Experiences From an Implementation Model of ARI Diagnostic Device in Pneumonia Case Management Among Under-5 Children in Peripheral Healthcare Centers in India.

OBJECTIVES: To address pneumonia, a major killer of under-5 children in India, a multimodal pulse oximeter was implemented in Health and Wellness Centers. Given the evidence of pulse oximetry in effective pneumonia management and taking into account the inadequate skills of front-line healthcare workers in case management, the device was introduced to help them readily diagnose and treat a child and to examine usability of the device. DESIGN: The implementation was integrated with the routine OPD of primary health centers for 15 months after healthcare workers were provided with an abridged IMNCI training. Monthly facility data was collected to examine case management with the diagnostic device. Feedback on usefulness of the device was obtained. SETTING: Health and Wellness Centers (19) of 7 states were selected in consultation with state National Health Mission based on patient footfall. PARTICIPANTS: Under-5 children presenting with ARI symptoms at the OPD. RESULTS: Of 4846 children, 0.1% were diagnosed with severe pneumonia and 23% were diagnosed with pneumonia. As per device readings, correct referrals were made of 77.6% of cases of severe pneumonia, and 81% of pneumonia cases were correctly given antibiotics. The Pulse oximeter was highly acceptable among health workers as it helped in timely classification and treatment of pneumonia. It had no maintenance issue and battery was long-lasting. CONCLUSION: Pulse oximeter implementation was doable and acceptable among health workers. Together with IMNCI training, PO in primary care settings is a feasible approach to provide equitable care to under-5 children.

Intrapartum Fetal Heart Monitoring Practices in Selected Facilities in Aspirational Districts of Jharkhand, Odisha and Uttarakhand.

BACKGROUND: The risk of mortality for the mother and the newborn is aggravated during birth in low- and middle-income countries due to preventable causes, which can be addressed with increased quality of care practices. One such practice is intrapartum fetal heart rate (FHR) monitoring, which is crucial for the early detection of fetal ischemia, but is inadequately monitored in low- and middle-income countries. In India, there is currently a lack of sufficient data on FHR monitoring. METHODS: An assessment using facility records, interviews and observation was conducted in seven facilities providing tertiary, secondary or primary level care in aspirational districts of three states. The study sought to investigate the frequency of monitoring, devices used for monitoring and challenges in usage. RESULTS: FHR was not monitored as per standard protocol. Case sheets revealed 70% of labor was monitored at least once. Only 33% of observed cases were monitored every half hour during active labor, and none were monitored every 5 min during the second stage of labor. More time was observed for monitoring with a Doppler compared with a stethoscope, as providers reported fluctuation in readings. Reportedly, low audibility and a perceived need of expertise were associated with using a stethoscope. High case load and the time required for monitoring were reported as challenges in adhering to standard monitoring protocols. CONCLUSION: The introduction of a standardized device and a short refresher training on the World Health Organization and skilled birth attendant protocols for FHR monitoring will improve usage and compliance.

Determining child drowning mortality in the Sundarbans, India: applying the community knowledge approach.

BACKGROUND: The Sundarbans in India is a rural, forested region where children are exposed to a high risk of drowning due to its waterlogged geography. Current data collection systems capture few drowning deaths in this region. METHODS: A community-based survey was conducted in the Sundarbans to determine the drowning mortality rate for children aged 1 to 4 years and 5 to 9 years. A community knowledge approach was used. Meetings were held with community residents and key informants to identify drowning deaths in the population. Identified deaths were verified by the child's household through a structured survey, inquiring on the circumstances around the drowning death. RESULTS: The drowning mortality rate for children aged 1 to 4 years was 243.8 per 100 000 children and for 5 to 9 years was 38.8 per 100 000 children. 58.0% of deaths were among children aged 1 to 2 years. No differences in rates between boys and girls were found. Most children drowned in ponds within 50 metres of their homes. Children were usually unaccompanied with their primary caretaker engaged in household work. A minority of children were treated by formal health providers. CONCLUSIONS: Drowning is a major cause of death among children in the Sundarbans, particularly those aged 1 to 4 years. Interventions keeping children in safe spaces away from water are urgently required. The results illustrate how routine data collection systems grossly underestimate drowning deaths, emphasising the importance of community-based surveys in capturing these deaths in rural low- and middle-income country contexts. The community knowledge approach provides a low-resource, validated methodology for this purpose.

