Prof. Shally Awasthi Department of Pediatrics, King George’S Medical University Lucknow, (U.P.) India

To Assess the Effectiveness of Various

Communication Strategies for Improving Childhood Pneumonia Case Management: A Community Based Behavioural Open Labeled Trial in Rural Lucknow, Uttar Pradesh, India

Project Report: From Nov 2015 to 30th September 2018

Prof. Shally Awasthi Department of Pediatrics, King George’s Medical University Lucknow, (U.P.) India

Funded by Bill & Melinda Gate's Foundation (Grant No.: OPP1084307) & INCLEN Trust International

Acknowledgement

This report has been developed under the project entitled “To Assess the Effectiveness of Various Communication Strategies for Improving Childhood Pneumonia Case Management: A Community Based Behavioral Open Labeled Trial in Rural Lucknow, Uttar Pradesh, India”, that has been sponsored by INCLEN Trust, through funding provided by Bill & Melinda Gates Foundation.

We are extremely grateful to the Bill and Melinda Gates Foundation who funded the project through INCLEN Trust.

We are also thankful to Mission Director, National Health Mission, Uttar Pradesh & General Manager, Child Health, National Health Mission, Uttar Pradesh and Department of Health and Family Welfare, Government of Uttar Pradesh without whose cooperation this project would not have accomplished its objective.

We would like to acknowledge with gratitude the functionaries and academicians of King George`s Medical University who facilitated the smooth conduction of this project since inception.

We are extremely thankful to Chief Medical Officer Lucknow, Medical Superintendents & Medical Officers at Community & Primary Health Centers, ANMs and ASHAs in all 8 rural blocks of Lucknow, who cooperated with the project team in every possible aspect.

We also wish to extend our gratitude to all respondent mothers from the community, who shared with us their knowledge related to pneumonia. It helped us to understand the pattern of health seeking behavior.

Project Team

Principal Investigator: Dr. Shally Awasthi Professor, Department of Pediatrics, King George’s Medical University, Chowk, Lucknow, U.P.India.

Co-Investigator: Dr. Monika Agarwal Professor, Department of Community Medicine, King George’s Medical University, Chowk, Lucknow, U.P. India.

Co-Investigator: Dr. C. M. Pandey Professor & Head, Department of Biostatistics and Health Informatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Data Collection and Analysis

Dr. Divas Kumar Project Coordinator Mr. Vivek Singh Nagwanshi Field Investigator Mr. Neeraj Kumar Verma Pharmacist Mr. Abhay Trivedi Field Worker Mr. Anuj Gopal Field Worker Mr. Ramdhani Sharma Field Worker Mr. Yogesh Bahadur Singh Field Worker Mr. Atul Chandra Secretarial cum Computer Assistant Mr. Nitish Srivastava Record Keeper

Table of Contents

Page no. 1. Executive Summary 1 2. Introduction 3 2.1.Socio-demographic and health profile of study area 3 2.2.Project Background 4 2.3.Study Rationale 5 2.4.Project Design 5 2.5.Project Objectives 6 2.5.1.Primary Objective 1 6 2.5.2.Primary Objective 2 6 2.6.Study Timelines 7-8 3.Pre Intervention Phase (Preparation for data collection & Intervention) 9 3.1.Development of Training Material & Data Collection Tools 9 3.2.Orientation Trainings 9 3.2.1.Orientation Training of Medical Officers 9-12 3.2.2.Orientation Training of ANMs 13-15 3.2.3.Orientation Training of ASHAs 16-18 3.3.Base Line Survey 19 3.3.1.Survey Methodology 19 3.3.2.Inclusion criteria for households 19 3.3.3.Data Collection 19 3.3.4.Quality Assurance 20 3.4.Infrastructural Strengthening 21 3.4.1.Establishment of Pneumonia Management Units 22 3.4.2.Establishment of Pneumonia Management Corners 23-25 3.5.Pneumonia Drug Kit 25 3.5.1.Procurement of drugs & packaging of Pneumonia Drug 25-27 Kits 3.5.2.Distribution of Pneumonia Drug Kits 27 3.6.IEC material 27 3.6.1.Methodology of IEC material development 27 3.6.2.Distribution of IEC material 28 4.Intervention Phase 29 4.1.Pneumonia Awareness Sessions 29 4.1.1.Pneumonia Awareness Sessions at CHCs & PHCs 29-30 4.1.2.Pneumonia Awareness Sessions at villages 30-31 4.1.3.Monitoring of Pneumonia Awareness Sessions 32 4.1.4.Re-distribution of IEC material 32 4.2.Utilization of 32 4.2.1.Pneumonia Drug Kits 32 4.2.2.Pneumonia Management Units & Corners 32-33 4.3.Re-Trainings 33 4.3.1.Re-Training of Medical Officers 33 4.3.2.Re-Training of ANMs 34-35 4.3.3.Re-Training of ASHAs 35-36

5. Post Intervention Phase 36 5.1.End Line Survey 36 5.1.1.Survey Methodology 36 5.1.2.Data Collection 36-37 5.1.3.Quality Assurance 37 6.Other Activities 37 6.1.World Pneumonia Day 37-38 6.2.Health Facility Audit 38-39 7.Technical Advisory Group (TAG) 39 7.1.TAG Meeting 39-40 7.2.TAG Visit 40 8.Data Analysis and Interpretation 40 8.1.Results of Base Line Survey 41-57 8.2.Adherence to Interventions (Pneumonia Awareness Sessions) 57-58 8.3.Results of Exit Interview of participants of Pneumonia Awareness 58-65 Sessions 8.4.Analysis of Pneumonia Drug Kit Utilization 65-66 8.5.Results of feedback about Pneumonia Drug Kit collected from 66-72 parents, whose children were treated with Pneumonia Drug Kit 8.6.Health Facility Audit Results 72 8.6.1.Status of availability of Amoxicillin 72 8.6.2.Status of availability of Oxygen 73 8.6.3.Utilization of Pulse Oximeter & Inhaler 73 8.7.Results of End Line Survey 74-99 8.8.Results against Objectives 100-101 8.8.1.Primary Objective 1 102-107 8.8.2.Primary Objective 2 107-116 9. Way Ahead 117-119

10. List of Tables Table 1: Demographic & Health profile of Lucknow 3 Table 2: Health Infrastructure of Lucknow District, at the time of initiation 4 of study Table 3: Study Design (2 by 2 factorial design) 5 Table 4: Qualification of participants who attended the training 10 Table 5: Result of Pre and Post Test of Medical Officers, conducted during 11 Orientation Training Table 6: Block wise attendance of participants 13 Table 7: Result of Pre and Post Test of ANMs, conducted during Orientation 14 Training Table 8: Block wise attendance of participants 16 Table 9: Result of Pre and Post Test of ASHAs, conducted during 17 Orientation Training Table 10: Equipments/Medicines provided to all the CHCs & PHCs 21 Table 11: List of CHCs where Pneumonia Management Unit was established 22 (along with date of establishment) Table 12: List of PHCs where Pneumonia Management Corner was 24 established (along with date of establishment) Table 13: IEC Material developed through project 28 Table 14: Block wise attendance of participants was as follows 34 Table 15: Block wise attendance of participants was as follows 35 Table 16: Intervention wise distribution of study population 41 Table 17: Intervention wise distribution of households on basis of 41 Table 18: Intervention wise distribution of households on basis of Type of 42 House Table19: Intervention wise distribution of households on basis of main 42 occupation of family Table 20: Intervention wise distribution of households on basis of type of 43 ration card (N=1596) Table 21: Intervention wise distribution of households on basis of availability 43 of separate kitchen Table 22: Intervention wise distribution of households on basis of source of 43 Fuel used for cooking (Multiple Response) Table 23: Intervention wise distribution of households on basis of source of 44 Drinking Water (Multiple Response) Table 24: Intervention wise distribution of households on basis of availability 44 of Electricity Table 25: Intervention wise distribution of households on basis of availability 45 of Toilet Table 26: Gender distribution of family members 45 Table 27: Marital Status of family members 45 Table 28: Population (Children between 2months to 59 months of age) 46 eligible for the survey Table 29: Gender distribution of eligible children 46 Table 30: Age Distribution of eligible children 46 Table 31: Whether the child suffered from Diarrhea /RTI/Fever/Convulsion in 47 last one year

Table 32: Whether the child suffered from Diarrhea in last one year 47 (n = 3194) Table 33: Place of the treatment for Diarrhea (last one year) (Multiple 47 Response) Table 34: Outcome of the treatment of Diarrhea (last one year) (n=737) 48 Table 35: Number of Episodes of Diarrhea in children in last one year 48 (Descriptive Statistics) Table 36: Total Expenditure on the Diarrhea for last one year (Descriptive 48 Statistics) Table 37: Whether the child suffered from RTI in last one year (n = 3194) 49 Table 38: Place of the treatment for RTI (last one year) (Multiple 49 Response) Table 39: Outcome of the treatment of RTI (last one year) (n=2420) 49 Table 40: Number of Episodes of RTI in children for last one year 50 (Descriptive Statistics) Table 41: Total Expenditure on the RTI (last one year) (Descriptive 50 Statistics) Table 42: Whether child suffered from running nose, since last one year? 50 Table 43: What type of treatment was given to child with running nose? 51 (Multiple Response) Table 44: What all types of health care providers were approached for 51 treatment of running nose (Multiple Response)? Table 45: Children who suffered from cough with fast breathing (with or 51 without chest in drawing), since last one year? Table 46: Type of treatment that was given to children suffering from 52 cough with fast breathing (with or without chest in drawing). (Multiple Response) Table 47: What all types of health care providers were approached for 52 treatment of children suffering from cough with fast breathing (with or without chest in drawing)? (Multiple Response) Table 48: Children who were admitted in hospital, for treatment of 52 pneumonia in last one year? Table 49: In which type of hospital, was the child was admitted first for 53 pneumonia? (n=33) Table 50: Mothers who have you ever heard about the illness called 53 "pneumonia"? Table 51: Symptoms of pneumonia as responded by mothers. (Multiple 54 Response) Table 52: Source of information about pneumonia? (Multiple Response) 54 Table 53: Mothers who had attended VHND in last 6 month (n=2379) 55 Table 54: Was any information on pneumonia was given on VHND? 55 (n=1535) Table 55: Who gave you pneumonia related information on VHND? 55 (Multiple Response) Table 56: Mothers who had attended routine immunization day in last 6 56 months? (n=2448) Table 57: Was any information on pneumonia was given on immunization 56 day? (N=1677) Table 58: Who gave you pneumonia related information on Immunization 56 day? (Multiple Response) Table 59: Adherence to interventions across 1st, 2nd & 3rd Interventions 58 (From October 2016 to December 2017) Table 60: Block wise distribution of exit interviews conducted after 59 Pneumonia Awareness Sessions Table 61: Block wise distribution of “type of Monitoring” for Pneumonia 59 Awareness Sessions for which these 2146 exit interviews were conducted Table 62: Place of Pneumonia Awareness Session, where these exit 60 interviews were conducted Table 63: Distribution of Pneumonia Awareness Sessions, according to 60 number of participants attending the Session Table 64: Distribution of Pneumonia Awareness Sessions, according to 60 number of MALE participants attending the Session Table 65: Distribution of Pneumonia Awareness Sessions, according to 61 number of FEMALE participants attending the Session Table 66: IEC Material Used during Pneumonia Awareness Sessions 61 Table 67: Distribution of Pneumonia Awareness Sessions, according to 61 Number of Posters displayed to conduct Pneumonia Awareness Session (8 Posters were provided by the project) (n=553 Observational PAS) Table 68: Distribution of Pneumonia Awareness Sessions, 62 according to Number of Story books given to the participants to read during session (5 Story Books were provided by the project) (n=553 Observational PAS) Table 69: Distribution of Pneumonia Awareness Sessions, according to 62 number of Audio Message played at CHC &PHC during Pneumonia Awareness Sessions (n=308 Observational PAS at CHC/PHC) Table 70: Distribution of Pneumonia Awareness Sessions, according to 62 number of Video Message played at CHC &PHC during Pneumonia Awareness Sessions (n=308 Observational PAS at CHC/PHC) Table 71: Distribution of Pneumonia Awareness Sessions, according to 63 number of Case Stories shown during Pneumonia Awareness Session (n=308 Observational PAS at CHC/PHC) Table 72: Distribution of participants on gender basis who gave feedback 63 about Pneumonia Awareness Session Table 73: Rating of participants about the pneumonia awareness session 63 Table74: Response of participants when they were asked that what new 64 steps are being taken for spreading awareness about pneumonia? Table 75: Response of participants when they were asked that what benefit 64 you got from attending pneumonia awareness session? Table 76: Advice from the participants about improving pneumonia 65 awareness session Table 77: Number of Pneumonia Drug Kits distributed by CHCs/PHCs & 65 ANMs Table 78: Intervention wise distribution of PDK distributed by ANM 66 Table 79: Intervention wise distribution of Case Record Forms filled by 66 Medical Officers, ANMs and ASHAs. Table 80: Intervention wise age distribution of children, treated with PDK, 67 from whom feedback was collected. Table 81: Source of pneumonia drug kit (for children for whom feedback 67 was collected) Table 82: Did the instruction card, available with pneumonia drug kit, was 68 read before you and made you understand completely? Table 83: Number of days Amoxicillin was administered to the child from 68 pneumonia drug kit. Table 84: of days Paracetamol was administered to the child from 68 pneumonia drug kit Table 85: Average number of days of consumption of Paracetamol & 69 Amoxicillin from Pneumonia Drug Kit in comparison to source of Pneumonia Drug Kit. Table 86: Children, whose parents tick mark in the table in instruction 69 card, after giving every dose of medication from the pneumonia drug kit. Table 87: Children who suffered from diarrhea/rashes, at the time of 69 treatment from pneumonia drug kit Table 88: Treatment taken for diarrhea & rashes (Above table) 70 Table 89: Outcome of child’s illness after the treatment from PDK 70 Table 90: Average number of days of consumption of medicine from PDK 71 (in comparison with outcome of illness) Table 91: Distribution of adverse events (diarrhea/rashes) encountered 71 after use of PDK, with outcome of illness Table 92: Availability of Amoxicillin (through government supply)at 72 Government Health Facilities -Pre, Mid and Post project interventions period Table 93: Availability of Oxygen (through government supply) at 73 Government Health Facilities -Pre, Mid and Post project interventions period Table 94: Intervention wise distribution of study population 74 Table 95: Number of households that were surveyed during Base Line 74 Survey Table 96: Intervention wise distribution of households on basis of Type of 75 Family Table 97: Intervention wise distribution of households on basis of Type of 75 House Table 98: Intervention wise distribution of households on basis of main 76 occupation of family Table 99: Intervention wise distribution of households on basis of type of 76 ration card (N=1434) Table100: Intervention wise distribution of households on basis of 77 availability of separate kitchen Table 101: Intervention wise distribution of households on basis of source 77 of Fuel used for cooking (Multiple Response) Table 102: Intervention wise distribution of households on basis of source 78 of Drinking Water (Multiple Response) Table 103: Intervention wise distribution of households on basis of 78 availability of Electricity Table 104: Intervention wise distribution of households on basis of 79 availability of Toilet Table 105: Gender distribution of family members 80 Table 106: Marital Status of family members 80 Table 107: Education Status of family members 81 Table 108: Population (Children between 2months to 59 months of age) 81 eligible for the survey Table 109: Gender distribution of eligible children 82 Table 110: Age Distribution of eligible children 82 Table 111: Whether the child suffered from Diarrhea /RTI/Fever/ 83 Convulsion in last one year Table 112: Whether the child suffered from Diarrhea in last one year 83 (n = 3302) Table 113: Place of the treatment for Diarrhea (last one year) (Multiple 83 Response) Table 114: Outcome of the treatment of Diarrhea (last one year) (n=1043) 84 Table 115: Number of Episodes of Diarrhea in children in last one year 84 (Descriptive Statistics) Table 116: Total Expenditure on the Diarrhea for last one year (Descriptive 85 Statistics) Table 117: Whether the child suffered from RTI in last one year (n=3302) 85 Table 118: Place of the treatment for RTI (last one year) (Multiple 86 Response) Table 119: Outcome of the treatment of RTI (last one year) (n=3216) 86 Table 120: Number of Episodes of RTI in children for last one year 86 (Descriptive Statistics) Table121: Total Expenditure on the RTI (last one year) (Descriptive 87 Statistics) Table 122: Whether child suffered from running nose, since last one year? 87 Table 123: Age distribution of children, who suffered from running nose in 88 last one year? Table 124: What type of treatment was given to child with running nose? 88 (Multiple Response) Table 125: What all types of health care providers were approached for 89 treatment of running nose (Multiple Response)? Table 126: Children who were advised follow up care after 72 hours for 89 running nose. (n=2336) Table 127: Children with running nose, who were taken for the follow- up 90 after 72 hours. (n=1953) Table 128: Children who suffered from cough with fast breathing (with or 90 without chest in drawing), since last one year? Table 129: Age distribution of children who suffered from cough with fast 91 breathing (with or without chest in drawing), in last one year? Table 130: Type of treatment that was given to children suffering from 91 cough with fast breathing (with or without chest in drawing). (Multiple Response)

Table 131: What all types of health care providers were approached for 92 treatment of children suffering from cough with fast breathing (with or without chest in drawing)? (Multiple Response) Table 132: Children who were advised follow - up care after 72 hours, for 92 from cough with fast breathing (with or without chest in drawing)? (n=585) Table 133: Children, suffering from cough with fast breathing (with or 93 without chest in drawing), who were taken for the follow- up after 72 hour. (n=542) Table134: Children who were admitted in hospital, for treatment of 93 pneumonia in last one year? Table 135: In which type of hospital, was the child was admitted first for 94 pneumonia? (n=30) Table 136: Mothers who have you ever heard about the illness called 94 "pneumonia"? Table 137: Symptoms of pneumonia as responded by mothers. (Multiple 95 Response) Table 138: Source of information about pneumonia? (Multiple Response) 96 Table 139: Mothers who had attended VHND in last 6 month (n=2434) 97 Table 140: Was any information on pneumonia was given on VHND? 97 (n=832) Table 141: Who gave you pneumonia related information on VHND? 97 (Multiple Response) Table 142: Mothers who had attended routine immunization day in last 6 98 months? (n=2460) Table 143: Was any information on pneumonia was given on immunization 98 day? (N=1104) Table 144: Who gave you pneumonia related information on Immunization 99 day? (Multiple Response) Table 145: Intervention wise distribution of new registered children (2-59 103 months of age) and childhood pneumonia cases diagnosed by doctors at government health facilities Table 146: Comparison of childhood pneumonia cases diagnosed by doctors 104 at CHC & PHC (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS) Table 147: Comparison of childhood pneumonia cases diagnosed by doctors 104 at CHC & PHC (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS) Table 148: Intervention wise distribution of estimated cases of childhood 105 pneumonia and children treated by pneumonia drug kit Table 149: Availability of Amoxicillin (through government supply) at 106 Government Health Facilities -Pre, Mid and Post project interventions period Table 150: Comparison of Children suffered from cough with fast breathing 107 with or without chest in drawing (Possible pneumonia), by Intervention.

Table 151: Comparison of health seeking behavior for childhood pneumonia 108 at the government health facilities (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS) Table 152: Comparison of health seeking behavior for childhood pneumonia 109 at the government health facilities (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS Table 153: Comparison of health seeking behavior for Diarrhea at the 110 government health facilities (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS) Table 154: Comparison of health seeking behavior for Diarrhea at the 110 government health facilities (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS) Table 155: Change in knowledge of mothers about the illness called 111 "pneumonia"? Table 156: Change in knowledge of mothers about any symptoms of 112 Pneumonia from base line to end line facilities (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS) Table 157: Change in knowledge of mothers about any symptoms of 112 Pneumonia from base line to end line facilities (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS Table 158: Change in knowledge of mothers about all symptoms of 113 Pneumonia from base line to end line facilities (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS) Table 159: Change in knowledge of mothers about all symptoms of 113 Pneumonia from base line to end line facilities (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS

Table 160: Change in knowledge of mothers about danger symptoms of 114 Pneumonia from base line to end line facilities (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS) Table 161: Change in knowledge of mothers about danger symptoms of 114 Pneumonia from base line to end line facilities (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS Table 162: Change in source of information about pneumonia 115 Table 163: Source of information about pneumonia? (Found only in 115 ENDLINE Survey)

11. List of Pictures Picture 1: Geographic distribution of Study Area 6 Picture 2: Group Photograph of participants on 07th Jan 2016 (Batch 1) 12 Picture 3: Group Photograph of participants on 08th Jan 2016 (Batch 2) 12 Picture 4: ANM training in progress at CHC 15 Picture 5: Role play by ANM for conducting Pneumonia Awareness 15 Session Picture 6: Respiratory Rate counting exercise 15 Picture 7: Orientation & Training of ASHAs at CHC 18 Picture 8: ASHAs completing Pre Test before training 18 Picture 9: Exercise to identify danger signs, during training 18 Picture 10: Role play exercise to conduct Pneumonia Awareness Session by 18 ASHAs Picture 11: Data Collection during Base Line Survey 20 Picture 12: Pulse Oximeter Provided through Project 21 Picture 13: Salbutamol Inhaler provided through project 21 Picture 14: Baby Mask & Spacer provided through project 21 Picture 15: Pneumonia Management Unit at CHC BKT 23 Picture 16: Pneumonia Management Corner at PHC Kasmandi Kala (Block 25 Malihabad) Picture 17: Green Pneumonia Drug Kit 26 Picture 18: Yellow Pneumonia Drug Kit 27 Picture 19: Distribution of IEC material to ASHAs at CHC Sarojini Nagar 28 Picture 20: Pneumonia Awasreness Session at PHC Kehla 30 Picture 21: Pneumonia Awasreness Session at PHC Kasmandi Kala 30 Picture 22: Pneumonia Awasreness Session at PHC Amethi 30 Picture 23: Pneumonia Awareness 31 Session at village Picture 24: Pneumonia Awareness Session at village 31 Picture25: Participants reading 31 story books during PAS Picture 26: Pneumonia Awareness 31 Session at village Picture 27: Re-training of Medical Officers at KGMU on 9th Nov 2016 33 Picture 28: Re-trainings of ANMs at their CHCs 35 Picture 29: Re-Trainings of ASHAs at CHC 36 Picture 30: Pneumonia Awareness Session at CHC Kakori on World 38 Pneumonia Day Picture 31: Pneumonia Awareness Session at CHC Malihabad on World 38 Pneumonia Day Picture 32: Pneumonia Awareness Session at CHC Mall on World 38 Pneumonia Day Picture 33: Pneumonia Awareness 38 Session at CHC Chinhat on World Pneumonia Day Picture 34: TAG Meeting held at KGMU on 9th Sep 2016 40 12. Annexure

Acronyms

1 AHS Annual Health Survey 2 ANM Auxillary Nurse Midwifery 3 APHC Additional Primary Health Centre 4 ASHA Accredited Social Health Activist 5 AWC Aanganwadi Centre 6 BCC Behaviour Change Communication 7 CAP Community Acquier Pneumonia 8 CHC Community Health Centre 9 CMO Chief Medical Officer 10 IEC Information Education and Communication 11 IMNCI Integrated management of neonatal and childhood illness 12 ITT Intention to Treat 13 KGMU King George's Medical University 14 NHM National Health Mission 15 PAS Pneumonia Awareness Session 16 PDK Pneumonia Drug Kit 17 PHC Primary Health Centre 18 RI Routine Immunization 19 RTI Respiratory Tract Infection 20 SC Sub Centre 21 SRS Sample Registration System 22 VHND Village Health & Nutrition Day 23 PP Possible Pneumonia

1. Executive Summary

Background: Community Acquired Pneumonia (CAP) is the leading cause of childhood morbidity and mortality worldwide and in India. It was estimated that 408,000 children less than 5 years died due to clinical pneumonia in India (World Health Statistics. Geneva: WHO; 2007). Many of these deaths can be averted by creating awareness in the community about early symptoms of CAP and by ensuring availability of round the clock, quality health care.

