Exploring the challenges in the management of childhood pneumonia-qualitative findings from health care providers from two high prevalence states in India.

India ranks among the top five countries in the world in child deaths due to pneumonia. Apart from poor public awareness, inadequate health infrastructure and treatment services have compromised effective management. This qualitative study guided by components of the Andersen-Newman's health care utilization framework explored contextual and community challenges faced by health care providers (HCPs) in the delivery of care services for children with pneumonia in select districts of Uttar Pradesh (UP) and Madhya Pradesh (MP). Semi structured interviews (SSIs) and focus groups discussions (FGDs) were carried out with a purposive sample of HCPs selected from three districts in each state. The HCPs included doctors and community health workers (CHWs). All SSIs and FGDs were audio- recorded, with consent, transcribed verbatim, entered into NVivo and analysed using thematic analysis. A total of 15 SSIs were conducted with doctors and eight FGDs were carried out with CHWs. Two themes that best explained the data were:, 1. Health systems: barriers faced in delivery of care services and 2. Evaluated Need: perceptions on community awareness and practices. According to the HCPs inadequacies in government health infrastructure both manpower and equipment, and skill deficits of paramedical staff and CHWs contributed to poor quality of care services for management of childhood pneumonia. This combined with inadequate understanding of pneumonia in the community, dependence on unqualified care providers and distrust of government hospitals acted as barriers to seeking appropriate medical care. Additionally, poor compliance with exclusive breast feeding practices, nutrition and hygiene had contributed to the high prevalence of the disease in these states. Strengthening public health facilities, instilling trust and confidence in people about the availability and the quality of these services and enhancing health literacy around childhood pneumonia would be critical towards protecting children from this disease.

Optimizing Care-Seeking for Childhood Pneumonia: A Public Health Perspective.

OBJECTIVE: This study examined the pattern of care-seeking behavior for childhood pneumonia and factors influencing it, in Madhya Pradesh (MP), Uttar Pradesh (UP) and Tamil Nadu (TN). METHODS: Using a mixed-methods design, consenting mothers of children less than 5 years with probable pneumonia participated in a household survey to assess their care-seeking behavior. A purposively selected sub-sample participated in semi-structured interviews (SSIs) to understand their perceptions on care sought, decision making abilities and cultural influences that governed these behaviors. Health care providers (HCPs) participated in SSIs and focus group discussions. RESULTS: A total of 2194 children were identified with probable pneumonia during the survey. 40 mothers and 41 HCPs participated in semi-structured interviews and focus group discussions. In MP, utilization of private allopathic care was high at 74%, about 8% went to unqualified care providers. In UP, 71% went to unqualified care providers and 5% did not seek care at all. In TN, 75% went to private allopathic doctors, and utilization of government care was higher (19%) compared to MP and UP. Qualitative findings revealed that cultural beliefs coupled with poor decision making abilities, poor understanding of illness and inappropriate care-seeking practices resulted in delays in care seeking, particularly in MP and UP. Inadequacies in government health infrastructure also contributed to their poor utilization. CONCLUSIONS: Promoting health literacy in communities and strengthening the reach of government health facilities will help in optimizing appropriate health care utilization for childhood pneumonia.

Where do mothers take their children for pneumonia care? Findings from three Indian states.

