Navjeevan (2010-2012)
Impact of promoting referral for newborns with danger signs and strengthening first referral level facilities on newborn survival – a cluster randomized trial (Department of Medical, Health and Family Welfare Services in collaboration with ARTH, WHO and UNICEF) Overview The intervention provides incentives to ASHAs for helping families in the decision to accept referral recommendations, the creation of a telephone helpline and of access to a pool of vehicles to facilitate transport to referral facilities, and providing social support during stay at hospital. In addition, first referral level facilities, i.e. Community Health Centres (CHCs), are being supported for improved management of labour, provision of essential newborn care at birth and management of sick newborns. The primary impact of the intervention will be measured in terms of reduction in newborn mortality, increased utilization of CHCs and district hospitals for newborns with severe illness. Rationale for the Project Interventions to improve newborn survival can be delivered during pregnancy, during labour and childbirth, and during the newborn period. Obstetric complications, particularly in labour, are a major source of stillbirths and early neonatal deaths. Intrapartum risk factors increase the risk of perinatal or neonatal death more than pre-pregnancy or antenatal factors. Improved delivery care, with labour surveillance for early identification of complications, such as provided by the partograph, has been associated with significant reductions in newborn mortality. Studies indicated that quality of delivery care in many health facilities do not meet the standards required for their full impact on maternal or newborn survival. While the provision of newborn care at the home and first level facilities such as primary health centres is a core child health intervention that is expected to reduce newborn mortality by over 30%, newborns that are severely ill will need to be referred to a higher level facility for care. Therefore this intervention was implemented and evaluated to understand the impact of improving access to quality referral care for newborns identified with danger signs in the community. It was conducted in settings where IMNCI had been implemented both at the community and first level facility. Key partners and their roles: The study was implemented by following key partners – Department of Medical, Health & FW services, Government of Rajasthan, ARTH Udaipur, UNICEF, Rajasthan and WHO. Their roles are mentioned below: THE STUDY Primary Objectives Secondary Objectives Intervention Clusters: Description of Activities: Please click here for a detailed report on the project.
SAMPOORNA (2011-15)
Impact Of Three Feeding Regimens On Recovery Of Children From Uncomplicated Severe Acute Malnutrition (SAM) In India A Randomized Controlled Trial (2011-15) Research Agencies: Society for Applied Studies, New Delhi, in partnership with Action Research & Training for Health (ARTH), Udaipur and Christian Medical College, Vellore Trial monitored by: Department of Biotechnology (DBT), Indian Council of Medical Research (ICMR) & Ministry of Health & FW, Government of India Technical oversight by: Department of Maternal-Child & Adolescent Health & Development, World Health Organization (WHO), Geneva Ethical oversight: Institutional Ethics Committees of participating research institutions and WHO ERC Financial Support: Bill & Melinda Gates Foundation India has the largest number of children affected by malnutrition in the world. As per the National Family Health Survey of 2005-2006, among children under the age of five. This is believed to be due to a combination of socio-economic and societal factors including poverty, food insecurity, gender inequality, disease and poor access to health and developmental services. Severe acute malnutrition is an extension of this problem and is a life threatening condition for children aged between 6-59 months. While prevention is essential to deal with the problem of malnutrition, prompt and effective management of SAM is a public health priority for preventing deaths among the affected children.The Sampoorna project is an attempt to resolve this situation. It involves comparing 3 different feeding regimen for nutritional recovery among children suffering from uncomplicated severe acute malnutrition. The emphasis is on community and home based management of uncomplicated severe acute malnutrition. Study Hypothesis: Ready to Use Therapeutic Food (RUTF) produced centrally or locally will be more effective compared to home prepared foods in achieving recovery 16 weeks after initiating treatment, among 6-59 month old children suffering from severe acute malnutrition (SAM) Objective: To evaluate the impact of 3 home-based food regimens (centrally produced RUTF, locally produced RUTF and Augmented Home Prepared Foods) on recovery of children with uncomplicated severe acute malnutrition, between 6-59 months. Primary Outcome: Recovery (weight for height at least -2 SD of mean) by 16 weeks after enrolment Secondary Outcomes: Study Sites: Urban slums in the national capital region (Delhi), Rural and tribal in southern Rajasthan (Udaipur and Rajsamand districts) Rural and urban Tamil Nadu Feeding regimens for home management of SAM: Implementation strategy: A team of trained surveyors covered each village, enumerated all children aged 6 – 59 months, and after consent measured mid upper arm circumference (MUAC). Children with MUAC below a cut-off level of 13 cm were transported to a field clinic where anthropometry (height, weight, etc) was carried out and a doctor screened for illness. Children with uncomplicated SAM are enrolled after consent in the trial, those without SAM or with complications are treated and / or referred to hospital by the physician. Enrolled SAM children received food supplies (RUTF or home foods as per random allocation) each week, and daily visits by a helper (a female neighbour) to help ensure regular feeding. Project staff also visited bi-weekly for counseling support and weekly for anthropometry. After recovery from SAM for 16 weeks (whichever is earlier), the child was linked to the nearest anganwadi for further management. During screening and enrolment, all children receive free treatment, transport and referral services. Implementation of Trial: As on 12th September 2014 a total of 287 children were enrolled. Treatment phase was completed by December 2014 while sustenance phase was completed by April 2015. Progress at the Rajasthan site (as on 31 December 2014): Villages covered 62 Households covered 18,300 Population covered 81,209 6 to 59 month old children identified 6,555 Children with arm circumference (MUAC) below 13 cm 1,378 (21.02%) Children with severe acute malnutration (SAM) identified 360 (5.49%) Total no. of SAM children enrolled 287 (79.72%)
Maternal morbidity, its burden, consequences and options for interventions in a rural area in Rajasthan (2007-2010)
ARTH is conducted a study on maternal morbidity with the following objectives: The study consisted of the following components: Study area: 49 villages in two blocks of Udaipur district and in one block of Rajsamand district covering a population of 54,000. As part of this, nearly 600 women were followed up at 6 weeks, 6 months and 12 months after delivery.