Hypothesis: Strengthening of public health system to provide sustainable quality care for cases of childhood pneumonia (CAP) followed by strategic dissemination of validated messages to community may improve care seeking behavior for CAP within 12 months that can be measured by 50% improved utilization of services from qualified public health care providers (over the utilization rate at baseline).

Primary Objective 1: To assess the effectiveness of an innovative package of “Community Orientation” of doctors and ANMs and ASHAs, PLUS infrastructural strengthening by (i) providing “Pneumonia Drug Kit” (PDK) (ii) establishing “Pneumonia Management Corner” (PMC) at additional primary health center (APHC) and (iii) “Pneumonia Management Unit” (PMU) at Community health center (CHC) ALONG with one of the 4 different behavior change communication interventions:

Intervention 1: Organizing Childhood Pneumonia Awareness Sessions (PAS) for caregivers of children <5 years of age during a routine immunization day, using self- developed and validated IEC materials, in APHCs and CHC monthly, conducted by a trained ANM and project facilitator. Intervention 2: Organizing PAS on Village Health and Nutrition Day (V.H.N.D.) only once a month by the ASHA worker trained for this.

Intervention 3: Combination of Both Intervention 1& 2 Intervention 4: Usual Care On: Number of clinical pneumonia cases-treated by ANMs/doctors with medicines from PDK OR Treated at either PMC or PMU

Primary Objective 2:To ascertain change, if any, in the types of health care providers’ service utilization for acute respiratory illness (ARI)/CAP in last one year in children less than 5 years pre and post intervention.

Research Design: A prospective Community Based Open Labeled Behavioral Trial conducted in 2 by 2 factorial design in 8 rural blocks of Lucknow district after (a) capacity building of doctors, ANMs and ASHA workers by conducting training sessions and (b) establishing of PMC, PMU and distribution of PDK and ensuring other infra-structural up-gradation for facility based management of CAP. Community survey was done at baseline and end line, by multistage cluster

sampling to collect information on changes in the types of health care providers’ service utilization for ARI/CAP. (Registration no.AEARCTR-0003137)

Results: From December 2015, Orientation trainings were done for Medical Officers [59/68 (87%) participants]; for ANMs in 9 batches [302/344 (88%)] and for ASHAs in 34 batches [1236/1486 (83%)]. After approximately one year, refresher trainings were organized for Medical Officers in November 2016 [31/69 (45%) participants]; for ANMs in 10 batches [292/327 (89%)] and for ASHAs in 34 batches [1203/1431 (84%)].

In December 2015, infrastructural strengthening of public health system was done by establishing 9 Pneumonia Management Units (PMU) in Community Health Centers and 33 Pneumonia Management Corners (PMC) in Primary Health Centres, with beds earmarked for the treatment of children with CAP. Project provided Pulse Oximeter, Salbutamol Inhaler with baby mask & spacer and Pneumonia Drug Kits. To assess the care seeking behavior for CAP, base line survey (Feb to May, 2016) and end line survey (Dec, 2017 to Apr/2018) were done. During the intervention phase, from August 2016 to December 2017, adherence to conduct of PAS was 92.7% (139/150) in intervention 1, 79.6% (4058/5100) in intervention 2, and 68.1% (3720/5460) in intervention 3. In blocks where PAS were conducted by ASHA, there was statistically significant increase in cases of CAP treated at CHC and PHC with corresponding (77.2%) increase of self-reported choice of government provider for its treatment, at end line. Where ANM delivered intervention, the improvement in these parameter after taking time trend into account, were not statistically significant. Follow up of 717 children treated with PDK was done and 85% (609/717) improved and 15% (108/717) took other treatment. Adverse effects reported with PDK were diarrhea in 3.9% (28/717) and rashes in 0.4% (3/717).

Conclusion: Conduct of PAS in the form of provision of validated visual aids to ASHA in village and training them for conducting awareness sessions with these in a standardized methodology resulted in increased trust in public health system as evident by improved care seeking.

Recommendation: Structured delivery of awareness about common childhood diseases by ASHA in villages after training & providing validated teaching aids and supportive supervision is likely to result in improvement in quality of care and will assist in achieving sustaining developmental goals.

The study is registered with “The American Economic Association’s Registry for Randomized Controlled Trials”. RCT ID is: AEARCTR-0003137

2. Introduction: Pneumonia, the leading cause of childhood morbidity and mortality worldwide, is responsible for deaths of more than 2 million children annually (UNICEF Progress Report on Child Mortality, 2014). Among these, two-third deaths are concentrated in just 10 developing countries, India being one of them. It is estimated that 408,000 children less than 5 years die due to clinical pneumonia in India(World Health statistics, 2007). Many of these deaths can be averted by creating awareness of the community about early signs of pneumonia and by ensuring availability of round the clock, quality health care.

2.1 Socio-demographic and health profile of study area: This study was conducted in rural areas of Lucknow district, which is the capital of state of Uttar Pradesh in North India. Lucknow district has a population of 4,589,838, of which 33.79% are rural. Here, there are 8 rural administrative blocks. The rural blocks have total population of 15,50,842, and total geographical area of 209542.744 hectare (Census 2011).

Table 1: Demographic & Health profile of Lucknow

Lucknow Uttar Pradesh Area (Census 2011) 2095.4sq kms (Rural 2,36,286 sq kms Lucknow) Rural Population (Census 2011) 15.51 Lakh 1551.11 Lakh Literacy % (Census 2011) 79.33 69.72 Crude Birth Rate (SRS 2014) 18.8 27.2 Infant Mortality Rate 45 (AHS 2011) 64 (NFHS - 4) Maternal Mortality Rate 330 (AHS 2011) 285 (SRS 2012-13) Under 5 Mortality Rate 60 (AHS 2011) 78 (NFHS - 4)

Public health system for each of these blocks comprises of at least one (and in one block two) community health center (CHC) with outpatient care by doctors including pediatricians and 30 inpatient beds. Under each CHC are primary health centers (PHCs) for approximately 100,000 population with outpatient facilities and 4 beds. The lowest level of care is through a sub-center with an ANM. Existing health infrastructure in Lucknow block at the initiation of the project is given in Table 2.

Table 2: Health Infrastructure of Lucknow District, at the time of initiation of study

Health Infrastructure of Lucknow District Number Blocks 08 * Community Health Centre (CHC) 09 Total Sub Centre (SC) 345 Functional SC 331 Non Functional SC 14 Additional Primary Health Centre (APHC) z28 Accredited Social Health Activist (ASHA) 1246 Auxillary Nurse Midwife (ANM) 331 Super specialty hospitals 03 District combined hospitals 04 District hospitals 03 District Women hospitals 02 Number of AYUSH hospital/dispensary 78 Number of Ayurvedic hospital/dispensary 49 Number of homeopath hospital/dispensary 29 *BKT Block has two CHCs. Rest 7 blocks have one CHC each.

2.2 Project Background: We conducted a project entitled “Improving household decision-making for the management of Pediatric pneumonia in Uttar Pradesh and Bihar” funded by Bill and Melinda Gates Foundation (Global Health Grant No: OPP1093327). In this project, after extensive formative research on childhood pneumonia in Uttar Pradesh and Bihar (14 districts), we found that pneumonia related morbidity and mortality can be averted if the following barriers are addressed:

(a) delay in symptom recognition (b) delay in timely and qualified health care seeking (c) distrust of the community on the available public health services.

Thereafter, we developed and validated text, audio, video messages to address these barriers. Specifically, messages were developed on

(a) symptom recognition (b) where and when to seek treatment (c) how to approach a care provider and negotiate for quality of care (d) risk vulnerability perception.

The proposed project aims to leverage the extensive work done and conduct operations research to address these three barriers to health care seeking through innovative community based approaches using messages developed by us as well as by strengthening the existing public health system. (Awasthi et al; available at “http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0123135”)

2.3 Study Rationale: Establishment of PMU, PMC, PDK plus community orientation of doctors, ANMs and ASHA workers: Strengthening the capacity CHCs, PHCs and SCs for the management of CAP will result in better delivery of pneumonia specific care; this will build community’s trust in the public health system.

Behavior change communication for demand generation for pneumonia management by the community: To ensure optimal utilization of augmented health facilities by measures mentioned above, a behavior change in the community will be needed, with respect to management of CAP. This behavior change can be brought about by various BCC strategies that utilize the messages developed by us. Effective behavior change is likely to result in demand generation for better quality of care from the public health sector for CAP by the community.

To identify the most effective BCC strategy, PAS will be conducted for caregivers who voluntarily bring their children for immunization either at the PHC/CHC or on VHND at the Anganwadi center (AWC) as are likely to be receptive to health education messages. There will also be diffusion of messages in the community. PAS will bridge the gap and build confidence of the community in the public health system and services. We will be able to identify what is the minimum effective package of services that will result in optimal utilization of augmented public health facilities.

2.4 Study Design: This was a Community Based Open Labeled Behavioral Trial conducted in 2 by 2 factorial design.

Table 3: Study Design (2 by 2 factorial design)

PAS at CHC/PHC Yes No

Gosaiganj Block and Mall Block BakshiKaTalab Block and Chinhat

(Intervention 1) Block

No (Intervention 4)

Malihabad Block and Sarojini Nagar Block and Kakori Block

Mohanlalganj Block (Intervention 2) PAS at Village at PAS Yes (Intervention 3)

Picture 1: Geographic distribution of Study Area

Twoblocks, proportionately equal in terms of number of ASHA workers (roughly equal to be number of villages) have been purposively paired and then randomly assigned to an interventional arm. 2.5 Project Objectives: 2.5.1 Primary Objective 1 Our primary objective 1 is to assess the effectiveness of an innovative package of orienting doctors and community health workers (CHW) about community perceptions on CAP barriers to qualified health care seeking plus infrastructural strengthening by (i) providing “Pneumonia Drug Kit” (PDK) (ii) establishing “Pneumonia Management Corner” (PMC) at primary health center (PHC) and (iii) “Pneumonia Management Unit” (PMU) at Community health center (CHC) ALONG with one of the 4 different behavior change communication (BCC) interventions: Intervention 1: Organizing Childhood Pneumonia Awareness Sessions (PAS) for caregivers of children <5 years of age during a routine immunization day, using self-developed and validated Information, Education and Communication (IEC) materials, in PHCs and CHC monthly, conducted by a trained Auxiliary Nurse Midwife (ANM) and project facilitators. Intervention2: Organizing PAS on Village Health and Nutrition Day (V.H.N.D.) once a month by the Accredited Social Health Activist (ASHA) trained to conduct such sessions Intervention3: Combination of Both Intervention 1& 2 Intervention4: Usual Care Outcome measure will be number of CAP treated by ANMs/doctors with medicines from PDK or treated at either PMC or PMU.

2.5.2 Primary Objective 2: Our primary objective 2 is to ascertain change, if any, in the types of health care providers’ service utilization for Acute Respiratory Illness (ARI)/CAP in last 12 months in children less than 5 years pre and post intervention.

2.6 Study Time Lines

Project Timelines Year 1 Year 2 Year 3

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Milestone Oct to Jan to Apr to Jul to Oct to Jan to Apr to Jul to Oct to Jan to Apr to Jul to Dec 15 Mar 16 Jun 16 Sep 16 Dec 16 Mar 17 Jun 17 Sep 17 Dec 17 Mar 18 Jun 18 Sep 18

Project Roll out

Pre Intervention Phase Development of Training Material & Data Collection Tools Orientation Training of Medical Officers Orientation Training of ANMs Orientation Training of ASHAs Base Line Survey Establishment of Pneumonia Management Units & Corners Distribution of Pneumonia Drug Kit Distribution of IEC Material Intervention Phase Pneumonia Awareness Sessions conduction & Monitoring Re-distribution of IEC Material Re-training of Medical Officers Re-training of ANMs Re-training of ASHAs

Year 1 Year 2 Year 3 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Milestone Oct to Dec Jan to Apr to Jul to Sep Oct to Dec Jan to Apr to Jul to Sep Oct to Dec Jan to Apr to Jul to Sep

15 Mar 16 Jun 16 16 16 Mar 17 Jun 17 17 17 Mar 18 Jun 18 18 Post Intervention Phase End Line Survey Data Management & Analysis

Other Activities Health Facility Audit TAG Meeting TAG Visit Pre Intervention Phase: October 2015 to July 2016

Intervention Phase: August 2016 to December 2017

Post Intervention Phase: January 2018 to September 2018.

3 Pre Intervention Phase (Preparation for Data Collection & Intervention) Project started on 15th October 2015, after seeking approval from

1. Institutional Ethics Committee, King George’s Medical University, via letter number 3692/Ethics/R.Cell-15, dated 02/03/2015(Annexure 1), 2. Mission Director, National Health Mission, Uttar Pradesh, via letter number APMU/CH/DM/29/2014-15, dated 01/07/2014(Annexure 2) 3. Office of Chief Medical Officer Lucknow via letter number MU. CHI. A./Project/PCPSS/2014-15/12000-16 dated 12/12/2014(Annexure 3). Pre intervention phase (October 2015 to July 2016) was utilized to develop various training materials, data collection tools, conduct Orientation trainings of Medical Officers, ANMs & ASHAs, conduct base line survey, procurement of drug & repackaging of Pneumonia Drug Kits, establishment of Pneumonia Management Units & Corners and distribution of IEC material to ASHAs and ANMs.

3.1 Development of training & Data Collection Tools Following training and data collection tools were developed. Then their pilot testing was done in real life situations, before finalizing.

1. Case Record Form for Medical Officers 2. Job Card for Medical Officers for assessment, classification and management of sick child (2 months to 5 years) presenting with cough and difficult breathing. 3. Case Record Form for ANMs 4. Job Card for ANMs for assessment, classification and management of sick child (2 months to 5 years) presenting with cough and difficult breathing 5. Case Record Form for ASHAs 6. Job Card for ASHAs for assessment, classification and management of sick child (2 months to 5 years) presenting with cough and difficult breathing 7. Base Line Survey Questionnaire 8. Instruction Card for Pneumonia Drug Kit (Annexure 4) 3.2 Orientation Trainings

3.2.1 Orientation Training of Medical Officers: Community Orientation of Doctors posted at Community Health Centers and Primary Health Centers was conducted on 7th& 8th Jan, 2016 at KGMU in 2 batches. Total 28 participants were registered on 7th Jan 2016 and 31 participants were registered on 8th Jan 2016. In all, training was attended by 59/68 (87%) Medical Officers.

Table 4: Qualification of participants who attended the training

Qualification No. of Participants Pediatrician 5 MBBS 20 Ayush 25 Other* 3 Anonymous 6 (did not disclose their qualification) Total 59 Participants who had previously received 3 F-IMNCI Training * MS & DGO

The objective of training was to orient Medical Officers about 1. Project & proposed activities 2. Assessment, classification and management of sick child (2 months to 5 years).

The agenda of orientation meeting was focused on the following items: a. Project Orientation b. Strengthening of infrastructure & activities proposed in the project c. Management of child (2 months – 5 years) with cough and difficult breathing at facility level d. Treatment of Severe Pneumonia & follow up care e. Recording and reporting of Pneumonia cases at various level f. BCC messages for childhood pneumonia

The training was provided by Project Investigator, Co-Investigator and other resource person from King George’s Medical University. A pre &post test was also completed by the participants A job card was also given to the participants explaining the assessment, classification and management of sick child (2 months to 5 years) presenting with cough and difficult breathing.

Table 5: Result of Pre and Post Test of Medical Officers, conducted during Orientation Training

Questions based on Questions based on Questions based on assessment of sick child classification of Pneumonia treatment of Pneumonia Qualification Total no. of % of participants who gave % of participants who gave % of participants who gave of participants participants correct response correct response correct response Pre Test Post Test Pre Test Post Test Pre Test Post Test Pediatrician 5 76 94 20 46 46 84 MBBS 20 52.5 71.5 28.5 48.5 31 57.5 Ayush 25 39.2 75.6 25.2 53.2 22 55.2 Others* 3 50 50 0 10 43.3 56.7 Anonymous 6 56.7 26.7 38.3 33.3 46.7 25.0 Total 59 49.2 69.7 25.9 46.9 30.8 55.4 IMNCI Trained 3 56.7 90 23.3 33.3 26.7 83.3 * MS & DGO

Training of Medical Officers significantly increases their knowledge on assessment of sick child, classification of Pneumonia and management of childhood pneumonia cases (p value <0.0001). Most significant improvement is shown by Ayush Medical Officers (p value of 0.002 for assessment of sick child and p value of 0.008 for classification & management of childhood pneumonia)

Picture 2: Group Photograph of participants on 07th Jan 2016 (Batch 1)

Picture 3: Group Photograph of participants on 08th Jan 2016 (Batch 2)

3.2.2 Orientation Training of ANMs The Community orientation meetings of ANM were conducted at their respective CHC’s. Total 302/344 (88%) ANMs attended the meeting in 9 separate batches at their respective CHC’s. Meetings were scheduled between 08-Feb-2016 to 01-Apr-2016.

Table 6: Block wise attendance of participants Sr. Name of Block Name of CHC No. of Date of Participants No. Batches Training 1 Gosaiganj Gosaiganj 1 08/Feb/2016 36/41 88% 2 Kakori Kakori 1 11/Feb/2016 42/45 93% 3 Sarojini Nagar Sarojini Nagar 1 01/Mar/2016 49/60 82% 4 Mall Mall 1 04/Mar/2016 23/30 77% 5 Mohanlal Ganj Mohanlal Ganj 1 08/Mar/2016 40/42 95% 6 Malihabad Malihabad 1 11/Mar/2016 37/40 93% 7 BakshiKaTalab BakshiKaTalab 1 14/Mar/2016 28/32 88% 8 Chinhat Chinhat 1 21/Mar/2016 28/35 80% 9 BakshiKaTalab Itaunja 1 01/Apr/2016 19/19 100% Total 9 302/344 88%

The objective of training was to orient ANMs about 1. Project & proposed activities 2. Assessment, classification and management of sick child (2 months to 5 years). 3. Conduction of Pneumonia Awareness Sessions (where applicable)

The agenda of orientation meeting was focused on the following items: a. Project Orientation (Including strengthening of infrastructure & activities proposed in the project) b. Management of child (2 months – 5 years) with cough and difficult breathing c. Recording and reporting of Pneumonia cases d. Distribution and reporting of Pneumonia Drug Kits. e. BCC messages for childhood pneumonia. f. Role play for conducting Pneumonia Awareness Session (only where applicable)

IMNCI Video in Hindi was used to teach participants on how to assess and classify CAP. The trainings were provided by Project Investigator and Co-Investigator.

A pre &post test was also completed by the participants.

A job card was also given to the participants explaining the assessment, classification and management of sick child (2 months to 5 years) presenting with cough and difficult breathing.

Table 7: Result of Pre and Post Test of ANMs, conducted during Orientation Training

Questions based on Questions based on Questions based on assessment of sick child classification of pneumonia management of pneumonia Block Total no. of % of participants who gave % of participants who gave % of participants who gave participants correct response correct response correct response Pre Test Pre Test Pre Test Post Test Pre Test Post Test BKT 28 60.4 80.7 89.3 98.2 89.3 95.7 Malihabad 31 61.3 73.9 93.5 100.0 79.0 93.5 Itaunja 19 74.7 76.8 97.4 89.5 88.2 81.1 Gosaiganj 34 57.9 74.4 97.1 98.5 83.1 82.9 Sarojini Nagar 46 50.9 67.6 76.1 93.5 48.5 65.2 Kakori 41 60.5 72.7 98.8 100.0 80.5 84.9 Chinhat 27 60.0 76.7 83.3 87.0 57.4 74.1 Mall 23 58.3 74.8 78.3 89.1 71.7 83.5 Mohanlalganj 40 64.4 70.7 92.7 85.4 75.0 81.0 Total 290 60.0 73.5 89.5 93.8 73.3 81.6

Training of ANMs significantly increases their understanding on how to assess sick child, classification and management of childhood pneumonia cases (p value <0.0001). Most significant improvement is shown by ANMs at Sarojini Nagar Block (p value of 0.016 for assessment of sick child and p value of 0.008 for classification & management of childhood pneumonia)

Picture 4: ANM training in progress at CHC

Picture 5: Role play by ANM for conducting Pneumonia Awareness Session

Picture 6: Respiratory Rate counting exercise

3.2.3 Orientation Training of ASHAs

As with ANMs, the community orientation meetings of ASHA’s were also organized at their respective CHC’s. Total 1236/1486 (83%) ASHAs attended the meetings in 34 separate batches. Meetings were scheduled from 04-Apr-2016 till 24-Jun-2016.