Childhood pneumonia accounts for 17% of IMR in India, posing a major health burden. With cultural beliefs influencing care seeking behaviour and disparities existing in health infrastructure across the country, an understanding of the underlying issues merits exploration. Study assessed prevalence of probable pneumonia and examined care seeking behaviour of mothers in three states, Madhya Pradesh (MP), Uttar Pradesh (UP) and Tamil Nadu (TN). This mixed methods study involved a household survey and qualitative interviews with mothers in three districts from each state. Households with children aged 2-59 months were screened to identify those with probable pneumonia; sub-sample of mothers participated in qualitative interviews. Care seeking behaviour was explored in the context of recognition of symptoms, nature of first care provided, time when care was sought outside the home and choice of health provider. Overall 17,442 children from 13,544 households were screened, of which 729 (MP), 752 (UP) and 713 (TN) children respectively, were identified with probable pneumonia; 72 mothers participated in the qualitative interviews. Three months period prevalence was estimated in study districts at 22.2%-MP 13.3%-UP and 8.4%-TN. Most mothers in MP and UP were not perceptive to severity of illness; type of care sought was often inappropriate, delayed, with home remedies and visits to unqualified care providers being their first response. In contrast, in TN, use of home remedies was minimal, going to untrained care providers, non-existent and more than 90% mothers sought appropriate care. Private doctors were the preferred choice among all mothers but utilization of government care was highest in TN (20%). Community health workers were underutilized, with less than 10% mothers consulting them. Need for educating mothers about appropriate care seeking and development of good health infrastructure as essential to attainment of better child health indices are advocated.

Impact of the introduction of the Haemophilus influenzae type b conjugate vaccine in an urban setting in southern India.

INTRODUCTION: Haemophilus influenzae type b was the leading cause of bacterial meningitis in infants and children below the age of two years prior to the introduction of H. influenzae type b conjugate vaccines. In December 2011, the Indian government introduced H. influenzae b vaccine in the state of Tamilnadu. A prospective surveillance for bacterial meningitis was established at the Institute of Child Health in Chennai to evaluate the etiology of meningitis and impact of the vaccine. MATERIAL AND METHODS: Infants aged one to 23 months who were admitted to the hospital with symptoms of suspected bacterial meningitis were enrolled and lumbar puncture was performed. Cerebrospinal fluid samples were analyzed for white blood cells, protein, and glucose. Bacterial culture and a latex agglutination test for common bacterial pathogens were performed. RESULTS: Between January 2009 and March 2014, 4,770 children with suspected bacterial meningitis were enrolled. Prior to the introduction of the vaccine, an average of 11.7 cases of H. influenzae b meningitis and 31.1 cases of probable meningitis with no etiology were identified each year. After introduction, the number of cases were reduced by 79% and 44% respectively. The average H. influenzae b vaccine coverage after introduction was 69% among all children with clinically suspected meningitis. In contrast, the mean number of aseptic meningitis and pneumococcal meningitis cases remained stable throughout the pre and post vaccination period; 28.2 and 4.8 per year, respectively. CONCLUSIONS: H. influenzae b conjugate vaccine reduced the number of cases of H. influenzae b meningitis and probable meningitis within the first two years of its introduction. The impact against meningitis was higher than the vaccination rate, indicating indirect effects of the vaccine. India has recently scaled up the use of Hib conjugate vaccine throughout the country which should substantially reduce childhood meningitis rates further in the country.

Primary health centres: preferred option for birthing care in tamilnadu, India, from users' perspectives.

Tamilnadu state of India witnessed an increasing trend of institutional deliveries since the beginning of 1990s, with decline of domiciliary deliveries to nearly zero now. Among the institutional deliveries, a shift has been observed since 2006 wherein primary health centres (PHC) have shown a four-fold increase in the number of deliveries while other public and private health facilities showed a decline, despite equal access by people to all categories of health facilities. A qualitative study was designed to explore the determinants that led to increased preference of PHCs for birthing care. In-depth interviews and FGDs were conducted with recently-delivering women and their spouses. User-friendly ambience, courteous attitude and behaviour of staff, good infrastructure, availability of qualified staff, and relative absence of informal payments have contributed to increased preference for birthing care in PHCs. Barriers to seeking care from secondary and tertiary-level public hospitals and private hospitals have also made women prefer PHCs.

Pediatric index of mortality 2 score as an outcome predictor in pediatric Intensive Care Unit in India.

