George Institute for Global Health, New Delhi, 110025, India
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18
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Alderman H, Nguyen PH, Menon P. Progress in reducing child mortality and stunting in India: an application of the Lives Saved Tool. Health Policy Plan 2020; 34:667-675. [PMID: 31529050 PMCID: PMC6880331 DOI: 10.1093/heapol/czz088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2019] [Indexed: 12/03/2022] Open
Abstract
The Lives Saved Tool (LiST) has been used to estimate the impact of scaling up intervention coverage on undernutrition and mortality. Evidence for the model is largely based on efficacy trials, raising concerns of applicability to large-scale contexts. We modelled the impact of scaling up health programs in India between 2006 and 2016 and compared estimates to observed changes. Demographics, intervention coverage and nutritional status were obtained from National Family and Health Survey 2005–6 (NFHS-3) for the base year and NHFS-4 2015–16 for the endline. We used the LiST to estimate the impact of changes in coverage of interventions over this decade on child mortality and undernutrition at national and subnational levels and calculated the gap between estimated and observed changes in 2016. At the national level, the LiST estimates are close to the actual values of mortality for children <1 year and <5 years in 2016 (at 41 vs 42.6 and 50 vs 56.4, respectively, per 1000 live births). National estimates for stunting, wasting and anaemia at are also close to the actual values of NFHS-4. At the state level, actual changes were higher than the changes from the LiST projections for both mortality and stunting. The predicted changes using the LiST ranged from 33% to 92% of the actual change. The LiST provided national projections close to, albeit slightly below, actual performance over a decade. Reasons for poorer performance of state-specific projections are unknown; further refinements to the LiST for subnational use would improve the usefulness of the tool.
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Affiliation(s)
- Harold Alderman
- Division of Poverty, Health and Nutrition, International Food Policy Research Institute (IFPRI), 1201 I Street NW, Washington, DC, USA
| | - Phuong Hong Nguyen
- Division of Poverty, Health and Nutrition, International Food Policy Research Institute (IFPRI), 1201 I Street NW, Washington, DC, USA
| | - Purnima Menon
- Division of Poverty, Health and Nutrition, International Food Policy Research Institute (IFPRI), 1201 I Street NW, Washington, DC, USA
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19
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Using mHealth to improve health care delivery in India: A qualitative examination of the perspectives of community health workers and beneficiaries. PLoS One 2020; 15:e0227451. [PMID: 31940326 PMCID: PMC6961923 DOI: 10.1371/journal.pone.0227451] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/18/2019] [Indexed: 11/19/2022] Open
Abstract
Background mHealth technologies are proliferating globally to address quality and timeliness of health care delivery by Community Health Workers (CHWs). This study aimed to examine CHW and beneficiaries’ perceptions of a new mHealth intervention (Common Application Software [CAS] for CHWs in India. The objectives of the study were to seek perspectives of CHWs and beneficiaries on the uptake of CAS, changes in CHW-beneficiary interactions since the introduction of CAS and potential barriers faced by CHWs in use of CAS. Further, important contextual factors related to CHW-beneficiary interface and dynamics that may have a bearing on CAS have been described. Methods A qualitative study was conducted in two states of India (Bihar and Madhya Pradesh) from March-April 2018 with CHWs (n = 32) and beneficiaries (n = 55). All interviews were conducted and recorded in Hindi, transcribed and translated into English, and coded and thematically analysed using Dedoose. Findings The mHealth intervention was acceptable to the CHWs who felt that CAS improved their status in the communities where they worked. Beneficiaries’ views were a mix of positive and negative perceptions. The divergent views between CHWs and beneficiaries surrounding the use and impact of CAS highlight an underlying mistrust, socio-cultural barriers in engagement, and technological barriers in implementation. All these contextual factors can influence the perception and uptake of CAS. Conclusions mHealth interventions targeting CHWs and beneficiaries have the potential to improve performance of CHWs, reduce barriers to information and potentially change the behaviors of beneficiaries. While technology is an enabler for CHWs to improve their service delivery, it does not necessarily help overcome social and cultural barriers that impede CHW-beneficiary interactions to bring about improvements in knowledge and health behaviors. Future interventions for CHWs including mHealth interventions should examine contextual factors along with the acceptability, accessibility, and usability by beneficiaries and community members.