Table 8: Block wise attendance of participants Sr. Name of Block Name of CHC No. of Participants No. Batches 1 Gosaiganj Gosaiganj 5 176/202 87% 2 Kakori Kakori 4 147/160 92% 3 Sarojini Nagar Sarojini Nagar 4 161/208 77% 4 Mall Mall 4 149/180 83% 5 Mohanlal Ganj Mohanlal Ganj 6 197/220 90% 6 Malihabad Malihabad 2 131/157 83% 7 BakshiKaTalab BakshiKaTalab 4 122/180 68% 8 Chinhat Chinhat 2 59/74 80% 9 BakshiKaTalab Itaunja 3 94/105 90% Total 34 1236/1486 83% The objective of training was to orient ASHAs about 1. Project & proposed activities 2. Assessment, classification and management of sick child (2 months to 5 years). 3. Conduction of Pneumonia Awareness Sessions (where applicable)

The agenda of orientation meeting was focused on the following items: a. Project Orientation (Including strengthening of infrastructure & activities proposed in the project) b. Identification and referral of child (2 months – 5 years) with cough and difficult breathing c. Recording, reporting and referral of Pneumonia cases d. BCC messages for childhood pneumonia. e. Role play for conducting Pneumonia Awareness Session (only where applicable)

Lectures and Video tools were used to impart training. These trainings were provided by Project Coordinator and Filed Investigator. Medical Superintendent at respective Community Health Centers were Observer for the trainings. A pre &post test was also completed by the participants. A job card was also given to the participants explaining the assessment, classification and management of sick child (2 months to 5 years) presenting with cough and difficult breathing.

Table 9: Result of Pre and Post Test of ASHAs, conducted during Orientation Training Questions based on Questions based on Questions based on assessment of sick child classification of pneumonia management of pneumonia Block Total no. of % of participants who gave % of participants who gave % of participants who gave participant correct response correct response correct response Pre Test Post Test Pre Test Post Test Pre Test Post Test BKT 121 59.2 74.2 86.4 93.8 87.2 94.6 Malihabad 131 51.1 75.8 84.4 93.9 82.4 93.1 Itaunja 94 65.0 78.9 88.8 94.1 91.0 92.0 Gosaiganj 176 60.5 73.9 81.3 90.6 86.9 90.9 Sarojini Nagar 161 56.5 79.0 74.5 95.7 92.5 97.2 Kakori 147 61.3 77.6 84.4 96.6 92.5 95.2 Chinhat 59 53.4 73.7 74.6 83.9 86.4 78.8 Mall 148 60.2 74.5 78.7 92.9 87.5 92.2 Mohanlalganj 196 58.0 75.6 74.0 94.1 91.1 93.1 Total 1233 58.5 76.0 80.4 93.4 88.9 92.9 ASHAs of all the blocks had demonstrated significant increase their knowledge on assessment, classification and management of childhood pneumonia cases (p value <0.0001).

Picture 7: Orientation & Training of Picture 8: ASHAs completing Pre Test ASHAs at CHC before training

Picture 9: Exercise to identify danger Picture 10: Role play exercise to signs, during training conduct Pneumonia Awareness Session by ASHAs

3.3 Base Line Survey Base Line Survey was started on 16-Feb-2016 and was completed on 12 –May-2016. It was conducted in all 8 rural blocks of the district Lucknow (capital of Uttar Pradesh)i.e. BakshikaTalab, Chinhat, Gosaiganj, Kakori, Malihabad, Mall, Mohanlalganj & SarojiniNagar. In each block 30 villages were selected and from each village 10 households were selected. 300 households were interviewed from each block. Overall 2400 households were interviewed for the study.

3.3.1 Survey methodology The sampling technique used for base line survey, was based on WHO 30 cluster sampling. Village data for all 8 blocks was taken from Census 2011. Census 2011 provides several characteristics of the village along with total number of households. Villages were stratified on basis of number of households. If the number of household were in the range of 1-200 the village was considered as small village, if in the range of 201-400 households then it was considered as medium village and if village has 401 or more households, then it was considered as large village. Each block was divided into three strata of small, medium and large village. Thirty villages were selected from each block using stratified random sampling with proportional allocation.

After the selection of the village, the households were selected for the study. For this ASHA/ANM were consulted and were asked for the list of the households having children aged between 2-59 months; such households were termed as Eligible Households. We divided each village into 5 ends i.e. east end, west end, south end, north end, and central part and we select 3 households from each part. We select 15 Eligible households from the list in each village, but survey was conducted in 10 Eligible households only from each village and rest of the 5 households was kept as a back-up plan.

3.3.2 Inclusion Criteria of the household Study was conducted only in those households which full-fill the following criteria: 1. Should live in the house since the last six months. 2. Should be the owner of the house. 3. Should stay in this house for one year. 4. Family should have children aged between 2-59 months.

3.3.3 Data Collection All the data in the survey was collected by interview method. Prior to the interview in the eligible households, consent of the head of the family was taken and in case if head of the family is not available then consent was taken by acting head of the family. In case interviewee refused to give consent then survey was not conducted in that household and

19 the field worker moved to the next eligible household and followed the same process. Data collection was started on 16th February, 2016 and ended on 12th May, 2016.

It was proposed to collect information at household level as well as individual level i.e., from each eligible mother of the households i.e. mother having at least one child aged between 2-59 months. A questionnaire was prepared according to the rural areas In the starting part information for the family member was asked, Socio-demographic condition of the households, complete information on the health status of the all the eligible children, also pneumonia like symptoms (running nose and cough with fast breathing[with or without chest in drawing]) to the individual child, then questions related to awareness of eligible mothers about pneumonia were asked. Questions were asked from the interrogators according to the survey methodology.

3.3.4 Quality Assurance Outcome of the data rely on the quality of the data, so the most important part of any survey is the quality of the data provided. If the data provided after the interview is not good than the outcome which estimated would not be possible. The quality assurance of the data was maintained by the visits made by Project Co-coordinator and Field Investigator. Project Coordinator monitored 20% and Field Investigator monitored 30%, of data collection process, to assure quality of data.

Picture 11: Data Collection during Base Line Survey

3.4 Infrastructural Strengthening Infrastructural strengthening of existing government health facilities (CHCs & PHCs) in rural blocks of Lucknow, was done with the objective of providing facility based care to the childhood pneumonia cases (2 months to 5 years).

For this purpose, we established Pneumonia Management Units at CHCs and Pneumonia Management Corners at PHCs. Along with this we provided material essential for the assessment and treatment of childhood pneumonia cases.

Table 10: Equipments/Medicines provided to all the CHCs & PHCs Sr. No. Name of Equipment/Medicine 1 Pulse Oximeter 2 Baby Mask with Spacer 3 Salbutamol Inhaler 4 Pneumonia Drug Kit

Picture12: Pulse Oximeter Provided Picture 13: Salbutamol Inhaler provided through Project through project

Picture 14: Baby Mask & Spacer provided through project

3.4.1 Establishment of Pneumonia Management Units The Pneumonia Management Units were established at the Community Health Centers (CHCs) with the objective of infrastructural strengthening, from 21-Jun-2016 to 05-Aug-2016.

The PMUs were meant for the treatment of pneumonia with fast breathing with lower chest in-drawing and admission of patients of pneumonia with hypoxia and severe pneumonia.

For this purpose Two existing beds were earmarked as pediatric pneumonia beds. Project provided Pneumonia Drug Kits, Pulse Oximeter, Spacer with baby mask and salbutamol inhaler.

State Government was requested to maintain 24*7 availability of Doctor & nurse; maintain supply of Injectable like ampicillin, gentamycin, ceftriaxone, corticosteroids and vasopressors (Dopamine), calcium, potassium, intra venous fluids like dextrose saline, ringer lactate; Oral antipyretics, co-trimoxazole, bronchodilators, oxygen, face mask, suction machine and mucus extractors, laryngoscope, endotracheal tube, ambu bag, thermometer, pediatric sphygmomanometer, nebulizer with nebulizer solution of salbutamol, epinephrine and steroid, intravenous cannula, venous cut open set, warn air blowers or heaters. The PMUs were established in all the 9 CHCs of all 8 rural blocks of Lucknow.

Table11: List of CHCs where Pneumonia Management Unit was established (along with date of establishment) Intervention Block CHC Date of establishment of PMU Intervention 1 Gosaiganj Gosaiganj 05-Aug-2016 Mall Mall 21-Jun-2016 Intervention 2 Kakori Kakori 11-Jul-2016 Sarojini Nagar Sarojini Nagar 29-Jul-2016 Intervention 3 Malihabad Malihabad 25-Jul-2016 Mohanlalganj Mohanla 01 - Aug - 2016 vcbbbbblganj Intervention 4 Chinhat Chinhat 05-Aug-2016 BakshiKaTalab BakshiKaTalab 23-Jun-2016 Itaunja 24-Jun-2016

Picture 15: Pneumonia Management Unit at CHC BKT

3.4.2 Establishment of Pneumonia Management Corners The Pneumonia Management Corners were established at the Primary Health Centers (PHCs) with the objective of infrastructural strengthening, from 21-Jun- 2016 to 30-Aug-2016.

The PMCs were meant for the treatment of pneumonia with fast breathing and stabilize & refer pneumonia with lower chest in-drawing hypoxia and severe pneumonia. For this purpose one existing beds were earmarked as pediatric pneumonia beds. Project provided Pneumonia Drug Kits, Pulse Oximeter, spacer with baby mask and salbutamol inhaler. State Government was requested to maintain 24*7 availability of Doctor & nurse; maintain supply of Injectibles like ampicillin, gentamycin, ceftriaxone, corticosteroids and; Oral antipyretics, co-trimoxazole, oxygen, face mask, suction machine and mucus extractors, laryngoscope, endotracheal tube, ambu bag, thermometer, pediatric sphygmomanometer,

The PMCs were established in all the 33 PHCs of all 8 rural blocks of Lucknow.

Table 12: List of PHCs where Pneumonia Management Corner was established (along with date of establishment) Intervention Block PHC Date of establishment of PMC Gangaganj 27-Jul-2016 Amethi 27-Jul-2016 Gosaiganj KatraBakkas 26-Jul-2016 Kewli 21-Jul-2016 Intervention 1 Behroli 21-Jul-2016 Bazar Gaon 04-Jul-2016 Mall Saspan 21-Jun-2016 Hasnapur 27-Aug-2016 Bada Gaon 06-Jul-2016 Kakori Fatehganj 06-Jul-2016 Ain 30-Aug-2016 Behta 19-Jul-2016 Intervention 2 Haravani 13-Jul-2016 Sarojini Nagar Chandrawal 13-Jul-2016 Nadarganj 13-Jul-2016 Uthrathiya 19-Jul-2016 Kasmandi Kala 04-Jul-2016 Malihabad Kehla 18-Jul-2016 Rahimabad 18-Jul-2016 Khujauli 20-Jul-2016 Intervention 3 Sisendi 20-Jul-2016 Mohanlalganj Nigoha 14-Jul-2016 DakhinaSekhpur 14-Jul-2016 Nagram 14-Jul-2016 Juggor 23-Jul-2016 PoorabGaon 23-Jul-2016 Chinhat Mahatma Gandhi 24-Aug-2016 Swasthya Kendra Kathwara 23-Jun-2016 Intervention 4 Rajgarha 15-Jul-2016 Gudumba 23-Jun-2016 BakshiKaTalab Kumharawa 24-Jun-2016 Mahona 23-Jun-2016 Bharigahna 24-Jun-2016

Picture 16: Pneumonia Management Corner at PHC Kasmandi Kala (Block Malihabad)

In addition this, project had also provided pediatric spyghnomanometers, nebulizers and glucometers. 3.5 Pneumonia Drug Kits Pneumonia Drug Kits were meant to treat patients (between 2months to 5 years), with Childhood Pneumonia, who can be managed without hospitalization.

3.5.1 Procurement of Drugs & Packaging of Pneumonia Drug Kit

Amoxicillin 250 mg Dispersible Tablets & Paracetamol 500 mg Tablets were purchased from open market. QC Certificate for individual batched of these drugs was also obtained. Pneumonia Drug Kits were first pilot tested in the field. Kits were shown to Medical Officers and ANMs, Their feedbacks were taken and valid ones were incorporated.

Permission from NHM was also obtained, to use NHM logo on Pneumonia Drug Kits, vide letter no. APMU/CH/DM/29/2015-16/10970 dated 01/03/2016.

The pneumonia drug kit had three components: a) Amoxicillin 250 mg Dispersible Tablet – They were packed in a small plastic envelop mentioning drug name, its batch number and date of expiry.

25 b) Paracetamol 500 mg Tablet – These were packed in a small plastic envelop mentioning drug name, its batch number and date of expiry. c) Instruction Card: An instruction card was enclosed in each kit. The front page of card depicts the signs & symptoms of Pneumonia. Second and third pages have instruction about usage of drug kit and the last page had a table, which was meant to be marked by the parent after every dose given from the kit. These all three components were packed in a bigger plastic envelop to form Pneumonia Drug Kit.

Pneumonia Drug Kits were prepared in two variants – Green & Yellow. Green Pneumonia Drug Kit: Green kits were meant for children between 2 - 12 months of age. The kit contains 10 tablets of Amoxicillin 250 mg Dispersible Tablet and 4 tablets Paracetamol 500 mg and an instruction card. Picture 17: Green Pneumonia Drug Kit

Yellow Pneumonia Drug Kit: Yellow kits were meant for children between 1 - 5 years of age. The kit contains 20 tablets of Amoxicillin 250 mg Dispersible Tablet and 4 tablets Paracetamol 500 mg and an instruction card.

Picture 18: Yellow Pneumonia Drug Kit

3.5.2 Distribution of Pneumonia Drug Kits Supply of Pneumonia Drug Kits from KGMU to CHCs & PHCs was initiated on 21- June-2016 and was maintained till October 2017. In the first month supply, 2462 Pneumonia Drug Kits were supplied to CHCs & PHCs (15 Green & 15 Yellow kits at each CHC and 10 Green & 10 Yellow kits at each PHC ).For ANMs, we had supplied 2 green and 2 yellow kits per ANM at their respective CHC as first month supply. Kits to ANMs were distributed through their respective CHCs. Based on the rate of consumption; kits were replenished at the facilities.

3.6 IEC Material 3.6.1 Methodology of IEC material development In our last study, after extensive formative research on childhood pneumonia in Uttar Pradesh and Bihar (14 districts), we found that pneumonia related morbidity and mortality can be averted if the following barriers are addressed: (a) delay in symptom recognition (b) delay in timely and qualified health care seeking (c) distrust of the community on the available public health services. Thereafter, we developed and validated text, audio, video messages to address these barriers. Specifically, messages were developed on (a) symptom recognition (b) where and when to seek treatment (c) how to approach a care provider and negotiate for

quality of care (d) risk vulnerability perception. Detailed project report is available at www.fightpneumonia.org

Table 13: IEC Material developed through project Sr. No Name of IEC Material Numbers 1 Posters 3 2 Story Calendars 5 3 Story Books 5 4 Video Messages 3 5 Case Stories 5 6 Audio Messages 4

3.6.2 Distribution of IEC material

The pre-developed and validated IEC material was distributed to ANMs & ASHAs in July to Sep 2016. The IEC material was distributed to all the ANMs and ASHAs across all the blocks.

The following materials were provided:

a. 3 Posters b. 5 Story Calendars c. 5 Story Books

ANMs and ASHAs were advised to display this material at Sub Centers & Aanganwadi Centers and use this material for the spread of awareness about Pneumonia by conducting Pneumonia Awareness Sessions (in applicable interventions only).

Picture 19: Distribution of IEC material to ASHAs at CHC Sarojini Nagar

4. Intervention Phase

Intervention phase was started on August 2016 and was continued till December 2017.

4.1 Pneumonia Awareness Sessions Pneumonia Awareness Sessions were conducted with the objective of creating awareness about: a. Early recognition of symptoms of Pneumonia b. Early care seeking c. Selection of service provider

Interventions were started from August 2017. Since this was a new program for the government health workers, months of August & September 2017 were considers as preparatory phase where Project Team facilitated and motivated the ANMs and ASHAs for conducting Pneumonia Awareness Sessions regularly.

4.1.1 Pneumonia Awareness Sessions at CHC & PHC: PAS at CHC & PHC were conducted by ANM, on routine immunization day, on monthly basis. These sessions were facilitated by project team. These sessions were conducted by using following IEC material, provided through project.

a. Video and audio messages through projector b. 5 posters c. 5 story calendars d. 5story books

PAS at CHC and PHC were conducted at Gosaiganj, Mall, Malihabad & Mohanlalganj blocks.

The participants in the Pneumonia Awareness Sessions were the parents of children who visit CHC/PHC for the immunization of their child. Small groups of 25 to 30 parents were collected at a time. ANM use to tell them about the symptoms of pneumonia, importance of early care seeking and place of treatment, with the help of video and audio messages (through projector and speaker), posters, story calendars and story books provided through the project. An exit interview of 2 to 3 participants was also conducted after the session.

Picture 20: Pneumonia Awasreness Picture 21: Pneumonia Awasreness Session at PHC Kehla Session at PHC Kasmandi Kala

Picture 22: Pneumonia Awasreness Session at PHC Amethi

4.1.2 Pneumonia Awareness Sessions at villages: PAS at villages were conducted by ASHA, on village health & nutrition day, on monthly basis. These sessions were conducted by using following IEC material, provided through project.

a. 5 posters b. 5 story calendars c. 5story books

PAS at villages were conducted at Kakori, Sarojini Nagar, Malihabad & Mohanlalganj blocks.

ASHA use to call the mothers having children between 2 months to 5 years, at anganwadi centers. Here she uses to inform the participants about symptoms of pneumonia, importance of early care seeking and place of treatment, with the help of posters, story calendars and story books provided through the project. An exit interview of 2 to 3

30 participants was also conducted after the session, when session was Observational (i.e. was conducted in presence of project staff).

Since ASHAs are incentive based workers, they expected monetary reward for the pneumonia awareness session they organize. We supplement this by providing them appreciation & recognition. We provide Certificate of Appreciation, at cluster meetings to those ASHAs, who were conducting PAS regularly. These kept them motivated and also motivate others to conduct PAS regularly.

Picture 23: Pneumonia Awareness Picture 24: Pneumonia Awareness Session at village Session at village

Picture25: Participants reading Picture 26: Pneumonia Awareness story books during PAS Session at village

4.1.3 Monitoring of Pneumonia Awareness Sessions

Regular monitoring of Pneumonia Awareness Sessions at CHC/PHC and villages was done by Project Staff, in order to maintain quality of sessions and motivation of Health Workers (ANMs & ASHAs).

Monitoring was done in two ways:

1. Observational Monitoring: These sessions were conducted in presence of Project Staff. All the pneumonia awareness sessions conducted at CHC/PHC were observational. At villages 3.5% sessions were observational. 2. By Interview Monitoring: This was done at village level, where Pneumonia Awareness Session was conducted by ASHA. When project staff visits the village, he uses to interview 2-3 participants, who had attended the last session conducted by ASHA.

Apart from this, regular telephonic calls were made to all the ASHAs, on monthly basis, to get update about the status of conduction of PAS in that month.

Simultaneously, physical verification was also made, whether posters and story calendars are displayed at strategic locations in the village. The physical verification was made at 70% of villages. Villages, where posters and story calendars, were not displayed, there ASHAs were motivated to display the IEC material.

4.1.4 Re-distribution of IEC material

It was noted that at many places these posters and story calendars were destroyed or mutilated, so Posters(3), Story Calendars(5) and Story books(5) were re distributed to all the ASHAs during May to August 2017, during the cluster meetings of ASHAs at CHC.

4.2.1 Utilization of Pneumonia Drug Kits

Soon after the supply of Pneumonia Drug kit, to the government health facilities, a regular weekly call was made to the designated person at the facilities. The objective of weekly calling was to access the number of cases of childhood pneumonia attended in OPD and number of cases of childhood pneumonia treated by Pneumonia Drug Kit.

This also gives information about the status of kits remaining at the facility. So, on the basis of usage of kits, re-supply of kits was maintained at the facilities.

4.2.2 Utilization of Pneumonia Management Units & Corners

Pneumonia Management Units were established at CHCs and Pneumonia Management Corners were established at PHCs. These units were utilized by medical Officers, to stabilize the childhood Pneumonia cases.

Medical officers do pulse oximetry, to assess the oxygen concentration, administer salbutamol through baby mask and spacer, provided through project, depending upon the clinical situation of child.

Medical Officers keep the children under observation at these Units & Corners. Depending upon the severity of disease, they either dispense Pneumonia Drug Kit or refer the child to higher centre for management.

As the feedback provided by Medical Officers, they found Pulse oximeter very useful in the assessment of children with fast breathing with or without chest indrawing. They also found Salbutamol inhalers useful, in situations where nebulizers are not available.