BACKGROUND AND AIMS: Pediatric index of mortality (PIM) 2 score is one of the severity scoring systems being used for predicting outcome of patients admitted to intensive care units (ICUs). The aim of the present study was to evaluate the usefulness of PIM2 score in predicting mortality in a tertiary care pediatric ICU (PICU) and to assess the associated factors in predicting mortality such as presence of shock, need for assisted ventilation and Glasgow coma scale <8. MATERIALS AND METHODS: This was a prospective observation study done at tertiary care PICU from May 2011 to July 2011. Consecutive 119 patients admitted to PICU (aged 1 month to 12 years) were enrolled in the study. PIM2 scoring was done for all patients. The outcome was recorded as death or discharge. The associated factors for mortality were analyzed with SPSS 17. RESULTS: PIM2 score discriminated between death and survival at a 99.8 cut-off, with area under receiver operating characteristic curve 0.843 with 95% confidence interval (CI) (0.765, 0.903). Most patients were referred late to this hospital, which explains higher death rate (46.2%), lesser length of hospital stay (mean 2.98 days) in the mortality group, and increased rate of mechanical ventilation (68.1%). Presence of shock was independently associated with mortality, as evidenced by binary logistic regression. CONCLUSION: PIM2 score discriminated well between survivors and death at PICU. Presence of shock was significantly associated with mortality.

Prospective multi-centre sentinel surveillance for Haemophilus influenzae type b & other bacterial meningitis in Indian children.

BACKGROUND & OBJECTIVES: Haemophilus influenzae type b (Hib) is one of the leading bacterial causes of invasive disease in populations without access to Hib conjugate vaccines (Hib-CV). India has recently decided to introduce Hib-CV into the routine immunization programme in selected States. Longitudinal data quantifying the burden of bacterial meningitis and the proportion of disease caused by various bacteria are needed to track the impact of Hib-CV once introduced. A hospital-based sentinel surveillance network was established at four places in the country and this study reports the results of this ongoing surveillance. METHODS: Children aged 1 to 23 months with suspected bacterial meningitis were enrolled in Chennai, Lucknow, New Delhi, and Vellore between July 2008 and June 2010. All cerebrospinal fluid (CSF) samples were tested using cytological, biochemical, and culture methods. Samples with abnormal CSF (≥10 WBC per µl) were tested by latex agglutination test for common paediatric bacterial meningitis pathogens. RESULTS: A total of 708 patients with abnormal CSF were identified, 89 of whom had a bacterial pathogen confirmed. Hib accounted for the majority of bacteriologically confirmed cases, 62 (70%), while Streptococcus pneumoniae and group B Streptococcus were identified in 12 (13%) and seven (8%) cases, respectively. The other eight cases were a mix of other bacteria. The proportion of abnormal CSF and probable bacterial meningitis that was caused by Hib was 74 and 58 per cent lower at Christian Medical College (CMC), Vellore, which had a 41 per cent coverage of Hib-CV among all suspected meningitis cases, compared to the combined average proportion at the other three centres where a coverage between 1 and 8 per cent was seen (P<0.001 and P= 0.05, respectively). INTERPRETATION & CONCLUSIONS: Hib was found to be the predominant cause of bacterial meningitis in young children in diverse geographic locations in India. Possible indications of herd immunity was seen at CMC compared to sites with low immunization coverage with Hib-CV. As Hib is the most common pathogen in bacterial meningitis, Hib-CV would have a large impact on bacterial meningitis in Indian children.

Increased Utilization of Primary Health Care Centers for Birthing Care in Tamil Nadu, India: A Visible Impact of Policies, Initiatives, and Innovations.

BACKGROUND: Tamil Nadu has been showing an increasing trend in institutional deliveries since early 1990's and has now achieved near 100%. Among the institutional deliveries, a change was observed since 2006, wherein primary health centers (PHCs) showed a four-fold increase in deliveries, while other public and private health facilities showed a decline, despite equal access to all categories of health facilities. What led to this increased utilization of PHCs for birthing care? MATERIAL AND METHODS: Policies, documents, and published reports of the Government of Tamil Nadu (GoTN) were reviewed and interviews were conducted with the various stakeholders involved in providing birthing care in the PHCs. This study analyzes the impact of the policies and supply side initiatives and innovations which led to increase utilization of the PHCs for birthing care. RESULTS: Scaling up of 24 × 7 services in all PHCs, upgrading PHCs with good infrastructure, human resources, and women friendly services have helped to boost the image of the PHCs. Pro-women policies like maternity benefit schemes, birth companionship, providing food, and compulsory stay for 48 h following delivery have attracted women towards PHC. Innovative strategies like maternity picnics and use of expected date of delivery (EDD) chart for follow-up have made women choose PHCs, while periodic reviews and support to staff has improved service delivery. CONCLUSION: Women centered policies, efficient managerial systems, quality care, and innovative marketing of services have together contributed to increased utilization of PHCs for birthing. Other states could explore the possibility of replicating this model to make optimal use the PHC facilities.

