Evaluating Maternal Health Services Within the Reproductive, Maternal, Newborn, Child Health and Adolescents (RMNCH+A) Framework Amidst the COVID-19 Pandemic in Rural India: A Comprehensive Mixed-Methods Analysis.

Background Around half of the pregnant women in India do not receive full antenatal care. During the year 2020, routine health services were further affected by COVID-19. This study was conducted to assess the effect of the pandemic on the delivery/utilization of reproductive, maternal, newborn, child health, and adolescent (RMNCH+A) services. Methodology The study, conducted in Wardha district, Maharashtra, from July to December 2020, aimed to assess maternal health. In Wardha block, 200 pregnant and postnatal women were surveyed using a multistage sampling approach. Adequate knowledge was gauged through Mother and Child Protection Card comprehension. Health system data for April to December 2020 was compared with 2019 district-wide. In-depth interviews were conducted with beneficiaries, including pregnant and post-natal women and healthcare workers. The qualitative inquiries involved medical officers, supervisory staff, community health officers, an auxiliary nurse and midwife (ANMs), Taluka Health Officers, and focus group discussions with accredited social health activists (ASHA), Anganwadi workers (AWW), and Village Health Nutrition and Sanitation Committee members. Results Essential services were delivered to both antenatal and postpartum women, though family planning services and health education were the worst affected. Among the survey respondents, 75% of the post-partum women were not using any contraceptives. District-wide coverage of post-abortion/MTP contraception fell by around 90% as compared to the previous year. The most common difficulties faced by the respondents in availing of the services were related to finances and arranging transport to visit health facilities. Conclusion Learning from the current pandemic for system strengthening, adequate manpower, and planning to prevent disruption of essential services and promoting e-health and m-health initiatives may prevent such catastrophic events in the future from affecting the delivery of routine services.

Magnitude and determinants of psychological morbidities among pregnant women: Results from a pregnancy cohort in rural Central India.

Background: Psychological morbidities are one of the emerging global health problems. It affects a considerable number of ante-natal women leading to consequences during the postnatal period as well. We conducted this research to study the magnitude and determinants of psychological morbidities during pregnancy. Methods: In this study, we included 650 pregnant women from an established cohort of 2500 pregnant women and assessed the psychological morbidities among them using the GMHAT/PC tool. Results: The overall prevalence of psychological morbidities during pregnancy was 14.6%, with anxiety and depression being the leading ones. Low education levels, lower socio-economic status, unintended pregnancy, complicated previous pregnancy, lack of family and social support, and domestic violence increased the odds of psychological morbidity. On Multivariate logistic regression, Low education levels increased the odds to more than twice [illiterate/primary schooling OR: 4.00, p = 0.026; secondary schooling OR: 2.64, p = 0.034; high school OR: 2.60, p = 0.033] unintended pregnancy [OR: 1.91, p = 0.043] and lack of family support [OR: 7.19, p < 0.001] increased the odds of psychological morbidity among pregnant women. Conclusion: Bringing these issues to the mainstream and addressing them by developing interventions to address them during the lifecycle of a female will help to prevent episodes of psychological stress and morbidity among pregnant females.

Vitalizing Community for Health Promotion Against Modifiable Risk Factors of Noncommunicable Diseases (V-CaN) in Rural Central India: Protocol for a Hybrid Type II Implementation Effectiveness Trial.

