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    1) ACCESS TO HEALTH SERVICES OF THE POOR AND UNDER - PRIVILEGED IN RANGA REDDY DISTRICT ANDHRA PRADESH

    Summary, Conclusions, Limitations and Recommendations
  • Over the last five decades there has been a tremendous growth of health care infra-structure in India. Along with this health care manpower has also grown immensely. At the same time, several studies have brought to light the poor access to services to the rural under-privileged groups. The health care system is being criticized as inefficient and having given rise to private unqualified medical practice in villages.
  • The present study was conducted to understand and analyse the various aspects of health care availability and access in under-privileged rural communities. The study was carried out in four mandals of Ranga Reddy district in Andhra Pradesh during 1996-97.
  • Objectives of the Study
  • To collect baseline information about the existing health service in the project area.
  • To identify the poor and under-privileged communities objectively and study their health problems.
  • To assess the access to health services of the under-privileged population in the project area.
  • To analyse problems of access in the selected areas.
  • Framework for the study:
  • The focus of the study was access to public health services. The issue was whether the fact that there is a large infrastructure available results in access to infrastructure and facilities. Availability included both reported availability from the system side and actual availability from the consumer perspective. Access, operationally included physical access, socio-cultural access, attitudinal access, time access, economic access and access through roads and transport. This study also attempted to assess the utilization of government health services by rural communities.
  • Design of the Study
  • The methodology included a multistage survey design to gather data from the house- holds. The survey was supported by focus group discussions, case studies and indepth functional analysis of available infrastructure, facilities and manpower. The survey was conducted at the mandal, subcentre, village and household levels using facility survey forms and questionnaires.
  • The information was linked together with the help of focus group discussions and case studies at different levels.Sample was selected based on access factors as criteria. Four mandals with varying degrees of access and geographic representation were selected Shamirpet, Maheshwaram, Nawabpet and Kulkacherla. All the habitations -villages, hamlets, thandas - in each mandal, were categorised into five groups based on physical and manpower access and one village from each category was selected for indepth study.
  • Inaccessible village with poor roads and no bus facilities at any time of the year. These were termed as Least Accessible Villages (LAV or category 1 villages).
  • Villages, hamlets/thandas with access to road and bus facilities but not having a sub centre headquarter located within the village. These were called Outreach Villages since health care services were provided as an outreach of the subcentre (OV or category II villages).
  • Subcentre headquarters villages having no resident ANM in the village. These were termed as Nominally Accessible Villages since an ANM was supposed to be living here but not staying (NAV or category III villages).
  • Sub-centre headquarters villages with ANN residing in the village. These were termed as ANM Resident Villages since she was living and was available (ARV or category IV villages).
  • PHC headquarters village with atleast one staff residing in the village. These were called PHC Access Villages because there was a PHC with atleast one staff member living but there was no guarantee that the doctor was available (PAV or category V villages).
  • The tools used in the study consisted of household schedules for opinion on availability, access, utilization and awareness of health services. A second set of schedules dealt with disease patterns and treatment seeking behaviour of communities. These schedules were a major illness schedule, a minor illness schedule and a maternal health schedule. Besides these, village and mandal facility checklists and focus group discussion guidelines were used. The data were collected by a team of trained field investigators for a period of 8 to 10 months. Data were compiled and analysed with the help of specially prepared computer programmes and presented in percentages. The qualitative information is presented in the form of access maps at the district, mandal and village levels.
  • Summary of Findings

  • Household survey revealed that 90% of the people were aware of the presence of an ANM but only about two third of them said she visited once a week whereas the remaining said that she visited rarely.
  • While the awareness of the presence of an ANM was almost universal, the level of awareness of other health functionaries was very low. Of the other field functionaries, people recalled only the female supervisor and the male worker, but not the others. In the villages where an ANM was living, the awareness of the male worker was high. Awareness of the presence of a female supervisor was high in inaccessible villages as well as villages where the ANM was living.
  • Regarding the presence of a health facility, nearly 50% of people living in villages where a subcentre was available said that they were not aware of the centre. This was due to a building not being available and the centre not conducting clinics regularly. More than 80 percent of the people responded positively to the question on whether. a clinic was ever conducted in their village. But only about 60% stated that the clinic was conducted once a week or more frequently. A quarter of the people said that clinics were rarely conducted in their villages.
  • While a high percentage of people said that the ANM worked well and behaved well with them, the percentage was not so high about her availability on time Private practitioners were the persons most frequently sought for treatment of minor as well as major disorders.
  • More than half of the deliveries were being conducted at home and by dais. A higher pro- portion of deliveries were conducted at the PHC and government institutions and by government functionaries rather than at private facilities or by private practitioners. The cost of delivery was about Rs. 200 including fee, medicines and ceremonies put together.
  • Home deliveries and deliveries within the government health system could be responsible for this low cost.
  • Conclusions

  • 1. Though huge infrastructure and facilities are available for health care service in rural areas, the actual access to these is poor. Utilization of available government health facilities is due to obstacles to access
  • 2. Actual availability versus nominal availability: Staff were available on paper but did not stay and were not available at the time of need both at the primary health centres as well as subcentres. This mismatch between nominal availability and actual availability of health facilities is the main problem in access.
  • 3. Location problems did not allow optimum utilization of facilities at PHC and subcentre. Poor physical access including location, roads, transport is the largest stumbling block to access to health facilities to rural areas.
  • 4. The huge network of infra structure and facilities is accessible to only a quarter of the villages and habitations on a weekly basis and to a minimum number of villages on a round the clock basis.
  • 5. When ANM resided in the village, not only was awareness and utilization high but it seemed to have an affect on people's awareness of other health functionaries like male health worker.
  • 6. Poor access to government health facilities resulted in people seeking treatment for minor ailments from private practitioners and spending unreasonably high amounts, specially for minor ailments.
  • 7. When larger proportion of deliveries are conducted by health personnel and in government health facilities, the total cost of delivery is low.
  • Limitations of the study:

  • There are some limitations in the study due to practical problems. The responses obtained on illnesses were based on self reports due to the investigators being non technical. For the same reason and because female investigators were hard to get to work in the villages, responses on reproductive health were incomplete and the data could not be used for analysis. Only the information on pregnancies and deliveries was adequate to some extent. Delivery information was therefore analysed, but not on pregnancy or reproductive tract problems which was sketchy.
  • Information on cost of treatment was also incomplete due to poor responses. Therefore only the total figure is reported and not broken down into subcomponents. Due to the large size of the data, there were several pieces of information missing in either one or other component and therefore the responses were converted to percentages and this form of reporting alone was used.
  • Recommendations
  • Functional analysis and rational location of centres for easier access: Initiating a functional analysis of the primary health centres and subcentres in the country will reveal the utilization of centres and the problems of access which are related to poor utilization. Locating infrastructure in inaccessible areas could be avoided in future, if this exercise is undertaken. The exercise will involve a massive exercise district by district, village by village. It could be completed through focus group discussions with villagers and health staff from the local areas and a record analysis. It would not be necessary to do a. house to house survey for such an analysis.
  • The findings of the analysis should become the basis for a more rational location of the health care facilities.
  • Rationalization of Facilities
  • Facilities need to be rationalized on service need of the community. Service need is indicated by not only epidemiological and socio demographic factors but also logistics and other developmental indicators of the specific area. Allocation of health facilities needs to be determined by people rather than administrative or political bodies far removed from reality. Area specific rational a11ocation needs to be taken up. The findings of the present study and discussions with community revealed that villages could be categorized into the following for their health facilities.

    A. Villages which have no facilities at present These are the most inaccessible villages with poor roads, transport and only visits of ANMs. They are either hamlets or tribal thandas with small population. Most of the people in these remote villages belong to scheduled caste groups. Literacy levels are low. Even dais and RMPs are not available in some of these villages. The villages with such characteristics can again be divided into three types with varying levels of development, size, availability and access.

  • Villages too small and with poor physical access: These are the most underprivileged groups since they have no facility and no capacity to access outside facility. It is such areas where no private practitioner would set up clinics. It is also these areas where the ANM is likely to visit least. All emergency facilities need to be made available for such habitations in one common area with training to one of the villagers. Overall monitoring and support may be done by a local group of women once they are oriented. Every day in the habitation needs to be trained. Once this is done, a weekly visit by the nearby subcentre ANM would be a bonus and support.
  • Very small villages but with good physical access and communication: These villages may be attached to the nearest larger village and a permanent ANM based in the larger village. All women may be encouraged for delivery by ANM or trained dai. lf no subcentre exists in this, it may be necessary to create an alternative centre either through a self employed ANM directly paid by the clients or an ANM hired by the local community and paid by the women's group through regular subscriptions from all villagers on the basis of a rural health insurance scheme. Such experiments are being carried out in one village in Shamirpet, after the completion of the quality of care project and in several villages of Alur mandal in Kurnool district, as part of a larger Reproductive and Child Health Project.
  • Large villages with poor access: There are several such villages which are outreach villages of the subcentres but larger than the subcentres in area and population. Such villages have to be taken up for opening new health centres specially if they do not have good access to other facilities. Kothur village in Shamirpet mandal is an example of this type of village. The three above categories of villages can be managed entirely by non medical health functionaries with referral support, provided residing in the facility is ensured.
  • B. Villages which have subcentres or PHCs located within them One village in every mandal has a PHC located with it, though the type of PHC differs. in the same manner, about 8- 10 villages in each mandal have a health subcentre located within them. These villages are usually bigger in size and many of them have better access to roads, transport and health facilities and services. Such villages can also be divided into three types.

  • Large villages with good access: There are several villages which are large and are strategically located with access to smaller ones. Ameerpet village of Maheshwaram is an example. These can be strengthened so that round the clock services are available. Instead of one two ANMs can be posted in these villages. They could function in the clinic and field on a rotation basis.
  • Mandal headquarter villages with very poor access and having facilities: Currently several of these are primary health centres but due to poor access they do not serve all the villages. Such villages should not be provided with additional infrastructure since it is not rational to give inputs where they cannot be used.
  • Mandal headquarter villages with good access to other villages and towns: Some of these villages are earlier block headquarter. All such places could be converted as round the clock services for all emergencies with inpatient beds. Additional doctors and clinical staff may be posted and field responsibilities for area under such villages may be handed over to field staff.
  • Rationalization of Personnel

  • Optimum use of personnel is an important indicator of efficient health care planning and monitoring. Placement, monitoring, supervision, support and appraisal need to be carried out regularly to ensure that personnel are used effectively. It is necessary to look at the functions and performance of each functionaries.
  • Optimum utilization of personnel requires an output analysis to be done of each worker to assess the amount of work turned out for the inputs received. The frank questioning of the futility having three medical officers in a centre which does not conduct a delivery or just does a few tubectomies per month has already started. The discussion of the worth of ANMs if they are making just a few non productive visits to villages is initiated. Staff functions need to be reallocated to ensure non overlapping and full capacity utilization. This study revealed that the presence of the ANM was felt but not of the other functionaries. It also showed that when an ANM resided in the village, the performance of the male worker also improved and people's awareness of his presence increased. The ANM, for many reasons is the key functionary in the village and efforts have to be taken to ensure optimum utilization.
  • Rationalization of job responsibilities

  • The types of functions to be carried out should become the basis for job responsibilities of staff. This should then form the framework for the type of staff to be trained and employed. The training, employment, deployment, reshuffling and redesignation of health staff in the PHC system has been carried out in an adhoc incremental manner, adding on, redesignating, modifying according to the policies, programmes and pressures from vested interests. Functions in the field need to be categorised into field functions, clinical functions, supervisory functions and managerial functions. A detailed chart has to be prepared of the load to be carried in each area. This will become the basis for the type and number of health staff. The excess staff may be re deployed for other type of activities. As an example, there are several categories and types of supervisors in the field, both male and female. While the RCH services will require more female supervisors with technical skill, the current man- power tables indicate that there are more male supervisors. But the number of male workers is limited. The male staff may be redeployed for initiating male responsibility in reproductive health and for village development activities. The public health nurse who is available in only one third of the PHCs in the State needs a redefining of responsibilities and area of functioning in order to ensure efficiency and accountability. Exercises in rationalization of facilities, services, and manpower may be carried out on a pilot basis in some areas. Experiences from these may be used for upscaling at the district level. informal discussions with staff revealed that rationalization of centres and duties will be a welcome exercise since it will help in better functioning.
  • 2) CONTENT AND IMPACT OF HEALTH BROADCASTS IN ANDHRA PRADESH

    Executive Summary
  • The present project is an attempt to analyse the media, audience and health experts perspectives on the coverage of health by electronic media (Govt) with special reference to contents. In communication terminology this can be said as "Media Agenda"," Public Agenda" and “Policy Agenda". While the policy agenda is framed by the Government, public agenda takes place depending on the needs perceived by the people. The media agenda while reflecting the above two also sets certain priori- ties based on the perceptions of the journalists. In an effective communication process, the gaps between these three will be normally minimal. However, in development communication this depends to a great extent on the co-ordination between the services providers and the media. Regular feedback and evaluation help to bridge the gaps between the three. The present project is an attempt in this direction to see how far the priorities set by the health and family welfare department are effectively translated to the electronic media and in turn how far the media is able to influence the public on important health issues. To realize this objective the following activities, are undertaken. 1. Content Analysis of Health Broadcasts Report No I (Media perspective) 2. impact of Health Broadcasts Report No II (Peoples perspective) 3. Focus group discussions Report No III
  • Health Expert's Perspective and a comparative analysis of three perspectives. The specific objectives of each study are stated separately in the respective reports.
  • Methodology

    1.Content Anlaysis of Health broadcasts

  • Details of Health Programmes broadcast during the period 1995- 1996 were collected from 6 AIR Stations, Doordarshan and E TV and were classified in to different categories of health issues. The analysis includes distribution of time allotted media wise, district wise, broad and specific topics, language, duration, timings, participants, formats etc.
  • 2.Impact of health broadcasts

  • After assessing the media ownership in the sample villages for 6000 household an impact assessment survey was conducted using a structured questionnaire. The survey covered 7 districts of the state (A.P.) based on the primary coverage zone of the selected 6 AIR Stations with a sample size of 3125.
  • 3.Health Experts Perspective and Comparative Analysis of three perspectives

  • Health experts' opinion about the priorities in coverage of health topics was developed through focus group discussions and the level of agreement among the three groups was measured.
  • The study has used both quantitative and qualitative techniques for the analysis of data with computer assistance.
  • The major conclusions of the study include the following

    Content Analysis

  • 1. The total duration of health programme~ broadcast during the financial year 1995-96 is around 340 hours.
  • 2. While All India Radio is the major contributor to health broadcasts Television's role is also not insignificant.
  • Almost all health topics are given some coverage except a few. However in the process the amount of coverage given to different topics is obviously not high.
  • All the stations have to followed reasonable criteria in selection of the topics. However some deviations were observed from the policy and priorities set by the Government in health programmes.
  • While Government electronic media by and large is reflecting the priorities defined by the Health Department the private media needs to be sensitized.
  • The weakest link in the chain of health, communication through electronic mass media is in the points of co-ordination between AIR/ Doordarshan on one hand and the State Government machinery on the other.
  • The study raised the following issues which are of some concern.

  • Whether it is desirable to broadcast many health topics with insignificant coverage or to select certain major issues and give extensive coverage.
  • Whether the topics need to be more specific or a broad discussion of the health problems would be sufficient.
  • What should be the nature of coverage? Is there a need, to formulate specific guidelines in scheduling contents of the programmes.
  • Impact Of Health BroadCasts

  • Around 81% household own radio set and 51.11% television while 32.94% are provided with cable connection and 11.59% subscribe newspapers and the household without any media are 22.8%.
  • Ownership of radio is high in rural, areas with an exception to tape recorder/ two-in-one and FM band radio. A noticeable difference between urban and rural in case of Doordarshan and cable television is observed which is similar for newspapers. Ownerships of VCR/VCP seems to be high in urban areas and people without any media are more from rural areas.
  • 34.43% of the respondents exclusively listen to radio and 32.7% television. People who claimed equal exposure to both radio and television are also in good number i..e, 34.85%.
  • Majority felt knowledge about the preventive measures as the prime utility of health broadcasts. In addition identification of symptoms of the diseases, developing good health habits, knowledge about the treatment to be taken etc. are also felt as important. The other uses perceived by the sample if not a high percentage are consequences of neglecting health, knowledge about side effects, Dos and Don’ts in general, health facilities provided by Government etc.
  • The health programmes of radio and television are mainly helpful in imparting knowledge on various health issues to a large extent. Impact of programmes in terms of practice is mostly in following certain guidelines. In contrast to these the effects of media programmes in bringing attitudinal change is insignificant.
  • The impact created by the health broadcasts on a 3 point scale show majority of the respondents at low and medium levels.
  • A high disparity between Medak and other districts is observed where the impact is at low level on the scale. This was followed by Tirupati where a relatively high percentage are at lower level.
  • Media wise difference in the levels of awareness is not much except a little more percentage are at medium level for radio and television.
  • Comparative analysis of media, audience and health experts perspectives on health broadcasts
  • The level of agreement among the three groups is measured using the statistical tool Kendall's co-efficient of concordance (W) and the level of agreement is observed to be moderate (W = 0.6) in general. However when analysed topic wise some variation is observed. No gaps in perspectives are observed among the three groups in case of programme production techniques. When the relationship between different groups is measured specifically by using rank correlation method the relationship between media and audience is quite satisfactory (r = 0.7) between health expert ~Rd audience the relationship is little (r= 0.3) and between media and health expert no relationship is observed (r= -(0.1 )). The comparative analysis reveals that the health information disseminated by media is having satisfactory impact on the audience. This gives an impression that any change in contents of hearth programmes can lead to change in impact in the same direction. However there is a need to provide the necessary inputs to media for effective health broadcasting.
  • 3) DOMESTIC VIOLENCE IN INDIA: EVIDENCE FROM RECENT SURVEYS

    Introduction

  • Violence against women is now recognised as a increasingly significant public health problem and violation of human rights. The effect of violence can be devastating to a woman’s reproductive health as well as her physical and mental well-being. World wide, one of the most common forms of violence against women is abuse by husbands which has been associated with a broad range of serious physical and mental health problems such as depressions, suicide and bodily injuries. Global studies have shown that women who have experienced physical assault are more likely to suffer from a variety of sexual and reproductive health problems including chronic pelvic pain, STDs, unwanted pregnancy and adverse pregnancy outcomes. Physical and sexual violence can also have an impact on fertility. Many international studies have found that women who suffer physical or sexual abuse are more likely to have more number of children. It was also been observed that high parity women are more at risk of violence than of low parity woman.
  • Though data on domestic violence are extensively available at international level, there is a dearth of information on the magnitude and patterns of domestic violence against women in India, particularly large-scale community based data. A few recent studies in India suggest a wide spread prevalence of violence, but these have been conducted at micro level. No data which can present the prevalence of domestic violence at national level are available except the National Family Health Survey-2 (NFHS-2) that has attempted to collect information on domestic violence at national level for the first time is of significance.
  • Survey Findings

  • The data used for the present analysis have been taken from NFHS-2. The NFHS-2 covers 91,196 households in 25 states covering 89,199 ever-married women in the age group 15-49. State-wise the variation in sample size is from 1500 to 10,000 in proportion to the population size of the states. An analysis of the data on domestic violence has been made by disaggregating the data collected through NFHS-2. An attempt has been made here to group the states into various zones based on the prevalence of domestic violence. In NFHS-2, the beating/physical mistreatment has been defined as slapping, hitting with hands or fists, with an object or weapon, kicking, twisting arms, burning the skin in anyway etc. The information on lifetime violence i.e. data on whether woman has been beaten or physically mistreated since age 15, have been used for this purpose. The data on justification of wife beating have also been analysed for the four south Indian states. In respect of data collection on domestic violence, validity may be affected by such factors as family’s privacy, social limitations, shamefulness/fear, perceptional differences resulting in under-reporting.
  • Table 1 provides data on domestic violence based on various studies conducted in different parts of the country. This table suggests a wide spread prevalence of domestic violence, the prevalence ranging from 22 to 75 percent among particular groups. In Punjab, 75 percent of the scheduled caste women reported being beaten frequently by their husbands and in Karnataka it is 22 percent. A comprehensive survey results from 1842 rural women aged 15-39 years in the state of UP and Tamil Nadu, indicate that 41 percent of the wives received beaten by their husbands. More recently, Visaria (2000) in a community-based survey of 346 rural women aged 15-34 years in Gujarat reported that 42 percent of them had experienced physical violence. According to the NFHS-2, the national figure for the prevalence of domestic violence in India is 21 percent.
  • Source

  • Rao, Vijayendra and Francis Bloch (1993). ‘Wife beating, its causes and its implications for nutrition allocations to children: In economic and Anthropological case study of a rural south Indian community’, World Bank policy research department, poverty and human resource division, Washington DC.
  • Jejeebhoy, J.S. (1998): Wife beating in rural India: A husband’s right? Evidences from survey data, Economic and Political Weekly, 33 (15), 855-860
  • Visaria, L (2000) Violence against women: A Field Study, Economic and Political Weekly 35 (20), 1742-1751.
  • National Family Health Survey-2 (NFHS-2) (1998-99)
  • Mahajan, A (1990) ‘Investigation of Wife Battering in Sooshma Sood (ed), Violence against women, Arihant Publishers, Jaipur, India.
  • Table 2 presents the classification states into zones as per the prevalence of domestic violence.
  • Table 2 shows that Rajasthan, Kerala, Gujrat and Himachal Pradesh falls under Zone 1 where the prevalence rates of domestic violence are low. The prevalence of domestic violence in these states are below 11 percent. The states that fall under Zone 2 are Manipur, Nagaland, Maharashtra, Goa, West Bengal, Assam, Delhi, Punjab, Haryana and Sikkim where the prevalence of domestic violence is between 11 to 20 percent.
  • Source: NFHS-2

  • (1998-99) States that fall under Zone 3 are Orissa, Bihar, Arunachal Pradesh, Andhra Pradesh, Uttar Pradesh, Jammu and Kashmir, Karnataka and Mizoram, where the prevalence is above 20% to 30%. The states that fall under zone 4 are Meghalaya (31%) and Tamil Nadu (40%) where the prevalence of domestic violence is the highest. In addition to the actual experience, the data on attitudes towards justification of wife beating were also analysed by specific reasons.
  • Source: NFHS-2 (1998-99)

    Source: NFHS-2 (1998-99)

    Conclusions

  • The analysis of the data on domestic violence suggests a wide spread prevalence of domestic violence in India. Though the violence is wide spread, its magnitude is not uniformly same in all the states of India. The prevalence of violence is the highest in Tamil Nadu (40 percent) followed by Meghalaya (31 percent) and the lowest in Himachal Pradesh (6 percent) followed by Gujrat and Kerala (10 percent each). Further the data show that the wife beating is not only deeply rooted, but also the predisposing attitudes that uniformly justify wife-beating which in turn are likely to lead to the persistence of this phenomenon for the years. Further research on this area is required to identify the causes of violence, the impact of health consequences of violence and women’s reaction and attitude towards violent incident. Hence the strategies to combat violence are urgently needed and these must address the root cause of violence, its health consequences and immediate needs of battered woman and also to bring about strategies to eliminate such kind of social evil.
  • 6) FINAL EVALUATION OF INTEGRATED NUTRITION & HEALTH PROGRAMME IN ANDHRA PRADESH Quantitative Survey – CARE – INDIA

    SUMMARY OF PHASE I

    The Phase I of the study has provided an opportunity to look into the exposure patterns of the citizens living in and around Hyderabad city. Further, an attempt is made to elicit the perceptions of the people of the historic city on environmental pollutants. In total 25 water points covering 1943 households with a population of 10,601;16 industrial points covering 1886 households with a population of 9776 and 25 road points covering 1431 households with a population of 7885 are selected for the study. The salient observations of this phase of the study as follows:

  • A total of 28,262 population are covered, in which 14,393 are males.18 per cent of them are illiterates.
  • 47. 5 per cent of the study population are living in kutcha hous.es, 50.9 per cent of the houses are not having cross ventilation facility.
  • 33.5 per cent are using LPG as cooking fuel. 84.2 per cent are provided with piped water for drinking purposes.
  • 34.4 per cent of the study population are using open fields for defecation. 34.9 per cent of the households have closed drainage system.
  • 81.4 per cent of the households have waste basket bins. 34.9. per cent of the households are using public dust bins. 37.0 per cent are emptying domestic solid wastes into nallas.
  • In only 18.2 per cent of the households the peridomestic environment is maintained cleanly.
  • The acute diseases are noted in 24'.6 per cent of the study population, while the chronic diseases prevalence is seen in 7:6 per cent. Acute diseases are found higher incidence amongst people living at industrial points (27.8 per cent). In comparison the incidence is 21.2 per cent & 24.3 per cent at road and water points respectively. ARI, skin diseases,diarrhoea and malaria are major acute illnesses noted. The study observed that the incidence of acute diseases is marginally high nearer to the source points than away from the source points (25.4 per cent and 24.2 per cent). Similar, situation is observed even in chronic disease prevalence, more so in diseases like bronchial asthma.
  • • An inverse relation is found between the occurrence of ARI and no. of rooms i.e., lesser the number of rooms higher is the incidence of ARI. ARI incidence is 12.7 per cent in single tenement households and 3.7 per cent amongst members in 6+ room houses. An ARI (14.6 per cent) incidence is noted in houses with no cross ventilation.
  • • In 50.7 per cent of the episodes of illness upto Rs.50 is spent for treatment and in 42.8 per cent of the cases Rs. 10 is spent towards transportation. The morbidity pattern is reported with wide variation between the different areas in the study.
  • SUMMARY OF PERCEPTIONS ON ENVIRONMENTAL POLLUTION
    The following is the summary of the findings:
  • 1. People are eager to discuss the local environmental issues.
  • 2. Only less than one-fourth of the respondents are aware of the diseases caused by overcrowding, ill-veritilation; water, food and air pollution. This is the initial response to the questions.
  • 3. The awareness levels have shown higher after providing some lead and after further probing. The increase is observed from the initial about 25 percent to 50 percent.
  • 4. People (71.3 %) accept that unhygienic practices are responsible for environmental pollution.
  • 5. Majority of the respondents (70.4 %) are willing to participate in the environ- mental development activities. This situation must be taken advantage by the governmental and non-governmental organisation in ensuring the people's willingness to fruitful actions.
  • SUMMARY OF PHASE II
  • Lead is a widespread toxic element which may have profound effect's on neuro behavioral development of children. Contamination of the environment due to lead appears to be escalating in developing countries particularly in the areas experiencing urbanization and rapid industrialization. The impact of the leaded gasoline is more important in Hyderabad urban agglomeration. Our efforts to evaluate the Environmental Lead exposure in children living different areas have strengthened this fact. The study focused on the Lead levels in the blood -this is an accepted indicator for reflecting of air pollution problem in urban settings. Significant similarities are observed when compared to the studies conducted elsewhere. The results of the study sends alarm about the hidden threat to the children of the Hyderabad city. The mean Blood Lead level of the total children covered is 15.31 ug/dL .This is quite higher than the mean blood lead level of the children of Delhi which is 9.6 ug/dL (S.T.Gogte et. al). The children(< 5 years) in urban area of Mexico city also shown mean blood value of 9.8+5.8 ug/dL (Isabelle Romieu et. al ). But in a study conducted by a postgraduate student of Osmania Medical college, Mean Blood lead levels of children in Hyderabad is shown as 23.1 ug/dL ,this high blood lead levels may be due to that sample {controls) taken from the children attending to the Niloufer Hospital only and it may not represent the total community of the Hyderabad.
  • This mean blood lead level is also higher than the safe limit of 10 ug/dL proposed by the CDC, Atlanta, USA (Center For Disease Control and Prevention). This high blood lead levels among the children may be due to escalating number of two wheelers which utilise the Leaded Petrol and ejecting Lead in to the atmosphere of city. In the city also Blood Lead levels are proportionate to the traffic. 17.46 ug/dL, 12.76 ug/dL, 11.93 ug/dL are respective values for High traffic, Medium traffic, Low traffic areas. Industrial area recorded a mean blood lead value of 32.63 ug/dL .This is very high when compared to the values extracted in two studies conducted in the industrial areas of the Mumbai where blood Lead levels are 12 ug/dL (Shenoi. R.P, 1991); 11.3 ug/dL (Khandekar, 1987).
  • A strong inverse relationship was observed between the Mean Hemoglobin levels and the Mean blood lead levels. Here Low traffic area recorded high Mean Hemoglobin value of 10.98 percent gm and Industrial area recorded low mean Hemoglobin value of 9.24 percent gm.
  • The Lead levels in the water and food to be not consistent with the traffic volumes. This may be due to some other influencing factors further air borne lead may not contaminate drinking water and food as much as in the case of dust. But in case of household dust, significant association is found between the Lead levels and type of the area. Dust lead levels are higher in the industrial area (268.57 ug/gm) and followed by the High traffic (109.71 ug/gm), Medium traffic (74.04 ug/gm), Low traffic (55.27 ug/gm) areas. Another important observation is higher mean blood Lead levels are occurring at the age group of 2 years. This finding strongly coincides with the result of a longitudinal study conducted in Port pirie city of Southern Australia (Baghurst et.al, 1992). This high blood lead levels at the age of 2 years may have adverse effects on nervous system of the children. Significant inverse relationship was found between the socio economic status of families and Mean blood lead levels.
  • Thus, the study brings to the limelight the increasing mean blood lead levels at a very young age amongst the children of Hyderabad city. Further it strengthens the relation of this toxic metal to the ever growing traffic volumes. In conclusion it warns all the concerned to protect the future citizens of our place by stepping up efforts to mitigate the problem without further delay.
  • 5) EVALUATION OF COMMUNICATION ACTIVITIES IN FAMILY WELFARE PROGRMMES OF SIX DISTRICTS OF ANDHRA PRADESH

