Turning the Gaze from Survive to Thrive for Children in India: Learnings from Two Case Studies.

Despite significant efforts and progress made in newborn care programs in India, implementation gaps persist across the continuum of care. The present case studies of two districts in Himachal Pradesh revealed that pathways of care were often fragmented with inconsistent linkages between facility and community due to poor documentation, lack of tiered referral, health system weaknesses, low utilization of primary level institutions, and inadequate post-natal home visits by Accredited Social Health Activists (ASHAs). Involvement of healthcare providers (HCPs) and frontline health workers (FHWs) was low and uneven in generating awareness across the districts with limited participation in supporting care in the community. Ensuring functionality of health centers and first-level care facilities; strengthening referral systems; adequate/trained human resources; strengthening routine health management systems, discharge processes and community-based care with adequate integration with facilities are necessary in closing access gaps.

Barriers in reaching new-borns and infants through home visits: A qualitative study using nexus planning framework.

Background: Home visitation has emerged as an effective model to provide high-quality care during pregnancy, childbirth, and post-natal period and improve the health outcomes of mother- new born dyad. This 3600 assessment documented the constraints faced by the community health workers (known as the Accredited Social Health Activists, ASHAs) to accomplish home visitation and deliver quality services in a poor-performing district and co-created the strategies to overcome these using a nexus planning approach. Methods: The study was conducted in the Raisen district of Madhya Pradesh, India. The grounded theory approach was applied for data collection and analysis using in-depth interviews, and focus group discussions with stakeholders representing from health system (including the ASHAs) and the community (rural population). A key group of diverse stakeholders were convened to utilize the nexus planning five domain framework (social-cultural, educational, organizational, economic, and physical) to prioritize the challenges and co-create solutions for improving the home visitation program performance and quality. The nexus framework provides a systemic lens for evaluating the success of the ASHAs home visitation program. Results: The societal (caste and economic discrimination), and personal (domestic responsibilities and cultural constraints of working in the village milieu) issues emerged as the key constraints for completing home visits. The programmatic gaps in imparting technical knowledge and skills, mentoring system, communication abilities, and unsatisfactory remuneration system were the other barriers to the credibility of the services. The nexus planning framework emphasized that each of the above factors/domains is intertwined and affects or depends on each other for home-based maternal and newborn care services delivered with quality through the ASHAs. Conclusion: The home visitation program services, quality and impact can be enhanced by addressing the social-cultural, organizational, educational, economic, and physical nexus domains with concurrent efforts for skill and confidence enhancement of the ASHAs and their credibility.

Growth Faltering Among Discharged Babies from Inpatient Newborn Care Facilities: Learnings from Two Districts of Himachal Pradesh.

OBJECTIVE: To determine the burden of early growth faltering and understand the care practices for small and sick babies discharged from newborn units in the district. STUDY DESIGN: Observational and follow-up study. PARTICIPANTS: 512 babies discharged from two Special Newborn Care Units (SNCUs) and four Newborn Stabilization Units (NBSUs) in two districts of Himachal Pradesh. METHODS: Anthropometric assessments, interview of mothers and Accredited Social Health Activists (ASHAs) conducted between August, 2018 and March, 2019. Change in weight-for-age z-score (DWAZ) of <-0.67SD between birth and assessment was used to define growth faltering. OUTCOMES: Proportion of growth faltering (or catch-down growth) in small and sick babies discharged from SNCUs and NBSUs, and infant care practices. RESULTS: Growth faltering was observed in a significant proportion of both term (30%) and preterm (52.6%) babies between 1 to 4 months of age. Among babies with growth faltering (n=180), 73.9% received a home visit by ASHA, and only 36.7% received a follow-up visit at a facility. There were 71.3% mothers counselled at discharge (mostly informed about breast feeding). Most (96.7%) mothers did not perceive inadequate weight gain in their babies post-discharge. During home visits, ASHAs weighed 61.6% of the infants with growth faltering. Amongst infants who had growth faltering, only 49.6% of mothers had been provided information about their infant's growth and 57.1% mothers had received breastfeeding counselling. CONCLUSION: Small and sick newborn infants (both term and preterm babies) discharged from special care newborn units are at increased risk of early growth faltering. Follow-up care provided to these infants is inadequate. There is a need to strengthen both facility-based and home-based follow up of small and sick newborn infants discharged from newborn care facilities.

