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Dr. Ajay Kumar Chakraborty FETP Scholar, 2008-10 Cohort National Institute of Epidemiology

Interaction with health workers improved awareness and desired care-seeking practices for childhood illness in Sundarban area, West Bengal, India, 2010. Awareness and health care-seeking practices for childhood illness in Sundarban backward zone, West Bengal, India, 2010.

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Dr. Ajay Kumar Chakraborty FETP Scholar, 2008-10 Cohort National Institute of Epidemiology

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  1. Interaction with health workers improved awareness and desired care-seeking practices for childhood illness in Sundarban area, West Bengal, India, 2010 Awareness and health care-seekingpractices for childhood illness in Sundarban backward zone, West Bengal, India, 2010 Dr. Ajay Kumar Chakraborty FETP Scholar, 2008-10 Cohort National Institute of Epidemiology Chennai, Tamil Nadu, India Dr. Ajay Kumar Chakraborty FETP Scholar, 2008-10 Cohort National Institute of Epidemiology Chennai, Tamil Nadu, India

  2. Background justification • Delay in appropriate care seeking leads to large number of child deaths globally • Integrated Management of Neonatal and Childhood Illness programme (IMNCI) addressing this issue in India • Improving management skill of health workers • Educating mothers to identify danger signs and seeking prompt care • Before implementation, we assessed base level situation in geographically vulnerable Sundarban area of South 24 Parganas district, West Bengal, India during 2010

  3. Objectives • Primary: • Estimate the proportion of mothers aware of danger sign of the ill children (<5 years) as per the IMNCI guidelines • Describe the help-seeking behaviour of the mothers • Secondary: • Determine the factors associated with mothers’ awareness (at least 2 danger signs) and help-seeking behaviour • Assess the knowledge of the peripheral health workers (female) regarding the management of “sick” children (<5 years)

  4. Methodology

  5. Study Area: Sundarban South 24 Parganas District, WB

  6. Study population, Study design, Sampling • Study population: • The mothers of the <5 years old children in Sundarban area (3.01 million), 24 Parganas (S) district, West Bengal, India • The Health workers (F) [Auxiliary Nurse Midwife] of Sundarban area • Study design– Cross-sectional survey • Sampling: • Cluster sampling (Probability proportional to size) of 552 mothers from 23 clusters (24/cluster) • [Awareness 60% (UNICEF: MICS-India 2000), 95% CI , 90% power, roh 0.02, Right size software] • Random sampling of 117 Health workers (F) • [Knowledge 50%, 95% CI, 80% Power, 20% absenteeism]

  7. Data collection and Analysis • Data collection procedure • Team of two trained social workers interviewed mothers • Pre-tested structured questionnaire in local language • IMNCI module based questionnaire administered by BMOH to the selected Health workers (F) • Data entry and analysis • Double entry, checked for consistency • Analysis using Epi-info 3.5.1 version software • Ethical Issues • Approved by Ethical Committee, NIE-Chennai • Informed consent, confidentiality, protection and support

  8. Operational Definitions • Danger sign: Child with any of the following sign or symptoms (IMNCI guideline, GOI/WHO): • Convulsions, unconsciousness, lethargy, vomits everything, breast feeding poorly, drinking poorly, ‘become sicker’, develops Fever, ‘feels Cold to touch’ (young infant), fast breathing, difficulty in breathing, blood in stool • Prompt care: Sought help outside home within 24 hours of the onset / identification of danger sign • Appropriate care:Approached for western system of medicine (allopathic) either from a qualified private practitioner or any government institute (including sub-centre) • Desired Care: Availing appropriate care promptly

  9. Result and Discussion

  10. Socio-demographic status of Study sample, Sundarban, 24Pgs, WB, 2010

  11. Demographic status of Study sample, Sundarban, 24Pgs, WB, 2010

  12. Awareness of Danger signs among 552 mothers of Sundarban, 24Prgs, W.B. 2010

  13. Illness and Help seeking behavior, Sundarban, WB, 2010 Illness episodes (N=552) Care seeking (N= 331)

  14. Choice of Provider (N= 331) Sundarban, WB, 2010

  15. Determinants of Mothers’ Awareness of at-least 2 danger signs (N= 552) • Income: • APL [AOR=1.5 (95% CI:1-2.1)] • Religion: • Muslim [AOR=1.8 (95% CI:1.1-2.7)] • Source of information of danger signs • Health Worker (F) [AOR=1.5 (95% CI-1.1-2.2)] • Age of child 2mo- 2 year [OR= 1.3 (0.9-1.8)]