4.3 Re-trainings

4.3.1 Re-training of Medical Officers On request of Medical Officers, a re-training of Medical Officers was conducted on 9th Nov, 2016 at KGMU. Total 31/69 (45%) Doctors including Pediatricians, Medical Officers and AYUSH doctors posted in Community Health Centre (CHCs) and Primary Health Centre (PHCs) of Lucknow district attended the re- training. The agenda of meeting was as follows: a. Project Orientation b. Strengthening of infrastructure & activities proposed in the project c. Management of child (2 months – 5 years) with cough and difficult breathing at facility level d. Treatment of Severe Pneumonia & follow up care e. Recording and reporting of Pneumonia cases at various level f. BCC messages for childhood pneumonia This training was administered by Principal Investigator and Co-Investigator.

Apart from this, one to one training of newly joined Medical Officers at their facilities was conducted as a continuous process. Picture 27: Re-training of Medical Officers at KGMU on 9th Nov 2016

4.3.2 Re-Training of ANMs

Re-trainings of ANMs were started on 29-Aug-2017 and completed on 31-Oct-2017. These re-trainings were provided at respective CHC’s, in 10 batches. The re-trainings were attended by 292/327 (89%) ANMs.

Table 14: Block wise attendance of participants was as follows Sr. No. Name of Block Name of CHC No. of Participants Batches 1 Malihabad Malihabad 1 34/38 89.0% 2 Gosaiganj Gosaiganj 1 35/38 92.0% 3 Sarojini Nagar Sarojini Nagar 1 47/53 89.0% 4 Mall Mall 1 24/26 92.0% 5 Mohanlal Ganj Mohanlal Ganj 2 42/48 87.5% 6 Kakori Kakori 1 29/34 85.0% 7 BakshiKaTalab Itaunja 1 21/26 81.0% 8 BakshiKaTalab BakshiKaTalab 1 37/40 92.5% 9 Chinhat Chinhat 1 23/24 96.0% Total 10 292/327 89.0%

The agenda of re-training was as follows: 1. Project Orientation (Including strengthening of infrastructure & activities proposed in the project) 2. Identification, treatment and referral of child (2 months – 5 years) with cough and fast breathing 3. Dispensing of Pneumonia Drug Kit. 4. BCC messages for childhood pneumonia. 5. Role play for conducting Pneumonia Awareness Session (only where applicable)

Lectures and Video tools were used to impart training.

Re-trainings were administered by Principal Investigator and Co-Investigator.

Picture 28: Re-trainings of ANMs at their CHCs

4.3.3 Re-Training of ASHAs

As decided during Joint Working Group Meeting at New Delhi on 27-March-2017, Re-trainings of ASHAs were started on 11-May-2017 and completed on 11-Aug-2017. These re-trainings are provided at respective CHC’s, in 34 batches. The re-orientation trainings were attended by 1203/1431 (84.1%) ASHAs.

Table 15: Block wise attendance of participants was as follows Sr. Name of Block Name of CHC No. of Participants No Batches 1 Mohanlalganj Mohanlalganj 5 164/220 74.5% 2 Kakori Kakori 4 139/160 86.9% 3 Itaunja BakshiKaTalab 2 89/101 88.1% 4 Gosaiganj Gosaiganj 4 144/196 73.5% 5 Malihabad Malihabad 4 130/154 84.4% 6 Mall Mall 4 150/165 91.0% 7 Sarojini Nagar Sarojini Nagar 5 186/206 90.1% 8 Chinhat Chinhat 2 68/74 92% 9 BakshiKaTalab BakshiKaTalab 4 133/155 86% Total 34 1203/1431 84.1% The agenda of re-training was as follows:

a. Project Orientation (Including strengthening of infrastructure & activities proposed in the project) b. Identification and referral of child (2 months – 5 years) with cough and difficult breathing c. BCC messages for childhood pneumonia. d. Role play for conducting Pneumonia Awareness Session (only where applicable)

Lectures and Video tools were used to impart training.

Re-trainings were administered by Project Coordinator and Field Investigator.

Picture 29: Re-Trainings of ASHAs at CHC

5. Post Intervention Phase Post Intervention phase started from January 2018.

5.1 End Line Survey

End Line Survey was started on 21-Dec-2017 and was completed on 25–Apr-2018. It was conducted in all 8 rural blocks of the district Lucknow (capital of Uttar Pradesh) i.e. Bakshi ka Talab, Chinhat, Gosaiganj, Kakori, Malihabad, Mall, Mohanlalganj & Sarojini Nagar. In each block 30 villages were selected and from each village 10 households were selected. 300 households were interviewed from each block. Overall 2400 households were interviewed for the study.

5.1.1 Survey Methodology

Survey was conducted in the same villages and households in which base line survey was conducted. A new household was included only in the following situations: a) Household does not have any eligible child (between 2 months to 5 years) now, b) Family had migrated, c) Head of household does not give his/her consent to conduct survey.

For selection of new household, list of households having children between 2 months to 5 years was obtained from ASHA/Anganwadi worker. From this list new household was selected on random basis. 18 % new households were included in the end line survey.

5.1.2 Data Collection

All the data in the survey was collected by interview method. Prior to interviewing the household, consent of the head of the family was taken and in case if head of the family is not available then consent was taken by acting head of the family. In case interviewee refused to give consent then survey was not conducted in that household and the field

36 worker moved to a new household and followed the same process. Data collection was started on 21st December, 2017 and ended on 25th April, 2018.

The information at household level as well as individual level i.e., from each eligible mother of the households i.e. mother having at least one child aged between 2-59 months, was collected. A questionnaire was prepared according to the rural areas. In the starting part, information for the family member was asked, Socio-demographic condition of the households, complete information on the health status of the all the eligible children, also pneumonia like symptoms (running nose and cough with fast breathing[with or without chest in drawing]) to the individual child, then questions related to awareness of eligible mothers about pneumonia were asked. Questions were asked from the interrogators according to the survey methodology.

5.1.3 Quality Assurance

The quality assurance of the data was maintained by the field visits made by Project Co-coordinator. 10% of the data collection process was monitored by Project Coordinator. 6. Other Activities 6.1 World Pneumonia Day 12th Nov 2016 was been observed as World Pneumonia Day. On this day Medical Officers posted at Community Health Centre (CHCs) and Primary Health Centre (PHCs) of Lucknow district, conducted Pneumonia Awareness Sessions at their respective centers, using the IEC material provided through the project.

They conducted these sessions to make general public, attending the OPD, aware about the early identification of Childhood Pneumonia, need for immediate treatment that too by a qualified doctor. They also inform the public, about the various steps taken through the project, to strengthen the management of childhood pneumonia cases.

Picture 30: Pneumonia Awareness Picture 31: Pneumonia Awareness Session at CHC Kakori on World Session at CHC Malihabad on World Pneumonia Day Pneumonia Day

Picture 32: Pneumonia Awareness Picture 33: Pneumonia Awareness Session at CHC Mall on World Session at CHC Chinhat on World Pneumonia Day Pneumonia Day

6.2 Health Facility Audit Health Facility Audit was conducted across all interventions (all CHCs and PHCs). The objectives of heath facility audit were to collect data on: a. Utilization of Pneumonia Drug Kit, b. Utilization of Pneumonia Management Units and Corners, c. To abstract data of number of clinical cases of childhood pneumonia, treated as outpatients or inpatients, from the records of CHCs and PHCs d. Availability of equipments and medicines necessary for management of childhood pneumonia cases.

Health Facility audit was conducted at:

a. Pre-Intervention (Feb 2016 to May 2016) b. Mid Intervention (Nov 2016 to Jan 2017) c. Post Intervention (Oct 2017 to Jan 2018)

7. Technical Advisory Group (TAG) 7.1 TAG Meeting

TAG was constituted in August 2016. Its members were as follows: 1. Mission Director (or his/her nominee), National Health Mission, Lucknow 2. Chief Medical Officer, Lucknow 3. General Manager-Child health, National Health Mission , Lucknow 4. Joint Director-Child health, Department of Health and Family Welfare, GoUP 5. Dr. JV Singh, Head of Department, Upgraded Department of Community Medicine & Public Health, King George`s Medical University, Lucknow 6. Representative from BBC Media 7. District Program Manager (DPM),National Health Mission , Lucknow 8. Dr. Narendra Arora, INCLEN, New Delhi 9. Dr. Manoj Das, INCLEN, New Delhi 10. Project Investigator and Co-investigators

First TAG meeting was held on 09th Sept 2016, at King George’s Medical University.

During the meeting project progress and future plans were discussed. Major conclusions drawn in the meeting: 1. A refresher training of Medical Officers may be conducted in October/ November 2016. 2. Look for the dispersible paracetamol tablet in the market along with QC certificate. 3. Reasons for delay in ASHA training were also discussed.

Actions taken: 1. Refresher training of Medical Officers was conducted on 9th Nov, 2017. 2. We searched for paracetamol dispersible tablet in the market, it was not available in1 the market. Picture 34: TAG Meeting held at KGMU on 9th Sep 2016

7.2 Technical Advisory Group Visit

TAG member Dr. Madhuri Kulkarni, visited the study site on 8th& 9th Feb, 2017. On Day 1 of visit, Dr. Kulkarni took updates about the project and its progress. She check all the project related records and interviewed the project staff including Principal Investigator, Co-Investigators, Project Coordinator and all other staff.

On Day 2 of her visit, Dr. Kulkarni made field visit. Firstly she went to Kakori Block (Intervention 2) and met the Medical Officers at CHC. Then she visited Gopramau Sub Centre in the same block, where PAS session was going on. Then she moved to Mall Block (Intervention 1). Here she met Medical Officers at CHC. Then she visited Saspan village, where ANM was conducting PAS session. Then she visited Malihabad Block (Intervention 3) and met Medical Officers and ASHA.

8. Data Analysis and Interpretation Data was collected in pre-designed questionnaires. Quality assurance techniques were deployed to maintain the quality of data. Data was entered into the MS Excel and data cleaning was done before the final analysis of data. Data was analyzed using SPSS.

8.1 Results of Base Line Survey Base Line Survey was conducted from 16-Feb-2016 to 12-May-2016. Table 16: Intervention wise distribution of study population Intervention Number of Number of Household Number of Eligible Eligible No. of couples having Villages Households Population Couples mothers* Children** Female in reproductive age group Intervention_1 60 600 3384 814 606 811 666 (Gosaiganj& MALL) Intervention_2 60 600 3408 821 617 852 682 (Kakor i&Sarojini Nagar) Intervention_3 60 600 3362 803 622 848 665 (Malihabad & MohanlalGanj) Intervention_4 60 600 3361 818 621 840 665 (BKT &Chinhat) Total 240 2400 13515 3256 2469 3351 2678 *Eligible Mother – Mother having at least one child between 2-59 months of age **Eligible Child – Child between 2-59 months of age Table 17: Intervention wise distribution of households on basis of Type of Family Interventions Joint n (%) Nuclear n (%) Total households n Intervention_1(Gosaiganj& MALL) 262 (43.67) 338(56.33) 600 Intervention_2(Kakor i&Sarojini Nagar) 238 (39.67) 362(60.33) 600 Intervention_3(Malihabad&MohanlalGanj) 240(40.00) 360(60.00) 600 Intervention_4(BKT &Chinhat) 230(38.33) 370(61.67) 600 Total 970(40.42) 1430(59.58) 2400

Overall 40% households were resided by joint families. Intervention 3 blocks (Malihabad & Mohanlalganj) has maximum percentage (40%) of joint families, while Intervention 4 blocks (BakshiKaTalab & Chinhat) has maximum percentage (62%) nuclear families.

Table 18: Intervention wise distribution of households on basis of Type of House

Interventions Kaccha Puhcca Semi Constructed Total n(%) n(%) n(%) households n Intervention_1(Gosaiganj& 141(23.50) 303(50.50) 156(26.00) 600 MALL) Intervention_2(Kakor 107(17.83) 356(59.33) 137(22.83) 600 i&Sarojini Nagar) Intervention_3(Malihabad 126(21.00) 321(53.50) 153(25.50) 600 &MohanlalGanj) Intervention_4(BKT 71(11.83) 389(64.83) 140(23.33) 600 &Chinhat) Total 445(18.54) 1369(57.04) 586(24.42) 2400

Overall 57% households had PUHCCA house. Intervention 4 blocks (BKT & Chinhat) has maximum percentage (65%) of Puhcca houses, while Intervention 1 blocks (Gosaiganj& Mall) has maximum percentage (23.5%) of Kaccha type of house.

Table19: Intervention wise distribution of households on basis of main occupation of family

Interventions Agriculture Daily wages Business Salary Professional Total n(%) n(%) n(%) n(%) n(%) house holds N Intervention_1 283(47.17) 227(37.83) 52(8.67) 37(6.17) 1(0.17) 600 (Gosaiganj& MALL) Intervention_2 218(36.33) 257(42.83) 75(12.50) 48(8.00) 2(0.33) 600 (Kakor i&Sarojini Nagar) Intervention_3 237(39.50) 241(40.17) 71(11.83) 48(8.00) 3(0.50) 600 (Malihabad& Mohanlal Ganj) Intervention_4 276(46.00) 191(31.83) 75(12.50) 52(8.67) 6(1.00) 600 (BKT & Chinhat) Total 1014 (42.25%) 916 (37.75%) 273 (11.4%) 185 (7.7%) 12 (0.5%) 2400 Of 2400 household main occupation of households was Agriculture (42.25%), daily wages (37.75%) and followed by business (11.4%), Salaried (7.7%), and Professionals (0.05%).

Table 20: Intervention wise distribution of households on basis of type of ration card (N=1596)

Interventions Above Below AntyodayaYojna Total Poverty Line Powerty n (%) households n (%) Line n (%) n Intervention_1 264(62.26) 106(25.00) 54(12.74) 424 (Gosaiganj& MALL) Intervention_2 228(60.00) 103(27.11) 49(12.89) 380 (Kakori & Sarojini Nagar) Intervention_3 194(48.14) 139(34.49) 70(17.37) 403 (Malihabad & MohanlalGanj) Intervention_4 251(64.52) 98(25.19) 40(10.28) 389 (BKT & Chinhat) Total 937(58.71) 446(27.94) 213(13.35) 1596 Among households surveyed, 1596 (66.5%) households had ration card.

Table 21: Intervention wise distribution of households on basis of availability of separate kitchen Separate Kitchen Total Interventions households Yes n (%) No n (%) (n) Intervention_1(Gosaiganj& MALL) 301(50.17) 299(49.83) 600 Intervention_2(Kakor i&Sarojini Nagar) 284(47.33) 316(52.67) 600 Intervention_3(Malihabad&MohanlalGanj) 279(46.50) 321(53.50) 600 Intervention_4(BKT &Chinhat) 269(44.83) 331(55.17) 600

Total 1133(47.21) 1267(52.79) 2400

52% households, across all four interventions did not possess a separate kitchen for cooking.

Table 22: Intervention wise distribution of households on basis of source of Fuel used for cooking (Multiple Response) Interventions Source of Fuel ( Out of 2400 household) LPG Wood Coal Dung Cake Kerosene Oil Electricity n (%) n (%) n (%) n (%) n (%) n (%) Intervention_1 214(35.67) 505(84.17) 3(0.50) 477(79.50) 7(1.17) 5(0.83) (Gosaiganj & MALL) (N=600) Intervention_2 246(41.00) 459(76.50) 2(0.33) 383(63.83) 18(3.00) 2(0.33) (Kakori & Sarojini Nagar) (N=600) Intervention_3 199(33.17) 509(84.83) 2(0.33) 468(78.00) 7(1.17) 6(1.00) (Malihabad & MohanlalGanj) (N=600) Intervention_4 303(50.50) 434(72.33) 0(0.00) 409(68.17) 3(0.50) 2(0.33) (BKT & Chinhat) (N=600) Total N=2400 962(40.08) 1907(79.46) 7(0.29) 1737(72.38) 35(1.46) 15(0.63)

It was observed that bio mass fuel like wood and dung cake were the commonest source for cooking. Less than half households (40%) also used LPG for cooking.

Table 23: Intervention wise distribution of households on basis of source of Drinking Water (Multiple Response)

Interventions Source of Fuel ( Out of 2400 household Piped Public Tap Hand Pump Tube well Well Other water Water n n (%) water n (%) source of supply (%) n (%) water n (%) n (%) Intervention_1 50(8.33) 90(15.00) 443(73.83) 15(2.50) 5(0.83) 6(1.00) (Gosaiganj & MALL) Intervention_2 70(11.67) 104(17.33) 393(65.50) 28(4.67) 3(0.50) 19(3.17) (Kakori & Sarojini Nagar) Intervention_3 72(12.00) 92(15.33) 425(70.83) 11(1.83) 8(1.33) 10(1.67) (Malihabad & MohanlalGanj) Intervention_4 78(13.00) 91(15.17) 389(64.83) 39(6.50) 2(0.33) 29(4.83) (BKT &Chinhat) Total 270(11.25) 377(15.71) 1650(68.75) 93(3.88) 18(0.75) 64(2.67)

Hand Pumps (68.75%) are the main source of drinking water in the surveyed households. Piped water supply is available only in 11.25% households.

Table 24: Intervention wise distribution of households on basis of availability of Electricity

Interventions Electricity Total households Yes n (%) No n (%) ((n) Intervention_1 423(70.50) 177(29.50) 600 (Gosaiganj& MALL) Intervention_2 478(79.67) 122(20.33) 600 (Kakori & Sarojini Nagar) Intervention_3 409(68.17) 191(31.83) 600 (Malihabad & MohanlalGanj) Intervention_4 538(89.67) 62(10.33) 600 (BKT &Chinhat) Total 1848(77.00) 552(23.00) 2400 77% households have electricity connection. Intervention 4 has highest percentage (89.7%) of households having electricity connection. Intervention 3 households have lowest percentage (68.2%) of electricity connection.

Table 25: Intervention wise distribution of households on basis of availability of Toilet Interventions Toilet Total households (n) Yes n (%) No n (%) Intervention_1(Gosaiganj& MALL) 139(23.17) 460(76.67) 600 Intervention_2(Kakor i&Sarojini Nagar) 184(30.67) 416(69.33) 600 Intervention_3(Malihabad&MohanlalGanj) 182(30.33) 418(69.67) 600 Intervention_4(BKT &Chinhat) 193(32.17) 407(67.83) 600 Total 698(29.08) 1701(70.88) 2400 29.1% households have toilet facility. Intervention 4 has maximum percentage (32.2%) of households having toilet facility. Intervention 1 has lowest percentage (23.2%) of households having toilet facility.

Family Information of the households

Table 26: Gender distribution of family members

Interventions Male n (%) Female n (%) Total n (%) Intervention_1 1676(49.52) 1708(50.48) 3384(25.03) (Gosaiganj & MALL) Intervention_2 1685(49.43) 1723(50.57) 3408(25.21) (Kakor i& Sarojini Nagar) Intervention_3 1680(49.97) 1682(50.03) 3362(24.87) (Malihabad & MohanlalGanj) Intervention_4 1688(50.21) 1673(49.79) 3361(24.86) (BKT & Chinhat) Total 6728(49.78) 6787(50.22) 13515(100.00)

Table 27: Marital Status of family members

Interventions Married Unmarried Widow/ Not applicable Total N n (%) n (%) Widower (For (%) n (%) Children) n (%) Intervention_1(Gosaiganj 1571(46.41) 131(3.86) 118(3.50) 1564(46.23) 3384(25.03) & MALL) Intervention_2(Kakor i& 1588(46.59) 128(3.77) 108(3.17) 1584(46.47) 3408(25.21) Sarojini Nagar) Intervention_3(Malihabad 1553(46.19) 119(3.53) 105(3.11) 1586(47.17) 3362(24.87) & MohanlalGanj) Intervention_4(BKT & 1558(46.35) 128(3.80) 124(3.65) 1553(46.20) 3361(24.86) Chinhat) Total 6270(46.39) 505(3.74) 454(3.36) 6286(46.51) 13515(100.00)

Table 28: Population (Children between 2months to 59 months of age) eligible for the survey Population eligible for survey Total population N (%) Eligible Children Population of age 60 Eligible Children (2-59 Interventions (2-59 months) months or above months) n (%) n (%) n (%) Intervention_1 811(24.20) 2573(76.03) 3384(25.03) (Gosaiganj & MALL) Intervention_2 852(25.45) 2556(75.0) 3408(25.21) (Kakor i& Sarojini Nagar) Intervention_3 848(25.03) 2514(74.78) 3362(24.87) (Malihabad & Mohanlal Ganj) Intervention_4 840(25.06) 2521(75.01) 3361(24.86) (BKT & Chinhat) Total 3351(100.0) 10164(75.21) 13515(100.00)

Child Section

Table 29: Gender distribution of eligible children Interventions Male Children Female Children Total Children n (%) n (%) n (%) Intervention_1 436(53.76) 375(46.24) 811(24.20) (Gosaiganj& MALL) Intervention_2 434(50.94) 418(49.06) 852(25.45) (Kakor i&Sarojini Nagar) Intervention_3 441(52.0) 407(48.0) 848(25.03) (Malihabad&MohanlalGanj) Intervention_4 440(52.38) 400(47.62) 840(25.06) (BKT &Chinhat) Total 1751(52.25) 1600(47.75) 3351(100.0) Across all the four interventions, there is similar distribution of children on gender basis. Male children are 52.25% and female children are 47.75%.

Table 30: Age Distribution of eligible children

Interventions 2-11 months 12-23 months 24-59 months Total Children n (%) n (%) n (%) n (%) Intervention_1 206(25.40) 208(25.65) 397(48.95) 811(24.20) (Gosaiganj& MALL) Intervention_2 228(26.76) 205(24.06) 419(49.18) 852(25.45) (Kakor i&Sarojini Nagar) Intervention_3 219(25.83) 217(25.59) 412(48.58) 848(25.03) (Malihabad&MohanlalGanj) Intervention_4 209(24.88) 197(23.45) 434(51.67) 840(25.06) (BKT &Chinhat) Total 862(25.72) 827(24.68) 1662(49.60) 3351(100.0)

Across all the interventions age distribution of eligible children is equal. 25.7% of children are between 2- 11 months of age. 24.7% children are from 12-23 months. Most of children (49.6%) belonging to 24-59 months.

