Where Ekjut Is Operational Health And Social Care Essay

During a discussion regarding home deliveries with a village Dai (Traditional Birth Attendant) in a remote tribal village of West Singhbhum district of Jharkhand; she said;

"In the earlier days deliveries used to take place in dark and unclean rooms without ventilation. Deliveries were done on mats or old clothes whichever was available at that moment. Earlier we used to assist the mother without washing our hands and used to keep the newborn a little away from the mother to avoid the newborn from taking in amniotic fluid and we cut the cord only when the placenta came out completely. We used to use roof tiles (Khapra) along with the old blade or knife to cut the cord. After separating the placenta we used to give honey and pig fat orally to the newborn and apply pig fat on whole body of the newborn and bathe the newborn with stale rice water (basi mard). We did not wrap the newborn with clothes but just let the baby lie over any cloth that was available."

Since Ekjut started organizing meetings with the community things started changing; According to the same dai; behaviors and practices started changing; she said;

"The practices are changing due to the meetings. Now, we cut our nails, remove the bangles, finger rings and wash hands with soap before helping in deliveries. Simultaneously, we advise to boil the thread and blade before use. Instead of bathing the newborn we apply mustard oil and wrap the newborn with clean and dry cloth and do not apply pig’s fat on the body of the newborn."

Background

More than 20 percent of the population of Jharkhand and Orissa belong to the scheduled tribes and 12 percent to the scheduled castes. Indigenous communities have higher mortality rates and poorer access to health services as compared to the non-indigenous population. Both maternal and neonatal mortality rates are high in these two states, and urgent efforts are needed to reduce them. As per the Sample Registration System 2009 estimates, Jharkhand’s Neonatal Mortality Rate (NMR) is 28 and the Maternal Mortality Ratio (MMR) is 261 . Orissa’s NMR is 43 and MMR is 258. The all-India figures are NMR 35, and MMR 212.

The prevalence of maternal depression is an increasing public health concern in low income countries because of its wide ranging implications for the health of the mother and infant. Delivery of appropriate interventions to prevent or treat maternal depression through health workers is a major challenge, especially in countries with under resourced health systems, despite evidence of the effectiveness of these interventions.

Neonatal mortality is also a major concern in developing countries. Participatory interventions are considered to be effective and have lasting impact. Large improvements were noted in birth outcomes in a poor rural population in Makwanpur, Nepal after a low cost, potentially sustainable and scalable participatory intervention was conducted with women’s groups. A note on the intervention is attached in Annexure A.

In India many such interventions have been carried out with women’s groups, but there is little documented evidence regarding effectiveness. However, an intervention conducted by Ekjut in Jharkhand and Orissa provides documented evidence.

Ekjut, meaning ‘coming together for a cause,’ is a non-governmental organization founded by Dr. Prasanta Tripathy and Dr. Nirmala Nair. It was founded to tackle the high levels of child deaths in the states of Jharkhand and Orissa. Ekjut, in partnership with the Institute of Child Health at University College, London, and with funding from the Health Foundation, a UK based charity, initiated a cluster randomized controlled trial to assess the impact of community mobilization through participatory women’s group on birth outcomes in poor rural communities.

Where EKJUT is Operational?

According to Dr. Prashant Tripathy, a founding member of Ekjut, "The partnering communities of Ekjut, belong to the indigenous communities (Adivasis), who live in the underserved areas of Jharkhand and Orissa. The terrains are difficult and health facilities are quite far away from where they live. Most deliveries happen at home. These communities belong to Hoe, Santhal, Juwang, Paraon and various other ethnic groups. We also work with Schedule Caste communities and people belonging to the other backward castes and the poor people living alongside them. About 73% of women who participated in Ekjut trial had not gone to school and many were asset-less and belonged to below poverty line".

Figure : Jharkhand and Orissa State Political Map highlighting the districts where Ekjut is working . Source: Maps of IndiaJharkhand (Ekjut presently works in six districts) and Orissa (Ekjut works in three districts) are two of the poorest states in eastern India. The average life expectancy among women in both states is about 60 years and around 63 percent are illiterate.