  16. Mothers aware when source of information was Health Workers • Aware when HW(F) was source of information : • Probably interaction during Immunization session as SC utilization was low for care-seeking during illness • During evaluation 88% found sharing key messages • HW(F) exposed to several training on IEC/BCC • Awareness with increasing child age: • Peak at 1-2 yrs; corresponding to immunization age group • Only when the ‘source of information’ was the health workers (Chi sq for linear trend= 4.5 p = 0.03) • Increased # of child not associated with awareness

  17. Aware Muslim mothers : Any role of HW? • Muslim mothers were Aware • But SES likely to be poorer • BPL [OR=1.4 (CI-1-2)]; uneducated [OR=3 (2-4.3)] • Likely to have younger child • More child below median age of 2 years (53% c.f. Hindu 48%) – immunization age group • Children mostly (95%,195/206) immunized, all from Government source (HW-F) • Better informed about Sub-centre working time [OR= 1.5 (1.04-2.1)] • Probably indicate they are utilizing their services

  18. Factors related with Care seeking • Prompt care: • With increasing # of danger signs [Chi sq for linear trend=7.06, p=0.008] • Aware Sub-centre working days [ AOR= 3.3, (1.2-9)] • Appropriate care: • Mothers educated > primary level [ AOR= 4.6,(1.2-18)] • Husband in service/higher occupation [AOR= 5.5,(1.1-27)] • Preferred qualified allopathic services [AOR= 71,(13-394)] • System of choice was allopathic [AOR= 9.8, (1.7-58)] • Aware Sub-centre working days [ AOR= 3.4, 1-11]

  19. Factors related with Desired Care • Desired care: • Preferred qualified allopath as 1st contact [AOR= 16, 95% CI (3.8-67)] • History of child death [AOR=15, (1.5-154)] • Increasing awareness level [Chi sq for linear trend= 3.5, p = 0.06] • Aware Sub-centre working days [ AOR= 4.4, 1.2-15.5]

  20. Interactions with HW lead to all desired care-seeking behavior • Interactions leading to desired care-seeking : • All positive behavior associated with ‘knowledge of SC working time’ • We assumed correctly informed of ‘SC working time’ - a surrogate for SC use and therefore scope for interaction • Mothers with child in immunization age group better informed of ‘SC working time’ [1-2 year 48%(42-54%); 3-5 years 43%(37-49%)]

  21. Knowledge score of Health Workers (F), Sundarban, India, 2010

  22. Our limitations • We have seen the association, dose response, plausibility but could not confirm causal relationship in absence of temporality • We did not assess health workers’ contribution on educating the community • We rather accepted ‘keeping correct information on Sub-centre functioning days’ as a surrogate indicator for Sub-centre use • We assumed Sub-centre use as synonymous to interaction with health workers • Based on previous observation • Informally confirmed by the mothers

  23. Conclusion..1 • Awareness level at par with Indian mothers • In spite of all poor SES, but compared to India during 2000AD • Mothers could identify most of the illnesses with danger signs • Prompt care a general practice, but not the appropriate care • Little gap in appropriate and desired care • Inadequate qualified provider, available only in selected areas, difficult communication • Interactions with HW lead to better awareness and desired care-seeking behavior

  24. Conclusion..2 • Health assistant females have overall good knowledge • but weak in identification of common element and case management • Sub-centre utilization was low • Better than the state. Alternate day service may be a deterrent factor for utilization during emergencies • For immunization purpose service utilization good • Key messages shared during contacts • Skill of behavioral changed communication not assessed • needs further assessment and planning

  25. Recommendation • Implement IMNCI programme and train the health workers identification and management of common elements including diarrhea and ARI based on IMNCI module • Extend the sub-centre working days to six days with the help of locally residing 2nd ANM • Further assessment of the communication skill of health workers • To improve awareness and utilization of prompt and appropriate services

  26. Action taken • Findings shared with World-Bank • Data is being used for planning activity • Findings shared with District authority • Training of IMNCI has started, key identified area getting more attention • Sub-centre started working six days a week • Where 2nd ANM is available (prior Govt. order)

  27. Acknowledgement • Faculty members of National Institute of Epidemiology (NIE), Chennai, India • District and Peripheral Health Workers, South 24 Parganas District, WB • Mothers of Sunderban area

  28. Thank you

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