Barriers to the Delivery and Uptake of Water Sanitation and Hygiene (WASH) Promotion and Infant Diarrhea Prevention Services: A Case Study in Rural Tribal Banswara, Rajasthan.

OBJECTIVE: We aimed to identify key barriers to Water Sanitation and Hygiene (WASH) promotion and infant diarrhea prevention services delivered by Accredited Social Health Activists (ASHAs) in rural India. METHODS: A case-study was conducted across nine tribal villages in Banswara district (Rajasthan), where in-depth observational and qualitative data was collected from frontline health workers and infant caregivers. RESULTS: ASHAs' prioritization of their incentive-based link-worker tasks over their health activist roles, limited community mobilization, and lack of monitoring of such activities hindered the delivery of WASH promotion and infant diarrhea prevention services. Caregivers' lack of trust in ASHA's health knowledge and preference for private providers and traditional healers also hindered the uptake of ASHA's health promotion services. CONCLUSIONS: Strengthening ASHAs' health activism roles and building trust on frontline health workers' knowledge among tribal communities will be the key to address the determinants of child malnutrition and stunting and accelerate progress towards the national development agenda.

Community engagement: The key to tackling Antimicrobial Resistance (AMR) across a One Health context?

Antimicrobial resistance (AMR) is a One Health problem underpinned by complex drivers and behaviours. This is particularly so in low - and middle-income countries (LMICs), where social and systemic factors fuel (mis)use and drive AMR. Behavioural change around antimicrobial use could safeguard both existing and future treatments. However, changing behaviour necessitates engaging with people to understand their experiences. This publication describes a knowledge-exchange cluster of six LMIC-based projects who co-designed and answered a series of research questions around the usage of Community Engagement (CE) within AMR. Findings suggest that CE can facilitate AMR behaviour change, specifically in LMICs, because it is a contextualised approach which supports communities to develop locally meaningful solutions. However, current CE interventions focus on human aspects, and demand-side drivers, of AMR. Our cluster suggests that broader attention should be paid to AMR as a One Health issue. The popularity of mixed methods approaches within existing CE for AMR interventions suggests there is interdisciplinary interest in the uptake of CE. Unfortunately, the specificity and context-dependency of CE can make it difficult to evaluate and scale. Nevertheless, we suggest that in synthesising learnings from CE, we can develop a collective understanding of its scope to tackle AMR across contexts.   .

COVID-19 vaccination and the power of rumors: Why we must "Tune in".

Rumors have significantly affected immunization campaigns in the past. The ongoing COVID-19 vaccination program in India needs to frame public communication messages both to promote vaccine demand and update as well as counter COVID-related rumors. COVID-related rumors have had wide-ranging effects in the country, from stigmatization of health workers to a crash of prices in the poultry sector. Appropriate communication strategies are critical for tracking, negotiating, and shaping perceptions around the vaccines and the program. Issues that will shape perceptions around the vaccines include product development, prioritization strategies, program rollout activities, and adverse effects following immunization and adverse effects of special interest.

Adopting an intersectoral One Health approach in India: Time for One Health Committees.

Following the several episodes of zoonotic disease outbreaks and the more recent COVID-19 pandemic, the Indian policy initiatives are committed to institutionalize One Health (OH) approaches and promote intersectoral, transdisciplinary collaboration and cooperation. The OH principle needs to be visualized beyond the scope of zoonoses. While conservation, ecological and veterinary professions are getting increasingly engaged with OH, most of the medical/clinical and social sciences professions are only peripherally aware of its nuances. The OH initiatives, by their essentially multidisciplinary nature, entail working across ministries and navigating tacit institutional hierarchies and allocating leadership roles. The logical operational step will be the constitution of One Health Committees (OHC) at the State and district levels. Here, we outline the key foundational principles of OHC and hope that the framework for implementation shall be deliberated through wider consultations and piloted and adopted in a phased manner.

Flies Without Borders: Lessons from Chennai on improving India's municipal public health services.

