Experiences in the villages of Gujarat

7/30/2019 Experiences in the villages of Gujarat

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Experiences in the villages of Gujarat

Shree Chhotubhai A. Patel Hospital and

Community Health CenterMota Fofalia, Gujarat, India

Reena Patel


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Topics to Cover

General statistics

Nutrition statistics

Structure of malnutrition management Current changes in management

Shakti Krupa Charitable Trust and Hospital

My project Future management of malnutrition

Our future involvement


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Indias General Statistics

Currently (2013) there are 1,270,272,105 people in

India = 17.3% of worlds population

~13% are children 0-6 years (158.8million)

Projected to be the most populous country by 2030

The WHO, World Health Report for mortality rates

per 100,000 population (2008): non-communicable diseases: 685

communicable diseases: 363

injuries: 99 Indiaonlinepages.com


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Breakdown of India and Our Site

State Level (29) Gujarat

District Level (33)

Vadodara aka Baroda

Taluka Level (13)

Sinor

Village Level (43) Mota Fofalia


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Government ofIndia

(GOI)

National Rural HealthMinistry

NRHM

District Level

Health Survey(2007-08)

International Institute

for Population ScienceIIPS

National Family

Health Survey-3(2005-06)

Ministry of Family Healthand Welfare

(MoFHW)

Nutrition Statistics


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National Family Health Survey - 3

Surveyed 109,041 households from 2005-2006

29 states in India = 99 percent of Indias

population Two national-level fact sheets and 29 state

fact sheets that provide estimates of more

than 50 key indicators of population, health,family welfare, and nutrition


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District Level Health Survey (DLHS) and

facility survey

Surveyed 720,320 households from 28 Statesat the district level

It was used to assess the utilization ofservices provided by government health carefacilities and peoples perceptions about the

quality of services Facility Survey: Sub-Centres, Primary Health

Center, Community Health Center, and DistrictHospital

www.rchiips.org


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Underweight- Weight for Age Acute and Chronic malnutrition

Stunting- Height for Age Linear growth retardation, past growth failure Recurrent or chronic illness

Wasting- Weight for Height Acute malnutrition

Mid-Upper Arm Circumference- Measure of muscle wasting Acute malnutrition

Anthropometric Measures


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60

57

56

48

45

43

42

41

40

38

37

30

Madhya Pradesh

Jharkhand

Bihar

Meghalaya

Gujarat

INDIA

Uttar Pradesh

Orrissa

Rajasthan

Uttranchal

Maharashtra

Tamil Nadu

Indias Nutrition Statistics

Percent of children < 5years: underweight

DLHS-3 (2007-08)

NFHS-3, 2005-06


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DLHS-2, 2002-04

Gujarat


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Gujarats Child Nutrition Statistics

Weight for Age criteria Weight for Height criteria

Normal %[Green]

Severe Under

Weight %

(Red)

Moderate

Under Weight

% [Yellow]

Normal %

Moderate Acute

Malnutrition(MAM) %

Severe Acute

Malnutrition

(SAM) %

44.6%

55.4%

28.3

%

16.3

% 5.8%

12.9

%

55.4

%

18.7%

Wasting (%)

25.9

%

SUW/ MUW

NFHS-3, 2005-06

Underweight (%)


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Indias Nutrition Statistics

rural areas

50% of young children are stunted

~1/2 are underweight

20% are wasted

urban areas

40 % of young children are stunted

1/3 are underweight

17% are wasted

There is a strong inverse relationship between undernutrition in children and the

level of wealth of the households that they live in. However, even in the wealthiest

households (households in the highest wealth quintile), one-quarter of children are

stunted and one-fifth are underweight.

DLHS 3, 2007-08


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48

28

48

19

0

50

100

% 1. Initiation of Breastfeedingwithin 1 hour of birth

2. Exclusive Breastfeeding

upto 6 months of life

3. Children 6-9 months fedComplementary foods

1+ 2+3

Source: DLHS-3 (2007-08)

Most mothers (57 percent) gave their babies something

other than breast milk to drink in the first three days

after birth.