The EKJUT Model

Ekjut’s intervention model is divided into four phases. These are: (1) Identifying and prioritizing the problems; (2) finding appropriate solutions and strategies together; (3) implementing the prioritized strategies; and (4) evaluating the impact of the intervention. These four phases are interlinked. Inputs and findings from each phase help to plan and build the next one. A flow chart is given below to demonstrate how each phase works and how these phases are interlinked.

http://www.ekjutindia.org/images/womengroupcycle.gif

Figure : The Ekjut Model Cycle

According to Dr. Nirmala, founding member of Ekjut "The unique feature of the whole process or the trial has been the approach, which has been divided into 4 phases. Initially the women came together and they try to understand or identify the problems that they face in the community related to maternal and new born health. The first phase is about 5 meetings where they identify their problems and then subsequently they have another set of 5 meetings where they try to think about what strategies they need to implement to overcome their problems. The discussions in the 11th meeting onwards are about implementation of whatever strategies have been decided upon. And finally the last two meetings are about evaluation. What they have done over the last 20 months, what lessons they have learnt and what have they actually been able to implement."

The women’s groups of 15-20 members each met monthly to discuss problems related to pregnancy, childbirth and the postnatal period These meetings were led by local facilitators trained in participatory communication methods; they were not health educators but received basic training to discuss health problems during pregnancy and childbirth. Women’s groups were also involved in savings and credit activities earlier.

PHASE 1 - Discussions around identifying and prioritizing problems

A series of interactions happened at the monthly meetings; the facilitators from Ekjut took the women’s group through a ‘5 meeting Participatory Learning & Action Cycle’ process. Facilitators, who were all women, encouraged the community women to discuss maternal and newborn problems using visual aids like picture cards, and at the end of the five meetings they were able to prioritize their problems.

The aim/purpose of these meetings being as stated below:

MEETING

AIM/ PURPOSE

Meeting 1

Introduce the project and the women’s group cycle

Meeting 2

Explore local practices and beliefs linked to pregnancy, childbirth and motherhood

Meeting 3

Identify maternal problems in the community

Meeting 4

Identify newborn health problems

Meeting 5

Prioritize the maternal and newborn problems the group wants to focus on

PHASE 2 – Plan Strategies

After prioritizing the problems in Phase 1, in the subsequent meetings the women’s group discussed appropriate strategies and solutions to be implemented for the identified problems. This phase was very important as it encouraged the community to think about possible solutions for their own problems. In this phase story-telling, games like the’bridge game’, role plays were performed so that the women gained a critical understanding of the specific issues.

A total of five meetings were held with these women’s groups in the second phase, the aim/purpose of these being as stated below:

MEETING

AIM/ PURPOSE

Meeting 6

Discuss causes and solutions to local maternal and newborn health problems through story-telling

Meeting 7

Identify strategies arising out of the solutions and understand opportunities and barriers before prioritizing them using the ‘bridge game’

Meeting 8

Discuss the process of sharing information on problems and strategies with the community

Meeting 9

Prepare a community meeting

COMMUNITY MEETING

At the culmination of the nine meetings, a community meeting was held to inform the larger community about how the women had arrived at the solution over the last nine months and decided on the possible strategies and to seek necessary support from the wider community.

PHASE 3 – Implement Strategies

In this phase identified strategies were implemented using participatory learning and action cycle of meetings with the women’s groups. Materials for individual meetings such as participatory games and strategies were included. Here the group members undertook responsibilities either individually or as a group to ensure that the prioritized strategies were implemented and they also tracked the progress of the work. Information about clean delivery practices and care-seeking behavior was shared through stories and games, rather than presented as key messages. They also discussed issues like inadequate care, unhealthy household environment, household food insecurity etc.

A total 10 meetings were held with women’s groups in the implementation phase, the aim/purpose of these being as stated below:

MEETING

AIM/ PURPOSE

PHASE 3 : IMPLEMENT STRATEGIES

Meeting 10

Discuss the implementation of strategies and undertaking responsibilities for implementation

Meeting 11

Review the progress of strategy implementation

Meeting 12

Discuss how maternal problems can be prevented

Meeting 13

Discuss how newborn problems can be prevented

Meeting 14

Discuss the home care solutions for selected problems

Meeting 15

Discuss facility-based care for selected problems

Meeting 16

Identify which problems are emergencies, prepare the group for emergencies and discuss ways of addressing delays in care-seeking

Meeting 17

Identify emergency and non-emergency problems, appropriate responses and referrals

Meeting 18

Learn about the activities of other groups and prepare for a cluster-level community meeting

CLUSTER-LEVEL COMMUNITY MEETING

PHASE 4 – Assess Impact:

Two meetings were organized with the women’s groups during this phase. In these meetings the group members discussed their achievements.

PHASE 4 : ASSESS IMPACT

Meeting 19

Review the cluster community meeting, discuss the activities and achievements of the group and evaluate each phase of the cycle

Meeting 20

Discuss possible behavioral changes linked to the intervention that occurred in the wider community

The Women’s group members towards the end of the cycle evaluated their performance regarding the meetings they liked the best and what they found useful, what impact the intervention had on the members themselves and also on the non-members/non-attenders/men and the larger community. They also explored what changes in key practices they had seen over the 2 years of the intervention and the support they had received from the family/community.