BACKGROUND: Low- and middle-income countries are facing the emerging burden of chronic noncommunicable diseases (NCDs). Apart from loss of human lives and premature deaths, NCDs result in huge costs for treatment to individuals and the health system. Although NCDs develop in later life, the risk factors begin at an early age. The key to the control of the global epidemic of NCDs is primary prevention based on comprehensive community-based programs. OBJECTIVE: This study aims to develop, implement, and evaluate the effect of a participatory health promotion initiative utilizing the existing mechanisms of Village Health Nutrition and Sanitation Committees (VHNSCs), women's self-help groups (SHGs), and schools on modifiable risk factors for NCDs among young people aged 10-30 years. METHODS: The proposed type II hybrid effectiveness implementation cluster randomized field trial will be conducted in the catchment area of 4 primary health centers (PHCs) in Wardha district, India, comprising 100 villages with a population of 144,000. Each PHC will be randomly allocated to one of the 3 intervention arms or the control arm. The 3-intervention arm PHCs will utilize a unique strategy with either VHNSC or SHG members or school students as change agents for health action against common modifiable NCD risk factors. This study will be implemented in 3 phases from January 2022 to December 2024. First, the preparatory phase for baseline assessments includes anthropometry, behavioral and biochemical risk factors for NCDs, and participatory development of the health promotion intervention modules. Second, the implementation phase will focus on capacity building of the change agents and implementation of the participatory health promotion initiative. The implementation will include organization of community-based events, 6-monthly participatory assessment of change, and preparation of a sustainability and exit plan toward the end of this phase. Third, the evaluation phase will consist of studying the effectiveness of each intervention strategy in the reduction of risk factor prevalence at the population level. RESULTS: We will assess 12,000 (3000 in each arm) randomly selected individuals for behavioral risk factors and 1600 (400 in each arm) individuals for biochemical risk factors during baseline as well as endline assessments. Difference in differences, ANOVA or multivariate analysis of covariance, and regression analysis will be performed to assess the effectiveness of the interventions. Qualitative methods such as focus group discussions and stories of change will be documented and analyzed using thematic framework analysis. The implementation outcomes will be reported using the PRISM (Practical Robust Implementation and Sustainability Model) RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. The results are expected to be published by mid-2025. CONCLUSIONS: This study will show the magnitude of risk factors for NCDs, its determinants, feasibility, effectiveness of community-based interventions, and health promotion models for NCD prevention. TRIAL REGISTRATION: Clinical Trials Registration India CTRI/2020/10/028700; https://ctri.nic.in/Clinicaltrials/showallp.php?mid1=47597&EncHid=&userName=V-CaN. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42450.

Safety, tolerability and immunogenicity of Biological E's CORBEVAX™ vaccine in children and adolescents: A prospective, randomised, double-blind, placebo controlled, phase-2/3 study.

BACKGROUND: After establishing safety and immunogenicity of Biological-E's CORBEVAX™ vaccine in adult population (18-80 years) in Phase 1-3 studies, vaccine is further tested in children and adolescents in this study. METHODS: This is a phase-2/3 prospective, randomised, double-blind, placebo-controlled study evaluating safety, reactogenicity, tolerability and immunogenicity of CORBEVAX™ vaccine in children and adolescents of either gender between <18 to ≥12 years of age in Phase-2 and <18 to ≥5 years of age in Phase-Phase-2/Phase-3 with placebo as a control. This study has two age sub-groups; subgroup-1 with subjects <18 to ≥12 years of age and subgroup-2 with subjects <12 to ≥5 years of age. In both sub groups, eligible subjects (SARS-CoV-2 RT-PCR negative and seronegative at baseline) were randomized to receive either CORBEVAX™ vaccine or Placebo in 3:1 ratio. FINDINGS: The safety profile of CORBEVAX™ vaccine in both pediatric cohorts was comparable to the placebo-control group. Majority of reported adverse events (AEs) were mild in nature. No severe or serious-AEs, medically attended AEs (MAAEs) or AEs of special interest (AESI) were reported during the study period and all reported AEs resolved without any sequelae. In both pediatric age groups, CORBEVAX™ vaccinated subjects showed significant improvement in humoral immune-responses in terms of anti-RBD-IgG concentrations, anti-RBD-IgG1 titers, neutralizing-antibody (nAb)-titers against Ancestral-Wuhan and Delta-strains. Significantly high interferon-gamma immune- response (cellular) was elicited by CORBEVAX™ vaccinated subjects with minimal effect on IL-4 cytokine secretion. INTERPRETATIONS: The safety profile of CORBEVAX™ vaccine in <18 to ≥5 years' children and adolescents was found to be safe and tolerable. Significant increase in anti-RBD-IgG and nAb-titers and IFN-gamma immune-responses were observed post-vaccination in both pediatric age sub-groups. The nAb titers observed in both the pediatric age cohorts were non-inferior to the adult cohort (BECT069 study) in terms of ratio of the GMT's of both the cohorts. This study shows that CORBEVAX™ vaccine is highly immunogenic and can be safely administered to pediatric population as young as 5 years old. The study was prospectively registered with clinical trial registry of India- CTRI/2021/10/037066.

