Report on Formative Research Findings - Fight … on Formative Research Findings This report has been developed under the project entitled “Improving household decisionmaking for

Report on Formative Research Findings

This report has been developed under the project entitled “Improving household decision-making for the management of Pediatric pneumonia in Uttar Pradesh and Bihar” funded by Bill and Melinda Gates Foundation (Global Health Grant No: OPP1093327).

We are extremely grateful to the Bill and Melinda Gates Foundation who provided us with an opportunity to carry on this research. We would like to acknowledge with gratitude the functionaries and academicians of King George`s Medical University who facilitated the smooth conduction of this project since inception. We are also thankful to the health functionaries of the Department of Health and Family Welfare, GoUP, NRHM, Uttar Pradesh and State Health Society, Bihar without whose cooperation this project would not have accomplished its objective. We are extremely thankful to all the Chief Medical Officers, Chief Superintendents and Medical Officers-in charge of the project blocks who cooperated with the project team in every possible aspect. We also wish to extend our gratitude to all respondents from the community-mother, father and grandmother-who shared with us their opinions, perceptions, thoughts and beliefs related to pneumonia. It helped us to understand the dynamics of health seeking behavior and to identify the delays in health care seeking which need to be addressed in future public policies/programs on childhood pneumonia. This research also benefitted from the technical guidance provided by the members of Childhood Pneumonia Behavior Change Communication Committee Group (CPBCCCG) group during the group meetings. We wish to thank all the members of the consultative group for endorsing and providing handholding support to this project.

Members of Childhood Pneumonia Behavior Change Communication Committee (CPBCCCG):

Dr. Gaurav Kumar-National Health Society (Bihar), Dr. Aruna Narain- NRHM (U.P.), Dr. Hari Om Dixit-NRHM (U.P.), Dr. Anil Verma-NRHM, (U.P.), Prof. Sanjata R. Chaudhary-Deptt. of Pediatrics, Patna Medical College & Hospital, Dr. Neeraj Agrawal-Deptt. of Community Medicine, AIIMS (Patna), Prof. J.V. Singh, Director-U.P. Rural Institute of Medical Sciences & Research, (Saifai), Dr. Chitranjan Roy-Deptt. of Community Medicine, Darbhanga Medical College (Laheriasarai Bihar), Dr. Shraddha Dwivedi-Deptt. of Community Medicine, Motilal Nehru Medical College, (Allahabad), Prof. Uday Mohan-Deptt. of Community Medicine, KGMU, (Lucknow), representative from Bill & Melinda Gates Foundation, representative from Rajiv Gandhi Mahila Vikas Pariyojna, representative from UNICEF, Lucknow, representative from Clinton Access Foundation, representative from FHI 360, representative from IIPH- Delhi,

representative from ICDS, Lucknow and team from project subgrantee-Point Blank Advertising Pvt. Ltd., Mumbai.

Acknowledgement

http://in.linkedin.com/company/bill-&-melinda-gates-foundation?trk=ppro_cprof�


Project Investigators

Principal Investigator: Prof. Shally Awasthi, Department of Pediatrics, KGMU, Lucknow.

Co-Investigator: Dr. Monika Agarwal, Department of Community Medicine, KGMU, Lucknow.

Consultants

Prof. Mark Nichter: Public Health and Family Medicine, University of Arizona, USA

Dr. Neeraj Mohan Srivastava : Knowledge Consultant, UNICEF, Uttar Pradesh.

Data Collection and Analysis:

Dr. Anant Prakash Mishra Project Coordinator

Ms. Tuhina Verma Social Scientist

Mr. Gulshan Sami Social Scientist

Mr. Ram Dhani Sharma Community Interviewer

Mr. Ranjan Khare Community Interviewer

Mr. Vijay Verma Community Interviewer

Mr. Manish Pandey Community Interviewer

Mr. Vineet Shukla Field Assistant

Mr. Sushil Kumar Field Assistant

Mr. Atul Chandra Secretarial Assistance

Mr. Hasib-ur- Rehman Data Manager

Ms. Shobha Pandey Translator

Report Writing: Prof. Shally Awasthi , Ms. Tuhina Verma and Mr. Gulshan Sami

Design and layout: Mr. Hasib-ur- Rehman and Mr. Atul Chandra

Note: Pictures used in this report have been exclusively taken for this project. The respondents have given written informed consent for use of these photographs in this report.

Project Team


S. No. Contents Page No.

1. Executive Summary 1 2. Introduction

2.1 Socio-Demographic and Health Profile of Project Area 2.2. Project Background & Goal Study Rationale Project Goal and Objectives Geographic Focus Ethical Compliance 2.3 Preparation for Data Collection

Video clippings on Childhood Respiratory Illness Vignettes Development & Pilot Testing of formative tools Themes for Data Collection in Formative Research Tools Team formation and Training

5 10 11 12 12 13 13 15 18

3. Methodology 3.1 Data Collection

Selection of districts Selection of blocks and sub-centers

3.2 Study Respondents and Eligibility Criteria Respondents for Key informant interviews Respondents for Semi structured interviews Respondents for Focus group discussion interviews

3.3 Data Management & Analysis Data Management Data Analysis

21 23 24 26 27 31 31

4. Results 4.1 Background characteristics of the respondents 4.2 Recognition of Common Childhood Illnesses 4.3 Local Terms for Pneumonia & Symptoms of Pneumonia 4.4 Home Remedies and Self Medication 4.5 Decision Making Process 4.6 Health Care Seeking Behavior 4.7 Community Health Worker 4.8 Rural Medical Practitioner

33 44 55 58 66 71 96 109

5 Emerging Themes and Conclusion 5.1 Message Domain 1: Symptoms recognition 5.2 Message Domain 2: Where and when to seek health care 5.3 Message Domain 3: How approach a Health Care Provider and negotiate for quality of care 5.4 Message Domain 4: Risk vulnerability perception

6. Recommendations and further research priorities

116 117 118 119 120

7 References 121 8 Maps

Map 1: Project Blocks in Uttar Pradesh Map 2: Project Blocks in Bihar

21 22

Table of Contents


9. LIST OF TABLES Table 1: Demographic & Health Profile Uttar Pradesh & Bihar Table 2: Rural Health Care Facilities and manpower in Uttar Pradesh and Bihar Table 3: Infrastructure available at the Rural Health Care Facilities in U.P. & Bihar Table 4: Population and Literacy rate in Project Districts Table 5: Infant Mortality Rates and Birth Indicators in Project Districts Table 6: Availability of Public Health Facilities and ASHAs in the Project Districts Table 7: Project Geographic Area and dialects spoken in that area Table 8: Training Sessions and Trainers Table 9: Eligibility Criteria for Caregivers of Key Informant Interview Table 10: Eligibility Criteria for Care providers of Key Informant Interview Table 11: Eligibility Criteria for Caregivers of Semi Structured Interview Table 12: Group and participant characteristic of Caregiver and Care provider Table 13: Frequency of responses obtained against each code and the standard term used

in this report Table 14: Field Schedule of the Data Collection Team Table 15: Number of Interviews/Discussions Conducted In Each State Table 16: Number of respondents in each interview/discussion Table 17: Median age of the Caregivers Table 18: Religion and Caste of the caregivers Table 19: Family Size and Family Type of the caregivers Table 20: Education and Occupation of the Caregivers Table 21: Sources of Information available with the Caregivers Table 22: Signs or Symptoms of Pneumonia Table 23: Caregivers Reporting of Signs of Severe Pneumonia & IMNCI Danger Signs Table 24: Terms for Pneumonia in Local Dialect Table 25: Terms/Phrases on signs / symptoms of Pneumonia in local dialect Table 26: Popular Home remedies used in project districts that are applied topically Table 27: Popular Home remedies used in project districts that are given orally Table 28: Popular Home remedies used in project districts that are applied topically and

given orally Table 29: Unique Home Remedies used in project Districts Table 30: Caregiver`s comparative of Village Based Doctor vs. Block Based Private

Doctor Table 31: Baseline Characteristics of Community Health Workers –Key Informant Table 32: Religion and Caste of Community Health Worker Table 33: Family Structure and Family Size of CHW Table 34: Educational status of CHW Table 35: Breathing Type Reported In Common Respiratory Illness. Table 36: Baseline Characteristics of RMP Table 37: Prescription pattern of RMP LIST OF FIGURES Fig. 1: Formative Research Techniques used in this project Fig. 2: Eligibility Criteria for Key Informant Interviews Fig. 3: Eligibility Criteria for Semi Structured Interviews Fig. 4: Eligibility Criteria for Focus Group Discussion Fig. 5: Relationship of Caregivers with the child Fig 6: Religion of the caregivers Fig 7: Caste of the caregivers Fig. 8: Family Type of the Caregivers Fig. 9: Family Size of the caregivers Fig. 10: Education of the Caregivers Fig. 11: Occupation of the respondents Fig. 12: Sources of information in Caregivers Family Fig. 13: Common Childhood Illnesses as reported by caregivers in Key Informant

interviews Fig. 14: Common Childhood Illnesses as reported by caregivers in Semi Structured

interviews

5 6 7 8 9 9 12 19 24 25 26 27 32 33 34 34 36 36 38 40 43 48 50 55 57 59 60 62 62 87 97 99 100 101 103 109 113 14 25 27 28 35 37 37 38 39 41 42 43 44 45


Fig. 15: Common Respiratory Illnesses as reported by caregivers in Key Informant interviews

Fig. 16: Common Respiratory Illnesses as reported by caregivers in Semi Structured interviews

Fig. 17: Breathing Pattern in Pneumonia as reported by caregivers in Key Informant interviews

Fig. 18: Breathing Pattern in Pneumonia as reported by caregivers in Semi Structured interviews

Fig. 19: Reported Danger Signs of Respiratory Illnesses in Key Informant Interviews Fig. 20: Reported Danger Signs of Respiratory Illnesses in Semi Structured Interviews Fig. 21: Signs and Symptoms of Pneumonia in Vignette I Fig. 22: Signs and Symptoms of pneumonia in Vignette II Fig. 23: Signs and Symptoms of pneumonia in Vignette III Fig. 24: Local Names of Pneumonia Fig. 25: Unique Home Remedies of Uttar Pradesh & Bihar Fig. 26: Primary Decision Maker as Reported by Younger Caregivers of Key Informant

Interviews Fig. 27: Primary Decision Maker as Reported by Older Caregivers of Key Informant

Interviews Fig. 28: Primary Decision Maker in Semi Structured Interviews Fig. 29: Health Care Seeking Pattern Reported by Respondents of Key Informant

Interviews in Scenario I Fig. 30: Health Care Seeking Pattern Reported by Respondents of Semi structured

Interviews in Scenario I Fig. 31: Health Care Seeking Pattern Reported by Respondents of Key Informant

Interviews in Scenario II Fig. 32: Health Care Seeking Pattern Reported by Respondents of Semi structured

Interviews in Scenario II Fig. 33: Health Care Seeking Pattern Reported by Respondents of FGD in Scenario II Fig. 34: Health Care Seeking Pattern Reported by Respondents of Key Informant

Interviews in Scenario III Fig. 35: Health Care Seeking Pattern Reported by Respondents of Semi structured

Interviews in Scenario III Fig. 36: Health Care Seeking Pattern Reported by Respondents of Focus Group

Discussions in Scenario III Fig 37: Duration of illness of cases till the date of interview Fig. 38: Choice of Health Care Providers based on 30 Cases from Uttar Pradesh and Bihar Fig. 39: Religion of the CHW Fig. 40: Caste of the CHW`s Fig. 41: Family Structure of CHW Fig. 42: Level of Education of the CHW`S Fig. 43: Common Childhood Illnesses as reported by CHW`s Fig. 44: Common Respiratory Illnesses as reported by CHW`s Fig. 45: Breathing Type in Pneumonia reported by CHW`s Fig. 46: Breathing Type in Cold/Flu/Congestion reported by CHW`s Fig. 47: Symptoms considered as danger signs Fig. 48: Common Childhood Illness as reported by RMP`s Fig. 49: Common Respiratory Illness as reported by RMP`s Fig. 50: Breathing Type - in Common Cold/Flu/Congestion as reported by RMP`s Fig. 51: Breathing Type - in Pneumonia as reported by RMP`s Fig. 52: Symptoms Considered As Danger Signs as reported by RMPs

45 46 47 47 49 50 51 52 53 56 64 66 67 67 72 73 75 76 77 79 80 81 83 85 99 99 100 101 102 103 104 104 105 110 111 111 111 112


1. Accredited Social Health Activists ASHAs

2. Acute Lower Respiratory Infection ALRI

3. Bachelor of Ayurvedic Medicine and Surgery B.A.M.S.

4. Block Based Private Doctor BBD

5. Chief Medical Officer CMO

6. Chief Medical Superintendent CMS

7. Community Health Centre CHC

8. Community Health Worker CHW

9. Health Education Officer H.E.O

10. Health worker (Male) HW(Male)

11. Integrated Management of Neonatal and Childhood Illness IMNCI

12. King George’s Medical University KGMU

13. National Family Health Survey NFHS

14. Other Backward Class OBC

15. Scheduled Caste SC

16. Scheduled Tribe ST

17. Village Based Rural Medical Practitioner RMP

Acronyms


Report on Formative Research Findings Page 1

Background:

In 2005, 2.3 million deaths were reported in children less than 5 years of age, and between ages of 1

month to 5 years, half of them were due to pneumonia or diarrhea, attributable to delayed

recognition of illness by families, delayed and poor access to qualified health care in a setting which

has untested home and traditional remedies for such illnesses and faith in incompetent and

unqualified rural medical practitioners in a background of high prevalence of under nutrition,

overcrowding, exposure to ambient air pollutants as a result of use of biomass fuel for cooking and

second hand smoke and low rates of immunization etc.

Hypothesis: Community empowerment for prompt recognition of childhood pneumonia,

understanding its severity and vulnerability of their child to adverse outcome due to delayed

qualified care seeking is possible by development of appropriate messages by in-depth formative

analysis of community constraints in real life and possibly diverse settings.

Goal: To create communications materials to improve household decision making when confronted

by lower respiratory illness in children in northern India.

Objective: One of the objectives of this project was to conduct formative research to assess

community perceptions about symptoms of pneumonia, care seeking behaviour and risk

vulnerability due to it. This report presents the findings of formative research of this Objective.

Settings: Since there are multiple dialects in Uttar Pradesh and Bihar, this formative research work

was done in dialect specific rural village settings as well as in the corresponding Primary Health

Centre (PHC) and Community Health Centre (CHC) of 7 districts of Uttar Pradesh and Bihar. The

project districts and the dialects spoken in each district were Lucknow (Awadhi), Gorakhpur

(Bhojpuri), Mahoba (Bundelkhandi), Agra (Braj) and Meerut (Khari Boli) in Uttar Pradesh and

Gaya (Maghai) and Darbhanga (Maithali) in Bihar.

Methods: Key Informant interviews, semi-structured interviews and focus group discussions were

used to collect information. Interview/discussion guides were prepared in English and Hindi. Case

studies that were collected as a part of another objective of this project were used to create vignettes.

These vignettes were used in interviews and focus group discussions probing decision making and

health care seeing behavior. Real life video clippings on a range of mild to severe ARI in children

under 5 years were shot. Three of these video clippings were used in focus group discussions

(n=42) with stakeholders across 7 districts to ascertain what signs were recognized and how serious

they were considered. All data collection guides were designed to collect information on taxonomy

of terms used for childhood pneumonia and pneumonia like presentations, perceptions of disease


severity, factors influencing health care seeking and choice of health care provider. Attempt was

made to elicit responses to various case scenarios and collect information on home remedies and

self-medication. Data was transcribed and translated into English. Codebook was developed for

coding and data interpretation. Themes were analyzed under each of the following four domains (a)

symptom recognition (b) where and when to seek treatment (c) how to approach a care provider and

negotiate for quality of care (d) risk vulnerability perception. These emerging themes gave insight

to the concepts for message development.

Findings: 43 Key informant interviews, 42 Semi-structured interviews and 42 Focus group

discussions were conducted in seven districts of Uttar Pradesh and Bihar. We recruited 303

caregivers and 75 care providers between October 2013 - January 2014. Among these 215/303 (70.9

%) caregivers and 58/75 (77.3%) care providers were from Uttar Pradesh and the rest were from

Bihar. The caregivers comprised of younger and older caregivers and fathers. The care providers

comprised of Community Health Worker (CHW) and Village Based Rural Medical Practitioner

(RMP). Baseline characteristics of the caregivers showed that 91.7% caregivers followed Hindu

religion while 7.9% followed Muslim religion. About 35.97 % caregivers identified themselves as

belonging to Other Backward Class (OBC) and almost a similar percentage (35.31%) identified

themselves as belonging to Scheduled Caste (SC). 23.10% belonged to General Category while the

rest belonged to Scheduled Tribe (ST). 53.80% belonged to single/nuclear family while 46.20%

belonged to joint family. 56.11 % respondents had family size of 6-10 members. Almost one-third

(31.35 %) caregivers were illiterate and 72.61 % caregivers were housewives. Information was

collected from the study participants on the availability of means of communication in their

household like mobile, newspaper, television without satellite network, television with satellite

network, radio. Mobile was the most popular source of information among the caregivers followed

by information obtained from other persons like neighbors/relatives in community. Radio was least

popular.

Sixty-seven CHWs participated in this study. Among these 77.61% (52/67) were from U.P. while

22.38% (15/67) were from Bihar. Sixty CHW`s participated in FGD`s while seven were a part of

key informant interviews. Out of the 60 CHWs who participated in focus group discussion, 95%

(57/60) were Hindus and 48.94 % (23/47) belonged to general category. 53.33% (32/60) CHW`s

belonged to nuclear family and 51.67% (31/60) had a family size of 0-5 members. Almost half 45%

(27/60) of the CHWs who participated in discussion were educated up to intermediate level. Eight

RMP`s were included for the interview. The youngest RMP was 33 years while the oldest one was

65 years. RMP practicing in Gaya was most experienced with 35 years of practice. The qualification


of only 3 RMPs were known while the qualifications of rest of them were unknown. Qualified

RMPs identified themselves as Bachelor of Ayurvedic Medicine and Surgery (B.A.M.S.).

Domain 1: Symptom Recognition: It was found that caregivers universally knew the term

‘pneumonia’ but did not know what the term “pneumonia” stands for & the risks associated with it.

Fast breathing as a symptom of pneumonia was not recognized universally. The caregivers

recognized chest in-drawing and fast breathing only when it was accompanied by chest in-drawing.

They were unable to appreciate signs of severe pneumonia like altered sensorium or audible sounds

like grunting and groaning when it appeared in our video clippings. The caregivers had no concept

of viewing the chest to observe respiratory rate. Interestingly, fever in isolation was not considered

as a symptom of respiratory illness. The caregivers missed the early stage of pneumonia when only

fast breathing was present. It led to delayed disease recognition.

Theme for Message Development (Domain 1)

Caregivers should be made aware that Fast Breathing is an early symptom and Chest in drawing is a

relatively late symptom of pneumonia. Chest exposure for thorough inspection should be done at

home in children with cough/cold.

Domain 2: Where and When to Seek Health Care: Caregivers/providers choose health care

facilities according to perceived severity of illness. There is an informal triage at community level.

The caregivers chose either to `wait & watch` or visit traditional healer or visit a RMP for a child

perceived as “less sick”. When the child was perceived to be “more sick” caregivers preferred to

visit a Block Based Private Doctor (BBD) more than RMP. The BBD or a Private Hospital at the

main block was preferred more for the child perceived to be “very sick child”. The Govt. Hospital

was least preferred for a child in similar condition because of the distrust of the community in the

public health system.


Early care seeking should be promoted. Faith of the community in Government Health System needs

to be strengthened. Caregivers must be made aware that care seeking from RMP for pneumonia

leads to delay which in turn can lead to prolonged illness and increased cost of treatment. They must

also be taught to closely look for fast breathing and chest in drawing and danger signs in their sick

child so that care seeking can be sought as early as possible.


Domain 3: How to Approach a Care Provider & Recognize for Quality of Care: Caregivers

were not concerned about the qualifications of a doctor as long as s/he had a good reputation in the

community. There was no concept of correct quality of care and perhaps the community was not

empowered/educated to recognize quality of care. They chose the RMP who was not usually

qualified. BBD was mostly qualified but such qualified doctors charge five times more fees than

RMP. BBD`s did not dispense medicines like the RMP but prescribed medicines and investigations.

RMP was available 24/7 and mothers would feel free to visit them even unaccompanied without

much decision making. There was no concept of “course of treatment” among caregivers. They were

told about feeding and diet changes during sickness. Community felt satisfied when the provider

reinforced the belief that pneumonia is caused by “cold”. Caregivers were not advised to monitor the

course of pneumonia. Doctors did not tell them about: (a) how to look for improvement or

deterioration (b) how long to wait while taking prescribed treatment & (c) where to go when

condition worsens

Theme for Message Development in (Domain 3)

Caregivers must be taught to ask the doctor about visible symptoms of improvement and for how

long to wait and where to go when the disease worsens.

Domain 4: Risk Vulnerability Perception: Caregivers were not able to report all WHO-IMNCI

Danger Signs. Only few respondents self-reported ‘refusal to feed’ and excessive crying, lethargy

and unconsciousness/seizures. Additional symptoms like fever, cold, coughing were reported as

Danger Signs much more than WHO-IMNCI Danger Signs. Caregivers did not knew that fever

alone is not an indicative of disease progression or improvement. They also were unaware that

maternal cough/cold can be self-limiting however a child with similar symptoms can progress to

fatal pneumonia. In addition, caregivers were unaware that children with cough/cold can have

different outcomes in same child or in different children.


Some children with ‘cough/common cold’ can progress to life-threatening pneumonia. Most of them

have self-limiting disease. Therefore, it was important to watch for early signs of pneumonia.



Socio-Demographic and Health Profile of Project States

This project is ongoing in two North Indian States of Uttar Pradesh and Bihar both of which have

poor health indices. Uttar Pradesh is the most populous and fifth largest state in India in terms of

area. It is divided into 75 administrative districts. Bihar lies to the east of Uttar Pradesh and is the

third most populous state in India . It is divided into 38 administrative districts. Both Uttar Pradesh

and Bihar have literacy rate lower than the national average. These states fare badly in the maternal,

neonatal and child health indices. Bihar and Uttar Pradesh have Infant Mortality Rate (IMR) and

Maternal Mortality Rate (MMR) above the national average. The Under 5 Mortality Rate (U5MR) in

both project states is much higher than the national figure. (Table 1)

Table 1: Demographic & Health Profile Uttar Pradesh & Bihar

India Uttar Pradesh Bihar

Area (Sq. Km) 3,287,590 243,286 94,163

Population (107 121.01 ) 19.96 10.38

Literacy (%) 74.04 69.72 63.82

Crude Birth Rate (CBR) 21.6 27.4a 26.7a a

Infant Mortality Rate (IMR) 42 53a 43a a

Maternal Mortality Rate (MMR) 212 359b 219b a

Under 5 Mortality Rate (U5MR) 52 68 a 57 a a

(Source: RHS Bulletin, March 2012, M/O Health & F.W., GOI ) a : SRS, 2012 b: SRS, 2009

Three-tier Primary Health Care System exists in Uttar Pradesh and Bihar. The subcentre is the most

peripheral point of contact between the Primary Health Centre (PHC) and the community. A

subcentre comprises of an average of 4 villages is manned by an ANM/Health Worker (Female) and

a Health Worker (Male). An average of 6 subcentres are tied to one block level PHC. A Medical

Officer along with paramedical and other support staff manages the PHC. Four PHCs are linked to a

CHC which is a 30 bedded hospital or a referral unit with specialized services.