Risk factors for mortality in community acquired pneumonia among children aged 1-59 months admitted in a referral hospital.

OBJECTIVE: To determine the case fatality rate and factors for death in community acquired pneumonia among children aged 1 month to 59 months admitted in a referral Hospital. DESIGN: Hospital based retrospective study. SETTING: Institute of Child Health and Hospital for Children, Chennai. PATIENTS: Case records of children aged 1 month to 59 months of age with pneumonia (clinically diagnosed pneumonia, radiologically diagnosed pneumonia, and clinically and radiologically diagnosed pneumonia), from January 2006 to December 2008. Outcome measures Case fatality rate (CFR) was calculated. Risk factors for mortality analyzed were young age of 1 to 6 months old, female sex, wheeze, respiratory rate >70/min, chest indrawing, altered level of consciousness, convulsions, shock, associated heart disease, recent measles, weight for age <-2 Z score and need for assisted ventilation. The association of risk factors to mortality was arrived at for all three categories of pneumonia cases separately. RESULTS: Case fatality rate was 8.2% (95% CI: 7.37- 8.99%). There was no significant difference in the CFR among the three study groups. Need for assisted ventilation alone was found to be an independent risk factor for mortality in children with pneumonia among all the study groups. Other risk factors like young age, weight for age <-2 Z score, altered level of consciousness, and congenital heart disease were also observed among these groups. CONCLUSION: Among 1 month to 59 months old hospitalized children with pneumonia, CFR was 8.2%. Need for assisted ventilation was a significant risk factor associated with mortality.

Lower airway anomalies in infants with laryngomalacia.

OBJECTIVE: To study the prevalence of associated airway anomalies in infants presenting with moderate to severe laryngomalacia. METHODS: Eighty three (83) symptomatic infants with recurrent respiratory symptoms including wheeze and cough diagnosed as moderate to severe laryngomalacia based on their clinical and direct laryngoscopic findings were subjected to fiberoptic bronchoscopy (FOB) during the period March 2007 to February 2009 in the Department of Pulmonology, Institute of Child Health and Hospital for Children, Chennai, India. Analysis of the clinical features, radiological findings and associated lower airway anomalies by FOB was done. RESULTS: Lower airway anomalies were demonstrated in 40 (48%) infants of the study population. Tracheomalacia was the most common lower airway anomaly 24 (29%) followed by bronchomalacia 8(10%) and tracheobronchomalacia 6 (7%). (4:1:1). CONCLUSION: Infants with moderate and severe laryngomalacia should be evaluated with flexible fibreoptic bronchoscopy to rule out associated lower airway lesions.

Fiberoptic bronchoscopy in unresolved atelectasis in infants.

This retrospective analysis documents the usefulness of fiberoptic bronchoscopy in finding the etiology of 56 cases of unresolved atelectasis in infancy, over a two year period (June 2005 to May 2007). Fiberoptic bronchoscopy identified the etiology leading to a revised diagnosis and change in management strategy in 38 (67.8%) cases, which included congenital airway anomalies (46.4%), inflammatory changes (10.7%), mucus plugs (28.5%), hypoplasia (4%), endobronchial granulation tissue (3.5%) and foreign body (3.5%). Fiberoptic bronchoscopy plays an important role in diagnostic work up of infants with unresolved atelectasis.