Development of a framework of intervention strategies for point of care quality improvement at different levels of healthcare delivery system in India: initial lessons.

BACKGROUND: Inadequate quality of care has been identified as one of the most significant challenges to achieving universal health coverage in low-income and middle-income countries. To address this WHO-SEARO, the point of care quality improvement (POCQI) method has been developed. This paper describes developing a dynamic framework for the implementation of POCQI across India from 2015 to 2020. METHODS: A total of 10 intervention strategies were designed as per the needs of the local health settings. These strategies were implemented across 10 states of India, using a modification of the 'translating research in practice' framework. Healthcare professionals and administrators were trained in POCQI using a combination of onsite and online training methods followed by coaching and mentoring support. The implementation strategy changed to a fully digital community of practice platform during the active phase of the COVID-19 pandemic. Dashboard process, outcome indicators and crude cost of implementation were collected and analysed across the implementation sites. RESULTS: Three implementation frameworks were evolved over the study period. The combined population benefitting from these interventions was 103 million. A pool of QI teams from 131 facilities successfully undertook 165 QI projects supported by a pool of 240 mentors over the study period. A total of 21 QI resources and 6 publications in peer-reviewed journals were also developed. The average cost of implementing POCQI initiatives for a target population of one million was US$ 3219. A total of 100 online activities were conducted over 6 months by the digital community of practice. The framework has recently extended digitally across the South-East Asian region. CONCLUSION: The development of an implementation framework for POCQI is an essential requirement for the initiative's successful country-wide scale. The implementation plan should be flexible to the healthcare system's needs, target population and the implementing agency's capacity and amenable to multiple iterative changes.

Operational Barriers in Providing Comprehensive Emergency Obstetric Care by Task Shifting of Medical Officers in Selected States of India.

BACKGROUND: A network of first referral unit (FRU) is set up to improve the availability and accessibility of comprehensive emergency obstetric care (CEmOC) services. To fill the gap of the scarcity of obstetricians and anesthetists at FRU, two short-term trainings in CEmOC and anesthesia were started for in-service medical officers. OBJECTIVE: This study aimed to assess the operational status of FRU in providing CEmOC services by task shifting of trained medical officers in selected states of India. MATERIALS AND METHODS: The study was done in seven states of India. A team of experts assessed conveniently selected health facilities designated as FRU by using a semi-structured, predesigned, and pretested checklist for CEmOC functionality status. A total of 50 designated FRUs were assessed and data were systematically analyzed. RESULTS: We documented the availability of five key elements for the operationalization of CEmOC services at FRU. Out of 50 facilities, 9 (18%) reported conducting operative delivery and 11 (22%) of the facilities were fully operational with all elements available. At 9 (18%) facilities, one element and, at 17 (34%) facilities, two elements were missing. The blood storage unit was the most important missing element (68%) followed by operative facilities (36%). The challenges of FRUs remained uniform across states. Barriers identified to operationalize FRU were the availability of trained doctors in cesarean section and anesthesia together, lack of operative facilities, and blood storage units. CONCLUSIONS: To operationalize the network of FRU for CEmOC services by task shifting of medical officer, it is important to ensure the availability of all five key elements together at all facilities.

