This article is the result of findings of Lot Quality Assurance Sampling that present and compares the findings of Public Health status indicators of Morang district over 2004 and 2006. Surveys’ findings are also been compared with data that come from Health Management Information System. This study aimed to see the trend of status of coverage of public health services in the district.

Nawaraj Subba¹ and Gagan Gurung²

Corresponding author: [1]Nawaraj Subba, District Public Health Office, Morang, Nepal; email: nrsubba@hotmail.com, website: www.subba.co.nr and 2Gagan Gurung SCF District Field Office, Morang, Nepal.

ABSTRACT

This article is the result of findings of Lot Quality Assurance Sampling that present and compares the findings of Public Health status indicators of Morang district over 2004 and 2006. Surveys’ findings are also been compared with data that come from Health Management Information System. This study aimed to see the trend of status of coverage of public health services in the district. Contraceptive Prevalence Rate (CPR) has slightly been increased from 41.0% in 2004 to 42.0% in 2006. Percentage of women having 4 ANC by Health Workers increased from 42.0% in 2004 to 46.0% in 2006. Proportion of mothers who received iron tablets during last pregnancy increased from 70.0% in 2004 to 80.0% in 2006. Similarly, proportion of mothers who received Vita A during last pregnancy also increased from 45.0% in 2004 to 55.0% in 2006. Percentage of mother who fed breast milk within 1 hour during last natal period increased from 24.0% in 2004 to 31.0% in 2006. Percentage of delivery conducted by health workers has been also increased from 52.0% in 2004 to 57.0% in 2006.

Keywords: LQAS, HMIS, PHC, Trend over two years, Data Analysis, Morang, Nepal.

INTRODUCTION

Morang is one of the Terai district located in Eastern Development Region comprising of 65 VDCs where 66 governmental health institutions are providing Primary Health Care services. According to the UNDP report 2001,¹ Human Development Index of the district is in better position among the districts in Eastern Development Region. Health Management Information System (HMIS) has reported the coverage and achievement of the district which is in increasing trend. But, these data mainly include service indicators which are collected by service providers and volunteers. Some indicators which are necessary for planning process do not come from the HMIS.² Different studies and review reports noted that both over reporting and under reporting in the programmes are still remained.³ Errors are found in the recording and reporting which begins right from the service providers while recording and reporting to health institutions. A descriptive cross sectional study is helpful to evaluate the situation of services and reporting status as well. Lot Quality Assurance Sampling (LQAS) method with random sampling has its own methodology to collect, analysis and interpretation of data. It gives us overall situation of a district as well as it indicates poor supervision areas in the district. The objective of survey is to assess the behavior as well as practice level of community regarding health related issues. Specific objectives are to assess the ANC/NC/PNC service status, assess immunization status of children and mother, assess utilization status of family planning services, assess the current status of primary health care out reach clinic (PHC-ORC), assess current status of health facility management committee (HFMC), and assess the Infection prevention practice status of health facilities.

METHODS

Study design: It is a descriptive study of cross-sectional type. Primary data collection by interviews with mothers, health workers, members of committees from randomly selected sites using questionnaires. Structured questionnaire were filled up by enumerator after having training. All data collected from questionnaire were entered into computer and processed using SPSS software. All precaution measures to prevent data entry errors were undertaken.

Study Population

A defining characteristic of LQAS uses a sample size of 19 for each SA. In this LQAS described by Joseph J. Valedez, Willium Weiss, Corey Leburg, Robb Davis state that randomly selected 19 samples from divided supervision areas is sufficient to distinguish between high and low coverage.⁴ Samples were taken as- 1. Married women having children of 12 to 23 months (n= 133), 2. Members of PHC-ORC (n=55), 3. Members of HFMC (n=63), 4. Health facilities staff for infection prevention practices (n=63).

Supervision Areas (SA)

As per described by LQAS method district has been divided into seven supervision areas. The total number of 65 VDCs divided into 6 supervision areas as 1, 2,3,4,5, and 6. Biratnagar Sub metropolitan city has been taken as a supervision area 7. SAs are-

Supervision Area A: Urlabari, Pathari, Sanischare, Rajghat, Hoklabari, Keraun, and Bayarban VDCs.

Supervision Area B: Itahara, Amardaha, Govindapur, Jhurkia, Sijuwa, Bardanga, Mahadewa, Hasandaha, Takuwa, amgachi, and Dainia VDCs.

Supervision Area C: Jhorahat, Bhaudaha, Indrapur, Belbari, Haraicha, Dangihat, Kaseni, Bahuni, Sidraha, Thalaha, Banigama and Motipur VDCs.

Supervision Area D: Sundarpur, Dulari, Mrigaulia, Hattimudha, Siswani Badahara, Baijanathpur, Tanki, Lakhantari, Dangraha, Katahari and Siswani Jahada VDCs.

Supervision Area E: Budhnagar, Darbesa, Babiabirta, Sorabhag, Bhatigach, Dadarbairia, Kadmaha, Amahi, Majhare, Nocha, Pokharia and Rangeli VDCs.

Supervision Area F: Letang, Jante, Bhogateni, Warangi, Kerabari, Pati, Yangsila, Singhadevi, Madhumalla, Tandi, and Ramite VDCs.

Supervision Area G: Biratnagar sub metropolitan ward No. 1, 2, 4, 5, 6, 7, 10, 11, 13, 14, 15, 16, 17, 18, 19, 20, and 22.

RESULTS

Table 1. Comparison Table of Major Indicators between LQAS 2004⁵ and 2006

Table 1 indicates that the trend of monthly meetings held has been increased from 49.1% in 2004 to 96.4% in 2006. Similarly, committees addressing at least three health management issues also increased from 41.8 in 2004 to 73.1% in 2006. Health institutions having updated financial records and reports increased from 88.5% in 2004 to 92.2% in 2006. Proportion of PHC-ORC those met all three criteria viz monthly meetings within last 3 months, addressing at least three management issues and having updated financial records and reports have significantly been increased from 42.0% in 2004 to 64.1% in 2006 that is also statistically significant. Reactivation of PHC-ORC management Committee has been successfully concluded in entire district with the support of SCF.⁶
Table  2. Primary Health Care-Out Reach Clinic

Table 2 shows that clinics running on schedule increased from 87.8% in 2004 to 91.6% in 2006. Similarly, ORC management committee’s meeting with taking minute has remarkably been increased from 9.5% in 2004 to 36.1% in 2006. All essential services provided by ORC as per protocol also been increased from 41.9% in 2004 to 56.2% in 2006. Proportion of those PHC-ORC who met all three criteria viz clinics which are running on schedule, meeting held with recorded minutes, and clinics providing all essential services package as per protocol has been improved from 9.0% in 2004 to 18.1% in 2006.