Ministry of Health and Family Welfare, Government of India (MoHFW: Rural Health Statistics in

India, 2012) report that there exists a shortfall of 38.2% Health Assistant (Female)/LHV, 52.6%

2.1 Socio-Demographic and Health Profile of Project Area


Health Assistant (Male) and 10.3% Allopathic Doctors against the total requirement at the PHC

level in India. Even out of the sanctioned posts, a significant percentage of posts are vacant at all the

levels. For instance, 7.8% of the sanctioned posts of HW (Female)/ ANM were vacant at all India

level. In addition, there was a shortfall of 69.7% specialists (Surgeons, Obstetricians &

Gynecologists, Physicians and Pediatricians) and 79.8% pediatricians at the CHC level against the

requirement. The data clearly indicates that there is a significant shortage of manpower at every

level of health facility in primary health care system in India. This is true for the state of Uttar

Pradesh and Bihar as well. Table 2 shows the manpower within the rural health care facilities in

Uttar Pradesh and Bihar.

Table 2: Manpower within the Rural Health Care Facilities in Uttar Pradesh and Bihar


Total Sub Centre 148366 20521 9696

Subcentre without ANM`s 4783 1155 410

Subcentre without HW(Male) 66425 18032 3423

Subcentre without both HW(Male)

and ANM

3159 1135 337

Total PHC`s 24049 3692 1863

Health Assistant(Female)/LHV at

PHC -In position

16109 2040 358

Health Assistant(Female)/LHV at

PHC - Shortfall

9152 1652 1505

PHC without a doctor 903 0 18

PHC without lab technician 7676 603 NA

PHC without pharma 5549 274 212

Total CHC`s 5858 1740 151 70

Physicians at CHC -In position 940 314 28

Physicians at CHC -Shortfall 3667 201 42

(Source: RHS Bulletin, March 2012, M/O Health & F.W., GOI Accessed vide website: http://mohfw.nic.in/WriteReadData/l892s/492794502RHS%202012.pdf)

In addition to shortfall of manpower, the public health facilities in Uttar Pradesh and Bihar also lack

essential infrastructure like shortage of beds, referral transport, electricity, water supply etc. (Table

3)


Table 3: Infrastructure available at the Rural Health Care Facilities in Uttar Pradesh &

Bihar


Functional PHC 23940 3692 1863

Number of PHC`s with atleast 4

beds

16035 2389 533

Number of PHC`s with referral

transport

11103 327 404

Functional CHC 4833 515 70

Number of CHC`s with atleast 30

beds

3455 515 70

Number of CHC`s with referral

transport

1962 515 70

Number of CHC`s with all 4

specialist doctors

890 182 18

(Source: RHS Bulletin, March 2012, M/O Health & F.W., GOI Accessed vide website : http://mohfw.nic.in/WriteReadData/l892s/492794502RHS%202012.pdf) #data of 2011

Socio-Demographic and Health Profile of Project Districts

The study was conducted in 7 districts of Uttar Pradesh and Bihar. A brief profile of project districts

is presented below.

Lucknow1

Gorakhpur

:It is situated on the banks of river Gomti in central Uttar Pradesh, North India. According

to the 2011 census, Lucknow district has a population of 4,588,455 and a literacy rate of 79.33%.

Awadhi is the main dialect of this district. 2

Agra

: It is a district situated on the basins of rivers Rapti and Rohini in Uttar Pradesh and

covers a geographical area of 3483.8 Sq. Km. Literacy rate of Gorakhpur is 73.25 %. 3

Mahoba

: This district is situated in western Uttar Pradesh on the banks of river Yamuna. It is bounded

by Mathura District in the North, Dhaulpur District in the South, Firozabad District in the East and

Bharatpur district in the West. Agra district is divided into six tehsils and fifteen blocks and has a

literacy rate of 69.40%. 4

1Source: lucknow.nic.in/ 2 Source: http:// gorakhpur.nic.in/ 3 Source: http://agra.nic.in/aboutdistrict.html#history 4 source: http://mahoba.nic.in/

: It is a small district in Bundelkhand region of Uttar Pradesh. It has a geographical area of

2884 s Sq. Km. and has 4 blocks. The district has a literacy rate of 66.94%.


Meerut5: Meerut district is a part of Meerut division in Uttar Pradesh. According to the 2011 census,

Meerut district has a population of 3,447,405 and a literacy rate of 74.80%, higher than the state

average of 69.72%. The child sex ratio of Meerut is 850, lower than the state average of 899.

(

Gaya

"Census of India 2011 – Provisional Population Totals – Uttar Pradesh – Data Sheet" ) 6

Darbhanga

: Gaya District lies in the Magadh Division in Bihar. The district has a common boundary

with the state of Jharkhand to the south. In 2006, the Ministry of Panchayati Raj named Gaya one of

the country's 250 most backward districts. 7: Darbhanga district of Bihar has a geographic area of 2279 sq. km. It is bounded on the

north by Madhubani district, on the south by Samastipur district, on the east by Saharsa district and

on the west by Sitamarhi and Muzaffarpur districts. Maithili is one of the main languages spoken in

this district.

The population and literacy rate within the project districts is summarized in Table 4.

Table 4: Population and Literacy rate in Project Districts

Stat

e

District Blocks Population in district of UP

like Population (10)

No. of

Village

Literacy

(%)

Total* Rural Urban

Utta

r Pr

ades

h Lucknow 8 45.88 16.42 29.46 822 79.33

Gorakhpur 19 44.36 35.67 8.69 2914 73.25

Agra 15 43.8 24.63 19.17 898 69.40

Mahoba 4 8.76 6.39 2.37 440 66.94

Meerut 12 34.47 17.44 17.03 622 74.88

Bih

ar Darbhanga 18 39.21 37.9 1.31 1088 58.27

Gaya 27 43.79 40.84 2.95 2774 66.35

Source: Ministry of drinking water & sanitation, (Rajiv Gandhi National Drinking Water Mission-2013-2014) *Census of India-2011 (Series-10 Up/Bihar)

Table 5 presents a brief overview of the IMR and CBR in project districts against their state average.

The infant mortality rate in rural districts are much higher than the urban districts clearly indicating

that health policies and programs for survival of children must be strategically positioned in the

rural.

5 source: http://meerut.nic.in/ 6 source: http://en.wikipedia.org/wiki/Gaya_district 7 source: http://darbhanga.bih.nic.in/history.htm


Table 5: Infant Mortality Rates and Birth Indicators in Project Districts

State District Infant Mortality Rate Crude Birth Rate

Total Rural Urban Total Rural Urban

Utt

ar P

rade

sh

IMR

=53

CB

R=2

7.4

Lucknow 44 53 34 18.4 22.4 15.2

Gorakhpur 62 64 56 24.3 28 16.3

Agra 53 53 52 23.9 25.6 22.2

Mahoba 47 52 38 24.7 24.5 25.5

Meerut 52 56 46 24.3 25.8 22.3

Bih

ar

IMR

=43

CB

R=2

6.7 Darbhanga 48 47 63 26.3 26.7 21

Gaya 52 54 46 24.4 25.7 19.9

Source: Annual health report -2012, Annual health survey bulletin (2011-2012)

Table 6 presents data on availability of public health facilities and ASHAs in the project district.

Uttar Pradesh has 20251 subcentres of which 7.79% (1600) are situated in five project districts of

Uttar Pradesh. Similarly, Bihar has 9696 subcentres of which 7.2% (699) are situated in two project

districts.

Table 6: Availability of Public Health Facilities and ASHAs in the Project Districts

State District Sub Centres PHC CHC District

Hospital ASHA (*)

Utt

ar P

rade

sh Lucknow 336 37 11 8 1551

Gorakhpur 448 87 9 2 3603

Agra 383 68 7 2 2806

Mahoba 140 21 3 2 697

Meerut 293 43 4 2 1431

5 Dist/(U.P.) 1600/20521 256/3692 34/515 16/152 10088/159437

Bih

ar Darbhanga 259 55 2 0 NA

Gaya 440 71 2 1 NA

2 Dist/ (Bihar) 699/9696 126/1863 4/70 2/36 NA


Study Rationale Pneumonia is one the leading causes of childhood deaths in developing countries. The incidence of

clinical pneumonia is 0.29 episodes per child-year in developing countries. This equates to 151.8

million new cases every year, of which 13.1 million or 8.7% are severe enough and require

hospitalization. The estimated incidence of pneumonia in India is 0.37 episodes per child-year,

which translates into 43 million new cases annually. (Igor Rudan, 2008). The third annual

International Vaccine Access Center's (IVAC) Pneumonia Progress Report 2012 says that almost

1,088 children under 5 years of age die every day in India, an increase of 6.7 per cent from 2008

IVAC data which reported 3.71 lakh annual deaths. These deaths due to pneumonia can be attributed

to low rates of exclusive breast-feeding (26.2%) (Srivastava & Awasthi, 2013), poor access to health

care and lack of finances (Pandey, 2012), exposure to ambient air pollutants, low immunization rates

(Corsi et al, 2009; Nath B et al, 2007).

According to National Family Health Survey-3 (NFHS), India has a high Neonatal Mortality Rate

(NMR) of 42.5, high Infant Mortality Rate (IMR) of 62.1 and Under Five Mortality Rate (U5MR)

An equally important reason for poor access to health care is lack of physical access to qualified

health care providers. In a recent survey by Chronic Care Foundation it was found that only 57.7 %

of the urban respondents found diagnostic centers available within accessible distance whereas only

34.3 % of the rural respondents state that there are diagnostic facilities available within accessible

distance (Ratna Devi, 2012). Hence, most rural persons seek first level of curative healthcare close

to home, and pay for a composite convenient service of consulting-cum-dispensing of medicines.

(Gautam et al, 2011)

of

81.9 [India Fact Sheet]. States of Uttar Pradesh and Bihar have a higher IMR of 67 and 91

respectively when compared to rest of India. In 2005, 2.3 million deaths were reported in children

between ages of 1 month to 5 years and half of them were due to pneumonia or diarrhea (Million

Death Study Collaborators, 2010]. Majority of deaths in India occur in rural areas (Kalter et al,

2011). One important reason for larger proportion of deaths in rural area is poor access to qualified

health care providers due to their shortage (Kalter et al, 2011).

Children between 12–23 months of age, 43.5% had received primary immunization in India whereas

only 23% had done so in U.P. (India Fact Sheet, NFHS-3 data, 2012) and 66.7% in Bihar (State

Health Society of Bihar). In urban Lucknow, it was found that care seeking for a neonatal sickness

2.2 PROJECT BACKGROUND & GOAL


from at least one qualified provider was only 50.8% (Awasthi et al, 2009), which is likely to be

much lower in rural areas. As per NFHS-3, in UP, only about half of children with diarrhea or ARI

or fever in the last two weeks were taken to a health facility (India Fact Sheet).

In order to reduce infant mortality, deaths due to childhood pneumonia have to be reduced, Thus,

there is a need to change community behavior in three distinct aspects: timely recognition of disease

and its severity, avail treatment from qualified health care provider and understanding the

consequences of inadequate and delayed care. There has to be a synergy between diarrhea as well as

pneumonia mortality reduction in India as lessons learned from former can be applied to the latter

(Nichter, 1993 & Gove and Pelto, 1994).

In order to leverage this gap , the study entitled “Improving household decision-making for the

management of Pediatric pneumonia in Uttar Pradesh and Bihar” has been sponsored by Bill

and Melinda Gates Foundation to create communications materials to improve household decision

making that will result in early care seeking for suspect pediatric pneumonia and hence improve

child survival.

Project Goal and Objectives Goal: To create communications materials to improve household decision making when confronted

by lower respiratory illness in children in Northern India.

Objective 1: To constitute a Childhood Pneumonia Behavior Change Communication Consultative

Group (CPBCCCG) of various stakeholders who can be potential change agents from the

government and non-government sector, civil society, potential implementation partners, content

experts and other community gatekeepers, like politicians.

Objective 2: To conduct formative research to assess community perceptions about symptoms of

pneumonia, care seeking behavior and risk vulnerability due to it.

Objective 3: To compile a set of pneumonia case studies where there was bad outcome, like

prolongation of hospital stay or development of complications or death.

Objective 4: To develop potential messages for improving recognition of symptoms of pneumonia

early, care seeking from a qualified provider and understanding the risks as a result of delay in

recognition and quality care.

Objective 5:( i) To test the potential messages in the community to identify the ones which are most

informative and validate their understandability on another set of community (ii) To customize the

selected messages for various different audience, if required prior to roll out.

Objective 6: To disseminate the research findings and messages among various stakeholders as

identified by the CPBCCCG.


In pursuance of objective 2, we conducted formative research in 7 pre-identified districts of Uttar

Pradesh and Bihar. Its findings are presented in this report.

Geographic Focus

This Formative Research was conducted in seven pre-identified districts of Uttar Pradesh and Bihar.

One block within each district was purposively selected and the CHC/PHC of that block was visited

by the project team to obtain a list of subcentres. Four to six subcentres in four directions of that

block were identified for data collection. Data was collected from the caregivers residing in villages

within those subcentres.

Table 7: Project Geographic Area and Dialects spoken in that area

State District Dialect Block Subcentres included for data collection

Utt

ar P

rade

sh

Lucknow Awadhi Bakshi Ka Talaab

Bhauli Rampur Rampur Bheda Sarsawan Shivpuri Tikari

Mahoba Bundelkhandi Charkhari

Aktauha Bamrara Chandauli Imiliya daang

Meerut Khari Boli Mawana

Jhunjhuni Sanaut Sandhan Tateena

Agra Braj Fatehpur Sikri

Daulatabad Doora Fatehpur sikari Nagar Olenda

Gorakhpur Bhojpuri Shahjanwan

Bhagoura Bharsaad Katai Teekar Seehapar Darghat Munda

Bih

ar

Darbhanga Maithali Bahadurpur

Bankipur Fekla Tara lahi Bahadurpur

Gaya Maghai Manpur

Biju Bagha Kharhari Manpur Sanaut Sohepur

Ethical Compliance

The project was submitted to the Institutional Ethics Committee of the Research Cell, King George`s

Medical University, Lucknow and an ethical clearance was obtained vide letter no. 5861/R-Cell-13

dated 1st Nov., 2013.


Video Clippings on Childhood Respiratory Illness Vignettes

Fifteen Video Clippings of Childhood Respiratory Illness Scenarios or Vignettes were made.

Children less than 5 years admitted in the in-patient ward of the Department of Pediatrics of King

George`s Medical University (KGMU) or attending the outpatient facility of KGMU else from the

Trauma Centre of KGMU were captured in video clippings. Childhood respiratory illness video

clippings were made for WHO-defined conditions like (a) non-severe pneumonia (b) severe

pneumonia (c) very severe disease with one or more danger signs (d) upper respiratory tract

infection, like common cold (e) noisy breathings as depicted by patient of croup and audible wheeze.

Written and informed consent was taken from the parents/legal guardians of the children prior to

making of the clippings. The identity of the subjects was kept anonymous. These vignettes were

shown to the CPBCCCG members during the first Childhood Pneumonia Behavior Change

Communication Consultative Group (CPBCCCG) prior to use in the field.

From among the 15 video clippings, three-which clearly demonstrated specific signs of pneumonia-

were selected. These were later used during the Focus Group Discussions in the field. The following

were the salient features of selected vignettes:

Respiratory Illness Vignette 1: It showed a child less than 5 years suffering from pneumonia.

The child had only fast breathing, which is an early sign of pneumonia.

Respiratory Illness Vignette 2: It showed a child less than 5 years suffering from severe

pneumonia. The child had chest in drawing along with fast breathing and difficult breathing.

Respiratory Illness Vignette 3: It showed a child less than 5 years suffering from very severe

pneumonia and danger signs. The child had chest in drawing along with fast breathing and

difficult breathing. In addition, it had signs of severe pneumonia like grunting/groaning and

altered sensorium.

Development and Pilot Testing of Formative Tools

Key informant interviews, semi structured interviews and focus group discussions were the

formative research techniques used in this project.

2.3 Preparation For Data Collection


Fig. 1: Formative Research Techniques used in this project

Data was collected using the following data collection tools from different category of stakeholders:

i. Key Informant Interview schedule - Caregivers

ii. Key Informant Interview schedule- Community Health Workers & Rural Medical

Practitioner

iii. Semi Structured Interview schedule - Caregivers

iv. Focus Group Discussion schedule - Caregivers & Community Health Workers

Case studies collected as part of Objective 3 in this project also helped in development of data

collection schedules.

Each interview schedule was developed in English and then translated into Hindi. Pilot Testing of

study instruments was done in hospital setting in Lucknow and in the rural areas adjoining Lucknow.

Mothers of children less than 5 years who were either admitted for Acute Lower Respiratory

Infection (ALRI) or who attended the outpatient department of Pediatrics in King George’s Medical

University (KGMU), Lucknow were approached for initial pilot testing. After this, instruments were

modified and another pilot testing was conducted in the rural area of Bakshi Ka Talaab (BKT) block

within Lucknow district. Here caregivers of healthy children less than 5 years were interviewed.

Based on the findings of pilot testing and experiential learning, the instrument was again modified

for understandability and content validity. The modified tool was again used for pilot testing on a

different set of mothers accompanying children admitted for ALRI in KGMU, Lucknow and on the


rural population in BKT. The instruments finalized after three stages of pilot testing were henceforth

used for data collection.

Themes for Data Collection in Formative Research Tools

Data was collected on the following thematic areas using the following questions to elicit responses:

Section I: Awareness about Respiratory Illnesses, Symptoms and Management

1. Can you tell us about the common illnesses experienced by children (<5 years) in this place?

2. Please tell us about ALL types of respiratory illnesses that children (<5 years) commonly get

here?

3. You have told us about some respiratory illnesses in children less than 5 years just now.

Which among these respiratory illnesses are the ones in which the child suffers from difficult

breathing OR slow breathing OR rapid breathing?

4. Describe each of these respiratory illnesses and help us learn the terms you use for the

symptoms associated with each illness? [Note each respiratory illness and its description.

Also probe for differences between different respiratory diseases –what are distinguishing

symptoms or features, seasons when they occur etc.]

5. You have told us about symptoms that are common in respiratory illnesses in children less

than 5 years. Now tell us, which among these symptoms are very serious and would lead you

to seek immediate medical care?

6. Can you tell us about common remedies that are readily available at home that you or your

neighbours use when your children less than 5 years suffers from respiratory illnesses?

7. Can you tell us about common medicines that are readily available at the nearest

pharmacy/drugstore or that is commonly prescribed by any healthcare provider that you or

your neighbours use when your children less than 5 years suffers from respiratory illnesses?

8. How long and for what should one wait and self treat before taking the child less than 5 years

suffering from respiratory illness to a clinic/practitioner?

9. Can you tell us about any diet changes that should be followed for a child less than 5 years

suffering from respiratory illness? [Probe: changes in quantity of diet, changes in

composition of diet, food perceived to be `cold` by the community, food perceived to be

`hot` by the community, changes in breastfeeding, changes in the amount of water to be

given to the child etc.]


10. Can you tell us about the things that we should do & not do when our children suffer from

respiratory illnesses? [Probe the practices related to respiratory illnesses: bundling the baby,

stop bathing, prayers, giving steam etc.]

Section II: Decision making within the family and Health Care Seeking

11. Which health care providers and health care facilities are there in your village and in the

adjoining village and within 20 km of this place who are commonly consulted by the local

people to treat children`s illnesses? Name them. [Probe about the availability of (a)

Traditional healers (òjha`, `tantrik `, `baba` etc.) (b) Rural probably non-qualified

practitioners (`vaids` or doctors who give allopathic/ayurvedic medicine/homeopathic

medicine medicine and/or syrup after removing its commercial packaging and injections ) (c)

Government Health Facilities (d) Community Health workers (ASHA, ANM etc.) (e) Rural

Qualified Medical Practitioners.]

12. Who is the primary decision maker in your family once the child less than 5 years is

recognized as being very ill?

13. What happens if the primary decision maker(s) named above is/are not at home? In that case,

who can make a decision?

14. Under what circumstances can you, being a mother/grandmother/ female relative of the child,

leave home, if person who often accompanied you to the doctor is not there? Suppose if there

is an emergency then which person may be approached to accompany you to clinic or doctor-

-neighbour, health worker etc.?

15. Are the neighbors or relatives ever involved in decision-making?

Section III: Case Scenarios / Video Clippings of Childhood Respiratory Illness Vignettes

In this section Case Scenarios or Respiratory Illness Vignettes were given to the respondents.

It should be noted that Case Scenarios were a part of Key Informant Interviews and Semi

Structured Interviews and were narrated to the respondents. Video clips on Respiratory Illness

Vignettes were shown during the Focus Group Discussions.

Case Scenarios

Case Scenario 1: Let us consider a situation in which your child less than 5 years is having

cough, runny nose and is warm to touch. He/she is otherwise healthy and is also feeding

/breastfeeding normally? Where will you go first to seek care if your child is having such a

condition? [Probe if local practitioner (`vaid`, òjha`, ` tantrik ` or any other traditional


healer), RMP or private doctor visited first over government health facility or community

health worker then for what reasons- for convenience , proximity, cost, trust, reputation of

that facility/practitioner, availability of doctor or medicines, quality of care etc?]

Case Scenario 2: Let us consider a situation in which your child less than 5 years was having

cough, runny nose, fever PLUS fast breathing and chest in drawing AND was drinking /

breastfeeding less than his/her daily intake? Where will you go first to seek care if your child

is having such a condition? [Probe if local practitioner (`vaid`, òjha`, ` tantrik ` or any other

traditional healer), RMP or private doctor visited first over government health facility or

community health worker then for what reasons- for convenience , proximity, cost, trust,

reputation of that facility/practitioner, availability of doctor or medicines, quality of care

etc.]

Case Scenario 3: Let us consider a situation in which your child was having cough, fever

PLUS difficult breathing, chest in drawing PLUS was unable

Video Clippings of Childhood Respiratory Illness Vignettes

to drink/breastfeed normally.