Table 31: Whether the child suffered from Diarrhea /RTI/Fever/Convulsion in last one year Interventions Yes Total Children n (%) n (%) Intervention_1 774(95.44) 811(24.20) (Gosaiganj& MALL) Intervention_2 788(92.49) 852(25.45) (Kakor i&Sarojini Nagar) Intervention_3 811(95.64) 848(25.03) (Malihabad & Mohanlal Ganj) Intervention_4 821(97.74) 840(25.06) (BKT &Chinhat) Total 3194(95.31) 3351(100.0) 95% of children suffered from Diarrhea/RTI/Fever/Convulsion in last one year. Table 32: Whether the child suffered from Diarrhea in last one year (n = 3194) Interventions Yes Total Children n (%) n (%) Intervention_1 174(22.48) 774 (Gosaiganj& MALL) Intervention_2 188(23.86) 788 (Kakori&Sarojini Nagar) Intervention_3 202(24.91) 811 (Malihabad & MohanlalGanj) Intervention_4 173(21.07) 821 (BKT &Chinhat) Total 737(23.07) 3194 23.07% children suffered from diarrhea in last one year Table 33: Place of the treatment for Diarrhea (last one year) (Multiple Response) Interventions Government Private Total Children Hospital Hospital Suffered with n (%) n (%) Diarrhea N

Intervention_1 23(13.21) 159(91.38) 174 (Gosaiganj& MALL) Intervention_2 17(9.04) 177(94.15) 188 (Kakori&Sarojini Nagar) Intervention_3 20(9.9) 185(91.58) 202 (Malihabad&MohanlalGanj) Intervention_4 21(12.1) 162(93.64) 173 (BKT &Chinhat) Total 81(10.99) 683(92.67) 737 Only 10.99% of children suffered from Diarrhea, visited Government Hospital for treatment.

Table 34: Outcome of the treatment of Diarrhea (last one year) (n=737) Interventions Recovered Not Recovered Total Children Suffered Children Children with DIARRHEA n (%) n (%) n (%) Intervention_1 168(96.55) 6(3.44) 174 (Gosaiganj& MALL) Intervention_2 186(98.95) 2(1.1) 188 (Kakori & Sarojini Nagar) Intervention_3 201(99.50) 1(0.04) 202 (Malihabad &MohanlalGanj) Intervention_4 172(99.42) 1(0.05) 173 (BKT & Chinhat) Total 728(98.77) 9(1.22) 737 Of these 737 children who suffered diarrhea and 90.77% children recovered from diarrhea only 1.22% children not recovered.

Table 35: Number of Episodes of Diarrhea in children in last one year (Descriptive Statistics) Intervention wise N Min Episode Max Mean Std. Number of episode of Diarrhea Episode Deviation Intervention_1 174 1 12 2 2 (Gosaiganj& MALL) Intervention_2 188 1 20 3 2 (Kakori&Sarojini Nagar) Intervention_3 202 1 20 3 2 (Malihabad&MohanlalGanj) Intervention_4 173 1 20 3 2 (BKT &Chinhat) Total 737 1 20 2.54 2.191 Across all four intervention average episode of diarrhea among children were similar Table 36: Total Expenditure on the Diarrhea for last one year (Descriptive Statistics) Intervention wise n Min Max Mean Median Expenditure for the treatment of Expenditure Expenditure Diarrhea Intervention_1 174 0 15000 865 200 (Gosaiganj& MALL) Intervention_2 188 1 20000 1201 300 (Kakori & Sarojini Nagar) Intervention_3 202 0 35000 1002 200 (Malihabad & MohanlalGanj) Intervention_4 173 0 15000 860 200 (BKT &Chinhat) Total Expenditure 737 0 35000 987.32 200

Table 37: Whether the child suffered from RTI in last one year (n = 3194) Interventions Yes Total Children n (%) N (%) Intervention_1 609(78.69) 774 (Gosaiganj& MALL) Intervention_2 579(673.43) 788 (Kakor i&Sarojini Nagar) Intervention_3 597(73.61) 811 (Malihabad & MohanlalGanj) Intervention_4 635(77.34) 821 (BKT & Chinhat) Total 2420(75.77) 3194 75.8% children suffered from RTI in last one year

Table 38: Place of the treatment for RTI (last one year) (Multiple Response) Interventions Government Private Total Children Hospital Hospital Suffered with RTI n (%) n (%) (N) Intervention_1 71(11.66) 571(93.76) 609 (Gosaiganj& MALL) Intervention_2 75(12.95) 538(92.92) 579 (Kakori & Sarojini Nagar) Intervention_3 68(11.39) 563(94.30) 597 (Malihabad & Mohanlal Ganj) Intervention_4 62(9.76) 606(95.43) 635 (BKT & Chinhat) Total 276(11.40) 2278(94.13) 2420 Only 11.4% children, suffered from RTI, visited Government Hospital for treatment.

Table 39: Outcome of the treatment of RTI (last one year) (n=2420) Interventions Recovered Not Recovered Total Children Children Children n (%) n (%) n (%) Intervention_1 608(99.84) 1(0.16) 609 (Gosaiganj& MALL) Intervention_2 575(99.31) 3(0.52) 579 (Kakori & Sarojini Nagar) Intervention_3 593(99.33) 4(0.67) 597 (Malihabad&MohanlalGanj) Intervention_4 632(99.53) 3(0.47) 635 (BKT &Chinhat) Total 2408(99.55) 10(0.41) 2420

99.6% children recovered from RTI.

Table 40: Number of Episodes of RTI in children for last one year (Descriptive Statistics) Intervention wise N Min Max Mean Std. Number of episode of RTI Episode Episode Deviation Intervention_1 608 1 14 4 2 (Gosaiganj& MALL) Intervention_2 580 1 14 4 2 (Kakori &Sarojini Nagar) Intervention_3 598 1 14 4 2 (Malihabad &Mohanlal Ganj) Intervention_4 634 1 14 4 2 (BKT &Chinhat) Total 2420 1 14 3.61 2.035

Table 41: Total Expenditure on the RTI (last one year) (Descriptive Statistics) Intervention wise N Min Max Mean Median Expenditure for the treatment of RTI Expenditure Expenditure Intervention_1 609 0 25000 362 100 (Gosaiganj & MALL) Intervention_2 579 0 30000 369 120 (Kakori & Sarojini Nagar) Intervention_3 597 0 45000 383 100 (Malihabad & Mohanlal Ganj) Intervention_4 635 0 18000 408 100 (BKT & Chinhat) Total Expenditure 2420 0 45000 380.66 100

Table 42: Whether child suffered from running nose, since last one year? Interventions Yes Total Children n (%) N (%) Intervention_1 725(89.40) 811(24.20) (Gosaiganj & MALL) Intervention_2 766(89.91) 852(25.45) (Kakori & Sarojini Nagar) Intervention_3 758(89.93) 848(25.03) (Malihabad & Mohanlal Ganj) Intervention_4 742(88.33) 840(25.06) (BKT & Chinhat) Total 2991(89.26) 3351(100.0) Out of total 3351 children 89.26% children reported to have running nose in last one year. Number of children (having running nose) is almost equivalent across all the interventions.

Table 43: What type of treatment was given to child with running nose? (Multiple Response) Interventions Medicine Home Remedy Medical prescribed by n (%) Store Doctor n (%) n (%) Intervention_1 416(57.38) 291(40.14) 35(4.83) (Gosaiganj & MALL) (N=725) Intervention_2 427(55.74) 279(36.42) 42(5.48) (Kakori & Sarojini Nagar) (N=766) Intervention_3 423(55.80) 256(33.77) 67(8.84) (Malihabad & Mohanlal Ganj) (N=758) Intervention_4 431(58.09) 318(42.86) 23(3.10) (BKT & Chinhat) (N=742) Total (N=2991) 1697(56.74) 1144(38.25) 167(5.58 For running nose 57% children were treated with medicines prescribed by a Doctor.

Table 44: What all types of health care providers were approached for treatment of running nose (Multiple Response)? Interventions Private Hospital Government Total Children who n (%) Hospital were treated by n (%) doctors n=2991 (%) Intervention_1 366(87.98) 49(11.78) 416 (Gosaiganj & MALL) Intervention_2 391(91.57) 36(8.43) 427 (Kakori & Sarojini Nagar) Intervention_3 391(92.43) 31(7.33) 423 (Malihabad & MohanlalGanj) Intervention_4 404(93.74) 26(6.03) 431 (BKT &Chinhat) Total 1552(91.46) 142(8.37) 1697 Among the children who visited government health facilities, maximum number was in Intervention 1 (11.78%).

Table 45: Children who suffered from cough with fast breathing (with or without chest in drawing), since last one year? Interventions Yes Total Children n (%) n (%) Intervention_1 189(23.30) 811(24.20) (Gosaiganj & MALL) Intervention_2 217(25.47) 852(25.45) (Kakori & Sarojini Nagar) Intervention_3 203(23.94) 848(25.03) (Malihabad & MohanlalGanj) Intervention_4 215(25.60) 840(25.06) (BKT &Chinhat) Total 824(24.59) 3351(100.0) Out of total 3351 children 24.6% children reported to have cough with fast breathing (with or without chest in drawing) in last one year. Frequency of such children (having cough with fast breathing with or without chest in drawing) is almost equivalent across all the interventions.

Table 46: Type of treatment that was given to children suffering from cough with fast breathing (with or without chest in drawing). (Multiple Response) Interventions Medicine prescribed by Home Remedy Medical Store Doctor n (%) n (%) n (%) Intervention_1 144(76.19) 50(24.46) 6(3.17) (Gosaiganj & MALL) (N=189) Intervention_2 165(76.04) 54(24.88) 8(3.69) (Kakori & Sarojini Nagar) (N=217) Intervention_3 146(71.92 67(33.00) 10(4.93) (Malihabad & Mohanlal Ganj) (N=203) Intervention_4 140(65.12) 96(44.65) 1(0.47) (BKT & Chinhat) (N=215) Total (N=824) 595(72.12) 267(32.40) 25(3.03) Majority of children suffering from cough with fast breathing were treated through medicines prescribed by Doctors. Table 47: What all types of health care providers were approached for treatment of children suffering from cough with fast breathing (with or without chest in drawing)? (Multiple Response) Interventions Private Hospital Government Total Children who n (%) Hospital were taken treatment n (%) from doctor for pneumonia N Intervention_1 131(89.73) 15(10.27) 146 (Gosaiganj& MALL) Intervention_2 157(95.15) 8(4.85) 165 (Kakori & Sarojini Nagar) Intervention_3 140(95.89) 4(2.74) 146 (Malihabad & MohanlalGanj) Intervention_4 136(97.14) 4(2.86) 140 (BKT & Chinhat) Total 564(94.79) 31(5.21) 595 Among the children, who visited government health facilities, maximum number was in Intervention 1(10.27%). Table 48: Children who were admitted in hospital, for treatment of pneumonia in last one year? Interventions Yes No Total number of n (%) n (%) children with possible pneumonia n (%) Intervention_1 10(5.29) 179(94.71) 189 (Gosaiganj & MALL) Intervention_2 6(2.76) 211(97.24) 217 (Kakori & Sarojini Nagar) Intervention_3 6(2.96) 197(97.04) 203 (Malihabad & MohanlalGanj) Intervention_4 11(5.12) 204(94.88) 215 (BKT &Chinhat) Total 33(4.00) 791(96.0) 824 4% children with possible pneumonia were hospitalized due to pneumonia in last one year.

Table 49: In which type of hospital, was the child was admitted first for pneumonia? (n=33) Interventions Government Private Total children hospital n (%) hospitalized for n (%) pneumonia N(%) Intervention_1 1(10.0) 9(90.0) 10 (Gosaiganj & MALL) Intervention_2 1(16.67) 5(83.33) 6 (Kakori & Sarojini Nagar) Intervention_3 2(33.33) 4(66.67) 6 (Malihabad & MohanlalGanj) Intervention_4 1(9.0) 10(90.1) 11 (BKT & Chinhat) Total 5(12.12) 28(87.88) 33 88% cases of pneumonia were hospitalized at Private hospitals.

Mother Section

Table 50: Mothers who have you ever heard about the illness called "pneumonia"? Interventions Yes Total n (%) n (%) Intervention_1 524(86.04) 609 (Gosaiganj & MALL) Intervention_2 549(88.98) 617 (Kakori & Sarojini Nagar) Intervention_3 543(87.30) 622 (Malihabad & MohanlalGanj) Intervention_4 566(91.14) 621 (BKT &Chinhat) Total 2182(88.38) 2469 88.4% respondent mothers told that they had heard about the illness called Pneumonia.

Table 51: Symptoms of pneumonia as responded by mothers. (Multiple Response) Interventions Cold and Running Fever Fast Difficulty in Chest In Not able Drowsy Mothers who ever Cough Nose n (%) Breathing breathing drawing to drink n (%) heard Symptoms n (%) n (%) n (%) n (%) n (%) n (%) of Pneumonia (n)

Intervention_1 177(33.78) 32(6.11) 127(24.24) 77(14.69) 82(15.65) 104(19.85) 44(8.40) 22(4.20) 524 (Gosaiganj & MALL) Intervention_2 211(38.43) 42(7.65) 142(25.87) 85(15.48) 84(15.30) 87(15.85) 38(6.92) 13(2.37) 549 (Kakor i& Sarojini Nagar) Intervention_3 132(24.31) 20(3.68) 98(18.05) 73(13.44) 52(9.58) 60(11.05) 25(4.60) 1(0.18) 543 (Malihabad & Mohanlal Ganj) Intervention_4 172(30.39) 33(5.83) 128(22.61) 71(12.54) 92(16.25) 82(14.49) 21(3.71) 5(0.88) 566 (BKT & Chinhat) Total 692(31.71) 127(5.82) 495(22.69) 306(14.02) 310(14.21) 333(15.26) 128(5.87) 41(1.88) 2182 Only 14% respondent mothers identified fast breathing as a sign of pneumonia. Table 52: Source of information about pneumonia? (Multiple Response) Interventions ASHA ANM AWW n (%) n (%) n (%) Intervention_1 6(2.79) 1(0.47) 3(1.40) (Gosaiganj & MALL) Intervention_2 12(4.48) 4(1.49) 9(3.36) (Kakori & Sarojini Nagar) Intervention_3 2(1.14) 4(2.29 1(0.57) (Malihabad & Mohanlal Ganj) Intervention_4 4(1.74) 5(2.17) 4(1.74) (BKT & Chinhat) Total 24(2.70) 14(1.58 17(1.91) 2.7 % respondents told that information on pneumonia was given to them by ASHA.1.58% respondents gained information about pneumonia from ANM and 1.91% respondents told that information on pneumonia was given to them AWW. Rest of the mothers get information from other sources like Private Doctors, family members & neighbors.

Table 53: Mothers who had attended VHND in last 6 month (n=2379)

Interventions Yes No Total mothers who heard n (%) n (%) about the VHND n (%) Intervention_1 373(64.98) 201(35.02) 574 (Gosaiganj& MALL) Intervention_2 367(60.46) 240(39.54) 607 (Kakori & Sarojini Nagar) Intervention_3 411(66.83) 204(33.17) 615 (Malihabad & MohanlalGanj) Intervention_4 384(65.87) 199(34.13) 583 (BKT &Chinhat) Total 1535(64.52) 844(35.48) 2379 64.5% mothers had attended VHND in last six months.

Table 54: Was any information on pneumonia was given on VHND? (n=1535) Interventions Yes No Total n (%) n (%) n (%) Intervention_1 11(2.95) 362(97.05) 373 (Gosaiganj& MALL) Intervention_2 29(7.90) 338(92.10) 367 (Kakori & Sarojini Nagar) Intervention_3 7(1.70) 404(98.30) 411 (Malihabad & Mohanlal Ganj) Intervention_4 19(4.95) 365(95.05) 384 (BKT & Chinhat) Total 66(4.30) 1469(95.70) 1535

4.3% mothers responded that information about Pneumonia was given on VHND.

Table 55: Who gave you pneumonia related information on VHND? (Multiple Response) Interventions ASHA ANM AWW n (%) n (%) n (%) Intervention_1 3(27.27) 4(36.36) 4(36.36) (Gosaiganj & MALL) (N=11) Intervention_2 16(55.17) 9(31.03) 5(17.24) (Kakori & Sarojini Nagar) (N=29) Intervention_3 2(28.57) 3(42.86) 2(28.57) (Malihabad & MohanlalGanj) N=7 Intervention_4 2(10.53) 3(15.79) 9(47.37) (BKT & Chinhat) N=19 Total (N=66) 23(34.85) 19(28.79) 20(30.30) 35% mothers responded that ASHA had given information about Pneumonia on VHND.

Table 56: Mothers who had attended routine immunization day in last 6 months? (n=2448) Interventions Yes No Total Mother who n (%) n (%) aware about the Immunization day n (%) Intervention_1 382(64.42) 211(35.58) 593 (Gosaiganj & MALL) Intervention_2 440(71.31) 177(28.69) 617 (Kakori & Sarojini Nagar) Intervention_3 437(70.37) 184(29.63) 621 (Malihabad & MohanlalGanj) Intervention_4 418(67.75) 199(32.25) 617 (BKT & Chinhat) Total 1677(68.50) 771(31.50) 2448

68.5% mothers attended routine immunization in last 6 months.

Table 57: Was any information on pneumonia was given on immunization day? (N=1677)

Interventions Yes No Total mothers n (%) n (%) who attended the Immunization day n (%) Intervention_1 6(1.57) 376(98.43) 382 (Gosaiganj& MALL) Intervention_2 23(5.23) 417(94.77) 440 (Kakori & Sarojini Nagar) Intervention_3 6(1.37) 431(98.63) 437 (Malihabad & MohanlalGanj) Intervention_4 15(3.59) 403(96.41) 418 (BKT &Chinhat) Total 50(2.98) 1627(97.02) 1677 3% mothers responded that information about Pneumonia was given on Immunization Day.

Table 58: Who gave you pneumonia related information on Immunization day? (Multiple Response)

Interventions ASHA ANM AWW n (%) n (%) n (%) Intervention_1 4(66.67) 3(50.0) 2(33.33) (Gosaiganj & MALL) (N=6) Intervention_2 14(60.87) 10(43.48) 1(4.35) (Kakori & Sarojini Nagar) (N=23) Intervention_3 2(33.33) 6(66.67) 4(66.67) (Malihabad & Mohanlal Ganj) (N=6) Intervention_4 1(6.67) 7(46.67) 1(6.67) (BKT & Chinhat) (N=15) Total (N=50) 21(42.00) 26(52.0) 8(16.0)

52% mothers responded that ANM had given information about Pneumonia on routine Immunization Day.

8.2 Adherence to Interventions (Pneumonia Awareness Sessions) The study had 4 intervention arms.

 Intervention 1: Pneumonia Awareness Sessions (PAS) were conducted by ANM on Routine Immunization Day, once a month, at CHC and PHC. Project team facilitated these PAS. These sessions were conducted in presence of project team.  Intervention 2: PAS was conducted by ASHA on Village Health & Nutrition Day, once a month, at Village.  Intervention 3: In this Intervention PAS was conducted both at CHC/PHC and Villages. ANM use to conduct PAS at CHC/PHC on Routine Immunization Day, once a month and Project team facilitated these PAS. Along with this ASHA use to conduct PAS at Village on Village Health & Nutrition Day, once a month.  Intervention 4: This was control arm. No PAS were conducted in this arm.

Interventions were started from August 2017. Since this was a new project for the government health workers, months of August & September 2017 were considers as preparatory phase where Project Team facilitated and motivated the ANMs and ASHAs for conduction of Pneumonia Awareness Sessions. During the preparatory phase 62.5% (5/8) PAS were conducted in Intervention 1, 37.1% (252/680) PAS were conducted in Intervention 2. In intervention 3, 45% (9/20) was conducted at CHC/PHC and 31.9% (226/708) were conducted at villages.

Interventions were completed in December 2017.

Table 59: Adherence to interventions across 1st, 2nd & 3rd Interventions (From October 2016 to December 2017)

Intervention Oct 2016 Jan 2017 to Apr 2017 to July 2017 to Oct 2017 to Total to Dec Mar 2017 Jun 2017 Sep 2017 Dec 2017 2016

Intervention 1 PAS Scheduled 30 30 30 30 30 150 PAS Done 27 27 30 26 29 139

% of PAS Conducted 90.0% 90.0% 100.0% 86.7% 96.7% 92.7%

Intervention 2* PAS Scheduled 1020 1020 1020 1020 1020 5100 PAS Done 795 823 759 822 859 4058

% of PAS Conducted 77.9% 80.7% 74.4% 80.6% 84.2% 79.6%

PAS at PAS Scheduled 30 30 30 30 30 150 CHC/PHC PAS Done 28 29 29 27 27 140 % of PAS Conducted 93.3% 96.7% 96.7% 90.0% 90.0% 93.3%

PAS at PAS Scheduled 1062 1062 1062 1062 1062 5310 Intervention 3* Village PAS Done 645 762 687 695 791 3580 % of PAS Conducted 60.7% 71.8% 64.7% 65.4% 74.5% 67.4%

Total for PAS Scheduled 1092 1092 1092 1092 1092 5460 Intervention 3 PAS Done 673 791 716 722 818 3720 % of PAS Conducted 61.6% 72.4% 65.6% 66.1% 74.9% 68.1%

From October 2016 to December 2017, 7917 (74%) Pneumonia Awareness Sessions were conducted out of scheduled 10,710 sessions.

*ASHAs were contacted telephonically, every month, to get update about the status of conduction of PAS in that month. Apart from this physical verification was conducted by project team at the villages for the status of conduction of PAS.

8.3 Results of Exit Interview of Participants of Pneumonia Awareness Sessions

We had conducted 2146 exit interviews, after the Pneumonia Awareness Sessions at CHC, PHC and villages. The following tables are in respect to these 2146 sessions.

