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.

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).

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.

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.

Incidence and correlates of "growth faltering" among 0-6 y children: a panel study from rural Wardha.

OBJECTIVES: To study the magnitude and determinants of growth faltering among 0-6 y children in adopted villages of medical college. METHODS: A total 305 children of less than 6 y were followed monthly for 1 y to assess the growth faltering. At each visit, the mothers/caretakers of children were interviewed and information regarding immunization, morbidity profile, dietary history and child feeding practices collected using a pre-tested interview schedule. Monthly anthropometric measurements of child were taken. Growth faltering has been defined as failure to gain weight or actual loss of weight, and weight gain less than 300 g over a period of three consecutive months. RESULTS: The cumulative incidence of growth faltering among 0-6 y children was 930 per 1,000 children per year (95% CI 900.8-959.2).The number of growth faltering episodes per child per year was 3.1 (95% CI 2.9-3.3). In the multivariate analysis, the authors found presence of anemia, presence of any illness and improper household ventilation as significant predictors of growth faltering. CONCLUSIONS: The present finding suggests more focus should be given on early detection and timely correction of growth faltering rather than just identification and treatment of severely malnourished children.

Prevalence and correlates of sustained hypertension in adolescents of rural Wardha, central India.

OBJECTIVE: To study the prevalence of hypertension and its determinants among adolescents in rural areas of Wardha. METHODS: The cross-sectional study was carried out in villages under PHC Talegaon (Talatule) of Wardha district of central India. Out of total population of 37,946 in the PHC, 7435 were adolescents. For the study purpose 1055 adolescents' were selected by simple random sampling method. Among sampled adolescents, 990 were interviewed and examined. The study was conducted during January 2008-December 2008. Hypertension was defined as raised BP (average SBP and/or DBP >95th percentile) for age, sex and height on two additional occasions. Data thus generated was entered and analyzed using epi_info 6. RESULTS: The prevalence of hypertension and pre-hypertension was found to be 3.4% and 10.6% respectively. Bivariate analysis showed significant association (p < 0.05) of hypertension and prehypertension with age, education, occupation, type of family, use of smokeless tobacco, amount of salt consumption, nutritional status, education level of mother and blood pressure level of mother, and father. On multivariate analysis of the present study, the final model by ordinal logistic regression showed significant association of hypertension/pre-hypertension of adolescents with age, type of family, BMI of adolescent and blood pressure of mother and father. CONCLUSIONS: The prevalence of hypertension and pre-hypertension was 3.4% and 10.6% respectively. The significant correlates of hypertension and pre-hypertension were age, type of family, BMI of subject and blood pressure of mother and father.

Health-promoting school initiative in Ashram schools of Wardha district.

BACKGROUND: We studied the effect of a health-promoting school-based intervention for disadvantaged children in the residential Ashram schools of rural Wardha, Maharashtra. METHODS: At baseline, 1287 children in 10 Ashram schools were examined using a locally adapted Global School-based Student Health Survey questionnaire. The haemoglobin level of all children was estimated using the haemoglobin colour scale. Body mass index and physical activity score for each child were calculated. The intervention was carried out through school health committees. After 1 year, 1226 children were examined using the same questionnaire. RESULTS: There was significant improvement in personal hygiene and reduction in hygiene-related morbidity among the children. The median haemoglobin level of the children increased from 10.7 g/dl to 11.4 g/dl. There was also a significant increase in the proportion of children with body mass index that was normal for age (5th-85th percentile) from 32.2% to 38.5%. CONCLUSION: The need-based participatory health-promoting school initiative for disadvantaged children in Ashram schools led to an improvement in their personal hygiene and health.

Community-led initiative for control of anemia among children 6 to 35 months of age and unmarried adolescent girls in rural Wardha, India.