    Conclusions

  • The Family Welfare Programme in our Country is at the Verge of completing 50 yrs. During this long Period, the programme has adopted a variety of communication strategies to promote awareness and acceptance of the services offered. Inspite of all these efforts there is still a wide gap in terms of awareness as well as acceptance. The work of communication extension officers in the state proved to be futile in winning the confidence of majority people owing to the lack of appropriate and effective communication methods. Bottle necks persist both at policy framing level and implementation level as well. In the former case the programme is a centralised one with all major decisions percolating down from the top with little or no participation of the people for whom the programme is actually meant and in the later the personnel involved in the programme are neither qualified in the concerned field nor trained exclusively for the assignment.
  • The acronym of MPHEO (Multi Purpose Health Education Officer) is half understood to denote Multi Purpose means all Purposes. Moreover it is a promotion post from supervisory cadre who's earlier responsibilities were not concerned with IEC activities. Coming to the material used for IEC activities, both hardware and software have many Lacelnac. In many places the IEC equipment like projector, generators, TV, VCPs Cassette Player etc, were out of order and dumped in a corner room. The Print Material like Poster, Pamphlets are also found in heaps and bounds in all DM&HO's Offices.
  • major conclusions of the study are enumerated below.
  • No regular Planning is done by the state or district officials concerned to improve IEC activities for faster and sustaining results.
  • Under utilization, no utilization and misuse of equipment like A.V. Vans, Projectors, Generators, VCP's, T. v. Sets etc.,
  • Diverting the funds for Non-IEC activities.
  • Lack of intra and intersectoral co-ordination between Family Welfare and other related Depts. Absence of Monitoring System.
  • Improper utilization of print material (like Poster, Pamphlets, Wall writing etc.) are aimed at illiterate population who C4n't read or grasp the message being conveyed.
  • Uneven way of maintaining records and reports
  • Confusion among the MPHEOs about their job responsibilities.
  • Lack of innovative and need based I EC activities through traditional Folk media.
  • Lack of Communication skills among extension officers.
  • Monotonous health talks without entertainment.
  • Financial Constraints
  • Future Strategy

  • The main objective of the study is to suggest a more appropriate cost effective strategy to strengthen the IEC activities, especially in rural areas which consist 70% of our country's population. As it is apparent from the data that neither the personnel involved nor the material produced is reaching the target population for creating awareness and changing the attitudes of the people. The future strategy therefore may be focused on the following aspects. There should not be any further promotion to MPHEO position from the lower cadre since the present MPHEOs are not able to carry out the given assignments properly and hence, it is likely to have negative impact on the prospective employees in this cadre. Private IEC consultants on the ratio of 1:3 PHCs may be appointed on contract basis whose responsibility should be to carry out all IEC activities in the allotted PHC areas with the involvement of PHC staff. This IEC consultant should conduct KAP study as a first step in the allotted PHC areas and then design appropriate need based and local specific strategies time to time to carry out IEC activities.
  • His IEC activities should be monitored by a state level IEC consultant who is also a private person employed on contract basis (Three consultants for three regions of A.P may be appointed).
  • There should not be any link between PHC-IEC consultant, DEMO and DM&HO etc., Keeping in view the rural illiterate population, visual media in the form of Video Films, 16mm, 35mm Films should be given top priority since, for them seeing is believing. These films should be an amalgamation of information, entertainment and thought provoking sequences which can register the long lasting impressions in the minds of the viewers. All private regional language T. V. Channels should allot 30% of their telecasting time for F.W. programmes according to the guidelines given by the Govt. on the timings. (for eg. before / in between the movie, popular serial, news etc.). Measures should be taken by the Govt. to ensure this.
  • School Children, Youth Organisation of respective areas should be involved in performing F.W. oriented programmes in popular Folk Media like Veedhi Bhagavatams, Oggukatha etc., and incentives like attractive prizes, Certificates by C.M. District Collector and Cash awards should be assured.
  • Minimum budget should be allotted to print media like poster, Pamphlets, Wall Writing etc., Since this is useful only to literate community which is well aware of F. W. Services and needs Little motivation.
  • Proper monitoring system should develop and periodic field visits by the state officials should be ensured.
  • 6) FINAL EVALUATION OF INTEGRATED NUTRITION & HEALTH PROGRAMME IN ANDHRA PRADESH Quantitative Survey – CARE – INDIA

    Executive Summary
  • Integrated Nutrition and Hea1th Project (IN HP} started in 1996 to improve the health and nutritional status of women and children in seven states: Andhra Pradesh, Bihar, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and West Bengal. The project targets children under age six, pregnant women and women with children under age 2 years. After obtaining baseline data, mid-term and final evaluations were undertaken. The results of the final evaluation of IN HP in Andhra Pradesh are presented here. A total of 2404 index mothers with children less than 2 years were interviewed. Of them 539 were from HI block, 546 from CB, 833 from other blocks and 486 from Demonstration site. The total Anganwadi centres covered were 151 and the total number of ANMs interviewed was 58.
  • Background Characteristics

  • The housing conditions and standard of living of household members indicated that 48 per cent of houses were pucca, 68 per cent of households had electricity, and 34 per cent had access to tap water. 92 per cent of the houses had no toilet facility. In the study area, 50 per cent of the mothers were OBCs, 27 per cent were STs, and 16 per cent were SCs. 63 per cent of the mothers were i1literate, 19 per cent had completed primary, 11 per cent had completed middle school and 9 per cent had above middle school education. 34 per cent of the mothers did not work outside home. Among those who worked, majority were wage labourers.
  • Majority of mothers (73%} were in the age group 20-29, 56 per cent had 2-3 living children, 52 per cent did not want any more children and a half of the respondents had a closed birth Interval of 2-3 years.
  • Regarding the profile of the children, 33 per cent were below age 6 months, 21 per cent were between 6-11 months and 47 per cent were between 12-23 months. Sex ratio (number of females for 1000 males} below 12 months was 990 and it was 892 for children between 12-23 months.
  • Women's Health and Nutrition

  • Women's health and nutrition has been one of the focus areas of IN HP programme. In the study population, 99 per cent of the mothers had received at least one antenatal check-up; more than half (53%) had received 3 antenatal check- ups. Among those who had received antenatal checkups, majority (63%) of them received them from private clinics. 55 per cent of the mothers received their first checkups during the first trimester. More than 90 per cent of the mothers received the recommended dose of TT vaccination, around 73 per cent received iron and, folic acid supplementation while only 16 per cent took deworming treatment. Forty-seven per cent of the women in the study areas reported some health problems during their pregnancy and 87 per cent of them had taken treatment from various sources. Food supplementation during pregnancy and lactation has been one of the important components in the IN HP programme. 32 per cent of the women received food from AWC for spot consumption during pregnancy. This was lowest (16%) in, HI block and (53%) in other areas. 16 per cent of the mothers received food for spot consumption for less than 3 months, 53 per cent for 3-6 months and 33 per cent for more than 6 months. Again, 16 per cent of the mothers received take home ration for less than 3 months, 51 per cent for 3-6 months and 34 per cent for more than 6 months. 75 per cent of the mothers who received take home ration, had shared their food with other family members. Regarding food intake during pregnancy, 22 per cent of the mothers have reported that they had increased their food intake, while 30 per cent indicated decrease in the intake and 48 per cent at the same amount of food as usual.
  • The food supplementation during lactation indicated that 22 per cent of the mothers received food from A WC for less than 3 months, 42 per cent for 3-6 months and 2 per cent for more than 6 months. About a half of the lactating mothers shared their food with other family members.
  • Regarding the frequency of distribution of food by AWC, 18 per cent of the mothers reported a daily distribution, 30 per cent reported it was weekly, and 31 per cent reported it was monthly.
  • Birth Planning
  • Thirty per cent of the women reported that they had kept the DDK ready. There was not much variation regarding this aspect by educational levels, caste groups and block types. Regarding the decision on place of delivery, majority of the illiterate mothers (67%) opted for home delivery, compared to the women of other educational categories. Similarly, the mothers of ST group (81 %), and tribal mothers (74%) decided to opt for home delivery compared to other groups. Decision on institutional delivery was made mostly by women with higher than middle school education, other caste group women and women from urban areas. Major reason for preferring a home delivery was that they could not afford the cost involved in institutional delivery. Avoidance of the risk, was the major reason for opting institutional delivery.
  • Delivery

  • The family welfare programme encourages women to deliver in a medical facility or, if at home, with assistance from a trained health personnel. Only 39 per cent of the births were conducted in a medical facility. Among the deliveries at home, more than half were attended to by untrained persons. 7 per cent of the mothers reported to have gone for MTP in the study area.
  • Family Planning

  • Forty-four per cent of the women in the study area were currently using some method of contraception. Permanent method of contraception was adopted by 40 per cent of the women and only 4 per cent were using spacing methods. 82 per cent of the women were using Tubectomy which was the most popular method of contraception. Sterilisation being the most popular method of contraception, women tended to adopt family planning only after achieving their desired family size. In the study area, the adoption of family planning methods was highest among those with more than three living children. Preference for sons seems to have had some impact on contraceptives use. Women who had one or two living sons were more likely to use contraception than women with no living son.
  • Children's Health and Nutrition

    Neonatal care
  • More than three-fourths of the babies did not have any complications in the neonatal period. Among those with complications, around 20 per cent received treatment which was provided by a private health facility. The major reason cited for not receiving treatment was that the mothers did not feel the need for it. The majority of the women responded that they had given bath to their babies within 8 hours after the birth.
  • Breast feeding practices
  • Breast feeding was nearly universal in the study population. More than 90 per cent of the children were being currently breastfed up to 15 months. Although breast feeding was nearly universal, only 8 per cent of the mothers initiated breast feeding within one hour of the birth of the baby. The custom of squeezing out colostrums was also prevalent in the study area. About 36 per cent of the mothers reported to have squeezed out milk before first feed. 50 per cent of the mothers had given something (like sugar, water, honey, jaggery etc.,) before first feed.
  • It is advocated that children should be on exclusive breast milk in the first four to six months. The percentage of children on exclusive breast milk in the first four months was only 40. Breast feeding practices among different educational, caste and block types indicated that illiterate respondents were breast feeding their children for a longer duration compared to educated mothers. Similarly, tribal mothers and mothers staying in the tribal block were breast feeding their babies for a longer duration.
  • Complementary feeding
  • Adequate and appropriate complementary foods are to be added to the infant diet starting from age 4-6 months. In the study areas, around 49 per cent of the children had received fluids even before completing the first month. It varied from 60 per cent in HI block to 30 per cent in CB block. Introduction of semi-solids or solids was delayed in the study area. Only 43 per cent of the children age 6-9 months had received semi-solids.
  • Immunization
  • Immunization coverage was far from complete in the study areas. Only 65 per cent of the children aged 12-23 months were fully immunized and around 2 per cent had not been immunized at all. Except for measles, coverage for all other vaccines was above 85 per cent. Coverage for measles was only 69 per cent. Analysis of vaccination coverage indicated that among children of mothers who were illiterate, and for STs, and tribal blocks, proportion of children who were fully immunized was lower.
  • Only 18 per cent of the children in the age group 12-18 months had received first dose of Vitamin A solution, only 5 per cent had received deworming tablets/syrup, and only 17 per cent had iron supplements.
  • Food supplementation
  • Around 38 per cent of the children of less than 6 months age had been brought to Anganwadi Centre, 75 per cent of the mothers with less than 3 months old child reported that Anganwadi worker visited their homes, and 43 per cent of the mothers did not receive any advice from AWW. 32 per cent of the mothers reported to have received food daily, 29 per cent fortnightly and 21 per cent, monthly. 6 per cent of the children did not consume the food received by them.
  • Prevalence and management of Diarrhoea and ARI
  • The information on the episodes of Diarrhoea and ARI during the two weeks prior to the survey was collected. Nearly 23 per cent of the children had diarrhoea in the last two weeks, 24 per cent had ARI and 51 per cent had prevalence of cold, cough. Around 54 per cent of the children had received treatment for diarrhoea and ARI respectively. 64 per cent of the mothers knew about ORS, 24 per cent had correct knowledge about feeding practices during diarrhoea. 95 per cent of the mothers had some knowledge regarding signs and symptoms of diarrhoea.
  • Nutritional Status
  • Based on the weight-for-age index, according to IAP classification, about 41 per cent of the children were undernourished and 34 percent could be so classified according to IRPM.
  • Community participation
  • INHP emphasises active community involvement in their programme so as to ensure that the community assumes the role of a catalyst for action. In this survey, information was collected on awareness and involvement of community members regarding various CARE related activities. 36 per cent of the mothers reported that the Nutrition and Health days (NHD) were held in their villages. Higher percentages of NHDs were held in CB and DS areas as compared to HI and other areas. Women were also aware of various services provided on nutrition and health days.
  • Regarding the involvement of household members in various community related activities, only 38 per cent of the women stated that they were involved in community group activities. Development of Women and Children in Rural Area (DWCRA) is the most popular community group wherein almost 80 per cent of the women reported to have participated. Though community participation was quite popular for income -generating activities, in the area of health, such participation was not as much encouraging. 36 per cent of the households contributed towards some form of community saving scheme. The awareness and participation of various CARE related activities by the community members were analysed with respect to different background characteristics. Awareness about Nutrition and Health days were lowest among illiterate women, ST women and women from urban areas. Other aspects like awareness regarding various services provided during NHDs and participation in various community group activities did not exhibit much variation across different background characteristics.
  • Service Environment of Anganwadi workers
  • Majority of the Anganwadi Workers were residing within the vicinity of the anganwadi centres (72%). Average number of Households and population covered by AWC was 233 and 960 respectively. 42 per cent of the AWCs were close to Sub centre, 54 per cent of the A WCs had a doctor/RMP close by, and 84 per cent of the AWCs had a daily living close by AWC. 91 per cent of the AWCs were visited by ANM during one month prior to date of survey and 65 per cent of the AWCs were, visited by ICDs supervisor during one month prior to date of survey. Block-wise variations in the above aspects indicated that in urban areas only 20 per cent of the AWW were staying within a radius of less than one Km from the anganwadi centre, as against 80 per cent in rural areas and 75 per cent in tribal areas. The average number of households and population covered by AWCs were lowest in tribal areas as compared to rural and urban areas. Urban AWCs had a doctor close by, while rural AWCs had access to dai. Rural AWCs were visited by ANM and ICDs supervisor more often as compared to urban and tribal AWCs.
  • Almost all AWCs had good supply of food items but, supply of medicines was' not adequate. 82 per cent of the AWCs had infant weighing scales, 67 per cent had adult weighing scales and 69 per cent had growth monitoring register. Majority of AWWs had obtained on-the-job guidance or participated in CARE supported activities. Assessment of the knowledge of AWW regarding various activities showed that almost all the AWWs were aware of the importance of colostrum. Only 44 per cent of the AWWs had correct knowledge, about exclusive breast feeding, 77 per cent had knowledge about complementary feeding and 70 per cent had knowledge about right age of administering measles vaccination. A lower percentage of AWW had right knowledge about supplementation of IFA tablets and the number of tablets to be consumed during pregnancy. Majority of the AWWs had knowledge regarding "five cleans" during delivery. Almost 83 per cent of the community members were involved in some health related activities. About 45 per cent of them were involved in transport/monitoring of AWC food or activities related to NHDs. Participation of community members in health related practices like drug banks, production/distribution of DDKs, loans for health reasons was less than 1O per cent.
  • Health providers in the study area reported that on an average they provided services to 50 women/children in a week. The services were mostly curative in nature for .ailments like ARI, diarrhoea etc. However, around one-fourth of them were providing TT immunizations and related antenatal services.
  • One-fourth of Dais in different programme areas were involved in CARE supported activities. Similar numbers reported involvement in NHDs. Only two- thirds of Dais were following the 'Five Cleans' in the safe delivery practice. Participation of community members/health providers/Dais in CARE supported activities in rural and urban blocks was reported by around 10 per cent in comparison to 50 in tribal block.
  • Service environment of ANM
  • Majority of the ANMs reported to be residing within the subcentre area: Average population covered by a subcentre was 4757 and average distance from the PHC was 11.4 Km. Majority of the ANMs reported that they received help from AWWs in carrying out their daily health related activities.
  • Seventy-five per cent of ANMs reported that supplies like IFA tablets, ORS, Vitamin A syrup, deworming tablets, were available. But supplies like condoms, DDKs were reported to be available among 25 per cent of ANMs. Infant and Adul1 Weighing scales were available with only two-thirds of ANMs. Stethoscope and BF apparatus were not available with more than 70 per cent of ANMs. Stock outs were also reported on essential medicines in fifty per cent of Subcentres. ANMs working in DS and HI blocks were more exposed to capacity building activities, as compared to ANMs in CB blocks.
  • 7) STUDY ON HOUSEHOLD HEALTH EXPENDITURE IN RURAL ANDHRA PRADESH

    Summary And Conclusions
  • This chapter recapitulates the salient findings of the study in brief and draws major conclusions.
  • The study of household health expenditure was carried out in Mahabubnagar district of Andhra Pradesh. Mahabubnagar was selected mainly because of its backwardness and proximity to carry out the survey. Four villages in the district under Janampet PHC were selected for the study. .A sample of 1022 households was drawn from the sample villages using systematic random sampling procedure. The data was collected using four types of interview schedules viz: Household Information Schedule, Minor Illness Schedule, Major Illness Schedule and MCH Schedule. Focus group discussions and interviews with local health functionaries private as well as public were held to get better insight into the health problems of the people.
  • Important findings of the study:
  • The study gives an illness report of 16.42% in the sample population of 6252. Of the 1322 cases of illness, 81.8 % suffered from minor illnesses and 18.2 % suffered from major illness. Predominant minor illnesses reported were fever, cold, cough, head ache, body ache, diarrhoea, injuries, eye problems etc. Of those who reported minor illness 20.76% were children below 5 years. An overwhelming proportion of those who suffered from minor illnesses were low income groups with annual income of less than Rs.12,000 and belonged backward castes.
  • Important major chronic illnesses reported were cardio vascular problems, breathing problems, skin diseases, aches and pains etc,. Major communicable diseases reported were typhoid, TB, malaria, jaundice etc. About half of those who suffered from major illness were in the age group of 15-59. Just as in the case of minor illness, majority of the people who suffered from major illness belonged to lower income group. 94.7% of the people with minor illnesses and 91.18% of those with major illnesses took treatment. The utilization of the PHC for treatment was 10.8% in the case of minor ailments and 4.15% in the case of major disorders. Where available private qualified doctors were preferred to unqualified doctors. 60.9% and 23.7% went to qualified and unqualified doctors respectively for treatment of minor ailments. Similarly 77.42% and 13.36% went to qualified and unqualified doctors respectively for treatment of major disorders. The role of unqualified doctors reduced in the case of major disorders. The ANM played a negligible role in treatment of minor illnesses and no role at all in treatment of major disorders. A higher percentage of people in the PHC village used its services compared to those from other villages. Allopathic system of treatment was the first choice (98.5%) for minor as well as major (95.87%) disorders. Ayurveda played a minor role and unani and homeopathic system were not at all used by the people in the survey. The role of herbal treatment and home remedies was negligible.
  • Average direct cost of treatment of minor illnesses was Rs. 84.15. Average indirect cost was Rs.29.56. Highest average cost was reported from Thimmapur -a village where there were no health facilities of any kind whether private or public.
  • As one would expect those who went to private practitioners spent the maximum amount for their treatment (Rs. 131).
  • Average direct cost of treatment for major illnesses was Rs.918 and average indirect cost was Rs. 131.85. Here again highest average cost was reported by the village which did not have any kind of health facility. 'Patients going to private health facility' were found to be spending higher amount on treatment. Surprisingly even those who were going to government hospital for treatment were found to be spending a substantial amount on medicines and transport. Average direct cost of antenatal checkup was found to be Rs. 103.58, and average indirect cost was Rs.117.84. 1he majority (85.9%) had availed antenatal care and 78.6% had taken TT injections. The cost of antenatal care was only Rs.8.4 at the PHC and Rs. 301.5 in the private sector.
  • Majority of the deliveries were conducted at home, and only 4 deliveries were held at PHC. Lowest cost for de-livery was at PHC (Rs.25.0) and highest at private nursing homes. Most of the deliveries were conducted by private health staff followed by dai and government health staff. The cost of having a delivery at home was six times higher (Rs.153.40) than having it in the PHC. The average cost of caesarian section was Rs.3455.55 and nine women had caesarian section during the reference period. Rural households spent enormous amounts on ceremonies and rituals during maternity and infant functions. Almost everybody made use of free government facility for immunization (98%). As for family planning operations, all the cases identified were tubectomy cases. Except for a few all the tubectomy operations were conducted at PHC (83.78%). The average cost for family planning operations was lowest at PHC (Rs.249.2) and highest at private nursing homes (Rs.1100).
  • Conclusion of the study:
  • People in low income rural households spent enormous amount on minor and major illnesses in the private sector.
  • The PHC has a minor role in treatment of minor illnesses and a negligible role in treatment of major illnesses.
  • Subcentres played a negligible role in the treatment of minor illnesses and no role at all in the treatment of major disorders.
  • People preferred to go to a qualified practitioner when available and this preference was higher for major disorders compared to minor illnesses.
  • The subcentre and PHC were utilized highly for preventive MCH services like antenatal checkups and child immunization.
  • The PHC was rarely used for delivery though the cost was very low.
  • The PHC was used most frequently for tubectomy operations, but here too the cost was high -though less than in the government hospital or private nursing home.
  • 8) IMPACT OF RICE SUBSIDY AND PROHIBITION POLICIES IN ANDHRA PRADESH

