Maternal healthcare seeking and determinants of adequate antenatal care and institutional childbirth among Indian tribes: A cross-sectional study from nine districts.

OBJECTIVE: To report the utilisation of maternal healthcare services and factors associated with adequate antenatal care and institutional childbirths among mothers in the tribal communities from nine districts in India. METHODS: Cross-sectional data were collected from 2636 tribal women who had a childbirth experience in the past 12 months. Socio-demographic, maternal healthcare services and health system-related details were collected. Multiple logistic regression analyses were done to identify factors associated with adequate antenatal care (receiving at least four antenatal care visits, the first visit being in the first trimester and receiving a minimum of 100 iron-folic acid tablets) and institutional childbirth (mother giving birth in a health facility). RESULTS: Only 23% of the mothers received adequate antenatal care. 82% were institutional childbirths. The logistic regression revealed that particularly vulnerable tribal groups (PVTGs), those lacking all-weather roads, and women of advanced age were at risk of inadequate antenatal care. Mother's education, health worker's home visits during pregnancy and reception of advice on antenatal care were significantly associated with the reception of adequate antenatal care. Having all-weather roads, and education of the mother and head of the household were positively associated with institutional childbirths, whereas PVTGs, children of birth order three or above, and working mothers were more likely to give childbirth at home. CONCLUSION: PVTGs are at risk of foregoing adequate antenatal care and are more likely to give childbirth at home. Having all-weather roads is a strong correlate of adequate maternal care. Outreach activities by the health workers are to be strengthened as they are positively and significantly associated with the reception of adequate antenatal care. Investing in education and other social determinants and addressing certain socio-cultural practices is important to improve maternal health.

Competency-based tool for evaluation of community-based training in undergraduate medical education in India - a Delphi approach.

INTRODUCTION: A community-based training (CBT) program, where teaching and training are carried out in the community outside of the teaching hospital, is a vital part of undergraduate medical education. Worldwide, there is a shift to competency-based training, and CBT is no exception. We attempted to develop a tool that uses a competency-based approach for assessment of CBT. METHODS: Based on a review on competencies, we prepared a preliminary list of major domains with items under each domain. We used the Delphi technique to arrive at a consensus on this assessment tool. The Delphi panel consisted of eight purposively selected experts from the field of community medicine. The panel rated each item for its relevance, sensitivity, specificity, and understandability on a scale of 0-4. Median ratings were calculated at the end of each round and shared with the panel. Consensus was predefined as when 70% of the experts gave a rating of 3 or above for an item under relevance, sensitivity, and specificity. If an item failed to achieve consensus after being rated in 2 consecutive rounds, it was excluded. Anonymity of responses was maintained. RESULTS: The panel arrived at a consensus at the end of 3 rounds. The final version of the self-assessment tool consisted of 7 domains and 74 items. The domains (number of items) were Public health - epidemiology and research methodology (13), Public health - biostatistics (6), Public health administration at primary health center level (17), Family medicine (24), Cultural competencies (3), Community development and advocacy (2), and Generic competence (9). Each item was given a maximum score of 5 and minimum score of 1. CONCLUSION: This is the first study worldwide to develop a tool for competency-based evaluation of CBT in undergraduate medical education. The competencies identified in the 74-item questionnaire may provide the base for development of authentic curricula for CBT.

Assessment of community-based training of medical undergraduates: Development and validation of a competency-based questionnaire.

BACKGROUND: The global shift toward competency-based education and assessment is also applicable to community-based training (CBT) of undergraduate medical students. There is a need for a tool to assess competencies related to CBT. This study aimed to develop a tool that uses a competency-based approach to evaluate CBT of medical undergraduates. METHODS: A preliminary draft of the questionnaire was prepared by the investigators based on a conceptual framework. Using the Delphi technique, this draft was further developed by a specialist panel (n = 8) into a self-administered questionnaire. After pretesting with students, it was administered to medical undergraduates (n = 178) who had recently completed Community Medicine. Item analysis and exploratory factor analysis were performed under which principal component analysis was used. Reliability was assessed by calculating Cronbach's alpha, convergent validity by correlating the scores with Community Medicine university examination scores, and construct validity by describing percentage variance explained by the components. RESULTS: A 74-item questionnaire developed after the Delphi technique was further abridged to a 58-item questionnaire. Cronbach's alpha of 74 and 58-item questionnaires were 0.96 and 0.95, respectively; convergent validity was 0.07 and 0.09, respectively; and percentage variance explained by the components were 69.3% and 70.1%, respectively. Agreement between scores of both versions was 0.76. DISCUSSION: The authors developed a questionnaire which can be used for competency-based assessment in community-based undergraduate medical education. It is a valuable addition to the existing assessment methods and can guide experts in a need-based design of curriculum and teaching/training methodology.