Evaluating the efficacy of a multistrain probiotic supplementation for prevention of neonatal sepsis in 0-2-month-old low birth weight infants in India-the "ProSPoNS" Study protocol for a phase III, multicentric, randomized, double-blind, placebo-controlled trial.

BACKGROUND: Progress has been made in the reduction of under-five mortality in India; however, neonatal mortality is reducing at a slower rate. Efforts are required to bring down neonatal mortality in order to attain the Sustainable Development Goal-3. Prevention of sepsis among the high-risk, vulnerable low birth weight neonates by a newer intervention with probiotic supplementation is promising. METHODS: A phase III, multicenter, randomized, double-blind, placebo-controlled study is being conducted at six sites in India. A total of 6144 healthy low birth weight (LBW) infants fulfilling the eligibility criteria would be enrolled within the first week of life, after obtaining written informed consent from the parents of the infant. Randomization in 1:1 ratio, stratified by site, sex, and birth weight, would be done through an interactive web response system (IWRS) using a standard web browser and email service. Vivomixx®, a probiotic containing a mix of 8 strains of bacteria, in a suspension form standardized to deliver 10 billion CFU/ml, or an organoleptically similar placebo would be fed to enrolled infants in a 1-ml/day dose for 30 days. The follow-up of enrolled infants for 60 days would take place as per a pre-specified schedule for recording morbidities and outcome assessments at the six participating sites. Screening for morbidities would be conducted by trained field workers in the community, and sick infants would be referred to designated clinics/hospitals. A physician would examine the referred infants presenting with complaints and clinical signs, and blood samples would be collected from sick infants for diagnosis of neonatal sepsis by performing sepsis screen and blood culture. Appropriate treatment would be provided as per hospital protocol. The study would be implemented as per the MRC guideline for the management of Global Health Trials in accordance with ICH-GCP and Indian Regulatory guidelines. A contract research organization would be engaged for comprehensive monitoring and quality assurance. The final analysis would be conducted in a blinded manner as per the statistical analysis plan (SAP) to estimate the primary outcomes of sepsis, possible serious bacterial infection (PSBI), and secondary outcomes. The codes will be broken after DMC permission. The protocol has been reviewed by the Research Ethics Committee of the Liverpool School of Tropical Medicine (REC-LSTM), from Research Ethics Committees of the six subject recruitment participating sites. DISCUSSION: This adequately powered and well-designed trial would conclusively answer the question whether probiotics can prevent neonatal sepsis in the high-risk group of low birth weight infants as indicated by a pilot study in 1340 LBW infants, evidence from systematic reviews of hospital-based studies, and a primary study on healthy newborns in Orissa. Results of the study would be generalizable to India and other low-middle-income countries. TRIAL REGISTRATION: Clinical Trial Registry of India (CTRI) CTRI/2019/05/019197 . Registered on 16 May 2019.

Effect of home-based newborn care on neonatal and infant mortality: a cluster randomised trial in India.

BACKGROUND: Home-based newborn care has been found to reduce neonatal mortality in rural areas. Study evaluated effectiveness of home-based care delivered by specially recruited newborn care workers- Shishu Rakshak (SR) and existing workers- anganwadi workers (AWW) in reducing neonatal and infant mortality rates. METHODS: This three-arm, community-based, cluster randomised trial was conducted in five districts in India. Intervention package consisted of pregnancy surveillance, health education, care at birth, care of normal/low birthweight neonates, identification and treatment of sick neonates and young infants using oral and injectable antibiotics and community mobilisation. The package was similar in both intervention arms-SR and AWW; difference being healthcare provider. The control arm received routine health services from the existing health system. Primary outcomes were neonatal and young infant mortality rates at 'endline' period (2008-2009) assessed by an independent team from January to April 2010 in the study clusters. FINDINGS: A total of 6623, 6852 and 5898 births occurred in the SR, AWW and control arms, respectively, during the endline period; the proportion of facility births were 69.0%, 64.4% and 70.6% in the three arms. Baseline mortality rates were comparable in three arms. During the endline period, the risk of neonatal mortality was 25% lower in the SR arm (adjusted OR 0.75, 95% CI 0.57 to 0.99); the risks of early neonatal mortality, young infant mortality and infant mortality were also lower by 32%, 27%, and 33%, respectively. The risks of neonatal, early neonatal, young infant, infant mortality in the AWW arm were not different from that of the control arm. INTERPRETATION: Home-based care is effective in reducing neonatal and infant mortality rates, when delivered by a dedicated worker, even in settings with high rates of facility births. TRIAL REGISTRATION NUMBER: The study was registered with Clinical Trial Registry of India (CTRI/2011/12/002181).