Survey of abortion services in Rajasthan (2003-04)
To work towards making safe abortion services accessible in rural areas, ARTH was part of a 6-state study on the situation analysis of abortion services. The study revealed that in Rajasthan:
Home Based Management of Young Infants (2002-09)
The Home Based Management of Young Infants (HBMYI) was a research study intended to study the effectiveness of a package of home-based interventions, delivered by a village-based worker, in reducing mortality of neonates and young infants (<60 days) in rural communities through a multi-site field trial. In Rajasthan, Rajsamand district was chosen in consultation with state and district authorities as it had neonatal mortality above 40 per 1000 births and more than 70 percent of deliveries occurred at home. A baseline study undertaken at the beginning of the study helped to assess the outcome and impact of the interventions. Teenage, first-time and illiterate mothers, and those from SC/ST and OBC communities exhibited the highest NMR in the baseline study. study was undertaken across four PHC areas of the district which followed two approaches- in two PHC areas village based female workers called shishu rakshaks (SR) were employed while in other two PHC areas anganwadi workers (AWW) have been trained to provide home-based care. The SR/AWW visited the families during pregnancy, delivery and 8 times during the first postpartum month. She educated the mother & family on newborn care and feeding, detected problems and managed or referred to them. This is carried out with extensive support from ARTH, ICDS and the health department. Over four years of the HBMYI implementation period (2004-2008), NMR decreased from 77.3 to 37.7 in the intervention area. This study demonstrated the feasibility of offering home based management of young infants from locally trained women in reducing NMR in rural/low resource settings.
Integrated Management of Childhood Illness Study (2001-03)
ARTH undertook a research study to assess whether training doctors in counseling improves care-seeking behaviour in families with sick children. The study was implemented in 12 PHC areas of Udaipur district, 6 of which were intervention areas and 6 were control areas. Doctors in intervention centres were trained in counseling, communication, and clinical skills, using the integrated management of childhood illness approach. The results of the study suggested that : The intervention site physicians reported that following training, use of local terms for danger signs and pictorial cards for demonstrating these signs helped them in communicating more effectively with the families. Sustained improvement in counselling performance would probably require, in addition to training, addressing systemic factors such as crowd management and queuing, scheduling field duties and administrative work in a manner that does not affect the time-availability for OPD.
ANM: What determines her decision to reside in the work area? (2000-01)
ARTH conducted a study to understand how ANMs in Rajasthan decide about residing within their work areas and to suggest policy and programmatic changes to encourage ANMs to reside in their work areas. A key finding was that the personal, family and security needs of ANMs deeply impact their availability on the ground, and hence their productivity and efficiency. Thus, efforts to encourage ANMs to reside in their work area should aim to enhance their ease of staying as well as enforcing accountability. The study put forth the following recommendations to encourage ANMs to reside within their work areas : The study found that the ANM takes an “economic” decision about whether or not to reside within her work area. This decision is taken after weighing the “ease of staying” and the “inconvenience of not staying” in the area. The study revealed that the ANMs were more likely to stay in their sub-centre villages if they had spent their growing years in a village, and if their sub-centre village was far from a city.