Table 60: Block wise distribution of exit interviews conducted after Pneumonia Awareness Sessions Blocks Number Percentage (%) Intervention 1 144 6.7 (Gosaiganj & Mall ) Intervention 2 971 45.25 Kakori & Sarojini Nagar) Intevention 3 1031 48.04 (Malihabad & MohanlalGanj) Total 2146 100.0 Among 2146 exit interviews conducted, 48% were conducted across Intervention 3, 45 % across Intervention 2 and 7% were conducted across Intervention 1.

Table 61: Block wise distribution of “type of Monitoring” for Pneumonia Awareness Sessions for which these 2146 exit interviews were conducted Blocks By Interview Observational Total (PAS was conducted prior & (PAS was feedback from participants was conducted in collected by project staff later) presence of Project Staff) Intervention 1 Not applicable 144(100.0) 144 (Gosaiganj & Mall ) Intervention2 854(87.95) 117(12.05) 971 Kakori & Sarojini Nagar) Intevention 3 744(72.16) 287(27.84) 1031 (Malihabad & MohanlalGanj) Total 1598(74.46) 548(25.54) 2146(100.0) Pvalue <0.0001 25.5% Sessions where exit interviews conducted were “Observational” i.e. these sessions were conducted in the presence of project staff.

For 74.5% sessions, exit interviews were conducted “By Interview” method, i.e. these sessions were conducted by ASHA in the villages and interviews of participants were conducted by project team later.

Since in Intervention 1, Pneumonia Awareness Sessions were conducted at CHC/PHC only and were facilitated by Project staff, so these are 100% Observational.

Table 62: Place of Pneumonia Awareness Session, where these exit interviews were conducted Place of PAS Conducted Number Percentage (%) CHC 76 3.54 PHC 232 10.81 Villages 1838 85.65 Total 2146 100.0 Out of these 2146 exit interviews, 86% were conducted at villages and rest 14% were conducted at Government health facilities (CHC/PHC).

Table 63: Distribution of Pneumonia Awareness Sessions, according to number of participants attending the Session Group of Participants attending Number of Percentage (%) Pneumonia Awareness Session Pneumonia Awareness Sessions Up to 20 participants attending the session 1773 82.6 21-40 participants attending the session 294 13.7 More than 40 participants attending the 79 3.7 session Total 2146 100.0 82.6% sessions were attended by group of 1-20 participants. There were only 3.7% sessions which were attended by more than 40 participants.

Table 64: Distribution of Pneumonia Awareness Sessions, according to number of MALE participants attending the Session Group of MALE Participants Number of Pneumonia Percentage (%) attending Pneumonia Awareness Awareness Sessions Session Up to 20 MALE participants attending 2140 99.7 the session 21-40 MALE participants attending the 6 0.3 session Total 2146 100.0 In 99.7% of sessions, Male participants were below 20 in number.

Table 65: Distribution of Pneumonia Awareness Sessions, according to number of FEMALE participants attending the Session Group of FEMALE Participants Number of Percentage (%) attending Pneumonia Awareness Pneumonia Session Awareness Sessions Up to 20 FEMALE participants 1832 85.4 attending the session 21-40 FEMALE participants attending 281 13.1 the session More than 40 FEMALE participants 33 1.5 attending the session Total 2146 100.0 In 85.4% of sessions, Female participants were below 20 in number.

Table 66: IEC Material Used during Pneumonia Awareness Sessions IEC material used to conduct PAS Number of PAS Percentage (%) Yes (Observational PAS) 553 25.9 Not Applicable (By Interview) 1593 74.1 Total 2146 100.0 IEC material was distributed to ANMs and ASHAs to conduct Pneumonia Awareness Sessions. Usage of this IEC material to conduct PAS was verified during Observational sessions only. Out of these 553 Observational PAS, 308 were conducted at CHC/PHC.

Table 67: Distribution of Pneumonia Awareness Sessions, according to Number of Posters displayed to conduct Pneumonia Awareness Session (8 Posters were provided by the project) (n=553 Observational PAS) No. of Posters used to conduct PAS Number of PAS Percentage (%) 0 3 0.54 2 3 0.54 3 16 2.89 4 41 7.41 5 26 4.70 6 58 10.49 7 11 1.99 8 395 71.43 Total 553 100.0 In 71% of Observational Pneumonia Awareness Sessions, all 8 Posters were used to conduct PAS.

Table 68: Distribution of Pneumonia Awareness Sessions, according to Number of Story books given to the participants to read during session (5 Story Books were provided by the project) (n=553 Observational PAS) Story Boos Read Number of PAS Percentage (%) 0 21 3.79 2 13 2.35 3 12 2.17 4 9 1.63 5 498 90.05 Total 532 100.0 In 90% of Observational Pneumonia Awareness Sessions, all 5 story books were given to participants to read.

Table 69: Distribution of Pneumonia Awareness Sessions, according to number of Audio Message played at CHC &PHC during Pneumonia Awareness Sessions (n=308 Observational PAS at CHC/PHC) Audio Message Played Number of PAS Percentage (%) 0 19 6.17 2 1 0.32 3 6 1.95 4 282 91.56 Total 289 52.26 ANMs conducted PAS at CHC/PHC in Intervention 1 & 3. During these PAS, Audio & video messages were played. Among 308 PAS conducted at CHC & PHC, all 4 audio messages were played in 92% sessions.

Table 70: Distribution of Pneumonia Awareness Sessions, according to number of Video Message played at CHC &PHC during Pneumonia Awareness Sessions (n=308 Observational PAS at CHC/PHC) Video Message Played Number of PAS Percentage (%) 0 18 5.84 2 1 0.32 3 288 93.51 Total 308 100.0 At CHC & PHC, all 3video messages were played during 93.5% sessions.

Table 71: Distribution of Pneumonia Awareness Sessions, according to number of Case Stories shown during Pneumonia Awareness Session (n=308 Observational PAS at CHC/PHC) Case Stories Showed Number of PAS Percentage (%) 0 18 5.84 1 1 0.32 3 4 1.30 5 285 92.53 Total 308 100.0 At CHC & PHC, all 5 case stories were shown during 92.5% sessions.

For these, 2146 Pneumonia Awareness Sessions, where exit interviews were conducted, 5781 participants were interviewed about the information gained, benefits and scope of improvement in Pneumonia Awareness Sessions.

Table 72: Distribution of participants on gender basis who gave feedback about Pneumonia Awareness Session Gender Number Percentage (%) Male 116 2.0 Female 5665 98.0 Total 5781 100.0 Feedback about PAS was collected from 5781 participants, among which 98% were females and 2% were males.

Table 73: Rating of participants about the pneumonia awareness session PAS rating Number Percentage (%) Very Good 2383 41.2 Good 2739 47.4 Fair 642 11.1 Normal 8 0.1 Bad/No Response 9 0.2 Total 5781 100.0 47.44% participants rated the PAS as “Good” and 41.2% participants rated it as Very Good.

To obtain this rating, participants were shown a “Pneumonia Awareness Session Rating Card”. This card shows ratings of Very Good, Good, Fair, Normal and Bad/No Response, along with corresponding similes.

Table74: Response of participants when they were asked that what new steps are being taken for spreading awareness about pneumonia? Steps taken to spread awareness about Pneumonia Response (%) (N=5781) Multiple Choice Conducting Pneumonia awareness programme 4402 (76.14) Distribution of pneumonia drug kit 4083(70.62) Establishment of pneumonia management/Unit 2854(49.36) Others 48 (0.08) Not Known 325(5.6) After attending PAS, 76% participants told that they came to know that PAS are now being conducted, 71% participants told that they came to know that PDK are available at CHC, PHC & ANMs. 49% participants told that they came to know that Pneumonia Management Units and Corners are being established at CHCs & PHCs.

Table 75: Response of participants when they were asked that what benefit you got from attending pneumonia awareness session? Benefits Response [(N=5781) Multiple Response] Session was not useful 36(0.62) Session was useful 11(0.19) Became aware that symptom of pneumonia is cough and cold 3301(57.10) Became aware that symptom of pneumonia is fever 1637(28.32) Became aware that symptom of pneumonia is fast breathing 2954(51.10) Became aware that symptom of pneumonia is chest in drawing 2927(50.63) Others symptoms (inability to feed , vomiting , diarrhea , others) 1181(20.43) Gained information about pneumonia 817(14.13) Gained information about place of treatment 1(0.02) After attending PAS more than 50% participants told that they came to know about the symptoms of pneumonia like cough, cold, fast breathing & chest in-drawing.

Table 76: Advice from the participants about improving pneumonia awareness session Advice Response [(N=5781) Multiple Response] No Advice/ continue as same 5204(90.02) PAS should be conducted on weekly basis 4(0.07) PAS should be conducted on fortnightly basis 2(0.03) PAS should be conducted on monthly basis 3(0.05) Repeated sessions of PAS should be conducted 5(0.09) PAS should be conducted in villages 47(0.81) PAS should be conducted in Mohallas 3(0.05) Pneumonia information should be given door to door 25(0.43) Prior information about organization PAS should be given 20(0.35) Audio and videos should be shown in villages 10(0.17) Video messages may be broadcasted on television 47(0.81) Posters having information about pneumonia should be pasted 30(0.52) in villages Others 54(093) 90% participants suggested that PAS should be continued in same way as they are being conducted. 8.4 Analysis of Pneumonia Drug Kit Utilization Pneumonia Drug Kit utilization was assessed through weekly calling to health facilities, Health Facility Audit and Case Record Forms filled by Medical Officers, ANMs and ASHAs.

Table 77: Number of Pneumonia Drug Kits distributed by CHCs/PHCs & ANMs Intervention Total no. of PDK distributed by CHCs/PHCs & ANMs Intervention 1 1774 Intervention 2 2190 Intervention 3 2187 Intervention 4 1579 ANMs identified 202 cases of childhood pneumonia in the field and treat them with PDK.

Table 78: Intervention wise distribution of PDK distributed by ANM Intervention Kits distributed by ANM Intervention 1 42 Intervention 2 69 Intervention 3 61 Intervention 4 30 Total 202

ASHAs identified 96 cases of childhood pneumonia in the field. They do respiratory rate count, record body temperature and referred the cases to CHC/PHC for further management. ASHAs also filled case record forms for these cases. 46 & 49 cases were identified & referred in Intervention 2 & 3 respectively.

Case record forms were to be filled by Medical Officers and ANMs, whenever they find a case of childhood pneumonia or they dispense Pneumonia Drug Kit. ASHAs were expected to fill case record form, whenever they find a case of Childhood Pneumonia. Interest of Government Health Workers in filling the case record forms was very low. Despite the large number of childhood pneumonia cases treated with Pneumonia Drug Kit, we have received very less number of case record forms.

Table 79: Intervention wise distribution of Case Record Forms filled by Medical Officers, ANMs and ASHAs. Intervention Medical Officer ANM ASHA Intervention 1 61 1 0 intervention 2 120 9 46 Intervention 3 102 1 49 intervention 4 35 0 0 Total 318 11 95 Intervention 2 & 3 were most active across all interventions, in filling case record forms for cases of childhood pneumonia.

8.5 Results of feedback about Pneumonia Drug Kit collected from parents, whose children were treated with Pneumonia Drug Kit

During the project, feedback of parents, whose child was treated with Pneumonia Drug Kit (PDK), was also collected.

Total 717 feedbacks were collected across all the interventions.

Table 80: Intervention wise age distribution of children, treated with PDK, from whom feedback was collected.

Number of children (for whom Total children Total no. of feedback was collected) (from whom children Intervention 2-11 12-23 24-59 feedback was treated with Months Months Months collected) PDK n (%) n (%) n (%) N (%) Intervention 1 48(26.82) 55(30.73) 76(42.46) 179(10.1) 1774 (Gosaiganj & Mall) Intervention 2 97(41.45) 65(27.78) 72(30.77) 234(10.7) 2190 (Kakori & Sarojini Nagar) Intervention 3 81(39.51) 61(29.76) 63(30.73) 205(9.4) 2187 (Malhibad & Mohanlalganj) Intervention 4 12(12.12) 20(20.20) 67(67.68) 99(6.3) 1579 (BKT&Chinhat) Total 238 (33.19) 201(28.03) 278(38.77) 717(9.3) 7740 Out of total 7740 children treated with PDK, feedback about PDK was collected for717 (9.3%) children. In Intervention 1, 10.1%, in Intervention 2, 10.7%, in Intervention 3, 9.4% and in Intervention 4, 6.3% of feedbacks were collected from parents whose child was treated with PDK.

Table 81: Source of pneumonia drug kit (for children for whom feedback was collected) Source of Pneumonia drug Kit Total Intervention Blocks ANM CHC PHC children n (%) n (%) n (%) n(%) Intervention 1 11(6.15) 32(17.88) 136(75.98) 179(24.96) (Gosaiganj& Mall) Intervention 2 60(25.64) 109(46.58) 65(27.78) 234(32.63) (Kakori&Sarojini Nagar) Intervention 3 19(9.27) 101(49.27) 85(41.46) 205(28.59) Malhibad&Mohanlalganj) Intervention 4 0(0.0) 25(25.25) 74(74.75) 99(13.80) BKT&Chinhat) Total 90(12.55) 267(37.24) 360(50.21) 717(100.0) P value <0.0001

This table shows the place or source from where these children get Pneumonia Drug Kit. Among 717 children, 50% received Pneumonia Drug Kit from Primary Health Centers, 37% from Community Health Centers and 13% from ANMs.

Table 82: Did the instruction card, available with pneumonia drug kit, was read before you and made you understand completely? Instructions Read Properly Number of Parents Percent (%) Yes 142 19.8 No 575 80.2 Total 717 100.0

20% parents told that instruction card, available with Pneumonia Drug Kit, was read and made understand to them, by the Medical Officer or ANM dispensing the kit.

Table 83: Number of days Amoxicillin was administered to the child from pneumonia drug kit. Number of days of administration of Children Percent (%) Amoxicillin 1 14 2.0 2 61 8.5 3 122 17.0 4 50 6.9 5 470 65.6 Total 717 100.0 Pneumonia Drug Kit although contains amoxicillin dosage for 5 days. 66% parents administer amoxicillin to their children for complete 5 days.

Table 84: of days Paracetamol was administered to the child from pneumonia drug kit Number of days of administration Children Percent (%) of Paracetamol 0 62 8.6 1 44 6.1 2 170 23.7 3 139 19.4 4 62 8.6 5 240 33.5 Total 717 100.0

Pneumonia Drug Kit contains 4 tablets of paracetamol. Paracetamol was advised to be administered only when body temperature of child rises. Paracetamol dosage advised for 2 months to 3 yrs child, was one fourth tablet and for children between 3 to 5 years of age, half tablet.

33.5% parents administer paracetamol for 5 days while 6% parents administer paracetamol only for 1 day.

Table 85: Average number of days of consumption of Paracetamol & Amoxicillin from Pneumonia Drug Kit in comparison to source of Pneumonia Drug Kit. Source of kit Paracetamol Amoxicillin Mean SD Mean SD ANM 3.28 1.81 4.61 .87 CHC 2.93 1.54 4.12 1.12 PHC 3.25 1.65 4.16 1.17 Average number of consumption of amoxicillin was 4.61 days when Pneumonia Drug Kit was dispensed by ANM.

Table 86: Children, whose parents tick mark in the table in instruction card, after giving every dose of medication from the pneumonia drug kit.

Tick Mark after the dose Children Percent (%) No 639 89.1 Yes 78 10.9 Total 717 100.0

90% parents did not mark tick in the table on the last page of instruction card (provided with Pneumonia Drug Kit), after administering each dosage of medicine.

Table 87: Children who suffered from diarrhea/rashes, at the time of treatment from pneumonia drug kit Number of Children Percent (%) Diarrhea Yes 28 3.9 No 689 96.1 Total 717 100 Rashes Yes 3 0.4 No 714 99.6 Total 717 100.0

% Distribution of Adverse Effects Reported with PDK 120 96.1 99.6 100 80 60 40 20 Number Number Children of 4 1 0 Diarrhea Rashes

Yes (%) No (%)

Out of total 717 feedbacks collected, 28 (3.9%) children reported diarrhea and 3 (0.4%) reported rashes, after treatment from Pneumonia Drug Kit.

Table 88: Treatment taken for diarrhea & rashes (Above table) Treatment taken Number of Children Percent (n =31) (%) Consult to Doctor 12 38.70 Terminate PDK 16 51.61 Other 03 9.67 Total 31 100.0 Among these 31 children, having side effects, 52% children terminate treatment from Pneumonia Drug Kit. 39% children consult to the doctor, for side effects.

Table 89: Outcome of child’s illness after the treatment from PDK Outcome of the ANM (%) CHC (%) PHC (%) Total (%) PDK Improvement 73(81.1) 225(84.26) 311(86.38) 609(84.93) No improvement 17(18.9) 42(15.74) 49(13.62) 108(15.07) Total 90(100.0) 267(100.0) 360(100.0) 717(100.0) P value 0.424

% Distribution of outcome of child's illness, depending on source of PDK 100 84.26 86.38 90 81.1 80 70 60 50 40 30 18.9

20 15.74 13.62 Number Number Children of 10 0 ANM CHC PHC

Improvement (%) No improvement (%)

85% of children treated with Pneumonia Drug Kit for Pneumonia, show improvement in their illness.

P value more than 0.05 shows that outcome of treatment from Pneumonia Drug Kit, does not depend on the source, i.e. whether kit is dispensed by Doctor at CHC/PHC or by ANM.

Table 90: Average number of days of consumption of medicine from PDK (in comparison with outcome of illness) Outcome of the PDK Paracetamol Amoxicillin Mean SD Mean SD Improvement 1.15 4.43 0.96 No improvement 2.12 1.70 3.27 1.43

This table indicates that children, who were administered amoxicillin for 4.43 days, show improvement in their illness.

Table 91: Distribution of adverse events (diarrhea/rashes) encountered after use of PDK, with outcome of illness Outcome of the PDK Diarrhea (%) Rashes (%) Improvement 2(7.1) 2(66.6) No improvement 26(92.85) 1(33.3) Total 28 3

93% of cases, who develop diarrhea after having Pneumonia Drug Kit, show no improvement in their illness (Pneumonia), while 33.3% cases that develop rashes, after having Pneumonia Drug Kit, show no improvement in their illness (Pneumonia). Rest all children having side effects, shows improvement in Pneumonia.

8.6 Health Facility Audit Results

8.6.1 Status of availability of Amoxicillin

Table 92: Availability of Amoxicillin (through government supply)at Government Health Facilities -Pre, Mid and Post project interventions period Pre intervention Mid intervention Post intervention phase phase phase (Nov 2017-Jan2018) (Feb 2016-May (Nov 2016- Intervention 2016) Jan2017) (Number of (Number of (Number of facilities facilities with facilities with with availability of availability of availability of Amoxicillin / Total Amoxicillin / Amoxicillin / Total Number of a Govt. Total Number of Number of a Govt. Health Facilities) a Govt. Health Health Facilities) Facilities) Intervention_1(Gosaiganj & MALL) 9/10 (90%) 9/10 (90%) 5/10 (50%) Intervention_2(Kakor i&Sarojini Nagar) 8/10 (80%) 8/10 (80%) 4/10 (40%) Intervention_3(Malihabad &MohanlalGanj) 10/10 (100%) 5/10 (50%) 6/10 (60%)

Intervention_4(BKT &Chinhat) 11/12 (92%) 10/12 (83%) 4/12 (33%)

8.6.2 Status of availability of Oxygen Table 93: Availability of Oxygen (through government supply) at Government Health Facilities -Pre, Mid and Post project interventions period Pre intervention Mid intervention Post intervention phase phase phase (Feb 2016-May 2016) (Nov 2016- Jan2017) (Nov 2017-Jan2018) (Number of facilities (Number of facilities (Number of facilities Intervention with availability of with availability of with availability of oxygen / Total oxygen / Total oxygen / Total Number of a Govt. Number of a Govt. Number of a Govt. Health Facilities) Health Facilities) Health Facilities) Intervention_1 (Gosaiganj& MALL) 4/10 (40%) 4/10 (40%) 4/10 (40%) Intervention_2 (Kakor i&Sarojini Nagar) 8/10 (80%) 6/10 (60%) 7/10 (70%) Intervention_3 (Malihabad & 8/10 (80%) 8/10 (80%) 10/10 (100%) MohanlalGanj) Intervention_4 (BKT &Chinhat) 5/12 (42%) 4/12 (33%) 7/12 (58%)

The oxygen supply was not regular throughout. Although there was slight improvement in oxygen supply by post intervention phase audit.

8.6.3 Utilization of Pulse Oximeter and Salbutamol Inhaler

Pulse Oximeter and salbutamol inhaler was provided to all CHCs(9) and PHCs(33). We had collected feedback of Medical officers about the usage of pulse oximeter and salbutamol inhaler.

33% Medical Officers responded that they had used pulse oximeter and found it very useful in assessing oxygen concentration in children with respiratory distress.

21% Medical officers said that they had used salbutamol inhaler, provided by project. They found it very effective, useful and equivalent to nebulization.

8.7 Results of End Line Survey

End Line Survey was conducted from 21-Dec-2017 to 25-Apr-2018.

Table 94: Intervention wise distribution of study population

Intervention Number Number of Household Number Eligible Eligible Couples of Households Population of mother Children** having Villages Couples * Female in reproductive age group Intervention_1 60 600 3316 761 616 849 613 (Gosaiganj & MALL) Intervention_2 60 600 3316 763 618 866 617 (Kakori & Sarojini Nagar) Intervention_3 60 600 3284 751 619 869 647 (Malihabad & MohanlalGanj) Intervention_4 60 600 3394 776 612 828 654 (BKT & Chinhat) Total 240 2400 13310 3051 2465 3412 2531 *Eligible Mother – Mother having at least one child between 2-59 months of age **Eligible Child – Child between 2-59 months of age

Table 95: Number of households that were surveyed during Base Line Survey

Interventions Household included in Total Baseline Survey households (N) Intervention_1 480(80.00) 600 (Gosaiganj& MALL) Intervention_2 500(83.33) 600 (Kakori & Sarojini Nagar) Intervention_3 492(82.0) 600 (Malihabad&MohanlalGanj) Intervention_4 496(82.67) 600 (BKT & Chinhat) Total 1968(82.0) 2400

Out of 2400 households, 1968 (82%) households during end line survey were those, which were surveyed during base line survey. 432 (18%) new households were surveyed during end line survey, to replace those households in baseline survey who were no longer eligible .

