Three Year Community Mobilization & Behaviour Promotion Trial in Rural U.P. & its Positive Influence on Maternal Behaviours & Infant Growth

Transcription

1 Three Year Community Mobilization & Behaviour Promotion Trial in Rural U.P. & its Positive Influence on Maternal Behaviours & Infant Growth Symposium organized by Food and Nutrition Department, Lady Irwin College & IntraHealth Inc. November 26, 2008 Vani Sethi 1, Sushma Kashyap 2, Siddharth Agarwal 1, R.M. Pandey 3, Dimple Kondal 3 1 Urban Health Resource Centre, 2 Department of Food & Nutrition, Lady Irwin College,, 3 Department of Biostatistics, All India Institute of Medical Sciences New-Delhi, India (vanisethi777@yahoo.com) 1

2 Background: 1. Positive Deviant (PD) families despite poverty rear well-nourished infants 1 2. PDs practice uncommon positive behaviours. 3. Community mobilization by PD Influencers/Advisors remains unexplored. Positive Deviants 1 Wishik and Vynckt. Am J Public Health 1976;66:

3 Research Design: 7 similarly poor matched villages in 1 ICDS block in Agra 3 neighbouring villages Intervention (I) 4 neighbouring Villages- Comparison (C) Baseline Survey (June-Nov,04) 0% EBF in 6th 48% WAZ<- 2SD (WHO,2006) Av. Population: 9,000 Govt. Health facility within 4 kms Infant <1yr UN=47.5% (I), 49.0%(C) 0% EBF in 6th 48% WAZ<-2SD (WHO,2006) (Dec 04-Feb 06) 6 mo follow-up of a birth cohort 14 mo Intervention by PD Advisors Monitoring & Evaluation Monitoring & Evaluation 3

4 1. Formation of PD Advisor groups involved 7 steps 2. Three Strategies were used by PD Advisor Groups for improving infant health 3. What were the nutrition outcomes? 4. What happened after 14 months? 4

5 Step 1: Identifying Positive Deviants (PDs) Out of 100 mothers of infants (<6 mo) Families with SLI score <25 (n=67) were categorized as poor Poor families whose infant s WAZ>-1SD NCHS median (n=25) were categorized as PDs 5

6 Step 2: Learning PD behaviours Revisit all 67 poor families Using Interview, HOME inventory, Elicitation study Socio-cultural factors Breastfeeding 1 Family Support Psychosocial care 2 Maternal self-efficacy 3 leading to PD Ref: 1 WHO Annex 2. Global Data Bank on breastfeeding. 2 Caldwell and Bradley. Home Observation for Measurement of the Environment. Little Rock, Ark, USA. University of Arkansas Press. 3 Middlestadt et al. Public Health Rep 1996; 3(1):

7 Factors Leading to PD VARIABLE SOCIOCULTURAL UNIVARIATE (p<0.05) 1. Birth order <3 BIVARIATE (ODDS RATIO) UNADJ ADJ** 2.6 ( ) 1.5 ( ) BREAST FEEDING FAMILY SUPPORT PYSCHOSOCIAL CARE SELF-EFFICACY 1. BF initiated timely 2. Avoiding prelacteals 3. BF>7times /d 1. Maternal autonomy 2. Family happy on child birth 1. Mother expresses her ideas 2. Keenness to learn 3. Baby clean and clad 4. Baby warm 1 1. High : 72% (PD) vs 30% (others) 5.8 ( ) ( ) 4.9 ( ) 3.1 ( ) 2.0( ) 7.5 ( ) 7.3 ( ) 3.7 ( ) 2.8( ) 3.0 ( ) 2.8( ) 3.8 ( ) 2.9 ( ) 3.0 ( ) 2.0 ( ) 10.5 ( ) 8.8( ) abdomen and sole warm to touch * p<0.05 chi-square/fisher s test ** Adjusted for maternal literacy and birth order 7

8 What enabled mothers practice positive behaviours self-efficaciously? 1. Grandmother advised/supported the mother. 2. Benefit centered around child and easing chores. 3. Tradition (s) favoured positive behaviour adoption. 4. Reinforcements by: government doctor/nurse/t.v. In 24 out of 25 PD families grandmothers were key influencers of positive practices - PD Advisors 8

9 Step 3: 24 PD advisors were persuasively motivated to form Village Health Groups 9

10 Step 4: Formation of Village Health Groups 21 PD advisors came forward + With Grassroot Service Providers = Formed 3 Groups Supporting Members: Gram Pradhan, PHC/CHC Doctors & Researcher Key Implementers were the 21 PD Advisors 10

11 Step 5: Each group defined group objectives & actions Group Objective: Ensure all babies are born healthy & stay healthy Group Name: Bal Gopal Seva Mandal Group action: counsel pregnant women, mothers, family members especially MILs 11