S/he is ALSO drowsy AND is having bluish discolouration of the lips? Where will you go

first to seek care if your child is having such a condition? [Probe if local practitioner (`vaid`,

òjha`, ` tantrik ` or any other traditional healer), RMP or private doctor visited first over

government health facility or community health worker then for what reasons- for

convenience , proximity, cost, trust, reputation of that facility/practitioner, availability of

doctor or medicines, quality of care etc.]

Video Clippings were shown during the Focus Group Discussions to ascertain what signs

were recognized and how serious they were considered. They also helped elicit the local

language of illness. Three video clips of 17 to 30 seconds duration were shown to group

participants using a hand held PICO projector. Vignettes depicting the following video

presentations were shown to the group:

Respiratory Illness Vignette 1:

It showed a child less than 5 years suffering from pneumonia.

The child had only fast breathing, which is an early sign of pneumonia.

Respiratory Illness Vignette 2:

It showed a child less than 5 years suffering from severe

pneumonia. The child had chest in drawing along with fast breathing and difficult breathing.

Respiratory Illness Vignette 3: It showed a child less than 5 years suffering from very severe

pneumonia and danger signs. The child had chest in drawing along with fast breathing and


difficult breathing. In addition, it had signs of severe pneumonia like grunting/groaning and

altered sensorium.

Section IV: Quality of Care

When you visited a health care provider for treatment of your child suffering from respiratory

illness and less than 5 years

16. Did you know whether he was a qualified or an unqualified health care provider? How did

you ascertain it?

17. Did the health care provider explain you about the illness and why it has occurred?

18. Was the child`s chest exposed for examination or was the child examined bundled

up/covered with clothes?

19. Did he measure body temperature with thermometer or did he not use the thermometer but

touched the child to know about temperature?

20. Did he have tools for examination: Stethoscope, thermometer etc.?

21. Did the practitioner tell you about the medicines and how much and in what method they

should be given to the child?

22. Did the practitioner tell you what to look for to know whether the child`s condition is

improving or not?

23. Were you asked to follow up after a certain period or did he visit your house to know the

condition of the child?

Team Formation & Training:

Researchers were hired and trained for work in the field settings. The team comprised of a Project

Coordinator, Social Scientists, Community Interviewers and Field Assistants. It was ensured that the

team members were fluent in local dialect of project districts. The project staff was provided seven

day training from 16th - 23rd

Sep., 2013. Trainers were Dr. Mark Nichter – Project Consultant, Dr.

Shally Awasthi- Principal Investigator and Dr. Monika Agarwal- Co-Principal Investigator.

Ms. Bindu Menon from our subgrantee PointBlank also participated in the meeting as observer.

Training was imparted using both class room teaching and field practice techniques. The sessions of

the training were as follows:


Table 8: Training Sessions and Trainers

Training Sessions Trainers

• Overview of the project

Day 1

• Overview of qualitative research & interviewing techniques

• Research and sampling methods to be used in this project

Dr. Shally Awasthi

• Research methods to be used in this project

Day 2

(a) conduction of case studies

(b) use of video presentation of illness signs

(c) use of decision making case story : vignettes

• How to conduct interviews and case studies with attention to ambiguity and specificity in use of terms and embodied knowledge.

• Basics of focus groups discussions

Dr. Mark Nichter

&

Dr. Shally Awasthi

• Preparations for first field exercises

Day 3

• Logistics and travel plan discussion

• Plan of data analysis

• Discussions with Pointblank on strategy for Message Development

Dr. Mark Nichter

&

Dr. Shally Awasthi

• Pneumonia: Incidence and Interventions

Day 4

• Key Informant Interview Technique

• Practice exercise at KGMU& Experience Sharing

Dr. Shally Awasthi

&

Dr. Monika Agarwal

• Semi Structured Interview Technique

Day 5

• Focus Group Discussion

• Practice exercise at KGMU&BKT& Experience Sharing

Dr. Shally Awasthi

&

Dr. Monika Agarwal

• How to conduct Case Study

Day 6

• Practice exercise at KGMU & BKT &Experience Sharing

Dr. Shally Awasthi

&

Dr. Monika Agarwal

• Practice exercise at KGMU& BKT &Experience Sharing

Day 7 --


The trainees conducted 12 in-depth interviews, 12 case studies and 2 focus group discussions to gain

firsthand experience in conducting formative research.

In discussion (L-R): Ms. Bindu Menon (Subgrantee), Prof. Shally Awasthi (PI) and Dr. Mark

Nichter (Consultant)

In addition to the above-mentioned training, the social scientist of this project was imparted training

for improved data management and analysis. The social scientist attended a five day workshop on

'Qualitative Research Methods and Data Analysis' organized by the Public Health Foundation of

India (PHFI) at New Delhi between Dec 2 - 6, 2013. Topics that were covered during the workshop

were: epistemology of qualitative research, choosing appropriate study designs in qualitative

research, recording qualitative data and data management using best practices, focus group

discussions and in-depth interviews, approaches to analysis of qualitative data and writing up

qualitative research for publication.

After training, the data collection team was divided into 2 independent teams each supervised by a

Project Coordinator and a Social Scientist respectively. Each Team comprised of two community

interviewers and a field assistant. Field schedule of the team was prepared.



Selection of Districts: Data was collected from pre identified seven districts of Uttar Pradesh and

Bihar. Each district was purposively selected on the basis of predominant dialect spoken there.

3.1 DATA COLLECTION

Map

1: P

roje

ct B

lock

s in

Utt

ar P

rade

sh


Map

2: P

roje

ct B

lock

s in

Bih

ar


Selection of Block and Sub Center`s:. List of all the blocks within a district was obtained. Out of

all the blocks, one block per district was purposively selected. The blocks selected in project district

were: Manpur block in Gaya district, Bahadurpur block in Darbhanga district, Bakshi Ka Talab

block in Lucknow district, Sahjanwan block in Gorakhpur district, Fatehpur Sikri block in Agra

district, Charkhari block in Mahoba district, Mawana block in Meerut district. Selected block was at

a distance of 20-25 km from the district capital and the Chief Medical Officer (CMO)/Chief Medical

Superintendent (CMS) of that block consented to cooperate in the study.

After this, the CHC/ PHC within that block were visited by the team. The team visited the CHC in

Uttar Pradesh. However, since there are no CHC`s in Bihar and only a Main PHC along with its

additional PHC`s at the block level, the team visited the main PHC in Bihar District. The team met

the CMO/ CMS and sensitized him about the project. After this, a list of all subcentres functional

within the selected CHC/PHC was obtained. From the list of subcentres, four to six sub-centers in

four corners of the CHC were identified and selected for data collection. Then, 1-2 villages

randomly selected within each sub center were selected and visited by the team for data collection.


Respondents for Key Informant Interviews

Six Key Informants per district were interviewed. They were: two younger caregivers, two older

caregivers, one Community Health Worker and one Rural Medical Practitioner in each block of

chosen district.

Table 9: Eligibility Criteria for Caregivers of Key Informant Interview

Younger Caregivers Older Caregivers

• Married woman aged 30 – 45 years • Mother of at least ONE child aged 1 month

to 5 years

• Married woman aged 45 – 60 years • Grandmother or

any other female relative of a family in which there is a child between 1 month to 5 years

• All children < 5 years of age in family of respondent reported healthy on day of interview • At least ONE child in the family of the respondent < 5 years of age suffered from respiratory

illness and took medical treatment in last 6 months. • Be local residents • Have time of about 1 hour for interview • Have given written, informed consent for participation

Interview with a younger mother in Meerut, Uttar Pradesh

3.2 STUDY RESPONDENTS & ELIGIBILITY CRITERIA


Identification and Selection of Caregivers for Key Informant Interviews: For the identification

and selection of caregivers, the team visited the village of the selected subcentre. The ASHA of that

village was approached and sensitized about the project. Project team identified the respondents with

assistance of ASHA. At places where the ASHA was unavailable, the Pradhan or any other

influential person from the community was approached for identifying respondents. Those

respondents were included who fulfilled the eligibility criteria and could provide rich contextual

information (Table 9).

After the caregivers were identified, they were approached and briefed about the project and purpose

of conducting this interview. The respondents were also informed that their identity will be kept

confidential and that their participation is purely voluntary. Only those respondents were included

who agreed to give written, informed consent for participation and those who had time for about 50

minutes for interview. Each interview lasted for approx. 40-50 minutes. Interviews were recorded

using a digital voice recorder. The care providers were chosen as per the eligibility criteria

described in Table 10.

Table 10: Eligibility Criteria for Care providers of Key Informant Interview

Community Health Worker Rural Medical Practitioner • Auxiliary Nurse Midwife (ANM) or a

Accredited Social Health Activists (ASHA) who has been in service for more than 2 years

• Rural Medical Practitioner who is practicing in the area for atleast 2 years & whose exact qualifications are not known

• Be local residents • Have time of about 1 hour for interview • Have given written, informed consent for participation

Fig. 2: Eligibility Criteria for Key Informant Interviews


Respondents for Semi Structured Interviews: In this study, six semi-structured interviews of were

conducted with caregivers- three older caregivers and three younger caregivers. For the selection of

caregivers, the team followed the same process as that with key-informant interviews. The team

liaisoned with ASHA for the identification and selection of caregivers. Those caregivers who

fulfilled the eligibility criteria and gave written, informed consent were included. It was ensured that

those caregivers were excluded who had already participated in any other project activity like key-

informant or focus group discussion. As with key-informant interviews, all the semi-structured

interviews were also audio-recorded. Approx. 40-50 minutes were spent in the rapport establishment

and in the conduct of interview.

Table 11: Eligibility Criteria for Caregivers of Semi Structured Interview

Younger Caregivers Older Caregivers

• Married woman ≤ 30 years

• Mother of at least ONE child aged 1

month to 5 years

• Married woman > 30 years

• Mother or grandmother or any other female

relative of a family in which there is a child

between 1 month to 5 years

• All children < 5 years of age in family of respondent reported healthy on day of interview

• At least ONE child of respondent < 5 years of age suffered from respiratory illness and took

medical treatment in last 6 months.

• Be local residents

• Have time of about 1 hour for interview

• Have given written, informed consent for participation


Fig. 3: Eligibility Criteria for Semi Structured Interviews

Respondents for Focus Group Discussion: Focus Group discussions were conducted with two

categories of respondents: caregivers and Community Health Workers (CHWs). Five Focus Group

Discussions were carried out with caregivers and one with CHW in each district. Further

categorization of the caregivers were as follows: two focus groups were conducted with younger

mothers, two conducted with older mothers and one focus group discussion conducted with a group

of fathers. The CHWs comprising of ASHAs and ANMs participated in focus group discussion

which was conducted at either the Community Health Centre or the Primary Health Centre.

Table 12: Group and participant characteristic of Caregiver and Care provider

Selection Criteria of Women (Category A)

Selection Criteria of Women (Category B)

Selection Criteria of Father Selection Criteria of CHW

(a) Married woman ≤ 30 years

(b) Mother of at least ONE child aged 1 month to 5 years suffered from respiratory illness and treated for respiratory illness in last 6 months.

(c) All children < 5 years of age in family of participant reported healthy on day of discussion

(a) Married woman > 30 years

(b) Mother of more than one child and with at least ONE child aged 1 month to 5 years suffered from respiratory illness and treated for respiratory illness in last 6 months

(c) All children < 5 years of age in family of respondent reported healthy on day of discussion

(a) Married men between 28-45 years

(b) Father of more than one child and with at least ONE child aged 1 month to 5 years suffered from respiratory illness and treated for respiratory illness in last 6 months

(c) All children < 5 years of age in family of respondent reported healthy on day of discussion

(a) Has been in service for more than 2 years

All participants must: a) Have given written, informed consent for participation b) Be local residents c) Have time of about 1 hour for discussion d) Be able to actively participate in a group


The caregivers were identified and approached with the assistance of ASHA (preferably) or else

with the help of Pradhan or any other influential member of the community. A list of all the eligible

respondents was prepared and those who had already participated in any other project activity were

excluded. After this, approximately 6-8 caregivers were approached by the team and explained

briefly about the purpose. Only those who had time of about 90 minutes were requested to

participate. It was ensured that the group was homogenous in certain way; all the respondents were

married, had a child less than 5 years in a family who had suffered from minor respiratory illness in

last 6 months for which he was not hospitalized and belonged to the same age group. The group,

however, reflected heterogeneity of education and caste.

Fig. 4: Eligibility Criteria for Focus Group Discussion

The respondents assembled for the discussion at the place that was convenient to the most group

members and ensured maximum privacy. Usually, such places were either the primary school

within that village or else the residence of any community member who volunteered to cooperate. A

closed setting, preferably a guest room with dim natural light was chosen so that the vignettes/video


clips can be shown to the respondents during the discussion. Although the ASHA helped in the

identification or selection of caregivers but was not present during the time of discussion.

The prospective respondents were seated in a semi-circular manner. They were sensitized about the

project and the purpose of conducting this interview. Only those respondents who gave written,

informed consent to participate were included. It was clarified to the respondents that their

participation was purely voluntary and they can leave the discussion any time, if they feel so.

Baseline information of the respondents was collected on relationship of the respondent to the child

and on the respondent’s age, education, occupation, caste, religion, family type, number of family

members. In addition, information was also collected on the resources available with them which

they used to obtain information. It was specifically asked if the respondents had a mobile, a

television with/without satellite facility, radio, read newspaper or obtained information from any

other sources.

Focus Group Discussion with fathers in Agra, Uttar Pradesh

The discussion was facilitated by the moderator usually in Hindi. However, a translator from the

local community was hired for translating Hindi into local dialect, if required. Detailed notes were

taken by a note-taker while an observer noted the non–verbal cues during the discussion. He also


drew the organogram. Most of the discussions lasted for about an hour. All the discussions were

audio-recorded using a digital voice recorder.

During the discussion, three illness video clippings were shown depicting different grades of

pneumonia and responses on key themes elicited around these three vignettes. Hand held projectors

(PICOs) were used to project video clippings of childhood respiratory diseases. After the video

clippings, two conceptualized stories/vignettes were narrated to the respondents.

The first story focused on Àbsence of Decision Maker`. The facilitator narrated the story of a nine

month old gild child who was perceived “sickly” by her parents. Once when she falls ill, the parents

resort to home treatment, which causes delay health care seeking. Health care seeking is further

delayed in the absence of primary decision maker, the father. The story explores in detail about the

decision making process and the constraints perceived by the respondents in decision-making. The

second story focused on Àbsence of Enabling Factors`. The story revolved around a 3 year old boy

who belonged to a financially weak family. Once when he falls sick, he is taken to multiple health

care facilities for health care facilities and delay is caused due to time spent during unqualified care

seeking. Both stories invoked responses from the caregivers on decision-making process, pattern of

health care utilization, choice of health care providers in each situation and concept of quality of

care in the community.


Data Management

Transcripts of Key Informant interviews, Semi Structured Interviews and FGDs were written by the

facilitator in Hindi. It was ensured that each transcript was prepared only after referring the field

notes and audio recordings. After this, the transcript was translated into English by a hired translator.

Transcripts and their translations were reviewed by Social Scientists as well as the Project Co-

coordinator. 10% transcripts were reviewed by the Principal Investigator and Co-Investigators.

Transcripts and audio recordings were also shared with the sub grantee Point Blank.

Data Analysis

Codebook

A codebook was developed for coding and data interpretation. Codebook was divided into five

heads: (i) Code Level I (ii) Short code -Level I (iii) Code Level II (iv) Short code - Level II (v)

Definitions of Code level I & II. Code Level I was the main code and the Code Level II was the Sub

Code that was a part of the broader domain of main code. Code definitions along with levels of code

were discussed and standardized as analysis progressed. Code Definition also included `When To

Use` and `When Not To Use` instructions. `When To Use` section gave specific instances, usually

based on the data, in which that particular code should be applied. Similarly `When Not To Use `

section gave instances in which the code might be considered but should not be applied (often

because another code would be more appropriate).

Coding, Analysis & Interpretation At the time of conception of the study, it was proposed that data analysis will be done using AnSWR

software, an unpaid software provided by Centre for Communicable Diseases (CDC). It was later

found that this software has been withdrawn by CDC for technical reasons and therefore unavailable

for use. The PI communicated with the website management team of CDC and the team confirmed

that AnSWR was unavailable for use at present. The team from CDC suggested another unpaid

software for qualitative analysis called EZ-Text (Version 4.0) [Assessed through: http://www.cdc-

eztext.com/]. The research team, however, faced some technical issues in importing its files to

different software. Therefore, the team decided not to use it for data analysis. Yet another qualitative

research software called ATLAS Ti was tested by the project team and used in Objective 3

[Compilation of Case Studies] of this project. Its trial version however had a limitation of only 50

codes and 100 quotations. It was for this reason it was decided not to use it for formative research

which will involve large volumes of data. After trying out multiple options for computer assisted

3.3. DATA MANAGEMENT & ANALYSIS


coding, it was finally decided, that manual coding will be done to develop concepts and derive at

themes.

For coding, each transcript was read and re-read by two researchers several times to understand and

decide what codes should be given to it. Any discrepancies that occurred during coding was resolved

by the analysis team in two ways (a) re-listening to the voice recordings of interviews/discussions

and (b) referring to the original transcripts and field notes. It was ensured that codes were not

allotted solely based on what was written in the transcripts. Non-verbal cues, gestures and behavioral

responses that were noted at the time of interview/discussion were also given importance. The

manner and the tone with which the word/phrase was said helped in allotting the level of emphasis

to a particular code.

• High Emphasis code was the opinion expressed with high intensity and stronger favorable

tone.

• Medium Emphasis code was the opinion expressed with slightly lesser intensity and slightly

less favorable tone.

• Low emphasis code was opinion expressed with lowest intensity and much probing.

The codes were entered in Microsoft Excel for easy management and for counting frequencies. For

the purpose of data interpretation, frequency of the responses obtained against each code was

reported using a standard term (Table 13). The team met every day and discussed with the PI to

understand emerging concepts. Concept emerging from one data collection technique was

triangulated with remaining two techniques. Themes were established based on all emerging

concepts.

Table 13: Frequency of responses obtained against each code and the standard term used in

this report

Frequency Standard Term Used in this Report

100% All Respondents

> 50% Most Respondents

30% - 50% Almost Half Respondents

15% - 30% Some Respondents

< 15% Few Respondents


Report on Formative Research Findings 33

In this study, 43 Key Informant interviews, 42 semi-structured interviews and 42 focus group

discussions were conducted in seven districts of Uttar Pradesh and Bihar. We recruited 303

caregivers and 75 care providers between October 2013 to January 2014. The field schedule and the

duration of the data collection/district is given in Table 14.

Table 14: Field Schedule of the Data Collection Team

Stat

e

District Block Duration (days)

Period of Trip

From To

Utta

r Pra

desh

Lucknow

Bakshi Ka Talab 7

15th

17 Oct. 13 th

Oct. 13 21

st24 Oct. 13

th Oct. 13

Gorakhpur

Sahjanwan 6 29th

1 Oct. 13 st Nov. 13

9th

10 Nov. 13 th

Nov. 13 Agra Fatehpur Sikari 8 18

th25 Nov. 13

th Nov. 13

Mahoba Charkhari 8 18

th25 Dec. 13

th Dec. 13

Meerut Mawana 8 16

th23 Jan. 14

rd Jan. 14

Bih

ar Gaya

Manpur 9 3rd

11 Jan. 14 th

Jan. 14 Darbhanga Bahadurpur 9 3

rd11 Dec. 13

th Dec. 13

Total Number of Field Days: 55

Number of Interviews/Discussions Conducted and Respondents Included

Number of Interviews/ Discussions conducted: In this study, we collected data from caregivers

and care providers. Data was collected from persons within a family who provide care to the child at

the time of illness. Mother, grandmother, female relative of the child or the father who fulfilled the

eligibility criteria were included as caregivers. The care providers were health care givers who were

approached by the caregivers for health care seeking at grass root level. These included the

government health functionary (ASHA or ANM) at the village/subcentre level and also the private

village based rural medical practitioner. Key Informant Interviews and Focus Group Discussions

were conducted with caregivers and care providers respectively while semi-structured interviews

were conducted with only with caregivers. Fathers were included for participation in the focus

group discussion. RMPs were interviewed using key informant while CHWs participated in key

4.1 Background Characteristics of Respondents


informant interviews as well as focus group discussions. Table 15 provides data on the number of

interviews/discussions conducted in each state.

Table 15: Number of Interviews/Discussions Conducted In Each State

Data Collection Technique State

Total Uttar

Pradesh Bihar

1. Key Informant Interviews 31 12 43

Caregivers Younger Caregivers 10 4 14

Older Caregivers 10 4 14

Care Providers Community Health Worker 5 2 7

Rural Medical Practitioner 6 2 8

2. Semi Structured Interviews 30 12 42

Caregivers Younger Caregivers 15 6 21


3. Focus Group Discussion 30 12 42

Caregivers

Younger Caregivers 10 4 14


Fathers 5 2 7

Care Providers Community Health Worker 5 2 7 Number of Respondents: We recruited 303 caregivers and 75 care providers in this project. Among

these 215/303 (70.9 %) caregivers and 58/75 (77.3%) care providers were from Uttar Pradesh and

the rest were from Bihar. 233/303 (76.89%) caregivers participated in focus group discussions,

28/303 (9.24%) in key informant interviews and 42/303 (13.86%) in semi-structured interviews

(Table 16)

Table 16: Number of respondents in each interview/discussion

District Respondent Category

Key Informant Interview

Semi Structured Interview

Focus Group Discussion

All districts Care givers 28 42 233

Care providers 15 00 60

Lucknow Care givers 04 06 34

Care providers 02 00 08

Agra Caregivers 04 06 35 Care providers 02 00 08


Mahoba Caregivers 04 06 36 Care providers 03 00 07

Meerut Caregivers 04 06 32 Care providers 02 00 07

Gorakhpur Caregivers 04 06 26 Care providers 02 00 17

Darbhanga Caregivers 04 06 35 Care providers 02 00 07

Gaya Caregivers 04 06 35 Care providers 02 00 06

Relationship of the Caregivers with the Child: 255/303(84.15%) females and 48/303(15.84%)

male caregivers were purposively selected for participation in all project activities. Among these

235/303 (77.55%) respondents were mothers while 17/303 (5.6%) were grandmothers. Only 3/303

(0.99%) female relatives were included in all activities. 72% of participants in key informant and

semi structured were mothers.(Figure5)

72%24%

4%

Mother Grand mother Female relative1

(Total Caregivers: 70=28(KI)+42 (SS)

Fig. 5: Relationship of Caregivers with the child in Key informant and semi structured interviews

Socio-Demographic Profile of the Caregivers Age of the Caregivers: The median age of caregivers is given in Table 17. The median age of the

younger and older caregivers in FGD was 31 (range 20-57 years) .The median age for male

caregivers was 31 (28-45 years). The younger and older female caregivers of Semi Structured

Interviews & Key Informant Interviews had a similar median age of 28 (range 22-36 years).