The use of a structured and phase-wise content in the meeting cycle and the emphasis on collective problem solving contributed to learning and confidence building. This appears to have been a key determinant of the intervention’s efficacy and acceptability. Local acceptability of the intervention, a participatory approach and community involvement are the key factors of the model. Acceptability was enhanced due to the deployment of local facilitators, use of appropriate discussion materials while keeping visual literacy in mind, and flexibility in the timing and content of meetings. Three additional features of the intervention, built on the participatory principles inherent to the women’s group intervention, were unique to the trial - involvement of the wider community, including local community health workers, and the active targeting of marginalized groups and pregnant women. Involvement of the wider community meant that the existing groups which were closed because they dealt with micro-credit activities, became open to all community members with the addition of the participatory cycle. Second, group members shared their problems and strategies with the wider community during village and cluster level meetings. Third, community members including men offered support in the implementation of the groups’ strategies.

COMMUNITY MOBILIZATION

SURVEILLANCE SYSTEM

FACILITATORS

IDENTIFIERS

MONITORS

NO COMMUNICATION

(To ensure there are no biases)

Surveillance of community mobilization activities

In order to implement this model a strong workforce was put in place by Ekjut. The following framework is a snapshot of this:

Facilitators were selected after holding discussions with opinion leaders, elders, headmen and women. Preference was given to local, literate married women, preferably a daughter-in-law, from selected villages.

They were trained in two phases lasting for five and two days at an interval of six months. Production and iterative adaptation of locally appropriate picture cards, stories and games increased acceptability and catalyzed learning and planning within groups.

Three to four Identifiers were selected for each cluster (one for 250 Households); they were selected from the same pool (Trained Birth Attendants [TBAs], family members of TBAs, men). Education was not a precondition for their selection. Identifiers received a one day formal training on recruitment. They identified births in their cluster and reported to monitors two to three times a month.

From this same pool again, some women were selected as Monitors. For selection as monitor one criterion was having around 10 years of schooling; and another criterion was having a bicycle for mobility. Monitors arranged appointments with the mother/family member to gather information within 42- 45 days, for live births. In cases of a still birth/neonatal death/maternal death there was flexibility in the appointment schedule.

Monitors received four days of training on recruitment. Their performance was reviewed on a weekly basis. They also received one refresher training and postnatal depression training, besides on-the-job training.

Note: Surveys should always be done by the people not involved in the Intervention EKJUT – No communication between Facilitators and Monitors to avoid biases during information gatheringThe Surveillance System

Randomized controlled trials are considered the most rigorous method to evaluate the impact of complex interventions. attention must be given to the contextual and process factors that affect the efficacy of such interventions in order to determine how results might be replicated in non-trial settings [i] . Community mobilization interventions raise specific evaluation challenges because their development, implementation and success involve a range of actors, activities and processes, often over prolonged periods of time [ii] .

In the community mobilization intervention of the Ekjut model, three contiguous districts of Jharkhand and Orissa—Saraikela Kharswan, West Singhbhum, and Keonjhar - were selected. The proportion of Adivasis (Tribals) within the study clusters was 58 to 70 percent. Twelve rural clusters per district were identified, with a mean population of 6,338 per cluster. The estimated population in these 36 clusters was 228,186 (2001 Indian census projections).

Figure : The Surveillance System Model – RCT. Note on Pradan

Cluster Selection - Under the Ekjut trial the selection of clusters had its own significance. It was very important to select the cluster in a scientific manner with defined criteria. The following criteria were used to select a cluster:

8 -10 villages per cluster

Cluster population= 5000-7000

High proportion of tribal (> 50%)

Preferably with existing SHG groups

Buffer zones in-between all clusters

Physically and functionally remote from health services

All the 36 cluster villages benefitted from the health service strengthening interventions [1] . However, the women’s group intervention took place in only half of the clusters. A system was put in place in which every mother who delivered was identified and they were interviewed by the monitors after 42 days of their delivery. A detailed questionnaire was filled in by the monitors and input into a database for analysis at a later date. In all 36 clusters all the births and deaths were identified by the key informants - identifiers. These key informants were responsible for around 250 households and they assisted the respective monitors. A monitor visited the mother’s house and confirmed the birth or death before conducting the interview. Monitors collected information regarding the birth/still birth/neonatal death (0-28 days)/ maternal death/woman’s death.

Ekjut also formed health committees in all intervention and control clusters so that community members would have the opportunity to express their opinions about the design and management of local health services.