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20
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Prost A, Nair N, Copas A, Pradhan H, Saville N, Tripathy P, Gope R, Rath S, Rath S, Skordis J, Bhattacharyya S, Costello A, Sachdev HS. Mortality and recovery following moderate and severe acute malnutrition in children aged 6-18 months in rural Jharkhand and Odisha, eastern India: A cohort study. PLoS Med 2019; 16:e1002934. [PMID: 31613883 PMCID: PMC6793843 DOI: 10.1371/journal.pmed.1002934] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 09/09/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Recent data suggest that case fatality from severe acute malnutrition (SAM) in India may be lower than the 10%-20% estimated by the World Health Organization (WHO). A contemporary quantification of mortality and recovery from acute malnutrition in Indian community settings is essential to inform policy regarding the benefits of scaling up prevention and treatment programmes. METHODS AND FINDINGS We conducted a cohort study using data collected during a recently completed cluster-randomised controlled trial in 120 geographical clusters with a total population of 121,531 in rural Jharkhand and Odisha, eastern India. Children born between October 1, 2013, and February 10, 2015, and alive at 6 months of age were followed up at 9, 12, and 18 months. We measured the children's anthropometry and asked caregivers whether children had been referred to services for malnutrition in the past 3 months. We determined the incidence and prevalence of moderate acute malnutrition (MAM) and SAM, as well as mortality and recovery at each follow-up. We then used Cox-proportional models to estimate mortality hazard ratios (HRs) for MAM and SAM. In total, 2,869 children were eligible for follow-up at 6 months of age. We knew the vital status of 93% of children (2,669/2,869) at 18 months. There were 2,704 children-years of follow-up time. The incidence of MAM by weight-for-length z score (WLZ) and/or mid-upper arm circumference (MUAC) was 406 (1,098/2,704) per 1,000 children-years. The incidence of SAM by WLZ, MUAC, or oedema was 190 (513/2,704) per 1,000 children-years. There were 36 deaths: 12 among children with MAM and six among children with SAM. Case fatality rates were 1.1% (12/1,098) for MAM and 1.2% (6/513) for SAM. In total, 99% of all children with SAM at 6 months of age (227/230) were alive 3 months later, 40% (92/230) were still SAM, and 18% (41/230) had recovered (WLZ ≥ -2 standard deviation [SD]; MUAC ≥ 12.5; no oedema). The adjusted HRs using all anthropometric indicators were 1.43 (95% CI 0.53-3.87, p = 0.480) for MAM and 2.56 (95% CI 0.99-6.70, p = 0.052) for SAM. Both WLZ < -3 and MUAC ≥ 11.5 and < 12.5 were associated with increased mortality risk (HR: 3.33, 95% CI 1.23-8.99, p = 0.018 and HR: 3.87, 95% CI 1.63-9.18, p = 0.002, respectively). A key limitation of our analysis was missing WLZ or MUAC data at all time points for 2.5% of children, including for two of the 36 children who died. CONCLUSIONS In rural eastern India, the incidence of acute malnutrition among children older than 6 months was high, but case fatality following SAM was 1.2%, much lower than the 10%-20% estimated by WHO. Case fatality rates below 6% have now been recorded in three other Indian studies. Community treatment using ready-to-use therapeutic food may not avert a substantial number of SAM-related deaths in children aged over 6 months, as mortality in this group is lower than expected. Our findings strengthen the case for prioritising prevention through known health, nutrition, and multisectoral interventions in the first 1,000 days of life, while ensuring access to treatment when prevention fails.
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Affiliation(s)
- Audrey Prost
- University College London, Institute for Global Health, London, United Kingdom
- Ekjut, Chakradharpur, Jharkhand, India
| | | | - Andrew Copas
- University College London, Institute for Global Health, London, United Kingdom
| | | | - Naomi Saville
- University College London, Institute for Global Health, London, United Kingdom
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21
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Nimmagadda S, Gopalakrishnan L, Avula R, Dhar D, Diamond-Smith N, Fernald L, Jain A, Mani S, Menon P, Nguyen PH, Park H, Patil SR, Singh P, Walker D. Effects of an mHealth intervention for community health workers on maternal and child nutrition and health service delivery in India: protocol for a quasi-experimental mixed-methods evaluation. BMJ Open 2019; 9:e025774. [PMID: 30918034 PMCID: PMC6475202 DOI: 10.1136/bmjopen-2018-025774] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Millions of children in India still suffer from poor health and under-nutrition, despite substantial improvement over decades of public health programmes. The Anganwadi centres under the Integrated Child Development Scheme (ICDS) provide a range of health and nutrition services to pregnant women, children <6 years and their mothers. However, major gaps exist in ICDS service delivery. The government is currently strengthening ICDS through an mHealth intervention called Common Application Software (ICDS-CAS) installed on smart phones, with accompanying multilevel data dashboards. This system is intended to be a job aid for frontline workers, supervisors and managers, aims to ensure better service delivery and supervision, and enable real-time monitoring and data-based decision-making. However, there is little to no evidence on the effectiveness of such large-scale mHealth interventions integrated with public health programmes in resource-constrained settings on the service delivery and subsequent health and nutrition outcomes. METHODS AND ANALYSIS This study uses a village-matched controlled design with repeated cross-sectional surveys to evaluate whether ICDS-CAS can enable more timely and appropriate services to pregnant women, children <12 months and their mothers, compared with the standard ICDS programme. The study will recruit approximately 1500 Anganwadi workers and 6000+ mother-child dyads from 400+ matched-pair villages in Bihar and Madhya Pradesh. The primary outcomes are the proportion of beneficiaries receiving (a) adequate number of home visits and (b) appropriate level of counselling by the Anganwadi workers. Secondary outcomes are related to improvements in other ICDS services, and knowledge and practices of the Anganwadi workers and beneficiaries. ETHICS AND DISSEMINATION Ethical oversight is provided by the Committee for the Protection of Human Subjects at the University of California at Berkeley, and the Suraksha Independent Ethics Committee in India. The results will be published in peer-reviewed journals and analysis data will be made public. TRIAL REGISTRATION NUMBER ISRCTN83902145.