BACKGROUND: Studies in India have reported a high prevalence of nutritional anemia among children and adolescent girls. Nutritional anemia is associated with impaired mental, physical, and cognitive performance in children and is a significant risk factor for maternal mortality. OBJECTIVE: To evaluate the effect of a community-led initiative for control of nutritional anemia among children 6 to 35 months of age and unmarried rural adolescent girls 12 to 19 years of age. METHODS: This Participatory Action Research was done in 23 villages of the Primary Health Centre, Anji, in Wardha District of Maharashtra. In February and March 2008, needs assessment was undertaken by interviewing the mothers of 261 children and 260 adolescent girls. Hemoglobin levels of adolescent girls and children were measured with the use of the hemoglobin color scale. The girls were given weekly iron-folic acid tablets, and the children were given daily liquid iron prophylaxis for 100 days in a year through community participation. The adolescent girls and the mothers of the children and adolescent girls were also given nutritional education on the benefits and side effects of iron supplementation. In June and July 2008, follow-up assessment was performed by survey and force field analysis. RESULTS: There was a significant reduction in the prevalence of nutritional anemia from 73.8% to 54.6% among the adolescent girls and from 78.2% to 64.2% among the children. There was improvement in awareness of iron-rich food items among the adolescent girls and the mothers of the children. The benefits to girls, such as increase in appetite and reduction in scanty menses, tiredness, and weakness, acted as positive factors leading to better compliance with weekly iron supplementation. The benefits to children perceived by the mothers, such as increase in appetite, weight gain, reduction in irritability, and reduction in mud-eating behavior, acted as a dominant positive force and generated demand for iron syrup. CONCLUSIONS: The community-led initiative for once-weekly iron supplementation for adolescent girls and iron prophylaxis for children, in addition to nutritional education, improved the hemoglobin status of children 6 to 35 months of age and unmarried rural adolescent girls 12 to 19 years of age.

Health expenditure and care seeking on acute child morbidities in peri-urban Wardha: a prospective study.

OBJECTIVE: To find out health expenditure in public and private sector consultations for common childhood (under 5) morbidities and to compare the clinical practices and the duration of illness for morbidities treated by public and private doctors. METHODS: The present prospective study over 12 months period was undertaken in the field practice area of a urban health centre in rural India. We could interview mothers of 202 enlisted children at monthly interval for one year. At each visits, mothers were asked to recall any morbidity for the child in the past four weeks, date of onset of symptoms and relief, source of treatment and recorded both direct and indirect expenditure. The data was entered and analyzed by using Epi_info 6.04 software package. RESULTS: Overall, there were 625 episodes of respiratory infection, out of which 377 (60.3%) were treated by private doctors, 158 (25.3%) were treated by government doctors and remaining 90 (14.4%) were treated at home. Significantly more episodes treated in government health facilities i.e., 12 (5.7%) were recommended or done laboratory test where only 13 (2.3%) consultations with private doctors were advised or done laboratory tests (p=0.015). Notably, 145 (25.5%) and 17 (8.1%) episodes treated by private doctors and government doctors respectively received injections (p=0.001). Average total expenditure on treatment of child morbidity was 189 INR (10% of total household income). Families with less monthly income (<1500) had significantly more expenditure (16.1%) on treatment of morbidities than those families who had higher (>1500) monthly income. CONCLUSIONS: About 10% of total household income was spent on the treatment of acute child morbidities. Private providers are preferred for the treatment of acute illnesses where both direct and indirect cost of treatment was high. Household with lower monthly income had to spend more on treatment of their sick children. Hence, while devising PPP and health care financing strategies for urban poor should emphasize to reduce health expenditure.

Effect of improvement of pre-school education through Anganwadi center on intelligence and development quotient of children.

OBJECTIVE: To find usefulness of a package of interventions to improve preschool education through Anganwadi centers on psychosocial development of children. METHODS: A case-control study was undertaken to evaluate an intervention. Eight Anganwadi centers were selected using simple random sampling out of sixteen Anganwadi centers in Talegaon PHC area where intervention was done. Ten children in age group of 4-6 years were selected randomly from each of the eight Anganwadi center in intervention arm. For each child from intervention arm, one agematched child was selected from the matched Anganwadi center. For each subject, Intelligence Quotient and Development Quotient were assessed. RESULTS: Mean Development Quotient (DQ) and Intelligence Quotient (IQ) values were higher among children in intervention Anganwadi centers (16.2 points for DQ and 10.2 points for IQ). This difference was found statistically significant (p = <0.01). Mean DQ among boys was found 10.1 points higher than that among the girls in control arm, this was statistically significant. According to multivariate linear regression model, the determinants of DQ were: intervention; age of the child; education of mother; sex of child; and PEM grade and the determinants for IQ were: intervention; age of the child; and income. CONCLUSION: This study shows that intervention to improve the Early Childhood Education and Development component through Anganwadi centers results in improvement in Developmental and Intelligence Quotient of children.

Process documentation of health education interventions for school children and adolescent girls in rural India.