Breastfeeding Statistics


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Indicator: Child Mortality

Infant mortality is steadily declining

Still, > than 1:18 children die within the first

year of life, and >1:13 die before age five

Mortality rates are 50% higher in rural than

urban areas

Scheduled Class/Tribe (23.5% of population)

are at greater risk


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Poor nutrition as a contributing factor

to child mortality

NFHS-3, 2005-06


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So whats been/being done?


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ICDS: Government Stewardship

Integrated Child Development Services was first launched in 1975

Developed by the GOI to combat malnutrition and health problems inchildren below 6 years of age and their mothers

They started the concept of an Anganwadi Centre (AWC) located in thevillages

The following services are sponsored by UNICEF and the World Bank

Immunization, Supplementary nutrition, Health checkup, Referralservices, Pre-school non formal education, Nutrition and Healthinformation

ICDS provides $10-22 per year per child

As of Jan 1, 2013 there are 1,300,000 AWCs and mini-AWCs in India


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Anganwadi Centre: AWC

Courtyard shelter

Angan: is where people get together to discuss, greet, socialize, even cook

and sleep. In the home it is the heart and considered sacred.


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Anganwadi Worker (AWW)

Role: health worker chosen from the community

4 months training in health, nutrition and child-care

Importance: link to rural and healthcare needs, buildscommunity trust, good advocate, affordable/accessible

Each AWC covers 1,000 population, Each AWW covers 150-200

children

Supervised and trained by ICDS government officials/agents


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AWW & AW helper


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AWC services

Growth Monitoring* Supplementary Nutrition Program in the AWC for 6 month

to 6 yrs old:

a) Energy dense Bal Bhog (3.5kg)/ month to 6mos to 3 yrs

b) Hot cooked food to 3 yrs to 6 yrs

c) Energy dense Take Home Ration (THR) for severeunderweight children

Milk to children 3-6 yrs, twice a week.

Fruits to children 3- 6 yrs, twice a week

Nutri-Candy with micronutrients (Iron, Folic acid, Vitamin Aand Vitamin C) for age group of 3 to 6 years

Mobile Anganwadi scheme for NREGA/Migrants population.

Conditional Cash Transfer Scheme- cash incentive forpregnant mothers to have institutional births


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To create awareness about nutrition in the community.

To counsel on Infant and Young Child Feeding (IYCF)

practices.

To mobilize the community to access health and

nutrition services.

To escort mothers with malnourished children to

nearest care centers & to motivate mothers to stayduring the intervention

To ensure that children are followed up at care centers

AWC services


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Bal Bhog = supplementary foods


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*Growth Monitoring

In 2008, ICDS adopted the new WHO ChildGrowth Standards (launched April 27, 2006).

Weight-for-age

Height-for-age

Weight-for-height

Measure physical growth and nutritional

status of children from birth to 5 years ageusing anthropometric measures

Using a Mamta Card to keep record


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Despite >80% of children under age six years lived in enumeration areas covered by an

anganwadi centre in the 12 months prior to the NFHS-3


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Sub-Centres/AWCs (village level)

Mamta Abihyan Initiative,routine care

Community Health Center (CHC)

Primary Health Center (PHC)

Child Development and NutritionCenters (CDNC)

District Hospital/MedicalCollege

District Nutrition Units

Current Referral Scheme

Care centers

Nutrition centers


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Recent Changes


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In 2009, the WHO came out with updated

growth standards with new cut-off values, and

with anthropometric measures

The Government of Gujarat is now adopting

this model to propose a new measure of

growth monitoring and management

guidelines for malnutrition referral andintervention


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MUAC as a measure of growth

monitoring

Benefit of MUAC

Same specificity as W/H Cheap

Easy to do

Does not factor in age Indicator of acute issue


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Severe Under Weight

(SUW) if : Weight for Age < -3SD

Moderate Under Weight

(MUW) if : Weight for Age < -2SD to

-3SD

WHO Growth Standards, 2009

Severe Acute Malnutrition

(SAM) if :

W/H < -3SD&/or

MUAC


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Mission Balam Sukham

happy childGovernment sponsored nutrition program

Previously known as Gujarat Nutrition Mission Statement

September 12, 2012


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Mission Balam Sukham

Gujarat govt

Budget 60 million rupees

($1,500,000)

2,000 rupees ($400) to each

18,000 villages in Gujarat


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Mission

To strengthen growth monitoring and evaluationsystem and bringing in subject specialist.