Antimicrobial prescription patterns for common acute infections in some rural & urban health facilities of India.

BACKGROUND & OBJECTIVES: Irrational use of antimicrobials is a key factor behind rapidly spreading antimicrobial resistance in microorganisms. This study was undertaken to determine the rate and pattern of antimicrobial prescribing in patients with uncomplicated acute respiratory infections, fever and diarrhoea attending a few rural and urban health settings. METHODS: The study was done in primary and secondary health care facilities of public/government and private settings at four sites in India. Patients with fever, cough, diarrhoea or ear, nose or throat infections of < 7 days were included. Pregnant women, lactating mothers, infants, seriously ill patients and patients with bloody diarrhoea or purulent nasal or ear discharge were excluded. RESULTS: Overall antimicrobial prescription rate was 69.4 per cent (95% CI 67.1, 71.7). Wide variation was observed (Thiruvananthapuram 47.6%, Lucknow 81.8%, Chennai 73.1% and Vellore 76.5%). Physicians practicing in rural and public/government settings prescribed antimicrobials more frequently than those in urban and private settings (83.8, 81.9, 68.3 and 68.2% respectively). Antimicrobials were more frequently prescribed for patients presenting with fever. Highest rate was noticed for children aged between 6 and 18 yr. Patients of the high-income group received antimicrobials more frequently (72.7%). In both public/ government and private settings, for patients who purchased medicines, the rate was higher (82.4 and 68.9% respectively), vs. those receiving free medicines (70.2 and 46.2% respectively). Two third of all antimicrobials prescribed were penicillins and co-trimoxazole, and > 40 per cent of prescriptions from private sector were quinolones and cephalosporins. INTERPRETATION & CONCLUSIONS: Our findings showed that prescription of antimicrobials for acute respiratory infections and diarrhoea was extremely common and warrants interventional strategies.

Does 3-day course of oral amoxycillin benefit children of non-severe pneumonia with wheeze: a multicentric randomised controlled trial.

BACKGROUND: WHO-defined pneumonias, treated with antibiotics, are responsible for a significant proportion of childhood morbidity and mortality in the developing countries. Since substantial proportion pneumonias have a viral etiology, where children are more likely to present with wheeze, there is a concern that currently antibiotics are being over-prescribed for it. Hence the current trial was conducted with the objective to show the therapeutic equivalence of two treatments (placebo and amoxycillin) for children presenting with non-severe pneumonia with wheeze, who have persistent fast breathing after nebulisation with salbutamol, and have normal chest radiograph. METHODOLOGY: This multi-centric, randomised placebo controlled double blind clinical trial intended to investigate equivalent efficacy of placebo and amoxicillin and was conducted in ambulatory care settings in eight government hospitals in India. Participants were children aged 2-59 months of age, who received either oral amoxycillin (31-54 mg/Kg/day, in three divided doses for three days) or placebo, and standard bronchodilator therapy. Primary outcome was clinical failure on or before day- 4. PRINCIPAL FINDINGS: We randomized 836 cases in placebo and 835 in amoxycillin group. Clinical failures occurred in 201 (24.0%) on placebo and 166 (19.9%) on amoxycillin (risk difference 4.2% in favour of antibiotic, 95% CI: 0.2 to 8.1). Adherence for both placebo and amoxycillin was >96% and 98.9% subjects were followed up on day- 4. Clinical failure was associated with (i) placebo treatment (adjusted OR = 1.28, 95% CI: 1.01 to1.62), (ii) excess respiratory rate of >10 breaths per minute (adjusted OR = 1.51, 95% CI: 1.19, 1.92), (iii) vomiting at enrolment (adjusted OR = 1.49, 95% CI: 1.13, 1.96), (iv) history of use of broncho-dilators (adjusted OR = 1.71, 95% CI: 1.30, 2.24) and (v) non-adherence (adjusted OR = 8.06, 95% CI: 4.36, 14.92). CONCLUSIONS: Treating children with non-severe pneumonia and wheeze with a placebo is not equivalent to treatment with oral amoxycillin. TRIAL REGISTRATION: ClinicalTrials.gov NCT00407394.

