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Community Based Response to Adverse Sex Ratio in district Alwar Rajasthan

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Background

The census data from 2001 revealed a concerning decline in the sex ratio in India, particularly in the age group of 0-6 years, dropping from 945 females per 1000 males in 1991 to 927 in 2001. This imbalance was particularly evident in states like Punjab, Haryana, Rajasthan, Gujarat, and Maharashtra. The data indicated an increasing trend in the relative mortality of girls after birth and gender imbalance in most states. Rajasthan, despite an overall improvement in sex ratio, experienced a continuous decline in the 0-6 age group from 954 in 1981 to 909 in 2001.

Sex ratio imbalance is seen as a result of both higher mortality rates for girls after birth and an increase in sex-selective abortions, reflecting underlying socio-economic and cultural practices. To address this issue, the Dignity of Girl Child (DGC) Program supported research and interventions in Rajasthan, impacting government administration, Community Based Organizations (CBOs), and mobilizing communities to enhance the dignity of girls in the state. Organizations were supported to strengthen grassroots and official responses against sex selection through sensitization and training on implementing the PC PNDT Act (Pre-Conception and Pre-Natal Diagnostics Technique Act).

Background

Cervical cancer is the second most leading cause of cancer deaths in India, which mostly occurs in women of the age of 35 years and above. To eliminate cervical cancer by 2030, WHO proposed a global strategy which says that 90% of girls must be fully vaccinated with HPV vaccine by the age of 15 years; 70% of women must be screened with a high-performance test by 35 years of age and again by 45 years of age; and 90% of women identified with cervical disease must receive treatment.

The disease is preventable through vaccination and screening. However, in India, HPV vaccination is yet to be included in National Immunization Programme (NIP). The availability of this vaccination is limited to private health facilities. Moreover, as per National Family Health Survey India (NFHS, 2019-20), only 3.1% eligible women have undergone screening.

To understand the reason for this gap, SWACH undertook a study in the form of an APW, (PO Number 2027553424) supported by WHO, SEAR. The study aimed to explore the current awareness level of cervical cancer amongst the various community stakeholders.

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Methodology

Review of situation of cervical cancer in different states of the country was undertaken to assess the progress of work and plans for elimination. On the basis of the literature reviewed it was concluded that there is a paucity of data on the knowledge and awareness of the community as well as the health care providers regarding cervical cancer.

Four knowledge and awareness screening assessment tools were developed to assess the knowledge and awareness of the community, teachers, the health care providers and the readiness of health facilities. These tools are:

I) A tool to assess the willingness of community (women of age above 35 years) to participate in prevention program.

II) A tool to assess the readiness of school to participate in prevention program.

III) A tool to assess the readiness of the health facilities to provide services such as diagnostic and treatment facility and facilities to participate in vaccination program.

IV) A tool to assess the knowledge and competence of the providers to participate in cervical cancer elimination program.

These tools helped to address the readiness of community, school, facility and health care providers to participate in the national cervical cancer elimination programme. The focus of these tools was on current knowledge, practices, attitudes towards vaccination, early recognition and prompt treatment amongst the clients and the providers. The focus of the study was on the basic health care providers.

The tools were pretested on a sample collected from the four groups, namely the community including women more than 35 years of age, teachers, health care facilities and the health care providers. The pre-testing of the tools helped to refine the tools.

Consent was obtained and the targeted groups were interviewed after briefing them about the purpose of the study. It was ensured that the respondent is able to understand the question. The responses were noted down by the investigator. The collected data was entered in MS excel sheet and was analysed.

The results showed that women from the community were aware of the local term used for cervix. They were not aware about the underlying causes; and the specific signs and symptoms associated with cancer cervix. Most of the respondents were not aware of vaccination to prevent cervical cancer. The awareness and knowledge of the community regarding cervical cancer was not satisfactory.

The teachers were also not aware of the symptoms as well as the mode of transmission of HPV virus. Only a few knew that a vaccine is available for cancer cervix but they did not know the name of the vaccine, the age requirements and dose of vaccination. The teachers were however, willing to participate in a vaccination drive if there is a government directive.

Though the private facilities provided various services like PAP smear test, visual examination by acetic acid, colposcopy, biopsy, etc. However, these services were not available in any of the basic health care facilities.

Professional Health care providers working in the field of medicine were aware about the specific cause as well as the signs and symptoms of cervical cancer but the basic health care providers were neither aware of the cause nor the signs and symptoms of the disease. The professional health care providers were aware that some vaccine to prevent cancer cervix is available but none of the basic health care providers knew the details of the vaccine.

The study suggested that awareness needs to be developed amongst the community and the basic health care providers. To generate awareness, a package is required and effective means of rolling it out in the targeted population needs to be assessed.

