PSBI implementation Research Community mobilization to nudge implementation: An anthropological perspective of implementation research on managing sick young infants with PSBI in SOMAARTH DDESS, MAN ANAGEMENT OF F POSS SSIBLE SERI RIOUS Palwal ( Haryana, India) BACTERIAL INFE FECTION (PSB SBI) IN N YOUNG INF NFANTS (0-59 DAYS) WHERE REFERRAL IS NOT FEASIBLE IN N SOMAARTH DDESS, PALWAL, L, HAR HARYANA Prof of Nar Narendra a K Aror ora Dr. Rup upak k Mukh khopad adhyay Department of Maternal, Newborn Health Department , Haryana Child and Adolescent Health (MCA )
Implementation Site- SOMAARTH DDESS ( Palwal District Haryana) 50 villages • CBR 26/1000 • NMR 21/1000 1,92,2017 population • Inst. Delivery 80% District Hospital 1 46 Medical Officers CHCs 46 ANMs 3 33 PHCs Staff Nurse 3 172 ASHAs Sub Centers 18
Coverage (Aug 2017 – Jan 2019) 5435 669 Pregnancy Sick Infants 12.7% of Live Births 5270 Live Births 403 PSBI (+FB Only) 8% of Live Births Critical Infection Clinical Severe Fast Breathing Fast Breathing Illness 0-6 days only 7-59 days 40 299 10 54
Implementation Research -Key Observations Case Identified Site of treatment Outcome PSBI Cases Haryana 5270 Live Births 8 % 403 PSBI ( 266 Other sickness) Who Identified Neonatal Mortality Other Cases 1% 55% 10% 34%
Implementation Research -Key Observations ( Care Seeking ) First Place of care seeking Place of Treatment
Implementation Research -Key Observations Treatment Adherence PSBI Cases who treated in Primary facility (n-126)
The Implementation Research framework emerged – At Glimpse Co Participatory Implementation 1 Implementation at restricted Geography Preparatory Activities 3 Strengthening Birth A Quarter 1 Surveillance Documenting actual • Quarter 2 Implementation research guideline finalization ground practices in partnership with MOHFW, State Programme Strengthening Identification of /determining gaps and B Office & other technical experts Sick newborn in Family and barriers • Engagement with local health administration timely referral • Engagement with community stakeholders • Study Tools and SOPs Ensuring appropriate Full Scale Implementation C Research assessment and 2 Implementation in whole treatment of Sick infant 4 Understand contextual study Area realities D Improving care-seeking and Quarter 3 community response Formative baseline study to document- Nudging the • Case seeking practices in community Quarter 4 • Primary, secondary and tertiary level Implementation Quarter 5 health service facilities Quarter 6 • Knowledge attitude and practices by frontline workers and community health workers
At Beginning of Implementation- What we experienced Doctors in PHC, CHC hesitated to ‘touch’ i.e., examine and manage sick newborns Key Nudge Areas ANMs did not consider themselves as treatment provider Knowledge to skill to Qualitative competency transformation Research Mothers had poor skills to identify through confidence building FINDINGS danger signs in their young infants Understand Community needs Empowerment of mothers and practices and communities for ASHAs gave little emphasis on “counseling of mothers” Understand Health system identifying their sick babies issues ( Systemic challenges, on danger sign, during infrequent & hasty home visits KAP of service providers) and seek care Sub centers, PHCs and CHCs have occasional stock-outs of drugs and supplies that are required for PSBI management.