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Affiliation(s)
- Sneha Nimmagadda
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
| | | | - Rasmi Avula
- International Food Policy Research Institute, New Delhi, India
| | - Diva Dhar
- Bill and Melinda Gates Foundation India, New Delhi, Delhi, India
| | | | - Lia Fernald
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Anoop Jain
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Sneha Mani
- International Food Policy Research Institute, New Delhi, India
| | - Purnima Menon
- International Food Policy Research Institute, New Delhi, India
| | - Phuong Hong Nguyen
- International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Hannah Park
- University of California San Fransisco, San Fransisco, USA
| | - Sumeet R Patil
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
| | - Prakarsh Singh
- Institute of Labour Economics (IZA), Seattle, Washington, USA
| | - Dilys Walker
- University of California San Fransisco, San Fransisco, USA
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Chakrabarti S, Raghunathan K, Alderman H, Menon P, Nguyen P. India's Integrated Child Development Services programme; equity and extent of coverage in 2006 and 2016. Bull World Health Organ 2019; 97:270-282. [PMID: 30940984 PMCID: PMC6438246 DOI: 10.2471/blt.18.221135] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 01/21/2019] [Accepted: 01/24/2019] [Indexed: 11/27/2022] Open
Abstract
Objective To investigate coverage and equity of India's Integrated Child Development Services programme across the continuum of care from pregnancy to early childhood, before and after the programme was expanded to provide universal access. Methods The programme offers nutrition and health services to pregnant and lactating mothers and young children. We used data from nationally representative surveys in 2005-2006 and 2015-2016, including 36 850 mother-child pairs in 2006 and 190 804 in 2016. We assessed changes in the equity of use of programme services by socioeconomic quintile, caste, education and rural or urban residence. We used regression models to investigate the determinants of programme use. Findings The mean proportion of respondents using programme services increased between 2006 and 2016, from 9.6% to 37.9% for supplementary food, 3.2% to 21.0% for health and nutrition education, 4.5% to 28% for health check-ups and 10.4% to 24.2% for child-specific services (e.g. immunization, growth monitoring). Wealth, maternal education and caste showed the largest positive associations with use of services. However, expansion in service use varied at the sub-national level. Although overall use had improved and reached marginalized groups such as disadvantaged castes and tribes, the poorest quintiles of the population were still left behind, especially in the largest states that carry the highest burden of undernutrition. Conclusion India's policy reforms have increased coverage of the programme at the national level, including for marginalized groups. With further scaling-up, the programme needs to focus on reaching households from the lowest socioeconomic strata and women with low schooling levels.
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Affiliation(s)
- Suman Chakrabarti
- Poverty, Health and Nutrition Division, The International Food Policy Research Institute, 2001 K Street NW, Washington DC, 20005, United States of America
| | - Kalyani Raghunathan
- Poverty, Health and Nutrition Division, The International Food Policy Research Institute, 2001 K Street NW, Washington DC, 20005, United States of America
| | - Harold Alderman
- Poverty, Health and Nutrition Division, The International Food Policy Research Institute, 2001 K Street NW, Washington DC, 20005, United States of America
| | - Purnima Menon
- Poverty, Health and Nutrition Division, The International Food Policy Research Institute, 2001 K Street NW, Washington DC, 20005, United States of America
| | - Phuong Nguyen
- Poverty, Health and Nutrition Division, The International Food Policy Research Institute, 2001 K Street NW, Washington DC, 20005, United States of America
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