    Summary Of Findings And Policy Implications

    Abstract

  • Of all the social welfare programmes, food subsidy and prohibition are important interventions in the context of providing food security to the poor and protecting the poor from hardships of alcoholism. Andhra Pradesh is probably the only state in India where populist programmes, namely subsidized rice at Rs.2 a Kg and prohibition were implemented at different time periods, although the policy on total prohibition could not continue for long. Till the implementation of total prohibition in the state in January 1995, the excise revenue on arrack was the second largest source of revenue for the state which d to finance the subsidized rice scheme.
  • The policies on rice subsidy and prohibition are the government interventions it improving the socio-economic well-being of the poor. What are the social and economic benefits that these welfare schemes have brought to the individual and family? What are the views and perceptions of the people towards these welfare measures? To what extent the prohibition policy has been strictly enforced? No government intervention programme will be successful however strong it is implemented, unless the public I supports the policy. These are some of the policy issues which need to be investigated. The present study was, therefore, undertaken with a view to find answers to some queries which have direct relevance for policy formulation and programme implementation.
  • The main objectives of the present study were to elicit views and perceptions of the people on government policies of rice subsidy and prohibition and to investigate whether these welfare schemes have benefited the lower strata of the society. The conclusions drawn in this study are based on data obtained from a sample of 3268 rural households from five districts of Vizianagaram, Nellore, Chittoor, Warangal and Mahabubnagar 15 urban households drawn from the slum population in the cities of Hyderabad and Visakhapatnam. About 1200 addict members were identified from the household survey and a separate questionnaire was administered to them. In addition to the survey data, data on procurement and distribution of rice through POS and procurement and liquor consumption compiled from secondary sources were examined.
  • In the state of Andhra Pradesh, agriculture and allied sectors constitute 36.2 per cent of the Net State Domestic Product. It also provides livelihood for about 70 per cent population. The per capita production of rice increased from 118 Kg in early 1960s in late 1980s and then declined to 135 Kg in early 1990s. The districts comprising of Godavari and Krishna rivers, which recorded high rate of growth during Green Revolution period showed much lower rates of growth in the eighties. The sluggish growth rate of food grains in the state was mainly due to absence of an effective agricultural : policy to boost food grain production in eighties, trend to switch over to aqua-culture and pisi-culture by coastal Andhra farmers and decline in rate of growth of irrigation in eighties as compared to seventies (Parthasarathy, 1995).
  • Prior to 1982-83, the procurement of rice in the state was generally low. After the introduction of 'two rupee a Kg rice scheme' the procurement of rice increased steeply and varied in the range of 2.5 to 3.5 million tonnes. The annual per capita quantity distributed through the PDS varied between 25 Kg and 37 Kg.
  • The subsidized rice scheme was introduced to improve the purchasing power of weaker sections of the society and thereby raise their nutritional standards. According 1993-94 estimates, about 22 per cent of population are living below poverty line in Andhra Pradesh. From the inception of subsidized rice scheme, about 70-80 per cent of household were given green/white ration cards. Hence the benefit of the scheme is enjoyed by non-poor households as well.
  • The network of fair price shops in rural Andhra Pradesh is fairly good with over 00 fair price shops catering to 27,000 villages in the state. The ratio of villages to fair price shops is 1: 1.13. In the state, on an average, there is one fair price shop for every 1750 persons.
  • The distribution of government tax revenues from various sources in Andhra Pradesh shows that the excise duty in absolute term increased almost five times from Rs.35 crore in 1971-72 to Rs.153 crore in 1980-81 and then by almost six times to reach Rs.923 crore in 1992-93. Of the total excise revenue during 1992-93, about 72 per cent derived from spirits (Arrack). In other words, a substantial burden of regressive excise duty was borne by the poor and middle class.
  • The Rs.2 a Kg rice scheme could not be implemented in isolation without taking Count its effects on the economy, rate of inflation and population growth. In the white paper on state finances, deficit was mainly emphasized on account of three populist programmes viz., Rs.2 a kg rice scheme, prohibition and power subsidy. The inclusion of non-poor in the subsidized rice scheme, shift in priorities from development activities to social sector spending, and fiscal unsustainability due to prohibition are the main lessons learnt from the populist programmes in Andhra Pradesh.
  • Detailed information on views and perceptions of the people on government policy on subsidized rice scheme, savings accrued due to availability of subsidized rice, types of food given to children and quality and value of purchase of selected food grains from PDS, open market and home grown stock was collected from the sample of 4800 households. These data were analyzed and key findings are reported in Chapter 3. The proportion of white card holders to total card holders varies in the range of 64 per cent in Srikalahasti mandal in Chittoor district to 92 per cent in Gantyada mandal of Vizianagaram district. In 18 of the 22 mandals, the percentage of white card holders is over 75.
  • About 98 per cent of respondents reported utilization of complete entitlement of the allotted quota of rice. The percentage utilization of entitlement of ration is 26 in case of edible oil, 67 in case of sugar and 98 in case-of kerosene. The borrowing of other's ration card for self consumption or providing one's card to relatives/friends/servants is reported to be very minimal.
  • For the entire sample, the per capita rice consumption is around 12.56 Kg in a month. Out of this total rice consumption, about 67 per cent is met from open market purchase while about 28 per cent comes from PDS supply. The per capita rice consumption varies from 10.6 Kg in Hyderabad urban slums to 14.0 Kg in Vizianagaram district.
  • The extent of PDS support in total rice consumption is 32 per cent in Visakhapatnam and Hyderabad urban slums. In rural districts, it varies from 25.2 per cent in Vizianagaram to 28.4 per cent in Mahabubnagar district. The total per capita rice consumption varies from 9.77 Kg in the lowest MPCE group to 17.52 Kg in the highest MPCE group. The market dependence of household consumption of rice increases with an increase in the MPCE of household; the purchase of rice from PDS is inversely related to the MPCE class Kg for the lowest MPCE class and 4.47 Kg for the highest MPCE class).
  • Data on rice purchases by all households in the sample are used to estimate the e gain due to rice purchase. The per capita income gain varies from Rs.12.81 in Vizianagaram district to Rs.18.95 in Visakhapatnam urban slums. The extent of income gain varies from Rs.12.90 per capita for the lowest MPCE class to Rs.20.94 for the highest MPCE class.
  • The views of respondents on changes in government policy on rice subsidy were in the survey. They clearly indicate that public opinion is strongly against any the price of rice and an overwhelming majority of respondents suggested a price of Rs.3 to Rs.4 and 16 per cent suggested a price of Rs.4 and above if full requirement of rice is made available by the government through PDS.
  • According to our survey data, a significant percentage of users of PDs are non- poor. Our estimates of target ratios indicate that the leakage of PDS to non-poor is about 60 per cent for the entire sample. This level of leakage varies from 55 per cent in Vizianagaram district to 72 per cent in Warangal district. This clearly indicates that a substantial number of non-poor are availing of rice subsidy right now. These findings have important policy implications. First, there is a need to correctly identify the target group of beneficiaries by weeding out non-eligible cards so that the benefits of subsidy go to the real poor. Second, by reducing the percentage of white card holders (self targeting), full requirement of rice consumption may be supplied to the white card holders at higher price since about 60 per cent of respondents in the survey expressed their willingness to pay higher price per Kg of rice in the event of government supplying full requirement of rice through PDs. These are the two issues which need urgent consideration by the government for the rice subsidy scheme to sustain for longer period.
  • Respondents were asked how the savings were spent in the form of expenditure because of availability of subsidized rice. About 96 percent of respondents reported that households savings were spent mainly for food consumption, 16 per cent reported on clothing, 3 per cent reported on entertainment and only 2 per cent reported cash savings.
  • About 52 per cent of respondents reported reduction in consumption of coarse cereals and shifted to rice after the introduction of rice subsidy scheme. The shift from coarse cereals to rice was also observed in all the socio-economic subgroups, although extent of shift varies from one subgroup to another.
  • Information regarding normal food given to children at home and any change in consumption of food from nutritious coarse cereals to rice was collected from the sample households. The usual food given to majority of children is rice preparation (88 per cent) wed by vegetables (77 per cent) and milk (33 per cent). The district wise data indicate that rice preparation is given to 82 per cent of children in Warangal district and 94 cent in Hyderabad urban slums. About a third of respondents in Visakhapatnam reported that they give starch (kanji) to their children. In Chittoor district about 11 per cent of respondents reported that their children are given ragi preparation. In Hyderabad urban slums, about 44 per cent said that their children are given wheat preparation. With economic status and shift in occupational structure from manual to white collar occupations, people tend to change their food habits and give wheat, egg and bakery food to their children.
  • Another populist programme introduced by the Government of Andhra Pradesh is prohibition policy which came into existence in January 1995 as a result of massive women's anti-arrack movement which started in Nellore district and spread throughout the state. All men (husbands) and women (wives) were interviewed and information on their perceptions of prohibition policy and benefits of prohibition was obtained.
  • The views of female respondents about the impact of prohibition in reducing liquor consumption were obtained. They reveal that the percentage of respondents consuming liquor declined to 31 from 35 during the period before and after the introduction of prohibition. However, the percentage of arrack consumers has declined significantly from 14.2 to 7.4 and toddy consumers increased from 19.4 per cent to 23.3 per cent. The percentage of liquor consumers has declined significantly in Visakhapatnam (28 to 15) and Vizianagaram (19 to 13), moderately in Chittoor (19 to 16) and Nellore (26 to 22) and negligibly in Hyderabad (39 to 36) and Mahabubnagar (55 to 54) district.
  • All the districts recorded declines in the level of arrack consumption during the pre and post prohibition period. A substantial decline recorded in the districts of Mahabubnagar and Visakhapatnam to the extent of 80 per cent. Vizianagaram and Nellore recorded moderate decline of about 55 per cent and the other three districts showed only marginal decline between 21 per cent in Warangal and 40 per cent in Hyderabad.
  • In order to get an idea of respondent's views on prohibition policy, information was collected from both husbands and wives. About three quarters of female respondents and 56 per cent of male respondents expressed their opinion in favour of implementation total prohibition. A significant proportion of male respondents (29 per cent) as compared to female respondents (17 per cent) expressed their opinion against prohibition. The pattern of difference between male and female respondents in their perceptions towards prohibition policy remains the same when data are classified by other background variables.
  • About 40 per cent of female respondents and 46 per cent of male respondents mentioned that prohibition policy has no impact and that liquor consumption continued to prevail in their locality. Respondents felt that prohibition has given way to illicit brewing. About 60 per cent of respondents in Visakhapatnam and about 65 per cent in Warangal reported availability of illicit liquor in their areas.
  • As toddy is permitted under dry law policy, about 34 per cent of female and 37 per male respondents reported that ban on liquor created an additional demand for and increased the household expenditure for the purchase of toddy. About 30 per cent of respondents (both males and females) reported that a shift to 'Gutka' and other intoxicants has occurred as a result of ban on liquor.
  • One of the major benefits that prohibition brings to the family is improvement in husband-wife relationship and reduction in family quarrels. About two-thirds of respondents have reported reduction in family quarrels. The extent of reduction in family quarrels as reported by respondents is highest in Mahabubnagar district followed by Nellore. About half of the respondents reported that the head of the family spends more time with children. Less than two-thirds reported improvement of health condition of children in the family. About two-thirds of both male and female respondents reported that prohibition had an impact in reducing the incidence of wife beating from moderate to significant extent.
  • In the present survey, all those persons having ever consumed liquor were identified as addicts and a separate questionnaire was administered to 1151 households in the sample districts. Nearly a quarter of households are identified as addict households. The rate of addiction is highest in Scheduled Tribes {32 per cent) followed by Scheduled Castes (28 per cent), Backward Castes {23 per cent) and Others (13 per cent). By occupational groups, the rate of addiction is highest among agricultural labours (24 per cent) and lowest among self employed in non-agriculture (16 per cent). The percentage of addict households increases steadily from 13.5 for the Group 1 (MPCE less than Rs.175) to 48.5 for Group 5 (MPCE more than Rs. 350). There exist a consistent and direct association between economic status and level of addiction. The extent of addiction is directly related to the size of the household. The proportion of addict households increases steadily from 20 per cent among 2 member households to 31 per cent among large size house- Ids of more than 7 members.
  • Age is an important biological variable which influences the behaviour of individual. Half of the addicts are aged between 25 and 44 years, slightly more than 26 per tare in the age group 45-54 years and about a fifth (21.2 per cent) are over 55 years of .Although inter district variations are noted, in all districts the addicts are mostly in working ages 25 and 54 years.
  • Most of the addicts are currently married and illiterate without any schooling. Most of the addicts are heads of the households. An overwhelming majority of addicts are labourers. The proportion of addicts employed as labourers (both in agriculture and non-agricultural) varies from 78 per cent in Hyderabad urban slums to 96 per cent in Nellore.
  • A majority of addicts (69 per cent) reported that toddy is available from the same village, but arrack is reported to be available from the same village only by 32 per cent. It is important to note that the percentage of respondents not reporting the place of getting alcohol is 27 in case of toddy and 55.4 in case of arrack, respectively.
  • For the combined sample of all districts, the number of arrack consumers declined by 40 per cent. However, there has been 14 per cent increase in the case of toddy consumers. The extent of decline of arrack by background variables varies from 40 per cent to 100 per cent. The data suggest that the prohibition policy has been partially effective in reducing the number of addicts.
  • The quantity and frequency of arrack consumption for the entire sample indicate a decline of 42 per cent in average quantity consumed and a decline of 47 per cent in average frequency of drinking. The extent of decline of 95 per cent in quantity consumed and 98 per cent in frequency of drinking is observed in Mahabubnagar district. A decline of about 50 per cent is reported in Vizianagaram, Nellore and Visakhapatnam urban slums. Moderate declines have been observed in the districts of Chittoor (23 per cent) and Hyderabad (40.5 per cent). In the district of Warangal arrack consumption declined by 3 per cent and the average frequency of drinking declined by 6 per cent. In most of the districts, addicts switched over to toddy drinking during prohibition period but they occasionally consumed illicit arrack. It is quite evident from the data that illicit arrack was available in most of the districts and particularly in the districts of Warangal and Chittoor where a majority of addicts continue to consume arrack with reduced frequency during prohibition period.
  • The decline in arrack consumption is directly related to economic status, the percentage reduction in quantity consumed declines consistently with rise in economic status. The largest decline of 72 per cent in arrack consumption is observed among addicts Group 1 with MPCE below Rs.175 and the smallest decline of 20 per cent in the MPCE above Rs.350.
  • All addicts were asked a series of questions to get their views on benefits of prohibition. The impact of prohibition is assessed in qualitative terms as reported by addicts. The addicts were asked to state whether the standard of living in their households has improved due to prohibition. About 70 per cent of addicts reported no change, 19 percent reported moderate improvement and 9 per cent reported significant improvement. Both Mahabubnagar (55 per cent) and Vizianagaram (33 per cent) stand out as districts significant proportion of addicts reported moderate to significant improvement in the standard of living of their households occurred as a result of implementation of prohibition. When addicts are classified by economic status in terms of MPCE, a significantly higher proportion of addicts from lower economic group reported moderate to significant improvement in the standard of living as compared to addicts belonging to upper economic strata.
  • Although a majority of addicts (73 per cent) reported no change in the consumption of milk in the household as a result of prohibition, a significant proportion of about 38 per cent of addicts reported an increase in milk consumption in the househo1d. A relatively large proportion of addicts (27 per cent) from MPCE less than Rs.175 reported increase in milk consumption as compared to other MPCE classes.
  • The addicts were asked whether prohibition brought any household savings. For the combined sample, about four-fifths of addicts reported no increase in household savings. About 27-28 per cent of addicts in Visakhapatnam and Mahabubnagar districts re- ported increase in household savings. About 22 per cent of addicts from MPCE class less than Rs 175 reported moderate to significant household savings as compared to 11 per cent in the highest MPCE class.
  • One of the social benefits of prohibition is that the savings accrued due to reduction in liquor consumption may be invested to improve children's education. About 51 per cent of addicts in Hyderabad slums and 25 per cent in Vizianagaram felt that there was an improvement in children's education.
  • Reduction of domestic violence is considered to be an important social benefit of prohibition. For the entire sample, 32 per cent of addicts perceived moderate reduction in domestic violence. Fifty per cent of addicts reported no change. The district wise data indicate that a significant proportion of addicts (60 per cent) from Mahabubnagar district reported reduction in domestic violence from moderate to significant level.
  • The addicts in the sample were asked whether there was any improvement in their health status as a result of reduction in frequency of liquor consumption. About 40 per cent of addicts in the total sample reported improvement of their health from moderate to significant level. The percentage of addicts reporting improvement of health varies 27 in Warangal district to 50 in Nellore district.
  • Overall, the implementation of prohibition in the state had a social impact to the individual and family as reported by the addicts in the sample. A significant proportion of ranging from 20 per cent to about 40 per cent reported moderate to significant improvement in living standard of household, increase in milk consumption by household members, household savings, improvement in children's education, improvement in health status and reduction in domestic violence. Due to short period of prohibition of a year and a half in the state the perceptions of social benefits of prohibition to the family and individual are not widespread among addicts in the sample.
  • Data on fertility and MCH care were also collected in the present survey. The information covered fertility, antenatal care received by all mothers whose living children are under 5 years of age, pregnant women receiving tetanus toxoid injection, place of delivery and immunization particulars of children below 5 years of age. Analysis of these data and the results are not presented in this report.
  • However, the preliminary analyses of data reveal that 78 per cent of mothers in the sample received antenatal care. Similarly, women received two doses of tetanus toxoid injection during pregnancy for about 80 per cent of births. About 55 per cent of births are delivered at home and about 38 per cent of such deliveries are not attended by trained medical professionals such as a doctor or a nurse/midwife.
  • Regarding immunization of children, the universal immunization programme has achieved only limited success in the state. According to our sample data, only 50 per cent of children ages 12-23 months are fully immunized against six common childhood diseases. Further, only about one third of mothers were able to show the immunization cards of their children to the interviewers. Levels of immunization coverage are directly related the percentage of mothers possessing the vaccination card.
  • These findings have important policy implications in the context of achieving 100 cent immunization coverage, improving nutritional level of mothers and children and providing food security at cheap price to the poor. There is a clear need to create awareness among the couples about the importance of antenatal care, immunization of their children and the need to preserve the vaccination card. Since mothers give utmost importance to preserve the ration card (white card), it would be a wise idea to combine the vaccination card with green card so that the vaccination cards can be preserved by the mothers. This would certainly improve the immunization coverage, especially among the lower economic strata of the society where the immunization coverage is generally low.
  • 9) MATERNAL MORTALITY IN FIVE DISTRICTS OF ANDHRA PRADESH

    Executive Summary
  • A three-stage community-based project on maternal mortality was undertaken in five districts of Andhra Pradesh, namely: Ad1labad, Anantapur, Karimnagar, Mahaboobnagar and Vizianagaram, for a period of one year. In brief, the objectives of the study were to: identify maternal deaths, conduct a detailed analysis of the identified maternal deaths through case studies and to design and implement feasible and realistic interventions to reduce maternal mortality in selected PHCs.
  • Maternal death was operationally defined as, "The death of any woman aged 12 to 50 years, either married or unmarried, starting from the first known time of pregnancy to 42 days after delivery due to any cause -obstetric, indirect, associated/medical or accidental and socio-cultural."
  • The study was conducted in three stages: Firstly, survey on maternal deaths was done in the project area through key informant interviews, record analysis and grapevine method. Secondly, the deaths were confirmed through verbal autopsy method and expert opinion of clinicians based on case sheets filled by staff. Case studies were conducted of deaths within last six months to the time of survey to analyse, the social, physical and health related processes involved in maternal death. Thirdly, situation-specific and community-based interventions were designed in a participatory manner and implemented for six months. The interventions are planned to be continued.
  • Three PHCs were selected from each of the five districts ensuring representativeness. The total population covered was 580,770 in 577 habitations. In the first stage a survey was conducted in all the 577 villages with the help of six trained investigators and two supervisors. Key informant interviews, record analysis and village grapevine techniques were used to gather information on births, deaths and maternal deaths during a reference period starting from April 1995 and ending with December 1996 or January, 1997. The confirmed maternal deaths were analysed and compared to the actual births, estimated births and maternal deaths for the project area for the year 1995-96.
  • Summary of the Findings

    A total of 132 confirmed maternal deaths were identified during the period with 69 deaths in the year 1.995-96, and 63 deaths during the incomplete year in 1996-97. The highest number of maternal deaths occurred in Mahabubnagar (35) and Adilabad (34), and the least in Anantapur (18) and Karimnagar (15). The ratio of maternal deaths to live births was 7.12 per 1000 live births. There was inter district variation with 10.88 in Mahabubnagar, 9.72 in Adilabad, 7.09 in Vizianagaram, 4.. in Anantapur and only 2.37 in Karimnagar. A high level of under-reporting of maternal deaths was observed in official records and reports. Some districts (Karimnagar and Mahabubnagar) reported no maternal deaths at all during entire years for the total district. Only 9 out of the 132 confirmed deaths were noted in subcentre or PHC records.

  • More than half of the deaths had taken place in the home and ten percent took place on the journey to hospital. Only a third of the women reached a hospital before death.
  • Nearly 20% of the deaths were of women less than 20 years.
  • More than half of the women died during the postnatal period (56.81%).
  • Half of the 132 maternal deaths occurred among women belonging to scheduled castes and scheduled tribes (28.780/u and 21.96% respectively). A very high per- cent of scheduled tribe women (78.94°fu) died in their homes with only 13.330/u reaching a hospital. Comparatively, 40 to 60% of women from other caste groups reached a hospital before death.
  • he mother's death had a drastic effect on the child. Of the 62 live born children to mothers who died, nearly half died within a year (47.56%).
  • September to November appeared to be peak months for maternal deaths in the project area.
  • More than half of the maternal deaths had taken place in small villages with population upto 1500. A quarter of the maternal deaths occurred in very small villages and hamlets with population upto 500. Often these were also the most interior tribal habitations.
  • Obstetric factors were the largest (71.96%) leading causes of maternal deaths. The triad of hemorrhage, eclampsia and puerperal sepsis accounted for 53.0% of the deaths.
  • Haemorrhage was the leading maternal killer which was responsible for the death of 21.20% of women. Eclampsia was next and was the cause of death in 18.18% of women. Puerperal sepsis was the cause of death in 13.63% of women. Besides the three maternal killers, obstructed labour and problems during delivery were responsible for 11.36% of deaths.
  • Hepatitis and anaemia were together responsible for the death of 15.15% of the women.
  • Associated medical causes were responsible for 8.33% of the maternal deaths.
  • Sociocultural factors like suicides, accidents and snake/scorpion bites were responsible for the death of 4.54% of the women.
  • Case Studies
  • Three case studies are presented in the report. These refer to the cases of : Pothuraju Vijayal: Too many wrong decisions ended her life Srisaila: Too weak and too late to seek help Kalamma: Looking for a better life

  • The three case studies demonstrate the broader realm within which maternal mortality takes place. The processes leading to death depict that majority of the factors leading to maternal death are outside the sphere of control of the woman or her family, and that solutions are to be sought within the community, social and health system rather than the individual pregnant woman. Single shot technological interventions may be helpful for some- time but may not be sustained without community participation. Care should be given throughout the three maternal stages and not only during the antenatal period. The whole women has to be nurtured, not the maternal alone.
  • Case studies also helped in sensitization of the staff since each one was assigned a case to do indepth analysis and conclude the reasons for death. Presentation and discussion of cases was cathartic. Staff also discussed the case in the village and an informal enquiry was conducted.
  • Interventions
  • Interventions were implemented in three PHCs of Mahabubnagar district. This district was chosen since it had the largest number of maternal deaths and was also considered the most backward district in the State. The objectives of the intervention stage of the project were to design situation-specific need-based interventions through active participation of community, dais and staff; to implement interventions through community support, review progress and redesign interventions for up scaling based on the outcomes. Participation was the overriding principle in the intervention stage.
  • Steps followed in intervention phase were:
  • 1. Designing interventions through situation analysis, prioritization of problems, identification of solutions and preparation of action plan
  • 2. Implementing interventions through administrative actions, and PHC level and community based activities
  • 3. Reviewing, evaluating and redesigning interventions through monitoring committee, seminars and workshops and analysis of outcomes
  • A situation analysis was done of the three PHCs - Janampet, Kodair and Padra - with all the staff and district administrators participating.
  • A profile of each PHC was prepared and maternal deaths were analysed. Problems, responsibilities and accountability related to maternal death were discussed.
  • Action plans were developed with each PHC working in groups with the help of project staff.
  • A list of specific interventions were proposed based on the situation Village-level meetings were held in villages to inform people of maternal deaths and discuss measures for reduction.
  • Areas of thrust of the situation-specific interventions
  • Kodair - Improved services by skilled dais who understand basic concepts and are self confident in dealing with problem situations.
  • Padra - Staff knowledge and skill enhancement with improvement in motivation through sensitization sessions.
  • Janampet - Round-the-clock delivery services at the PHC with referral linkages. Interventions were implemented for six months initially and are planned to be continued.
  • Salient outcomes of the interventions:

    Village-wise maternal record by dais is being maintained, especially in Kodair Round-the-clock delivery service in one PHC at Janampet is continued Rise in reporting maternal death compared to other PHCs in the same district. More than 50% of Dais trained and helped to gain confidence Staff trained and sensitized in all PHCs on maternal deaths Perceptible reduction in maternal deaths in the three PHCs compared to last year Increased awareness and participation of community

  • 1. The period of study was short -less than 2 years for survey and only six months for interventions. A request was placed to the funding authorities to permit ex- tension and this has been agreed to.
  • 1. The period of study was short -less than 2 years for survey and only six months for interventions. A request was placed to the funding authorities to permit ex- tension and this has been agreed to.
  • 2. The number of PHCs covered was only 15, i.e. only three in each district. Had a different sampling been adopted and more districts taken, probably the information would have been more representative.
  • 3. Information on births and deaths was not full proof since this was not the major focus of the study and a system of adding on to official records and taking the aggregate was followed.
  • 4. There were several problems in the identification of cause of maternal death due to non technical field investigators. Often the information on the preliminary report form was inadequate.
  • 5. Urban areas were not included in the study.
  • 6. Interventions were implemented in three PHCs for a period of 6 months only.
  • Conclusions of the Study:
  • There is a high level of under reporting of maternal deaths in the community and therefore hospital deaths alone cannot be taken to infer maternal mortality figures at any level-district, state or country.
  • The roots of maternal mortality are in social and cultural inequalities and therefore the problem of maternal mortality should be tackled at the most basic social level with gender equity, more equitable distribution of services throughout the maternal period and services closer to the home than in hospitals.
  • The strategy in the three PHCs has shown that there is great potential in the field to tackle the problems. This study has shown that community level interventions are feasible and effective. There is a positive response from community for participation and monitoring. The concept and model use in this study can be replicated.
  • Staff can be motivated and sensitized to perform better and their interest can be sustained through systematic resources. Dais are eager to share experiences and look for leadership in organizing them- selves in order to provide better services and improve their self image. Dais are capable of accurate reporting (oral) and can monitor the women under their care.
  • 10) MEENA COMMUNICATION PLAN IN AP(SPONSORED BY UNICEF)