Development of a hub and spoke model for quality improvement in rural and urban healthcare settings in India: a pilot study.

OBJECTIVE: Hub and spoke model has been used across industries to augment peripheral services by centralising key resources. This exercise evaluated the feasibility of whether such a model can be developed and implemented for quality improvement across rural and urban settings in India with support from a network for quality improvement. METHODS: This model was implemented using support from the state and district administration. Medical colleges were designated as hubs and the secondary and primary care facilities as spokes. Training in quality improvement (QI) was done using WHO's point of care quality improvement methodology. Identified personnel from hubs were also trained as mentors. Both network mentors (from QI network) and hub-mentors (from medical colleges) undertook mentoring visits to their allotted facilities. Each of the participating facility completed their QI projects with support from mentors. RESULTS: Two QI training workshops and two experience sharing sessions were conducted for implementing the model. A total of 34 mentoring visits were undertaken by network mentors instead of planned 14 visits and rural hub-mentors could undertake only four visits against planned 18 visits. Ten QI projects were successfully completed by teams, 80% of these projects started during the initial intensive phase of mentoring. The projects ranged from 3 to 10 months with median duration being 5 months. DISCUSSION: Various components of a health system must work in synergy to sustain improvements in quality of care. Quality networks and collaboratives can play a significant role in creating this synergy. Active participation of district and state administration is a critical factor to produce a culture of quality in the health system.

Qualitative Assessment of Life Skill Development of Adolescent Girls through Kishori Panchayat: An Adolescents for Health Action Model in Selected Villages of Rural Central India.

BACKGROUND: The "Adolescents for Health Action model," Kishori Panchayat (KP) is an innovative approach for mobilizing and empowering adolescent girls by enhancing their life skills by participating in various community health activities, a platform for interaction with peer-groups, villagers, community leaders, and health-care providers. AIM: The aim of the study is to follow-up the quantitative data regarding the effectiveness of KP in enhancing life skill education among adolescent girls who are members of KP compared to Non-KP girls. OBJECTIVES: The main objectives are: (1) to study the knowledge and perceptions regarding life skills among adolescent girls (12-18 years) of KP and non-KP and (2) to identify features of KP and related contextual factors that contributed to the outcome. METHODOLOGY: The qualitative study was carried out among 100 KP girls and non-KP girls, respectively (12-18 years), under 20 villages of rural Wardha district over 1-year period after obtaining consent in writing from participants and Institutional Ethics Committee. Focus group discussion was conducted in each village. Key informant interviews of social workers of KPs and school teachers conducted until data saturation. RESULTS: Findings suggest that KP girls had more knowledge and perception regarding life skills and their application compared to non-KP girls. Life skill education program by KP was found to be received positively by adolescent girls. CONCLUSION: Institutionalization of this can help in building a sustainable model for empowerment of adolescent girls.

Assessment of Functioning of Village Health Nutrition and Sanitation Committees in a District in Maharashtra.