Table 17: Median age of the Caregivers

Data Collection Technique Respondent Category N Median Range


Younger and Older Female Caregivers 182 31 20-57 years

Male Caregivers (Fathers) 48 31 28-45 years

Semi Structured Interviews & Key Informant Interviews

Younger and Older Female Caregivers

70 28 22-36 years

Religion & Caste of the Caregivers: Out of 303 caregivers who participated in our study, most of

the respondents 278/303 (91.7%) followed Hindu religion while 24/303 (7.9%) followed Muslim

religion. Only a single respondent of focus group discussion followed Sikh religion.[Table 18,

Figure 6] Information was collected from the respondents on the caste to which they belonged.

About one-third respondents belonged to OBC and another one-third to SC. Less than one-third

belonged to General category. Least number of respondents 17/303 (5.6%) respondents belonged to

Schedule Tribe. .[Table 18, Figure 7]

Table 18: Religion and Caste of the caregivers

Key Informant Interviews

(n=28)

Semi Structured Interviews

(n=42)


(n=233)

Total

(n=303) N (%) N (%) N (%) N (%)

Religion

Hindu 22 (78.57) 38 (90.48) 218 (93.56) 278 (91.75) Muslim 06 (21.53) 04 (9.42) 14 (6.00) 24 (7.92) Sikh 0 (0) 0 (0) 1 (0.42) 1 (0.33) Caste

General 07 (25) 14 (33.33) 49 (21.03) 70 (23.10) Schedule Caste 06 (21.43) 11 (26.09) 90 (38.62) 107 (35.31) Schedule Tribe 01 (3.57) 06 (14.28) 10 (4.29) 17 (5.61) Other Backward 14 (50) 11 (26.19) 84 (36.05) 109 (35.97)


60, 86%

10, 14%

Hindu Muslim

100%

Hindu25

170, 92%

14, 8% 1, 0%

Hindu Muslim Sikh

Fig 6: Religion of the caregivers

21, 30%

17, 24%7, 10%

25, 36%

General Scheduled Caste

Scheduled Tribe Other Backward

39, 21%

72, 39%10, 5%

64, 35%

General Scheduled Caste

Scheduled Tribe Other Backward

10, 21%

18, 37%

20, 42%

General Scheduled CasteScheduled Tribe Other Backward 27

Fig 7: Caste of the caregivers


Size and structure of Caregiver`s Family

Almost an equal proportion of respondents belonged to joint and nuclear family types. 137 of 233

respondents (58.8%) in Focus Group Discussion belonged to nuclear family while 44 of 70

respondents (62.8%) in semi structured and key-informant interviews belonged to joint family. Most

of the respondents 170/303 (56.1%) had 6-10 members in the family while 92/303 (30.3%) had a

family size between 0-5 members. (Table 19, Figure 8 & 9)

Table 19: Family Size and Family Type of the caregivers


(n=28)


(n=42)


(n=233)

Total

(n=303).

N (%) N (%) N (%) N (%)

Family Type

Joint 18 (64.29) 26 (61.90) 96 (41.20) 140 (46.20)

Single/nuclear 10(35.71) 16 (38.10) 137 (58.80) 163 (53.80)

Family Size

0-5 4(14.29) 6(14.29) 82 (35.19) 92(30.36)

6-10 16(57.14) 25(59.52) 129 (55.36) 170(56.11)

11-15 7(25.00) 7(16.67) 17 (7.30) 31(10.23)

16 and above 1(3.57) 4(9.52) 5 (2.15) 10 (3.30)

106, 57%

79, 43%

Nuclear

Joint

14, 41%20, 59%

Younger women

Nuclear

Joint

12, 33%

24, 67%

Older women

Nuclear

Joint

31, 65%

17, 35%

Nuclear

Joint

28

Fig. 8: Family Type of the Caregivers


10, 14%

41, 59%

14, 20%

5, 7%

0-5 6-10 11-15 more than 15

59, 32%

107, 58%

14, 7%

5, 3%

0-5 6-10 11-15 more than 15

23, 48%22, 46%

3, 6%

0-5

6-10

11-15 26

Fig. 9: Family Size of the caregivers

Education and Occupation of the Caregivers

Most of the caregivers 95/303 (31%) were illiterate. 74/303 (24.4.%) were either literate or primary

qualified. Only 92/255(7%) of the female caregivers were high school qualified.[Table 20] We

found that more female caregivers (36.07%) were illiterate as compared to male caregivers (6%) [

Figure 10] Thus, it appears that male caregivers were better educated than the female caregivers.


Table 20: Education and Occupation of the Caregivers


(n=28)


(n=42)


(n=233)

Total

(n=303)

N (%) N (%) N (%) N (%) Education

Illiterate 15(53.57) 17(40.48) 63(27.04) 95(31.35)

Literate 1(3.57) 4(9.52) 29(12.45) 34(11.22)

Primary Pass 2(7.14) 5(11.90) 33(14.16) 40(13.20)

Middle Pass 6(21.43) 6(14.29) 44(18.88) 56(18.48)

High School Pass 1(3.57) 4(9.52) 28(12.02) 33(10.89)

Intermediate Pass 2(7.14) 4(9.52) 21(9.01) 27(8.91)

Graduate 1(3.57) 1(2.38) 11(4.72) 13(4.29)

Post Graduate 0(0.00) 1(2.38) 4(1.72) 5(1.65)

Occupation

Housewife 25 (89.29) 39(92.86) 156 (66.95) 220(72.61)

Farmer 1(3.57) 0 (0.00) 22(9.44) 23(7.59)

Self employed 1 (3.57) 0 (0.00) 8(3.43) 9(2.97)

Service 0 (0.00) 0 (0.00) 9(3.86) 9(2.97)

Labourer 1 (3.57) 2 (4.76) 32(13.73) 35(11.55)

Unemployed 0 (0.00) 0 (0.00) 6(2.58) 6(1.98)

Other 0 (0.00) 1 (2.38) 0(0.00) 1(0.33)


46%

7%10%

17%

7%

9%

3% 1%Illitrate

Literate

Primary

Middle

High School

Intermediate

Graduate

Post Graduate

32%

15%16%

20%

7%

8%

2%Illitrate

Literate

Primary Pass

Middle Pass

High School Pass

Intermediate Pass

Graduate

6%4%

8%

15%

31%

13%

15%

8%Illitrate

Literate

Primary Pass

Middle Pass

High School Pass

Intermediate Pass

Graduate

Post Graduate

29

Fig. 10: Education of the Caregivers

Occupation of the caregivers is shown in Table 20. Since male caregivers or father were included in

this study only for the focus group discussion while the female caregivers participated in all three

data collection techniques, it was obvious that most of the caregivers 220/303(72.61%) were

housewives. 42% of the male caregivers who participated in focus group discussion were farmers

while 21% were labourers and 12% of them were unemployed. [Figure 11]


84%

1% 2% 1% 12%

Housewife

Farmer

Self employed

Service

Labourer

12%

42%

8%

17%

21%Unemployed

Farmer

Self employed

Service

Labourer

92%

2%1%1%

4%Housewife

Farmer

Self employed

Service

Labourer

Fig. 11: Occupation of the respondents

Sources of Information available with the Caregivers

Details were collected from the caregivers on the sources available for obtaining information.

Information was collected on the availability of means of communication in their household like

mobile, newspaper, television without satellite network, television with satellite network, radio. In

addition, respondents were asked if they obtained information from other persons like

relatives/neighbors or from community health worker. People reported multiple sources of

information. Mobile was the most popular source. Most (81.8%) respondents possessed one mobile

per family which was usually carried by the male member. Other persons like neighbors/relatives

formed the next popular source (44.2%) for obtaining information. Radio was less preferred and

only 9.2% respondents obtained any information from it. Newspaper (25.08%) was also less popular

but more popular than radio. Television without satellite connection (34.2%) was used as a source of

information more than the radio and newspaper.[Table 21, figure 12]


Table 21: Sources of Information available with the Caregivers


(n=28)


(n=42)


(n=233)

Total

(n=303).

N (%) N (%) N (%) N (%) Mobile 19 (67.86) 30(71.43) 199 (85.41) 248(81.85)

Radio 2 (7.14) 6 (14.29) 20(8.58) 28(9.24)

Newspaper 17 (60.71) 9(21.43) 50(21.46) 76(25.08)

TV without Cable 17 (60.71) 12(28.57) 75(32.19) 104(34.32)

TV with Cable 12 (42.86) 15(35.71) 29(12.45) 56(18.48)

Other Persons (Relatives/Neighbors)

20 (71.43) 22(52.38) 92(39.48) 134(44.22)

Others (ASHA/ ANM/ AWW)

28 (100.00) 0(0.00) 52(22.32) 80(26.40)

49

8

26 29 27

42

28

0

10

20

30

40

50

60

Mobile

Radio

Newspaper

TV without CableTV with Cable

Other persons

Others

158

1537

60

17

92

52

0

20

40

60

80

100

120

140

160

180

Mobile

Radio

Newspaper

TV without Cable

TV with Cable

Other persons

Others

41

5

13 1512

0

5

10

15

20

25

30

35

40

45

Mobile

Radio

Newspaper

TV without Cable

31

Fig. 12: Sources of information in Caregivers Family


Common Childhood Illnesses

The caregivers were asked about the illnesses that are common in children less than 5 years of age.

The respondents reported a wide range of illnesses like diarrhea, pneumonia, body ache,

cold/flu/congestion, cough, fever, skin diseases, whooping cough, jaundice, vomiting, typhoid etc.

The gamut of responses included both disease names and symptoms. Symptoms like body ache,

vomiting, crying etc. were self-reported when asked about common childhood illnesses clearly

indicating that respondents were not able to differentiate between diseases and symptoms.

Cold/flu/congestion, cough and fever were the most common childhood illnesses. It is important to

note that the caregivers reported `pneumonia` less than fever and cold/flu/congestion but reported it

more than diarrhea and jaundice (Figure 13 & 14).

0

20

40

60

80

100

120

Younger CareGiver Older Caregiver Younger CareGiver Older Caregiver

Uttar Pradesh Bihar

Pneumonia

Cold/Flu/Chest congestion

Fever

Cough

Diarrhoea/Loose motion

Jaundice

Vomiting/Nausea

Others

Fig. 13: Common Childhood Illnesses as reported by caregivers in Key Informant interviews

4.2 RECOGNITION OF COMMON CHILDHOOD ILLNESSES


0

20

40

60

80

100

120

Younger Older Younger women Older

U.P. Bihar

Pneumonia


Fever

Cough

Diarrhoea/Loose motion

Jaundice

Vomiting/Nausea

Fig. 14: Common Childhood Illnesses as reported by caregivers in Semi Structured interviews

Types of Common Respiratory Illnesses

The respondents were asked about the respiratory illnesses that were common among children less

than 5 years. Pneumonia and cold/flu/congestion were reported by the respondents as respiratory

illnesses that were common in children less than 5 years. Cough and fever were reported by few

respondents and seemingly not understood to be respiratory illnesses. (Figure 15 & 16)

0

20

40

60

80

100

120

Younger Caregiver

Older Caregiver

Younger Caregiver

Older Caregiver

Younger Caregiver

Older Caregiver

Uttar Pradesh (n=20) Bihar (n=8) Total (n=28)


Fever

Cough

Pneumonia

Others

Fig. 15: Common Respiratory Illnesses as reported by caregivers in Key Informant interviews


0

20

40

60

80

100

120

Younger Caregiver Older Caregiver Younger Caregiver Older Caregiver Younger Caregiver Older Caregiver

U.P. Bihar Total

Cold / Flu/ Congestion Fever Cough Pneumonia

Fig. 16: Common Respiratory Illnesses as reported by caregivers in Semi Structured interviews

Types of Breathing Pattern

The caregivers were asked about the difference in patterns of breathing which occur when children

less than 5 years suffer from respiratory illness. Their responses can be categorized into: Fast

Breathing, Slow Breathing and Difficult Breathing. The respondents reported that both fast breathing

and difficult breathing occur in pneumonia. Fast Breathing and difficult breathing were, however,

reported more than slow breathing. Possibly, caregivers knew that slow breathing does not occur in

pneumonia but were unclear if fast or difficult breathing occurs in pneumonia (Figure 17 &18).

It can be interpreted that:

• Respondents were unclear about Breathing Pattern in Pneumonia. • Fast Breathing was NOT UNIVERSALLY recognised as a sign of pneumonia.


Fig. 17: Breathing Pattern in Pneumonia as reported by caregivers in key informant interviews

Diffi

cult

brea

thin

g

Diffi

cult

brea

thin

g

Diffi

cult

brea

thin

g

Diffi

cult

brea

thin

g

Diffi

cult

brea

thin

g

Diffi

cult

brea

thin

g

Slow

bre

athi

ng

Slow

bre

athi

ng

Slow

bre

athi

ng

Slow

bre

athi

ng

Slow

bre

athi

ng

Slow

bre

athi

ng

Fast

bre

athi

ng

Fast

bre

athi

ng

Fast

bre

athi

ng

Fast

bre

athi

ng

Fast

bre

athi

ng

Fast

bre

athi

ng

0.00

20.00

40.00

60.00

80.00

100.00

120.00

Younger Caregiver

Older Caregiver Younger Caregiver

Older Caregiver Younger Caregiver

Older Caregiver

Uttar Pradesh Bihar Total

Fig. 18: Breathing Pattern in Pneumonia as reported by caregivers in Semi Structured interviews

Danger Signs of Respiratory Illnesses The Integrated Management of Neonatal and Childhood Illness (IMNCI) strategy forms the core of

newborn and child health strategy of the Government of India under the Reproductive Child Health

II and National Rural Health Mission. IMNCI based classification of pneumonia is as follows:


Table 22: Signs or Symptoms of Pneumonia

Classification Signs or Symptoms

Pneumonia Fast breathing* • ≥ 50 breaths/min in a child aged 2–11 months • ≥ 40 breaths/min in a child aged 1–5 years

Chest in drawing

Severe pneumonia Cough or difficulty in breathing with: • Oxygen saturation < 90% or central cyanosis • Severe respiratory distress (e.g. grunting, very severe • chest in drawing) • Signs of pneumonia with a general danger sign (inability to breastfeed or drink, lethargy or reduced level of consciousness, convulsions)

In this study we tried to find out if the caregivers self reported those signs that are considered

dangerous enough to take the child out of the house for health care seeking. The respondents were

asked about the symptoms in children who were less than 5 years which they considered as danger

signs and for which they sought treatment from outside. These were then compared with IMNCI

danger signs.

The respondents in Key Informant Interviews reported symptoms like high fever, excessive

coughing, fast breathing, difficult breathing, chest in drawing, irritability (sleeplessness), excessive

crying, lethargy, refusal to feed, cold and others (Figure 19). Symptoms listed in others category

included body ache, loose motions, vomiting etc. as The most frequently reported danger signs

reported by the respondents of Key Informant Interviews were high fever, cold and chest in drawing.

Danger signs listed in IMNCI like inability to breastfeed or drink and lethargy were reported by very

few respondents. In addition, reduced level of consciousness or convulsions, also listed in IMNCI

general danger sign list were not self reported by any respondent in Key Informant Interview.

Summarizing, we can say that additional symptoms like fever and cold were reported less than

IMNCI danger signs.


Youn

ger

Youn

ger

Youn

ger

Youn

ger Yo

unge

r

Youn

ger

Youn

ger

Youn

ger

Youn

ger Yo

unge

r

Old

er

Old

er

Old

er

Old

er

Old

er

Old

er

Old

er

Old

er

Old

er

Old

er

Old

er

0

20

40

60

80

100

120

Others category included danger signs as : loose motions, vomiting, body ache etc.

Fig. 19: Reported Danger Signs of Respiratory Illnesses in Key Informant Interviews

The respondents of semi-structured interviews were asked the same question about danger signs as

that in key informant interview. The respondents reported high fever, excessive coughing, fast

breathing, chest in drawing, irritability (sleeplessness), excessive crying, up rolling of

eyes/unconsciousness, lethargy and refusal to feed as danger signs (Figure 20). Among these high

fever, fast breathing and up rolling of eyes/unconsciousness were reported as the danger signs by

most of the respondents. It is important to note that IMNCI danger sign of up rolling of

eyes/unconsciousness were reported by the respondents only on deep probing. Rest of the general

danger signs like lethargy or reduced level of consciousness and refusal to feed were reported less

than high grade fever.

Thus, it can be interpreted that:

• All IMNCI Danger Signs are not recognised by the caregivers.

• Additional Symptoms like fever, cold, coughing were reported as Danger Signs more than the IMNCI Danger Signs.


Fig. 20: Reported Danger Signs of Respiratory Illnesses in Semi Structured Interviews

Table 23: Caregivers Reporting of Signs of Severe Pneumonia & IMNCI Danger Signs

Signs of Pneumonia Reporting level

1. Signs of Severe Pneumonia like grunting, very severe chest in drawing etc.

Not Reported

2. Inability to breastfeed or drink Few Reported

3. Lethargy or reduced level of consciousness Few Reported

4. Convulsions Few Reported Signs and Symptoms of Pneumonia:

The caregivers were shown Video Clippings of Childhood Respiratory Illness Vignettes during the

Focus Group Discussions to ascertain if they could recognise signs of pneumonia. As already stated

on page 14 of this report, the respondents were shown three video clippings and the respondents

asked after each video as to what they could see and hear in each of them.

Respiratory Illness Vignette 1: When the respondents were shown the first video clipping showing

a child less than 5 years suffering from fast breathing, they were unable to notice fast breathing in it.

During discussions in most districts, the respondents assumed the child to be perfectly healthy and

“not suffering from any illness”. In very few districts, they reported additional symptoms like fever,

abdominal distension etc. but not fast breathing.


Fig. 21: Signs and Symptoms of Pneumonia in Vignette I

Respiratory Illness Vignette 2: The respondents were shown the second video clipping with a child

less than 5 years suffering from chest in drawing along with fast breathing and difficult breathing.

Most of the younger mothers were able to recognise chest in drawing along with fast breathing.

However, only some older caregivers were able to recognise chest in drawing along with fast

breathing (Figure22). In contrast to mothers/grandmothers, few fathers were able to recognise fast

breathing accompanying chest indrawing. Thus, fathers seemed to recognise lesser symptoms than

the mothers. It also appears that fast breathing is recognised only when accompanied by chest in

drawing and not alone. Since fast breathing was not recognised alone as is clear from the findings of

Vignette 1, it can be thus concluded that fast breathing is promptly recognised when accompanied by

chest in drawing but not alone.

Interpretation for Video I: • Fast breathing ALONE as a sign of pneumonia is not recognised.

^^bles cPps rks T;knk gk¡Qus dh vkSj iatjk ekjus dh vkokt vk jgh gSA lkal ysus esa lhVh dh vkokt vk jgh gSA ?kM+?kM+kgV dh vkokt vk jgh gSA We can hear that the child is breathing fast and there is chest indrawing. We can hear a whistling sound while breathing. There is also some obstructive sound that can be heard.” [Video 2, Father- Darbhanga (FGD)] “ge lHkh us bl rjg ds y{k.kksa okyk cPpk ns[kk gSA [kqn ds cPps esa ns[kk gSA bl cPps dks fueksfu;k gSA lnhZ gSA isV ekjrk gSA lkal ugha ysrs gSA gdedkrk gSA jksrk jgrk gSA bldks MkWDVj ds ikl ys tkrs gSA We have all seen a child with such symptoms. It happened even to our child. The child is having pneumonia. He is having cold. He is having chest in drawing. Such a child will not be able to breathe properly. He will not be able to talk properly and will keep on crying. Such a child should be taken to a doctor. ” [Video 2, Older mother-Darbhanga (FGD)]


Fig. 22: Signs and Symptoms of pneumonia in Vignette II

Respiratory Illness Vignette 3: The respondents were shown the third video clipping showing a

child less than 5 years suffering from very severe signs of pneumonia and danger signs. The child

had chest in drawing along with fast breathing and difficult breathing. In addition, it had signs of

severe pneumonia like grunting/groaning and altered sensorium. Most of the caregivers said that

they somehow knew the child is “very sick” but could not link it with pneumonia. Caregivers were

unable to appreciate altered sensorium or audible sounds like grunting and groaning. Interestingly,

some of the respondents reported that the child was having fever possibly interpreting that whenever

the child is “very serious” he must be suffering from fever.

When the third vignette was shown to a group of fathers they were able to recognize difficult

breathing more than the mothers. Fathers could not recognize altered sensorium. Some fathers could

recognise grunting and groaning more than mothers.

Interpretation for Video II • Fast Breathing was recognised by most younger caregivers, some older caregivers

and few fathers. • Fast breathing alone Not Universally Recognised


Fig. 23: Signs and Symptoms of pneumonia in Vignette III


Interpretation for Video III • Caregiver knew the child is “very sick” but could not link it with pneumonia.

*Interestingly some respondents also perceived child in video was having fever.

• Caregiver could not appreciate altered sensorium or audible sounds like grunting and groaning.

• Fathers were able to recognise difficult breathing more than the mothers

• Some fathers could recognise grunting and groaning more than mothers.


Local Terms of Pneumonia

We tried to find out from the respondents what they called and how they described childhood

pneumonia in their local dialect. Caregivers were asked what they called Pneumonia in their local

dialect. We found that pneumonia was known by different names in different districts. It is however

important to note that the term “pneumonia” was common in all districts. The respondents explained

that although pneumonia may be called by additional names in their community but they were

familiar with the term “pneumonia”. Many younger caregivers opined that the local terms were used

only by elderly in their household like grandmothers, mother-in-law etc. but currently they do not

use these local dialect terms in their routine life.

The following table lists the local terms used by caregivers for pneumonia in their respective district

Table 24: Terms for Pneumonia in Local Dialect

S.no. District Common Term

Additional names of Pneumonia in local dialect

1 Lucknow

PNE

UM

ON

IA

Pasuri chalna , Panjar lagna

2 Gorakhpur Haafa Daafa , Jooda

3 Agra Unera , Palaria , Pasuri

4 Mahoba Jooda / Badi sardi /Pasuria /Hadda /Chhoti sardi

5 Meerut Pankhi Chalna /Dabba ho gaya/ Mittha ho gaya/ Pasli chalna

6 Gaya Almunia / pankh phekna / hafni hona / Panjara phekna

7 Darbhanga Almunia

4.3 LOCAL TERMS OF PNEUMONIA & SYMPTOMS OF PNEUMONIA


Local Names of Pneumonia

&

MeerutPankhi Chalna

AgraUnera/Palaria/pasuri

GorakhpurHaafa Daafa/

Jood

DarbhangaAlmunia

GayaAlmunia/

pankh phekna/hafni hona

LucknowPasudi chalna

MahobaJooda/

Badi sardi

District DialectLucknow Awadhi

Mahoba Bundelkhandi

Meerut Khari Boli

Agra Braj

Gorakhpur Bhojpuri

Darbhanga Maithali

Gaya Maghai

Fig. 24: Local Names of Pneumonia

Local Description of Symptoms

We obtained information from the caregivers as to how they described symptoms of chest in-

drawing, fast breathing and difficult breathing in their local dialect district across all project districts.