India's cities face key challenges to improving public health outcomes. First, unequally distributed public resources create insanitary conditions, especially in slums - threatening everyone's health, as suggested by poor child growth even amongst the wealthiest. Second, devolving services to elected bodies works poorly for highly technical services like public health. Third, services are highly fragmented. This paper examines the differences in the organisation and management of municipal services in Chennai and Delhi, two cities with sharply contrasting health indicators. Chennai mitigates these challenges by retaining professional management of service delivery and actively serving vulnerable populations - while services in Delhi are quite constrained. Management and institutional issues have received inadequate attention in the public health literature on developing countries, and the policy lessons from Chennai have wide relevance.

An Uphill Task for POSHAN Abhiyan: Examining the Missing Link of 'Convergence'.

The Participatory Approach for Nutrition in Children: Strengthening Health, Education, Engineering and Environment Linkages (PANChSHEEEL) project is a collaboration between University College London, Save the Children India, Jawaharlal Nehru University and Indian Institute of Technology Delhi to develop a socio-culturally appropriate, tailored, integrated and interdisciplinary intervention in rural India and test its acceptability for delivery through Anganwadi Centre (AWCs) and schools. Recognizing the socio-ecological determinants of under-nutrition, the POSHAN Abhiyan (POSHAN Mission) adopts a multi-sectoral approach to achieve five goals, of which two are directly related to children. The POSHAN Abhiyan resonates with the conceptual framework of the PANChSHEEEL study in its interdisciplinary scope and focus on local linka ges. This paper draws upon empirical evidence from the PANChSHEEEL Project in Banswara (one of the POSHAN mission districts), Rajasthan to help understand linkages between policy and practice, specifically the challenges of operationalizing 'convergence', the core strategy of the Abhiyan.

A Landscape Analysis of Human Milk Banks in India.

OBJECTIVES: To evaluate the existing status of human milk banks in India with reference to infrastructure, human resources, funding mechanisms, operating procedures and quality assurance. METHODS: A pretested questionnaire was administered to 16 out of 22 human milk banks across India, operational for more than one year prior to commencing the study. RESULTS: 11 (69%) milk banks were in government or charitable hospitals; only 2 (12.5%) were established with government funding. 8 (50%) had a dedicated technician and only 1(6%) had more than five lactation counsellors. Milk was collected predominantly from mothers of sick babies and in postnatal care wards followed by pediatric outpatient departments, camps, satellite centers, and homes. 10 (63%) reported gaps between donor milk demand and supply. 12 (75%) used shaker water bath pasteurizer and cooled the milk manually without monitoring temperature, and 4 (25%) pooled milk under the laminar airflow. 10 (63%) tracked donor to recipient and almost all did not collect data on early initiation, exclusive breastfeeding or human milk feeding. CONCLUSIONS: Our study reports the gaps of milk banking practices in India, which need to be addressed for strengthening them. Gaps include suboptimal financial support from the government, shortage of key human resources, processes and data gaps, and demand supply gap of donor human milk.

Successful switch (tOPV to bOPV) in India: Tribute to a resilient health system.

In accordance with the end game strategies for polio eradication a synchronized switch plan from tOPV to bOPV was implemented globally in 2016. The National Committee for Polio Eradication (NCCPE) validated the switch activities in India. An expert group of 104 academics conducted field visits in 25 states and 2 Union territories for independent verification (after an initial round of verification by the National Polio Surveillance Project [NPSP]). The objectives were to validate withdrawal and disposal of tOPV by screening cold chain points in public and private sector health facilities in both rural and urban areas; additionally, availability of bOPV and IPV was also documented. 34 filled tOPV and 5 empty vials were detected inside cold chain equipment and 17 outside. The disposal mechanism was found to be reasonably adequate. The key strategies -- 'throttling' of vaccine supplies well ahead of the switch date while preventing stock outs at various immunization points, simultaneously working with the regulators to delicense the tOPV on the switch date and helping manufacturers to calibrate vaccine production according to national timelines, and strong and persistent advocacy with professional associations to align with national bOPV and IPV policy facilitated successful accomplishment of the switch process. Effective implementation of the switch strategy in India also bears testimony to the resilience of the health system operating under diverse and heterogeneous governance.