Nutritional status of pre-school children in southern Rajasthan (1999-2000)
A study was conducted in five blocks across 2 districts of southern Rajasthan to estimate the prevalence of stunting, wasting, and those underweight among rural preschool children (0-35 months) and to compare the degree of stunting among beneficiaries and non-beneficiaries of ICDS supplementary nutrition. The study found that protein malnutrition was highly prevalent among rural children aged less than three years, as evidenced by high levels of wasting (19.4%), stunting (53.8%), and underweight (53.8%). It appears that a major reason for malnutrition among children under 3 years of age is difficulty in weaning. The finding that babies born at close birth intervals of less than 3 years were stunted, underscores that malnutrition may be a consequence of high and uncontrolled fertility in the area. There was no significant difference found in the prevalence of wasting or stunting between beneficiaries and non-beneficiaries of ICDS programmes. 16.8% of children aged 6 to 35 months received supplementary food from the anganwadis, which was only 43.1% of the maximum children that could have been targeted by the programme. Children born in scheduled tribes and scheduled caste households were significantly more malnourished than those born to other castes. The further a child lived from the Anganwadi, the less likely it was to receive the food supplement. Low level of routine contact with health care providers made it less likely that early malnutrition in children could be detected and treated by such providers.
Prabal Yatra (2023 onwards)
A community-based intervention to promote healthy ageing in southern Rajasthan Background According to population projections, by 2050, the global population of older persons will double to 1.5 billion, while in India, they will increase from 8.6% to 19.5% of the population. With rapid reduction in fertility and increase in life expectancy, the proportion of older persons in the population will increase, leading to a change in the dependency ratio. There need to be systems in place to ensure that older persons remain healthy, have access to health care as needed and go through life’s journey with good quality of life. In rural-tribal areas of southern Rajasthan, awareness of and access to health care for older persons is limited. ARTH has worked on health of older persons in the region since 2018, providing access to care for chronic illness via fixed-site monthly health camps, referral to higher institutions and home care by outreach workers. Our experience reveals an evident lack of self-care and a dominant societal narrative that as people become older, they are expected to progressively decline, fall prey to illness and fight a losing battle with life. Meanwhile, the current focus of health systems is on facility-based geriatric care at regional, district and block levels, with less attention to prevention, rehabilitation or community care. We experienced the need to introduce a positive narrative within our effort to ensure that older persons enjoy a safe, healthy and dignified life and remain productive members of the community. On 1 Oct 2023, International Day of Older Persons, ARTH launched ‘Prabal Yatra’ – a community based approach to promote and enable healthy ageing among older persons in southern Rajasthan. The healthy ageing intervention is meant to facilitate timely access to clinical care as and when needed. The objectives of this intervention are: Six internal capacities are key to ensuring healthy ageing – they include mobility, nutrition, vision, mood/loneliness, hearing and cognition. In the launch phase of our intervention we will work only on the first four domains.All activities under this programme will be undertaken via the Prabal Yatra Manch – a village based platform of older persons, where all older persons of the village will connect with each other and with ARTH and any similar agency that wishes to help improve their lives or health. Prabal Yatra is being implemented in select villages of 8 rural blocks of Udaipur and Rajsamand districts of southern Rajasthan. This intervention was started in 104 villages, with a total population of around 2 lakhs, where we estimate around 14,000 older persons reside.On establishing the intervention in these villages, we have now expanded to 112 villages and plan to expand further. We also connected with political representatives and government officials in the area through the events and received an enthusiastic response, stating that this intervention had begun at the right time. Key Activities: Progress so far:
Community support groups facilitate health care of older persons (2022 onwards)
ARTH has helped create community support groups for older persons, which have been named Buzurg Milan Samooh. These are groups consisting of older persons in a specific hamlet of the village, aged 50 years and above. The thought behind creating such groups is that several older persons in rural areas face increasing loneliness and isolation as their mobility becomes restricted, families turn nuclear and resources to travel and meet decline. The group serves as a platform for them to meet and socialize, to share problems or common issues and to seek support from similar others in working out a solution. It also enables ARTH to share and better deliver preventive health care and nutrition interventions, to link older persons to its primary health care camps and clinics, and to support referral for investigations and specialised treatment in the city, should that become necessary. Each of these meetings is conducted once a month and is facilitated by ARTH’s field staff. In the 1st meeting, most people are quiet and reserved, as they are not sure what the meeting is about. Field staff present in the meeting explain to them the reason for organizing it, while also pushing them to speak and express themselves. By the 3rd meeting of the group, people express themselves a lot better and have discussions on various topics – their daily lives, how things were before when they were young, their eating habits, etc. They are also encouraged to sing songs and tell stories, the main goal being that by the end of the meeting they feel happier and socially closer to each other. By September 2023, 109 older persons’ support groups have been created in 8 blocks of southern Rajasthan and their experience is being monitored. Issues like old age and widow pensions, health problems and the availability of subsidised grain have already come up during conversations. Problems related to sustaining health, nutrition and wellness (a significant proportion of older persons are undernourished) and digital access to pensions are numerous, but a beginning has been made and older persons now have a group to belong to.