BACKGROUND: Community participation is one of the core principles of primary healthcare. The village health nutrition and sanitation committee (VHNSC), one of the elements in implementation of the National Health Mission (NHM), is an example of community participation. There are not many studies conducted to assess the actual participation of VHNSC in health-care delivery at the village level. OBJECTIVE: The objective of the study is to develop a VHNSC Maturity Index (VMI) and pilot it to assess the institutional maturity of VHNSC. MATERIALS AND METHODS: This community-based, cross-sectional study was conducted in 83 villages under four Primary Health Centres (PHCs) of the Wardha Community Development block. VMI was developed, Through several discussion sessions with VHNSC members and staff of the DCM; observations of VHND; attending VHNSC monthly meetings; the VMI was finalized after piloting it in all the four PHC areas. RESULTS: All the 83 VHNSCs were constituted as per norms led down under NHM. Forty-eight (57.8%) VHNSCs had developed an annual Village Health Action Plan, 72 (86.7%) VHNSCs had ≥4 meetings held in the past 6 months, and ≥70% attendance in the past 6 months was observed in 40 (48.2%) VHNSCs. A majority of 82 (98.8%) VHNSCs helped in organizing the village health and nutrition day, 59 (71.1%) VHNSCs monitored the implementation of national health programs. The entire untied fund received in the previous year was utilized by 68 (81.9%) VHNSCs. CONCLUSION: The study shows that VMI can be used for continuous monitoring and assessment tool for VHNSC to evaluate and plan different health activities.

A randomized Phase III clinical trial to assess the efficacy of a bovine-human reassortant pentavalent rotavirus vaccine in Indian infants.

Rotavirus is the most common cause of moderate-to-severe infant diarrhoea in developing countries, resulting in enormous morbidity, mortality, and economic burden. A bovine-human reassortant pentavalent rotavirus vaccine (BRV-PV) targeting the globally most common strains was developed in India and tested in a randomized, double-blind, placebo-controlled end-point driven Phase III efficacy clinical trial implemented at six sites across India. Infants 6 to 8weeks of age were randomized (1:1) to receive three oral doses of BRV-PV or placebo at 6, 10, and 14weeks of age along with routine vaccines. Home visit surveillance was conducted to detect severe rotavirus gastroenteritis (SRVGE) and safety outcomes until the children reached two years of age. A total of 3749 infants received BRV-PV while 3751 received placebo. At the time of the primary end-point (when the minimum number of cases needed for analysis were accrued) the vaccine efficacy against SRVGE was 36% (95% CI 11.7, 53.6, p=0.0067) in the per protocol (PP) analysis, and 41.9% (95% CI 21.1, 57.3, p=0.0005) in the intent to treat (ITT) analysis. Vaccine efficacy over the entire follow-up period (until children reached two years of age) was 39.5% (95% CI 26.7, 50, p<0.0001) in the PP analysis and 38.8% (95% CI, 26.4, 49, p<0.0001) in the ITT analysis. Vaccine efficacy against the very severe rotavirus cases (VSRVGE, Vesikari score≥16) was 60.5% (95% CI 17.7, 81, p=0.0131) at the time of the primary analysis and 54.7% (95% CI 29.7, 70.8, p=0.0004) for the complete follow-period in the PP population. The incidence of solicited, unsolicited, and serious adverse events were similar in both the vaccine and placebo groups. Likewise, the number of intussusceptions and deaths were similar between both groups. Thus, BRV-PV is an effective, well tolerated and safe vaccine in Indian infants. (Trial registration: Clinical Trials.Gov [NCT 02133690] and Clinical Trial Registry of India [CTRI/2013/05/003667]).

Reframing undergraduate medical education in global health: Rationale and key principles from the Bellagio Global Health Education Initiative.