A Qualitative Analysis of the Barriers and Facilitators for Breastfeeding and Kangaroo Mother Care Among Service Providers, Mothers and Influencers of Neonates Admitted in Two Urban Hospitals in India.

BACKGROUND: Known interventions like breastfeeding and kangaroo mother care (KMC) can avert a large share of infant deaths. Mother Baby Friendly Initiative Plus (MBFI+) is an integrated approach to ensure exclusive human milk diet through promotion of breastfeeding, KMC, and provision of donor human milk (DHM) to vulnerable neonates lacking mothers' own milk. MATERIALS AND METHODS: Qualitative research was conducted among 56 service recipients including mothers and key influencers and 9 service providers to understand their knowledge, perceptions, and practices on breastfeeding, KMC, DHM, and human milk banks (HMBs) in 2 facilities in India, one with and another without an operational HMB. This article presents the findings on breastfeeding and KMC. RESULTS: Nearly all mothers mentioned that antenatal visits lacked information on breastfeeding. Most were unaware of the recommended duration of exclusive breastfeeding. Most parents knew about the benefits of breast milk and colostrum. Limited staff and privacy in facilities resulted in inadequate breastfeeding and milk expression support to mothers, who found feeding of preterm and low-birth-weight babies challenging. Mothers shared challenges in breastfeeding at home, such as low family support and privacy and burden of household chores. Only those mothers who practiced KMC were aware of its benefits. Few service providers and recipients were comfortable with the practice of wet nursing in the absence of breastfeeding. CONCLUSIONS: MBFI+ is a promising approach to strengthen breastfeeding and KMC. Quality counseling on breastfeeding and milk expression from antenatal period, increasing awareness and training on KMC for mothers, improving infrastructure, addressing staff shortage, and building capacities of hospital staff on MBFI+ are needed.

Malnutrition in Chakradharpur, Jharkhand: an anthropological study of perceptions and care practices from India.

BACKGROUND: This study aims to investigate the knowledge, perception and practices related to health, nutrition, care practices, and their effect on nutrition health-seeking behaviour. METHODS: In order to have maximum representation, we divided Chakradharpur block in Jharkhand state into three zones (north, south and centre regions) and purposively selected 2 Ambulatory Therapeutic Feeding Centre (ATFC) clusters from each zone, along with 2 villages per ATFC (12 villages from 6 ATFCs in total). In-depth interviews and natural group discussions were conducted with mothers/caregivers, frontline health workers (FHWs), Medicins Sans Frontieres (MSF) staff, community representatives, and social leaders from selected villages. RESULTS: We found that the community demonstrates a strong dependence on traditional and cultural practices for health care and nutrition for newborns, infants and young children. Furthermore, the community relies on alternative systems of medicine for treatment of childhood illnesses such as malnutrition. The study indicated that there was limited access to and utilization of local health services by the community. Lack of adequate social safety nets, limited livelihood opportunities, inadequate child care support and care, and seasonal male migration leave mothers and caregivers vulnerable and limit proper child care and feeding practices. With respect to continuum of care, services linking care across households to facilities are fragmented. Limited knowledge of child nutrition amongst mothers and caregivers as well as fragmented service provision contribute to the limited utilization of local health services. Government FHWs and MSF field staff do not have a robust understanding of screening methods, referral pathways, and counselling. Additionally, collaboration between MSF and FHWs regarding cases treated at the ATFC is lacking, disrupting the follow up process with discharged cases in the community. CONCLUSIONS: For caregivers, there is a need to focus on capacity building in the area of child nutrition and health care provision post-discharge. It is also recommended that children identified as having moderate acute malnutrition be supported to prevent them from slipping into severe acute malnutrition, even if they do not qualify for admission at ATFCs. Community education and engagement are critical components of a successful CMAM program.

Understanding Barriers and Facilitators for Human Milk Banking Among Service Providers, Mothers, and Influencers of Preterm and Sick Neonates Admitted at Two Health Facilities in a Metropolitan City in India.