ASHAs’ awareness, perspective and practices Knowledge Correct Knowledge What all are Danger Signs ? Visits On Home delivery 60 Visits On Institutional Inspect for skin pustules 100 delivery 50 89.7 90 84.5 84.5 82.8 40 81 80 79.3 Inspect behind ear Breast feeding 80 75.9 74.1 30 70 65.5 20 60 Colostrum feeding 10 Inspect the baby back Should be given 50 0 43.1 40 Umbilicus red /Pus Correct Position of 30 discharge Breastfeeding 16.7 20 10 3.3 very low birth weight Fever 0 low birth weight Hypothermia
Mothers’ awareness, perspective and practices on care seeking Danger sign counseling WHEN COUNSELED 100 During both 86 90 80 ANC and ANC PNC 80 PNC 70 67 16% 70 60 58 56 56 56 56 54 54 52 52 60 49 50 40 During only 40 26 PNC 23 30 16 16 50% 20 Not 8 8 7 4 10 discussed 0 34% COUNSELING PROPORTION 83.44 none partial Adequate 46.36 33.77 19.87 9.27 7.28 ANC PNC
Mothers’ awareness, perspectives and practices on care seeking Qualitative findings Proportion of Qualifiers Adjectives Used What are the symptoms of serious illness ? Respondents < 10 percent <1+ Very few Do not 10 - 24 percent 1+ Some Some Features know 25 - 49 percent 2+ Approx. half 50 - 75 percent 3+ Majority Feeding Related Symptoms* 2+ 3+ 76 - 89 percent 4+ Most 0 @ Body temperature** 5+ > 90 percent 5+ Almost all Movement of infants (voluntarily or 4+ 1+ when stimulated)*** Breathing (fast/chest in drawing)**** 2+ 2+ Abnormal movements/ Seizures/ 4+ 1+ Convulsions***** Change in skin color****** 2+ 3+ Some features * Reduced feeding/prolonged crying /fever/vomiting ** Fever (hot to touch, feel cold)/reduced feeding/prolonged crying(restless ness or stomach ache) @ No one mentioned about low temperature *** Decreased movements (lethargic/laying down/less movements) /difficulty in breathing **** Fast breathing/difficulty in breathing/cough/fever/pneumonia ***** Seizures/lethargic ****** Jaundice, color change with growth
care seeking Mothers’ awareness, perspectives and practices on care seeking Occasionally Consult & *In case of (Fever, Care Seeking Seek Advice Cough, Vomiting, Behavior Diarrhea, (Young Infants)@ Pneumonia) Cold, Cough, Diarrhea (Mild) *Cold, Cough, Fever, Diarrhea, Pneumonia, *Cold, Cough, Fever, Cholera, Jaundice Diarrhea, Pneumonia, ASHA (Severe) Cholera Recover on Own Advice & Traditional Referral Home Refer to Healers Remedies Hospital • Wait & Watch Hospitals Village Doctors (Government, Private) (RMP) When not When not • Clinics improving improving Difference: a). Severity; b). Availability of money; c). Mother’s Education @ ANM not mentioned.
How we nudged the Implementation
Handholding and Confidence building – Community workers Early identification and prompt mobilization to nearby health facility Strengthening timely 3 Support to mobilize sick Training Workshops of 2 1 HBNC visits infants to nearby health ASHAs facilities How to identify danger signs in Encouraging ASHAs to perform HBNC young infants ( 0-59 days) visits timely and call follow up. Social mobilization to improve ASHAs stake in community ( ASHAs How ASHA can teach Working with PHC /CHC to improve On as key person to support appropriate mothers to identify danger ground ASHA supervision care seeking) signs Monthly meeting with CHC /PHC to discuss ► 6 Training workshops (By District Health ► HBNC visit related issues with ASHA System) Improving referral linkage between coordinators Medical officers at PHCs/CHCs and 172 trained ASHAs ► ASHAs by- Monthly meeting to discuss specific referral issues – Improving case triaging OPD arrangements
Handholding and Confidence building – Doctors / ANMs/Stuff Nurse Starting appropriate treatment without delay 3 2 1 Training workshops of Enhance confidence of heath doctors, nurses and ANMs service providers to manage sick young infants (post Improving communications for training hand holding) responsible referral How to identify danger signs in young infants (0-59 days) How to assesses and give Emphasizing to inform higher facility IMNCI trained supervisors and treatment at the time of referral paediatricians supported medical officers and nurses through periodic 3 days workshops by senior IMNCI health facility visits Indicating Place of referral at the time training experts from Safdarjung of referral hospital , Delhi Strengthening PMSMA clinic for ANC / PNC counseling One day hands-on practical training at Advocating for referral transport to Safdarjung PICU on danger sign Quarterly meeting in CMO office on super specialty hospital ( identification Health facility performance and issues Saftdarjung), for critical cases related to service provision and service 5 workshops (By District Health System) delivery 46 Doctors ► Using social media group for 46 ANMs strengthening referral network ► 33 Staff Nurses ►
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