Table 3. Infection Prevention (%)

Table 3 shows that practice of sterilization using functioning or boiling pot with cover is increased from 70.9% in 2004 to 92.1% in 2006. Similarly, disposal of sharp instruments and wastage properly remarkably increased from 46.2% in 2004 to 94.2% in 2006. The proportion of health institutions having punctured proof containers also increased from 90.9% in 2004 to 97.0% in 2006. Health workers who wash their hands with soap water are slightly increased from 92.6% in 2004 to 94.1% in 2006. Proportion of those health facilities who met all four criteria viz doing sterilization using functioning or boiling pot with cover, disposal of sharp instruments and medical wastage properly, having puncture proof container and washing hands with soap and water has significantly been improved from 46.1% in 2004 to 68.3% in 2006 which is also statistically significant. Training for health workers on infection prevention and supervision of health institutions are taken place for improving infection prevention. Supervisors from supporting partners are going to visit health facilities and giving supervision report including infection prevention which allowed taking action accordingly. Supplementary logistic supply and maintenance of equipments are also being done by supporting partners.⁷

Table 4. Maternal and Child Health Status over LQAS 2004 and 2006

Table 4 shows that Contraceptive Prevalence Rate had slightly been increased from 41.1% in 2004 to 42.1% in 2006. Percentage of women having 4 ANC by Health Workers increased from 41.9% in 2004 to 45.7% in 2006. Percentage of mothers who received iron tablets during last pregnancy increased from 70.2% in 2004 to 80.1% in 2006. Similarly, percentage of mothers who received Vita A during last pregnancy also increased from 45.1% in 2004 to 55.1% in 2006. Practices of breast feeding also been improved. Percentage of mother who fed breast milk within 1 hour during last natal period increased from 24.1% in 2004 to 31.3% in 2006. Percentage of delivery conducted by health workers also been increased from 52.5% in 2004 to 56.7% in 2006. It is encouraging to note that proportion of delivery conducted by skilled health workers is increasing from 38.0% in 2004 to 43.4% in 2006.

DISCUSSION

This article explored mainly coverage of different services in Morang district. Coverage is the percentage of people in any given area (a catchments area or supervision area) who know of and/or practice a recommended health behavior or who receive a particular service. Measles coverage, according to DPHO/HMIS 2062/63 is reported as 91.0% which is found 93.0% in LQAS 2006. According to DPHO/HMIS 2062/63,⁸ CPR is reported as 69.6% which is found only 42.0% in LQAS 2006. SA 6 that is Letang, Jante, Bhogateni, Warangi, Kerabari, Pati, Yangsila, Singhadevi, Madhumalla, Tandi and Ramite VDCs are having comparatively poor CPR according to decision rule. According to DPHO/HMIS 2006, the percentage of women having four ANC by Health Workers is 41.9% which is found 45.7% in LQAS 2006. But, SA 6 has got comparatively poor coverage of fourth ANC visits as per decision rule. The percentage of mothers who received iron tablets during last pregnancy is 32.4% in LQAS 2004 which increased 37.7% in LQAS 2006. Similarly, the percentage of mothers who received Vita A during last pregnancy is 45.1% in LQAS 2004 which increased 55.1% in LQAS 2006. Complete immunization or measles vaccination is 92.9% which was traced by observing card and by taking history. SA 4 that is Indrapur, Dulari, Mrigaulia, Tetaria, Hattimudha, Siswani Badahara, Baijanathpur, Tanki, Lakhantari, Dangraha, Katahari and Siswani Jahada VDCs have got comparatively poor immunization coverage in the district. Delivery conducted by health workers is 52.5% in LQAS 2004 which increased 56.7% in LQAS. But, According to DPHO/HMIS 2062/63 it is only 23.0 percent. In Jhapa the delivery conducted by health workers was 21.8% in 2004⁹ and 27.6% in 2006.¹⁰ In Sunsari the delivery conducted by health workers was 13.2% in 2004¹¹ and 31.0% in 2006.¹²

In Morang, the status of coverage of Public Health Programme is increasing year by year. The impact of the coverage has resulted positive result in child health by decreasing infant mortality rate.¹³ Supervision areas 4 and 6 are found comparatively weaker in achieving coverage. So, these areas draw attention of managers of district and community level institutions accordingly. Data those come from DoHS/HMIS¹⁴ and survey findings resemble regarding EPI and safe motherhood programmes. But, data remarkably varies regarding CPR and delivery conducted by health workers in district. It is often been raised some questions about under reporting of delivery conducted by health workers which is as low as 23.0% in ERHD/HMIS.¹⁵ Now, survey has discovered it as 56.7% deliveries conducted by health workers in Morang. Similarly, according to HMIS, Morang district has reported CPR as 69.6% which is also remarkably higher. But, CPR is only 42.1% found in the LQAS 2006. It might be due to proportion of CYP which is mainly occupied by VSC and of which most of the clients are coming from India and adjoining districts. However, findings of surveys have opened rooms for further assessment especially on the indicators as CPR and delivery conducted by health workers. Such type of LQAS surveys at regular interval are needed and to be institutionalized in district health system.

ACKNOWLEDGEMENT

Authors appreciate with gratitude for the support provided by SCF (US) in conducting this study. Thanks also go to health workers from DPHO Morang and SCF District Field Office staff of Biratnagar involved in the study.