Interventions for Child Drowning Reduction in the Indian Sundarbans: Perspectives from the Ground.

Drowning is a leading cause of child death in the coastal Sundarbans region of India due to the presence of open water, lack of supervision and poor infrastructure, but no prevention programs are currently implemented. The World Health Organization has identified interventions that may prevent child drowning in rural low-and middle-income country contexts, including the provision of home-based barriers, supervised childcare, swim and rescue training and first responder training. Child health programs should consider the local context and identify barriers for implementation. To ensure the sustainability of any drowning prevention programs implemented, we conducted a qualitative study to identify the considerations for the implementation of these interventions, and to understand how existing government programs could be leveraged. We also identified key stakeholders for involvement. We found that contextual factors such as geography, cultural beliefs around drowning, as well as skillsets of local people, would influence program delivery. Government programs such as accredited social health activists (ASHAs) and self-help groups could be leveraged for program implementation, while Anganwadi centres would require additional support due to poor resourcing. Gaining government permissions to change Anganwadi processes to provide childcare services may be challenging. The results showed that adapting drowning programs to the Sundarbans context presents unique challenges and program customisation.

Effects of participatory learning and action with women's groups, counselling through home visits and crèches on undernutrition among children under three years in eastern India: a quasi-experimental study.

BACKGROUND: India faces a high burden of child undernutrition. We evaluated the effects of two community strategies to reduce undernutrition among children under 3 years in rural Jharkhand and Odisha, eastern India: (1) monthly Participatory Learning and Action (PLA) meetings with women's groups followed by home visits; (2) crèches for children aged 6 months to 3 years combined with monthly PLA meetings and home visits. METHODS: We tested these strategies in a non-randomised, controlled study with baseline and endline cross-sectional surveys. We purposively selected five blocks of Jharkhand and Odisha, and divided each block into three areas. Area 1 served as control. In Area 2, trained local female workers facilitated PLA meetings and offered counselling to mothers of children under three at home. In Area 3, workers facilitated PLA meetings, did home visits, and crèches with food and growth monitoring were opened for children aged 6 months to 3 years. We did a census across all study areas and randomly sampled 4668 children under three and their mothers for interview and anthropometry at baseline and endline. The evaluation's primary outcome was wasting among children under three in areas 2 and 3 compared with area 1, adjusted for baseline differences between areas. Other outcomes included underweight, stunting, preventive and care-seeking practices for children. RESULTS: We interviewed 83% (3868/4668) of mothers of children under three sampled at baseline, and 76% (3563/4668) at endline. In area 2 (PLA and home visits), wasting among children under three was reduced by 34% (adjusted Odds Ratio [aOR]: 0.66, 95%: 0.51-0.88) and underweight by 25% (aOR: 0.75, 95% CI: 0.59-0.95), with no change in stunting (aOR: 1.23, 95% CI: 0.96-1.57). In area 3, (PLA, home visits, crèches), wasting was reduced by 27% (aOR: 0.73, 95% CI: 0.55-0.97), underweight by 40% (aOR: 0.60, 95% CI: 0.47-0.75), and stunting by 27% (aOR: 0.73, 95% CI: 0.57-0.93). CONCLUSIONS: Crèches, PLA meetings and home visits reduced undernutrition among children under three in rural eastern India. These interventions could be scaled up through government plans to strengthen home visits and community mobilisation with Accredited Social Health Activists, and through efforts to promote crèches. TRIAL REGISTRATION: The evaluation was registered retrospectively with Current Controlled Trials as ISCRTN89911047 on 30/01/2019.