Ensuring growth monitoring and promotion byimproving

Survey efficiency

Weighing efficiency

Plotting of weights on growth charts, and

Identification of undernourished children and detection of

growth faltering and stagnation and focusing on the mostvulnerable- SAM, MAM, SUW and MUW

Amongst other mission statements not shown


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Developing and Integratingappropriate Referral and Practice

Guidelines as outlined in the WHO

child growth standards and the

identification of severe acute

malnutrition in infants and children.

Operational Structure: Three tier approach


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Children admitted

with defined SAM

criteria with Medical

Complications

Children admitted

with defined SAM &

MAM criteria without

Medical

Complications*

Children admittedwith defined SAM

criteria with severe

Medical

Complications/

Oedema

Operational Structure: Three tier approach

*Medical complication: infection, edema, failure of appetite test


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Village (Sub-centres)Village Child Nutrition Centres (VCNCs) at AWCs

Who qualifies: SAM & MAM criteria without Medical Complications

Duration : 30 days

Cost approx Rs 40/child/day

managed by AWW, AWH & ASHA.

Community (CDNCs)Child Malnutrition Treatment Centres(CMTCs)

Who qualifies: SAM criteria with medical complications

Duration: 21 days

Costs approx Rs 200/ child/ day

Daily visit by a Trained Doctor

Mother/guardian accompany onsite, compensated Rs 100/d forwage loss.

District Hospital/Medical College (Baroda)NutritionRehabilitation Centers (NRCs)

Who qualifies: SAM criteria with severe Medical Complications/Failed Appetite test/Oedema

Duration: 25 days.

Costs approx Rs 250/ child/ day

Daily visit by a Trained Doctor

Mother/guardian with child and compensated Rs 100/day forwage loss.


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For children admitted at -3 SD weight-for-height defined by the WHO standards, a

discharge at -2 SD and at -1 SD corresponds on average to a weight gain of 9% and 19%

respectively.

NRC CMTC

WHO Standard for therapeutic feeding programs


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Shakti Krupa Charitable TrustEmpowering Citizens to Strengthen the Roots of the Nation

www.shaktikrupa.org

P i t K 12 S h l


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Private K-12 School

50-bed adult hospital

Community Health Center

3 Ambulances Helipad

Farm for agricultural

empowerment

Government recognized


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Shree Chhotubhai A. Patel Hospital


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Dr. Singh (OBGyn) and Dr. Nilesh (internist)

with nursing staff.

Also pictured: Meghna and Dr. Maloney

The Staff

Dr. Pradeep (Internist)


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Swaddle technique

Avg birthweight ~2.5kg

Post-partum room

&

Well baby Nursery


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Community Health Centre

Second tier care center: Child Development

and Nutrition Center (CDNC)

In 2011, the AWWs in the surrounding Talukaof Sinor referred their children to Mota Fofalia

for a pilot program using new WHO standard

of care

They referred 144 children who were classified

as SAM for treatment

d h l b d f d


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10 day hospital based refeeding

program

Based on WHO treatmentstandards for SAMchildren

10 -21 day stay, until child

reaches target weight Components:

Initial management of thechild:

Management of co-morbidities: hypoglycemia,diarrhea, vomiting

Administering electrolytesolution: ReSoMal

10 d h i l b d f di


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10 day hospital based refeeding

program Feeding:

F-75 formula: 75kcal and 0.9gprotein/100ml

Amounts per reference card

Refeeding without laboratorymonitoring

F-100 formula: 100 kcal and2.9g protein/kg/100ml

Monitoring of vital signs and

Involving mothers in the care

10 day teaching program forfamilies: Hygiene

Food choices and preparation

Danger signs

SAM G j Pil M


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SAM program Gujarat Pilot Mota

Fofalia

144 children treated in 2011

Discharged when they reached target weight

Should be about 15% weight gain to go up 1SD

Long term outcomes ???


