Awareness and health care-seekingpractices for childhood illness in Sundarban backward zone, West

Bengal, India, 2010

Dr. Ajay Kumar Chakraborty

FETP Scholar, 2008-10 Cohort

National Institute of Epidemiology

Chennai, Tamil Nadu, India

Interaction with health workers improved awareness and desired care-seeking

practices for childhood illness in Sundarban area, West Bengal, India, 2010

Dr. Ajay Kumar Chakraborty FETP Scholar, 2008-10 CohortNational Institute of Epidemiology Chennai, Tamil Nadu, India

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Background justification

• Delay in appropriate care seeking leads to large number of child deaths globally

• Integrated Management of Neonatal and Childhood Illness programme (IMNCI) addressing this issue in India – Improving management skill of health workers – Educating mothers to identify danger signs and

seeking prompt care• Before implementation, we assessed base

level situation in geographically vulnerable Sundarban area of South 24 Parganas district, West Bengal, India during 2010

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Objectives

• Primary:– Estimate the proportion of mothers aware of

danger sign of the ill children (<5 years) as per the IMNCI guidelines

– Describe the help-seeking behaviour of the mothers

• Secondary:– Determine the factors associated with mothers’

awareness (at least 2 danger signs) and help-seeking behaviour

– Assess the knowledge of the peripheral health workers (female) regarding the management of “sick” children (<5 years)

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Methodology

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Study Area: Sundarban South 24 Parganas District, WB

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Study population, Study design, Sampling

• Study population: – The mothers of the <5 years old children in Sundarban area

(3.01 million), 24 Parganas (S) district, West Bengal, India– The Health workers (F) [Auxiliary Nurse Midwife] of Sundarban

area

• Study design – Cross-sectional survey

• Sampling: – Cluster sampling (Probability proportional to size) of 552

mothers from 23 clusters (24/cluster)• [Awareness 60% (UNICEF: MICS-India 2000), 95% CI , 90% power, roh 0.02, Right

size software]

– Random sampling of 117 Health workers (F)• [Knowledge 50%, 95% CI, 80% Power, 20% absenteeism]

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Data collection and Analysis

• Data collection procedure– Team of two trained social workers interviewed mothers – Pre-tested structured questionnaire in local language– IMNCI module based questionnaire administered by BMOH to

the selected Health workers (F)

• Data entry and analysis– Double entry, checked for consistency– Analysis using Epi-info 3.5.1 version software

• Ethical Issues– Approved by Ethical Committee, NIE-Chennai– Informed consent, confidentiality, protection and support

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Operational Definitions• Danger sign: Child with any of the following sign or

symptoms (IMNCI guideline, GOI/WHO): – Convulsions, unconsciousness, lethargy, vomits

everything, breast feeding poorly, drinking poorly, ‘become sicker’, develops Fever, ‘feels Cold to touch’ (young infant), fast breathing, difficulty in breathing, blood in stool

• Prompt care: Sought help outside home within 24 hours of the onset / identification of danger sign

• Appropriate care: Approached for western system of medicine (allopathic) either from a qualified private practitioner or any government institute (including sub-centre)

• Desired Care: Availing appropriate care promptly

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Result and Discussion

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Socio-demographic status of Study sample, Sundarban, 24Pgs, WB, 2010

Socio-Demographic Indicators

Mother (n=549) Father (n=549)

# % # %

Religion- Hinduism 346 63

Economic status-Below Poverty level (BPL) 262 48

Education- Illiterate Up to Primary level Above Primary

123135291

222554

84132333

152461

Occupation- Homemaker/Agriculture

Working/ Labors

Service or business

48168

0

8812

0

177279

93

325117

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Demographic status of Study sample, Sundarban, 24Pgs, WB, 2010

Demographic status Mother (n=552)

# %

Previous child death (# of child) 60 9

# living child- One Two-Three Four or more

21526572

394813

Sex of Referent child- Male 299 54

Age group (Ref. Ch)- < 60 days. 2 mo- 1 year. 1-3 Year. 3-5 Year

19116217200

3.421

39.336

Immunization: Complete for Age . Not at all

47214

863

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Awareness of Danger signs among 552 mothers of Sundarban, 24Prgs, W.B. 2010

Can say > 3 danger signs

(28%, 95%CI-21-36%)

Can say 2 danger signs, (32%, 95%CI-

26-38%)Can say 1

danger sign, (33%, 95%CI-25-

40%)

Can not name any danger sign, (7%, 95%CI-3.6-

11%)

0 20 40 60 80 100

Became more ill

Drinking poorly

Unconsciousness

Feels cold to touch

Breast feeding poorly

Convulsions

Has fast breathing

Lethargy

Blood in stool

Vomits everything

Has difficult breathing

Develops Fever

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Illness and Help seeking behavior, Sundarban, WB, 2010

Delayed Care Prompt

Care (62%)

In-appro-priate Care

Appro- priate Care (36%)

Illness episodes (N=552)

Care seeking (N= 331)

Others

Desired Care (28%)

Not IllIllness,

60%

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Choice of Provider (N= 331) Sundarban, WB, 2010

No Treat-ment5%

Other ISM1%

Faith Healer- 0%Medicine shop 3%

Govt SC 4% (0.2%)