Table 25 presents the terms/phrase in local dialect along with their explanation in English.


Table 25: Terms/Phrases on signs / symptoms of Pneumonia in local dialect

Sign/symptom Terms/Phrase in Local Dialect Terms/Phrase in English

Chest In-drawing • Panjara maarna

• Panjara ander dhasna

• Pasli tez chala

• Pet maarna

• Hafni maarna

• Chhati dhasna

• Palaria upar jheeng rahi hai

• Hadda chalna

• Pasuri

• Panjara phekna

• Pankhi chalna

• Ribs move inside

• Ribs move fast

• Chest goes in/sinks

Fast Breathing • Haafne lage/Dam phoolna

• Saans Tez Chale

• Saans bhagti hai

• The breathing becomes fast

• Breathlessness

Difficult Breathing • Saans lene main kathinai

• Saans upar neeche aana (Kaankhte)

• Mooh se saans lena

• Ruk ruk ke saans lena

• Gale ki nali band ho jaate hai aur sikud

jaate hai

• Hakmata

• Breathing goes up and down

• Child breathes from mouth

• Veins in neck block and

contract

• Child breathes with mouth

open and pulled upwards

Emerging theme: Pneumonia

Pneumonia was reported to be one of common childhood illnesses and also a respiratory illness by the caregivers. The term "Pneumonia" was understood across all 7 districts even though there are additional words for it in local dialects. Thus, messages should be developed around the term "pneumonia"


Information was elicited about the home remedies given to children less than 5 years who suffered

from respiratory illness. They were also asked to explain as to how the home remedy was prepared,

for how long was it administered to the child and how was it administered to a sick child .

We prepared a list of all the remedies that were prepared at home by the caregivers. From this list,

we segregated remedies based on the method of administration of home remedies into:

o Home Remedies that were used for Topical Application

o Home Remedies that were used for Oral administration

o Home Remedies that were used for both Topical and Oral Administration.

These remedies included under each category were common across all project districts. The

respondents reported that the information about these home remedies has percolated from the elders

in their family very often from grandmother/grandfather of the child. Sometimes they obtained

information from other persons in locality. Most of these remedies were used for 1-2 days or until

the illness did not subside. The period till the remedies were used depended on the perception of the

caregivers about the severity of disease. The caregivers administered home remedies till they

perceived illness to be manageable at home and “not severe”. As soon as they felt that it cannot be

managed at home, they sought medical advice outside their home.

Home Remedies Commonly Used for Topical Application

Home remedies were applied on the chest, forehead and palms of hand and on the toes of the child.

They were prepared using different ingredients in different types of oil or by extracting juices of

locally available wild herbs/plants. Egg was another ingredient commonly used in many topically

applied home remedies. Vicks Vaporub (Topical Ointment with medicated vapors) was also

commonly used for topical application. List of commonly applied home remedies is presented in

Table 26

4.4. HOME REMEDIES & SELF MEDICATION


Plant of “Kukraundha”

Table 26: Popular Home remedies used in project districts that are applied topically

Home Remedy Method of preparation/ place of availability

Respiratory Illness in which it is

commonly used

Home Remedies prepared by using different types of oil

Turpentine Oil Bought from market Cold and congestion

Sesame oil (“Tilli”) Bought from market Cold and congestion

Garlic, “ajwain”, fenugreek, “heeng” and mustard oil

All heated in mustard oil Cold and chest-in-drawing

Nutmeg(“jaiphal”) and mustard oil

Nutmeg extract and mixed in mustard oil. Used especially during winter season

Chest-in-drawing and congestion

Mustard oil and Garlic Garlic is boiled in mustard oil Cough and cold

Mustard oil, Garlic and “Ajwain”

Garlic and “Ajwain” boiled in mustard oil. Used especially during winter season

Chest-in-drawing

Mustard oil and camphor Bought from market Chest-in-drawing

Dalda (`Vanaspati` oil) Dalda is massaged on the chest of the child and a piece of cotton kept on it

Cold and congestion

Cow’s ghee (Fat extracted from cow`s milk)

It is massaged onto the chest of child. Used especially during winter season

Chest-in-drawing

Home Remedies prepared by using locally available wild plants/herbs

“Kukraundha “ ( a locally found plant)

Leaves of “Kukraundha” extract Cold and congestion


“Gendla” (a locally found plant)

Leaves of “Gendla” extract Cold

Home Remedies prepared by using eggs

Crude egg Massage with yolk of crude egg Cold and congestion

Egg Yolk of egg poured on a plain paper and pasted on the chest of sick child

Chest-in-drawing

Additional remedies used at home

Vicks Bought from market Cold

Fomentation by cotton cloth Cloth is fomented on fire. Cold and congestion

Home Remedies Commonly Used for Oral Administration

Information was obtained from the caregivers on home remedies that were administered orally to the

child who suffered from respiratory illness. Some home remedies were prepared using ingredients

easily available at home like turmeric, nutmeg, fats, ginger, honey, garlic etc. Sometimes juice of

extracts of herbs/locally available plants like “seej”, basil (“tulsi”) etc. were given to treat respiratory

illness. Occasionally, locally available commercially packaged non–allopathic tablets like

“Sanjeevani” and Musk (“kasturi”) tablets were given to the sick child. They were easily available at

the village grocery store or chemist shop at an affordable price. (Table 27).

Table 27: Popular Home remedies used in project districts that are given orally

Home Remedy Method of preparation/place of availability

Illness in which it is commonly used

Home Remedies prepared by using different ingredients easily available at home

Turmeric and Nutmeg Turmeric and Nutmeg extracted and mixed in mother’s milk

Cold

Turmeric and “ghee” (clarified butter)

Both mixed together Congestion

Garlic Garlic crushed and burnt in earthen lamp then given with mother’s milk

Cold

Asafetida (“Heeng”) It is mixed with mother’s milk and given to the child

Cold and stomach related ailment.


Ginger and honey Extract of ginger and honey is mixed and given to the child

Cough and cold

Turmeric and Nutmeg Both are mixed in mother’s milk. Cold

Turmeric and “ghee” (clarified butter)

both mixed together and applied on the chest of sick child

congestion

Clove, Asafetida (“heeng”) and “ajwain”

All are all roasted and given with mother’s milk

Cold

Home Remedies prepared by using herbs/locally available plants

Leaves of” Seej” (a locally found plant)

Extract of “seej” boiled and strained and then given to the sick child

Cold and congestion.

Basil (“Tulsi”) leaf and Honey Extract of basil mixed with honey Cold

Commercially available tablets used at home

“Sanjeevani” Tablet Commercially available Cold

Musk (“kasturi”) Tablet Commercially available Cold

Plant of “Seej” Plant of “Tulsi”

Home Remedies Commonly Used both for Topical and Oral Administration

There were some home remedies that were used topically and also administered orally to treat the

child suffering from respiratory illness. Egg, clarified butter, alcohol, “Kukraundha” (a locally

found plant) etc. were some remedies that were applied topically and administered. (Table 28)


Table 28: Popular Home remedies used in project districts that are applied topically and given orally

Home Remedy Method of preparation/place of availability

Illness in which it is commonly used

Crude Egg Crude egg is whipped and applied topically or used orally

Cold and congestion

“Ghee” (clarified butter) Bought from market Cold and chest-in-drawing

Cow’s “ghee” and salt Bought from market Chest-in-drawing

“Kukraundha” (a locally found plant)

Extract of “Kukraundha “ leaves mixed in mustard oil

Cold and congestion

Alcohol Bought from market Cold and congestion

Ajwain and mustard oil Ajwain is roasted and mixed in mustard oil

Cold and congestion

Unique Home Remedies

In addition to the home remedies that were popular and used by the respondents across all districts,

we also gained information on those home remedies that were unique and district specific. Table 29

summarizes such remedies.

Table 29: Unique Home Remedies used in project Districts

District where unique home

remedy is used

Home Remedy Preparation and use

Luck

now

Peacock feather Feather of peacock is burnt and its ash mixed in honey

“Mukaiyya” (locally found plant)

Extract of mukaiyya taken out and orally given to get relief from cold.

Kerosene oil It is used for treatment of chest in- drawing.

Gor

akhp

ur Black Tea, “ajwain” & basil

leaves All the three mixed together and a concoction prepared.

“Noorani” oil Available in the market and used for treating cold and chest in- drawing.

Agr

a “Mahua oil”

It is rubbed on the chest of sick child to get relief from chest in-drawing

Ajwain” and betel leaf Both extracted and orally administered.

M a h o b a Òpium` Opium is extracted and mixed in the milk of mother


and orally administered

`Gendla` (locally found plant)

Leaves of “gendla” extracted and given to the sick child to get relief from cold

Àkaundha` (locally found plant)

Roots of “akaundha” extracted and mixed in mother’s milk to get relief from cold and congestion.

Mee

rut Fish oil Topically applied for getting relief from chest in-

drawing

`Kala baans` with honey Leaves of “kala baans” roasted and mixed with honey and salt and orally administered

Gay

a

Bamboo stick and coconut Coconut is dried and burnt on bamboo stick and then child is fomented.

`Ghee` and clove “Ghee” and clove are heated on fire and then topically applied

`Ghee` and camphor Ghee and camphor are heated together and then applied topically to get relief from chest in- drawing.

Dar

bhan

ga

Pig’s oil It is topically used for treatment of cold and congestion

Honey and `pipri`

Honey and pipri put on a paper and then that paper is pasted on the temple of child.

`Muthia fasid` (a locally found plant)

Leaves of muthia fasid are boiled and its extract taken out. It is orally administered

Seeds of “Ghunchu”


Fig. 25: Unique Home Remedies of Uttar Pradesh & Bihar

Self Medication

We discussed from the caregivers if they self medicated when their child suffered from respiratory

illnesses. Only few caregivers reported self-prescription. Caregivers named oral antibiotic medicines

like Amoxicillin and Septran and injectible antibiotics like Gentamycin, Monoceff, antipyretics like

Paracetamol, Crocin, Calpol and Combiflam, anti tussives like Imbrodil and Corex syrup. Cortico-

steroids like Betnisol, Broncho–dilator like Deriphylin, injection/tablet and anti-diarrheal,

antispasmodics and also topical medicines. The caregivers who shared the names of medicines

clarified that self-prescription was done only until they perceived illness to be manageable at home.

Caregiver generally named more than one medicine. Some caregivers also reported use of Over the

Counter(OTC) Drugs like “Sanjeevani” tablets, Musk deer “Kasturi” tablets, “Vicks” (vaporizer

ointment) “Pudinhara”(a digestive syrup made from herbs), “Anand kar”, “Ajoobi”(a balm for

headache) and “Raahat rooh oil”. The formulations of some OTC drugs are unknown.

Caregivers mostly purchased the drugs from the local grocery store and sometimes from local

chemist. They also said that they stored the medicines at home and sometimes used stored

blisters/bottles of medicines earlier prescribed by RMPs without consulting any practitioner.


After the self-prescription or home remedies failed to show any improvement the caregivers decided

to seek care from outside. The decision making process has been dealt in detail in the subsequent

chapter.

^^ ,d ckj MkDVj dks fn[kykrs gSa nok j[kh jgrh gSA ;fn cPpk ml nok ls Bhd gks x;k rks fQj t:jr iM+us ij mls fiykrs gSaA Medicine is kept at home. In case the child had got well on using that particular medicine, it is used again when required” [Caregiver, BKT, (FGD)]

MkDVj tks nok nsrs gSa mldk uke 'kh'ks ij fy[k nsrs gSaA tc cPpk nksckjk chekj iM+rk gS ogh ns nsrs gSaA We write names of medicines on bottles. When the child gets ill we use the same bottles of medicine.” [Caregiver, BKT (FGD)]


An attempt was made to understand the decision making process within a family when a child less

than 5 years suffers from respiratory illnesses. Key Informant Interviews, Semi Structured

Interviews and Focus Group Discussions were used to obtain information on the decision-making

process, the primary decision maker and the family members involved in decision-making. The

decision making process was discussed in detail during the focus group discussion with the help of a

story that revolved around the absence of the decision maker and the dilemma protagonist caregiver

in the story faces to seek health care seek for her sick child. The story elicited responses from the

participants of the focus group on how and when they recognize respiratory illnesses, how they

decide to seek care, who else within the family were involved in decision making, who accompanied

them for health care seeking and what were the constraints that they faced before stepping out of the

house for health care seeking.

Primary Decision Maker

It was reported by the younger caregivers of Key Informant Interviews that the father was the

primary decision maker followed by the grandmother. Members of the extended family played the

least important role in decision-making. In contrast to younger caregivers, the older caregivers

informed that the grandmother was the primary decision maker in their family followed by

grandfather. Since the group of respondents for older caregivers also included grandmothers,

possibly they mooted their important role in decision-making and may discuss it with grandfather of

the child, if required (Figure 26 &27).

Father is the primary decision maker followed by grandmother

0

1

2

3

4

5

6

7

8

Mother Father Grandmother GrandfatherMembers Extended Family

High Emphasis

Medium Emphasis

Low Emphasis

3

Fig. 26: Primary Decision Maker as Reported by Younger Caregivers of Key Informant Interviews

4.5. DECISION MAKING PROCESS


Grandmother is the primary decision maker followed by grandfather 4

0

2

4

6

8

10

12

14

Mother Father Grandmother Grandfather Members Extended Family

High Emphasis

Medium Emphasis

Low Emphasis

Fig. 27: Primary Decision Maker as Reported by Older Caregivers of Key Informant Interviews

Respondents of Semi Structured Interviews reported that decision-making depends on the type of

family (Figure 28). It appears that in a single family, the father was the primary decision maker

while in a joint family the grandmother was the primary decision maker.

Fig. 28: Primary Decision Maker in Semi Structured Interviews

Information was obtained from the CHWs about the primary decision maker in the community

where they were posted. Almost half CHWs informed that in their community both mother and


father were the primary decision makers. However, some CHWs named both grandfather and

grandmother as the primary decision makers.

Decision Making Process The mothers were not the primary decision makers. Discussions during focus groups clearly

indicated that the mother is the first to recognize illness as she spends more time with the child than

any other family member. Even the father who participated in focus group discussion clearly opined

that mothers are “responsible for the child” and thus “she is the first to notice that the child is

unwell”. They added that even before alarming the family to seek health care from outside, she

usually tries out home remedy. They added that it is only when the mother found the home remedies

ineffective thereafter she approached the primary decision maker for further advice. The father of

the child is involved at this stage of decision making if it is single family. Within the joint family,

the father along with grandmother/grandfather may be involved the decision- making. In case the

Thus for Primary Decision Making, it can be interpreted that

• Mother is NOT the Primary Decision maker

o First to recognise illness BUT not the sole decision maker. She INFORMS

“primary decision makers”

• Other People within the family were primary Decision makers

o Father (Single family).

o Grandmother/grandfather (Joint family).

• Thus the trio finally involved in decision making are:

o Mother+ Father+ Grandmother/Grandfather

^Êkk¡&cki ¼ekrk&firk½ gh fu.kZ; ysrs gSaA Only mother-father are the primary decision makers" [CHW-Agra (Key Informant)]

^^llqj dk QSlyk eq[; gksrk gSaA Father-in-law (grandfather) is the main decision maker"

[CHW-Darbhanga (Key Informant)]

^^?kj ds cM+s] nknk&nknh ;k ukuk ukuhA Elders of the family. Grandfather-grandmother or maternal grandfather grandmother".

[CHW –Gaya (Key Informant)]


primary decision maker is absent then the mother may use the mobile to seek advice from him for

further plan of action.

Person accompanying sick child for seeking health care

Most of the respondents reported that they sought help from other family members for health care

seeking. Most of them sought help from the father of the child or the grandfather or grandmother.

However, some of them opined that they may go alone to the village based rural medical practitioner

if they perceived the sickness to be unmanageable and there was an urgency.

The respondents added that if they had to visit a health facility or a practitioner outside the village

then they seek the help of their family members. They opined that they may take the help of

neighbours or relatives if the primary decision maker within their family was not present.

The CHW`s were also asked about the members of a family who according to them accompanied the

sick child for health care seeking in their community. Almost half CHWs perceived that both mother

and father accompany the sick child for health care seeking. Some CHWs also informed that

grandfather might accompany the sick child for health care seeking. Few CHWs reported either

father or grandfather might accompany the sick child for health care seeking.

We collected information from the RMP as to which family members usually accompanied the sick

child to their clinic. Most RMPs said that often mother alone would carry the sick child to their

clinic. Almost half reported father as the family member who often accompanies the sick child.

Some RMPs said grandfather/grandmother may come with the child.

^^cPps ds ekrk&firk vkrs gSaA Both mother and father come with the child" [CHW, Agra (Key Informant)]

^^cPps ds ekrk&firk] nknk&nknh vkrs gSaA T;knkrj cPps dh ek¡&nknk vkrs gSaA xk¡o dk ;gh :y gS] fd cPps dh ek¡ vk;sxh vkSj mldk nknk cPps ds lkFk vk;sxkA firk dHkh dHkkj vkrs gSaA Child’s mother-father, grandfather-grandmother come. Mostly, mother and grandfather come with the child. Rule of the village is that mother will always be accompanied by grandfather. Father comes rarely". [ CHW , Mahoba (Key Informant)]

^^ igys ek¡ gh ijs’kku gksrh gSA ifr dks crkrh gSA igys viuk mipkj djrh gSA It is the mother who first gets upset (when she notices that the child is sick). She then tells her husband. First she does treatment at home". [Father, Gorakhpur (FGD)]


Thus after triangulating information from the key informant interview, semi structured

interview and focus group discussion it can be interpreted that:

• The mother was reported to be the first person to recognise and report “if the child is

sick or needs to be taken out”

• After this she consults either her husband or in-laws for health care-seeking. This

may be in two ways:

o Face-to-face discussion

o Discussion over mobile

• The mother is accompanied by either the husband or the members of extended

family to accompany her for health care seeking.

Emerging Theme: Decision Making for Health Care Seeking Mother is responsible for the recognition of illness. Decision making for health care seeking is done by the father along with the grandmother / grandfather especially in a joint family.


Caregivers were asked about the health care seeking behavior when their child less than 5 years

suffers from respiratory illness. We tried to elicit information from the respondents on the range of

health care providers available within their community and the factors that influence community`s

health seeking behavior and choice of health care providers. The health seeking behavior was

understood from both the caregivers perspective and care providers perspective. The respondents of

key informant interviews and semi structured interviews were narrated some sickness scenarios

while the respondents of focus group discussions were shown video clippings on clinical illness

vignettes and response obtained from them on who and why would they visit for health care seeking,

thinking prospectively.

Sickness Scenario I

Caregivers Perspective on Sickness Scenario I

The respondents of Key Informant Interviews were narrated Sickness Scenario I and were asked

about the type of facility/practitioner they would choose for the treatment of child in similar

scenario. Some of the caregivers in U.P. opined that they would choose services of a village based

RMP or a BBD in such scenario. In Bihar, all the younger mothers and most of the older mothers

preferred village based RMP over BBD as none mothers chose a BBD in such scenario. Few of the

caregivers in U.P. also expressed the need of visiting a government facility in such scenario.

Traditional Healer was chosen by only a few care givers. Few younger and older mothers in U.P.

opined that they would prefer to visit a traditional healer in such scenario. In contrast in Bihar none

opined visiting a traditional healer in such condition (Figure 29).

Illness Vignette on Sickness Scenario I(Video Clip)

Child less than 5 years having only fast breathing as a symptom of pneumonia

Sickness Scenario I (Narrated)

Child less than 5 yrs. is having cough, runny nose and is warm to touch. He/she is otherwise healthy and is also feeding/ breastfeeding normally

4.6. HEALTH CARE SEEKING BEHAVIOR OF CAREGIVERS


Fig. 29: Health Care Seeking Pattern Reported by Respondents of Key Informant Interviews in Scenario I

Respondents of Semi Structured Interviews were narrated the same scenarios as those of Key

Informant Interviews. Almost half of all respondents in Semi-Structured Interviews opined that they

would prefer to visit a village based RMP for health care seeking. BBD was the second choice for

health care seeking by some respondents in both states. Few respondents preferred a government

medical college while few others said they would prefer to wait and watch for the illness to subside

on its own or else wait for the visit of ANM at village. Private hospital was least preferred as the

child was perceived to be less sick (Figure 30).

When we analyze the data individually for Uttar Pradesh and Bihar we found that village based

RMP was the most preferred choice for health care seeking in both states. However, differences

existed in the second choice of practitioner. In Uttar Pradesh, BBD was the second choice for health

care seeking while in Bihar Government Medical College was the second choice. Also some

respondents in Bihar would prefer to `wait and watch` for the illness to subside on its own or else

would use treatment at home in the meantime.


5

0

5

10

15

20

25

30

35

40

45

50


Perc

enta

ge

Wait and Watch/Home TreatmentTraditional Healer/Spiritual HealerVillage Based Rural Medical Practitioner

Block Based Private doctor

A.N.M.

Medical College

Private Hospital

Fig. 30: Health Care Seeking Pattern Reported by Respondents of Semi structured Interviews in Scenario I

Respondents of Focus Group Discussions were shown an illness vignette with a child with fast

breathing only. Most of the caregivers opined that the child in the video was “Not Sick” hence felt

that no treatment was needed for this child.

Health care provider`s Perspective On Sickness Scenario I

Sickness Scenarios were narrated to the CHWs and village based RMPs and inquired what they

would they do when they come across a child with similar symptoms. Most CHWs would prefer to

treat the child themselves. The same was expressed by village based RMPs. Some CHWs would

advise the caregivers to consult government facility in such scenario whereas only few RMPs would

advise the caregivers to consult government facility. It can be interpreted that the child with fast

breathing only was perceived to be less sick by the care providers and they will self treat such a

child and not refer.


Sickness Scenario II:

Caregivers of Key Informant Interviews were narrated Sickness Scenario II and were asked in detail

about the type of facility/practitioner they would choose for their sick child suffering with similar

situation. In U.P. few of the younger and older caregivers said that they would prefer to go to village

based RMP for treatment .In contrast, in Bihar, most younger and all older caregivers would choose

to go to village based RMP. Most caregivers in U.P and younger mothers in Bihar would prefer to

visit a BBD for a child in similar sitaution. None of the caregivers preferred to avail the facilities of

either private hospital or government facility in such a situation (Figure 31).