References

1 UNDP. Annual report on Human Development Index, 2001

2 DPHO/Morang. Report on Annual Review Meeting, 2060/61

3 DPHO/Morang. Report on EPI Micro planning in Morang district, District Public Health Office Morang, 2006

4 Valadez JJ, Weiss W, Leburg C, Davis R. A trainers Guide for Baseline Surveys and Regular Monitoring, NGO Networks, 2002

5 SCF. Lot Quality Assurance Sampling in Morang district Nepal, 2004

6 SCF. Field Report on PHC-ORC Reactivation Programme in Morang, 2005

7 NFHP. Field Report on Supervision of Morang District, 2005/2006

8 DPHO. Annual Report of District Public Health Office Morang, 2062/63

9 DPHO/Jhapa. Annual Report of District Public Health Office Jhapa, 2060/61

10 DPHO/Jhapa. Annual Report of District Public Health Office Jhapa, 2062/63

11 DHO/Sunsari. Annual Report of District Public Health Office Sunsari, 2060/61

12 DHO/Sunsari. Annual Report of District Public Health Office Sunsari, 2062/63

13 Subba NR. Assessment of Morang Innovative Neonatal Intervention, 2004

14 MoH/DoHS. Annual Report of Ministry of Health, Department of Health Services, 2061/62

15 ERHD. Annual Report of Eastern Regional Health Directorate Dhankuta, 2061/62

The objective of the study was to assess the practices of using modern, self and alternative medication on the basis of socio-economic status.

Subba NR[a]

Abstract

Introduction

Health Seeking Behavior is a usual habit of a people or a community that is resulted by the interaction and balance between health needs, health resources, socio-economic and cultural as well as national/ international contextual factors.[1] It is behavior of using health services within existing health system or treatment seeking behavior of the latest illness as reported by them. This was categorized as (a) Modern medication such as Hospital, HP/SHP and private clinic (b) Alternative medication such as Ayurvedic and Homeopathic system of medication; and (c) Self-medication such as Dhami/Jhakri (Shaman healers), drug retailers, grocery keepers, drug peddlers, household medicine and other than modern and alternative medication. Kafle and Gartoulla[2] and Gartaula[3] have categorized self medication as Shamanism, Priest, Dhami-Jhakri, herbal, drug retailers, grocery, kit-bag, drug peddler, neighbour, following old medicine prescriptions etc and except the present prescription by qualified medical practitioners. WSMI[4] has indicated as Self-medication is the use of specifically designed, labeled and authorized medicines available legally without prescription for the treatment or prevention of common illnesses, which can be recognized by the people. Traditional medicine is not included in the national health system.  If traditional medicines are legally available without a doctor’s prescription, then they are included in what we call self-medication. Alternative medicine is medicine which is outside the regular allopathic medicine.[5] Sometimes it is accepted by national health plans for coverage and sometimes it is not.[6] This would cover for example, acupuncture, ayurvedic, naturopathy, and homeopathic medicine etc.

Methodology

This is a cross sectional and descriptive type of study based on information acquired from field visit carried out in January 2001. Semi structured questionnaire sheets containing both open and close ended question regarding health seeking behavior of the community were administered to 175 sample households of Katahari and Baijanathpur Village Development Committee (VDC) of Morang district. Sample were selected from the VDCs rosters using random number table and respondents were asked relevant questions with the history of illness/disease within three months from interview date. Of those who were ill/sick person of the above criteria were consulted for detailed information otherwise only demography was taken for the rest. Data were analyzed utilizing the Epi Info 6.0 statistical package. Data from pre-coded questions were entered into Epi Info 6.0 database. Attempts were made to minimize the potential error using Check file the data entry edit program. The Check file incorporated skip patterns, legal values and range checks that facilitated more rapid and accurate data entry. The participants were requested for Focal Group Discussion (FGD) to have one and half an hour’s sessions for the reason of their self-medication during household visits.  Personal contacts with self-medicated population within three months of study period were made to have 8 persons in one FGD and attempted total ten FGD with 80 persons. Verbal consent was taken before taking interviews and FGDs.

Results

Table 1:  Education and Sickness (n=175).

Table 1 presents the status of sickness on the basis of educational level in the community.

Proportion of felling sick of uneducated was higher as 74.0 percent (130) than educated 26.0 percentage (45). SLC pass and above was considered as educated and SLC failed and below were considered as uneducated in the study.

Table 2: Education and Medications (n=175).

Table 2 indicates that practice of using self-medication by uneducated Rajbanshi was significantly higher than educated (P< 0.05).

Table 3:  Medications by Economic status (n=175).

Table 3 presents that people having less than 2 Bighas land were adopting self medication significantly (P=0.05). Likewise, people having more than 4 Bighas land adopting alternative medication was also significant (P= 0.05). People were classified into three categories on the basis of land ownership as (a) Less than 2 Bighas, (b) 2.1-4 Bighas, (c) More than 4 Bighas.

Table 4: Diseases reported during encounter with the respondents (n=175).

Table 4 shows that symptoms like headache, bodyache, weakness and fever were reported by more than 30 percent respondents. ARI, Diarrhoal diseases, APD were reported by more than 13 percent respondents. Skin diseases, tuberculosis, rheumatoid arthritis were reported by more than 5 percent respondents.

Table 5: Medication sought by the family (n=175)

Table 5 presents medications sought by the family in any kind of latest illness during past three months. Modern, self and alternative medications were sought by 96 percent. 57.1 percent and 22.8 percent respectively.

Table 6: Expenses for Treatment (n=168).

Table 6 indicates that bulk amount of expense goes on purchasing drugs (58.0 percent), followed by paying doctors fees (19.5 percent ). And 5.0 percent cost goes for transportation, 3.7 percent for helper and 13.8 percent for others. Average expenditure per sick respondent was Rs.1 031.64

Table No. 7:  Affordability as perceived by the Respondents (n=175).

Table No. 9 suggests that 73.2 percent  people were reported inability to afford the cost for treatment.