Factors affecting antibiotic prescribing pattern in pediatric practice.

To determine the proportion of children receiving antibiotics for common illnesses and to understand the antibiotic prescription ptern and factors influencing it, a cross sectional study was done among the private practitioners in Chennai, India 403 prescriptions by 40 physicians from selected health facilities were analyzed 79.9% of children with ARI (Acute respiratory infection) and ADD (Acute watery diarrhea) were prescribed antibiotics. Penicillins (43.9%) were the commonest antibiotic prescribed. Factors like postgraduate qualification, experience of physician, source and method of updating knowledge, inpatient practice setting and presence of fever influenced the antibiotic prescription.

Domestic violence and its mental health correlates in Indian women.

BACKGROUND: Domestic spousal violence against women has far-reaching mental health implications. AIMS: To determine the association of domestic spousal violence with poor mental health. METHOD: In a household survey of rural, urban non-slum and urban slum areas from seven sites in India, the population of women aged 15-49 years was sampled using probability proportionate to size. The Self Report Questionnaire was used to assess mental health status and a structured questionnaire elicited spousal experiences of violence. RESULTS: Of 9938 women surveyed, 40% reported poor mental health. Logistic regression showed that women reporting 'any violence' -- 'slap', 'hit', 'kick' or 'beat' (OR 2.2, 95% CI 2.0-2.5) -- or 'all violence' -- all of the four types of physically violent behaviour (OR 3.5, 95% CI 2.94-3.51) -- were at increased risk of poor mental health. CONCLUSIONS: Findings indicate a strong association between domestic spousal violence and poor mental health, and underscore the need for appropriate interventions.

Spousal physical violence against women during pregnancy.

OBJECTIVE: To determine the prevalence of physical violence during pregnancy and the factors associated with it. DESIGN: A population-based, multicentre, cross sectional household survey. SETTING: Rural, slum and urban non-slum areas of Bhopal, Chennai, Delhi, Lucknow, Nagpur, Trivandrum and Vellore, in India. PARTICIPANTS: A total of 9938 women who were 15 to 49 years of age and living with a child younger than 18 years old. METHODS: Probability proportionate to size sampling of households was performed in three strata. Trained field workers administered a structured questionnaire. Women who reported domestic violence were asked about violence during pregnancy. Outcome variables included six violent behaviours: slap, hit, kick, beat, use of weapon and harm in any other way. Moderate to severe violence was defined as experience of any one or more of the following behaviours: hit, beat or kick. Odds ratios were calculated for risk and protective factors of violence during pregnancy using logistic regression. MAIN OUTCOME MEASURES: Physical spousal violence. RESULTS: The lifetime experience, during pregnancy, of being slapped was 16%, hit 10%, beat 10%, kicked 9%, use of weapon 5% and harmed in any other way 6%. Eighteen percent of women experienced at least one of these behaviours and 3% experienced all six. The overall prevalence of moderate to severe violence during pregnancy was 13%. Logistic regression showed that the factors determining whether a woman experienced moderate to severe violence during pregnancy were: husband accusing wife of an affair (OR 7.1; 95% CI 5.1 to 9.8), dowry harassment (OR 4.1; 95% CI 2.8 to 6.1), husband having an affair (OR 3.7; 95% CI 2.8 to 4.8), husband being regularly drunk (OR 3.2; 95% CI 2.6 to 4.1), low education of husband (OR 2.8; 95% CI 1.4 to 5.6), substance abuse by husband (OR 2.6; 95% CI 1.3 to 5.5), no social support (OR 1.8; 95% CI 1.1 to 3.0), three or more children (OR 1.6; 95% CI 1.2 to 2.1) and household crowding (OR 1.1; 95% CI 1.0 to 1.2). CONCLUSION: In this study, 12.9% of women experienced moderate to severe physical violence during pregnancy. Suspicion of infidelity, dowry harassment, husband being regularly drunk and low education of husband were the main risk factors for violence during pregnancy.