OBJECTIVE: To undertake process documentation (PD) of two health education interventions for tribal school children (6-14 years) and adolescent girls (12-19 years) in rural central India. METHODS: The present participatory process documentation exercise was undertaken at Kasturba Rural Health Training Center, (KRHTC), Anji, which is a field practice area of the Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram. The various steps identified for process documentation were decided after reviewing the monthly and annual reports of KRHTC, training reports, published research papers, flipbooks and daily diaries of health educators. In order to get the health educators' perceptions, a free listing and pile sort exercise on the domain of 'perceived advantages of the present approach' was undertaken, followed by a semi-structured Focus Group Discussion (FGD) with the educators. A two-dimensional scaling and hierarchical cluster analysis was completed with the pile sort data to get the collective picture of perceived advantages. RESULTS: The health education interventions were need-based, focusing on a target audience. The approach was community-based and has the potential to stimulate an action-experience-learning cycle of health educators and community members by stimulating their creative potential. The health educators found locally-developed handmade flipbooks with relevant messages and culturally sensitive pictures to be facilitating factors. CONCLUSIONS: The present study provided process documentation of two health education interventions which could be useful to both governmental and non-governmental organizations working in resource poor rural settings of developing countries.

Awareness and health care seeking for newborn danger signs among mothers in peri-urban Wardha.

OBJECTIVE: To find out awareness of mothers about newborn danger signs and their health care seeking behavior for sick newborns in the peri urban field practice area of Urban Health Centre in Wardha. METHODS: Triangulated study of quantitative (survey) and qualitative (mapping, pair-wise ranking exercise) methods were undertaken. 72 identified mothers of children (0-11 months) in social mapping exercise were interviewed by trained social workers using pre-designed and pre-tested questionnaire and by paying house to house visits. The structured questionnaire covered information on newborn danger signs, health care seeking and socio-demographic information. The data was analyzed by using Epi_info software package. A pair-wise ranking exercise for assessment of preferred health care facility for sick newborn was undertaken with the group of purposively selected mothers. RESULTS: Out of 72 mothers, 29 (40.3%), 16 (22.2%) and 10 (13.9%) identified difficulty in breathing, poor sucking and lethargy/unconsciousness as newborn danger signs respectively. Only 7(9.7%) and 2 (2.8%) identified convulsion and hypothermia as newborn danger signs respectively. About 27 (37.5%) babies were sick during newborn period. About 11(15.3%) and 8 (11.1%) were reported to have poor sucking and difficulty in breathing respectively. All sick newborns with danger signs were taken to the doctor and only two mothers consulted faith healer for treatment. CONCLUSION: Considering the poor awareness of mothers regarding newborn danger signs, there is need for raising awareness building which required for early recognition and prompt treatment. Apart from strengthening government health facilities, the capacity of intermediate non government health care providers should be developed for newborn care.

A community based approach to improve health care seeking for newborn danger signs in rural Wardha, India.

OBJECTIVE: To find out the effect of community mobilization and health education effort on health care seeking behavior of families with sick newborns, and to explore the rationale behind the changed health care seeking behaviors of mothers in a rural Indian community. METHODS: In the present community based participatory intervention, a triangulated research design of quantitative (survey) and qualitative (Focus group discussions, FGDs) method was undertaken for needs assessment in year 2004. In community mobilization, women's self help groups; Kishori Panchayat (KP, forum of adolescent girls), Kisan Vikas Manch (Farmers' club) and Village Coordination Committees (VCC) were formed in the study area. The trained social worker facilitated VCCs to develop village health plans to act upon their priority maternal and child health issues. The pregnant women and group members were given health education. The Lot Quality Assurance Sampling (LQAS) technique was used to monitor awareness regarding newborn danger signs among pregnant women. In year 2007, a triangulation of quantitative survey and a qualitative study (free list and pile sort exercise) was undertaken to find out changes in health care seeking behaviors of mothers. RESULTS: There was significant improvement in mothers' knowledge regarding newborn danger signs. About half of the mothers got information from CLICS doot (female community health worker). The monitoring over three years period showed encouraging trend in level of awareness among pregnant women. After three years, the proportion of mothers giving no treatment/home remedy for newborn danger signs declined significantly. However, there was significant improvement in mothers' health care seeking from private health care providers for sick newborns. CONCLUSION: The present approach improved mothers' knowledge regarding newborn danger signs and improved their health care seeking behavior for newborn danger signs at community level. Due to lack of faith in government health services, women preferred to seek care from private providers.