Govt Institute12% (10%)

Non Qualified Private (Homeo

system)9%

Non Qualified Private (Western

system)46%

Private Institue

7%

Qualified Private (Allopath)

13%

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Determinants of Mothers’ Awareness of at-least 2 danger signs (N= 552)

• Income:– APL [AOR=1.5 (95% CI:1-2.1)]

• Religion:– Muslim [AOR=1.8 (95% CI:1.1-2.7)]

• Source of information of danger signs– Health Worker (F) [AOR=1.5 (95% CI-1.1-

2.2)]

• Age of child 2mo- 2 year [OR= 1.3 (0.9-1.8)]

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Mothers aware when source of information was Health Workers

• Aware when HW(F) was source of information : – Probably interaction during Immunization session as SC

utilization was low for care-seeking during illness – During evaluation 88% found sharing key messages – HW(F) exposed to several training on IEC/BCC

• Awareness with increasing child age:– Peak at 1-2 yrs; corresponding to immunization age group– Only when the ‘source of information’ was the health

workers (Chi sq for linear trend= 4.5 p = 0.03)– Increased # of child not associated with awareness

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Aware Muslim mothers : Any role of HW?

• Muslim mothers were Aware– But SES likely to be poorer

• BPL [OR=1.4 (CI-1-2)]; uneducated [OR=3 (2-4.3)]– Likely to have younger child

• More child below median age of 2 years (53% c.f. Hindu 48%) – immunization age group

• Children mostly (95%,195/206) immunized, all from Government source (HW-F)

– Better informed about Sub-centre working time [OR= 1.5 (1.04-2.1)]

• Probably indicate they are utilizing their services

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Factors related with Care seeking

• Prompt care:– With increasing # of danger signs [Chi sq for linear trend=7.06,

p=0.008]

– Aware Sub-centre working days [ AOR= 3.3, (1.2-9)]

• Appropriate care:– Mothers educated > primary level [ AOR= 4.6,(1.2-18)]– Husband in service/higher occupation [AOR= 5.5,(1.1-27)]– Preferred qualified allopathic services [AOR= 71,(13-394)]– System of choice was allopathic [AOR= 9.8, (1.7-58)]– Aware Sub-centre working days [ AOR= 3.4, 1-11]

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Factors related with Desired Care

• Desired care:– Preferred qualified allopath as 1st contact

[AOR= 16, 95% CI (3.8-67)]– History of child death [AOR=15, (1.5-154)]– Increasing awareness level [Chi sq for linear

trend= 3.5, p = 0.06]– Aware Sub-centre working days [ AOR=

4.4, 1.2-15.5]

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Interactions with HW lead to all desired care-seeking behavior

• Interactions leading to desired care-seeking :– All positive behavior associated with

‘knowledge of SC working time’– We assumed correctly informed of ‘SC

working time’ - a surrogate for SC use and therefore scope for interaction

– Mothers with child in immunization age group better informed of ‘SC working time’ [1-2 year 48%(42-54%); 3-5 years 43%(37-49%)]

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Knowledge score of Health Workers (F), Sundarban, India, 2010

Knowledge Score Health Workers (N=114)

Mean score (proportion)

SD

Total score 60 10

New-born Care 89 22

Anemia and malnutrition 70 25

Identification of general danger sign 66 18

Management of Diarrhoea 61 17

Breast feeding 58 28

Management of ARI 55 18

Identification of common elements 8 18

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Our limitations

• We have seen the association, dose response, plausibility but could not confirm causal relationship in absence of temporality

• We did not assess health workers’ contribution on educating the community– We rather accepted ‘keeping correct information

on Sub-centre functioning days’ as a surrogate indicator for Sub-centre use

– We assumed Sub-centre use as synonymous to interaction with health workers

• Based on previous observation • Informally confirmed by the mothers

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Conclusion..1

• Awareness level at par with Indian mothers– In spite of all poor SES, but compared to India during 2000AD

• Mothers could identify most of the illnesses with danger signs

• Prompt care a general practice, but not the appropriate care– Little gap in appropriate and desired care

– Inadequate qualified provider, available only in selected areas, difficult communication

• Interactions with HW lead to better awareness and desired care-seeking behavior

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Conclusion..2

• Health assistant females have overall good knowledge– but weak in identification of common element and

case management• Sub-centre utilization was low

– Better than the state. Alternate day service may be a deterrent factor for utilization during emergencies

– For immunization purpose service utilization good– Key messages shared during contacts

• Skill of behavioral changed communication not assessed– needs further assessment and planning

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Recommendation Implement IMNCI programme and train the

health workers identification and management of common elements

including diarrhea and ARI based on IMNCI module

Extend the sub-centre working days to six days with the help of locally residing 2nd ANM

Further assessment of the communication skill of health workers To improve awareness and utilization of prompt and

appropriate services

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Action taken

Findings shared with World-BankData is being used for planning activity

Findings shared with District authority Training of IMNCI has started, key identified

area getting more attention

Sub-centre started working six days a week Where 2nd ANM is available (prior Govt.

order)

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Acknowledgement

• Faculty members of National Institute of Epidemiology (NIE), Chennai, India

• District and Peripheral Health Workers, South 24 Parganas District, WB

• Mothers of Sunderban area

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