Global health education (GHE) continues to be a growing initiative in many medical schools across the world. This focus is no longer limited to participants from high-income countries and has expanded to institutions and students from low- and middle-income settings. With this shift has come a need to develop meaningful curricula through engagement between educators and learners who represent the sending institutions and the diverse settings in which GHE takes place. The Bellagio Global Health Education Initiative (BGHEI) was founded to create a space for such debate and discussion and to generate guidelines towards a universal curriculum for global health. In this article, we describe the development and process of our work and outline six overarching principles that ought to be considered when adopting an inclusive approach to GHE curriculum development.

Prevalence of hypertension and variation in blood pressure among school children in rural area of Wardha.

OBJECTIVE: To study the prevalence of hypertension and variation in blood pressure (BP) level among school children in rural India. DESIGN: A cross-sectional study was conducted during the period from April 2010 to March 2012. SETTING: Participants comprised of 958 school children (in the age group of 6-16 years) from 83 schools covered by three randomly selected primary health centers. MATERIALS AND METHODS: After obtaining informed consent from the school principal, a pretested questionnaire was administered and anthropometric measurements were taken. Hypertension was defined as systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) ≥95 th percentile for age, gender, and height measured on three distinct occasions. RESULTS: Overall, prevalence of hypertension and was found to be 29 (3.0%). The proportion of hypertension among males was 13 (2.8%) against 16 (3.2%) in females. Overall mean SBP level was 97.2 mmHg and DBP level was 62.1 mmHg. CONCLUSION: SBP and DBP found to be correlated with the body mass index, waist circumference, which identifies the need of proper dietary changes at individual and family level. Constructed nomogram for study participants show lesser SBP and DBP values for 90 th and 95 th percentiles among Indian children when compared to NHLBP guidelines. This suggests lesser BP cut-off needed to identify maximum hypertensive population among Indian children.

Nutritional status and its correlates among tribal children of Melghat, central India.

OBJECTIVE: To find out the magnitude and epidemiological determinants of malnutrition among 0-6 y tribal children. METHODS: A community based cross sectional study was done in the villages of Melghat in central India. The information of 540 children in the age group 0-6 y was collected. The newly developed WHO growth standards were used to calculate conventional indices of malnutrition (underweight, stunting and wasting) and composite index of anthropometric failure (CIAF). Univariate and multiple logistic regression analysis were used to find out the correlates of malnutrition. RESULTS: The prevalence of malnutrition among these tribal children in terms of underweight, stunting, and wasting were 60.9 %, 66.4 % and 18.8 % respectively. Malnutrition in terms of composite index of anthropometric failure (CIAF) was 76.3 %. The important correlates of malnutrition that emerged out of this study were the age of child, age of mother less than 20 y at her first pregnancy, practice of not feeding colostrum, calorie deficit diet, anemia and morbidities like diarrhea and acute respiratory illnesses. CONCLUSIONS: The prevalence of malnutrition was high in tribal children. The health care delivery at village level should be strengthened for early diagnosis and prompt treatment of anemia and other morbidities in children. The strategies are needed to delay the child bearing age in this community and improve breast feeding practices.

Quality of health assistants in primary health centres in rural maharashtra, India.

INTRODUCTION: Health assistants are important functionaries of the primary health care system in India. Their role is supervision of field-based services among other things. A quality assurance mechanism for these health assistants is lacking. The present study was undertaken with the objectives of developing a tool to assess the quality of health assistants in primary health centres (PHCs) and to assess their quality using this tool. METHODOLOGY: Health assistants from three PHCs in the Wardha district of India were observed for a year using a tool developed from primary health care management Aavancement program modules. Data was collected by direct observation, interview, and review of records for quality of activities. RESULTS: Staff strength of health assistants was 87.5%. None of the health assistants were clear about their job descriptions. A supervisory schedule for providing supportive supervision to auxiliary nurse midwives (ANMs) was absent; most field activities pertaining to maternal and child health received poor focus. Monthly meetings lacked a clear agenda, and comments on quality improvement of services provided by the ANMs were missing. CONCLUSION: Continuous training with sensitization on quality issues is required to improve the unsatisfactory quality.