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Established Follow-up

There hasnt been any.hadnt


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My Project

h l f ll h h ld


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The Plan: To follow up on the 144 children

treated at the CDNC at Shree Chhotubhai

Hospital for 10 days in 2011 The Follow-up: weight, MUAC, dietary history,

recent illnesses

The Team: 1 driver, 1 sister (nurse), 1 ward-boy, myself

The Equipment: 1 electronic weight scale,

MUAC tape, 1 heavy duty vehicle, and a lot ofpatience

The Route: 7 day adventure to 28 of 36

villages in the Sinor Taluka

Hashmuk (not shown), primary driver


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Parul, Nurse

Ashok, Ward

Boy

Bhagu, Driver(hes usually more happythan depicted here)


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AnganwadiCenters

step one


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Village-to-Village

step two


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House-to-Housestep three


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Visited 28/36 villages in Sinor Taluka


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Were able to find 85 of 144 children = 59% Children not accounted for:

12 children in those 8 villages we did not go to

2 children passed away* Children were out of town for Holi celebration

Children were with their parents in the farm

R lt


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Results

Of the 85 children found and measured by MUAC:

63 were green (74.6%)15 were yellow = moderate acute malnutrition (17.4%)

7 were red = severe acute malnutrition (8%)

No child had edema on exam

One child with a mild skin infection

*2 children expired, cause unknown, unrecorded

- 1 was taken to a nearby hospital the other was not hospitalized.

- From word of mouth, they both had an infection

Reported Illness in past 2 weeks:

ARI: 36/85, (42%)

Diarrhea: 20/85, (23.5%)

Fever: 22/85 (26%)


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Successes and Attributes

Majority of children were green!

Parents seemed educated appropriate

nutrition

Intra-village and inter-village awareness of

community members

Respect for Mota Fofalias hospital


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Shortcomings, Improvement needs

- Efficiency of growth monitoring records and interpretation- Efficient referral systems and communication

- Follow-up structure and plans


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Future Malnutrition Management


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At the Local Level

Growth Monitoring:

Using MUAC as a marker for acute wasting and a

criteria for referral

Making appropriate referrals

Education

Workshops for teaching new VCNC guidelines at to

the village workers Improve approach of teaching feeding practices to

families


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Training Day


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At a Taluka Level

Electronic Data Collection as a means for:

Efficient and simple ways to record anthropometricmeasures

Quick reference Ease of follow-up

Database for research

Current idea is using a mobile data entry system To allow quick transfer of communication for

appropriate referral


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At a District Level

Building NRCs in more accessible locations

while providing adequate treatment, with

appropriate resources and management

Advantages: closer outreach to the ruralpopulation, decreased transportation cost,

ease of navigation, trust in a community

stronghold


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New Pediatric Center

Equipped w/ a: NICU, PICU, an operating room, 4 general wards and 4 special rooms


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2nd floor: Pediatric OR2nd floor: Nursing area

Main entrance Connection to Adult Hospital


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Nutrition Rehabilitation Center

The Shree Chhotubhai A. Patel Hospital will soonprovide a new NRC for the district of Vadodara


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Our Involvement

U of U Pediatrics Department and the


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U of U Pediatrics Department and the

SKCT partnership?

For residents

Opportunity to learn how to

build from the ground up

Clinical experience rotationfor residents

Public health project

development

For the university program

potential global health

fellowship site


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Potential Project Ideas

Developing and researching public healthinterventions Anemia, Vitamin A follow-up research

Smoke exposure in homes

Diarrheal disease Genetic syndromes

Malaria research

Defining outcomes and accountability QI projects

Developing appropriate care processmodels and overseeing integration


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References

International Institute for Population Sciences (IIPS) andMacro International. 2007. National Family Health Survey(NFHS-3), 200506: India: Volume I. Mumbai: IIPS.

WHO child growth standards and the identification of severeacute malnutrition in infants and children. World Health

Organization, United Nations Children's Fund. Publication2009.

District Level Health Survey 3 (DLHS) website: rchiips.org

World Health Statistics 2012. Global Health Indicators.www.who.int/healthinfo

Guidelines on Facility Based Management of MalnourishedChildren. Commission of Health, Government of Gujarat,Gandhinagar. 2012.


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Questions?

Every revolution has to originate from villages; only then can it be successful.

Mahatma Gandhi


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Thank You!

Experiences in the villages of Gujarat

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