Discussion

Katahari and Baijanathpur VDCs are located nearby Biratnagar sub metropolitan city. Private allopathic clinics conducted by paramedics were abundant in the local market, which were familiar also in the community. So, minor injuries and ailments were being treated there. They have also got facility of Koshi Zonal Hospital for emergency and special services. People those who need higher services for emergency, obstetrics and chronic cases, used to go to higher service centers located at Biratnagar, Dharan, Kathmandu and even India. Rajbanshi people were deeply attached with their Self-medication practices. They readily go to Dhami/Jhakri/Shaman due to their cultural factor and because of their perceived satisfaction. During FGD it was noted that lack of adequate money to pay for modern medication also leads them to go for Self-medication. Poor Rajbanshi adopted self medication was significant (P<0.05) in Katahari and Baijanathpur VDCs (Table 3). Similarly, practices of using self-medication by uneducated was highly significant (P=<0.05) in the community (Table 2). Niroula, B.B.[7], noted in Benighat that going to a faith healer is a ritual for seeking treatment, but if the illness persists even after two or three visits to a healer, the people of Benighat seek modern medicine. Many of them also use self-medication, with medication bought at the medicine shop. Others try herbal medications they have tried before. However, treatment-seeking behavior is changing with the availability of the modern health care facility in the area. Treatment-seeking behavior is largely determined by types of illness and popular beliefs regarding them. The cultural diversity brought about by caste and ethnic mix and topographical variations extends to health-seeking behavior. Some of the health beliefs may be common to all caste-ethnic groups but some are more specific to a particular caste and ethnicity. Developments in modern medicine and expansion of modern health care facilities have played a very important role in reducing morbidity and mortality in the developing world. Despite a steady penetration of modern health care services, economic underdevelopment has also led to a relatively weak health infrastructure in Nepal. Health improvement programme A Summary report[8] has revealed that 20 percent disadvantaged and 11 percent general population in Eastern development region were getting treatment from traditional healers. However, modern, self and alternative medications were indispensable part of health seeking behavior (Table 5) in Rajbanshi community.

An average treatment cost per case was Rs. 1031.64 (SD=6). They had taken either loan (14%) or had to sell land, animals, grains or personal belongings (53%). The bulky proportion (57.8%) expenses felled on buying drugs and for fees (19.55%) thereafter, for transportation 5percent , helper 3.74%, others 13.84 percent (Table 6).  Seventy three percent respondents reported inability to afford the expenses for modern medication (Table No. 7). The issue of expensive medical treatment and difficulty in affordability was also pointed out during focus group discussions. Therefore, the cost for modern medical treatment was said to be unaffordable for majority of people in Rajbanshi of Katahari and Baijanathpur of Morang. According to public health point of view, it is one of the major causes for poor access to health care services for needy people.

Communities

Rajbanshi[9] is one of the 61 ethnic groups in Nepal. Ethnic or Indigenous people are having low health status in the world.[10] Tamang, A., et.al,[11] described treatment seeking behavior which is determined by perceived causes of reproductive health problems. The family members believe that modern medicines will not work (ineffective) if the patient is not first seen by a faith healer. Visit to a health facility becomes inevitable only when problem gets worse or unbearable. Because of their beliefs on witchcraft, reliance on traditional faith healer (TFH) for treatment is quite strong among all the ethnic communities. Tamang girls would confide their Severe Reproductive Health problems with their mothers who would in turn prescribe herbal/home made remedies. Reliance over Traditional Faith Healer for treatment of problems is also common among Tamang girls. A large proportion of adolescent had experienced menstrual, reproductive or urinary tract disorders and only few had sought care. There is a need to tailor program to suit the needs of specific ethnic groups.

Uneducated Rajbanshis reported more sickness than educated people (Table 1) and they are also using more self medication (Table 2) in Katahari and Baijanathpur in Morang. A number of studies have found a correlation between knowledge and delayed diagnosis. Knowledge includes the ability to recognize symptoms, identify causes and transmission routes, and familiarity with the availability of cure. Although the evidence doesn’t conclusively suggest that knowledge independently determines care-seeking behavior, the correlation about knowledge and timing of diagnosis is well documented.¹⁴

Diseases reported by more than thirty percent respondents were mainly symptoms like headache, bodyache, weakness and fever. ARI, Diarrhoeal diseases, APD were reported by more than 13 percent respondents. Skin diseases, tuberculosis, rheumatoid arthritis were reported by more than 5 percent of respondents (Table 4). Annual Report of Department of Health Services[12] noted top 5 diseases as skin diseases, ARI, diarrhoeal diseases, Intestinal worms and Pyrexia respectively. A study[13] has realized that women could describe only obvious symptoms of their illness such as headaches, fevers, joint aches and body aches. They were more knowledgeable about pregnancy and delivery related problems than illnesses such as tuberculosis, malaria and typhoid. This lack of knowledge contributed to their delay in seeking care.

Waisbord[14] felt that the TB control community has recognized and addressed system components in which behavior is a key issue. Both diagnosis delay and non-completion of treatment are two central behavioral challenges. Several ongoing national and global initiatives that are part of TB control programs also aim to address behavioral challenges. Programs that offer enablers such as transportation and food subsidies for patients assume that by minimizing costs the numbers of patients seeking diagnosis and care would increase. Murphy, E.M.[15], argued that in an earlier day, the task of changing health related behavior was thought to be simply a matter of sending health messages such as “Breastfeed your baby!” or “Use condoms!” to those who were perceived to need them-a one direction communication approach. Today, sound health promotion programs no longer rely on one shot exhortations via booklets, posters, or media broadcasts. They encompass extensive research on relevant audiences; skill-building; multi-channeled education and advocacy using influential persons; policy development; community mobilization; and organizational, economic, and environmental change. This approach recognizes that human beings live in a dynamic “social ecology” as well as a physical one. Because poverty, gender inequity, and other disparities are underlying causes of under nutrition, addressing this health problem requires behavior change at multiple levels.

Conclusion

Modern, self and alternative medications were indispensable part of health seeking behavior of Rajbanshi community in Katahari and Baijanathpur VDCs of Morang. Modern medication was equally popular in both poor and rich or educated and uneducated. But, majority of people had reported modern medication as expensive medication. Uneducated Rajbanshis reported more sickness. Significant number of Rajbanshis having less than 2 Bighas of land and uneducated were adopting self medication in the community.

Acknowledgement

I would like to extend my sincere gratefulness to Dr. A.B. Joshi and Dr. Ritu Prasad Gartoulla for providing valuable guidance to conduct this study. Acknowledgement is also due to cooperation provided by the local communities, school teachers, health workers of Katahari and Baijanathpur VDCs of Morang.

References

Heath system research training series, WHO/ IDRC, 1991.

[2] K Kafle, Gartoulla RP, Self-medication and its impact on essential drugs

Scheme in Nepal, W.H.O. DAP – 10, 1993.

[3] Gartoulla RP, An introduction to medical sociology and medical anthropology,

RECID, Kathmandu, Nepal, 1998.