Illness Vignette on Sickness Scenario II (Video Clip)

Child less than 5 years having fast breathing , difficult breathing and chest in- drawing.

Sickness Scenario II (Narrated)

Child less than 5 yrs. is having cough, runny nose fever, fast breathing and chest in-drawing. He/she is also feeding/ breastfeeding less than usual.

Emerging Theme: Sickness scenario I

Emerging theme in scenario I is that since caregivers perceived the child “Not Sick” hence no treatment was required to this child. If the child is “Mild” sick then they would consult traditional healer and village based rural medical practitioner. Likewise, in the case of care providers emerging theme is that all of them would treat themselves and would not refer the child in scenario I.


Fig. 31: Health Care Seeking Pattern Reported by Respondents of Key Informant Interviews in Scenario II

Sickness Scenario II was also narrated to the respondents of Semi Structured Interview. In U.P. most

of the respondents have reportedly chosen BBD. Medical college, ANM, Village based RMP and

wait and watch/ home treatment are some other facilities/practitioners that few caregivers would

prefer in U.P.. In Bihar most mothers chose BBD for scenario II. Medical college was preferred by

some respondents. Few of the mothers have reportedly chosen village based RMP here. Overall, in

both U.P. and Bihar, most of the respondents opined that they would choose BBD. Only a few chose

visiting a Medical College, Private hospital, ANM, village based RMP and wait and watch/ home

treatment in such a situation (Figure 32).


11

0

10

20

30

40

50

60

70

80

Uttar Pradesh (n=30)

Bihar (n=12) Total (n=42)

Wait and Watch/Home Treatment

Village Based Local Doctor


A.N.M.

Medical College

Fig. 32: Health Care Seeking Pattern Reported by Respondents of Semi structured Interviews in Scenario II

Video II: Focus Group discussion

Respondents of focus group discussion were shown an illness vignette and health care seeking

discussed in detail in response to sick child.

Video Clip during the Focus Group Discussion with CHW in Gorakhpur


Since the respondents perceived this child as “sick” they said that they would use home remedy for

1-2 days. It is only after they have tried home remedy they would prefer seeking health care from

outside. After this they were most likely to avail services of a village based RMP who is often

unqualified. In case the child “does not get well” from this village based doctor they would move

further to visit a BBD. Government Medical College was preferred only after the respondents felt

that they have tried home remedies, visited village based RMP or BBD but has still not recovered

from illness. Traditional /spiritual healer was mentioned by few respondents as the second choice for

health care seeking (Figure 33).

0

5

10

15

20

25

30

35

First Choice Second Choice Third Choice Fourth Choice

Num

ber o

f FG

D`s

Home Remedy

Traditional /Spiritual Healer


Block Based Private Practitioner

Government Facility

Medical College

12

Fig. 33: Health Care Seeking Pattern Reported by Respondents of FGD in Scenario II

Health care provider`s Perspective On Sickness Scenario II

Most of the CHWs opined that they would refer the sick child to government facility for treatment

while a few opined referring such a sick child to private/ government facility.


Almost half village based RMP opined that they would prefer themselves to provide treatment to a

sick child with similar condition as in Scenario II. Another half village based RMP said that they

would monitor the condition of the child themselves and if the child with similar condition does not

improve even after 1-2 days treatment, then they would advise the caregivers to take such a child to

a government hospital.

Sickness Scenario III

Caregivers of Key Informant were narrated Sickness Scenario III also and were asked about the type

of facility/practitioner they would choose to avail treatment for a sick child in this scenario. In U.P.

Illness Vignette on Sickness Scenario III (Video Clip)

Child less than 5 years having fast breathing, difficult breathing, chest in- drawing as well as grunting/ groaning and altered sensorium.

Sickness Scenario III (Narrated)

Child less than 5 yrs. is having cough, runny nose fever, difficulty in breathing and chest in- drawing. He/she is unable to drink/ breastfeed normally. He/ she is also unconscious and is having bluish

^^bl rjg ds cPps dks rqjar lkeqnkf;d LokLF; dsUnz esa pkbYM Lis'kfyLV ds ikl Hkstuk pkfg,A This child should be immediately sent to child specialist at CHC''

[CHW-Gorakhpur] ^^bl rjg ds cPps dks pkbYM Lis'kfyLV ds ikl fjQj dj nsaaxsaA ge muds vfHkHkkodksa ls vPNs MkDVj ds ikl tkus dks dgrs gSa& pkgsa og izkbZosV gks ;k ljdkjhA Refer this child to a child specialist. I ask them to consult a good doctor either private or government''

[CHW- Meerut]

Emerging Theme: Sickness scenario II

Care Givers: Caregivers prefer use of home remedy while they wait and watch at home. If there is no improvement in the condition of the child then they first go to village based doctor and then to block based private doctor.

Care Providers: Rural medical practitioner would treat the sick child themselves in scenario II while Community health workers would advise the caregiver to avail treatment at government hospital for a sick child.


most of the younger caregivers would go to private hospital whereas most older caregivers would

prefer to go to government hospital. Some younger and older caregivers reportedly chose BBD. In

Bihar all older mothers and few younger caregivers would go to BBD. Few of the younger

caregivers in both U.P. and Bihar would prefer to go to government facility (Figure 34).

Fig. 34: Health Care Seeking Pattern Reported by Respondents of Key Informant Interviews in Scenario III

During the Semi Structured Interviews respondents were narrated the same scenario as that Of Key

Informant Interview. Almost half of the respondents in U.P. opined that they would prefer to go to

private hospital, as they perceived the child as “very sick”. Some would go to BBD or Government

Medical College for getting their child treated. Only few wished to visit a village based RMP in such

a situation. Most of the respondents in Bihar however preferred to go to BBD. Government Medical

College or private hospital would also be preferred by some respondents. Overall, in U.P. and Bihar,

almost half respondents would choose either a block based private doctor or a private hospital and

only some would choose Government Medical College for getting treatment to a sick child as in

Scenario III. It shows a clear preference of the respondents for private sector. It is also interesting to


note that only a few would choose village based local doctor in this scenario clearly indicating that

choice of health care provider depends on the perceived severity of illness of the respondents (Figure

35).

17

0

10

20

30

40

50

60

70


Perc

enta

ge



Medical College

Private Hospital

Fig. 35: Health Care Seeking Pattern Reported by Respondents of Semi structured Interviews in Scenario III

Caregivers in Focus Group Discussion were shown a third illness vignette and were inquired about

the health care seeking in context of the video shown to them. The respondents in focus group

discussion also showed a preference for private sector. After viewing the video clip, respondents in

most FGDs said that they would visit a BBD while almost half said that they would prefer a Private

Hospital in such a scenario. Village Based RMP, Government Medical College or home remedies

were reported by very few respondents as the first choice for health care seeking.

The respondents were further inquired what they would do in a situation if the practitioner/facility

which they preferred the most was unavailable/could not be utilized. The respondents said that in

case the village based RMP was unavailable or they were unable to seek care at private hospital then

they would utilize the services of either a BBD or else would go to a Government Medical College

or else try home remedies to provide intermittent relief to the child (Figure 36).


0

2

4

6

8

10

12

14

16

18

20

First Choice Second Choice Third Choice Fourth Choice

Num

bder

of F

GDs

Home Remedy

Ojha /Traditional Healer


Block Based Private PractitionerPrivate Hospital

Government Facility

Medical College

18

Fig. 36: Health Care Seeking Pattern Reported by Respondents of Focus Group Discussions in Scenario III

Health care provider`s Perspective On Sickness Scenario III

Sickness scenarios were narrated to the care providers to obtain information on case management in

such scenario. Most of the CHWs opined that they would refer the sick child to a government

facility, preferably at the district level “as all facilities are there”. Few of the CHWs said that they

would refer the child to a private doctor.

^^ NksVk eksVk vLirky dke ugha djsxkA ,sls cPps dks fdlh izkbZosV cM+s vLirky ys tkuk pkfg,A ugh arks fdlh ljdkjh cM+s vLirky esa ys tkuk pkfg,A Any small hospital will not do. Such a child should be taken to a big private hospital. Otherwise, such a child should be taken to a big government hospital.” [Video 3, Father- B.K.T. (FGD)]


As with the CHW`s, some village based RMP would refer the sick child to district level

government health facility. Some village based RMP said they would advice treatment of such a

child at the hospital level –this hospital may be a government hospital or a private hospital. They

believed that the child requires treatment at the hospital level, as he was perceived “serious”.

^^,sls cPps dk dksbZ bykt ugha djsxsaA muls ¼vfHkHkkod ls½ dgssaxsa fd bl cPps dks rqjar ftyk vLirky ys tkvks vkSj Bhd ls bykt djokvksA Will not give any treatment to this child. Take this child to a district hospital as soon as possible and treat there properly''. [RMP – Mahoba (Key Informant)]

^^,sls cPps dks rqjar fjQj dj nsaxsaA mls ftyk vLirky ds cPpksa okys okMZ ys tk,aA Will refer the child immediately. Take him/her to children’s ward at district hospital'' [RMP - KI -Darbhanga.] ;g cPpk cgqr xEHkhj gS] ,sls cPps dks ,d vPNs izkbZosV MkDVj ds ikl fjQj dj nsaxsa D;ksafd ogka ij lHkh lqfo/kk,a gksrh gSaA This child is very serious. Will refer him/her to a good doctor in private as there are all the facilities available. Here, there is no facility available. Here, time goes waste".

[RMP –Agra (Key Informant)

Emerging Theme: Sickness scenario III

Caregivers: In the context of scenario III caregivers first prefer to go to block based private doctor then to private hospital and in the end when there is no relief then they go to government hospital.

Care Providers:

Community Health Workers: Community health workers would send the sick child having symptoms mentioned in the above scenario directly to government health facility.

Village Based Local Doctor: Village based local doctor would advise the parents of sick child having symptoms mentioned in the above scenario to go to child specialist and government health facility.


Health Care Seeking Behaviour from Case Studies (Information obtained from another

Objective of this project)

We recruited 30 cases between September 2013 - January 2014 of which 25 were from Uttar

Pradesh and 5 were from Bihar. Children between 1 month to 5 years of age were recruited from the

following government hospitals:

(a) King George's Medical University in Lucknow, Uttar Pradesh

(b) Darbhanga Medical College and Hospital in Darbhanga, Bihar

(c) Anugrah Narayan Magadh Medical College & Hospital (ANMMCH) in Gaya, Bihar

(d) Lala Lajpat Rai Meerut Medical College in Meerut, Uttar Pradesh.

In addition to hospitals, we also recruited a case from Mahoba District Hospital and another from the

field.

Anugrah Narayan Magadh Medical College & Hospital (ANMMCH) in Gaya, Bihar


King George's Medical University in Lucknow, Uttar Pradesh

The children resided in urban and rural areas of Uttar Pradesh and Bihar. Majority of them were

infants 23/30 (76.7 %) and male 23/30(76.7%). An equal percentage (76.7%) resided in rural areas.

We asked the interviewees about the duration when the symptoms were noticed first to the time they

were admitted to the last health facility (Figure 37).

Fig 37: Duration of illness of cases till the date of interview


We interviewed the parents or the close relative of the child to understand the entire episode of

illness. With the exception of a single case where the respondent was grandfather and in another

case where the interviewee was a grandmother in all other cases interviewees was either the mother

or the father. All the interviewees had been with child since the onset of illness. 53.3% interviewees

lived to a joint family and 46.7% lived in a single family.

Fig. 38: Choice of Health Care Providers Based on 30 Cases from Uttar Pradesh and Bihar

Caregivers were asked about the pathways which they adopted when they sought health care for

their sick child. Almost half the respondents visited Village Based RMP soon after the onset of

illness while some caregivers visited BBD. Even a few had visited a traditional healer immediately

after the onset of illness. Unqualified health care seeking may have caused delay. Only few

caregivers had visited the Government Medical Hospital or a government facility and those that had

visited had been shifted to another practitioner/facility due to different reasons. The caregivers had

visited the private hospital or the government facility only when they were advised/self-decided to

move to a second facility as their child was not showing improvement.

Emerging Theme Case studies

Village based local doctor and Traditional healer was preferred over Private block based doctor as the first choice for health care seeking. Unqualified health care seeking was found to be the cause of delay in almost all of the cases. Before coming to the Medical College/Hospital caregivers visited at least 2 health practitioners / facilities.


Reasons for Caregivers Preference for Village Based RMP

The caregivers cited various reasons for preference of village based RMP:

• Easy Accessibility and Availability of village based Rural Medical Practitioner: The village

based doctor was easily assessible and practiced within /outskirts of the village. The Village

Based Doctor was also available at odd hours and this round the clock availability made him very

popular.

• Availability of BP machine, thermometer, weighing machine, stethoscope, medicines: The

village based doctor possessed a Blood Pressure Machine, thermometer, weighing machine,

stethoscope and medicines. This made him popular as the usage of these increased his credibility.

• Good treatment outcome: The caregivers believed that the treatment by village based rural

doctor often had a good treatment outcome.

• Culturally acceptable for woman to go unaccompanied: The village based doctor was trusted

by the caregivers and it was culturally acceptable for mother of sick child to go unaccompanied.

• Fees less and also on credit/barter: The respondents said that the village-based doctor charged

less fees than block based private doctor. A village-based doctor may charge anything between

INR 25-40 while a private block based doctor charges upto INR 300.In addition, he calls the sick

child for follow up and will again charge fee for that. Private block based doctor does not prepare

medicine. He will write medicines and investigations that need to be done.

Table 30 summarizes the reasons why village based RMP is more preferred than BBD as first point of contact.

“izkbZZosV esa de ls de 300@ yxrs gSa ] ikap fnu ckn fQj 300@& ysaxsa] ;s rks Qhl gS] nok vkSj tkap ds vyx ls ysaxsa A Private (block based private doctor) will charge atleast Rs. 300. He will again charge Rs. 300 after 5 days.This is just the fees. There will be expenses on medicine and investigations as well”. [(Father, Meerut (FGD)]


Table 30: Caregiver`s comparative of Village Based Doctor vs. Block Based Private Doctor

Criterion Village Based Local Doctor

Block Based Private Doctor

Place of Practice Small room Big room + facilities +helpers

Availability at Night Yes No

Consultation Fee Nominal (Rs. 25-40)

High (Rs. 100 onwards)

Fees inclusive of Medicine Yes No

Treatment on credit Yes No

Investigations recommended No Yes

Possibility of Mother alone visiting the clinic if required

High Possibility Less possibility

Medicine

Self Prepared by • assembling loose tablets • mixing tablets in syrup • Grinding tablets and

keeping it in paper packets

Prescribes commercially packaged medicine

Home visit Yes No

Calls for follow up visit and takes fee for each follow up visit

No Yes

“dEikmaMj gh xkao esa cSBrs gSaA fdlh MkDVj ds lkFk cSB ds FkksM+k cgqr lh[k tkrs gSaA nok esa gh mudh Qhl eSust gks tkrh gSA Xywdkst+ yxk nsrs gSa mlh esa 250@ rd lh/ks gks tkrs gSa A Compounder (helper of the doctor) are there in the village. They learn it in the company of some other doctor. Their fees is included within the charges for medicines. They give glucose and earn as much as Rs. 250 straight away. ” [ASHA worker, Lucknow (FGD)]


A Village Based Rural Medical Practitioner

Reasons for Preference of Caregivers for the Private Sector

All the caregivers preferred private sector because they offered “better facilities”. Facilities for

nebulisation and availability of incubator, oxygen mask, steam by machine, fomentation etc. were

preferred by the caregivers. Even the CHWs confirmed that these days even village based RMP had

started to nebulise children, which impressed community people and was perceived to be good

treatment for respiratory illness.

Caregivers opined that they get effective and “correct” treatment in private sector and also provide

better care. Most of the caregivers preferred to go to private sector because medicines are effective

or “good”. In addition, medicines are available within the premises. They also provide injections if

necessary. Some caregivers said that although the expenses at the private hospitals is high but still

“their treatment is effective”. Some caregivers preferred private sector due to immediate facility of

admission, less waiting time, round the clock availability of facilities and availability of treatment

during emergency also. Good behavior of staff and cleanliness were also some of the reasons cited

^^vktdy xkao MkDVj e'khu ls Hkki nsrs gSa] blfy, yksx vLirky vkus dh t:jr ugha le>rs gSaA These days even doctors sitting in villages use a steam machine (for nebulization). So we do not feel the necessity to go to a hospital.” [ASHA, Gorakhpur (FGD)]


by the caregivers for preference. Some said that they prefer private because it is secure with less

crowding. Less consultation time was also the reason told by few caregivers.

In addition to the above reasons, a certain social status was attached with the private sector.

Caregivers opined that well-to-do families sought private care while lesser offs went to government

hospitals.

Reasons for Non Preference of Caregivers for the Government Sector

Most of the community did not prefer to go to government facility as they lacked trust on its

treatment because of perceived poor outcome. They felt that the government doctors prescribe

medicines which is unavailable in the government facility but has to be purchased from the market.

In addition the government facilities were overcrowded. Some of the community members did not

prefer government facility because they believed that government facilities do not admit patient even

if he/she is critical. Instead they refer the patient to some other place. Their perception was that sick

child will not be benefitted even if they go to government facility and medicine is also not available

there. Thus lack of trust, unavailability or limited availability of medicines/facilities/services and

overcrowding were some of the factors cited by the caregivers for not opting a government facility

as first preference.

^îSls okys izkbZosV esa tkrs gSa] de iSls okys ljdkjh esa fn[kkrs gSA Only people who are well to do go to private” [ASHA, Gorakhpur (FGD)]

“ljdkjh esa MkWDVj Bhd ls bykt ugha djrs gSaA nokbZ Hkh ugha nsrs gSaA vxj dHkh nsrs Hkh gSa] rks ljdkjh nok;sa gekjs cPpksa dks lwV ugha djrh gSA The government doctor does not treat us well. They do not give medicines. Even if they give us, and that is rare, government medicines do not suit our children”

[Younger Mother, Darbhanga, Bihar (FGD)]


Community Health Centre at Sahjanwa Block in Gorakhpur District (U.P.)

In Patient ward of the Department of Pediatrics, Mahoba District Hospital


Caregivers Perception of Quality Of Care

Ways by which a community ascertains the qualification of a doctor Most of the respondents did not ascertain the qualifications of a doctor by viewing the signboard.

Only some said they believed that the doctor was qualified by reading at the signboard of a doctor.

Rest of the respondents described different ways to ensure that the doctor whom they intend to visit

was qualified. Some of these methods were:

1. Ask from other villagers/neighbours/relative to know if the doctor`s treatment is effective and

had a good outcome. If the information obtained was in favour of a particular doctor, he was

believed to be good. Some of them also reported a good outcome within their family after

treatment, which had increased trust.

2. Respondents said that they did not prefer to ask the doctor face-to-face about his qualifications.

They would rather collect information about the doctor from the villagers/neighbours/relative.

3. If the doctor used a stethoscope to examine the child or else if the clinic of the doctor was

always crowded with patients (hence showing popularity) he was believed to be a good doctor.

4. One interesting fact that emerged from the findings was that a doctor was presumed qualified if

he had better 'suvidha' (facilities). A doctor having a better infrastructure and facilities in clinic

like having a glass partition in the clinic, helper etc. was considered better qualified than a non

qualified (`jhola chaap`) doctor.

^^fMxzh okyk MkDVj 'kh'ks ds dejs esa cSBrs gSaA muds ikl gsYij gksrs gSaA >ksyk>ki vdsys cSBrs gSaA A doctor with a degree sits in a room with glass partitions. He has helpers. A jhola chaap sits alone at his room (clinic).” [Older Caregiver, Meerut (Key Informant)]

“>ksyk >ki MkDVj dh NksVh Dyhfud gksrh gS] izf'kf{kr MkDVj dh cM+h Dyhfud gksrh gS vkSj lHkh lqfo/kk,a gksrh gSaA fMxzh okys MkDVj ds ;gka cksMZ yxk gksrk gSA Jholachhap has a small clinic. Qualified has a big clinic, there are all facilities. A degree holder has a signboard” [Older caregiver, Meerut (Semi Structured)]

^^MkDVj vPNs gSa] i<+s fy[ks gSaA MkDVjh Hkh i<+h gSA vkyk yxkdj ns[krs gSaA ukM+h idM+dj ns[krs gSaA lhad Mkydj ns[krs gSaA He is a good doctor. He has studied medicine. He uses a stethoscope and also counts the pulse. He uses a long rod (thermometer) for examination”.

[Younger caregiver, Lucknow (Key Informant)]

oks ,slk ekurs gSa fd tgka cPps dks ges'kk ns[krs gSa] ogha fn[kkus ij cPpk Bhd gks tk,xk] dga vkSj tkus ij ugha** Community always believes that the doctor whom they have always been visiting routinely will make the child well. They will not go elsewhere.” [CHW, Gorakhpur (FGD)]


5. The respondents believed that a qualified doctor did not visit the homes of the sick patients. An

unqualified doctor visited their homes and asked their well-being.

Similar to the respondents in Semi structured interviews and focus groups, most of the respondents

from key informant interviews also felt that popularity of the doctor was the most important attribute

that they looked for before seeking health care. More older than younger women in all districts

believed popularity to be an important parameter. The younger caregivers reported that good

outcome and better infrastructure were some important things that they ascertained before selecting

a village-based doctor.

Method of Examination and Consultation The respondents were also asked about the method of consultation, examination and prescription of

medicine of the village based doctor, whom they most frequently visited.

Conversation between the doctor and caregiver prior to examination: The caregivers were asked

if the doctor they visited (i) informed them about illness (what has happened to the child) and (ii)

explained the reason as to why this particular illness has occurred. Most of the caregivers said that

the doctor informed them about the name of illness. Almost half the respondents reported that the

doctor which they frequently visited never told them about the cause of illness. In contrast, another

half said that the doctor told them about the cause of illness. The causes that commonly led to

sickness in the child as told by the doctor to these caregivers were: change in season, lower

immunity of the child, unhygienic living conditions etc.

Similar to the respondents in Semi Structured Interviews and Focus Groups, most of the respondents

from Key Informant Interviews in all districts also reported that the doctor informed them about the

name of illness. Except in Meerut district, less than half respondents in remaining 6 districts reported

that the doctor informed them about the cause of illness.

Examination:

^îzf'kf{kr MkDVj csgrj iksft'ku esa gksrk gS] >ksykNki MkDVj >ksyk Mkydj iwjs xkao esa ?kwerk gSA vPNk MkDVj ,d txg gh dqlhZ ij cSBrk gSA A qualified doctor has a better position. A non-qualified doctor roams around with a bag on his shoulders. A qualified one sits on chairs.”