Monitoring and Surveillance process

A 10 step process was followed under the surveillance system. Following is a description of each step.

STEP 1: All births identified by identifiers and reported to the monitor

STEP 2: Monitor confirms the event, pays a token remuneration to the identifier and arranges an appointment

STEP 3: Monitor reports to the supervisor on a weekly basis

STEP 4: Monitor interviews the family members; supervisors are present in 10% interviews to perform quality check

STEP 5: Monitor submits the completed questionnaire on a weekly basis and the supervisor rechecks the questionnaires. (Clarifications are sought and questionnaires re-sent to field if necessary)

STEP 6: Supervisors fill the district level register formats

STEP 7: Questionnaire submitted for data entry

STEP 8: Data entry done by the three data entry operators

STEP 9: Data cleaning and analysis

STEP 10: Dissemination of results

Impact / Findings

Impact on Morality Figures

Baseline

Year 1+

Year 2+

Year 3+

Intervention

Control

Intervention

Control

Intervention

Control

Intervention

Control

Births

2457

2235

3171

3052

3404

3135

3195

3073

Still births

109

73

98

92

118

100

85

88

Maternal deaths

16

7

20

30

22

18

7

12

Stillbirth rate per 1000 births

44.4

32.7

30.9

30.1

34.7

31.9

26.6

28.6

Neonatal mortality rate per 1000 live births

61.8

53.6

55.6

53.4

37.1

59.6

36.3

64.3

Perinatal mortality rate per 1000 births

85.1

68.4

67.4

65.2

57.0

75.0

47.5

73.5

Maternal Mortality Ratio per 100000 live births

681.7

323.8

650.8

1013.5

669.5

593.0

225.1

402.0

Data are unadjusted. *Excluding migrated mothers and infants. †Including migrated mothers and infants.

Table 16.1: Impact and Findings: Published in Lancet Article Vol 375 April 3, 2010 pg 1190 - "Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster randomized controlled trial

Assessment of the impact noted a 32 percent reduction in NMR during the three year trial, after adjusting for clustering, stratification and baseline differences. MMR was also lower in the intervention than in the control clusters.

Qualitative evidence from the study of the trial’s process showed that community mobilization through women’s groups might have contributed to avoidance of maternal deaths, though the study was not powered to detect differences in maternal mortality. No significant differences were noted in health care seeking behavior between control and intervention clusters. However, home care practices showed substantial improvements. Improved hygiene and care practices were the most likely mechanism of mortality reduction. The most striking reduction in mortality rate was noted in early neonatal deaths.

Changes in Care

Intervention clusters

Control clusters

Births

9468

8867

Any antenatal care

74%

75%

≥3 antenatal care visits

32%

41%

Institutional deliveries

14%

20%

Birth attended by formal provider (doctor or nurse)

16%

23%

Home deliveries

8084

7034

Birth attended by traditional birth attendant

33%

38%

Birth attendant washed hands with soap

41%

23%

Safe-delivery kit used

32%

18%

Plastic sheet used

26%

8%

Cord tied with boiled thread

32%

11%

Cord cut with new or boiled blade

83%

79%

Live births (home deliveries)

7890

6873

Cord undressed or dressed with antiseptic

84%

89%

Infant wrapped within 30 min

36%

43%

Infant not bathed in first 24 h

27%

22%

Infants alive at 1 month

8807

8119

Any of three infant illnesses (cough, fever, diarrhea)

20%

29%

Care-seeking behavior in event of infant illness

54%

44%

Exclusive breastfeeding for first 6 weeks

80%

69%

Data are number (%), unless otherwise indicated. *Adjusted for clustering and stratification only. †Adjusted for clustering, stratification, maternal education, assets, and any tribal affiliation. ‡Excludes births to migrated mothers and twins. §Denominators are number of infants with any of three infant illnesses: 1739 for intervention clusters and 2388 for control clusters.

Table 16.2: Impact and Findings: Published in Lancet Article Vol 375 April 3, 2010 pg 1190 - "Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster randomized controlled trial

Although there was no significant effect on maternal depression, reduction in moderate depression was 57 percent in the third year. It has been hypothesized that the large reduction in moderate depression seen in the third year could have occurred through improvements in social support and problem solving skills of the groups. Adequate social support reduces the risk of depression during pregnancy and is an important social determinant of mental health. Group meetings also strengthened problem solving skills, a component of psychotherapeutic interventions that has been shown to affect depression in other settings.