    Execute Summary
  • Need based IEC strategy has been hall mark of Meena Communication Initiative. It was conceived with the primary goal of sensitizing the community on the issues relating to girl child and also reveal the vast untapped potential of the grossly neglected and discriminated girl child. Indian Institute Health and Family Welfare (IIHFW), in collaboration with UNICEF, and with active support from Department of Women and Child Development and Department of Health & Family Welfare, Govt. of Andhra Pradesh, has undertaken a research project entitled ‘Meena Communication Plan in Andhra Pradesh’. The core objectives of the Meena communication Initiative were to create concerning the girl child through planned IEC activities carried out by trained field level functionaries, to increase the awareness of ICDS and Health functionaries by ensuring incorporation of girl child issues in their in-service training curriculum and to assess the impact of IEC on the community
  • Orientation training under 'Meena communication Plan’ to one hundred and five faculty members representing District Training Teams and Regional Training Centres of Health and Family Welfare, and Anganwadi Training Centres of Women and Child Welfare, Government of Andhra Pradesh on girl child issues and gender sensitization under Meena communication Plan yielded positive results. Based on the feedback, it was found that gender related issues, IEC material including video films on Meena are now part of their ongoing training programmes and other community based IEC activities, thereby effectively carrying forward the intended messages of social change.
  • The field study component of the project was confined to Anantapur and Mahabubnagar districts of Andhra Pradesh. Forty randomly selected villages under Peddavaduguru and Koilakonda mandals served as experimental areas and ten randomly selected villages under Hanwada and Gooty mandals of Anantapur and Mahabubnagar districts served as control areas respectively.
  • The study was carried out in four stages. In the first stage baseline data were collected from randomly chosen 1110 adult respondents and 1000 child respondents representing both experimental and control areas.
  • In the second stage IEC material required to carry out the communication activities was developed and replicate. The IEC material include eight animated video films on Meena; a facilitators’ guide, explaining the methods for usage of eight animated films in an interactive way and the means of ensuring feedback; four multicoloured posters on themes viz., (i) Girl child education (ii) Age at marriage (iii) Nutrition and (iv) Personal and Public Hygiene; four multicoloured pictorial booklets on subjects like (i) Diarrhoea Management (ii) Education (iii) Personal & Public hygiene and (iv) Nutrition; and a folder on ‘Meena Communication Plan in Andhra Pradesh’.
  • In the third stage, Community based IEC activities were carried out for a period six months sin the selected experimental study areas. A series of video films with animated cartoon character Meena as a social activist – a charming & dynamic catalyst was used to counter the social evils, bring awareness in the community regarding need to educate the girl child and advocate the rights of the girl child. Because talking to the community about Meena was found to absolutely necessary.
  • The pre-conceived notions which exist in the community towards girl child, have to be effaced.
  • The Meena initiative was hence targeted at the fathers and mothers, brothers and sisters, uncles and aunts, neighbours and relatives, teachers and students, friends and foes of immeasurable Meenas out there waiting desperately for resuscitation. Hence all the IEC activities revolving around Meena were carried out through well trained field functionaries like anganwadi workers, health functionaries, mother’s group leaders, literacy volunteers, NGO representatives, youth leaders and school teachers. Active collaboration of Directorate of Field Publicity and Song and Drama division of Government of India was sought in carrying out community based IEC activities. The priority areas in the communication plan include rights of the girl child, education, health, nutrition, water, sanitation and environment. Distribution of pamphlets, screening of video films on ‘Meena’ for the community members and children, use of folk forms like ‘Harikatha’ Performances, display of posters developed under the project as well as supplied by Women and Child Development department and use of pictorial booklets on Meena by children, public meetings, sport events, competitions, rallies, exhibitions etc., set the desired tone for discussion or debate on girl child issues.
  • In the fourth and final stage, a repeat survey was conducted to assess to impact of the communication activities under the project.
  • The socio-economic profile of the subjects indicated that more than half adults were illiterates and belonged to backward casts. Most of them were found to be from poor economic background.
  • Parents who ranked their daughters initially low on positive personality traits like self respect, self confidence, decision making power, courage, general intelligence being tidy, truthful, cheerful, gregarious etc., ranked them significantly higher on all these traits in the post IEC intervention period. A similar trend was observed the responses given by girl children, who ranked themselves on par with boys on all these traits after the educational intervention. This clearly indicates the efficacy of IEC intervention in boosting girls' personality.
  • Parents also noticed a marked improvement in the health and hygiene practices of children in general, slightly more in their daughters in particular due to IEC interventions under the project. These habits include daily brushing of teeth, taking bath, wearing only washed clothes etc.
  • Though, overall both boys and girls obtained improved scores for health and hygiene habits, there was not much of change in certain habits like washing hand with soap after defecation, footwear usage and cutting nails periodically due to Meena IEC intervention. Focus group discussions conducted on community members had revealed information pertaining to some problem areas. Though most of the girls enrolled in schools, the fact that they continue to work in hazardous pesticide ridden cotton fields and stone cutting work in quarry fields came to light through focus group discussions.
  • Focus group discussions had shed light on community's perception on girl child as depicted in the several off repeated local sayings/ proverbs. They are 1. Bringing up daughter is like watering the neighbour’s garden, 2. Female crop is the normal crop, Male crop is the commercial crop, 3. Where should the poor man get the dowry from?, 4. It is better to be tree in the jungle rather be born as a girl, 5. A girl's life is akin to a banana leaf, 6. The birth of a girl child is the beginning of adversity. 7. A girl's life is a sheer waste 8. A girl is a rabbit in the kitchen, 9. A girl is a doll in the market place, 9. A girl can be bought with money, 10. Why let girl study? to work, or to rule the world? 11. Never believe the laughing woman, 12. Girls take birth to change 'Gotras', 13. Man is spoilt by staying indoors. Woman is spoilt by being outdoors, 14. A woman is a caterpillar, A man is a butterfly…….. and many more. In fact these sayings or proverbs were effectively used during IEC intervention period in the study villages to depict the plight of girl child in our society.
  • Parents were seen to change their perceptions on girl children after educational intervention. Most of them had agreed to the need for providing higher education to the girls. Similarly most of them also declined to show preference for sons in the post IEC intervention period and instead they had developed keen interest in the girl's welfare. After the intervention most of the parents stated that they started treating both daughters and sons equally. Similarly majority of the adults also realized that daughters are more hard working than sons. Similarly majority of the children accepted that girls can also compete with boys. Both adult as well as child subjects unanimously agreed for the need for stopping discrimination against girl child. Most of the parents were able to perceive the existence of gender discrimination at least in the areas of food distribution, imparting education, early marriage and employment opportunities due to IEC interventions. Children also showed remarkable change in perceiving the problems of girls are concerned. Now they are more aware of gender discrimination existing in the realm of teaching, general treatment, meting out punishments etc. IEC intervention perhaps taught them to become more assertive and vocal.
  • Meena communication plan, though in a small way, had a positive effect on enrolment girls in school and in controlling school dropout rate. Most parents as well as children evinced keen interest in the formal schooling.
  • The IEC intervention also affected working regimen of girl children. Those going out to work for earnings or for additional income, were seen to discontinue working and started studies instead.
  • Yet another positive influence of the Meena communication plan on adult's psyche was the belief that their daughter's have to be married, not merely on the basis of attaining menarche, but only either after completion of studies or becoming self dependent.
  • The absence of fun, play and toys in the life of the children studied, cluing pre as well as post IEC intervention periods was both shocking and distressing. Greater recreation and free time for play among children for their proper development has to be brought home to the parents in future IEC activities. Lack of formal schooling and relentless working schedule stresses the need for new awakening among the community as regards the poor plight of the working children. Deliberate and sustained initiatives similar to Meena may prove to be an effective tool in this direction.
  • Though given high preference, only half of adults respondents and a quarter of child respondents actually utilized the regular mass media channels like Television and Radio to obtain information pertaining to gender discrimination. Most parents as well as children could not only recall the various channels used under the project, but also the core messages on issues relating to girl child. The most sought after and popular ones among both adults and children were found to be the video films and other IEC material on Meena. A majority of the adult respondents were aware and also participated in various IEC activities being organized under the project like Public meetings, group discussions etc. Similarly majority of children also participated in various sport events and competitions enthusiastically. Their active involvement underscores the importance of a useful IEC intervention like the present one.
  • About half of adult respondents participated in group discussions organized mostly by anganwadi workers, village elders and mothers' group leaders, however majority of the children mentioned about their participation in group discussions organized as a part of IEC activities by school teachers or anganwadi workers.
  • Most of the subjects of the study population could recall the essential messages conveyed mainly through Meena video films and other IEC activities organized under the project. These messages included need for removal of gender discrimination, Girls also need education, Child's nutritional requirements are not based on gender, Use of ORS to control diarrhoea, No gender bar to obtain loan from a bank, Legal age at marriage for girls and Boys, Girls should be more courageous, Offering and acceptance of dowry is punishable under law and Essentiality of personal/ public hygiene and Potable drinking water for good health. Similarly though, most of the parents of study population realized the importance of a). schooling and studies for girls, b). keeping the surroundings clean and tidy and c). maintenance of personal hygiene, only a small percentage of respondents actually implemented the essence of messages like admission of the children into either bridge school or regular school, not sending their children to work or at least continuing both studies and work.
  • Various IEC activities under the project conducted at the institutional and community levels received wide publicity both by the electronic and print media. Video films on Meena were telecast under the teleschool programme of Doordarshan Kendra, Hyderabad. In addition, local cable TV networks of study areas have also telecast all the episodes of Meena video films. Educational Media Research Centre, Hyderabad documented all the IEC activities carried out under the project and produced an educational programme entitled 'My Rights and Dreams' which will be telecast under the Country Wide Class Room chunk of Doordarshan Kendra (Television India) in due course. All the local newspapers widely covered the events under the project.
  • The overall impact of IEC interventions under Meena Communication Initiative was more than satisfactory, as vast majority of children could recall the messages given to them. However they could not persuade their parents to convert these messages into action. The parents of majority of working children perhaps refused to enroll them in schools. Most of the children, though enrolled in schools, were seen attending their work and earning money. This finding under covers the need for more vigorous and sustained IEC activities involving departments of education, labour, women and child development and health. Such intensive, behavioural change striving programmes should be targeted at adults in the community and at home to achieve the desired goal.
  • 11) CARE-INTEGRATED NUTRITION AND HEALTHPROGRAMME MID TERM EVALUATION –QUANTITATIVE SURVEY IN ANDHRA PRADESH

    Executive Summary

    CARE-INDIA has started Integrated Nutrition and Health programme (INHP) in 1996 with the objective to work with government and non-government partners to improve the health and nutrition status of women and children. CARE-India has adopted a four-pronged strategy for implementation of programme and divided the area under the programme into four blocks viz., High Impact (HI), Capacity Building (CB), Basic Nutrition (BN) and Food Monitoring (FM) blocks.

  • 1. In High Impact areas, it aims to demonstrate that communities can continue with the existing structures and systems to increase coverage rates and improve' community health and nutrition status.
  • 2. In Capacity Building areas, it aims to demonstrate that counterparts can implement high impact strategies which enable communities to achieve health improvements following capacity 'building and action plan sessions.
  • 3. In Basic Nutrition areas, there is a systematic transition from existing activities which monitor the receipt of food by the Anganwadi Centre (AWC) to improved targeting and monitoring of food received by eligible women and children.
  • 4. In Food Monitoring areas, the aim is to increase participation, of counterparts to make more efficient the monitoring, management and movement of food commodities.
  • A baseline survey was conducted in September 1996 to establish initial status against which programme achievements could be measured. IIHFW was identified to conduct the Mid- Term Evaluation (Quantitative Survey) in the state of Andhra Pradesh. FRHS, Ahmedabad has co-ordinated the activity as Nodal agency. The evaluation design involved a population based survey. The methodology adopted for sampling was the cluster sampling method. One cluster represented a related A WC area. Social mapping technique was adopted to ensure representation of all communities and areas of A W centre. A client questionnaire, a village profile questionnaire and an ANM questionnaire were used as survey instruments. Subsequently, a population based survey was conducted in six districts of AP in November-December 1998. The salient observations based on the survey focussing on key outcome indicators are discussed below. These indicators are based on key intervention areas like prevention and rehabilitation from malnutrition; women’s health and nutrition; and prevention and management of infection.
  • A total of 1603 of children under two years (Index Children), belonging to two HI, two CB, on, SN and on, FM blocks were covered. In the process 32,112 population was surveyed.
  • Fifty four percent of the Index children have normal nutritional status as per weight for age while rests were in different grades of malnutrition. Severe forms of malnutrition were observed in only 5 percent. A 10 percent reduction in the malnutrition rates was observed both in HI-1 and CB-1 blocks when compared to the Baseline situation. Supplementary food was received by 60 percent of mothers during index pregnancy. Majority (75 percent) of these women did not share the supplementary food received from AWC with others. About 50 percent of lactating mothers have received food from AWCs. Fifty seven percent of Children between 6-23 months have received supplementary food in the week prior to the survey. About 20 percent increase in the receipt of supplementary food was noted in HI-1 block when compared to BLS.
  • Breast feeding was initiated in 89 percent of children within first 3 days of birth. While the percentage of breast fed within first six hours was found to be only 50 percent. There is an increase between 12-40 percent in the initiation of breast feeding with first six hours in HI-1 and CB-1 blocks at MTE. Exclusive breast feeding for first 4 months was observed only in 34 percent of children. Complementary feeding with mushy food at age 6-9 months was observed in only half of the children.
  • Fully immunized children according to UIP cards and mothers response was observed in 54 percent of children between 12-23 months. About 7 percent remained not immunized.
  • About 95 percent of mothers received antenatal care, during index pregnancy. Ninety three percent of mothers have received 2 doses of Tetanus Toxoid injections during index pregnancy. Iron and Folic Acid tablets were distributed to 70 percent of mothers. But one-fourth of them received required 100 tablets. Even the consumption of 100 IFA tablets was observed in only 23 percent of mothers. Consumption of 100 IFA tablets remained same as in BLS even in HI-l and CB-l blocks.
  • About two-thirds of the deliveries have occurred at home. Among these about 40 percent were assisted by untrained persons.
  • Terminal methods of family planning was adopted by about 34 percent of the parents. Tubectomy was the choice of sterilisation most preferred among these. Male sterilisation was preferred to a higher level in HI-2 and BN blocks. Current use of spacing methods was observed in only 2 percent of parents.
  • Vitamin A supplementation remained to be as low as 3-15 percent among children of different age groups.
  • Prevalence of Diarrhea and ARI in the proceeding 2 weeks of the survey was noted in 16 and 19 percent of the children. Less than one-fourth of the children suffering from diarrhea were administered ORS. Three-fourth of the children suffering from ARI were taken to health providers for necessary care.
  • About 10 percent of households have been participating in the community groups: About two-third of women have taken health related loans. Two percent of households have started borrowing from community grain banks.
  • Thus the Mid-term Evaluation quantified the coverage of health and nutritional services in 90 Anganwadi Centers in CARE operated INHP blocks in 6 Districts of Andhra Pradesh. After analysis the Investigators have made recommendations for enhancing the functioning AWWs through in-situ / institutional training, supportive supervisory services, increase coordination with ANMs, ensuring food security at home level and community gardening etc. It is felt that MTE could not capture the community participation of different intensities / grades in these blocks. Investigators have identified the constraints about the results at MTE for drawing inferences and suggested necessary caution in interpreting the data. The agency felt that the observations of MTE must be used as benchmark for future studies.
  • In conclusion, CARE-INHP in Andhra Pradesh has made good beginning in these two years of implementation in the right direction. The state agency is optimistic that activities like Community grain banks, community drug banks and Nutrition and Health Days will make further inroads in various areas of operations and able to meet the challenge of enhancing the health status of status of women and children.
  • 12) NUTRITION EDUCATION FOR ADOLESCENT GIRLS IN THE SLUMS OF TWIN CITIES UNDER IPP –VIII, HYDERABAD

    Executive Summary
  • The Indian population has crossed the one billion mark in the new millennium, out of which about 21 per cent are adolescents (10-19 yrs). The key role of this group in enabling India to achieve its goal of population stabilization is increasingly being recognized now. The United Nations Inter Agency Working group on population and Development has infact chosen 'adolescents' as its priority theme for the year 1999-2000. An overview of the studies available confirms the need for a special focus on the improvement in health and nutritional status of adolescents. Since majority of adolescent girls especially representing lower segments of our society are malnourished coupled with co-existence of social maladies like son preference, incidence of early marriage and high rates of maternal mortality, a strong focus on improvement in nutritional and health status of adolescents girls is warranted. Therefore a study was undertaken to assess the nutritional status of the adolescent girls and devise, carry out & measure the impact of edud~li6nal intervention on the nutrition knowledge of adolescent girls in the selected one hundred slums of twin cities under IPP-VIII, Hyderabad.
  • The study was conducted in three stages. In the first stage, baseline data on 2500 adolescent girls (10-19 yrs) were collected using a specially designed comprehensive pretested interview schedule. In the second stage an intensive nutrition education intervention was carried out covering all the adolescent girls living in slums for a period of 6 months mainly through IPC techniques. In the third stage, a repeat survey was conducted to find out the impact of nutrition education intervention in terms of improvement in knowledge scores. Though an effort was made to contact the same adolescent girls (follow up), only 2,326 could be covered during endline survey. The balance of 174 adolescent girls living in the same slums though covered as substitutes/replacement to make up the envisaged 2,500 sample, they were excluded for the purpose of analysis.
  • The mean age of the adolescent girls was 14.3 years and majority of the girls were unmarried.) The educational levels of the adolescent girls revealed that 13.2 percent of them were illiterates, around 38% of them had primary education and 44% of them had high school (7 -10 years) education. Distribution of the respondents according to religion showed that the majority of them were Hindus (69.5%) and one third of them were Muslims. Among Hindus, greater proportions were either from backward castes (32.8%) or scheduled castes (28.3%). Regarding the type of family, 82.8% of respondents belonged to nuclear family.
  • Majority of respondents had 6-7 members in their family comprising on an average 3 males and 4 females. Regarding the educational background of the parents, almost half of the respondents had illiterate fathers and around two third of them had illiterate mothers.
  • The mean height of subjects is 147.1 cms and their mean weight is 38.7 kg. The heights and weights of the adolescent girls were far below the NCHS standards and the deficit increased with age. Further, the maximum increase in the height and weight was observed between 10 and 14 years of age and later it was stabilised.
  • The malnutrition among the adolescent girls was found to be quite rampant. Only 21.9% were categorised as normal. Among those who were malnourished, 7.2% were severely malnourished, 27. 9% moderately malnourished and 43% were mildly malnourished.
  • The weight for height classification indicated that half of the subjects were normal. A sizeable number of them were seen to compromise on growth (1 7.8%) and a good number of them (31.8%) were also observed to be lighter as they were found to be either mildly or moderately malnourished as per the weight-for-height NCHS Standards.
  • The prevalence of chronic energy deficiency (BMI < 18.5) was found to be ranged between 98.7 & 51.2 percent among adolescent of 10-16 years age. However as the age increases the prevalence of chronic energy deficiency decreases and it reached to 3.7.4 percent at the age 19 years.
  • The analysis of diet survey revealed that except the daily consumption of cereals the intakes of all other food items were found to be far below the suggested daily requirement. Regarding the nutrient intake, baring the intake of Vitamin C (51 mg), Folic Acid (137ug) and to some extent fat (20 gms), (recommended dietary allowances for adolescents as suggested by ICMR, in respect of major nutrients like proteins, energy, calcium, iron Vitamin A etc., were not met.
  • Iron deficiency anaemia was found to be the most common nutritional problem encountered by respondents. The data revealed that about 88% of subjects were found to be suffering from mild (49.0%), moderate (31.1 %) and severe (7.9%) anaemia. Only 12.0% of respondents were found to be having normal haemoglobin levels of > = 12 g/dl.
  • The mean age at menarche observed in the study population was 12.4 years. The widely reported premenstrual symptom was headache (11.7%), white discharge (9.9%), pimples (9.5%) and a few girls reported other problems like fatigue, irritability, depression etc. Apart from pre-menstrual symptoms the girls reported menstrual problems also. The most commonly reported menstrual problem was dysmenorrhoea (pain in abdomen) (42.6%), the other problems were backache (26.5%), tiredness (23.8%) and irritability (15.3%).
  • Among the adolescent girls the knowledge regarding sexuality and related areas were found to be low. Majority of the girls did not know what safe sex means. The knowledge regarding STDs were found to be relatively better. The data revealed that 69.4 percent of the girls had awareness regarding STDs and 70.2 percent of the girls had awareness regarding abortion.
  • Information about knowledge of family planning is also an important component as far as adolescent girls are concerned. Almost half of the adolescent girls were aware about the female temporary methods. Regarding the knowledge of terminal methods of family planning, all of them knew about the tubectomy and only 15.8% of them knew about vasectomy.
  • Out of the 40 married girls 33 girls were pregnant. Out of the total pregnant girls 48.5 percent have registered their pregnancy and all those who registered have used government services. All of them have received TT immunization and IFA tablets. The preferred place of delivery among them was government hospital (48.5%) and private hospital: was next in order of preference (42.4%).
  • Community based IEC intervention activities were conducted for a period of six months in all the intervention areas mainly through IPC techniques. Besides regular media like Television, Radio, Newspaper and Magazines, the other IEC tools used in educational activities included Cooking Demonstrations, Posters, Informative Booklet, Innovative Games and Nutrition Melas.
  • To inculcate the habit of taking more iron and calcium based preparations and energy and protein rich recipes in their daily meals, cooking demonstrations were held in all the intervention areas. They were held in collaboration with Food and Nutrition Extension Board, Govt. of India. Adolescent girls were taught how to prepare simple iron and calcium rich recipes. They were also exposed to nutrient values of some commonly consumed food articles, choosing the energy and protein rich food articles, right cooking methods and some tips to preserve nutrients while cooking.
  • To infuse or build self-confidence and self-esteem among adolescent girls, some innovative games were developed. About twenty adolescent girls in each slum were exposed to participatory learning activities in the form of games. These innovative games are intended to build self confidence, knowledge and skills and to empower girls to begin to shape their own life.
  • The approach used in these games is called 'experimental learning'. It helps girls to participate in learning and learn from their own experiences, with facilitator-trainer as a guide. The games include 'My Daily Routine And My Meal', 'I Would Like To Introduce Myself', 'Role Model or Woman We Admire', ' My Grand Mother, Mother And Myself' and 'Good Health Practices During Menstruation'. All the games are based on the experimental learning model. Situations and problems are presented, discussed and analyzed. Problem- solving is emphasized. All the participants learnt things through a process of experience sharing activities, reflections and discussion. A facilitator's guide was prepared to aid the field investigators to conduct the games in the community for adolescent girls.
  • These games are intended to motivate young girls to change undesirable behaviours and adopt new behaviours, promote participation in the learning process. It is hoped that the experience gained by the participants would be applied in similar situations being encountered by them in future.
  • The informative booklet on' Adolescent Health and Nutrition' prepared in local language telugu are being distributed to all willing and telugu speaking adolescent girls is a ready reckoner to assess the nutritional status and nutrient requirements on their own. The booklet also contains information on growth and development during adolescence, recommended dietary allowances, balanced diet, menstruation and some commonly asked questions/queries by adolescent girls and their clarifications.
  • Four multicoloured posters on education, nutrition, health & hygiene and age at marriage evoked positive response among subjects.
  • All the respondents were given information pertaining to their heights and weights, anaemia status etc. Both moderately and severely anaemic girls were given folifer tablets through UHPs to correct anaemia.
  • In collaboration with three NGOs viz., Pratyamnaya, Sivaranjani Educational Society and CHAIN operating in the study area, seven 'Nutrition Melas' were conducted. More than 2000 adolescent girls including other than sample population participated in these one day melas. Besides cooking demonstrations, experts have taken sessions on following areas:
  • 1. Adolescent growth & development, 2. Nutritional requirements & balanced diet, 3. Menstrual hygiene & Health care and 4. Women empowerment.
  • Poster exhibition on nutrition was also held. Services of Gynaecologist, Paediatrician, Public Health Specialist, Nutrition and Communication experts were utilized. Counselling sessions were held and many doubts with regard to nutrition, healthy cooking practices and menstruation were clarified by concerned specialists. Adolescent girls themselves presented some cultural items like songs, street play etc. All the willing adolescent girls were given TT injections by the concerned UHP staff.
  • Aspects like adolescent growth and development, nutritional requirements, balanced diet, desirable food habits, right cooking methods, problems during menarche, age at marriage, care during pregnancy and lactation were dealt with in detail during IEC intervention. In addition, areas like building positive personality traits, countering the normal social depiction of adolescent girls in the society, inculcating health and hygiene habits were also included in IEC campaign. Though baseline data were available, based on the suggestions given by the participating NGOs and link volunteers, sensitive aspects like sexuality, family planning methods were excluded in the IEC campaign. The following results throw a light on the impact of IEC intervention on selected aspects.
  • Channels/sources/methods utilized during the IEC intervention like multi-coloured posters and innovative games reached about 45% of the study population. More than 30% of the subjects were exposed to cooking demonstrations. Nearly one-quarter of the respondents received and read the pictorial booklet on adolescent nutrition. One-fifth of the sample subjects attended 'Nutrition Melas' being organized as a part of the IEC campaign. Almost all the respondents received information pertaining to their heights and weights and anaemia status. During the pre and post education intervention period, only one third of the respondents received nutrition related information through Television, 2% of the subjects through radio and about 4% of subjects through newspaper and magazines indicating limited reach of mass media channels in the study population.
  • The knowledge about physical changes during adolescence has improved from 7.3 percent to cent percent. In the same way 56.4 percent of the girls after intervention stressed the need of early education on menstruation as against 43.8 percent in the baseline. About 70% of the subjects specifically mention that they received information on growth and development for the first time during IEC intervention.
  • Regarding the menstrual hygiene, almost three fourth of the girls had knowledge of right method of using the sanitary pads. That means they were cleaning and drying pads properly or they were using commercially bought pads as absorbents. After the intervention more than 85 percent of the girls reported right method of using the pads as against 75% in the pre intervention period. Further, after the educational intervention it was also observed that they were changing their pads more often than they did it previously.
  • AII the subjects were asked to recall the foods rich in nutrients like iron, calcium, protein and energy. The result, clearly indicate that 776% could correctly identify the foods rich in iron 55.2% could recall calcium rich foods and 62% could list the energy and protein rich recipes/food articles.
  • The consumption of various food items based on the previous day’s diet was also analyzed. It was found that more than 90 percent of the girls had consumed cereals and fats/oils on the previous day. More than 60 percent of the girls had consumed vegetables (73.6%) and pulses (63.5%). Only less than 30% of the girls had consumed milk, meat or fruits. The usage of all other food items like, millets, oil seeds, rice flakes, condiments, jaggery, sprouted and fermented foods was found to be very low (less than 10%). Further, 37.9 percent of the girls were using iodized salt for cooking in their families. The consumption of various food items also has changed after the intervention. The striking difference can be seen in the consumption of millets like ragi which is especially rich in iron and calcium. Only 3.5 percent of the girls had consumed millets in the baseline and the figure had gone up to 97.9 percent after IEC intervention. Further, an improvement was also observed in the consumption of iodized salt.
  • The majority of the families were (52.9%) cleaning rice in water thrice or more than that before cooking. Majority of them (83.4%) were also discarding canjee and excess water after cooking. They were also seen to sieve the flour before use (93.2%). A small proportion of the families was even discarding excess water after cooking dal / vegetables (7.7%). The awareness regarding the nutrient loss due to discarding water was also not very high. Only 48.2% of the girls knew that there will be a loss of nutrients if they remove water. Almost all of them followed the practice of covering the vessels while cooking and 70.2% stated that they wash the vegetables before cutting. The results of post intervention suggests an improvement in the practice of right cooking methods like discarding caknjee has come down to 28.9%.
  • The legal minimum age at marriage is not widely known in the study population. Overall only 60.6 percent of the girls reported correctly the minimum legal age at marriage for both boys and girls. The results of the post intervention survey indicated an increase in the awareness of legal age at marriage. After the intervention, the figure increased to 83.6 percent.
  • Data related to pregnancy, ante natal care, delivery, immunization and breast feeding were also collected from the sample population. Out of the total, 58.2 percent of the girls stated that they know what pregnancy is, and this percentage rose to 60.7% after educational intervention.
  • Majority (68.9%) of the girls did not know when a woman should register the name for ante natal checkups. During pre educational intervention only 13.3% reported that soon after the cessation of the menstrual cycle the woman should register for antenatal checkups and this percentage rose to 24.8% after intervention. Marginal increase in the knowledge was observed with regard to the need for pregnant women to take TT immunization (36.8% - 45.8%), take adequate rest (85.4% -89.6%), avoid heavy work (11.6% -24.4%), need to protect themselves from anaemia (43.3% -51.0%) and take good food (38.9% -47.9%). Most of the girls could not identify the categories of women who fall under high risk. Only a small proportion of the girls during pre intervention identified short stature (4.3%), young and old age pregnancy (5.1% and 3% respectively), high parity pregnancy (3.5%) etc as high risk cases. However, after intervention around 32% of adolescent girls could correctly identify all the high risk pregnant cases.
  • Knowledge regarding the vaccine preventable diseases, the most well known disease was Polio (72.2%) This percentage rose to 90% after educational intervention. Majority of the girls did not have a role model (806%). A comparison of data on the pre and past intervention period also did not indicate any major change regarding their role models. The pattern regarding their role model almost remained the same (77.6%) except that a few more could spell out who their role model is.
  • Most of the girls graded themselves, a, cheerful (90 I %), cooperative (808%), truthful (75.9%), tidy (71.4%). However, only a very few rated themselves as courageous (27.9%) or possess self confidence (34.4). After the IEC intervention though the trend remained the same, there was slight increase in each of these categories. The mean per cent score has also increased from 66.5 to 73.9
  • On the whole it was felt that the adolescent girls were in agreement with the accepted social norm, For example most of the girls agreed that they are generally quiet (87.6%) emotional (80.5%) dependent (76.5%) subservient (76.7%) etc However, only some of the girls stated that they are incapable (27.2%) or unimportant (39.4%). After the intervention, the mean percent score of girls holding negative concept, regarding their social depiction came down slightly (65.3% to 58.7%).
  • Overall the adolescent girls were found to follow good health and hygiene habits. In most of the categories the per cent distribution is above 80. A comparative analysis of pre and post intervention figures indicate that, as per the expectation, the health and hygiene habits improved (90.7%) in follow up cases.
  • Nearly sixty per cent of the subjects mentioned that they had attended more than one programme being organised under IEC intervention those who were exposed to IEC intervention, nearly 82% of the subject appreciated the information given under IEC intervention and 18.3% were undecided about the quality of information given to them.
  • In conclusion, the adolescent girls not only exhibited a higher levels of knowledge with respect to some aspects, but also to some extent translated knowledge acquired into action. Hence, one can say with certain level of confidence that overall the IEC activities were successful in bringing about behavioural change.
  • 13) OPERATIONS RESEARCH PROJECT ON REPRODUCTIVE AND CHILD HEALTH IN ALUR MANDAL, KURNOOL DISTRICT, ANDHRA PRADESH

    Executive Summary

    The Study

  • In Andhra Pradesh (A.P), about 97% of contraceptive users are women and the most predominant method is female sterilisation. This indicates the women's desire to limit their family size to ensure a better quality of life for themselves and their children. There is a growing awareness the most of the reproductive problems that women face have their roots in social and economic issues and they have to be addressed so as to ensure safe motherhood and child survival. The goal is to ensure that women in child -bearing age receive more appropriate reproductive health care and that the children have better access to the needed preventive and curative services.
  • Against this background, a pilot project was initiated in May, 1996 in Alur Mandal, Kurnool district, of A.P. The broad objectives were to increase the coverage rates of Maternal and child health care, to improve the screening, diagnosis and treatment of reproductive tract infections and diseases, to improve the referral system and to enhance the community participation in the delivery of RCH care. After a thorough study of the project area with respect to tile existing health infrastructure and considering the expectations of the local population, the following innovative approaches were adopted in the project area:
  • 1. One Multipurpose Health Asst. (Female)/ANM was appointed for every village, on contract basis, ensuring her availability round the clock and accessibility of health services.
    2. Services of a lady gynaecologist and one staff nurse (part-time) were utilized for dealing with referral patients and conducting women health clinics.
    4. The referral system was reinforced with appropriate registers and cards.
    5. Implementation, monitoring and supervision were decentralized.
    6. Community mobilisation activities were facilitated through the formation of Women's Health Groups, Youth Groups and Village Health Committees.
  • Background Information Of The Study Area
  • Alur mandal in Adoni sub-division was selected for implementing the project. During the census period between 1991 and 2001 the mandal population has increased from 44,806 to 48,951 .The total literacy rate rose from 25% to 51.7% and female literacy has gone up from 13.2% to 36.4%. The average household size was 5.9 and the contraceptive prevalence rate due to sterilisation was 36.7% (1996 Base line). There is a Primary Health Centre (PHC) in the Allure manual, covering 18 villages and 4 hamlets. The community Health Centre (CHC) located at Govt. Hospital, Alur, has been serving as referral hospital. The project was initiated in May, l996. Before implementing the project, the recruitment of ANMs, their training and provision of equipment, drugs and registers and reports were completed. Apart from regular monitoring of the project, base line, midterm and end line surveys were carried out in all the 18 villages and 4 hamlets. In addition, during the end line survey, another set of 18 villages were included in four neighbouring PHCs to serve as control area.
  • Coverage

    There were 18 villages and 4 hamlets in the project area. During the first year (1996-97) one ANM was provided for every village, as mentioned earlier, for coverage of MCH programme. A population of 2250 was covered by her. After the reorganisation, from the second year onwards, in all 13 ANM's were in place, out of whom 3 were regular and 10 on contract basis, thus covering a population of 3250.