[4] Reinstein J, World Self Medication Industry (WSMI), UK, www.wsmi.org, 2001

[5] Agarwal SK, A guide to Alternative medicine, Indian board of Alternative

Medicine (IBAM), Calcutta, India, n.d.

[6] Gartoulla RP, Therapy pattern of conventional medicine with other alternative

Medicine, RECID, Kathmandu, Nepal, 1998.

[7] Niroula BB, Use of health services in Hill villages in Central Nepal, Population

Studies Center, University of Pennsylvania, Philadelphia, 1994

[8] Subba NR, Poudel D, Karkee S, Health Improvement Programme Summary report,

HMG/MoH/Eastern Regional Health Directorate, Britain Nepal Medical Trust, 2003

[9] Prospectus, HMG, MLD, National Committee for Development of Nationalities,

2000.

[10] Mabuhang BK, Policy Approaches to Indigenous People on Health Issues,

Population and Development in Nepal Journal, TU CDoPS, Kathmandu, 2000;7

[11] Tamang A, Tamang J, Adhikari R, Severity Perceptions of Health Problems and Treatment

Seeking  Behavior among Adolescent Girls in Nepal, Conference on Young People’s

Sexual and Reproductive Health Needs in Asia, New Delhi, 2004.

[12] DoHS, Annual Report, Ministry of Health, Department of Health Services, Kathmandu, Nepal,

2002

[13] World Bank, Understanding Access, Demand and Utilization of Health Services by Rural

Women in Nepal and their Constraints, 2001

[14] Waisbord, Behavioral barriers in tuberculosis control: A literature review, The

CHANGE Project/Academy for Educational Development, 2005.

[15] Murphy EM, Promoting Healthy Behavior, Health Bulletin of Population Reference

Bureau, USA, 2005;2

This paper presents the demographic status of vasectomy clients in Sankhuwasabha district in Eastern Nepal based on the 427 fact-sheets taken

Nawa Raj Subba

ABSTRACT

This paper presents the demographic status of vasectomy clients in Sankhuwasabha district in Eastern Nepal based on the 427 fact-sheets taken at camps in district during 3 consecutive years. More than half (55.0%) of the clients were Brahmin and Chhetri. Major occupation of clients was agriculture (73.7%) with s literacy rate of 83%. Mean age of vasectomy clients and their wives was 32.5 and 28.7 years respectively and age of youngest female child was 3.9 years. Of the total, 55.8% couple have had used temporary contraceptives before having vasectomy. As a part of screening procedure, blood pressure of more than half clients (54.6%) was measured and found to be within normal range.

INTRODUCTION

It has been experienced that vasectomy target could not have been achieved in hilly and mountainous districts compared to districts located in plain (Terai) areas in Nepal.¹ This has been due to the lack of doctors and other management problem for years. In addition, there might be socio-cultural reasons as well.

This paper presents the findings of a cross-sectional study done to assess the demographic, social and personnel characteristics of vasectomy clients in Sankhuwasabha district, one of the Himalayan districts located in Koshi zone in Eastern Development Region.

MATERIALS AND METHODS

Face-Sheets¹ were taken from the vasectomy clients. A total of  427 Face-Sheets was taken as samples that were filled up at the time of Vasectomy conducted Fiscal Years 056/57, 057/58 and 058/59 covering District Hospital 1, Primary Health Care Centre 1, Health Posts 12, Sub-Health Posts 25 of Sankhuwasabha district. Data from pre-coded questions were entered into Epi Info 6.0 database and were analyzed using Epi-Info Statistical package.

RESULTS

This paper presents the demographic status of vasectomy clients in Sankhuwasabha district in Eastern Nepal based on the 427 face-sheets taken at camps during 3 consecutive years. More than half (55.0%) of the clients were Brahmin/Chhetri (Table 1). Major occupation of clients was agriculture (73.7%) with literacy rate 83.0% (Table 2). Mean age of vasectomy clients and their wives was 32.5 and 28.7 years respectively. An average number child of a client was 3.2 years. Age of youngest male child was 4.7 years and female child was 3.9 years. Of the total, 55.8% couple have had used temporary contraceptives before having vasectomyThe age of last male and female child was 4.7 and 4.0 years, respectively.

Table 1. Ethnics of Vasectomy Clients in Sankhuwasabha District

Table 2. Occupation of Vasectomy Clients and their spouse in Sanlhuwasabha District.

Table 3. Educational status of Vasectomy clients

Table 4. Type of contraception used by the clients

Table 3 shows the educational status of clients. Approximately one-fifth of vasectomy clients were illiterate. Over two-third clients could read and write. Small number had education above SLC. Seven percent of clients had experienced loss of their child before vasectomy.

As a part of screening procedure, blood pressure of more than half clients (54.6%) was measured and found to be within normal range.

DISCUSSION

In Nepal, 30.0% of total population is comprised of Brahmin/Chhetri.^2,3 In Sankhuwasabha district Brahmain/Chhetri is 55%.³ Most of the people in this district are engaged in agriculture and this was well reflected in this study as well (74.0% clients were involved in agriculture). In Terai, the occupational figure is slightly different and only half (52.0).⁴ onvolved in agriculture.

The illiteracy rate in Sankhuwasabha district⁶ is 50.8% (literacyrate of Nepal is 53.7%).³ However, the literacy rate of clients was 83% indicating that educatin (awareness) of people plays great role in family planning by vasectomy. The mean age of vasectomy clients is studied in this study (32.5 years) was similar to the mean age of vasectomy clients in USA (31 years).⁵ In Nepal, the mean number of children ever born at age 25-29 women group is 2.71 whereas the mean number of living children of the same age group is 2.43 children.³ However, the mean number of children ever born at age 25-29 women group of the vasectomy clients in Sankhuwasabha district was 3.3 and mean number children children of the same age group was 3.2 children.

It has been found that 39.0% women and 44.0% men were on temporary contraception practice in Eastern mountainous region.⁴ In this study the number was low, 18% men and 37% women had used temporary method of contraception prior to the vasectomy. About ten percent of newly married non-pregnant women in Nepaluse injectable contraception (Depo-Provera)¹ while 25.6% women of 15-29 years age group have taken (Depo-Provera).⁴ Overall, Depo-Provera user married women of reproductive age in Eastern Nepal ws 31%⁶ However, 57.8% of vasectomy clients revealed that their wives had used Depo-Provera. None of the subjects had symptoms of hypertension and might be associated with their life-style.