Table 96: Intervention wise distribution of households on basis of Type of Family Interventions Joint Nuclear Total n (%) n (%) households (N) Intervention_1 363(60.50) 237(39.50) 600 (Gosaiganj& MALL) Intervention_2 382(63.67) 218(36.33) 600 (Kakori&Sarojini Nagar) Intervention_3 396(66.0) 204(34.00) 600 (Malihabad & Mohanlal Ganj) Intervention_4 355(59.17) 245(40.83) 600 (BKT &Chinhat) Total 1496(62.33) 904(37.67) 2400 Overall 62% households were resided by joint families. Intervention 3 blocks (Malihabad & Mohanlalganj) has maximum percentage (66%) of joint families, while Intervention 4 blocks (BakshiKaTalab & Chinhat) has maximum percentage (41%) nuclear families.

Table 97: Intervention wise distribution of households on basis of Type of House Interventions Kaccha Puhcca Semi Total n(%) n(%) Constructed households n (%) (N) Intervention_1 109(18.17) 368(61.33) 123(20.50) 600 (Gosaiganj& MALL) Intervention_2 79(13.17) 424(70.67) 97(16.17) 600 (Kakori & Sarojini Nagar) Intervention_3 85(14.17) 391(65.17) 124(20.67) 600 (Malihabad &MohanlalGanj) Intervention_4 55(9.17) 420(70.0) 125(20.83) 600 (BKT &Chinhat) Total 328(13.67) 1603(66.79) 469(19.54) 2400

Overall 67% households had PUHCCA house. Intervention 2 blocks (Kakori&Sarojini Nagar) and Intervention 4 blocks (BKT & Chinhat) has maximum number of Puhcca houses, while Intervention 1 blocks (Gosaiganj& Mall) has maximum percentage (18%) of Kaccha type of house.

Table 98: Intervention wise distribution of households on basis of main occupation of family Interventions Agricultu Daily Business Salary Professi Total re wages n (%) n (%) onal househol n (%) n (%) n (%) ds (N) Intervention_1 227 265 52 51 5 600 (Gosaiganj & (37.83) (44.17) (8.67) (8.50) (0.83) MALL) Intervention_2 165 281 81 65 8 600 (Kakori&Saroji (27.50) (46.83) (13.50) (10.83) (1.33) ni Nagar) Intervention_3 210 260 75 49 6 600 (Malihabad & (35.0) (43.33) (12.50) (8.17) (1.00) MohanlalGanj) Intervention_4 220 219 90 64 7 600 (BKT & (36.67) (36.50) (15.0) (10.67) (1.17) Chinhat) Total 822 1025 298 229 26 2400 (34.25) (42.17) (12.42) (9.54) (1.08)

Of 2400 household main occupation of households was Daily wages (42.17%) and Agriculture (34.25%) followed by business (12.42%), Salaried (9.54%), and Professionals (1.08%).

Table 99: Intervention wise distribution of households on basis of type of ration card (N=1434) Interventions Above Below Antyodaya Total Poverty Powerty Yojna households Line n (%) Line n (%) n (%) (N) Intervention_1 175 (44.87) 167 (42.82) 48 (12.31) 390 (Gosaiganj& MALL) Intervention_2 143 (43.47) 149 (45.29) 37 (11.25) 329 (Kakori&Sarojini Nagar) Intervention_3 133 (37.15) 169 (47.21) 56 (15.64) 358 (Malihabad & Mohanlal Ganj) Intervention_4 140 (39.22) 174 (48.74) 43 (12.04) 357 (BKT & Chinhat) Total 591 (41.21) 659 (45.96) 184 (12.83) 1434 Among households surveyed, 1434 (59.75%) households had ration card.

Table 100: Intervention wise distribution of households on basis of availability of separate kitchen Interventions Separate Kitchen Total Yes n (%) No n (%) households (N) Intervention_1 304(50.67) 296(49.33) 600 (Gosaiganj & MALL) Intervention_2 293(48.83) 307(51.17) 600 (Kakori &Sarojini Nagar) Intervention_3 285(47.50) 315(52.50) 600 (Malihabad & MohanlalGanj) Intervention_4 286(47.67) 314(52.33) 600 (BKT & Chinhat) Total 1168(48.67) 1232(51.33) 2400

Almost half of the households in across all four interventions did not possess a separate kitchen for cooking.

Table 101: Intervention wise distribution of households on basis of source of Fuel used for cooking (Multiple Response) Source of Fuel ( Out of 2400 household) LPG Wood Coal Dung Kerosene Electricity Interventions n (%) n (%) n (%) Cake Oil n (%) n (%) n (%) Intervention_1 355(59.1) 500(83.3) 2(0.33) 490(81.6) 7(1.2) 1(0.17) (Gosaiganj& MALL) (N=600) Intervention_2 403(67.1) 444(74.0) 0(0.0) 423(70.5) 1(0.17) 3(1.0) (Kakori&Sarojini Nagar) (N=600) Intervention_3 367(61.2) 475(79.1) 0(0.0) 459(76.5) 2(0.33) 2(0.33) (Malihabad & MohanlalGanj) (N=600) Intervention_4 403(67.2) 378(63.0) 1(0.17) 374(62.3) 2(0.33) 2(0.33) (BKT & Chinhat) (N=600) Total 1528(63.7) 1797(74.8) 3(0.13) 1746(72.7) 12(1.0) 8(0.33) It was observed that bio mass fuel like wood and dung cake were the commonest source for cooking. However more than half the households also used LPG for cooking.

Table 102: Intervention wise distribution of households on basis of source of Drinking Water (Multiple Response) Interventions Source of Fuel ( Out of 2400 household) Piped Public Hand Tube well Well Other water Tap Pump water n (%) source of supply Water n (%) n (%) water n (%) n (%) n (%) Intervention_1 36(6.0) 5(1.0) 539(90.0) 2(0.33) 0(0.0) 30(5.0) (Gosaiganj & MALL) Intervention_2 60(10.0) 11(2.0) 456(76.0) 6(1.0) 0(0.0) 91(15.2) (Kakori & Sarojini Nagar) Intervention_3 53(8.83) 13(2.1) 516(86.0) 1(0.17) 3(1.0) 46(8.0) (Malihabad & Mohanlal Ganj) Intervention_4 87(14.5) 4(1.0) 449(75.0) 7(0.17) 2(0.33) 89(15.0) (BKT & Chinhat) Total 236(9.8) 33(1.1) 1960(82.0) 16(1.0) 5(0.21) 256(11.0)

Hand Pumps (82%) are the main source of drinking water in the surveyed households. Piped water supply is available only in 9.8% households.

Table 103: Intervention wise distribution of households on basis of availability of Electricity Electricity Total Interventions households Yes n (%) No n (%) ((n) Intervention_1 479(79.83) 121(20.17) 600 (Gosaiganj& MALL) Intervention_2 529(88.17) 71(11.83) 600 (Kakori&Sarojini Nagar) Intervention_3 464(77.33) 136(22.67) 600 (Malihabad & MohanlalGanj) Intervention_4 555(92.50) 45(7.50) 600 (BKT &Chinhat) Total 2027(84.46) 373(15.54) 2400 84.5% households have electricity connection. Intervention 4 has highest percentage (92.5%) of households having electricity connection. Intervention 3 households have lowest percentage (77%) of electricity connection.

Table 104: Intervention wise distribution of households on basis of availability of Toilet Toilet Total Interventions households Yes n (%) No n (%) (n) Intervention_1 191(32.0) 409(68.17) 600 (Gosaiganj& MALL) Intervention_2 241(40.17) 359(59.83) 600 (Kakori & Sarojini Nagar) Intervention_3 237(40.0) 363(60.50) 600 (Malihabad & MohanlalGanj) Intervention_4 288(48.0) 312(52.0) 600 (BKT &Chinhat) Total 957(40.0) 1443(60.0) 2400 40% households have toilet facility. Intervention 4 has maximum percentage (48%) of households having toilet facility. Intervention 1 has lowest percentage (32%) of households having toilet facility.

Family Information of the households

Table 105: Gender distribution of family members Interventions Male n (%) Female n (%) Total n (%) Intervention_1 1642(49.52) 1674(50.48) 3316(24.91) (Gosaiganj & MALL) Intervention_2 1639(49.43) 1677(50.57) 3316(24.91) (Kakor i& Sarojini Nagar) Intervention_3 1641(49.97) 1643(50.03) 3284(24.67) (Malihabad & MohanlalGanj) Intervention_4 1704(50.21) 1690(49.79) 3394(25.50) (BKT & Chinhat) Total 6626(49.78) 6684(50.22) 13310(100.0)

Table 106: Marital Status of family members Interventions Married Unmarri Widow/ Not applicable Total n (%) ed Widower (For Children) n (%) n (%) n (%) n (%) Intervention_1 1539(46.41) 128(3.86) 116(3.50) 1533(46.23) 3316(24.91) (Gosaiganj & MALL) Intervention_2 1545(46.59) 125(3.77) 105(3.17) 1541(46.47) 3316(24.91) (Kakori& Sarojini Nagar) Intervention_3 1517(46.19) 116(3.53) 102(3.11) 1549(47.17) 3284(24.67) (Malihabad & MohanlalGanj) Intervention_4 1573(46.35) 129(3.80) 124(3.65) 1568(46.20) 3394(25.50) (BKT & Chinhat) Total 6174(46.39) 498(3.74) 447(3.36) 6191(46.51) 13310(100. 0)

Table 107: Education Status of family members Interventions Illiterate No Formal Class I Class VI Class XI Graduate Post Children not Total n (%) Education to V to X to XII n (%) graduate of school going n (%) n (%) n (%) n (%) n (%) n (%) age (below 3 years of age) Intervention_1 432(13.0) 454(13.6) 676(20.3) 802(24.1) 206(6.21) 168(5.07) 32(0.97) 546(16.47) 3316(24.91) (Gosaiganj & MALL) Intervention_2 433(13.0) 510(15.3) 673(20.3) 750(22.6) 206(6.21) 150(4.52) 25(0.75) 569(17.16) 3316(24.91) (Kakor i& Sarojini Nagar) Intervention_3 385(11.7) 463(14.1) 708(21.5) 809(24.6) 181(5.51) 151(4.60) 21(0.64) 566(17.24) 3284(24.67) (Malihabad & MohanlalGanj) Intervention_4 485(14.2) 474(13.9) 695(20.4) 828(24.4) 186(5.48) 146(4.30) 44(1.30) 536(15.79) 3394(25.50) (BKT & Chinhat) Total 1735(13.0) 1901(14.2) 2752(20.6) 3189(23.9) 779(5.85) 615(4.62) 122(0.92) 2217(16.66) 13310(100.0) 44.5% of population surveyed had education between Class I to X. 27.2% population is either illiterate or has no formal education. Only 5.54%population is graduate or above.

Table 108: Population (Children between 2months to 59 months of age) eligible for the survey Population eligible for survey Total population Interventions Eligible Children Population of 60 months n (%) (2-59 months) n (%) or above n (%) Intervention_1 849(25.60) 2467(74.40) 3316(24.91) (Gosaiganj & MALL) Intervention_2 866(26.12) 2450(73.88) 3316(24.91) (Kakor i& Sarojini Nagar) Intervention_3 869(26.46) 2415(73.54) 3284(24.67) (Malihabad & MohanlalGanj) Intervention_4 828(24.40) 2566(75.60) 3394(25.50) (BKT & Chinhat) Total 3412(25.63) 9898(74.37) 13310(100.0)

Children Section

Table 109: Gender distribution of eligible children Interventions Male Children Female Children Total Children n (%) n (%) n (%) Intervention_1 452(53.24) 397(46.76) 849(24.88) (Gosaiganj& MALL) Intervention_2 454(52.42) 412(47.58) 866(25.38) (Kakori&Sarojini Nagar) Intervention_3 469(53.97) 400(46.03) 869(25.47) (Malihabad&MohanlalGanj) Intervention_4 429(51.81) 399(48.19) 828(24.27) (BKT &Chinhat) Total 1804(52.87) 1608(47.13) 3412(100.0) Across all the four interventions, there is similar distribution of children on gender basis. Male children are 53% and female children are 47%.

Table 110: Age Distribution of eligible children Interventions 2-11 months 12-23 months 24-59 months Total n (%) n (%) n (%) Children n (%) Intervention_1 132(15.55) 136(16.02) 581(68.43) 849(24.88) (Gosaiganj& MALL) Intervention_2 105(12.12) 149(17.21) 612(70.67) 866(25.38) (Kakori&Sarojini Nagar) Intervention_3 108(12.43) 151(17.38) 610(70.20) 869(25.47) (Malihabad & MohanlalGanj) Intervention_4 110(13.29) 138(16.67) 580(70.05) 828(24.27) (BKT &Chinhat) Total 455(13.34) 574(16.82) 2383(69.84) 3412(100.0)

Across all the interventions age distribution of eligible children is equal. 13% of children are between 2- 11 months of age. 17% children are from 12-23 months. Most of children (70%) belonging to 24-59 months.

Table 111: Whether the child suffered from Diarrhea /RTI/Fever/Convulsion in last one year Interventions Yes Total Children n (%) n (%) Intervention_1 817(96.23) 849(24.88) (Gosaiganj& MALL) Intervention_2 840(97.0) 866(25.38) (Kakori&Sarojini Nagar) Intervention_3 838(96.43) 869(25.47) (Malihabad&MohanlalGanj) Intervention_4 807(97.46) 828(24.27) (BKT &Chinhat) Total 3302(96.78) 3412(100.0) 97% of children suffered from Diarrhea/RTI/Fever/Convulsion in last one year. Table 112: Whether the child suffered from Diarrhea in last one year (n = 3302) Interventions Yes Total Children n (%) n (%) Intervention_1 236(28.89) 817(24.74) (Gosaiganj& MALL) Intervention_2 268(31.90) 840(25.44) (Kakori & Sarojini Nagar) Intervention_3 277(33.05) 838(25.38) (Malihabad & MohanlalGanj) Intervention_4 262(32.47) 807(24.44) (BKT &Chinhat) Total 1043(31.59) 3302(100.0) 32% children suffered from diarrhea in last one year

Table 113: Place of the treatment for Diarrhea (last one year) (Multiple Response) Interventions Government Private Total Children Hospital Hospital Suffered with n (%) n (%) Diarrhea n Intervention_1 47(19.92) 205(86.86) 236 (Gosaiganj& MALL) Intervention_2 38(14.18) 252(94.03) 268 (Kakori&Sarojini Nagar) Intervention_3 68(24.55) 242(87.36) 277 (Malihabad&MohanlalGanj) Intervention_4 38(14.50) 240(91.60) 262 (BKT &Chinhat) Total 191(18.31) 939(90.03) 1043 Only 18% of children suffered from Diarrhea, visited Government Hospital for treatment.

Table 114: Outcome of the treatment of Diarrhea (last one year) (n=1043) Interventions Recovered Total Children Children Suffered with Diarrhea n Intervention_1 236 236 (Gosaiganj& MALL) Intervention_2 268 268 (Kakori & Sarojini Nagar) Intervention_3 277 277 (Malihabad & MohanlalGanj) Intervention_4 262 262 (BKT &Chinhat) Total 1043 1043 All children recovered from Diarrhea.

Table 115: Number of Episodes of Diarrhea in children in last one year (Descriptive Statistics)

Intervention wise N Min Episode Max Mean Std. Number of episode of Episode Deviation Diarrhea Intervention_1 236 1 10 2 2 (Gosaiganj& MALL) Intervention_2 268 1 10 2 2 (Kakori & Sarojini Nagar) Intervention_3 277 1 10 2 2 (Malihabad & MohanlalGanj) Intervention_4 262 1 20 3 2 (BKT &Chinhat) Total 1043 1 20 2.42 1.827

Table 116: Total Expenditure on the Diarrhea for last one year (Descriptive Statistics) Intervention wise n Min Max Mean Median Expenditure for the Expenditure Expenditure treatment of Diarrhea Intervention_1 236 0 12000 536 115 (Gosaiganj& MALL) Intervention_2 268 0 11000 693 108 (Kakori & Sarojini Nagar) Intervention_3 277 1 14000 574 100 (Malihabad & MohanlalGanj) Intervention_4 262 0 17000 678 100 (BKT & Chinhat) Total Expenditure 1043 0 17000 622.04 100

Table 117: Whether the child suffered from RTI in last one year (n=3302) Interventions Yes Total Children n (%) n (%) Intervention_1 786(96.21) 817(24.74) (Gosaiganj& MALL) Intervention_2 820(97.62) 840(25.44) (Kakori & Sarojini Nagar) Intervention_3 827(98.69) 838(25.38) (Malihabad & MohanlalGanj) Intervention_4 783(97.03) 807(24.44) (BKT &Chinhat) Total 3216(97.40) 3302(100.0)

97% children suffered from RTI in last one year

Table 118: Place of the treatment for RTI (last one year) (Multiple Response) Interventions Government Private Total Children Hospital Hospital Suffered with n (%) n (%) RTI (n) Intervention_1 177(22.52) 725(92.24) 786 (Gosaiganj& MALL) Intervention_2 126(15.37) 781(95.24) 820 (Kakori&Sarojini Nagar) Intervention_3 203(24.55) 756(91.41) 827 (Malihabad&MohanlalGanj) Intervention_4 130(16.60) 736(94.0) 783 (BKT &Chinhat) Total 636(19.78) 2998(93.22) 3216 Only 20% children, suffered from RTI, visited Government Hospital for treatment. Table 119: Outcome of the treatment of RTI (last one year) (n=3216) Interventions Recovered Not Recovered Total Children Children Children n (%) n (%) n (%) Intervention_1 786(100.0) 0(0.0) 786 (Gosaiganj& MALL) Intervention_2 818(99.76) 2(0.24) 820 (Kakori&Sarojini Nagar) Intervention_3 826(99.88) 1(0.12) 827 (Malihabad & Mohanlal Ganj) Intervention_4 782(99.87) 1(0.13) 783 (BKT &Chinhat) Total 3212(99.88) 3(0.09) 3216 99.9% children recovered from RTI. Table 120: Number of Episodes of RTI in children for last one year (Descriptive Statistics) Intervention wise n Min Max Mean Std. Number of episode of RTI Episode Episode Deviation Intervention_1 786 12 1 4 2 (Gosaiganj& MALL) Intervention_2 820 12 1 4 2 (Kakori&Sarojini Nagar) Intervention_3 827 12 1 4 2 (Malihabad & Mohanlal Ganj) Intervention_4 783 12 1 4 2 (BKT &Chinhat) Total 3216 1 12 4.05 2.73

Table121: Total Expenditure on the RTI (last one year) (Descriptive Statistics) Intervention wise n Min Max Mean Median Expenditure for the Expenditure Expenditure treatment of RTI Intervention_1 786 0 35000 201 100 (Gosaiganj& MALL) Intervention_2 819 0 12000 231 100 (Kakori&Sarojini Nagar) Intervention_3 825 0 45000 354 100 (Malihabad & MohanlalGanj) Intervention_4 783 0 70000 327 100 (BKT &Chinhat) Total Expenditure 3216 0 70000 278.69 100

Table 122: Whether child suffered from running nose, since last one year? Interventions Yes Total Children n (%) n (%) Intervention_1 789(92.93) 849(24.88) (Gosaiganj& MALL) Intervention_2 814(94.00) 866(25.38) (Kakori&Sarojini Nagar) Intervention_3 822(94.59) 869(25.47) (Malihabad&MohanlalGanj) Intervention_4 775(93.60) 828(24.27) (BKT &Chinhat) Total 3200(93.79) 3412(100.0)

Out of total 3412 children 94% children reported to have running nose in last one year. Number of children (having running nose) is almost equivalent across all the interventions.

Table 123: Age distribution of children, who suffered from running nose in last one year? Age group (In months) Child suffered from running nose, since last three months Total Children Yes n (%) No n (%) n (%)

2-11 415(91.21) 40(8.79) 455(13.34) 12-23 564(98.26) 10(1.74) 574(16.82) 24-59 2221(93.20) 162(6.80) 2383(69.84) Total 3200(93.79) 212(6.21) 3412(100.0)

Number of children suffered from running nose across all age groups is equivalent, with maximum effect on children of 12 to 23 months age group.

Table 124: What type of treatment was given to child with running nose? (Multiple Response) Interventions Medicine Home Remedy Medical prescribed by n (%) Store Doctor n (%) n (%) Intervention_1 550(69.71) 339(42.97) 40(5.07) (Gosaiganj& MALL) (N=789) Intervention_2 585(71.87) 365(44.84) 38(4.67) (Kakori & Sarojini Nagar) (N=814) Intervention_3 624(75.91) 338(41.12) 49(5.96) (Malihabad & Mohanlal Ganj) (N=822) Intervention_4 577(74.45) 334(43.10) 33(4.26) (BKT &Chinhat) (N=775) Total (N=3200) 2336(73.00) 1376(43.0) 160(5.00)

For running nose 73% children were treated with medicines prescribed by a Doctor.