12 Step 6: For ensuring reach to all households Through social mapping each PD Advisor took charge of homes around her house (of their kin) 12

13 Step 7: Capacity Building of the 3 Groups Weekly participatory sessions Technical Interventions - Antenatal Care - Intrapartum Care - Newborn Care (BF, warmth, infection prevention) - Post neonatal Care upto 6 month - Identification of danger signs and timely referral 13

14 1. How PD Advisor groups were formed? 2. For next 12 months, using three strategies the 3 Groups worked for improving infant health 3. What were the nutrition outcomes? 4. How these groups are evolving into strong CBOs? 14

15 Strategy 1: Demand Generation 1. Early pregnancy enrollment 2. Home visitations by PD Advisors: - Bimonthly - antenatal period - Assisting TBA with home delivery 1 - Atleast 3 visits in neonatal period - Monthly visits upto 6 mo postpartum 1 If requested by the family, escort hospital delivery cases 15

16 Reinforcing Messages through.. Health film viewing Monthly immunization day Wall Paintings 2 Local level events;1 Saas-Bahu Samaelan Group meetings held once in 16 2 mo

17 Strategy 2: Ensuring reach & quality of government health services/supply 1. Community-PHC/CHC linkage fostered Doctors Involved & kept updated 2. Groups assisted ANM on monthly NHD Met for micro-planning a day prior to NHD Venue: fixed & accessible VHW s escorted & counselled beneficiaries 3. To tide over supply scarcity: Elected depot holders kept buffer stocks. Social Marketing: IFA, Condoms, Mala N & Home-based DDKs. Profits collected were used to start a health fund 2% monthly interest). 17

18 Strategy 3: Community-based Monitoring & Bimonthly Supportive Supervision 18

19 Non-Monetary Incentives, Recognition & Advocacy 19

20 Monitoring & Evaluation: Birth Cohort Follow-up Intervention Area Comparison Area 174/148 Preg. Contacted/enrolled 173/138 March-Aug 05 Deliveries Deaths Live birth cohort enrolled for 6 mo. follow-up home visits (day <48 hrs, 7,30,60,90,120,150,182) BF, Morbidity (last 30, 7,1 day (s)), Weight, Length Data Analysis: Stata (Version 9): GEE, Effect Size 20

21 1. How PD Advisor groups were formed? 2. For 12 months, using three strategies PD Advisor Groups worked for improving infant health 3. What were the nutrition outcomes? 4. How these groups are evolving into strong CBOs? 21

22 There was 53% effect size increase in initiation of BF within 1 hour of birth % infants initiated BF within 1 hr of birth In intervention phase (2005) Baseline(2004) Effect size of change = +53.3% 0 Intervention Area Comparison Area 22

23 16% intervention infants were exclusively breastfed throughout six months postpartum 100 Comparison Area (N=74) Intervention Area (N=75) % infants EBFduring the time period days 0-30 days 0-60 days 0-90 days days days days Time period 23

24 80% intervention infants were ageappropriately immunized 2.7% 80% Intervention Area Comparsion Area Complete Immunization: BCG+ 3 doses of DPT upto six mo 24

25 Comparison infants underweight was 20% higher b/w 1-3 mo & 10% higher b/w 4-6 mo % WAZ<-2SD WHO 2006 standard median Intervention Area Comparison Area mo 1mo 2mo 3mo 4mo 5mo 6mo 25 Age (completed months)

26 1. How PD Advisor groups were formed? 2. For 12 months, using three strategies PD Advisor Groups worked for improving infant health 3. What were the nutrition outcomes? 4. What happened after these 14 months? 26

27 Informal groups to CBOs Feb 06 6 months Gap from Mar-Jul 06 Aug 06 Each CBO (15 members): Incl. Adolescents, literate women, ASHA Elected leaders Made group rules Continuing 5 activities/mo 1. Group meeting (a day prior to NHD) 2. Assisting ANM during NHD 3. One group problem solving meeting 4. Assisting delivery when called 5. Interloaning through Health Fund 27

28 Each CBO has Literate Group Coordinator Conducts Home visits Antenatal: Monthly Postnatal: Day 0,7, 30, 60 Keeps records of each pregnancy upto DPT-Booster Paid an activity-linked honorarium: (Rs /mo by researcher) CBO Coordinator CBO CBO 28

29 Effect of Intervention : 2005 to 2008 First 14 mo (2005) Groups left alone (Mar-Aug 06) CBOs functional (Jan 07-Jun 08) IFA Consumption In Pregnancy (%) >60% NHD Reach (%) BF initiated within 1 hr of birth 29

30 Grandmothers, often termed as Barriers Can be Effective Facilitators of Change 30