    Maternal Health

    Different aspects relating to maternal health during pregnancy period, have shown an improvement in the project area. These are detailed below: The end line survey showed that the percentage of antenatal registration in the experimental area had increased from 69.9 to 93.9 in 2001. In the control area, it was 65.5. In respect of pregnant women those who had received TT2/Booster in the experimental area had gone up from 28.9% to 86.9%, while in the control area it was 59.4%. Percentage of deliveries attended by trained personnel in the experimental area increased from 51.6 to 85.6 and in the control area it was just 27.7%.This may be due to round the clock availability of ANM in experimental village, and also because of proper antenatal care. Figures in respect of institutional deliveries in the experimental area were 16.9% as against 19% in 2001 and in the control area it was 17%. Similarly in increase in percentage of pregnant women who had received IFA tablets in the experimental area was observed 43.9 to 90.7 in 2001. The corresponding figure in tile control area was 54.2%.

    Child Health

    In respect of immunisation, it was seen that the percentage of children aged 12-23 months who were fully immunized had increased in experimental area from 45.4 in to 90.8 in 2001 with the control area registering 55.1%. There was an increase in percentage prevalence of diarrhoea in the experimental area from 7.7 to 17.6 in 1999.The prevalence of Diarrhoea was higher in the experimental area (1 0.6%) than in the control area (8.5%). ARI prevalence increased from (4.6% to 7.8%) between base line and end line survey. However, during the end line survey the prevalence of ARI was 7.8%, marginally higher than base line survey. The reason for this higher prevalence of diarrhoea and ARI in the experimental area could be the continuous rains during three months period prior to the end line survey.

    Executive

    The types of reproductive morbidity considered in the present context were (a) menstrual disorders, (b) gynaecological conditions and (c) RTI/STDs. The prevalence of menstrual disorders had increased from 1.7% to 22.3% and in control area it was 33.9%. Similarly the gynaecological conditions had increased from 3.9% to 8.5%. The prevalence of RTI/ STDs had declined from 23% to 13.2%. However, in the control area the prevalence of both these conditions was lower. It is possible that this lower prevalence in the control area could be due to under reporting because of inhibition of women who were interacting with the investigators for the first time. On the other hand in the project area, women had been interacting with the health staff more frequently and could overcome inhibitions in responding to such enquiries.

    The percentage of women who had been taking treatment was consistently increasing for the three types of reproductive morbidity in the experimental area. In respect of women who had been taken treatment for menstrual disorders, the percentages were 26.6 at midterm and 75.9 in end line. Similarly, for gynaecological conditions, the figures were 16.4% and 18.8% while for RTI/STDs they were 17% at midterm and 50.4% at end line.

    Referal Cases

    One of the objectives of the project was to build a good referral system. For this purpose, specific referral registers and referral cards were introduced. The patients were treated at Community Health Centres (CHC), Alur, Women and Children Hospital, Adoni and General Hospital, Kurnool. It was observed that about 94% of all referral cases were treated CHC, Alur, which was the referral hospital. In other words, the CHC was able to meet the needs of almost all cases thus reflecting the confidence of the population in tile CHC as a caretaker of their health, needs.

    Community Participation

  • During 1998-99, the primary objective of the project was to sustain this model through increased community participation and community financing. Village health committees, women health groups, adolescent groups and youth groups were formed and activated as a part of community mobilisation activity.
  • The success of projects of this nature hinges on the sustainability of the village health centre (VHC). Therefore the community initiated collection of monthly contributions at the rate of Rs.2-3 per “Rice Card". In fact, this amount was fixed by the community earlier at one of the group meetings. Participation of the community in this effort was initially slow but it steadily increased with time. Based on the quantum of contributions and degree of involvement of the community, village health centres were handed over to the Village Health Centre Management Committee (VHCMC) .Four villages started contributing 50% of the ANM's salary since January 2001 and the last set of 5 village health centres contributed from November 2001 onwards. With effect from January 2002, the community members are expected to bear the entire salary of ANM. As on December 2001 the total community contribution was Rs. 1,35,516. The amount was collected during the last two years of the project period. Funds so received were spent not only on ANM's salary, but also on maintenance of VHC. 75% of women during midterm survey and 68% during end line survey expressed their willingness to contribute towards ANM's salary. This decline was due to changes in PDS policy. The percentage of rice cardholders was reduced from 80 to 51.8 because of weeding out of bogus cards in the community. Hence discussions were held with mandal level officers and with the community to increase the contributions so that the amount collected could meet the financial commitment towards ANM's salary. In the control villages, about 99% of women expressed their willingness to have a village health centre. 71% of them were willing to contribute for ANM's salary provided the ANM stayed in their village, extending antenatal services and conducting deliveries.
  • Impact Of The Project Safe Delivery

    One of the key aspects wherein the project showed its impact was the percentage of the women being delivered by the trained personnel. The figure had increased from 51.6% to 85.6%. The components of the safe delivery include (a) ANC registration (b) TT injection (c) Consumption of IFA tablets (d) A minimum of three antenatal visits, (e) Use of DDKs. Performance with respect to all the service components of safe delivery was higher in the experimental than in the control area. Thus, the availability and accessibility of the ANM were the most important factors which determined the safe delivery.

    Decline In The Number Of Births

    Another indicator for the success of the project was the declining number of births compared to the base line. There was a continuous and steady decline in the total number of births from the starting of the project till its end. The total births recorded in 2000-2001 were 76.6% of those in the base year. In other words, 23% of the births were averted.

    Reduction In proportion Of Infant Deaths To Total Deaths

    The key indicator of impact of a Maternal and Child Health Programme is infant mortality. The proportion of infant deaths to total deaths declined from 18.1% in 1996-97 (Base Line) to 9.4% in 2000-2001 (upto March, 2001).

    Acceptance Of Family Planning

    A comparative increase in the number of sterilisations was observed. It was seen that the rate of sterilisation among those having two children or less had Increased from 30.3% in 1995-96 to 37.9% in 1998-99 and 46.8% in 2001.

    Community Participation And Financing

    Community participation and community financing of the project make it a self- sustaining activity of the society. Community participation was measured in terms of awareness about the project objectives, inputs and management of the village health centres. Almost all the women utilised the services provided at Govt. Hospital, Alur. During the end line, 86.4% reported that they would like to manage the village health centre in future. The community had agreed to pay for the ANM's salary. Out of 10 ANMs on contract, 9 ANMs were to be paid 100% salary from January 2002 onwards from community contribution. The remaining centre would be transferred and handed over to the District Medical and Health Office (DM & HO) for posting a regular ANM. A meeting was held on 10th December 2001 between the project coordinators and members of VHCMC, sarpanches, women members of panchayat, mandal president, and ex-MLA of the project area. Officials including Mandal Revenue Officer (MRO), Nodal officer, DM & HO, Dy. DM&HO, PHCMO, and other staff of PHC including ANMs attended that meeting. The purpose of the meeting was to discuss the future monitoring, payment of salary to ANM with effect from January 2002 onwards, maintenance of VHCs etc., It was unanimously agreed by all the participants that they would strive hard to maintain VHCs with community contribution.

    14) A REPORT ON PERSPECTIVES ON INJECTABLE CONTRACEPTIVES: A MULTICENTRIC STUDY ON USERS AND PROVIDERS

    Summary
  • The current trend of increasing acceptance of female sterilization seen in the country including Andhra Pradesh, is not considered a healthy one. One way of reducing this problem is the availability of wider range of contraceptives for spacing. The addition of Injectable Contraceptives (IC) to the band of available methods for spacing has been welcomed. However, concerns have been expressed in different quarters regarding the risk of down-playing the side-effects of IC use by providers on the one hand and the undue restriction on women's choice of contraceptives in India in case IC were to extended or its availability limited.
  • Against this background, Indian Institute of Health & Family Welfare (llHFW), Hyderabad participated in a multi-centric people centered research study sponsored by UNFPA in Collaboration with Government of India, on "Clients and Providers Perspectives on IC".
  • Conducted in the twin cities of Hyderabad and Secunderabad, this interview study involved participation of 10 providers and 50 users of IC, following the normal code of ethics expected of such research studies. Apart from the general profile of users reproductive history, reproductive intentions, previous contraceptive use, reasons for switching over to IC decision making about spacing, side effects with IC, service satisfaction counselling, experience of IC use product image, affordability of IC were the aspects investigated. In addition, partners' participation, side-effects, likes and dislikes about IC, use continuation-discontinuation data were obtained.
  • Information on risks and benefits of IC provides imposed limitations on IC use, determination of choice of contraception, provider perception on IC including affordability and service needs, was elicited.
  • Feedback from Users’

  • It was evident from the information collected that users of IC were from all socio- economic categories.
  • The fact that except for one user, all had come to know about IC only through the provider/nurse is indicate of poor promotion/awareness activities regarding IC. Also, the IEC material available on IC was poor and did not have any impact. Majority of users perceived IC as a good method as it does not require any vaginal pelvic examination, once in three months can maintain secret and new method. While a half of the users expressed service satisfaction of using IC, a third were unhappy with it because of its side-effects. But depending on their attitude the same side-effects such as ammenorrhoea were cause of liking as well as disliking IC for different reasons. Proper counselling was found to be needed to overcome such fallacies. Misconceptions did exist on such aspects of ammenorrhoea viewed as stopped of bad blood in the body or as a cause for the notion that they are pregnant. Majority felt that IC was affordable but not by those were non working or poor in joint families Partner participation in terms of accompanying the respondents to clinic's etc. was poor but secret use and busy working schedule of husbands were some of the reasons put forward in this regard.
  • Use discontinuation was mostly due to persisting side-effects mostly ammenorrhoea and the need to have a child.
  • Perceptions of Providers

  • Almost all the providers expressed the opinion that IC to users were those willing to space between children, but they are comprised those who disliked user of IUCD/OC Pills and those with obstetric history of painful menstruation.
  • Low levels of education and lack of promotion regarding awareness of IC were responsible for low levels of usage.
  • Since ammenorrhoea was the main disturbing side-effect, they felt that strong counselling on menstrual abnormalities and return of fertility were identified as thrust areas for counselling as well as IEC support.
  • Providers spelt out considered opinions/contraindication on imposed limitations for IC use. Most of the providers felt that providers need orientation training and provided with material highlighting latest scientific information on IC. That would help practitioners in showing experience, selection of suitable clients, better and effective counselling and appraise them of side-effects such as depletion of BMD, Cancer risk etc.
  • A round table meeting of providers, experts in Obstetrics and Gynaecology and public health yielded several useful suggestions for expanding IC services.
  • Conclusions

  • Improving the wide range of contraception to increase the contraceptive prevalence rate, the users' perspectives become the main focus. This study was aimed to know the perspectives of users' and providers' on IC.
  • The results of the study will be useful to Family Welfare Programme of India. Based on the results study recommends introduction of IC into Health Care Delivery System. Although some of the findings led to recommendations which were specific to individuals based on their social and cultural values.
  • Some of the findings from the study are conclusive, especially those concerning the effects of clients characteristics in the choice of use of IC regarding their perceptions in use continuation highly associated with their need and counselling services. The results are very useful, especially for identifying interventions related to increase wide range of contraceptives to be tested through operations research studies before introducing.
  • Recommendations

  • 1. The awareness about IC needs to be improved regarding the method, itself, availability, effectiveness, etc.
    2. Strengthening of educational programmes particularly interpersonal activities was identified as an important area for improving acceptability. It could help in generating discussions on advantages and disadvantages, as well as effectiveness.
    3. Educational material on factual information needs to be designed. It could help in dispelling, misconceptions about amenorrhoea.
    4. Counselling had positive effect on method use continuation. Providers should improve counselling skills or they should have a separate counsellor at the health facility.
    5. The awareness among health staff/personnel at different levels needs to be promoted to cater to the contraceptive needs of the women or minimize the contraceptive unmet need.
    6. In different places of India the services of the IC in public health system, needs to be expanded on pilot basis before introducing it in Family Planning Programme.
  • 15) PREVENTION AND CONTROL OF ANAEMIA IN RURAL ADOLESCENT GIRLS THROUGH SCHOOL SYSTEM IN MEDAK DISTRICT OF ANDHRA PRADESH

    Executive Summary

    Background

  • Iron Deficiency Anaemia (IDA) is the most common nutritional disorder, affecting people from all walks of life. It interferes with pregnancy outcome in women, physical and cognitive development in young population and productivity in general population. High priority being given to adolescent girls in the realm of Reproductive and Child Health (RCH) programme. Adolescent girls are highly vulnerable to nutritional disorders, specially IDA, which severely affects their general health. Since the national programme for prevention and control of anaemia is not catering to this section, they continue to exhibit high levels of IDA. A lasting solution to the problem of anaemia in pregt1ant women can be found by targeting the intervention to adolescent girls who are soon to enter marriage, family life and attain motherhood. Such intervention must attempt to raise t11eir own iron stores and sustain normal levels of Hb. This will not only improve their physical and mental capacity but also subsequently reduce the incidence of low birth, weight of infants and maternal mortality rates.
  • To prevent and control the problem of anaemia among adolescent girls, multi- centric studies, were conducted with UNICEF support employing weekly Iron and Folic Acid (IFA) supplementation. The studies have clearly demonstrated the efficacy of once-a-week IFA tablet containing 100 mg of elemental iron and 0.5 mg of folic acid in raising the haemoglobin level similar to that seen with the same dose level of iron given daily and thus reduce anaemia prevalence: Side effects were far fewer with weekly supplementation compared to daily iron administration.
  • Recognizing the enormous potential of the school system, a project supported by UNICEF was undertaken by IIHFW to prevent and control anaemia in adolescent girls utilizing the school system in the backward mandals of Medak district, Andhra Pradesh.
  • Objectives

  • To assess the feasibility and acceptability of supervised weekly supplementation of iron and folic acid to school going adolescent girls (10- 15 years) to prevent and control anaemia through joint involvement of the departments of education and health.
  • To improve the knowledge, attitude and understanding of adolescent girls regarding ill effects of anaemia and convince them of the usefulness of weekly supplementation of iron and folic acid through appropriate IEC 1ntervention.
  • To assess the impact of the programme in reducing the prevalence of anaemia using haemoglobin as an indicator and scale-up the programme in the entire district in a phased manner.
  • Study Area

    The study was conducted in Medak, a border district of Andhra Pradesh, in two phases. Phase -I of the project was initiated during the academic year 2001 -2002 in Medak, in 16 Government high schools located in Hathunura and Kondapur mandals. Since the other main purpose of the study is to scale up this approach in the remaining mandals of the district in a phased manner, in Phase-II, besides continuing weekly IFA supplementation for the academic year 2002-2003, two more mandals namely Jinnaram and Pulkal were included in the study. All the 14 high schools were covered under Phase -II.

    Methodology

  • A combination of anthropometry, clinical, biochemical and interview schedule methods was used to assess the nutritional anaemia status and KAP of subjects. In both the phases, the project was executed in four stages.
  • Consultation cum planning meetings with state level officials from departments of education and health; orientation training programmes for medical officers, paramedics, school principals & teachers; selection of schools & subjects and collection of baseline data were some of the activities undertaken during the first stage.
  • Activities pertaining to development and distribution of IEC materials for school teachers were undertaken during the second stage. A project logo; three Posters; two folders; a guide for stake holders entitled 'Prevention and control of Anaemia in Adolescent Girls through School System' along with instructions on how to use the project support IEC material; IFA indent form to obtain monthly requirement and utilization o f IFA tablets; IFA compliance card to monitor the regular consumption of IFA were some of the IEC materials utilized in IEC activities.
  • Weekly supplementation of IFA to all adolescent girls through schoolteachers for one academic year or 52 weeks along with IEC intervention was undertaken in the third stage. In the fourth stage evaluation in terms of improvement in blood Hb levels and awareness of anaemia was done after 52weeks of IFA consumption under phase I and again after 104 weeks and 52 weeks of IFA supplemented groups under phase II of the project.
  • Coverage

    All adolescent girls between 10 and 15 years of age, studying in 6th to 10th standards of 16 high schools located in Hathnura and Kondapoor mandals were enlisted during phase I of the study. A total of 1811 adolescent girls were enrolled in classes 6 to 10. About 1516 subjects, accounting for 83.7% of the total enrolled subjects were covered under baseline of the study. However, 740 paired subjects were covered after one and two years of IFA supplementation, accounting for 48.8% subjects covered at baseline of phase I. Similarly all the 14 high schools located in the newly selected mandals viz., Pulkal and Jinnaram, studying in 6th to 10th standards were ensiles during phase II. There were 1881 girls enrolled in classes 6th to 10th standard and 1555 subjects, accounting for 82.7% of the total enrolled subjects were covered under baseline of the study. However, 883 paired subjects were covered after one year of IFA supplementation, accounting for 56.8% subjects covered in baseline of phase II of the study.

    Preparatory Activities

    Individual counselling sessions by the project investigators preceded the weekly 1FA supplementation. Parents were also informed of the project and their permission was obtained for enrollment of the girls. IFA supplementation was initiated in August 2001 under phase I and during the same month in 2002, Under Phase II. All the severe cases of anaemia were referred to PHC for treatment. Side-effects like abdominal pain, nausea, vomiting, diarrhoea, were observed in about 38% of girls at the beginning of project. In a majority of cases, such effects were reported when supplementation was taken on empty stomach or during mild sickness or without sufficient intake of water etc. The project investigators and PHC Medical Officers conducted counseling sessions in the selected schools and advised discontinuation of the drug, when side effects were very severe and recurring. Measures like effective monitoring and assurance from PHC/Project Staff, positive coverage of project details in press, sensitizing officials from Panchayat Raj Institutions and other departments like revenue immensely helped in the smooth functioning of the project. Socio-economic profile.

    Nutritional Status

    The mean age of the phase I & II subjects was 12.5 + 1.38 years. Classwise percentage coverage figures indicate that around 20% of girls were studying in 6th to 9th standards and nearly 16% in 10th standard. Majority of the girls belonged to backward caste (5%), representing nuclear family (67.3%), residing in semi-pucca house (79%), without a toilet facility (78.9%), fetching water from public tap (38.4%), with illiterate mother (74.8%) & father (38.4%), having cultivation background (67.1%), possessing white ration care (60.7%), using wood as cooking fuel (76.3%) indicating their poor socio-economic background. Around 50% of the girls had attained menarche. The mean age at menarche was 12.2 ± 0.9 years.

    The mean height and weight of the phase I subjects were 146.20 ± 8.35 cms and 34.92 ± 7.2 kgs respectively. Similarly the mean height and weight of the phase II subjects were 145.67 ± 8.35 cms and 34.51 ± 7.1 kgs respectively. Though the pattern of growth of the girls was similar to that of NCHS standards, the heights and weights deficit increased with age. In other words, the subjects were shorter and lighter compared to NCHS standards. Anaemia Status
    Iron deficiency anaemia was encountered in 81% of phase I subjects and 85.6% phase II subjects. Mild, moderate and severe grades of anemia were observed in 63.2%, 12.5% and 5.3% of phase I respondents respectively. Similarly, 63.2%, 16.1% and 6.3% of phase II subjects suffered from mild, moderate and severe grades of anaemia respectively.

    Programme Participation

    Initially only 33.4% of phase I and 16.4% of phase II respondents reported that they came to known about the current project through school teacher. However, after the objectives of the programme were explained in detail, majority of the subjects of phase I (96.5%) and II (99.5%) showed their willingness to enroll themselves as beneficiaries of the programme.

    Changes in Status of Anaemia

    Percentage of subjects with normal Hb. values increased from 19.0 (baseline) to 59.8 and 87.0 after one year and two years of IFA supplementation respectively. Similarly, under phase II, percentage of subjects with normal Hb values also increased from 14.4 (baseline) to 46.8 after one year of IFA supplementation \with concomitant decrease in mild and moderate grades of anaemia. The reduction of anaemia was 40.8% and 27.2% after one and two years of IFA supplementation respectively among phase I subjects. Similarly the reduction of anaemia was 32.4% in phase II subjects after one year of IFA supplementation. Initially a meagre percentage of phase I (7.4%) and phase II (2.9%) subjects were aware of the problem of anaemia. These percentages increased to 78.1 and 82.6 after one and two years of intervention respectively under phase I and to 84.4 among phase II subjects after one year of supplementation. For recalling the signs and symptoms of anaemia which included fatigue, breathlessness, breaking out in cold sweat, pallor in eyes, tongue and nails, giddiness, poor appetite and oedema, initially a mean percentage score of 19.9 was obtained by phase I subjects, which decreased to 14.5 after one year and 9.0 after two years of IFA supplementation. Similarly the subjects of phase II scored 12.6% initially, which drastically reduced to 9.2% after one year of supplementation. Only 0.4% and 0.7% of phases I and 11 baseline subjects could mention desired Hb levels in blood. These percentages increased to 64.5 and 66.8 after one and two years of intervention respectively under phase I and 49.5 among phase II subjects.
    Low percentage of subjects under phase I (2.2% - 4.6%) and phase II (0.6% - 2.2%) mentioned the various causes of anaemia like low intake of iron rich foods, worm infestations, taking tea immediately after meals, excess menstrual bleeding and recurrent malaria fever etc. These percentages increased to 44.1 -72.8 and 56.5- 94.3 after one and two years of supplementation under phase I and to 44.1 -91.5 under phase II. Initially only 3.5% of phase I and 1.5% of phase II subjects mentioned about adolescent girls as the most Vulnerable section for anaemia. However after introduction of the project, 65.9% of phase I subjects after year and 85.0% after two years of IFA supplementation came to know about the vulnerability of adolescent girls for anaemia. Similarly 82.4% of phase II subjects also referred to adolescent girls as vulnerable population for anaemia.
    A merger percentage of respondents of phases I (2.6% - 4.0%) & II (1.3% - 2.2%) could list the consequences of anaemia like frequent illness, less menstrual bleeding, irregular menses and fatigue etc. These percentages increased to 33.8% - 63.9% after first year and 36.8% - 72.7% after second year of supplementation under phase I and 35.8% - 76.6% after one year of supplementation under phase II.

    Anaemia Control Programme

    Initially only 4.6% and 12.9% of subjects under phases I and II respectively were aware of the adolescent anaemia control programme. However after one year and two years of IFA introduction 70.5% and 86.1% of subjects respectively under phase I and 88.7% of subjects under phase II mentioned about the anaemia control programme. A meager percentage of respondents under phases I (3.6% - 4.2) and II (6.4% - 7.8%) during baseline mentioned of the various measures to prevent anaemia, which include consumption of iron rich foods, IFA tablets, deworming drug and avoiding tea/coffee immediately before or after meals. However after one year of IFA intervention nearly 80% and after two years of invention about 90% of subjects under phase I and around 90% again under phase II clearly stated the measures to control anaemia.

    Nutrition Knowledge

    Nutrition knowledge of the subjects of phases I and II was examined in terms of their awareness regarding iron, calcium, protein & energy and vitamin C rich foods. The respondents exhibited very low levels of awareness as reflected by the small percentages (1.9% - 22.6%) of respondents providing correct answers for most of the queries. However, after supplementation majority of subjects ranging from 64.9% to 97.7% could correctly list the foods under various nutrition sub-heads. Similarly after IFA intervention between 60% and 70% subjects under both the phases mentioned the importance of sprouting and fermentation to increase the nutrient value of foods for better absorption of iron in the body. Similar increase in knowledge (71.8% - 85%) can be noticed regarding awareness on consumption of tea/coffee before or after meals inhibiting the absorption of iron. Between 75% and 97% of subjects of both the phases were aware of the importance of iron rich foods in prevention of anaemia among adolescent girls.

    Iron Rich Foods

    Consumption of iron rich food articles like finger millet (Ragi), greens, meat and vitamin C rich foods like sprouted grams and citrus fruits on the preceding day was recalled by 36.3%, 20.1%, 11.3% and 3.4% of the subjects respectively during baseline survey in phase I. These figures rose to 53.9%, 28.4%, 12.8% and 6.2% after first year and were maintained more or less at the same level i.e., 55.4%, 29.2%, 17.8%, and 7.2% after 2 years of intervention. One could notice a similar trend in phase II subjects after one year of intervention. The percentage of subjects who were habituated to taking tea/coffee before meal decreased from 23.4% to 17.6% after first year and 7.6% after second year of intervention under phase I. A similar decrease i.e., 11.0% to 2.5% was noticed among subjects of phase II.

    Information Sources

    Majority of the subjects covered under both the phases recognized the importance of teacher as a source of information regarding anaemia. Though health staff played a meager role (10%) during first year of intervention, their role was found to be crucial during second year of intervention under phase I (70.2%) and phase II (66.6%) indicating their increased involvement in the implementation of the programme. Television and Radio played a minor role in disseminating information on anaemia under both the phases. Posters, folders and booklet were some of the sources through which between 42.7% - 73.5% of respondents received information on anaemia under phases I & II. Similarly cooking demonstrations reached 19.5% during first year and 26.5% of subjects during second year under phase I and 44.7% of subjects under phase II. A majority of respondents (80% - 95%) claimed that the IEC material provided was only partially useful to them to comprehend various aspects of anaemia and the control programme. Majority of respondents (70% - 88%) perceived that the IFA supplementation improved their concentration in studies, breathing problem, appetite and gave a sense of feeling better.

    Paired Analysis

    A total 740 paired subjects or 48.8% of the 1516 baseline respondents could be covered for heamoglobin estimation after two years of IFA supplementation and a total of 883 paired subjects or 56.8% of 1555 baseline respondents were covered from one year of IFA supplementation. The reasons for this rather low coverage include non-availability of X standard students, general absenteeism of students, non-cooperation of subjects etc.