The awareness package covering important aspects of cervical cancer related to its elimination was developed in simple, easy to understand language. The package was prepared in Hindi and English.

Assessment of awareness and care provision in abortion

Globally unsafe abortion is one of the major preventable causes for maternal deaths. Laws protecting women’s health and rights are important for decreasing the number of women undergoing unsafe abortion. In SEAR, India and Nepal has most liberal abortion laws. The quality of available services, clinical skills of the service providers, timely records, standardized reporting mechanism, use of records/ reports in decision making, and availability of services have to be tracked and researched. There is a need to find out both supply and demand side factors which is affecting the accessibility, availability and use of existing services.

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SEARO, WHO has developed a tool which has two parts;

• The first part is to understand the demand side factors like capturing women’s knowledge on abortion laws in the country, the services availability, their utilization and existing social norms and support.
• The second part is a service provision tool to capture the type of available abortion services, post abortion care and family planning including complications management.

To pilot the “Guide to Community based Health Workers and Booklet for the Community to support Individuals’ Self Care on Safe-abortion, Post-abortion Care and Contraception

The study was an extension of the project of developing the Illustrated guide and Pictorial booklet on Safe abortion with the aim to pilot the two documents before adoption by member countries of South East Asia Region of WHO, It was conducted between 16.10.2023 to 31.12.2023 with the funding from WHO and had the following

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Specific Objectives

• To translate the ‘Illustrated Guide for Community based Health Workers’ and the ‘Pictorial booklet for women in the community’ for promoting self-care on Safe abortion, Post-abortion care and Contraception into ‘Hindi’.
• To train Community based Health Workers on the contents and usage of the ‘Illustrated guide’ and ‘Pictorial booklet’.
• To pilot the ‘Illustrated guide’ and the ‘Pictorial booklet’ on self-care in the community and determine the change in knowledge levels of the participants.

The study area was conducted in two rural districts of the state of Haryana, north India with the following methodology

• Both the documents were translated into the native language of the study area which was Hindi.
• After translation, 10 hard copies of the Illustrated Guide and 60 hard copies of the Pictorial Booklet were generated for piloting in the field.
• 10 Community based Health Workers were identified from the study area with the help of field staff at SWACH.
• A training programme was then organized in the premises of SWACH Foundation at Panchkula wherein information was provided on the contents and usage of the Illustrated guide and Pictorial booklet to the Community based Health Workers.

Community based Research on understanding of male reproductive health and feasibility of specific interventions

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Background

Reproductive and child health (RCH) has received increasing attention in India. The MCH and family planning program were consolidated into child survival and safe motherhood program. A major deficiency in these programs is the relative inattention to male involvement. This is now being increasingly discussed. With the rising rates of sexually transmitted infections (STIs) and increasing threat from HIV/AIDS epidemic it is being increasingly realized that marginalization of men will be harmful to the health of the women as well. Meaningful involvement of men in reproductive and child health requires a deep understanding of sexuality, male sexual behaviour and their determinants like alcohol, drug addiction etc. In addition, understanding of perceptions regarding sexual health problems in males and their care seeking pattern when sick are important in shaping the policy towards male involvement in reproductive health. Keeping these points in mind, a study was conducted with the following objectives

Objectives

• To determine men's perceptions and understanding of their own and their partner's reproductive physiology and sexuality.
• To understand men's pattern of marital and non- marital sexual behavior.
• To assess men's health care seeking with respect to sexual and reproductive behavior.
• To investigate popular health care providers practices in the management of men's reproductive and sexual health problems.
• To improve the treatment practices and prevention advice given by the popular health care providers in dealing with the problems relating to men's reproductive health.
• To strengthen the capacity of the popular health care providers in tackling
• Common concerns and behavioral reproductive health problems of men through interpersonal communication.
• To create awareness in the community regarding male reproductive health problems
• To enable the use of appropriate preventive and health care seeking behaviour.

Quintuply‑fortified salt for the improvement of micronutrient status among women of reproductive age and preschool‑aged children in Punjab, India: protocol for a randomized, controlled, community‑based trial

The burden of iron, zinc, vitamin B12, and folate deficiencies among women of reproductive age (WRA) in India is high. India’s 2016–2018 Comprehensive National Nutrition Survey (CNNS) found that while 31% of adolescents were deficient in zinc nationwide; in Punjab, this prevalence was 52%. Micronutrient deficiencies during the preconception and antenatal period increase the risk of adverse pregnancy and birth outcomes. Zinc is essential for immune health, reproductive function, growth, and development, and its deficiency during pregnancy has been associated with an increased risk of preterm birth. Vitamin B12 and folate are essential for DNA synthesis and neurological development, and deficiencies increase the risk of miscarriage and congenital abnormalities, including neural tube defects. Large-scale food fortification (LSFF) is an effective, low-cost, and safe strategy to address micronutrient deficiencies at the population level. Among the food vehicle options available in resource-poor settings, salt is considered effective because it is relatively inexpensive, consumed in fairly consistent amounts across population