[Older caregiver, Charkhari, Bihar (Key Informant)]

^^ >ksykNki MkDVj gekjs ?kj Hkh vk tkrk gS] i<+k fy[kk MkDVj dHkh ugha vk,xkA i<+kfy[kk MkDVj >ksyk ugha Mkyrk gSA The Jhola Chaap visited our houses himself where as an educated will never come. A person who is educated do not hang bag.” [Older caregiver, Mahoba (FGD)]


Unbundling the child for examination: Most of the respondents reported that the doctor whom

they very often visited removed the clothes

Use of stethoscope: All the respondents used a stethoscope for examining the child.

Use of thermometer: Most of the respondents said that their doctor used a thermometer to measure

temperature. Few of them said that their doctor counted pulse rate instead of thermometer. Almost

an equal number said that the doctor used both the thermometer and counted pulse rate.

Similar to the respondents in Semi Structured Interviews and Focus Groups, most of the respondents

from Key Informant Interviews reported that the doctor uncovered the child just to put a stethoscope.

All the respondents reported that the doctor, which they visited, used a stethoscope and a

thermometer. None of the respondents self reported that the doctor asked them if the child was

feeding or not. In all districts, younger caregivers reported about the use of thermometer as well as

counting pulse.

Availability of facilities and medical equipments with doctor: The respondents were asked about

the facilities or medical equipments available with the village based doctor that they most frequently

visited. Among the medical equipments commonly reported by most of the respondents were

thermometer and stethoscope. In addition to these items, few respondents also mentioned availability

of blood pressure monitors, X-ray machines, stretcher, `bhaap dene wala yantra` ( instrument used

to give steam / nebulizer machine) , fomentation machine, weighing machine etc.

Frequency and method of administration of medicine: The respondents were asked as to whether

the doctor explained them about the dose and method of administration of the medicine to the sick

child. Most of the respondents said that the doctor informed them as to how frequently the medicine

has to be given to the sick child. They further informed that the doctor told them whether the

medicine has to be given in morning, evening, or every X hours. For this, few respondents reported

that the doctors whom they consulted wrote on the medicine sachets and educated members.

The respondents were also asked if the doctor explained them as to how a medicine has to be given

to the child. Most of the respondents could not self-report about the method of administration of the

medicine. Only some (26%) respondents were able to explain the method of administration. They

informed that the doctor sometimes told them orally or otherwise wrote the instructions for giving

^îqfM+;k ij uEcj Mky nsrs gSa&1]2] 3A rhu VkbZe f[kykuk gSa] lqcg] nksigj] 'kke A tks i<+k gS og rks i<+ ds tku ysrk gSA lhji ij Hkh uEcj Mky nsrs gSaA He (doctor) writes numbers like 1, 2, 3 on the sachet. It should be given three times-morning, afternoon, evening. Those who are educated know it by reading. Numbers are given on syrup bottle also". [ Younger Mother, Mahoba ( FGD) ]


medicines on a slip or a paper sachet in which he dispensed loose medicines. Some common

methods of administration self-reported by the respondents were:

Giving medicine along with luke warm water

Mixing dry powdered medicine in hot water and then giving it to child

Pill to be given with milk or water

Time spent on Consultation: The village based doctors spent 1-2 minutes with the patient and

another 2-3 minute for medicine.

All the respondents in key informant interviews said that the doctor told them about dose and

method of administration. Few respondents also self reported that doctor told them as to what diet

should be given to the child and also informed that the doctor prepared medicines himself.

Monitoring the condition of sick child: The respondents were asked if the doctor explained them

how to monitor the condition of the child at home. Most of the respondents reported that the doctor

did not inform them as to how to monitor the condition of the sick child at home. The respondents

said that the doctor examined the child himself in the follow up visit and then informed the parents

that the child`s condition is improving, deteriorating or stable. They were not able to clearly tell on

their own on what symptoms he looked for to ascertain if the child was improving. On probing, they

informed that progression of fever or cough were the signs they looked for to ascertain if the child

was improving.

They never educated the parents to monitor the condition of the child. Only few (14 %) respondents

reported that the doctor informed them

1) To monitor if the child starts playing

as to how to ascertain if the child is improving at the time of

first visit. The doctor usually told them one of the following

2) To monitor if the breathing in the sick child becomes normal

3) To monitor if difficult breathing reduces.

One caregiver narrated how their doctor tells them to monitor in the following verbatim

“;fn eka cki i<+s fy[ks gSa rks crkrs gSa fd FkekZehVj yxkdj cq[kkj ns[k ysukA ;fn lq/kkj ugha gqvk rks fQj vkukA If the parents are educated the doctor tells them to use a thermometer and keep on checking the progress of fever. If there is no improvement, then come again.”

[Older caregiver, Meerut, KI]


Most of the respondents reported that the doctor himself told them about the condition of the child

when they visited his clinic for follow up. None of them mentioned that the doctor taught them as to

how to monitor a sick child at home.

Follow up: The respondents were asked if the doctor which they consulted called them for follow up

at his clinic and after how long. In addition, the respondents were asked if the doctor ever visited

their homes for follow up. All respondents reported that the doctor called them for follow up at the

clinic. Some (23%) of the respondents reported that the doctor advised them for follow up in 1-2

days. Almost a similar number of respondents reported that the doctor called them for follow up

within 3-4 days. Rest visited them visited doctor after more than 4 days None of the respondents

reported that the doctor visited their home for follow up. Also it was not clear from the verbatim of

the respondents if they complied with the advice of the doctor for follow up or not.

All the respondents reported that they were called for follow up but did not clear if they complied

with follow up advice given by the doctor.


The Community Health Workers (CHWs) namely the ANM and the ASHA participated in this

study. Key Informant Interviews and Focus Group Discussions were conducted with the Community

Health Workers to obtain information on their recognition of symptoms of pneumonia and how they

manage cases of pneumonia at the community level. Information was also obtained from them on

their perception of risk vulnerability. In addition, we collected information from the CHWs on the

health care seeking behavior of the community in which they lived.

Identification and Selection of Community Health Workers

For the identification and selection of Community Health Worker, the project team visited the office

of the Chief Medical Officer (C.M.O.) at the Community Health Centre (CHC) in Uttar Pradesh or

Medical Officer In Charge (MO i/c) at the Primary Health Centre (PHC) in Bihar and sensitized him

about the project. After seeking his cooperation, the team obtained a list of all functional subcentres

within selected block from the Health Education Officer (H.E.O) in Uttar Pradesh /Health Manager

(in Bihar). The list of subcentre also included names of ANM`s posted in a particular sub centre and

AHSA` posted at the villages in the ambit of a particular subcentre. Health Education Officer

(H.E.O)/Health Manager also helped the team to establish liaison with the CHWs and informed the

day where the CHW could be met at the CHC/PHC during routine meeting / reporting. The team

decided to conduct interview/discussion on that particular day at the CHC/PHC.

Key Informant Interview: One CHW who could provide rich information was interviewed at each

project district. The team identified and purposively selected a CHW with the help of Health

Education Officer (H.E.O) /Health Manager who fulfilled the eligibility criteria. Before the initiation

of the interview, the respondent was explained about the purpose of project and the interview.

Thereafter, written informed consent was obtained and baseline characteristics of the respondents

were noted. Each interview was audio recorded. In six of seven project districts, ANMs were key

informants while in Lucknow district ASHA was the key-informant.

Focus Group Discussion: One discussion per district was conducted at the CHC/ PHC of the

selected block. A heterogeneous group of 6-8 ASHA and ANM was formed for each discussion. It

was ensured that the ASHA and ANM belonged to different subcentres. ASHAs who were already

included for Key Informant interviews were not included in FGD. Informed consent was taken from

the CHWs before the start of every discussion. Baseline characteristics of the respondents were

noted. Each discussion was audio recorded.

4.7 Community Health Worker


Interview with a CHW at Darbhanga in Bihar

Key Findings

Baseline Characteristics of CHW`s who participated in Key Informant Interviews

Information was collected from the CHWs on their age, experience, subcentre where they are posted

and any additional training related to childhood illnesses which they have attended. However, no

information was collected on religion, caste, family type and family structure in the interviews.

Baseline characteristics of the CHWs who participated in Key Informant Interviews has been given

in Table 31.

Table 31: Baseline Characteristics of Community Health Workers –Key Informant

S. No. District Block Age

(in years) Subcentre

name

Distance of sub centre from CHC (UP) /

PHC (BIHAR)

Experience

(in years) Additional Training

1 Lucknow BKT* 29 Tikari 4 4 None

2 Gorakhpur Sahjanwa 54 Bharsad 5 28

Training on common childhood illnesses at Medical College Gorakhpur.

3 Agra Fatehpur Sikri 55 Doora 10 33 Training on childhood

illnesses under NRHM

4 Mahoba Charkhari 53 Akthoha 30 11 One day Training on immunization and twelve days combined training.

5 Meerut Mawana 24 Tigree 8 2 None

6 Darbhanga Bahadurpur 38 Bahadurpur 0 6 Training on Diarrhoea

7 Gaya Manpur 29 Gere 5 3 Training on Newborn Comprehensive care

*The respondent was an ASHA while in the remaining interviews the respondents were ANM`s


Of the 7 CHWs interviewed, the youngest one interviewed was of 24 years and the oldest was of 55

years. The distance between the CHC/PHC where they were interviewed and their place of posting

ranged from zero km to a maximum of 30 km. CHWs had a wide variation of work experience. The

CHW of Meerut had the least experience of only 2 years. In contrast, CHW of Agra district with an

experience of 33 years was most experienced. CHWs of Lucknow and Meerut had no additional

training, whereas the remaining 5 CHWs had some additional training on child illness under

National Rural Health Mission, immunization, Diarrhoea and training on New Born Comprehensive

Care respectively.

Baseline Characteristics of CHW`s who participated in Focus Group Discussions

Before the start of discussion, information was collected from the respondents on religion, caste,

family structure, number of family members and education. 60 CHWs participated in discussions –

47 were from U.P. while 13 were from Bihar. In all, 19 ANMs and 41 ASHA participated in Focus

Group Discussions across all project districts. Of these 15 ANMs and 32 ASHAs participated in 5

FGDS in U.P. and 4 ANMs and 9 ASHAs in 2 FGDs in Bihar. An effort was made to ensure that

there was representation from all castes.

Religion: Out of the total 60 CHWs who participated in focus group discussions, 95% (57/60) were

Hindus, while the rest were Muslims. In U.P. 95.74% (45/47) CHWs were from the Hindu

community while only 4.26% (2/47) belonged to Muslim community. This pattern was more or less

same in Bihar also where, 92.31% (12/13) CHWs were Hindus and rest of them from Muslim

community (Table 32 Figure 39).

Caste: Caste composition revealed that CHWs identified themselves as belonging to different

castes. In U.P 48.94 % (23/47) CHWs belonged to general category, with OBCs coming next with

29.79% (14/47). Schedule caste formed the 3rd major chunk in the caste composition of CHWs with

19.15% (9/47). However, only 2.13% (1/47) CHWs belonged to schedule tribe category. In Bihar,

there were only 23.08% (3/13) CHWs from both general and schedule caste category. There was

only 1 CHW (7.69%) from schedule tribe category. Other backward caste category formed the major

part in the caste composition of CHWs in Bihar with 46.15% (6/13) belonging to this caste (Table 32

Figure 40).


Table 32: Religion and Caste of CHW

U.P. (n=47) Bihar (n=13) Over all (n=60)

N (%) N (%) N (%)

Religion

Hindu 45(95.74) 12(92.31) 57(95.00)

Muslim 2(4.26) 1(7.69) 3(5.00)

Caste

General 23(48.94) 3(23.08) 26(43.33)

Scheduled Caste 9(19.15) 3(23.08) 12(20.00)

Scheduled Tribe 1(2.13) 1(7.69) 2(3.33)

Other Backward 14(29.79) 6(46.15) 20(33.33)

Fig. 39: Religion of the CHW Fig. 40: Caste of the CHW

Family Structure CHW: Of the total no. of CHWs, 53.33% (32/60) of them belonged to nuclear

family, whereas the remaining CHWs came from joint family. In U.P., 55.32 % (26/47) CHWs were

from nuclear family, while 44.68% (21/47) were from joint family. Bihar also reported almost the

same pattern with 46.15% (6/13) CHWs belonging to nuclear families whereas rest of them from

joint families (Table 33 Figure 41).


Table 33: Family Structure and Family Size of CHW

U.P. (n=47) Bihar (n=13) Over all (n=60)

N (%) N (%) N (%)

Family Structure

Nuclear 26(55.32) 6(46.15) 32 (53.33)

Joint 21(44.68) 7(53.85) 28(46.67)

Family Size

0-5 25(53.19) 6(46.15) 31(51.67) 6-10 21(44.68) 4(46.15) 25(41.67) 11-15 0(0.00) 3(46.15) 3(5.00) more than 15 1(2.13) 0(46.15) 1(1.67)

Fig. 41: Family Structure of CHW

Education: Almost half 45% (27/60) of the CHWs who participated in discussion had attained

education upto Intermediate level. 20% (12/60) of CHWs were High school qualified. Middle pass,

graduate and post graduate CHWs followed next with 13.33%, 11.67% and 10% respectively. In

U.P. middle pass CHWs were 12.77% (6/47), high school pass were 21.28% (10/47), intermediate

pass were 48.94% (23/47) with graduate and postgraduate coming in the end with 6.38% (3/47) and

10.64% (5/47) respectively (Table 34 Figure 42).


Table 34: Educational status of CHW

Education U.P. (n=47) Bihar (n=13) Over all (n=60)

N (%) N (%) N (%) N (%) N (%) N (%)

Middle Pass 6 (12.77) 2(15.38) 8(13.33)

High School Pass 10 (21.28) 2(15.38) 12(20.00)

Intermediate Pass 23(48.94) 4(30.77) 27(45.00)

Graduate 3(6.38) 4(30.77) 7(11.67)

Post Graduate 5(10.64) 1(7.69) 6(10.00)

Fig. 42: Level of Education of the CHW`S

Common childhood illness: The community health workers were asked about the common

illnesses that are likely to occur in children less than 5 years of age in the key informant interview

and focus group discussion. All the CHWs named Pneumonia, Diarrhoea and Fever as common

childhood illness. Most of the CHWs reported cough, cold and congestion as common childhood

illness. Jaundice, Polio, Malaria, Cholera, Measles and Chicken pox, Diphtheria, Tuberculosis,

Night blindness, Typhoid, whooping cough etc. were some other common childhood illnesses

reported by CHW. All the CHWs named Pneumonia, Fever, Diarrhoea, Jaundice as common

childhood illness. Cholera, Measles, Polio, Whooping cough, Tuberculosis, Tetanus, Asthma was

reported by some CHWs in the FGD (Figure 43).


Fig. 43: Common Childhood Illnesses as reported by CHW`s

Common Respiratory illness: After the common childhood illnesses, CHWs were asked to name

common respiratory illnesses found among children less than 5 years. To this, all the CHWs

reported Pneumonia as one of the common respiratory illness found among children less than 5

years. Some CHWs named cough, cold and congestion as common respiratory illness. Fever as

common Respiratory illness was named by only a few CHWs. All the CHWs named Pneumonia as

the common respiratory illness. Other respiratory illnesses reported by CHWs in FGD were Cold

and Congestion, Fever, Cough, Bronchitis and Asthma (Figure 44).

Thus it can be interpreted that:

Pneumonia, Diarrhoea and Fever was reported by all respondents Cough, Cold and Congestion was reported by most respondents Jaundice, Polio, Malaria, Cholera, Measles, Chicken Pox was reported by few

respondents


Fig. 44: Common Respiratory Illnesses as reported by CHW`s

Breathing Type in Common Respiratory Illness: CHWs were asked about the type of breathing

that usually occurs in common respiratory illnesses. The type of breathing that commonly occurs in

pneumonia and Common Cold / Flu / Congestion were asked. All CHWs reported difficult

breathing, most reported fast breathing, while almost half of them reported slow breathing in

Pneumonia. Thus, CHWs reported difficult breathing more than fast breathing. The same question

was repeated for another illness common cold/flu/congestion. In response, almost half CHWs

reported difficult breathing in common cold/flu/congestion. Only some CHWs reported Fast

breathing and slow breathing as a breathing type in common cold/flu/congestion. It can be

interpreted that difficult breathing was reported more by the CHWs than fast breathing even in

common cold/flu/congestion (Table 35 Figure 45).

Table 35: Breathing Type Reported In Common Respiratory Illness.

Common Cold / Flu / Congestion

Pneumonia

Fast breathing Some Most

Slow breathing Some Almost half.

Difficult breathing Almost half All


Fig. 45: Breathing Type in Pneumonia reported by CHW`s

Fig. 46: Breathing Type in Cold/Flu/Congestion reported by CHW`s

Symptoms Considered As Danger Signs: It was asked from the CHWs as to which symptoms they

considered as danger signs in children who were less than 5 years and for which they sought

treatment from outside. Most CHWs reported chest in-drawing and high fever as danger signs.

Difficult breathing, cold and laziness were reported as danger signs by almost half CHWs. Some

considered excessive cough and refusal to breastfeed/eating as danger signs in children less than 5

years. Interestingly, fast breathing as well as excessive crying were the symptoms that were reported

as danger signs by only few CHWs. Diarrhoea, chicken pox, malnutrition and excessive vomiting

were some other symptoms that were considered as danger signs by few CHWs.

It was striking to note that IMNCI general danger signs of inability to breastfeed or drink,

lethargy or reduced level of consciousness and convulsions were not reported by any CHWs. Only

some CHWs were able to report refusal to breastfeed/eating as danger signs (Figure 47).


Symptoms considered as danger signs (some/few):

Fig. 47: Symptoms considered as danger signs

Prescription Pattern of CHWs: CHWs were asked about the medicines they prescribed to children

less than 5 years suffering from respiratory illness. Most of them said they prescribe few type of

medicines to the children less than 5 yrs. suffering from Pneumonia. Almost half CHWs said they

prescribed antipyretic medicines to the children less than 5 years. Oral antibiotics were prescribed by

some of them. Few CHWs prescribed anti-tussive medicines to children whereas injectable

antibiotics, cortico steroids and bronchodilator were prescribed by none of the CHWs to children

less than 5 years in respiratory illness.

Diet Changes Advised To Caregivers of Children suffering from Respiratory Illnesses:

The community health workers were asked about any diet change they would advise to the

caregivers who have children less than 5 years suffering from respiratory illness.

Breastfed child: When the caregivers were asked about the advice they would give to the caregivers

of a child who was on exclusive breast feeding, most CHWs reported that they advise caregivers to

continue breastfeeding even when their child suffers from respiratory illness. Few CHWs advised

mothers of such children to avoid ‘cold food’ such as curd, rice, and banana since they believed that


if the mother continues to have `cold food` the cold may pass on to the mother and further on to the

breastfed child. Only few CHWs promoted use of warm water/fluids.

Older child: All CHWs advised the caregivers of older children to avoid ‘cold food’ like banana,

curd, rice, oranges etc. when their child suffers from respiratory illness. Most CHWs promote ‘hot

food’ items like almond, groundnut, eggs, masoor lentil, jaggery etc. They also advised use of warm

water/fluids to a child suffering from respiratory illnesses.

General advice to Caregivers of Children suffering from Respiratory Illnesses: It was asked

from the community health workers whether they give any advice to caregivers when their children

less than 5 years suffer from respiratory illness. All CHW's said they inform caregivers on what they

should do and what they should not do to help early recovery of their sick child. They advise that

child should be protected from catching cold, not to bath the child with cold water, make the child

wear warm / extra clothes and not to let them play outside the house when it is too cold.

^^cksyrs gS cPps dks BaM ls cpk;saA xeZ j[ksA [kkus&ihus esa BaMh thts ugha nsus dks dgsxsa] tSls twl] Qy] pkoy uk nsA xje pht esa lwi] nky dk ikuh] nfy;k] ek<+ ¼pkoy dk ikuh½ nsaaA ikuh xje djds fiyk;saA Advise them to keep the children away from cold. Keep them warm. Avoid giving ‘cold food’ like juice, fruits, rice. Give ‘hot food’ like soup, porridge, water strained from pulses and rice. Warm/boiled water should be given" [CHW-Gaya(Key Informant)] ^^cPpks dks BaMh pht euk djrs gSaA ngh] eB~Bk] ve:n vkfnA Advise the children to avoid eating curd, buttermilk, guava etc". [CHW-Agra(Key Informant)] ^^BaMk lkeku ugha nsuk] xje lkeku nsuk gSaA pkoy ugha nsuk] Qy&Qwy ugha nsuk] twl ugha nsuk] xje pht jksVh] nky] lCth nsaA ikuh xje djds nsaA Avoid giving ‘cold’ food; promote hot food .Rice, fruits, juice should not be given. Hot food stuff like chapatti, pulses, and vegetables should be given. Water should be given boiled". [CHW- Darbhanga (Key Informant)]

^^vxj cPps dks [kk¡lh vk jgh gS rks cPps dks pkoy ugha nsxsa] ngh ugha nsxsaA Lruiku djkrs jgrs gSA xje ikuh mcky dj nsrs gSaA If the child is having cough, avoid giving rice and curd as sputum is formed. Continue breastfeeding; give boiled water to the child as suggested by doctor".

[CHW-Gorakhpur (Key Informant)] ^^BaM ds ekSle esa BaMh pht u f[kyk;sa] tSls j[kk [kkuk u nsa] dqN lfCt;k¡] f?k;k] rksjh u nsa] pkoy] dsyk] phdw] iihrk] larjk ugha nsrs gSaA xquxquk ikuh gh nsaA ek¡ dk nw/k ,sls gh fiykrs gSaA Avoid giving ‘cold’ food during winters like rice, banana, papaya,`cheeku’, orange; some vegetables like bottle gourd, torai and stale food. Give fresh food, almond, groundnut. Give lukewarm water. Continue breastfeeding." [CHW-Meerut (Key Informant)]


Method of Examination of a child with respiratory illness: It was discussed with the respondents

as to how they examined the child with respiratory illness. Most CHWs said they touched the pulse

to know the temperature. Surprisingly only a few of them used a thermometer.

Information about dose of medicine and method of administration: Information was gathered

from the CHW about the dose of medicine and method of administering these medicines which they

advice to caregivers of children less than 5 years suffering from respiratory illness. Most CHWs said

that they informed caregivers about the dose of medicine and how the medicine has to be

administered to a child with respiratory illness. Almost half CHWs give antipyretics like

paracetamol while some of them give oral antibiotics like cotrimoxazole.