These results may reflect and confined to the study district’s situation. However, present study is based on the face-sheets. In this district, certain caste/ethnic groups are still far from access of vasectomy contraception the program focusing in this regard should be encouraged.

REFERENCES

1. DHO, Sankhuwasabha, District Health Office Sankhuwasabha Nepal, Vasectomy Face Sheets, Fiscal Years 2056/56, 2057/58, 2058/59.

2. DBS, Statistical Pocket Book Nepal, His Majesty’s Government Nepal Planning Commission, Central Bureau of Statistics, Kathmandu Nepal, 2002.

3. DDC, District Profile of Sankhuwasabha district, District zDevelopment Committee Sankhuwasabha, 2001.

4. Subba NR, Health Seeking behavior of Rajbanshi ethnic of Katahari and Baijanathpur in Morang, 2001.

5. Vasectomy Project Washington State Family Planning and Reproductive Health, State Department of Health Family Planning and Reproductive Health, P.O. Box 47883, Olympia, Washington, 98504-7883, 2002, www.fprh.index.htm

6. EDR, Annual Report of Eastern Region Fiscal Year 2057/58, His Majesty’s Government of Nepal, Ministry of Health, Department of Health Services, Regional Health Directorate Eastern Development Region, Dhankuta, 2059.

This is a retrospective comparative study on Morang Innovative Neonatal Intervention (MINI) a project which aims at reducing neonatal deaths by controlling neonatal infections.

Nawa Raj Subba
Senior Public Health Administrator

Abstract

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Introduction: This is a retrospective comparative study on Morang Innovative Neonatal Intervention (MINI) a project which aims at reducing neonatal deaths by controlling neonatal infections. Objectives: The objective of the assessment aims to assess the situation of neonatal health in intervention VDCs. Methodology: Baseline assessment, trainings, supervision and monitoring was conducted during project implementation. Tools are service registers used by Health Workers and FCHVs, reporting formats, service cards, supervision check-lists and reports, forms, regular review meetings’ reports and HMIS data. Primary data collected by questionnaires, in-depth interviews with health workers and beneficiaries. Data has been regularly entered into computer and reviewed on monthly basis from July 2004 to September 2006. Results: FCHVs have captured 58 percent of expected pregnant women in their wards of VDCs. FCHVs have taken birth weights of 99% babies of registered babies. Of them 12% babies was found under weight. FCHVs followed up 83% of these under weight babies. FCHVs assessed as 23% of local bacterial infection and 15% of possible severe bacterial infection. FCHVs first managed 70%, VHWs and MCHWs first managed 16% and health institutions first managed 14% of Possible Severe Bacterial Infection (PSBI). Of total 895 PSBI 39 percent neonates were treated by home visits and 44% by health facilities. In the intervention area 68% population has been occupied by Dalits, Indigenous people and Muslims which are considered as Disadvantaged Groups (DAG) in Morang district. NMR is estimated as 21 per 1000 live births in the district. Conclusion: MINI has served neonates mainly for disadvantaged population living in the community level in Morang district. It has played its role in lowering NMR. It has also supported other existing public health programmes. Recommendation: It demands close monitoring of overall programmes. Some incentives for FCHV and CHWs are needed. Provision of application of local antibiotics on cord is a issue which often attracts attention to be added in the national protocol.

Key words

Neonatal Mortality, FCHV, VHW, MCHW, Morang,

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Background

Nepal is one of the countries having highest IMR in the world. Since the proportion of NMR is almost constant despite there is remarkable decrease of IMR over a decade of 1991 to 2001 in the country.[1]

Nepal has experienced the trend as remarkable decrease in <5 yrs mortality but no changes in neonatal mortality rate. Safe motherhood programmes, Community Based-Integrated Management of Childhood Illness (CB-IMCI) programmes are going on in primary health care package, but it is inadequate to fulfill the requirement of basic neonatal health care services. On this background, National Neonatal Health Policy 2004 has been formulated in the country. Policy has opened rooms for piloting neonatal health care projects in districts. Morang district has got neonatal health care pilot programme named as Morang Innovative Neonatal Intervention (MINI), which aims at reducing neonatal deaths by controlling neonatal infections. Neonatal period is classically defined as first 28 days of life. But, MINI has defined neonatal period as the first 60 days of life in the programme. A similar neonatal programme Projahnmo Project Shylet in Bangladesh[2] defined the neonatal period as the first 40 days of life.

Human Development Indicators 2001[3] of Morang district are in better condition in the Eastern region and country as well. But population size of the district is second highest in the country and highest in the Eastern development region. A joint effort of District Public Health Office (DPHO) Morang and Morang Innovative Neonatal Intervention (MINI) or John Snow International (Research & Training) has got two years achievements and experiences in Morang district. About nine months period has been passed solely in preparation phase for training for trainers, training for health workers and FCHVs in the communities. Service intervention was begun from June 2005 in 21 Village Development Committees (VDC) in the district.

Objectives

Objectives of the study is to assess the effectiveness of the programme by assessing situation of neonatal health in the population of intervention VDCs and compare it with non-intervention VDCs. Objective of the study also includes comparing other existing programme performance in intervention and non-intervention VDCs.

Methodology

It is a retrospective comparative assessment. Series of trainings, supervision and monitoring was conducted during project implementation. Interventions were ANC counseling, baby weight taking, treatment and refer of neonatal infections and PNC counseling by FCHVs and CHWs. Expected outcome was identifying birth weights, diagnosis of neonatal infection and treatment or refer to the health institutions. Tools used were service registers used by Health Workers and FCHVs, Reporting Formats, Service Cards, Supervision Check-lists, questionnaires. Study of Secondary data from MINI data base was taken place. Health Management Information System (HMIS), Regular Review Meetings’ reports, Supervision and monitoring reports, published reports and forms: birth information (form A), diagnosis record (form B), vital statistics after 2 months (form C) and treatment record (form D) are also taken as tools. Primary data collection by in-depth interviews with health workers and beneficiaries from randomly selected sites using check lists. Data Processing: Data has been put regularly into computer under access and excel software and analyzed it monthly. DPHO Morang, District Technical Working Group (DTWG) and MINI programme have fulfilled their responsibilities of managing and analyzing data during intervention. According to the baseline household survey^[4], the selection of VDCs to receive the package of interventions was done by randomly selecting 2 out of 6 PHCs and 4 out of 10 health posts (both done proportionate to the number of VDCs they serve).