    Paired Analysis

    The mean hemoglobin level of phase I paired sample at the baseline was 11.1 ± 1.1 g/ dl which increased to 12.1 ± l.0 g/dl and 12.6 ± 0.7 g/ dl after one and two years of IFA supplementation respectively. Similarly the mean hemoglobin level of phase II paired sample at the baseline was 10.7 ± 1.l g/dl which increased to 11.7 ± 1.1 g/ dl after one year of IFA supplementation.
    A distinct trend towards improvement, and a clear shift to the better Hb levels from the baseline to the end of 1 year and 2 years of IFA supplementation was evident from an examination of the frequency distribution of Phase I subjects based on 1 g/dl Hb interval. Two years of IFA intervention had virtually eliminated subjects in 8.0 to 9.0 g/ dl Hb value interval. Similar pattern of Hb. distribution is noticed after one year of IFA supplementation in Phase II subjects.

    Efficacy of IFA on Grades of Anaemia

    The efficacy of IFA tablet supplementation can be gauged by the fact that half of those who took the tablets showed improvement in their Hb. status. There was a perceptible shift from moderate grade of anemia to mild grade and also to normal grade. However, a sizeable number of subjects (42.9%) remain unchanged as they continued to remain in the same grade. On the contrary, 7% of the subjects registered a decline as their hb. status deteriorated from normal to mild and to moderate grade. Similarly in two years IFA supplemented subjects, it improved in 38.5%, while no improvement was seen in 57.0% and declined in 4.5% under phase I. The percentage figures in one year IFA supplementation under phase II also indicated that it improved in 45.5% remained static in 50.3% and declined in 4.7% of subjects.

    Efficacy of IFA on Haemoglobin improvement

    The real impact of IFA supplementation is assessed in terms of improvement of 1 g/ dl or more in the Hb levels. Under Phase I, 50.9% had improved their Hb levels by more than 1 g/dl at the end of 1 year of IFA supplementation. During the 2nd year of supplementation, 33.6% had shown similar improvement. In Phase II, 47.5% of subjects had improved their Hb levels. However, 43.1% of subjects at the end of one year supplementation, 60.9% after 2 years supplementation under phase I and 50.6% under phase II showed no such improvement (remained between -0.99 and + 0.99 g/dl Hb status) and in the remaining subjects, it declined by <= 1g/dl hemoglobin.

    IFA Dose Response

    The results of the study revealed that in subjects who had consumed more than 50 tablets, 68.2% and 74.4% were found to be normal after 1 year and 2 years of IFA supplementation respectively. Similarly 69.5% of phase II subjects who had consumed more than 50 IFA tablets were found to be normal after one year of supplementation. The study also revealed that perceptible improvement in Hb levels was seen after consumption of more than 45 IFA tablets in a year.

    IFA Compliance

    Though all the subjects were given a folder, which can be used as a self monitoring compliance tool, it did not serve the purpose. Similarly the individual compliance cards given to the teacher to monitor the consumption of IFA by the subjects was not filled properly and regularly by them. Hence, recall of consumption of IFA tablets by the respondent was taken to compute the compliance. About 55% and 73.4% of subjects covered after one year and two years of IFA supplementation under Phase I and 66.5% of subjects under Phase II had consumed all the IFA tables indicating good compliance. About 36% in one year supplemented group and nearly 20% subjects under both the phases skipped 1-5 tables. About 8%, 5.7% under phase I and 1.5% under phase II did not consume 6-10 tablets and the remaining subjects skipped more than 10 IFA tablets.
    More then seventy-two per cent of subjects after one-year IFA supplementation, 93% of subjects after two years of IFA supplementation under phase I and 67.2% of phase II subjects revealed that the school teacher was solely responsible for the good compliance for IFA tablets. Vomiting, stomachache and giddiness were some of the side effects reported by 13% to 38% of the subjects cover under phase I & II of the project. However, 40% of the phase I and 18.8% of phase II had regularly consumed IFA despite experiencing side effects. More than 95% of subjects under both the phases received enough IFA tablets during holidays and nearly a half of the subjects covered under phases I and II declared that they were feeling better after taking IFA regularly.
    The feasibility study has helped in providing the much needed direction in utilizing the immense potential of school system for improvement of nutritional status of school going adolescent girls. The successful initiation of the project was ensured through the certain specific measures such as orientation training programmes for medical officers, paramedics, school principals and teachers, individual counseling sessions preceding the weekly IFA supplementation. Prior parent approval for enrolment, referring severe cases of anaemia to PHC for treatment, counseling sessions by health staff on side effects and focusing on discontinuation of the drug whenever side effects were very severe or recurring. Smooth functioning of the programme was also helped by effective monitoring and assurance from PHC/Project staff, total support and involvement of school teachers and principals, coverage of project details in press, sensitizing officials from Panchayat Raj Institutions and other departments like revenue.
    Considering the significant rise in haemoglobin levels, it can be said that the once-a-week IFA supplementation to school-going adolescent girls through the involvement of school teachers, supported by health staff for a period of two years, with adequate IEC support proved to be a fruitful strategy with good compliance. There was virtual elimination of moderate anaemia significantly in the ‘Normal’ category raising to an astounding 87%. This approach which aims to put the iron back into adolescent girls is perhaps a very pragmatic one, hence could be scaled-up to cover the entire district.

    16) A QUICK FEEDBACK STUDY ON ORAL REHYDRATION THERAPY CAMPAIGN IN ANDHRA PRADESH

    (24TH JUNE TO 29TH JUNE 1996)
    Executive Summary

    The Department of Family Welfare Government of Andhra Pradesh has conducted a campaign on Oral Rehydration Therapy from 24.6.96 to 29.6.96 in the state with a view to increase use of ORS and educate the mothers/caretakers about diarrhoeal case management. The present report is a quick feedback study on the programme with an objective of assessing the effectiveness of the campaign and measuring the degree of awareness of mothers about ORT. The Sample consisted of 1500 mothers each having children below 5 years of age. The survey was carried out in six districts of A.P each of which represented a particular region. The questionnaire was administered to the mothers by trained investigators and the data obtained was computed using a statistical package on the computer. The following are the major conclusions of the study:-

  • 59.4% of mothers are aware of ORS of which a majority are from Hyderabad slums.
  • The brand name of ORS is not very popular and is more known as a powder for treatment of diarrhoea.
  • Among the mothers who know about ORS 75.3% have heard about ORS for the first time during the campaign.
  • Many mothers are not aware of ORS depot facility extended during the campaign and the number who said that they were consulted regarding the same is also very less.
  • The Average degree of awareness of mothers about ORT is 46.6%. When distributed on a 5 point scale, most of the mothers are in low level, followed by medium.
  • District variations in degree of awareness about ORT show that Prakasam scored highest average followed by Nalgonda .Hyderabad stood lowest followed by Anantapur. The averages of Adilabad and Vizianagaram are almost equal in the second position.
  • 80.4% of the mothers from Hyderabad slums have claimed to be knowing about ORS. However further analysis has revealed that the knowledge is at low level.
  • Among the different components of ORT, messages about ORS (Preparation, Frequency of feeding and Storage of prepared solution} have reached the mothers more. Dehydration symptoms and identification of critical condition in diarrhoeal case management did not have much impact.
  • Interpersonal communication seems to have played a major role in the campaign. Among the sources Doctor was rated high followed by Doordarshan and AWW (Angan Wadi Worker). While Radio and relatives were rated significantly the scores given to the Private TV channels in this study are insignificant.
  • Majority of the mothers rated Doctor as their First, Second, and Third preference for treatment of diarrhoea.
  • Age, Education, Caste have shown influence on the responses to some extent. A further analysis has revealed the influence to be more at very low and low levels of awareness.
  • Certain aspects like distance, ORS depot facility, mothers with infants etc have shown positive influence however at lower levels.
  • No association could be observed between particular source (media) of information and degree of awareness. However, mothers who received information from more number of sources have shown higher degree of awareness.
  • Mothers do not perceive death as a consequence of diarrhoea if neglected among children. Superstitions continue to play a major role contributing to diarrhoeal deaths. Supporting this was a death recorded during the study period in Anantapur by the Investigators
  • More campaign and door to door services were suggested by mothers as means of popularising ORS.
  • Half of the mothers who are aware of ORS have no reservations about the same. However a significant number of mothers still find ORS a new concept, the powder not tasty, believe more in private doctors and have no faith in government supply.
  • 17) A STUDY TOWARDS ERADICATION OF POLIO, NEONATAL TETANUS AND MEASLES FROM ANDHRA PRADESH

    Executive Summary

    The research project entitled "Towards eradication of polio, measles and neonatal tetanus in A.P." was sanctioned under IPP VI of the World Bank, by the Commissioner, Family Welfare, Govt. of A.P. to the Department of Epidemiology, Indian Institute of Health and Family Welfare, in March 1996.

    The following are the objectives of the research project

  • Study and analyse the immunization coverage among pregnant women and infants in all the districts of the State, covering rural, urban and tribal areas.
  • Study the incidence and prevalence of polio, neonatal tetanus and measles mortality and morbidity in A.P.
  • Study all the reasons for low measles coverage and suggest a strategy for improving the situation.
  • To identify the short comings in the implementation of the immunization programme, such as quality of services, supervision and logistic support.
  • To conduct a task analysis of the health functionaries in relation to immunization.
  • The project was carried out in 2 phases. In phase I the secondary data reported by the offices of the D.M. & H.O.S. on immunization coverage for polio/DPT, measles in children under 13 months and also tetanus toxoid immunization in pregnant women was collected from 19 districts. The data could not be obtained from 4 districts headquarters. However the overall data for these 4 districts (Krishna, Prakasam, Hyderabad and Anantapur) was obtained from the commissionerate of Family Welfare, Hyderabad. The secondary data was obtained PHC wise with immunization coverage on pregnant women and children <12 months and also reported cases and deaths due to polio, measles and neonatal tetanus.

    The analysis of the data showed that 3 districts namely Chittoor, Kurnool and Nellore reported relatively lesser coverage for polio/DPT and measles in children. (44.55% for both polio and measles in the 3 districts). These district reported cases of measles from their PHCs. Hence it was decided to cover these 3 districts in detail in Phase II. Studies were carried out in Chittoor and Kurnool.

    Another pattern which emerged was the reporting of presence of measles cases in the districts which reported high coverage i.e. > 90% Mahabubnagar district was selected to do the intensive study.

    3 ITDA areas namely Rampachodavaram (East Godavari district) Paderu (Vizag district) and Utnoor (Adilabad district) were selected for studying the immunization coverage in the tribal areas. For urban studies, data from the district head quarters hospitals of Nizamabad, Warangal, Kakinada, Vizag, Tirupathi, Guntur, Vijayawada and Fever Hospital, Hyderabad were collected on the number of cases and deaths due to measles, polio and neonatal tetanus. Reply postcards were supplied to the MPHWs (F) of the 3 districts namely Chittoor, Kurnool, and Mahabubnagar to send monthly report on occurrence of cases of polio, measles and neonatal tetanus and deaths due to these. This forms the prospective aspect of the study for finding out the incidence.

    The data from Phase II studies showed that the low coverage is due to both logistic as well as socio-cultural factors. The pockets where the coverage was very low, are characterised by population who refused to have immunization for their children due to ignorance and who were guided by their own cultural beliefs. The logistic problems are many such as absence of proper supervision, lack of staff and vaccine and improper maintenance of cold chain etc. This data is reported in detail in the Phase II section of the report. The reported high coverage coupled with high incidence of measles in the districts such as Mahabubnagar , also raises a lot of queries as to the performance of the staff and the potency of the vaccine in that area. Strategies are suggested based upon the findings. 14 postcards reporting cases of measles received from sub centres of Mahabubnagar district, show that intense efforts have to be taken in this region. The overall impression obtained from the study that the reported coverage on immunization among infants and pregnant women is good and the lacunae which were detected during intensive study can be easily tackled with a little more effort on the part of the health functionaries, leading towards eradication of polio, measles and neonatal tetanus in early 2000s.

    18) FINAL EVALUATION OF INTEGRATED NUTRITION & HEALTH PROGRAMME IN ANDHRA PRADESH QUANTITATIVE SURVEY – CARE – INDIA

    Executive Summary

    Integrated Nutrition and Hea1th Project (IN HP) started in 1996 to improve the health and nutritional status of women and children in seven states: Andhra Pradesh, Bihar, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and West Bengal. The project targets children under age six, pregnant women and women with children under age 2 years. After obtaining baseline data, mid-term and final evaluations were undertaken. The results of the final evaluation of IN HP in Andhra Pradesh are presented here. A total of 2404 index mothers with children less than 2 years were interviewed. Of them 539 were from HI block, 546 from CB, 833 from other blocks and 486 from Demonstration site. The total Anganwadi centres covered were 151 and the total number of ANMs interviewed was 58.

    Background Characteristics

  • The housing conditions and standard of living of household members indicated that 48 per cent of houses were pucca, 68 per cent of households had electricity, and 34 per cent had access to tap water. 92 per cent of the houses had no toilet facility. In the study area, 50 per cent of the mothers were OBCs, 27 per cent were STs, and 16 per cent were SCs. 63 per cent of the mothers were illiterate, 19 per cent had completed primary, 11 per cent had completed middle school and 9 per cent had above middle school education. 34 per cent of the mothers did not work outside home. Among those who worked, majority were wage labourers.
  • Majority of mothers (73%) were in the age group 20-29, 56 per cent had 2-3 living children, 52 per cent did not want any more children and a half of the respondents had a closed birth interval of 2-3 years.
  • Regarding the profile of the children, 33 per cent were below age 6 months, 21 per cent were between 6-11 months and 47 per cent were between 12-23 months. Sex ratio (number of females for 1000 males) below 12 months was 990 and it was 892 for children between 12-23 months.
  • Women's Health and Nutrition

  • Women's health and nutrition has been one of the focus areas of IN HP programme. In the study population, 99 per cent of the mothers had received at least one antenatal check-up; more than half (53%) had received 3 antenatal check- ups. Among those who had received antenatal checkups, majority (63%) of them received them from private clinics. 55 per cent of the mothers received their first checkups during the first trimester. More than 90 per cent of the mothers received the recommended dose of TT vaccination, around 73 per cent received iron and folic acid supplementation while only 16 per cent took deworming treatment. Forty-seven per cent of the women in the study areas reported some health problems during their pregnancy and 87 per cent of them had taken treatment from various sources. Food supplementation during pregnancy and lactation has been one of the important components in the IN HP programme. 32 per cent of the women received food from AWC for spot consumption during pregnancy. This was lowest (16%) in HI block and (53%) in other areas. 16 per cent of the mothers received food for spot consumption for less than 3 months, 53 per cent for 3-6 months and 33 per cent for more than 6 months. Again, 16 per cent of the mothers received take home ration for less than 3 months, 51 per cent for 3-6 months and 34 per cent for more than 6 months. 75 per cent of the mothers who received take home ration, had shared their food with other family members. Regarding food intake during pregnancy, 22 per cent of the mothers have reported that they had increased their food intake, while 30 per cent indicated decrease in the intake and 48 per cent at the same amount of food as usual.
  • The food supplementation during lactation indicated that 22 per cent of the mothers received food from A WC for less than 3 months, 42 per cent for 3-6 months and 2 per cent for more than 6 months. About a half of the lactating mothers shared their food with other family members.
  • Regarding the frequency of distribution of food by AWC, 18 per cent of the mothers reported a daily distribution, 30 per cent reported it was weekly, and 31 per cent reported it was monthly.
  • Birth Planning

  • The questions on birth planning mostly pertained to Disposable Delivery Kit (DDKs), decision on place of delivery, person who conducted the delivery and the reasons for not planning the birth.
  • Thirty per cent of the women reported that they had kept the DDK ready. There was not much variation regarding this aspect by educational levels, caste groups and block types. Regarding the decision on place of delivery, majority of the illiterate mothers (67%) opted for home delivery, compared to the women of other educational categories. Similarly, the mothers of ST group (81%), and tribal mothers (74%) decided to opt for home delivery compared to other groups. Decision on institutional delivery was made mostly by women with higher than middle school education, other caste group women and women from urban areas. Major reason for preferring a home delivery was that they could not afford the cost involved in institutional delivery. Avoidance of the risk, was the major reason for opting institutional de1ivery.
  • Delivery

  • The family welfare programme encourages women to deliver in a medical facility or, if at home, with assistance from a trained health personnel. Only 39 per cent of the births were conducted in a medical facility. Among the deliveries at home, more than half were attended to by untrained persons. 7 per cent of the mothers reported to have gone for MTP in the study area.
  • Family Planning

  • Forty-four per cent of the women in the study area were currently using some method of contraception. Permanent method of contraception was adopted by 40 per cent of the women and only 4 per cent were using spacing methods. 82 per cent of the women were using Tubectomy which was the most popular method of contraception. Sterilisation being the most popular method of contraception, women tended to adopt family planning only after achieving their desired family size. In the study area, the adoption of family planning methods was highest among those with more than three living children. Preference for sons seems to have had some impact on contraceptives use. Women who had one or two living sons were more likely to use contraception than women with no living son.
  • Children's Health and Nutrition Neonatal care

  • More than three-fourths of the babies did not have any complications in the neonatal period. Among those with complications, around 20 per cent received treatment which was provided by a private health facility. The major reason cited for not receiving treatment was that the mothers did not feel the need for it. The majority of the women responded that they had given bath to their babies within 8 hours after the birth.
  • Breast feeding practices

  • Breast feeding was nearly universal in the study population. More than 90 per cent of the children were being currently breastfed up to 15 months. Although breast feeding was nearly universal, only 8 per cent of the mothers initiated breast feeding within one hour of the birth of the baby. The custom of squeezing out colostrums was also prevalent in the study area. About 36 per cent of the mothers reported to have squeezed out milk before first feed. 50 per cent of the mothers had given something (like sugar, water, honey, jaggery etc.,) before first feed.
  • It is advocated that children should be on exclusive breast milk in the first four to six months. The percentage of children on exclusive breast milk in the first four months was only 40. Breast feeding practices among different educational, caste and block types indicated that illiterate respondents were breast feeding their children for a longer duration compared to educated mothers. Similarly, tribal mothers and mothers staying in the tribal block were breast feeding their babies for a longer duration.
  • Complementary feeding

  • Adequate and appropriate complementary foods are to be added to the infant diet starting from age 4-6 months. In the study areas, around 49 per cent of the children had received fluids even before completing the first month. It varied from 60 per cent in HI block to 30 per cent in CB block. Introduction of semi-solids or solids was delayed in the study area. Only 43 per cent of the children age 6-9 months had received semi-solids.
  • Immunization

  • Immunization coverage was far from complete in the study areas. Only 65 per cent of the children aged 12-23 months were fully immunized and around 2 per cent had not been immunized at all. Except for measles, coverage for all other vaccines was above 85 per cent. Coverage for measles was only 69 per cent. Analysis of vaccination coverage indicated that among children of mothers who were illiterate, and for STs, and tribal blocks, proportion of children who were fully immunized was lower. ,/li>
  • Only 18 per cent of the children in the age group 12-18 months had received first dose of Vitamin A solution, only 5 per cent had received deworming tablets/syrup, and only 17 per cent had iron supplements.
  • Food supplementation

  • Around 38 per cent of the children of less than 6 months age had been brought to Anganwadi Centre, 75 per cent of the mothers with less than 3 months old child reported that Anganwadi worker visited their homes, and 43 per cent of the mothers did not receive any advice from AWW. 32 per cent of the mothers reported to have received food daily, 29 per cent fortnightly and 21 per cent, monthly. 6 per cent of the children did not consume the food received by them.
  • The information on the episodes of Diarrhoea and ARI during the two weeks prior to the survey was collected. Nearly 23 per cent of the children had diarrhoea in the last two weeks, 24 per cent had ARI and 51 per cent had prevalence of cold, cough. Around 54 per cent of the children had received treatment for diarrhoea and ARI respectively. 64 per cent of the mothers knew about ORS, 24 per cent had correct knowledge about feeding practices during diarrhoea. 95 per cent of the mothers had some knowledge regarding signs and symptoms of diarrhoea.
  • Nutritional Status

  • Based on the weight-for-age index, according to IAP classification, about 41 per cent of the children were undernourished and 34 percent could be so classified according to IRPM.
  • Community participation

  • IN HP emphasises active community involvement in their programme so as to ensure that the community assumes the role of a catalyst for action. In this survey, information was collected on awareness and involvement of community members regarding various CARE related activities. 36 per cent of the mothers reported that the Nutrition and Health days (NHD) were held in their villages. Higher percentages of NHDs were held in CB and DS areas as compared to HI and other areas. Women were also aware of various services provided on nutrition and health days.
  • Regarding the involvement of household members in various community related activities, only 38 per cent of the women stated that they were involved in community group activities. Development of Women and Children in Rural Area (DWCRA) is the most popular community group wherein almost 80 per cent of the women reported to have participated. Though community participation was quite popular for income -generating activities, in the area of health, such participation was not as much encouraging. 36 per cent of the households contributed towards some form of community saving scheme. The awareness and participation of various CARE related activities by the community members were analysed with respect to different background characteristics. Awareness about Nutrition and Health days were lowest among illiterate women, ST women and women from urban areas. Other aspects like awareness regarding various services provided during NHDs and participation in various community group activities did not exhibit much variation across different background characteristics.
  • Service Environment of Anganwadi workers

  • Majority of the Anganwadi Workers were residing within the vicinity of the anganwadi centres (72%). Average number of Households and population covered by AWC was 233 and 960 respectively. 42 per cent of the AWCs were close to Sub centre, 54 per cent of the A WCs had a doctor/RMP close by, and 84 per cent of the AWCs had a daily living close by AWC. 91 per cent of the AWCs were visited by ANM during one month prior to date of survey and 65 per cent of the AWCs were visited by ICDs supervisor during one month prior to date of survey. Block-wise variations in the above aspects indicated that in urban areas only 20 per cent of the AWW were staying within a radius of less than one Km from the anganwadi centre, as against 80 per cent in rural areas and 75 per cent in tribal areas. The average number of households and population covered by AWCs were lowest in tribal areas as compared to rural and urban areas. Urban AWCs had a doctor close by, while rural AWCs had access to dai. Rural AWCs were visited by ANM and ICDs supervisor more often as compared to urban and tribal AWCs.
  • Almost all AWCs had good supply of food items but, supply of medicines was not adequate. 82 per cent of the AWCs had infant weighing scales, 67 per cent had adult weighing scales and 69 per cent had growth monitoring register. Majority of AWWs had obtained on-the-job guidance or participated in CARE supported activities.
  • Assessment of the knowledge of AWW regarding various activities showed that almost all the AWWs were aware of the importance of colostrum. Only 44 per cent of the AWWs had correct knowledge, about exclusive breast feeding, 77 per cent had knowledge about complementary feeding and 70 per cent had knowledge about right age of administering measles vaccination. A lower percentage of AWW had right knowledge about supplementation of IFA tablets and the number of tablets to be consumed during pregnancy. Majority of the AWWs had knowledge regarding "five cleans" during delivery.
  • Almost 83 per cent of the community members were involved in some health related activities. About 45 per cent of them were involved in transport/monitoring of AWC food or activities related to NHDs. Participation of community members in health related practices like drug banks, production/distribution of DDKs, loans for health reasons was less than 1 0 per cent.
  • Health providers in the study area reported that on an average they provided services to 50 women/children in a week. The services were mostly curative in nature for "ailments like ARI, diarrhoea etc. However, around one-fourth of them were providing TT immunizations and related antenatal services.
  • One-fourth of Dais in different programme areas were involved in CARE supported activities. Similar numbers reported involvement in NHDs. Only two- thirds of Dais were following the 'Five Cleans' in the safe delivery practice. Participation of community members/health providers/Dais in CARE supported activities in rural and urban blocks was reported by around 10 per cent in comparison to 50 in tribal block.
  • Service environment of ANM

  • Majority of the ANMs reported to be residing within the subcentre area. Average population covered by a subcentre was 4757 and average distance from the PHC was 11.4 Km. Majority of the ANMs reported that they received help from AWWs in carrying out their daily health related activities.
  • Seventy-five per cent of ANMs reported that supplies like IFA tablets, ORS, Vitamin A syrup, deworming tablets, were available. But supplies like condoms, DDKs were reported to be available among 25 per cent of ANMs. Infant and Adult Weighing scales were available with only two-thirds of ANMs. Stethoscope and BP apparatus were not available with more than 70 per cent of ANMs. Stock outs were also reported on essential medicines in fifty per cent of Sub centres. ANMs working in OS and HI blocks were more exposed to capacity building activities, as compared to ANMs in CB blocks.
  • 19) Impact Assessment of IEC Support to Strengthen the Routine Immunization Programme in Focus Districts of Andhra Pradesh and Karnataka States of Southern India (Supported by UNICEF -HFO)

    Executive Summary

    Introduction

  • The Public Health Scenario in India underwent a metamorphosis in the later part of 20th Century. Child health received utmost attention and a series of massive National Health and Nutrition Programmes were introduced to check the deadly childhood diseases. Universal Immunization Programme (UIP) launched in 1985-86 was one such ambitious programme, for protection against six killer diseases like Tuberculosis, Poliomyelitis, Diphtheria, Pertussis, Tetanus and Measles, which got integrated into Child Survival and Safe Motherhood (CSSM) Programme and currently into Reproductive and Child Health (RCH) Programme.
  • Despite the success of UIP in most parts of the country, there still exist several areas, where it could not make the desired impact. At the request of Governments of Andhra Pradesh and Karnataka, UNICEF - Hyderabad Field Office has placed consultants in identified low-coverage districts, to support the Information, Education and Communication (IEC) strategies being pursued there for strengthening Routine Immunization (RI).
  • The significance of IEC inputs to invoke the real demand for health intervention programmes was well recognized and documented. The optimum utilization of IEC inputs will enhance awareness, modify attitudes and behaviour, which ultimately improves the health status of population IEC thus becomes a basis for definite and practical solution to the innumerable health problems and its consequences.
  • The identified districts for IEC interventions for promotion of RI programme include Kurnool, Mahabubnagar, Nalgonda, Ranga Reddy, Visakhapatnam and Srikakulam districts in Andhra Pradesh (AP) and Raichur, Bijapur, Gulbarga, Bellary, Koppal and Bagalkot districts in Karnataka state. The envisaged IEC interventions were mainly targeting on: Five percent increase in coverage of RI; holding sessions as per micro plan; reduction of drop-out rates; active coordination between AWW and ANM in disseminating information on immunization and childcare guidance to care givers; raising community awareness regarding vaccine preventable diseases and nullifying community resistance to RI.
  • Indian Institute of Health and Family Welfare (IIHFW), Hyderabad has carried out a community-based study to assess the impact of IEC support to RI in focus districts of Andhra Pradesh and Karnataka states.
  • The main objective of the study was to provide base-line and end-line information on the following indicators to assess the impact of IEC in terms of:
  • Objective

  • Percentage of people aware of immunization messages,
  • Sources of these messages,
  • Knowledge of the community about RI -number of vaccines as well as Schedule
  • Knowledge about the place/day/time of service delivery
  • Immunization coverage of children and pregnant women
  • Reasons for partial or non-immunization.
  • Changes in final behavioural outcome of taking a child for RI.
  • Methodology