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Methodology

• The study protocol was approved by the Institutional Review Board, University of California San Francisco, Institutional Ethics Committee, Post Graduate Institute of Medical Education and Research, and Health Ministry’s Screening Committee (HMSC) of India.
• A formative cross-sectional study among NPWRA in Mohali district, Punjab, (December 2020 and February 2021) was conducted to assess: (1) the prevalence of inadequate micronutrient intake and micronutrient deficiencies, (2) average discretionary salt intake, and (3) the optimal levels of micronutrients to be added to the MFS. The current paper reports the results of these formative assessments, which informed the design of the MFS trial.
• Potentially eligible participants were NPWRA (18–49 years) living in the district. A census of all households (n = 2974) was carried out in a subset of 11 villages. Households that did not have a WRA and did not plan to stay in the area for at least one month were excluded from the sampling frame, reducing the number of potentially eligible households to 2614.
• On the screening day, potential study participants were excluded from the study if they (1) had experienced nausea or vomiting in the past three days (symptoms of early pregnancy), (2) had a hemoglobin concentration less than 8 g/dL as measured from a finger prick blood sample using the Hemocue® Hb 301 system (Angelholm, Sweden), (3) planned to leave the study area for one month or more in the next 12 months, (4) had any medical condition that required regular visits to a health facility or (5) did not use refined salt as the primary source of household discretionary salt.
• After screening, eligible NPWRA interested in participating in the study provided informed consent, including assent to undertake anthropometric assessments in their children under five years, and were enrolled in the study.
• Data were collected on household socio-demographic characteristics, salt procurement and utilization practices, and household food security after enrolment. Dietary intake was assessed in the home of all participants. One-day in-home weighed food records were collected from all 100 NPWRA participants and repeated on a non-consecutive day approximately one week later among a sub-sample of 40 NPWRA.
• On the dietary assessment day, for each food or beverage item, including discretionary salt and water consumed by the participant, the time, place, amount consumed, and the amount left over were recorded by field research assistants on paper forms.
• Detailed recipes of mixed dishes consumed by participants prepared during the dietary assessment period were collected in real-time. For any left-over mixed dishes prepared the previous day, the recipe was recalled or estimated using raw ingredients (including water) to represent the final dish.
• Women were asked to appear for the biochemical and anthropometric assessment in a fasted state (no food or beverages apart from water consumed within the past 8 h) between 6.30 am to 10.30 am at a central location in the village.
• All samples were placed in electronic portable coolers maintained at 4 _C and transported to the field laboratory for processing.
• Morning spot urine samples (50 mL) were collected from each participant woman at home and transported to the field laboratory for processing.
• A team of two trained individuals completed the anthropometric assessments of participant women and their children under five years of age following standard procedures.
• Processing and Analysis of Biological Specimens were done.
• To demonstrate the potential effect of salt fortification on inadequate and excessive intake in the current sample, a two-step model simulation referred to as the “shrink then add” approach was used. The first simulation step involved modeling the effect of the four nutrients consumed from the usual diet only. The second step modeled the effect of the four micronutrients from food sources plus the anticipated amount of each micronutrient that the MFS would contribute based on the estimated intake of discretionary salt obtained from the weighed food records.
• The prevalence estimates of inadequate and excessive intake were reported for each simulation to demonstrate how much the intake of the MFS will potentially affect the baseline prevalence estimates of inadequate intake.
• The MFS premix was manufactured before the modeling activity was conducted. Therefore, it was only possible to adjust the micronutrient content of the MFS by varying the premix: salt blending ratio. Our approach was to ensure that the simulated prevalence of excessive intake did not exceed >5% for any micronutrient.
• Given the micronutrient content of the women’s usual diet, iron was the key micronutrient that drove these analyses. The levels of iron in the MFS premix: salt blending ratio were varied from the maximum possible level (2.5 mg/g of salt) and in decreasing amounts to determine the fortification level that ensured the prevalence of excessive iron intake did not exceed 5%.
• The fortification level for iron dictated the corresponding fortification levels of zinc, vitamin B12, and folic acid.

Whereas most women enjoy healthy experience of pregnancy and childbirth, a proportion of women may experience complicated or high risk pregnancies (HRP). These HRP Conditions can occur anytime during the whole course of the pregnancy and childbirth and can contribute to deaths and adverse outcomes. A project entitled “Improving the management of high risk pregnant women in a district in Haryana, India” was undertaken in district Ambala with support from state National Health Mission and World Health Organization. The goal was timely recognition, appropriate referral, completion of appropriate treatment and resolution of high risk pregnancy to reduce adverse foeto-maternal outcomes.