Results

Table 1. Castes and ethnics distribution of service users in intervention area.

Table 1 shows distribution of the caste and ethnics receiving services in population from 21 intervention VDCs. In the intervention area 68% population has been occupied by Dalits, Indigenous people and Muslims which are considered Disadvantaged Groups (DAG) in Morang district. Brahmin 14%, Chhetri 12%, Newars 3% and others 3% have also taken services from this programme.

Table 2. Service indicators regarding Home visits in Intervention Area

Table 2 indicates as FCHVs have captured 58 percent of expected pregnant women in their wards of VDCs. It is noted that 58% of households are visited by FCHVs.  FCHVs have taken birth weights of 99% babies for whom weight was taken. Of them 12% babies was found under weight. FCHVs followed up 83% of these under weight babies. FCHVs assessed as 23% of local bacterial infection and 15% of possible severe bacterial infection. FCHVs first managed 70%, VHWs and MCHWs have managed 16% and 14% managed by health institutions of Possible Severe Bacterial Infection (PSBI). Of total 895 PSBI 39 percent neonates were treated by home visits and 44% by health facilities. It is noted that these activities are not undertaken by FCHVs in non-intervention VDCs or they usually did not do these jobs.

Table 3. Neonatal Mortality Rate in Morang following MINI Intervention

Table 3 shows the status of NMR in Morang. At the beginning of the intervention of MINI, it was total 13 neonatal deaths recorded out of 420 births records. After one year of intervention neonatal deaths had been recorded 114 out 6046 births. NMR may be estimated as 21 per 1000 live births in the district. According to census 2001[5], NMR is 39 per 1000 live births in Nepal.

Table 4. Comparison of district’s achievement over Pre and Post MINI intervention

Table 4 indicates that BCG, DPT3 and Measles vaccination coverage was 94%, 73% and 80% in the year 2061/62 which increased as 100%, 100% and 91% respectively in the year 2062/63. Similarly, Target achievement of TT2, 4ANC visits and PNC visits in FY 2061/62 was 62%, 40% and 38% which found 61%, 44% and 39% respectively in the year 2062/63. Most of the indicators found improved in FY 2062/63 than previous year.

Table 5. Comparison of Target Vs Achievement in between Intervention and Non-Intervention VDCs

Table 5 shows that achievement of BCG coverage in intervention is 94 percent, whereas it is 99 percent in non-intervention VDCs. Similarly, Measles coverage in intervention VDCs is 88 percentages, whereas it is 95 percentages in non-intervention VDCs. ANC 4 visit is 50 percent in intervention VDCs whereas it is 47 in non-intervention VDCs. Proportion of delivery conducted by health workers is 12 percent in intervention whereas it is 9 percent in non-intervention VDCs. Status of EPI program coverage in intervention VDCs has been found lower than non-intervention VDCs. However, coverage or achievement of rest of the programme such as safe motherhood and nutrition programme has got positive trend.

Table 6. Comparison of Per PHC-ORC Served in between Intervention and Non-Intervention VDCs

Table 6 shows the number of clients served per clinic was 26 in FY 2061/62 which increased as 29 in 2062/63. Likewise number of clients served by a clinic in intervention was 33 in FY 2061/62 which dropped as 31 in FY 2062/63. Therefore, the trend of PHC-ORC serving per clinic is found increased in non-intervention VDCs whereas decreased in intervention VDCs. The CPR in Morang is considered to be highest in Eastern development region.[6] Its major proportion is occupied by Voluntary Surgical Contraception (VSC).

Researcher attempted to take some in-depth interviews with some beneficiaries and health workers in field visits. A mother of a neonate who was recently recovered from the treatment said, “This programme is effective program which take care of we poor and Dalits people. We are really grateful to the government.” A VHW said “we have got two-three hours more work load after this MINI intervention. Since almost all neonates get well from the treatment community people and/or caretakers have acknowledged our treatment. Now we have found us differently in our profession. We are satisfied with the programme. Although, it might have affected to conduct the EPI-ORC, PHC-ORC sessions, we are trying to manage it.”

Some technical problems are found in treatment protocol which may requires consideration. As per our protocol health workers leaves cut umbilicus by applying nothing. Some caretakers are tended to put dust over the umbilicus since they see fresh bleeding. One case of neonatal infection of such incident was investigated in the district. Therefore, application of antiseptic on umbilical cord is felt need of health workers as they often reported in the review meetings. It is a subject to be reviewed in the infection control protocol.[7]

Discussion

According to DoHS Annual Report 2004/2005,[8] the ANC first visits as % expected a pregnancy is 77.7% in Morang and national average is 68.8%. The highest numbers of neonatal deaths are in south-central Asian countries and the highest rates are generally in sub-Saharan Africa. The countries in these regions (with some exceptions) have made little progress in reducing such deaths in the past 10-15 years. Globally, the main direct causes of neonatal death are estimated to be preterm birth (28%), severe infections (26%), and asphyxia (23%). Neonatal tetanus accounts for a smaller proportion of deaths (7%), but is easily preventable. Low birth weight is an important indirect cause of death. Maternal complications in labour carry a high risk of neonatal death, and poverty is strongly associated with an increased risk. Preventing deaths in newborn babies has not been a focus of child survival or safe motherhood programmes. While we neglect these challenges, 450 newborn children die every hour, mainly from preventable causes, which is unconscionable in the 21st century.[9]

There is considerable interest in Nepal and other countries in addressing neonatal mortality.  Nepal has demonstrated a remarkable decline in infant and child mortality over the past 2 decades.  However, there has been less improvement in neonatal mortality, and an increasing proportion of under-5 deaths (40%) are now in the neonatal period.[10] Proportion of home delivery in intervention VDCs of Morang[11] district is 69.6% which is still vast majority 86.7% in Kailali[12] and its national[13] average is 88.9%. Nepal Demographic and Health Survey 2001 has estimated that in Nepal nearly 50,000 children under one year of age die every twelve months. Two third of them die within 28 days of age, resulting 30,000 neonatal deaths per year. This means three to four newborns are dying every hour in Nepal. The majority (86.1%) of deaths occurred at home, with only 141 (13.2%) occurring at the health facility.[14] A study of low birth weight from four regional hospitals has found a weighed mean incidence of 27%. The strongest risk factors for low birth weight were maternal weight, previous preterm delivery, short birth interval and paternal employment in Agriculture.[15]