  • Multi-stage stratified sampling technique involving both random and purposive methods was adopted for the selection of households. In the first stage, three districts each from Andhra Pradesh (AP) and Karnataka states were randomly selected from the 12 focus districts. In the second stage, a total of 34 Primary Health Centres (PHCs) from Karnataka and 26 PHCs from AP were purposively selected, based on low RI coverage figures. In the third stage, 6 -12 villages were purposively identified in the selected PHCs, where coverage of RI was found to be low due to resistance factors or non accessibility/availability of services. In addition one village from all selected PHCs, with no special IEC intervention drive was also covered to serve as control areas. In the identified villages, all the mothers of children below 2 years were enlisted and subsequently an effort was made to cover at least 70% of them.
  • The study was conducted in two phases. Base-line (BL) and End-Line (EL) data were collected in first and second phases respectively to measure the impact of IEC support to strengthen RI programme.
  • Coverage

  • The study covered 122 Villages in Mahabubnagar, Nalgonda and Srikakulam districts, under 26 Primary Health Centres of Andhra Pradesh. The mean distance of villages from PHC was 9.6 kms and from sub-centre it was 3.9 kms. During baseline and end line periods, about 80% of mothers of U2 children could be contacted to assess the status of RI. Similarly, in Karnataka state, the study covered 147 Villages in Bijapur, Gulbarga and Bellary districts, under 34 Primary Health Centres. The mean distance of villages from PHC was 9.3 kms and from sub-centre it was 5.5 kms. During baseline and end line periods, 73.4% and 62.3% of mothers of U2 children were covered under the study.
  • Profile of Mothers of U2 Children

  • The mean age of mothers of U2 children of both baseline and end line study was 23 years in AP and 24 years in Karnataka states. About three-fourth of them in AP and half of them in Karnataka were illiterates. The mean years of schooling among literates was only 7 in both the states. The mean age at marriage was 16.7 years and mean age at first pregnancy was 18.3 years in AP and 17 and 19 years respectively in Karnataka, indicating early marriage and early pregnancy. More than 90% in AP and 80% in Karnataka were Hindus, mostly representing backward castes, scheduled castes and scheduled tribes. The mean family size was 5.2 members, with a family monthly income of Rs. 1681, about 70% engaged in manual labour, representing nuclear families, possessing white ration card given to families living in Below Poverty Line (BPL) and around half residing in kutcha type of houses in AP which reflect their low socio-economic background. In Karnataka, the mean half (43%) possessing Green/yellow ration card, given to families living in Below Poverty Line (BPL) and nearly one-third residing in Kutcha (31%) type of houses, with a mean family income was Rs. 2336. In Karnataka, since the family size is larger than AP, the per capita income worked to be more or less same in both the states. The distribution of subjects by socio-economic and demographic characteristics in control areas was also found to be similar to that of experimental areas.
  • In AP the coverage of two or more doses of TT Immunization remained at 92% even after intervention. Around 3% of them either did not receive any TT or received only one dose. The TT coverage in control villages was also remained more than 90% during both the periods of survey.
  • In Karnataka, only 70.3% of subjects received the stipulated two or more doses of TT, which increased to 83% after intervention, showing nearly 13% increase. The percentage of increase was 15 in Gulbarga, 14 in Bellary and 9 in Bijapur. Around 9% of sample received only one dose and 5.5% of subjects did not receive any TT indicating the need and scope for improvement. In control villages the percent increase under TT coverage was only 3.1% (70.2%-73.3%) as against 13% in experimental areas.
  • Type of Delivery and Its Attendance

  • As a whole, deliveries taking place at home were around 60% in AP, which has come down to 58% after IEC intervention and concomitant increase was noticed in institutional deliveries. Likewise after IEC intervention, attendance at delivery by trained medical personnel was doubled in Mahabubnagar and trebled in Nalgonda district. In Karnataka state, as a whole, deliveries taking place at home were around 67.9% which has come down to 64.6% after IEC intervention. The decrease in home deliveries was relatively more in Gulbarga (12.5%), than in Bellary (4.9%) or Bijapur (2.3%). Needless to state the converse of this was true with regard to institutional deliveries. Likewise after IEC intervention, attendance at delivery by trained medical personnel, especially by medical officer increased from 19.2% to 26.5% in Karnataka. The percentage of increase was slightly more in Bijapur (10.1%), than in Gulbarga (8.2%) or Bellary (3.7%). Some increase in trained TBA in Gulbarga & Bellary districts was noticed at delivery site. On the whole, the intervention could not bring major improvement in this aspect.
  • In both the states, the gender-wise sample coverage distribution of first born U2 child during BL and EL was about 55% male and 45% female and this appears to be in line with the general sex distribution for that age. The gender wise distribution was almost similar in all the districts.
  • In both the states, around half of the children in all the districts were aged 12 to 23 months. More than one-fourth of children in AP and one-fifth in Karnataka were aged less than 6 months. More than 70% of second born child in AP and more than 40% In Karnataka belonged to age of less than 6 months. In AP, the mean age of 1st born child was around 11 months and 2nd born child was around 5 months. Similarly in Karnataka the mean age of 1st child was around 12 months and 2nd child was 8.6 months. The profile of U2 children in control areas was comparable to that of experimental areas.
  • Awareness of Mothers on Aspects of Child Immunization

  • On an average, 62.3% of the mothers were aware of Childhood immunization for protection from 7 killer diseases in AP (Tuberculosis, Poliomyelitis, Diptheria, Pertussis, Tetanus, Hepatitis B and Measles). The intervention has helped in elevating this to 78.2%. Interestingly the increase in awareness is found to be uniform in all the three districts. Regarding he when asked to recall 7 killer diseases, it was found that they were more familiar (92.7%) with diseases like Polio after intervention, while their post-intervention knowledge of Tetanus, Tuberculosis, Measles and Hepatitis B was either doubled or trebled. Surprisingly, the set of three diseases DPT, has not spread as much as it is expected, basing on data (10% to 23%). Awareness of immunization schedule among the subjects was trebled after intervention. At the point of recall of the schedule, out of these, 43.8% who were made aware this way, all districts seemed to be ranking below average, but after the intervention the results were striking (73%-97%), particularly cent per cent in Nalgonda district.
  • In Karnataka, on an average, nearly half of the mothers were aware of Childhood immunization for protection from 6 killer diseases (Tuberculosis, Poliomyelitis, Diptheria, Pertussis, Tetanus, Hepatitis B and Measles). The intervention has helped in elevating this to 85.5%. Interestingly, the awareness levels were uniform in all the three districts. Among those who were aware, all most all the subjects could list out all the 6 killer diseases across the board. Awareness of immunization schedule among the subjects increased from 32% to 75% after intervention. The percentage of increase in awareness of immunization schedule was 55% in Bellary and Bijapur and only 19% in Gulbarga. Almost all subjects could recall the schedule in all the districts.
  • In AP and Karnataka, the post-intervention level of awareness with regard to monthly immunization session in their villages was very high (95% and 94%). With regard to day of immunization, in AP majority of subjects(63.5%) mentioned that normally immunization session in a month was held on Wednesday. Some mentioned it as Saturday (20.4%). In Karnataka, majority (67.9%) of respondents mentioned it as Thursday. Some mentioned it as Sunday (12.4%).
  • Antigen Dose-wise Coverage in 12-23 Months Children

  • In all 94.2% of children in AP and 85.9% in Karnataka had been reportedly immunized at the time of BL survey, which went up to 95% and 92% respectively after intervention. The information on who accompanied the child for getting it immunized was also obtained. More than 99% in AP and 91% in Karnataka, women themselves or with the help of their kith and kin have taken the child for immunization. In Both the states, the trend has been uniform in all the districts in this regard.
  • Immunization Card and Drop-out Rate

  • The possessing of immunization card has increased by about 10% (61.8% to 72.7%) in AP and 30% (54.3% to 84.6%) in Karnataka.. The pooled values for coverage of different vaccinations went up by 10% in AP and 6% to 19% in Karnataka. Drop-out rate was computed with respect to different vaccinations in the schedule in both the states and did not change much after intervention.
  • Full Immunization Coverage

  • About a half of the children surveyed in AP were found to be in the 12 -23 months age category .The proportion of these cohort children who were fully immunized (BCG, OPV3, DPT3, Hepatitis B3 and Measles) increased from 51.5% to 73.1%, correspondingly reducing non-immunized children from 17.1% to 1.7%. The intervention had simply doubled the coverage of fully immunized children in Srikakulam district. In other two districts the increase was only 10% and 8%. The increase in full immunization coverage in control areas was only 3% (62.6% -65.6%) during two periods of time, as against 21.6% in experimental areas.
  • In Karnataka about 60% and 51% of children surveyed during BL & EL respectively were found to be in the 12 -23 months age category .The proportion of these cohort children who were fully immunized (BCG, OPV3, DPT3 and Measles) increased from 23.5% to 63.8%, thereby correspondingly reducing non-immunized children from 5.7% to 1.7%.
  • The percentage of increase due to intervention was 58.9% in Gulbarga, 33.1% in Bellary and 28.9% in Bijapur districts. The increase in full immunization coverage in control areas was 29.3% (29% -58.3%) during two time periods, as against 40.3% increase in experimental areas.
  • The positive change between experimental and control areas in the coverage of children for full immunization during end line period in Andhra Pradesh and Karnataka was 18.5% and 11% respectively attributable to intervention.
  • Reasons for Partial/non-immunization

  • The proportion of subjects (38.2%) who have not attached importance to get their child completely immunized has come down to 18.1 %, indicating some good change in the attitudes after the intervention in AP. This was prominently (30%) seen in Mahabubnagar and Srikakulam districts of AP. Similarly not holding immunization sessions as per the schedule has come down from 13.9% to 8.6%. The non- availability of vaccine has also come down from 2.8% to 1.0%.
  • In Karnataka, not holding immunization session for some time was the major reason mentioned by nearly 43% of respondents during baseline, which has drastically come down to 6.1% after intervention. Non-availability of vaccines was another reason mentioned by 9.9% of subjects during end line. The percent respondents who have not attached importance required for complete immunization has come down from 10.6% to 7.4% after intervention. Similarly, due to religious beliefs, nearly 16% of Bijapur subjects did not opt for immunization during base line, and this has come down to 7.8%. after intervention.
  • The subjects were also asked to recall the location, where the immunization session was held. Mostly, the Immunization sessions took place as out-reach sessions in the village itself. The interventions tremendously enhanced this activity to 97.9% from 66.4% in AP. Whereas, in Karnataka, out-reach sessions in the village itself accounted for 63.5% and Govt. facility accounted for 33.4% in all the districts.
  • Rumours

  • Overall, only 3.6% of subjects in AP and 21% in Karnataka reported rumours or misinformation in the villages in the baseline as a reason for non immunization of the child. The reasons include 'obeying elders' instructions', 'not to entertain government programmes', 'child loses weight', 'non-immunized elders are presently more healthy', 'side effects', 'paralysis of legs or hands' etc. The end line results under this head is a little staggered and stood at 2.5% in AP, whereas in Karnataka, it reduced to half and stood at 9.1%.
  • Acceptor and Provider Behaviour

  • In both the states, about 90% of subjects, mentioned AWW as the chief source of information regarding immunization programme, during base line and end line, which speaks of her commitment and popularity in the village. Second to this source was MPHA (M/F) at 10%. Meagre percentage of subjects mentioned other sources like Members of Self Help Groups, Mothers Committee Members, Neighbours etc.
  • Around 95% of subjects in both the states testified that the vaccinator spoke to them politely and also informed about possible side-effects too. All the four side- effects viz. 'fever', 'soreness', 'abscess', 'swelling/lump' were mentioned by all most all the respondents in the three districts of AP and 60% to 90% of respondents of Karnataka. More than 90% in AP and 75% in Karnataka stated that that the vaccinator gave them the needed advice. Also mentioned under this head by majority were reassurances regarding common treatment for reactions, care at the injection site, initial aid and medication to be given to the child and steps to be taken if reaction worsened or persisted.
  • Observation of safe practices during immunization sessions in AP was noticed by 67.6% of subjects, which rose to 80.5% after intervention. The corresponding percentage figures for Karnataka were 49.2% and 76.5%. In both the states, the highest rate recorded (85%) was with regard to examination of infant/child. The use of disposable injections rose to 96.2% from 73.4% in AP. In Karnataka the use of auto disable injections, disposable syringes and sterile syringes was noticed by 53.3%, 55.2% and 69.2% of respondents respectively after intervention, registering 10 to 20 percent increase from the baseline. ,/li>
  • The use of safety box for disposing of used syringes/needles was previously noticed or observed by 75.5% of subjects, which after intervention went up to 81.1 % in AP. In Karnataka, it was observed earlier by 48.3%, after intervention, it went up to 68.6%. The awareness with regard to maintenance of cold chain/ice box was similarly increased to 21.4% in AP and 16.6% in Karnataka.
  • The type of advice received from the vaccinator by the subjects regarding information about the next immunization session, clarification of doubts and education about potential side-effects due to immunization were all well above the desirable levels (80% ), with further rise after intervention (90% ) in AP. In Karnataka, barring vaccinator clarifying the doubts (2% up) the rise in the levels for other two aspects was more than thirty percent from the baseline values.
  • Final Behaviour

  • Data shows that the child's immunization was volunteered by 44.3% of subjects initially in AP. Post intervention reveals a steep decline and places it at 19.8%. This can be interpreted as to be having the influence of department staff promoting the immunization by door-to-door invitation (55.5% to 77.8%) during intervention period. However in Karnataka it was totally reverse. Initially it was volunteered by only 26.9% of subjects, which has increased to 63.4% after intervention. The concomitant decrease was found in department staff promoting the immunization by door-to-door invitation (69.3% to 33.8%).
  • Additional information

  • In addition to immunization related information, aspects like use of iodized salt, birth registration, exclusive breastfeeding, complimentary feeding, hand washing etc., were also dealt during IEC intervention period with limited success. Messages like use of soap or cleaning agent for washing hands, instead of only with water, pre-Lacteal feeding, exclusive breast feeding, possession of birth registration certificate etc., could not translate in to action as expected in both the states.
  • IEC Messages on Immunization

  • The IEC messages on immunization at PHCs, Sub-centres, AWCs gone up by 15% to 20% in AP and 35% to 41% in Karnataka after intervention. Not much improvement in utilization of school buildings and hospitals for disseminating immunization related information, even though they seemed to be important vantage points. In AP, the other locations like Panchayat Building, Main Roads etc., were not being focused for utilization. In Karnataka an improvement of 20% was found in case of AWCs and Panchayat buildings. For other locations like school buildings, main roads etc the rise was around 13%. Data categorically confirming the fact that a lot needs to be done with regard to enlightening the target groups on immunization through messages by all possible centres.
  • Source of Information on Immunization

  • In Andhra Pradesh, information on immunization seemed to make an impact broadly through 'posters' and 'tom, tom' way of publicity in all the districts and needless to say that intervention influenced it further by 20%. One-third of the subjects after intervention were getting the information by tuning on Radio and TV. There was a visible increase of 15% to 30% across the districts, messaging through banners after the intervention. In Karnataka, after intervention nearly 80% mentioned TV, around 70% mentioned 'announcements' and 'tom, tom' as important sources of information on immunization. Around 50% of subjects also mentioned Radio, Cinema, Posters, Wall Writings, Audio Visual Vans and Banners as some sources indicating their use during intervention. Hoardings (13%), Melas (19%) and folders (16%) were other sources for information on immunization mentioned by subjects.
  • Participation of Opinion Leaders

  • In both the states Anganwadi worker was found to be chiefly responsible for rendering services pertaining to immunization, irrespective of intervention. There was 7% to 17% increase in AP and 20% to 64% in Karnataka as far as participation of School Teacher, Sarpanch, Dai and VAO in promoting immunization services are concerned. Participation of others like Caste/Religious leaders, RMP, NSS Volunteers, Pvt. Doctors etc remained low in Karnataka (11% -14%) and very low (3% to 9%) in AP.
  • Popularization Immunization Programme

  • The study sought information from the respondents regarding participation of different local groups/organizations in the task of popularization of immunization. Participation of 'Self Help Groups' was noticed by 42.2% in AP and 62.7% in Karnataka subjects after intervention. Initially only 27.8% and 14.5% of subjects from AP and Karnataka confirmed their participation in RI programme. In Karnataka, participation of Mothers Committee, Women health group was observed by 72.1 % and 63.3% of respondents respectively. The registered increase was 57.8% and 48.2% from the baseline values. However, in AP their participation remained almost static at 12% and 28% even after intervention, indicating the failure of the system to take their help in organizing the RI. Between 55% & 59% of subjects confirmed the participation of NGO, Janani Team and Mahila Mandal groups in popularizing the RI in Karnataka. Participation of other groups like Youth club, Education Committee etc was observed by 31% and 24.4% of respondents after intervention in Karnataka. Their participation was negligible in AP.
  • The respondents were questioned if they had noticed immunization related information at different events/occasions. In AP, 42% had got to know such information during joint house visits by ANM and AWW. It is more so (62%) in Mahabubnagar. Group Meetings have also hit the mark (28%), Rallies (27.5%) and Traditional Folk Methods (24.6%) were next in order. In Karnataka, more than 92% of respondents have happened to know such information during joint house visits by ANM and AWW in all the three districts. Street plays were witnessed by 83.8% of subjects after intervention. Group meetings and Rallies have also hit the mark (69%). Traditional Folk Methods were witnessed by 30% of subjects.
  • Suggestions

  • The operationally most feasible and best way of achieving high levels of immunization coverage in the community is minimizing drop-out rates. It calls for an immediate improvement in tracking the registered child for completion of the entire course of vaccination. Because drop-out rates of >10% indicate system failure. In both the states, despite the best efforts during intervention, drop-out rate could not be improved. The programme implementers should focus on this subject matter or issue. The coverage of TT immunization for pregnant women was fairly good (92%) in Andhra Pradesh, whereas in Karnataka it was found to be only 83%, indicating the need and further scope for improvement.
  • The positive correlation between coverage of children and availability of the services within the reach of villagers draws attention on two factors: a). need for organizing the fixed immunization sessions at the community, where low proportions of children were covered and b). need to improve demand generation activities, where the coverage is poor despite better service availability at the community level. Universal immunization coverage can be achieved only if the reach is at least around 90%. To achieve this goal, the very low and low coverage areas with around 50% (alarming situation) of full immunization like in the present study areas, should be focused by the respective state authorities. A concerted effort is necessary in this regard. Though the post intervention coverage data for full immunization was 73% in AP and 64% in Karnataka, in terms of improvement, the increase was 21% in Andhra Pradesh and almost 40% in case of Karnataka. District-wise disintegrated data clearly shows that the percentage of increase was 59% in Gulbarga, 33% in Bellary and 29% in Bijapur districts of Karnataka. Similarly in Srikakulam district the percentage of increase was 35%, 18% in Nalgonda and only 12% in Mahabubnagar districts of Andhra Pradesh. The usage of IEC and involvement of opinion leaders and local organizations were better in Karnataka, than in Andhra Pradesh. It appears from the data that in AP the organizers were solely dependent on AWW, whereas in Karnataka to some extent the involvement of other opinion leaders and local organizations was ensured. Similarly rumours or misinformation was reduced by half in Karnataka and 0.3% in AP. In Srikakulam district base line data shows that, non/partial immunization was attributed to rumours by nearly 7% of subjects, which has come down to only 4% after intervention. Likewise, in Bellary and Bijapur, around 30% and 18% of subjects respectively did not opt for immunization due to misinformation, which has come down to half after intervention. The objective of nullifying the community resistance to RI was not achieved. Sustained efforts are needed in this direction. To improve the coverage, the organizers in AP were dependent on house-to-house visits, rather than encouraging the subjects coming to the immunization centre voluntarily, as in Karnataka, which is long lasting and desirable. Provision of universal immunization cards, holding immunization sessions as per the schedule, filling up of vacant positions of personnel by the health department, use of all important and permanent locations to disseminate immunization related information, involvement of opinion leaders and local organized groups and enough IEC material for frontline workers with Inter Personal Communication (IPC) skills will certainly improve the coverage of immunization.
  • The monitoring of availability of quality services at the community level, demand generation activities and ensuring the right of every child need to be addressed by the Department of Health and Family Welfare -Governments of Andhra Pradesh and Karnataka, Ministry of Health and Family Welfare -Government of India, Local Civil Societies and all other partners promoting immunization.
  • 20) IMPACT OF THE SPECIAL CAMPAIGN ON ORAL REHYDRATION THERAPY AND ACUTE RESPIRATORY INFECTIONS IN ANDHRA PRADESH

    Summary And Conculsions

    The Department of Family Welfare Government of Andhra Pradesh has con- ducted a special campaign on ORT and ARI in the state from June 23-29, 1997 with an objective to increase the knowledge levels of mothers in managing Diarrhoea and Pneumonia among children. The present report is an evaluation of the effectiveness of the campaign in terms of exposure to the campaign and increase in levels of awareness of mothers about ORT and ARI. The study included pre and post campaign survey in six districts of the state covering the three regions. A sample of 3000 mothers were contacted for the data. A structured questionnaire was administered to the same respondents during pre and post campaign period and the following conclusions are drawn from the analysis.

  • 1. Nine out of ten mothers indicated cold and cough as the common ailment among children while 69 per cent reported fever, 53 per cent mentioned diarrhoea.
  • 2. About 72 per cent of mothers indicated 3 to 5 loose motions a day as a symptom of diarrhoea.
  • 3. ORS is known to 58 per cent of mothers with children below five years. The mothers ever used ORS packets is 39 per cent.
  • 4. Majority of mothers continue breast milk feeding (92 per cent) to their infants during diarrhoea.
  • 5. Fifty five per cent of the respondent mothers related the occurrence of diarrhoea to dirty surroundings and 35 per cent felt due to unhygienic/ contaminated drinking water could be a source of diarrhoea.
  • 6. Listlessness of children (60 per cent) and sunken eyes (49 per cent) are considered as dangerous signs of severe diarrhoea. Only a quarter of respondent mothers have knowledge that severe diarrhoea causes dehydration and may lead to death.
  • 7. More than four-fifths of mothers confirmed the effectiveness of ORS. The knowledge of mothers about ORT is observed to be quite high with significant gain from campaign.
  • 8. Sixty per cent of mothers consider cough and cold among children as symptoms to be taken seriously. A significant increase reported in post campaign as compared to pre campaign survey.
  • 9. Knowledge about the symptoms of Pneumonia was low among mothers as compared to diarrhoea. However, the campaign did help in .increasing the knowledge levels of mothers about consequences of severe cough and cold.
  • 10. Death as the consequence of neglecting phemonia was understood by 49 per cent of mothers. The pre and post campaign difference in figures also revealed that the campaign has good effect in disseminating the knowledge levels of mothers in understanding seriousness of ARI.
  • 11. The percentage of mothers received information about the campaign is 59 per cent of ORT and 41 per cent of ARI.
  • 12. The mean degree of knowledge of mothers about different aspects of ORT and Am is 42.6. The average knowledge levels of ORris relatively better than ARI (34.55 and 25.59 respectively). The average level of exposure to campaign activities is 24.81.
  • 13. The levels of knowledge by districts show that Chittoor, West Godavari, Vizianagaram and Warangal are above state aggregate in knowledge about the ORT and Am. The districts which were below the state average ( Kurnool and Mahabubnagar) were observed to be in better position as far as expo- sure to campaign is concerned.
  • 14. The de-hydration and Re-hydration concepts is reported to be relatively less. An increase is noticed from pre and post campaign in case of knowledge about the sources of availability of ORS packets.
  • 15. The farther distance of the village from mandal headquarters and higher age of the mother have shown lower influence about the special campaign.
  • 21) TOTAL HEALTH AWARENESS CAMPAIGN IN 49 MANDALS OF SEVEN BACKWARD DISTRICTS OF ANDHRA PRADESH – 1996-97

    Executive Summary

  • The Total Health Awareness Campaign was launched in June 96 to spread awareness on different components of family welfare like girl child education, age at marriage, ante natal care, post natal care, immunisation, spacing methods, sanitation and hygiene. The campaign, which was implemented by 46 Non-Governmental Organisations [NGOs] in 49 backward mandals located in seven backward districts of Telangana viz, Adilabad, Medak, Nalgonda, Khammam, Warangal, Mahaboobnagar and Ranga Reddy, was completed in January 97 in all the above districts barring Ranga Reddy. The districts were chosen on the low performance of three vital health indicators- Crude Birth Rate, Crude Death Rate and Couple Protection Rate. The campaign which lasted for eight months covered 1386 villages encompassing a population of over 17 lakhs. In Ranga Reddy the campaign came to an end in March 97 as the campaign began late i.e. in January 97. The delay in launching the campaign in Ranga Reddy was due to the inability of Vizianagaram district to take up the campaign and the same had to be implemented in Ranga Reddy after considerable loss of time.
  • The mandals were selected on the basis of the low female literacy rate. The Total Health Awareness Campaign was a sequel to a similar campaign which was implemented in Nellore district during 1994-95. The Nellore campaign covered 400 villages in the district with IEC components encompassing street plays, songs, skits and visual material for neo-literates, It was found that the campaign in Nellore not only made the people aware of their health needs but also helped them in changing their attitudes towards seeking qualitative and timely health care. Besides, the Nellore campaign, which was implemented with the help of the NGOs had developed a sustained demand for safe health care services through primary health centres and sub-centres resulting in the achievement of all family welfare goals. Keeping the Nellore experience in mind, a plan was drawn up to implement Total Health Awareness Campaign in seven backward districts of Telangana through varied IEC components with the help of NGOs. ,/li>
  • The study was implemented in three phases. In the first phase, the NGOs, selected for the campaign, had undertaken a precampaign survey in their respective mandals to gauge the awareness levels on different aspects of family welfare. The precampaign survey had enabled the NGOs to assess the communication needs of the target population and design their campaign accordingly.
  • In the second phase, the NGOs and their volunteers with the help of Health Committees carried out the IEC campaign in their mandals.
  • In third phase, an independent agency carried out the post campaign survey in which the respondents of the pre-campaign survey were again interviewed to study whether the IEC campaign has improved the awareness and attitudinal levels on health and family welfare issues.
  • Though it was intended to complete the IEC campaign in five months initially, the same could not be done because of various constraints like bad weather during the monsoon and the frequent power cuts. The rains had upset the schedule of the IEC campaign and the power cuts had forced postponement of campaign as the campaign had to be carried out only in the. late evenings or nights to ensure larger participation of the target groups.
  • Besides, the campaign was affected by extremist violence in some of the districts like Warangal where the campaign had to be suspended in some of the mandals because of the disturbed conditions.
  • Among the various IEC components that were used during this campaign were kalajathras, group discussions, video shows, well baby shows, rallies, exhibitions, wall paintings, wall writings and stickers. Though the utility of the wall writings and stickers in the largely illiterate mandals was debated, the NGOs had gone ahead with these activities too as they felt that they would serve as reminders for the literate population. Some of the NGOs extended their activities beyond the IEC campaign by organising health camps and sterilisation camps. Many of the NGOs who participated in the campaign took an active part in ORS campaign, Pulse Polio and School Health Check Up programmes. In quite a few instances, the NGOs had assisted the medical staff of the government in successful implementation of their sterilisation camps by undertaking social mobilisation.
  • To enable the NGOs to plan their IEC campaign and make it effective, an IEC Consultant was appointed to visit the project area and make suggestions to the participating NGOs. At several places, the IEC Consultant advised the NGOs to build a rapport with the target population before implementing the campaign as credibility of the source of communication plays a key role in the absorption process of the messages. The NGOs were asked to deliver only one, or two messages at a time instead of transmitting all the family welfare messages at a time as the absorption and retention capacity of the target population is very limited. Though the NGOs were laying much stress on the kalajathras they were told that the kalajathras will not have the desired impact if all the messages were delivered within one or two hours without subsequent follow up in the form of group discussions. In many of the instances, the group discussions were not conducted effectively. The NGOs were told that the group discussions will have the desired impact only when the facilitator i.e. the volunteer commands the respect of the target population and conducts the discussions among homogenous groups i.e. focused group discussions, as the communication needs of the groups vary widely. The NGOs were constantly advised to train their volunteers adequately in different aspects of family welfare if they are to make the group discussions effective. The NGOs were also advised to study the immediate local health needs of the target population and start the campaign by taking up issues pertaining to the local health needs as this would build the necessary rapport with the local population, a prerequisite so critical for the successful implementation of the campaign.
  • After the completion of the campaign, an external research agency was appointed to conduct post campaign evaluation. The agency was given the names of the respondents who were interviewed in the precampaign survey and to a large extent the same respondents were interviewed by the external agency. As per the findings of the post- campaign study, the performance in four mandals turned out to be excellent, while in eleven mandals the campaign achieved good results. The performance in twenty seven mandals was moderate while in seven mandals the campaign was rated poor.
  • The major findings of the study are:

    District -wise Findings

  • The Post-campaign study assessed the performance of the IEC campaign, implemented in 49 mandals, of seven districts, on a quantitative measurement scale based on the cumulative differential scores achieved by each mandal. According to the scores registered in the seven districts, the IEC campaign had the highest impact in Medak, followed by Adilabad, Ranga Reddy, Warangal and Khammam.
  • However, it had negligible impact in Nalgonda and Mahabubnagar. The district-wise impact with regard to various health and Family Welfare Programme indicators revealed that in terms of girl-child education, Warangal had the highest awareness while Mahabubnagar registered the lowest. Regarding legal age of marriage, the highest awareness about it was registered in Warangal and lowest in Mahabubnagar, Khammam. Medak registered the highest increase in terms of the respondents getting their children married within legal norms.
  • Medak and Adilabad revealed higher perception and attitude change in terms of getting ANC done under trained medical staff. The highest percentage increase in getting deliveries done in Govt. hospitals and medical centres was in Warangal and Khammam. In terms of breast-feeding immediately after child-birth, Medak, Nalgonda .Adilabad and Ranga Reddy registered perceptible increase in awareness and attitude change. Medak and Warangal and Adilabad showed higher awareness and attitude change in terms of using ORS to treat diarrhoea.
  • Awareness about FP methods was quite high in all the districts with Medak registering the highest percentage with Nalgonda having the lowest awareness of. Medak registered an increase of in the use of FP spacing methods while Khammam, Medak and Ranga Reddy did well in the practice of FP terminal methods. Detailed findings with graphs are found in post evaluation study conducted by external agency. These are some of major findings.
  • A) Girl-Child Education
  • Regarding the need to provide education to the girl child the highest awareness was registered in Kothaguda (89%) in Warangal and Vemunapall1 (88%) in Adilabad, followed by Korvi (87%) in Warangal and Manoor (84%) in Medak and Narnoor & Jaipur in Adilabad and Kullcharam in Medak, all with 82%. The lowest level of awareness was registered in Bashirabad(33%), Midgil (40%), followed by Nannel (45%) and jadcherla (48%).
  • The highest increase in awareness about girl-child education after the IEC campaign, was registered in Chivemla (12%) and jainoor, Bhupalapalli, Korivi and Kothaguda all 11% each.
  • The highest degree of attitude change in terms of sending girls to school was in Doma (70%) followed by Chivemla (67%) and Korivi (62%) and Korivi (62%). The lowest degree of attitude change was registered in julurapadu (12%) followed by Gundala, Midjil Nannel, Vailerupadu, Maddur and Bashirabad, all sending less than 30% girls to school.
  • B) Legal Age of Marriage
  • The highest percentage of awareness about the legal age of marriage was in Dindi (76%) followed by Regode (74%) and the lowest degree of awareness was registered in Gattu (26%) and Kalahari (27%) and Nannel (27.5%). The highest percentage increase in awareness after the'IEC Campaign, was noticed in Regode (15%) followed by Doma(12%), .V.R.Puram (11 %) and Chivemla and Kowdipalli with (8%) increase. The highest percentage of respondents getting their daughters married according to legal norms was registered in Mulkalapally (30%) followed by Sirpur-Utnoor (29%), , Jaipur (28%) and Nampally (25%).
  • The highest increase in attitude change towards adhering to legal marriage norms was registered in Mulkalapally (19%) followed by Dharoor (11 %), Mirdodi (9%) and 6% each in Chivemla, Regode and Vailerupadu.
  • The lowest percentage of respondents who are getting their daughters married according to the legal age of marriage, was registered in Manoor (7%), Maddur (8%) Kulcharam (9%} and (16%) each in Midgil, julurapadu and Gattu.
  • C) Spacing Methods
  • The highest percentage of awareness about FP Spacing Methods was in Doma(79%) followed by Mirdodi (74%) Dharoor (73%) and Regode and Kalhair (71 %each). The lowest percentage of awareness was in kanagal (26%) followed by Maddur (27%),Kothapally (29%) and Bashirabad (30%). The highest Increase in awareness of FP Spacing methods after the IEC Campaign, was in jainoor (10%) followed by Chivemla and Dindi (9%) and Murkapally (7%). The highest percentage in terms of attitude and practice of spacing methods, was registered in Doma (33%) followed by Dharoor (25%) and Chennaraopet (23%). The lowest attitude and practice was noticed in Kanagal (3%) followed by Kothaguda and Nallabellly (4%) Manoor (5%), Gudur, Nawabpet and Shahabad (7% each) and Midjil, Vaddepalli and Nampally with just 8% each, and P.A.Pally and Turkapally (9% each) who were practicing FP Spacing methods.
  • The highest percentage increase in attitude change and practice was observed in Doma (13%) followed by Regode (10%) and Chivemla and Korivi (9% each).
  • D) Terminal Methods
  • Awareness about FP terminal methods was very high in almost all mandals, barring a few. The highest percentage of awareness was registered in Gundala (89%) followed by Korivi (87%), Vailerupadu and Nampally (84%), Dharoor and Doma (83%), Kothaguda and V.R.Puram (81 %) and Wajedu (80%). The lowest awareness level for his variable was noticed Midjil (60%), Chivemla (61%) and Sirpur-Utnoor (62%). The highest percentage increase in awareness levels after the IEC campaign, was in Mulkalapally and Dharoor (12%) followed by Tekulapally (8%) and Mirdoddi, Regode, Vaddepalli, Jainoor and Maddur (7%) each.
  • In terms of attitude and practice, Wajedu, Korivi and V.R.Puram with 48% registered the highest adoption of FP terminal methods in the campaign, followed by Mulkapally (47%), Vailerupadu (46%), Doma and Kulkacherla and Kothaguda, Mirdoddi and Nampally around 40%. The lowest practice was noticed in Utnoor (9%), Sirpur- Utnoor (10%), Bashirabad (11 %) and jadcherla (15%).The highest increase in attitude and practice after the IEC campaign was in Vemunapalli (12%) followed by Dharoor (1O%), Regonda(7%) and in Mirdoddi, Jaipur, Manoor and Nallabellly, all with 6% each.
  • E) Ante-Natal Care
  • There was high degree of awareness and attitude change about getting ANC check-up done in Govt. Hospitals or with the help of ANMs and trained “dayees" with Kulkacherla in Ranga Reddy district registering the highest percentage of awareness of91.9% followed by P.A.Pally with 91.1.% and Kothaguda with 88.9%. The lowest figure was in Wajedu (36.9%) followed by Gattu (37.8) and Sirpur-Utnoor (48.2%).
  • F) Hospital vs Home Deliveries
  • The highest percentage of awareness and attitude change of this variable was in Kulcharam (63.6%) in Medak district and Nampally (62.3%) in Nalgonda district. The lowest percentage was registered In Maddur (16.7%) followed by Jaipur (26.7%), Chennaraopet (33.8%), Raikode (34.6%) and Tekulapally with 37.5% .There are more people new availing trained medical facilities for their deliveries, either at Govt. hospitals, or under the guidance and supervision of ANM's and trained "dayees". But despite this, the trend of home deliveries still continues.
  • G) Advantages of Breast -feeding
  • There was very good response to both awareness and attitude change regarding breast-feeding either immediately or the next day of delivery. The highest .awareness was in Gundala(91.9%) in followed by Narnoor (91.8%), Mulkalapally (91.6%) and V.R.Puram(91.4%). The lowest awareness was in Raikode (45.7%) followed by Chennaraopet (50,0%) and Midjil (615%). Despite the IEC campaign, there are still 12-15 per cent people who are wasting the precious mother's milk due to ignorance and misinformation about the quality of breast-milk immediately after delivery.
  • H) Use of ORS to control Diarrhoes
  • The highest awareness and attitude change towards use of ORS to control diarrhoea was in Bhupalapalli (58.4%) in Warangal district followed by Raikode (54.3%) and Dharoor (54%). The lowest use of ORS was in Nannel (5%), Maddur (6.7%) and julurapadu (8.5%). After the IEC campaign, it was noticed that the earlier trend to treat diarrhoea as a matter of superstition which could be treated through "mantras" or even black magic or special potions, is slowly eroding. There is more use of HMF (Home - made fluid) to control diarrhoea. But despite all this, there is serious need to educate the people about the causes of this dreaded ailment, which seems to be lacking.
  • 22) EVALUATION OF KRISHNA COMMUNITY HEALTH INTERVENTIONS PROGRAMME

    Executive Summary

    Introduction

  • LEPRA Society, a national NGO, is actively involved in enhancing community health through emphasis on community health promotion, community health services delivery and community resiliency. It has implemented a three-year community health project, called Krishna Community Health Intervention (KRISCHIP), in five mandals of Krishna district of Andhra Pradesh, a southern state of India, since April 1, 2004 to March 31, 2007 with TB Alert, UK as a consortium partner and Vasavya Mahila Mandali (VMM) as a local partner. The project covered 15.6 lakh people in a phased manner in four rural zones of Krishna district, namely Nandigama, Gannavaram, Machilipatnam and Nuzividu comprising 580 villages and one urban zone covering 130 slums in Vijayawada. All urban interventions were taken up by VMM.
  • Purpose

  • The overall purpose of KRISCHIP was to reduce the vulnerability of poor rural and urban communities to the spread of TB, HIV/AIDS, malaria, leprosy and other diseases more often seen among poorer sections of the society. It has successfully established a system of working with government health workers to improve diagnosis and treatment skills as well as to increase referrals to appropriate treatment facility. It has also worked with community based groups to raise awareness particularly among the scheduled castes, tribes, urban poor and other vulnerable groups. The project came to an end on 31st March 2007.
  • The Indian Institute of Health and Family Welfare, Hyderabad was commissioned by the LEPRA Society to carry out third party evaluation of the inputs, outputs, outcome and impact of the project with the following objectives:
  • Objectives

  • To study the impact of KRISCHIP interventions in terms of reduction in the spread of TB, HIV/AIDS, Leprosy, Malaria and Filarial diseases assessed through proxy indicator like increase in referrals.
  • To evaluate various IEC interventions in terms of enhancement of knowledge, attitudes and practices and utilization of services by the vulnerable community members.
  • To suggest improvements, reinforcements and optimization of existing resources, services and opportunities for effective continuation of interventions.
  • Research Design
  • The study was carried out in the project area of Krishna district of Andhra Pradesh, a southern state of India, covering all four rural zones viz., Nandigama, Gannavaram, Machilipatnam, Nuzividu mandals and one urban zone of Vijayawada. In addition Gudivada – a non KRISCHIP intervention area was taken to serve as control to assess the impact.

    A combination of descriptive and exploratory research formed the research design. Both quantitative and qualitative scientific tools like questionnaire, interview schedule, focus group discussion and case study were used for the purpose of data collection. To study the community response, multi-stage stratified random sampling method was adopted. The data were collected by two research teams, each consisting of three investigators and one supervisor. The sample covered 142 village health volunteers. In addition, a total of 1851 households formed the community sample representing 4 rural intervention zones and 185 community members from a non intervention area to serve as control. A total of 16 Focus Group Discussions and 5 case studies were also conducted under the study. The data pertaining to utilization of services by community members for four diseases was obtained from MIS section of KRISCHP office, Vijayawada, for timeline analysis.

    KRISCHIP Interventions

  • Community capacity building, various IEC activities including observation of disease specific days, health camps, networking, constitution of project coordination committee and formation of health forums at the village level were some of the important activities carried out during the intervention period. All key initiatives of this project were carried out by trained village health volunteers. The main aim of this initiative was to sensitize the vulnerable and marginalized segments, especially elders, women and children to the core public health needs and priorities and enhance their capacity to raise themselves above the vicious circle of infectious and life-style-related diseases. Each form of intervention was injected by a mix of traditional and innovative initiatives. As a result of these interventions, it is expected that an increasing number of patients suffering from the focal diseases will utilize the available treatment facilities. The final summary tables from 109 to 118 reflect the overall status of KRISCHIP interventions.
  • Utilization of Services

  • To study the possible relation between the time and the referrals for diagnosis/treatment of four diseases, the data were subjected to regression test. The analysis of the pooled data revealed that there is a linear relationship between the time and number of people referred for different diseases for the years 2005 – 2006 and 2006 -2007 in all the five intervention zones. The regression coefficients were statistically significant (P< 0.01) indicating the positive effect of various interventions under KRISCHIP in generating the demand for utilization of services through increase in referrals (Tables. 102 and 103).
  • Zone-wise Performance

  • Analysis of zone-wise data available for 2006-2007 also indicated the existence of statistically significant (P<0.01) linear relationship between the time and number of people referred for all four diseases for testing/treatment facilities in Gannavaram and Nuzividu zones; barring leprosy for remaining three diseases in Vijayawada zone; except TB and leprosy for remaining two diseases in Nandigama zone and only for TB in Machilipatnam zone (Tables 104 to 108 and Graphs 2 to 6).
  • Profile of Village Health Volunteers

  • Village health volunteer representing the sample drawn from project areas, were mostly females, with a mean age of 31.1 years, who completed 10 years of schooling, belonged to Hindu religion, mostly from SC/ST/BC community, living in a nuclear family, with a family size of 4.4 members, either agricultural labourer or artisan and earning a mean family income of Rs.2920 per month. The listed motivational reasons for taking up voluntary work by majority of volunteers include zeal to render health services, inculcate healthy habits in the community, do social service, extend a helping hand in the disease control programs, create awareness regarding chronic diseases, wipe out apprehensions and misconceptions regarding chronic diseases and take action in chronic disease prevention programs.
  • About half of volunteers had some previous experience in rendering health services and were able to spend more than three hours time towards service to the community members. There was a very deep sense of awareness about duties and responsibilities among majority of health volunteers which include awareness generation, convergence, case identification, motivation of patients to take treatment regularly, removing apprehensions and providing referral services.
  • Profile of Community Members

  • Community members representing the sample were mostly middle aged, with a mean age of 34.8 years, a majority of them were engaged in manual labour or agriculture-related activities, most of them were Hindus, mostly representing SC/ST/BC community, living in a nuclear family, with a mean family size of 4.3 members. More than half of them were literates, with 7.7 mean years of schooling. A very large majority of them (82.0%) possessed white ration card given to below poverty line families, had a mean income of Rs.2444 per month, living in a kutcha or semi-pucca type of house, possessed simple household items like Fan, Watch, Bicycle etc. indicating their poor socioeconomic status.
  • Knowledge, Attitudes and Practices (KAP)

  • It is imperative that the village health volunteers, who were chosen under the project, should possess complete knowledge on five focal diseases to carry out the various interventions effectively. KAP scores obtained by volunteers on tuberculosis, leprosy, malaria, filaria and HIV/AIDS were taken as proxy indicators to assess their field performance. The overall percent mean KAP scores for all five focal diseases together obtained by volunteers was nearly 45% and community members could score only 27%, whereas community members of non-intervention area scored only 16.5%, indicating an increase of about 10% more knowledge among community members of intervention areas, attributable to interventions carried out under the project.
  • Disease-wise KAP percent scores clearly indicated that with regard to HIV/AIDS, volunteers possessed nearly 50% knowledge, while the same was 43% for malaria. Whereas, community members showed 45% knowledge of HIV/AIDS and 41% knowledge of malaria indicating the success of volunteers in transferring the knowledge to community, as far as these two diseases are concerned. Though volunteers possessed around 45% knowledge with regard to leprosy and filaria, they could transmit only 14.2% and 12.7% of knowledge to the community. With regard to tuberculosis, volunteers obtained 39.7%, whereas community scored only 23.2% indicating their limited success.
  • The results also indirectly indicate that there is a need to conduct periodic in-service training programmes for all village health volunteers to improve their KAP on five diseases, so that they can sensitize a larger percent of the community members more effectively. Though village health volunteers expressed their satisfaction with regard to induction and refresher training programmes organized under the project, they desired more such programmes on a regular basis. It was also suggested to provide the expertise of a resource person available all round-the-clock so as to clear doubts on technical matters, if any.
  • Zone-wise Ranking of KAP Scores

  • A comparative analysis of mean percent KAP score obtained by a typical community member representing Nandigama zone ranked first with 34.1% score. Gannavaram with 29.4%, Vijayawada with 27.3% and Machilipatnam with 25.7% score stood in 2nd, 3rd & 4th positions respectively. All these scores were significantly higher (P< 0.01) than scores obtained by community members representing the control area. However, community members representing Nuzividu zone stood last with 21.5% score and it is not significantly higher than the score of control area.
  • Though there are differences in disease-wise KAP scores among zones, interestingly the pattern of scoring was found to be similar with high scores for HIV/AIDS, followed by Malaria, TB, Leprosy and lastly Filaria. In implementing various IEC activities, perhaps volunteers of all zones maintained uniformity in giving disease wise priority.
  • IEC Activities

  • A number of Information, Education and Communication (IEC) activities were undertaken by Village Health Volunteers under the project in order to bring about community awareness with regard to five focal diseases. Television, Radio, Cinema and News Papers were used under Mass Media; Posters, Hoardings, Pamphlets, Pictorial Booklets, Wall Writings, Banners were also extensively used under Little Media; Screening of Video Films through IEC Van, Staging of Street Play, Mike Announcements, Tom-tom, Observation of Disease Awareness Days, Public Meetings, Group Meetings, Rallies were different IEC methods adopted. In addition, involvement of ANMs, AWWs, WHVs, Asha Mitras, Private Doctors, RMPs and NGO volunteers was also sought for the implementation of IEC activities. To improve community knowledge, only 47% of village health volunteers reported high usage of various IEC inputs under the project.
  • Disease-wise Ranking by IEC Utilization

  • The support of mass media was better for creating awareness on HIV/AIDS (44.8%) than for malaria (10.1%), tuberculosis (8.7%), filaria (5.8%) and leprosy (3.3%). Usage of little media channels, involvement of opinion leaders and usage of different methods for IEC activities in disseminating information regarding five focal diseases also followed the same trend of mass media.
  • Zone-wise Ranking by IEC Utilization

  • The mean percent IEC utilization scores obtained by community members representing Machilipatnam (18.3%), Nandigama (17.1%) and Gannavaram (16.9) were more or less similar, though chronologically ranked 1st, 2nd and 3rd. Similarly Vijayawada urban (14%) and Nuzividu (13.8%) zones scored more or less same, though stood in 4th and 5th ranks for their IEC utilization.
  • Mass Media Utilization

  • An attempt was made to rank the zones based on various components of IEC utilization. Machilipatnam zone ranked first as far as utilization of mass media channels for community awareness activities are concerned, followed by Gannavaram, Nandigama, Vijayawada and Nuzividu zones in a descending order standing 2nd, 3rd, 4th and 5th positions.
  • Little Media Utilization

  • A large number of little media tools produced specially under the KRISCHIP were utilized more effectively in Vijayawada urban zone standing 1st, followed by Machilipatnam standing 2nd in the ranking. Though chronologically ranked 3rd, 4th and 5th ranks, the utilization levels of little media were found to be almost similar in Gannavaram, Nuzividu and Nandigama zones.
  • Utilization of Various Methods of Dissemination

  • Usage of various methods of dissemination was found to be similar in Nandigama and Gannavaram zones, though standing 1st & 2nd, closely followed by Machilipatnam zone with 3rd position. Similar low levels of utilization were reported in Nuzividu and Vijayawada zones, though ranked 4th & 5th positions.
  • Involvement of Various Categories of Opinion Leaders in IEC Activities

  • Nandigama zone stood 1st rank as far as involving various categories of opinion leaders in IEC activities are concerned. Similar levels of their involvement were noticed in Machilipatnam, Gannavaram and Nuzividu zones, though chronologically standing 2nd, 3rd and 4th ranks. Community members of urban Vijayawada could not notice their involvement in a big way and stood 5th in ranking.
  • Triangulation of Data

  • Data obtained from different tools should give results reflecting similar trends or picture. An effort was made to compare the zone-wise community KAP scores with that of referrals mobilized by the volunteers based on percent R2 values through triangulation of data. Gannavaram zone has shown consistency as far as leprosy and HIV/AIDS diseases are concerned by standing in 2nd position in community KAP scores as well as mobilization of more referrals by volunteers for these diseases which in turn is measured through percent R2 values. Similarly, Vijayawada Urban zone had shown consistency with regard to malaria and HIV/AIDS diseases by standing in 3rd position in both KAP scores and referrals. Malaria is the only disease, where Nandigama zone stood 1st in both KAP scores and referrals. Machilipatnam zone has not shown any such consistency for all four diseases. Nuzividu zone surprisingly stood last on community KAP scores, which were also not significantly higher than the scores obtained by community members in control area. However, it stood 1st as far as mobilizing more referrals in 2006-2007 for tuberculosis, HIV/AIDS and leprosy diagnosis/treatment facilities are concerned, perhaps indicating a good reporting system.
  • Village Health Forums

  • Most of the Village Health Volunteers (91.5%) reported successful formation of village health forums and majority of them (81.5%) were fully satisfied with their functioning. However, between 5% and 10% of community members reported the presence of health forums in implementing IEC activities. The villagers' awareness with regard to village health forums was rather vague. They stated that they were aware of the existence of health forums, but not their functions. It clearly indicates that there is an urgent need to involve more community members in the functioning of health forums or improve its visibility, so that the good work turned out by them obtains community endorsement, support and full credit. Most of the FGD participants were of the opinion that over involvement of local leaders in the functioning of health forums and its programs may create problems. They opine that a good program can be implemented even without participation of local leaders. Involvement of local NGOs in the functioning of health forms was tried out in some villages with positive results as reported in the case let. Other villages can also try out this method. It is also suggested that all the members of health forums could interact with a few other progressive or best forums in Krishna district in order to learn from other forums' experiences and possibly emulate best practices so that their qualitative output is enhanced. A noteworthy point was that many health forums were of the opinion that they have a limited role to play in the advancement of public health in the village. A mentor could be deputed from LEPRA Society to provide limited but critical and well- defined inputs to each health forum for its sustained and effective functioning. Leadership could make a critical difference to a health forum.
  • Socio-cultural Factors

  • Information on the influence of social, cultural and psychological factors on the patients and their family members regarding coming terms with disease was emanated from Focus Group Discussions (FGDs). Community strongly felt that barring malaria, the remaining four diseases were attached with social stigma. They were of the opinion that no village is free from these chronic diseases. Every village has its own disease burden. Some villagers expressed their gratitude to village health volunteers and both mass and little media for creating awareness in the community. The repeated visits of volunteers to their houses have definitely influenced their minds to switch over to healthy life-styles. Many villagers found a tremendous change in the perception of the community. Now they have increasingly realized the importance of early diagnosis of diseases like leprosy & TB. They also knew that these diseases could be cured completely with the help of regular treatment.
  • Special Events

  • Between 60% and 90% of health volunteers reported the observation of World AIDS Day, Anti Leprosy Week, World TB Day and Anti Malaria Week in their areas of operation. However, only 10% of community members mentioned about the observation of World AIDS Day and less than one per cent referred to observation of other days. It clearly indicates that volunteers observed it as a routine ritual and failed to involve or mobilize large number of community members.
  • Satisfied Patients as Motivators

  • The results of case lets clearly indicate that a satisfied patient can help the volunteers in disseminating information pertaining to the specific disease and provide motivation to community to utilize the diagnostic/treatment facilities. Village health volunteer’s simple personalized health communication is enough to bail out a patient from a health crisis. The case lets also threw light on how unqualified medical parishioners and sometimes private medical hospitals exploit by hoodwinking vulnerable patients. To a great extent KRISCHIP interventions have successfully curtailed such exploitations and helped many to utilize available free diagnostic and treatment facilities. These are few strongest messages emanated from caselets.
  • Feedback

  • Insecticide Treated Bed Nets (ITBNs) were distributed as a Malaria/Filaria preventive measure in all Vijayawada urban slums. About fifty percent of respondents covered under the sample received such nets as a part of KRISCHIP interventions and more than eighty percent of those who have received such nets reported their usage as 'satisfactory'. Though more than 90% of volunteers felt that KRISCHIP definitely helped in increasing the awareness on critical illness/disease, only one-fourth of community members endorsed such opinion, indicating the large need to do more in implementing such awareness generation programmes. Community members stressed the need to continue same strategies more effectively even for future intervention programmes.
  • Suggestions

    Regular monitoring and supportive supervision from KRISCHIP, incentives in the form of monthly performance-based honorarium, appreciation certificates and clarification of doubts over five focal diseases are critically required for volunteers to make the health communication mechanism and system set up by KRISCHIP sustainable in the long term. The results also stress the need for more sustained efforts in this direction, which in turn may enhance both the demand and utilization of services. Community members articulated the need to choose more educated people as KRISCHIP volunteers. IEC activities need to be conducted in different places of the village, provide advanced information regarding location and timings of health clinics for diagnosis and treatment facilities for five focal diseases and finally provision of escort to treatment facility by the volunteer. The community needs to be informed in advance also about timings of IEC activities. Discussion or explanation by volunteers after screening of video films should become a routine affair. Awareness generation through a rally in the village should be made more interactive. Distribution of pamphlets or folders should be followed by explanation by volunteer. Provision of good quality services at treatment facilities are other essentials in order to help KRISCHIP reach its logical conclusion of mass qualitative health care for all in Krishna district.

    The study gave rise to following derivatives, thus causing imbroglio. Why there was a sudden steep increase in referrals of all diseases more so for Malaria during January - March 2006? Is it due to sudden increase in prevalence of disease, wrong diagnosis, more IEC activities, special drive or better reporting?,/p>

  • Why zone-wise referral data for April to June 2005 were not available, similarly there are some blanks in data base of 2006-07. Is the management of KRISCHIP keeping track of quality of data through graphs or any other method? If yes what actions are taken to improve the situation?
  • Despite low community KAP scores, why referrals were more in Nuzividu zone and inspite of better community KAP scores, why referrals were very less in Machilipatnam zone?
  • The mandate of KRISCHIP was to give equal importance to all five diseases in its IEC interventions. However, one finds patterned differences in community KAP scores for all five diseases. Is it due to more focus on HIV/AIDS, followed by Malaria, TB, Leprosy and Filaria in IEC?
  • Inspite of possessing fairly better knowledge by village health volunteers, why low community KAP scores for Filaria, Leprosy and even TB?
  • Why less priority was given to Leprosy and Filaria by both local mass media and village health volunteers?
  • Why low visibility of opinion leaders was noticed in IEC activities in all zones, particularly in urban Vijayawada?
  • At this juncture, indeed it requires brainstorming of all stakeholders to analyze and arrive at facts in order to develop a more appropriate future strategy to meet the desired objectives of the project

    Conclusion

  • To conclude, health promotion, with focus on IEC must be recognized as a primary professional activity of all categories of health care providers. Health promotion efforts must be coordinated with the many related activities and programs of the health care delivery system. KRISCHIP through its genuine interventions has tried to achieve this integration with limited success.