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Objectives of the project were

• Identification of appropriate pathways in management of selected high risk conditions in pregnancy that contribute to adverse foeto-maternal outcomes.
• Recognition of modifiable barriers to implementation and how to overcome these barriers.
• Assessment of district hospital for their readiness to provide appropriate services to the patients referred.
• Appropriate management of high risk pregnant women through iterative engagement of NHM and district health system.

Capacity Development And Covergence Of Village Committes (Clean Pads)

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Background

Practice of using homemade pads during menstruation is quite widespread in rural and urban slum areas of Haryana. Home-made pads are made from old clothes or rags that are available in households. These are generally not clean. A project supported by Department of Rural Development Government of Haryana was started to bring out a change in the existing practice of discontinuation of the homemade pads and use of clean pads. The access to clean pads available in market as sanitary pads is limited in the urban slums. Locally assembled clean pads may help to increase their access. In order to promote women empowerment, and narrow the gender imbalances, it was proposed by SWACH to bring about convergence amongst different committees established at the village level (village panchayat, health and sanitation committee, sakshar mahila samuh etc.) and interested people in the villages and urban slums to promote the adoption and use of clean pads during menstruation. This would contribute to better hygiene, reduction of HIV/AIDS, STI and RTIs, and women empowerment by reducing the absenteeism at school and at work resulting from menstruation. The adoption of this practice would also serve as an entry point for building the life skills of female adolescents.

Methodology

• An advocacy kit was developed that comprised of definition of menstruation, its importance, and current practices relating to menstruation in the rural area, the implications of the use of home-made pads, clean pads and sanitary pads that are sold in the market. It includes a description of the correct use and safe disposal of the used pads. The kit also provides a broad guidance on the promotion of use of clean pads in the villages and urban slums. Guidance is also provided on the possible role that different members in the community can play to promote the use of clean pads/sanitary pads. The advocacy kit was developed to seek the support and cooperation of state and district level officers of various departments i.e. health, rural development, education, social welfare, women and child development etc. for the promotion of clean pads and to enlist their support. The kit was used during the district level orientation meetings and subsequent meetings with individual officers and functionaries at different levels.
• Development of training package for self-help groups (SHGs): An SHG training package was developed comprising of the chapters: Importance of use of clean pads during menstruation, Role of SHGs in promotion and use of clean pads, assembly of clean pads, Demand creation by involving key persons and institutions that come in contact with women and adolescents, Identification of key distributors in the villages.
• As a part of the training package for publicity and advocacy, a flyer was developed. This contained a comparison between home-made pads and clean pads, the description about correct use of clean pads and safe disposal of used pads.
• Prior to district orientation meetings efforts were made by SWACH to prepare a training package. The component of the training package relating to assembly of clean pads from cotton and gauze as well as the details of procurement of raw materials, maintaining stocks etc. had to be dropped since the strategy of clean pads produced from cotton and gauze was discontinued.
• The first district level meeting was held at Gymkhana club Kurukshetra on 24.6.08. It was emphasized that the proposed clean pad project should be an integral part of the total sanitation program currently being implemented the district. It was decided that the proposed project would be initiated in those villages where there is a demand and the SHG is interested to take up this challenging job. Depending on the success the effort will be expanded. During the discussions, the Interest of the different groups was assessed and the most enthusiastic participants were selected. Keeping in mind the logistic difficulties it was decided to choose area where the interest was maximal and the distances to be covered are manageable given the limitations of staff to train and supervise the SHGs. The program could be scaled up based on initial experience.
• The second district level orientation meeting was held in Yamunanagar district. There were 103 participants in the meeting. Eight ladies were trained to prepare pads from cotton and gauze. This demonstration was given to the participants (including officials) in groups. Discussions were also held with the officials of the various departments, federation members of SHGs SMS etc. It was considered that instead of making pads from cotton and gauze efforts should be made to procure a machine and the required raw materials to produce a quality product that was environmentally appropriate. Advocacy materials developed by SWACH were distributed.
• The orientation meeting in district Ambala was conducted on 1.9.08. There were 52 participants including the key officials of various line departments, federation members of the SHGs SMS etc. The main issues discussed were (a) the product should be market competitive (b) the proposed clean pads should be distributed free of cost.
• After ensuring the feasibility of procuring the machine and the raw materials required for producing clean pads a decision was made to procure the machine and start the production of clean pads by the use of this technology. A communication was made to all the concerned ADCs in Ambala division regarding the inauguration of the installation of the machine and a demonstration on how to produce clean pads by the use of this machine.