^^gekjs ikl tk¡p djus dk lk/ku ugha gSaA gkFk ls Nw¡ dj gh tk¡p dj ysrs gSaA We don’t have tools of examination. We only touch to know the temperature of the child.” CHW-Mahoba (Key Informant) ^^cq[kkj Nwdj ns[krs gSaA uk[kwu esa ihykiu ns[krs gSaA thHk dk rkyw ns[ksaA vk¡[k dk ihykiu ns[ksaA Mk;fj;k esa pqVdh djds ns[krs gSaA We touch to know the temperature of the child. Observe yellowishness in the eyes, nails and palate of tongue of the child. Pinch the child in case of diarrhea". [CHW-Darbhanga(Key Informant)]

^^ cPpks dks BaM ls cpk dj j[ksa] xje diM+s iguk;saA BaMh pht [kkus dks uk nsA Protect the child from cold; make him/her wear warm clothes. Avoid giving ‘cold food’" [CHW-Lucknow (Key Informant)]

^^foDl dh ekfy'k djus dh lykg nsrs gSaA BaM ls cpk dj j[kksa] dSi oxSjk iguk dj j[kksaA I advise them to massage the child with Vicks. Protect them from cold, make them wear woolen cap etc."

[CHW-Meerut (Key Informant)] ^^cPps dks ges'kk BaM ls cpk;sa] ckgj [ksyus uk ns] xje diM+s iguk;sa] BaMh pht [kkus dks u nsA ikuh mcky dj ds nsaA cPps dk iSj <dk gksuk pkfg;sA Always protect the child from cold, do not let them play outside. Make them wear warm clothing, avoid giving’ cold ‘food, water should be given boiled, legs and head of the child should be covered properly".

[CHW- Gaya (Key Informant)]


Signs of Improvement told by CHWs to Caregivers: CHWs were asked about the signs of

improvement that they explain to the caregivers to help them ascertain if their child’s condition is

improving or stable. All the CHWs informed that they explain the parents to assess themselves if

their child’s condition is improving or not. They told the parents that if the child’s condition

improves, then the child will become playful, his/her temperature will come down, he/she will

breathe normally and ribs will not retract. They also told the parents that the child will feed normally

and will stop crying.

^^cPps esa vxj lq/kkj gks jgk gSa] rks cq[kkj de gks tk;sxkA ilfy;k¡ ugha /klsaxh] lkal ukeZy ysxkA If the child’s condition is improving then his/her temperature will come down, ribs will stop retracting and child will breathe normally." [CHW-Meerut(Key Informant)]

^^vxj cPpk lkal Bhd ls ys jgk gSa] nw/k ih jgk gSa] cq[kkj de gks rks lq/kkj gks jgk gSaA If the child is breathing normally, is feeding and temperature is also down, then it means there is some improvement in the condition of pneumonia.” [CHW-Darbhanga (Key Informant)]

^ûkeZyh 2 fnu dh nok nsrs gSaA 2 lky rd ds cPps ds fy, VSCysV ds pkj VqdM+s djds 2 lky ds ls Åij dk gS] rks vk/kh xksyh lqcg nksigj 'kke dks nsrs gSaA Normally give medicines for 2 days. For children up to 2 yrs.1/4 of tablet and for children above 2 yrs. ½ tablet thrice a day."

[ CHW-Meerut (Key Informant)] ^^rhu fnu rd nok nsrs gSA T;knk ugha nsrs gSaA nks lky ls Åij okyksa dks vk/kh&vk/kh xksyh lqcg&'kke nsrs gSaA nks lky ls de mez okyks dks ge nok ugha nsrsA I prescribe medicines only for three days, not more than that. 1/2 tablet twice a day for children above 2 years. I do not give medicines to children less than 2 years". [CHW- Agra(Key Informant)] ^^cq[kk+j jgus ij ,d lky ls de mez ds cPps dks 2-5 ,e-,y rFkk ,d o"kZ ls Åij okys cPps dks 5 ,e-,y- ,d ls nks fnu rd nsus ds fy, dgrs gSaA ,d ls nks fnu ls T;knk ughaA In case of fever we give 2.5 ml. syrup for a child less than 1 year. For child above 1 year we advice 5 ml. syrup for 1-2 days. We do not ask to give medicine themselves for more than 2 days" [CHW-Gaya(Key Informant)]

Emerging Theme: Community Health Worker

The Community Health Worker is not able to recognize fast breathing as an early sign of pneumonia. They were also not able to report IMNCI danger signs. The CHW have

limited information on how to manage pneumonia cases at the community level.


Identification and Selection: The community participated in the identification and selection of

caregivers. Opinion was sought from the caregivers who they considered as the popular village

based RMP who had been practicing in the area for more than 2 years. This was corroborated with

other influential members of the community and during interviews with community health worker.

After this, the team identified village based RMP and he was approached and explained about the

purpose of study and interview. Informed consent was taken from the RMP and each interview was

audio-recorded with prior consent. Interviews were conducted at the clinic of RMP located in the

village or on the outskirts of the village. One RMP was interviewed in six of the seven project

districts. Only in Mahoba district two RMPs were interviewed.

Key Findings

Baseline Characteristics of RMP

Before the start of each interview, information was collected from the RMPs about their age,

experience, qualification and distance of their clinic from CHC/PHC (Table 36). However, no

information was collected from them on their religion; caste, and family structure.

Table 36: Baseline Characteristics of RMP

S.No. District Age (in years)

Distance from CHC/PHC

(KM)

Experience

(in years)

Qualification

1 Lucknow (BKT) 33 4 3 Unclear

2 Gorakhpur (Sahjanwa) 53 15 25 B.A.M.S.

3 Agra (Fatehpur Sikri) 55 10 33 B.A.M.S.

4 Mahoba (a) (Charkhari) 53 1 20 B.A.M.S.

5 Mahoba (b) (Charkhari) 55 8 22 Unclear

6 Meerut (Mawana) 28 7 8 Unclear

7 Darbhanga (Bahadurpur)

28 6 10 Unclear *

8 Gaya (Manpur) 65 6 35 Unclear **

4.8 Village Based Rural Medical Practitioner


The RMPs belonged to a wide age group. The youngest RMP was 33 years while the oldest one was

65 years. RMP practicing in Gaya was most experienced with 35 years of practice. The RMP who

practiced in Lucknow had only 3 years of experience. Some of them practiced as close as only 1 km

from the CHC/PHC while distance may extend upto 15 km. The qualification of only 3 RMPs were

known and they identified themselves as Bachelor of Ayurvedic Medicine and Surgery (B.A.M.S.).

The qualifications of rest of them were unknown. Some of them had inherited practice from their

forefathers while others

Common Childhood Illness: The Village based Rural Medical Practitioner was asked to name the

common illnesses that are likely to occur in children less than 5 years. Most of the RMPs named

pneumonia, diarrhoea, cold and congestion as common childhood illnesses. Some of the RMPs

reported vomiting as common childhood illness. Meningitis, jaundice, typhoid, bronchitis and polio

were reported by few RMPs (Figure 48).

Fig. 48: Common Childhood Illness as reported by RMP`s

Common Respiratory illness: After the common childhood illnesses, RMPs were asked to name

common respiratory illnesses found among children less than 5 years. To this, all the RMPs reported

pneumonia as the common respiratory illness found among children less than 5 years. Most RMPs

named cold and congestion as common respiratory illness. Fever was named by some RMPs.

Asthma, Whooping Cough & Bronchitis were other illnesses reported by few RMPs (Figure 49.)


Fig. 49: Common Respiratory Illness as reported by RMP`s

Breathing Type in Common Respiratory Illness: RMPs were inquired about the type of breathing

that usually occurs in common respiratory illnesses. It was probed in detail as to what type of

breathing commonly occurs in pneumonia. Most RMPs reported fast breathing as common

respiratory illness, while some of them reported difficult breathing in Pneumonia. Clearly, fast

breathing is seen as a symptom by the RMPs more than difficult breathing. (Figure 50) The same

question was repeated for common cold/congestion. In response, almost half RMPs reported difficult

breathing in common cold/flu/congestion. Few reported fast breathing as a breathing type in

common cold/flu/congestion (Figure 51).

Fig. 50: Breathing Type - in Common Cold/Flu/Congestion as reported by RMP`s

Fig. 51: Breathing Type - in Pneumonia as reported by RMP`s


Symptoms Considered As Danger Signs: It was asked from the RMPs as to which symptoms they

considered as danger signs in children who were less than 5 years suffering from respiratory illness.

Almost half reported chest in- drawing and high fever as danger signs. Difficult breathing, excessive

crying, diarrhea, vomiting and excessive cough were reported as danger signs by few RMPs.

Interestingly, fast breathing was reported by none of the RMPs as danger sign.

It was striking to note that IMNCI general danger signs of grunting, inability to breastfeed or drink,

lethargy or reduced level of consciousness and convulsions were not reported by any RMPs. Only

few RMPs were able to report convulsion as danger signs (Figure 52).

Fig. 52: Symptoms Considered As Danger Signs as reported by RMPs


Prescription Pattern of RMP

Table 37: Prescription pattern of RMP Prescription Pattern RMP

(Self Reported) (N=8)

Oral antibiotics* Almost half

Injectible antibiotics Some**

Antipyretics Some

Anti tussives Some

Cortico steroids Some

Broncho-dilator Some

Indigenous No information

Mixed (anti-diarrheals, antispasmodics, topical) Few

* Syrup and tablets both ** However, most said injections are important

RMPs were asked about the type of medicines they prescribed to children less than 5 years suffering

from respiratory illness. Almost half of them said they prescribed oral antibiotic medicines like

Amoxicillin, Sporidex, and Sefodoxim syrup. Some of them said they prescribed Injectible

antibiotics like Monoceff, Taxim and Salbectum, antipyretic medicines like Cenarest, Paracetamol

and Aceclopara, anti tussives like Trimonic and Tixylyx syrup, Cortico steroids like Dexona

injections and Broncho dilator like Deriphylin injection/tablet to the children less than 5 years. Few

of them said they prescribed anti-diarrheal like Lomophen, antispasmodics like Baralgon and topical

medicines also (Table 37).

Importance of Injections: RMPs were asked about the importance of injections to which most of

them said injections are important. They recounted that injections helps to manage “situation” and

keep “situation under control” when the child is very critical. They also opined that injection

provides “fast relief” from illness. Many RMPs also reported that injections are demanded from the

caregivers to provide easy relief.

^^batsD’ku nsuk t:jh gS] batsD’ku 'kjhj esa rqjUr dke djrk gSA 5 feuV ;k 20&30 feuV esa daVªksy dj ysrk gSA Giving injections is important; its starts working immediately in the body. It controls the disease in 5 minutes or 20-30 minutes." [RMP-Darbhanga (Key Informant)] ^êS batsD’ku de yxkrk gw¡] ij cgqr ls ek¡&cki gh batsD’ku yxkus dks dgrs gSaA I give injections rarely. Many parents insist on giving injections to their child."

[RMP-Lucknow (Key Informant)]


General Advise to Caregivers at the Clinic: RMPs were inquired about the advice they give to

caregivers at the clinic. All the RMPs said they advise the caregivers to protect the child from

catching cold, not to bath the child with cold water and also avoid giving cold food items and make

the child wear extra clothes/covered.

Diet Changes Advised for Children Suffering From Respiratory Illness:

The village based Rural Medical Practitioners were asked if they advised any changes in diet for a

child who suffered from respiratory illnesses. The RMPs recounted that they advised diet changes

during respiratory illnesses.

Breastfed child: When the RMPs were asked about the advice they would give to a child who was

breast feeding they informed that for a child who was breastfeeding the mother has modify her diet.

Most RMPs advised mothers of breastfed child to avoid ‘cold food’ items such as curd, rice, banana,

orange etc. Some RMPs advise caregivers to continue breastfeeding even during respiratory illness.

Further, RMPs advised that intake of warm water/fluids should be increased to provide relief .

Older child: All RMPs advised older children to avoid ‘cold food’ like banana, curd etc. when the

older child suffered from respiratory illness. Most RMPs advocated intake of ‘hot food’ items like

jiggery, groundnuts etc. They also advised increased intake of warm water/fluids in childhood

respiratory illnesses.

^^ ek¡ BaMh phtsa u [kk,] tks cPpk eka dk nw/k ihrk gS] eka dk vlj cPps esa tkrk gS nw/k ds }kjkA Mother’s who breastfeed their child should not eat cold food items. Through milk that cold transfers to the sick child." [RMP—Meerut (Key Informant)]

^Êkk¡ dks BaMh pht ugha [kkuh pkfg, & ngh] eV~Bk] lVj iVj pht ugha [kkuh pkfg,A Mother should not eat cold food items-like curd buttermilk and all such things."

[RMP-Gaya (Key Informant)]

^êk¡ dk nw/k cPps dks fiykus ds fy, dgrs gSaA ;fn ugha ihrk gS rks xk; dk nw/k fiykus ds fy, dgrs gSaA I advise to give mother’s milk to the child. If he/she is not able to drink, then ask to give cow’s milk" [RMP-Agra (Key Informant)]

^^[kkus esa pkoy uk ns] larjk] ekSleh uk ns cPps dksA Child should not be given rice, orange, sweet lime" [RMP-Meerut (Key Informant)]

^^cPpk cM+k gS rks Hkkr ugha [kkuk pkfg,] ikyd] dn~nw ugha [kkuk pkfg,] BaMk ikuh ugha ihuk pkfg,A It the Child is older, then he/she should not eat rice, spinach, pumpkin. Should not drink cold water". [RMP-Darbhanga (Key Informant)]

^^cPps dks lnhZ okyk [kkuk ugha feyuk pkfg,] mM+n dh nky] elwj dh nky] lnhZ okys Qy& xUUkk] ve:n ugha [kkuk pkfg,A Child should not get cold food items like urad dal, masoor dal, fruits cold in nature like sugar care, guava should not be eaten" [RMP -Mahoba(Key Informant]


Methods of Examination and Consultation: : It was also inquired from the RMPs about the

method used by them for examining the children less than 5 years suffering from respiratory illness.

All RMPs took the history of the sick child who comes to their clinic. Most of them use stethoscope

and thermometer for examining the sick child. Some examined the sick child by exposing the chest,

while some RMPs touched the pulse to know temperature. Normally, RMPs take 1-2 minutes for

examining the sick child but if they are dispensing drugs also then they may take 2-3 minutes.

Signs of improvement assessed by RMP: RMPs were inquired about the signs of improvement

they have to look for, to ascertain whether sick child’s condition is improving or not. They were not

able to specify the signs of improvement they have to look for, when probed further, they said they

monitor improvement in the sick child through reduction in fever, cough and breathing rate.

Follow-up: RMPs were inquired about the follow-up of sick child less than 5 years suffering from

respiratory illness. Most RMPs said they do not visit the house of sick child instead they call the

patients at their clinic, while some of them said they visit the house of patients whenever they get a

call from the parents of sick child.

^^lnhZ dk osx ¼lkal½ T;knk gS rks dksbZ lq/kkj ughaA gk¡duk de gS] rks lq/kkj gks jgk gSaA If there is rapid breathing, then there is no improvement in the condition of child, however if the rate of breathing is less, it means there is some improvement" [RMP-Mahoba (Key Informant)]

Emerging Theme: Village Based Rural Medical Practitioner

The RMP is not able to recognize fast breathing as an early sign of pneumonia. They were also not able to report IMNCI danger signs. The RMP has limited information on how to manage pneumonia cases at the community level although they were very popular and often the first contact of health care seeking at the community level.



Mes

sage

Dom

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1 Sy

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om R

ecog

nitio

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What Caregivers Know

What Caregivers Don’t Know Confusion Interpretation

Insight/Strategy for Message

Development

Themes for Messages/Action

Universally know the term ‘pneumonia’

Do not know what pneumonia stands for & risks associated with it. Symptoms of pneumonia a) Fast breathing NOT universally recognized b) Recognize chest in-drawing and fast breathing ONLY when accompanied by chest in-drawing. c) could not appreciate altered sensorium or audible sounds like grunting and groaning Differentiation from common cold [Fast breathing, difficult breathing reported by some] No concept of viewing the chest to observe respiratory rate Fever in isolation not considered as a symptom of respiratory illness.

Concept of ‘difficult breathing ‘ problematic as it can occur in blocked nose also

Delayed disease recognition {early stage where only fast breathing present missed}

Pneumonia has cough/fever with fast breathing which progresses to disease worsening manifested as chest in-drawing Delayed recognition of Pneumonia can lead to death. Observe chest movements and respiration. Don’t wait for chest in-drawing

Fast breathing as an early symptom Chest in-drawing as a relatively late symptom Chest exposure for thorough inspection to be done at home in children with cough/cold.

Emerging Themes and Conclusion


M

essa

ge D

omai

n 2

Whe

re a

nd W

hen

to S

eek

Hea

lth C

are

What Caregivers Know

What Caregivers Don’t Know Confusion Interpretation


Development


Caregivers/providers choose health care facilities according to perceived severity of pneumonia Informal triage at community level Less Sick Child: Wait & Watch or visit Traditional healer ~ Village Based Doctor (VBD) More Sick Child: Block Based Private Doctor (BBD) > VBD Very Sick Child: BBD ~ Private Hospital > Govt. Hospital

DELAY

• caused by home remedies and/or visiting VBD.

• BBD takes limited responsibility when disease progresses.

Government facilities (CHC) have referred the child to district hospital, hence perception that CHC cannot treat pneumonia. ANM also advises parents to use their discretion on choice of health facility when the child is severely sick.

Delay in care-seeking after disease recognition Unqualified Health Care Seeking cause of delay Socially acceptable for mothers to take child alone to village based doctor plus accessible, affordable plus available plus trusted

It saves life/faster cure/fewer sickness days/lesser expenditure if the sick baby reaches the ‘right doctor’ in shortest time. ‘Right doctor’ is medically qualified doctor

Early care-seeking Instill faith in Govt. Health System Avoid care-seeking from VBD for pneumonia Closely look for breathing and danger signs for early care-seeking.


M

essa

ge D

omai

n 3

How

To

App

roac

h a

Car

e Pr

ovid

er &

Neg

otia

te F

or Q

ualit

y of

Car

e

What Exists What caregivers are NOT informed

Confusion Interpretation


Development


VBD not usually qualified whereas BBD mostly qualified. Qualified doctors charge more than five times more fees but prescribe medicines. More qualified doctors don’t dispense medicines and prescribe investigations Caregivers NOT trained to monitor disease Most caregivers demand and get injections No concept of “course of treatment” among caregivers Only told about feeding changes in child, diet changes in mother Community satisfied when provider reinforces the belief that pneumonia is caused by “cold”

Doctor doesn’t tell them about: (a) how to look for improvement or deterioration (b) how long to wait while taking prescribed treatment & (c) where to go when condition worsens

Signboard on Doctor’s clinic stating “Child Specialist” or “Child Care Center” inspires faith in them

Important to train a mother to “monitor pneumonia” improvement/deterioration to be demanded from the care provider [This is quality care] Will avoid delay in recognizing worsening of disease

Caregivers to be taught through messages to observe chest movements and respiration as well as danger signs of pneumonia and general childhood illnesses through messages. Care providers to reinforce the same messages. IF care providers’ advice is in resonance with the messages heard about disease monitoring known by the mother THEN care provider is likely to be good.

To ask doctor about visible symptoms of improvement and for how long to wait and where to go when disease worsens


Mes

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Ris

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ulne

rabi

lity

Perc

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What Caregivers

Know

What Caregivers Don’t Know

Confusion Interpretation

Insight/Strategy for

Message

Development


Sign of deterioration: Additional Symptoms like fever, cold, coughing reported as DANGER signs > IMNCI Danger Signs. Few know ‘refusal to feed’ and excessive crying; few know lethargy and unconsciousness/Seizures

All IMNCI Danger Signs not recognised. Fever alone not indicative of disease progression or improvement. Maternal cough/cold can be self-limiting; however, her child with similar symptoms can progress to fatal pneumonia. Children with cough/cold can have different outcomes in same child or in different children

For how long to wait at home in a child with common cold. Certain home remedies can depress child sensorium therefore mask disease progression. Parents might think it as improvement. Actions for care-seeking often directed by perceived grade of fever

---------

Link pneumonia with child loss/death; Link chest in-drawing as sign of delay/No further time to waste Link delay in getting treatment from ‘right doctor’ as quickly as possible with bad outcome

Some children with ‘cough/common cold’ can progress to life-threatening pneumonia. Most of them have self-limiting disease. Therefore watch for early signs of pneumonia.


Recommendations and Areas of Future Research

1. Community Awareness of pneumonia: Our study found that the community is familiar with the word pneumonia but was unable to recognize its signs and symptoms. They also were unaware of the consequence of late recognition of pneumonia. The communication tools developed in this project target these findings. Thus, there is a need of wide dissemination of messages developed through this project. Messages must percolate from caregivers to grass-root level health care providers to district hospital. All private health care providers including the village based local doctor need to be given the same messages. IEC material may be displayed in the community through Village Health Nutrition and Sanitation Committee (VHNSC). It needs to be explored further as to how NGOs can be involved to impart health education to the community. A Pneumonia information book may be developed and distributed widely across all stakeholders.

2. Strengthening the Government Public Health Services: We have learnt from our study that there exists distrust in the community of public health services. Therefore, the community resorts to seek care from unqualified health care provider, which causes further delay. Hence, there is a need to build trust of the community in the public health system through system strengthening and quality improvement. Few of the reasons for the lack of community`s trust are unavailability of the medicines as well as health care functionaries at public health facilities. Research on managing ARIs should focus on newer, innovative mechanism to strengthen services and facilities at the public health facilities and make them more responsive to the needs of the community. We found in our research that the community aspires to seek information from the ASHAs on childhood illnesses but in contrast, the ASHA workers have limited knowledge on childhood pneumonia management. They have not been trained on ARI management. The presence of ASHAs in each village must be leveraged for management of childhood pneumonia cases. Initiatives must be taken to orient the ASHAs about the barriers to health care seeking that exist in the community and ways of mitigating these. Further research can be undertaken to explore if ASHAs can play a role to provide outreach education on pneumonia to caregivers in villages.

3. Involving the RMPs in community wide pneumonia program: We found in our research that RMPs were not only the first point of contact for health care seeking but also the most trusted. We also found that these RMPs were able to judge when to treat and when to refer cases of childhood pneumonia based on “perceived severity of illness” but were unable to recognize IMNCI danger signs. Therefore, strategies to define the role of RMPs in a community wide pneumonia program needs to be explored further. Future research has to look into ways as to how the services of the RMPs can be acknowledged.


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References

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Mohan%2BP%5bauth%5d�

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Mishra%2BA%5bauth%5d�

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Gaonkar%2BN%5bauth%5d�

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Biswas%2BAB%5bauth%5d�

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Balakrishnan%2BS%5bauth%5d�

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Arya%2BG%5bauth%5d�

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=PubMed&term=%20Babille%2BM%5bauth%5d�

Project Team Members

Documents

Report on Formative Research Findings - Fight … on Formative Research Findings This report has been developed under the project entitled “Improving household decisionmaking for