People have well accepted neonatal health services provided by FCHV, MCHW and VHW at community level. Mothers feel convenient home visits, since they reluctant to take out their neonates from house due to cultural barrier. Now, people are gradually changing their attitude and behavior regarding taking care of neonatal care in time. People are impressed with the cure rate of Gentamicin injection. Neonates got well from the treatment even those neonates who were given up their hope by their parents to live any longer. VHWs and MCHWs play vital role in the MINI programme. They have provided home visits for curative services at home. This is one of the first programmes which have established warm relation ship with people by health workers at the door of clients. Community has recognized health workers are helpful for us who save life of neonates from the mouth of deaths in our own house.  Recognition from people is one of the major factors which made health workers motivated towards the neonatal health programme. District health system have accepted this programme as a part of own regular programme which need based and useful. Now, system has adopted this programme and can run even after support from partners would not be any longer.[16]

This programme has been able to include socially marginalized caste and ethnics who are hard to access due to socio-economic and cultural factors. Service users from disadvantaged groups such as Dalits, indigenous people and Muslims have comprised of 60 percent of the total service users population.

So many positive trend on safe-motherhood, family planning, and CB-IMCI been reported. But EPI coverage and coverage of PHC-ORC are adversely affected by the programme since it is relatively lower than the non-intervention area. Routine immunization and PHC-ORC are adversely affected due to double responsibilities of attending Gentamicin injection and EPI session or PHC-ORC on the same day. This is a big challenge for district management which requires due attention for prevention of adverse effect on EPI session and PHC-ORC.

Review meetings report[17] on reproductive health or safe motherhood programme have revealed issues to be considered while formulating comprehensive maternal and child health programme in the district. There was already provision of Birth Preparedness Packages (BPP) for TBA in the district. A supportive partner BNMT put some its effort on the promotion of BPP is selected VDCs. But it has reported that it was inadequate. More orientations for TBAs and pregnant women are needed and more IEC materials to be produced for all VDCs in the district.

Conclusion

In Morang, MINI programme has involved Community Health Workers and Female Community Health Volunteers in serving neonates. Remarkable numbers of neonates are covered by the programme. Morang district has got estimated NMR as 21/1000 live births in 2006. The neonatal health programme has supported other existing public health programme. But performance of EPI-ORC and PHC-ORC are slightly decreased in intervention area which demands close and regular monitoring. Success is possible in low-income countries without access to high technology.[18] However, incentives for FCHV such as providing bicycle, dress, monthly meeting allowance is necessary. Similarly an incentive package for Community Health Workers (CHW) is also required to make effective neonatal health care programme.

Acknowledgement

Researcher duly acknowledges the support of JSI R&T for technical and financial support. Sincere thanks goes to Dr. B.D. Chataut, Dr. Neena Khadka, Dr. Penny Dawson, Dr. Sudhir Khanal, and Dr. Jagannath Sharma, for providing technical guidelines in the programme. Thanks also go to Mr. Ram Bahadur Baniya, Mr. Vijay Sing GC, Mr. Tekraj Koirala and all DPHO and MINI staff for playing vital role in project implementation with keeping mutual cooperation. At last but not least thanks goes to District Technical Working Group (DTWG) for the support and guidance.

References

[2] Peter J Winch, M Ashraful Alam, Afsana Akther, et.al. Local understandings of vulnerability and  protection during the

neonatal period in Sylhet district, Bangladesh: a qualitative study, Lancet 2005; 366: 478-85.

[3] UNDP. Report on Human Development Index. 2004.

[4] DPHO, JSI, SNL. Baseline Survey Report on Neonatal Health in Morang District Nepal. 2005.

[5] CBS. Census Report. National Planning Commission, Central Bureau of Statistics, Kathmandu Nepal, 2001.

[6] ERHD. Annual Reports, MoHP, Eastern Regional Health Directorate Dhankuta, 2057/58, 2058/59, 2059/60, 2060/61,

2061/62.

[7] Luke C Mullany, Gary L Darmstadt, Subarna K Khatry, et al. Topical applications of Chlorhexidine to the  umbilical cord

for prevention of Omphalitis and neonatal mortality in southern Nepal: a Community-based, cluster-randomised trial.

Lancet 2006; 367: 910-18.

[8] DoHS. Annual Report, Ministry of Health and Population, Department of Health Services, Kathmandu,

Nepal, 2004/2005.

[9] Joy E Lawn, Simon Cousens, Jelka Zupan. 4 million neonatal deaths: When? Where? Why? www.thelancet.com retrieved

on March 5, 2005.

[10] UNICEF. Nepal Multiple Indicator Surveillance. Fifth Cycle:  Care During Pregnancy and Delivery:

Implications for Protecting the Health of Mothers and their Babies. June 1998.

[11] DPHO Morang/MINI. Baseline Survey Report on Neonatal Health in Morang District Nepal. 2005.

[12] SNL/CSF. Baseline Survey Report on Saving Newborn Lives in 18 VDCs and 1 municipality of Kailali, 2003.

[13] DoHS. Demographic and Health Survey, Ministry of Health Department of Health Services, 2001.

[14] F. Baiden1, A. Hodgson1, M. Adjuik1, et.al. Trend and causes of neonatal mortality in  the Kassena- Nankana district of

northern Ghana, 1995-2002, Tropical Medicine and International Health,  Volume 11 no 4 pp 532-539 April 2006.

[15] MIRA/UNICEF. Low Birth Weight prevalence and associated factors in four regions of Nepal, Kathmandu. 2000.

[16] Subba NR. Assessment Report on Morang Innovative Neonatal Intervention. 2006.

[17] DPHO, Annual report, District Public Health Morang. 2061/62.

[18] Jose Martines, Vinod K Paul, Zulfiqar A Bhutta, et.al. Neonatal survival: a call for action. Lancet 2005; 365: 1189-97.