Mental Health

Year 2

Year 3

Intervention

Control

Intervention

Control

Mothers (n)

3332

3016

3120

2963

No or mild depression (10-15)

88%

87%

95%

90%

Moderate Depression (16-30)

11%

13%

5%

10%

Severe Depression (31-50)

<1%

<1%

<1%

<1%

Source: Endnote [iii] 

Table 16.3: Impact and Findings: Published in Lancet Article Vol 375 April 3, 2010 pg 1190 - "Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster randomized controlled trial

The acceptability was evident from the high population coverage. In the Ekjut trial, the coverage of women’s groups was one group per 468 population, highest among other comparable trials (1:756 in Makwanpur, 1:1414 in Bangladesh).

Challenges and Learning’s

The team initially experienced difficulties in building a rapport with marginalized tribal communities and dealing with expectations of financial gains. Facilitators had to contend with dominant group members and cancellations during festivals and cultivation periods. They had to deal with the presence of men during sensitive discussions. They also had to ensure participation during internal conflicts within villages. Group members were sometimes constrained by in-laws and TBAs in the implementation of strategies, as some felt that the contents went against traditional beliefs and practices.

Improvement in care seeking was slower; marginalized groups, tribal communities and more so the poorest among them, had difficulty in accessing services. The remoteness of the villages, poor access to transport and bad road conditions compounded these communities’ social isolation.

Scaling Up

After the successful demonstration the model has been tried in other parts of the country, recently in Madhya Pradesh. Ekjut started the operation of the model in these places.

Credibility of the model: This model is based on sound evidence. The trial was registered as an International Standard Randomized Controlled Trial. The results have been published in Lancet and BMC International Health and Human Rights. The trial has been recognized as Trial of the Year by the Society for Clinical Trials. This award is given annually to the clinical trial that best embodies the following aspects:

 It improves the lot of mankind. 

 It provides the basis for a substantial, beneficial change in health care. 

 It reflects expertise in subject matter, excellence in methodology, and concern for study participants. 

 It overcomes obstacles in implementation. 

 The presentation of its design, execution, and results is a model of clarity and intellectual soundness. 

The model has been successfully implemented in rural tribal settings in underdeveloped districts. The impact is tangible and clearly associated with the intervention.

Relevance: The model is relevant in the national context. Reducing the high neonatal mortality rate is a priority, and government is actively looking for solutions. It is hypothesized that the Ekjut intervention was successful because the interventions were operationalized with local adaptations and the intervention had adequate population coverage. Scaling up this community mobilization intervention will require detailed understanding of the way in which changing contexts, delivery mechanisms and implementation styles will affect key characteristics of the intervention.

Scalability: The model is effective in reducing NMR. The intervention requires a training and support structure to mange facilitators in charge of 12-14 groups per month, with every group responsible for a population of about 500 and for recruiting up to half of newly pregnant women. Scaling up this community based intervention will require a detailed understanding of the way in which changing contexts, delivery mechanisms and implementation styles will affect key characteristics of the intervention. The researchers estimated that the additional cost of introducing support to these groups per newborn life saved was around $910. Whether the central or state governments, non-governmental organizations or a combination of the two would pay for supporting these groups is still a question.

Annexure A: Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: Cluster-Randomized controlled trial [iv] 

Neonatal deaths in developing countries account for the largest contribution to global mortality in children younger than five years. Ninety percent of deliveries in the poorest quintile of households happen at home. It has been postulated that a community based participatory intervention could significantly reduce the neonatal mortality rate.

The intervention pair-matched 42 geopolitical clusters in Makwanpur district, Nepal, selected 12 pairs randomly and randomly assigned one of each pair to intervention or control. In each intervention cluster (average population 7,000); a female facilitator convened nine women’s group meetings every month. The facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them. They also monitored birth outcomes in a cohort of 28,931 women, of whom eight percent joined the groups. The primary outcome to measure was the neonatal mortality rate. Other outcomes included stillbirths and maternal deaths, uptake of antenatal and delivery services, home care practices, infant morbidity, and health-care seeking behavior.

As per the findings from 2001 to 2003, the neonatal mortality rate was 26·2 per 1,000 (76 deaths per 2,899 live births) in the intervention clusters compared with 36·9 per 1,000 (119 deaths per 3,226 live births) in the control clusters. Stillbirth rates were similar in both groups. The maternal mortality ratio was 69 per 100,000 (two deaths per 2,899 live births) in the intervention clusters compared with 341 per 100,000 (11 deaths per 3,226 live births) in the control clusters. Women in intervention clusters were more likely to have antenatal care, institutional delivery, trained birth attendance, and hygienic care than those in the control clusters.

It can be concluded that birth outcomes in a poor rural population improved greatly through a low cost, potentially sustainable and scalable, participatory intervention with women’s groups.