BACKGROUND: Scaling-up human milk banks (HMBs) is a promising solution for saving vulnerable newborns. Exploring perceptions and practices on donor human milk (DHM) and HMBs is essential to strengthen and scale-up an integrated HMB system resting on a model called the "Mother Baby Friendly Initiative Plus" (MBFI+), which includes promoting breastfeeding, encouraging kangaroo mother care, and providing safe DHM to vulnerable babies without access to mother's own milk. MATERIALS AND METHODS: A qualitative research was conducted among 56 service recipients including mothers and key influencers and 9 service providers to understand their perceptions and practices on DHM and HMBs. RESULTS: Service providers opined that DHM is safe and lifesaving for vulnerable babies. Challenges shared were limited supply of DHM because of low awareness on milk donation, shortage of trained staff, and risk of milk contamination. They stated that although most mothers were comfortable in donating milk, few were reluctant to donate milk as they feared shortage of milk for their own babies, or milk expression may cause weakness. Recipient mothers accepted use of DHM as per facility norms but had concerns about donor mothers' health and hygiene and measures for ensuring milk safety. Most grandmothers were resistant toward donating or receiving DHM for their grandchildren. Many fathers were comfortable with donating once they knew it is lifesaving and did not compromise supply for their babies. Service providers shared opportunities for scale-up, like improving awareness and infrastructure, lactation counseling by skilled personnel, supportive hospital environment, and establishing HMBs in every city and district. CONCLUSIONS: Human milk banking should be strengthened as part of the MBFI+ model. For this, behavior change communication targeted at mothers and influencers about breastfeeding and HMB from the antenatal period, capacity-building among service providers, and government ownership is necessary.

Establishing a Demographic, Development and Environmental Geospatial Surveillance Platform in India: Planning and Implementation.

BACKGROUND: Inadequate administrative health data, suboptimal public health infrastructure, rapid and unplanned urbanization, environmental degradation, and poor penetration of information technology make the tracking of health and well-being of populations and their social determinants in the developing countries challenging. Technology-integrated comprehensive surveillance platforms have the potential to overcome these gaps. OBJECTIVE: This paper provides methodological insights into establishing a geographic information system (GIS)-integrated, comprehensive surveillance platform in rural North India, a resource-constrained setting. METHODS: The International Clinical Epidemiology Network Trust International established a comprehensive SOMAARTH Demographic, Development, and Environmental Surveillance Site (DDESS) in rural Palwal, a district in Haryana, North India. The surveillance platform evolved by adopting four major steps: (1) site preparation, (2) data construction, (3) data quality assurance, and (4) data update and maintenance system. Arc GIS 10.3 and QGIS 2.14 software were employed for geospatial data construction. Surveillance data architecture was built upon the geospatial land parcel datasets. Dedicated software (SOMAARTH-1) was developed for handling high volume of longitudinal datasets. The built infrastructure data pertaining to land use, water bodies, roads, railways, community trails, landmarks, water, sanitation and food environment, weather and air quality, and demographic characteristics were constructed in a relational manner. RESULTS: The comprehensive surveillance platform encompassed a population of 0.2 million individuals residing in 51 villages over a land mass of 251.7 sq km having 32,662 households and 19,260 nonresidential features (cattle shed, shops, health, education, banking, religious institutions, etc). All land parcels were assigned georeferenced location identification numbers to enable space and time monitoring. Subdivision of villages into sectors helped identify socially homogenous community clusters (418/676, 61.8%, sectors). Water and hygiene parameters of the whole area were mapped on the GIS platform and quantified. Risk of physical exposure to harmful environment (poor water and sanitation indicators) was significantly associated with the caste of individual household (P=.001), and the path was mediated through the socioeconomic status and density of waste spots (liquid and solid) of the sector in which these households were located. Ground-truthing for ascertaining the land parcel level accuracies, community involvement in mapping exercise, and identification of small habitations not recorded in the administrative data were key learnings. CONCLUSIONS: The SOMAARTH DDESS experience allowed us to document and explore dynamic relationships, associations, and pathways across multiple levels of the system (ie, individual, household, neighborhood, and village) through a geospatial interface. This could be used for characterization and monitoring of a wide range of proximal and distal determinants of health.