Table 125: What all types of health care providers were approached for treatment of running nose (Multiple Response)? Interventions Private Government Total Children Hospital Hospital who were treated n (%) n (%) by Doctors N=2336 (%) Intervention_1 501(91.09) 71(12.91) 550 (Gosaiganj& MALL) (N=550) Intervention_2 558(95.38) 37(6.32) 585 (Kakori & Sarojini Nagar) (N=585) Intervention_3 554(88.78) 90(14.42) 624 (Malihabad & MohanlalGanj) (N=624) Intervention_4 539(93.41) 54(9.36) 577 (BKT &Chinhat) (N=577) Total (N=2336) 2152(92.12) 252(10.79) 2336 Among the children who visited government health facilities, maximum number was in Intervention 3 (14.42%)

Table 126: Children who were advised follow up care after 72 hours for running nose. (n=2336) Interventions Advise for follow - up care Total Children who after 72 hours were taken treatment Yes n (%) No n (%) by doctors n=2336 (%) Intervention_1 473(86.0) 77(14.0) 550 (Gosaiganj& MALL) Intervention_2 476(81.37) 109(18.63) 585 (Kakori&Sarojini Nagar) Intervention_3 525(84.13) 99(15.87) 624 (Malihabad&MohanlalGanj) Intervention_4 479(83.02) 98(16.98) 577 (BKT &Chinhat) Total 1953(83.60) 383(16.40) 2336

84% of children were advised for follow up care after 72 hours.

Table 127: Children with running nose, who were taken for the follow- up after 72 hours. (n=1953) Interventions If yes , did you go for the Total Children who follow- up after 72 hours were advised for Yes n (%) No n (%) follow up n=1953 (%) Intervention_1 176(37.21) 297(62.79) 473 (Gosaiganj& MALL) Intervention_2 215(45.17) 261(54.83) 476 (Kakori&Sarojini Nagar) Intervention_3 217(41.33) 308(58.67) 525 (Malihabad & MohanlalGanj) Intervention_4 214(44.68) 265(55.32) 479 (BKT &Chinhat) Total 822(42.09) 1131(57.91) 1953

Only 42% cases go back for follow up care after 72 hours.

Table 128: Children who suffered from cough with fast breathing (with or without chest in drawing), since last one year? Interventions Yes Total Children n (%) n (%) Intervention_1 147(17.31) 849(24.88) (Gosaiganj& MALL) Intervention_2 162(18.71) 866(25.38) (Kakori&Sarojini Nagar) Intervention_3 149(17.15) 869(25.47) (Malihabad&MohanlalGanj) Intervention_4 154(18.60) 828(24.27) (BKT &Chinhat) Total 612(17.94) 3412(100.0) Out of total 3412 children 18% children reported to have cough with fast breathing (with or without chest in drawing) in last one year. Frequency of such children (having cough with fast breathing with or without chest in drawing) is almost equivalent across all the interventions.

Table 129: Age distribution of children who suffered from cough with fast breathing (with or without chest in drawing), in last one year? Age group (In Child suffered from cough with fast breathing Total months) with or without chest in drawing Children Yes No n (%) n (%) n (%) 2-11 119(26.15) 336(73.85) 455(13.34) 12-23 117(20.38) 457(79.62) 574(16.82) 24-59 376(15.78) 2007(84.22) 2383(69.84) Total 612(17.94) 2800(82.06) 3412(100.0) Children of age group 2-11 months suffered most (26.15%) from cough with fast breathing (with or without chest in drawing), in last one year.

Table 130: Type of treatment that was given to children suffering from cough with fast breathing (with or without chest in drawing). (Multiple Response) Interventions Medicine Home Medical Store prescribed by Remedy n (%) Doctor n (%) n (%) Intervention_1 139(94.56) 42(28.57) 4(2.72) (Gosaiganj & MALL) (N=147) Intervention_2 152(93.83) 37(22.84) 5(3.09) (Kakori & Sarojini Nagar) (N=162) Intervention_3 143(95.97) 40(26.85) 7(4.70) (Malihabad & Mohanlal Ganj) (N=149) Intervention_4 151(98.05) 39(25.32) 0(0.0) (BKT & Chinhat) (N=154) Total (N=612) 585(95.59) 158(25.82) 16(2.61) Majority of children suffering from cough with fast breathing were treated through medicines prescribed by Doctors.

Table 131: What all types of health care providers were approached for treatment of children suffering from cough with fast breathing (with or without chest in drawing)? (Multiple Response) Interventions Private Government Total Children Hospital Hospital who were taken n (%) n (%) treatment from doctor for pneumonia N Intervention_1 119(85.61) 21/139(15.10) 139 (Gosaiganj& MALL) Intervention_2 141(92.76) 18/152(11.84) 152 (Kakori&Sarojini Nagar) Intervention_3 123(86.01) 32/143(22.37) 143 (Malihabad & MohanlalGanj) Intervention_4 141(93.38) 15/151(9.93) 151 (BKT &Chinhat) Total 524(89.57) 86(14.70) 585

Among the children, who visited government health facilities, maximum number was in Intervention 3 (22.37%).

Table 132: Children who were advised follow - up care after 72 hours, for from cough with fast breathing (with or without chest in drawing)? (n=585) Interventions Advise for follow - up Total Children suffered care after 72 hours from childhood Yes No pneumonia n (%) n (%) n (%) Intervention_1 128(92.09) 11(7.91) 139 (Gosaiganj& MALL) Intervention_2 137(90.13) 15(9.87) 152 (Kakori&Sarojini Nagar) Intervention_3 137(95.80) 6(4.20) 143 (Malihabad &MohanlalGanj) Intervention_4 140(92.72) 11(7.28) 151 (BKT &Chinhat) Total 542(92.65) 43(7.35) 585 93% of children were advised for follow up care after 72 hours.

Table 133: Children, suffering from cough with fast breathing (with or without chest in drawing), who were taken for the follow- up after 72 hour. (n=542) Interventions If yes , did you go for the Total children follow- up after 72 hours advised for Yes No follow- up n (%) n (%) n (%) Intervention_1 65(50.78) 63(49.22) 128 (Gosaiganj& MALL) Intervention_2 83(60.58) 54(39.42) 137 (Kakori&Sarojini Nagar) Intervention_3 79(57.66) 58(42.34) 137 (Malihabad & MohanlalGanj) Intervention_4 88(62.86) 52(37.14) 140 (BKT &Chinhat) Total 315(58.12) 227(41.88) 542

Only 58% cases go back for follow up care after 72 hours.

Table134: Children who were admitted in hospital, for treatment of pneumonia in last one year? Interventions Yes No Total number n (%) n (%) of children with possible pneumonia n Intervention_1 2(1.3) 145(98.64) 147 (Gosaiganj& MALL) Intervention_2 6(3.7) 156(96.30) 162 (Kakori&Sarojini Nagar) Intervention_3 11(7.3) 138(92.62) 149 (Malihabad & Mohanlal Ganj) Intervention_4 11(7.1) 143(92.86) 154 (BKT &Chinhat) Total 30(4.90) 582(95.10) 612

4.90% children with possible pneumonia were hospitalized due to pneumonia in last one year.

Table 135: In which type of hospital, was the child was admitted first for pneumonia? (n=30) Interventions Government Private Total children hospitalized hospital n (%) for pneumonia n (%) n (%) Intervention_1 1(50.0) 1(50.0) 2(6.67) (Gosaiganj& MALL) Intervention_2 1(16.67) 5(83.33) 6(20.0) (Kakori&Sarojini Nagar) Intervention_3 3(27.27) 8(72.70) 11(36.67) (Malihabad & MohanlalGanj) Intervention_4 4(36.30) 7(63.6) 11(36.67) (BKT &Chinhat) Total 9(30.0) 21(70.0) 30(100.0)

70% cases of pneumonia were hospitalized at Private hospitals.

Mother Section

Table 136: Mothers who have you ever heard about the illness called "pneumonia"? Interventions Yes No Total n (%) n (%) n (%) Intervention_1 596(96.75) 20(3.25) 616(24.99) (Gosaiganj& MALL) Intervention_2 609(98.54) 9(1.46) 618(25.07) (Kakori&Sarojini Nagar) Intervention_3 611(98.71) 8(1.29) 619(25.11) (Malihabad&MohanlalGanj) Intervention_4 597(97.55) 15(2.45) 612(24.83) (BKT &Chinhat) Total 2413(97.89) 52(2.11) 2465(100.0) 98% respondent mothers told that they had heard about the illness called Pneumonia.

Table 137: Symptoms of pneumonia as responded by mothers. (Multiple Response) Interventions Cold and Running Fever Fast Difficulty in Chest In Not able to Drowsy Mothers who Cough Nose n (%) Breathing breathing drawing drink n (%) ever heard n (%) n (%) n (%) n (%) n (%) n (%) Symptoms of Pneumonia (n) Intervention_1 299(50.1) 144(24.16) 136(22.82) 163(27.35) 110(18.46) 187(31.38) 110(18.46) 18(3.02) 596 (Gosaiganj & MALL) Intervention_2 271(44.50) 259(42.53) 197(32.35) 334(54.84) 257(42.20) 299(49.10) 247(40.56) 44(7.22) 609 (Kakori & Sarojini Nagar) Intervention_3 345(56.46) 190(31.10) 210(34.37) 330(54.01) 237(38.79) 343(56.14) 203(33.22) 44(7.20) 611 (Malihabad & MohanlalGanj) Intervention_4 256(42.88) 162(27.14) 105(17.59) 140(23.45) 104(17.42) 157(26.30) 111(18.59) 20(3.35) 597 (BKT &Chinhat) Total 1171(48.53) 755(31.29) 648(26.85) 967(40.07) 708(29.34) 986(40.86) 671(27.81) 126(5.22) 2413 Almost 54% respondents from Intervention 2 &3, identified fast breathing as a sign of pneumonia. Whereas only 27% and 23% respondents identify fast breathing as a sign of pneumonia in Intervention 1 & 4 respectively.

Table 138: Source of information about pneumonia? (Multiple Response) Interventions ASHA ANM AWW PHC CHC POSTER VIDEO RADIO OTHER n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Intervention_1 88(14.77) 48(8.05) 2(0.34) 6(1.01) 15(2.52) 21(3.52) 15(2.52) 0(0.0) 277(46.48) (Gosaiganj & MALL) (n=596) Intervention_2 399(65.52) 97(15.93) 12(1.97) 2(0.33) 6(0.99) 85(13.96) 2(0.33) 2(0.33) 272(44.66) (Kakori&Sarojini Nagar) (n=609) Intervention_3 402(65.79) 81(13.26) 18(2.95) 16(2.62) 12(1.96) 88)(14.40) 24(3.93) 1(0.16) 266(43.54) (Malihabad & Mohanlal Ganj) (n=611) Intervention_4 41(6.87) 11(1.84) 9(1.51) 1(0.17) 2(0.34) 3(0.50) 0(0.0) 0(0.0) 305(51.09) (BKT & Chinhat) (n=597) Total (N=2413) 930(38.54) 237(9.82) 41(1.70) 25(1.04) 35(1.45) 197(8.16) 41(1.70) 3(0.12) 1120(46.42) 38.5 % respondents told that information on pneumonia was given to them by ASHA.46% respondents gained information about pneumonia from other sources like Family members & neighbors. ASHA is the major source of information about pneumonia in intervention 2 & 3, accounting to 66%.

Table 139: Mothers who had attended VHND in last 6 month (n=2434) Interventions Yes No Total mothers who heard n (%) n (%) about the VHND n (%) Intervention_1 173(28.60) 432(71.40) 605 (Gosaiganj & MALL) Intervention_2 239(38.74) 378(61.26) 617 (Kakori & Sarojini Nagar) Intervention_3 229(37.12) 388(62.88) 617 (Malihabad & MohanlalGanj) Intervention_4 191(32.10) 404(67.90) 595 (BKT &Chinhat) Total 832(34.18) 1602(65.82) 2434 34% mothers had attended VHND in last six months. Table 140: Was any information on pneumonia was given on VHND? (n=832) Interventions Yes No Total n (%) n (%) n (%) Intervention_1 22(12.72) 151(87.28) 173 (Gosaiganj& MALL) Intervention_2 133(55.65) 106(44.35) 239 (Kakori & Sarojini Nagar) Intervention_3 123(53.71) 106(46.29) 229 (Malihabad & Mohanlal Ganj) Intervention_4 13(6.81) 178(93.19) 191 (BKT & Chinhat) Total 291(34.98) 541(65.02) 832 56% mothers in Intervention 2 and 54% mothers in Intervention 3, responded that information about Pneumonia was given on VHND.

Table 141: Who gave you pneumonia related information on VHND? (Multiple Response) Interventions ASHA ANM AWW n (%) n (%) n (%) Intervention_1 21(95.45) 6(27.20) 2(9.09) (Gosaiganj& MALL) Intervention_2 127(95.49) 22(16.54) 12(9.02) (Kakori & Sarojini Nagar) Intervention_3 120(97.56) 15(12.20) 20(16.26) (Malihabad & MohanlalGanj) Intervention_4 11(84.62) 2(15.38) 3(23.08) (BKT & Chinhat) Total 279(95.88) 45(15.46) 37(12.71) ASHA is the key informant about Pneumonia on VHND.

Table 142: Mothers who had attended routine immunization day in last 6 months? (n=2460) Interventions Yes No Total Mother who aware about n (%) n (%) the Immunization day n (%) Intervention_1 270(43.97) 344(56.03) 614 (Gosaiganj& MALL) Intervention_2 298(48.22) 320(51.78) 618 (Kakori & Sarojini Nagar) Intervention_3 294(47.50) 325(52.50) 619 (Malihabad & Mohanlal Ganj) Intervention_4 242(39.54) 370(60.46) 612 (BKT &Chinhat) Total 1104(44.82) 1359(55.18) 2463 45% mothers attended routine immunization in last 6 months.

Table 143: Was any information on pneumonia was given on immunization day? (N=1104) Interventions Yes No Total mothers who n (%) n (%) attended the Immunization day n (%) Intervention_1 60(22.22) 210(77.78) 270 (Gosaiganj& MALL) Intervention_2 247(82.89) 51(17.11) 298 (Kakori & Sarojini Nagar) Intervention_3 229(77.89) 65(22.11) 294 (Malihabad & Mohanlal Ganj) Intervention_4 24(9.92) 218(90.08) 242 (BKT &Chinhat) Total 560(50.72) 544(49.28) 1104 83% mothers in Intervention 2 and 78% mothers in Intervention 3 responded that information about Pneumonia was given on routine immunization day.

Table 144: Who gave you pneumonia related information on Immunization day? (Multiple Response) Interventions ASHA ANM AWW Relative n (%) n (%) n (%) &Neighbor n (%) Intervention_1 48(80.0) 28(46.67) 2(3.33) 2(3.33) (Gosaiganj& MALL) (N=60) Intervention_2 242(97.98) 83(33.60) 2(0.81) 2(0.81) (Kakori&Sarojini Nagar) (N=247) Intervention_3 221(96.51) 76(33.19) 6(2.62) 6(2.62) (Malihabad & MohanlalGanj) (N=229) Intervention_4 19(79.17) 6(25.0) 4(16.67) 4(16.67) (BKT &Chinhat) (N=24) Total (N=560) 530(94.64) 193(34.46) 14(2.50) 14(2.50)

ASHA is the key informant about Pneumonia on routine immunization day.

8.8 Results against Objectives

Flow diagram of 8 rural blocks randomly allocated for Monthly Pneumonia Awareness Session (PAS) during Routine Immunization Day at CHC & PHC by ANM

8 Rural Blocks in Lucknow District

Total Area (Rural) – 2095.4 sq kms Total Population (Rural) - 15.51 Lakh

Randomized by Blocks (balanced in groups of Four Blocks) (Aug 2016 to Dec 2017)

4 Blocks – ANM conducts PAS 4 Blocks – Open controls (Usual Care) monthly on Routine Immunization (With 22 CHCs & PHCs) Day at CHC/PHC. (With 20 CHCs & PHCs)

Total PAS conducted – 279/300 (93%)

Quarterly visit at each health facility to record number cases between 2 to 59 months[For the period July 2016 to Oct 2017] of:  New cases – 143865  Possible Pneumonia cases – 22910

Base line Survey – 120 Villages / 1200 Households / 1659 Children (2 to 59 months) End line Survey – 120 Villages / 1200 Households / 1715 Children (2 to 59 months) Total Possible Pneumonia Cases: 1436

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Flow diagram of 8 rural blocks randomly allocated for Monthly Pneumonia Awareness Session (PAS) during Village Health & Nutrition Day at Villages by ASHA

8 Rural Blocks in Lucknow District

Total Area (Rural) – 2095.4 sq kms

Total Population (Rural) - 15.51 Lakh

Randomized by Blocks (balanced in groups of Four Blocks) (Aug 2016 to Dec 2017)

4 Blocks – ASHA conducts PAS 4 Blocks – Open controls (Usual Care) monthly on Village Health & Nutrition Day at Villages. (421 villages)

(386 villages)

Total PAS conducted – 7638/10410 (73.4%)

Quarterly visit at each health facility to record number cases between 2 to 59 months[For the period July 2016 to Oct 2017] of:  New cases – 143865  Possible Pneumonia cases (2 to 59 months) – 22910  Base line Survey – 120 Villages / 1200 Households / 1700 Children (2 to 59 months) End line Survey – 120 Villages / 1200 Households / 1735 Children (2 to 59 months) Total Possible Pneumonia Cases: 1436

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8.8.1 Primary Objective 1 The Primary Objective 1-To assess the effectiveness of an innovative package of “Community Orientation” of doctors and ANMs and ASHAs, PLUS infrastructural strengthening by (i) providing “Pneumonia Drug Kit” (PDK) (ii) establishing “Pneumonia Management Corner” (PMC) at additional primary health center (APHC) and (iii) “Pneumonia Management Unit” (PMU) at Community health center (CHC) ALONG with one of the 4 different behavior change communication (BCC) interventions.

Intervention 2: Organizing PAS on Village Health and Nutrition Day (V.H.N.D.) once a month by the ASHA worker trained for this.

Intervention 3: Combination of Both Intervention 1& 2

Intervention 4: Usual Care

Outcome measures against primary objective 1are: Number of clinical pneumonia cases-

1. Treated by ANMs/doctors with medicines from PDK OR 2. Treated at either PMC or PMU

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Table 145: Intervention wise distribution of new registered children (2-59 months of age) and childhood pneumonia cases diagnosed by doctors at government health facilities July 2016 – Oct 2017 New registered New registered Childhood % Childhood Intervention Children at Children with pneumonia pneumonia health facilities diagnosis diagnosed by Children ( 2-59 months ) 2-59 months doctors (2-59 months) (%) ( 2-59 months ) (CI 95%) Intervention_1 29113 1524 (5.2) 186 12.2(10.56-13.85) (Gosaiganj & MALL) Intervention_2 35095 8398(23.9) 1612 19.2(18.35-20.04) (Kakori & Sarojini Nagar) Intervention_3 40080 2499(6.2) 412 16.5(15.03-17.94) (Malihabad & MohanlalGanj) Intervention_4 39577 1870(4.7) 273 14.6(13.0-16.20) (BKT &Chinhat) Above table shows the number of children registered at government health facilities during the period from July 2016 to Oct 2017 and number of children who were diagnosed as a case of childhood pneumonia by the doctors at these facilities.

Across the 4 interventions 19.2 % (18.35-20.04) children were diagnosed as childhood pneumonia cases in intervention 2, which is followed by intervention 3, 16.5% (15.03-17.94) Intervention 4 14.6(13.0-16.20) and Intervention 112.2 ,(10.56-13.85). All Four Interventions are dissimilar for the childhood pneumonia (p <0.001). Through comparison of all interventions we found that in intervention -2, ASHAs spread awareness about establishment of pneumonia management units and corners at government health facilities along with symptoms of pneumonia and importance of immediate health seeking.

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Table 146: Comparison of childhood pneumonia cases diagnosed by doctors at CHC & PHC (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS) Childhood pneumonia diagnosed by doctors at CHC & PHC / New registered cases with diagnosis at CHC & PHC Diff p value (2-59 months) (%) (One Tail) Intervention 1 & Intervention 3 Intervention 2 & Intervention 4 (ANM delivering PAS) (ANM not delivering PAS) (%) (%)

598/4023 1885/10268 3.68 0.999 (14.68%) (18.36%)

In Interventions where ANMs were conducting PAS (Intervention 1 & 3) 14.7% of new cases diagnosed as CAP whereas in interventions where ANMs did not conduct PAS (Intervention 2 & 4) there was 18.3%, and the difference was not statistically significant.

Table 147: Comparison of childhood pneumonia cases diagnosed by doctors at CHC & PHC (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS)

Childhood pneumonia diagnosed by doctors at CHC & PHC / New registered cases with diagnosis at CHC & PHC (2-59 months)

p value Diff Intervention 2 & Intervention Intervention 1 & Intervention 4 (%) 3 (ASHA not delivering PAS) (%) (ASHA delivering PAS) (%)

2024/10897 459/3394 5.05 <0.0001 (18.57%) (13.52) In Interventions where ASHAs were conducting PAS (Intervention 1 & 3) 18.57% new cases were diagnosed as CAP whereas interventions where ASHAs did not conduct PAS (Intervention 2 & 4) there was 13.52% new cases of CAP, and the difference was statistically significant.

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Table 148: Intervention wise distribution of estimated cases of childhood pneumonia and children treated by pneumonia drug kit July 2016 – Oct 2017 New registered Estimated Pneumonia % children Intervention cases of Children Children of Drug Kit who treated by at health facility childhood distribution pneumonia ( 2-59 months ) pneumonia by ANM or drug kit ( 2-59 months) (%) CHC or PHC Intervention_1 29113 3493(12.2) 1774 (Gosaiganj& MALL) 50.21 Intervention_2 35095 6668(19.2) 2190 32.84 (Kakor i&Sarojini Nagar) Intervention_3 40080 6813(16.5) 2187 32.10 (Malihabad & MohanlalGanj) Intervention_4 39577 5936(14.6) 1579 26.60 (BKT &Chinhat)

This table shows intervention wise distribution of estimated children of childhood pneumonia during the period July 2016 – Oct 2017 Among four interventions 50% of children were treated by Pneumonia Drug Kit (PDK) in intervention 1 followed by Intervention 3- 32.01 %, Intervention 2 -32.84% and Intervention4- 26.60%. Remaining Children of childhood pneumonia were treated by medicines by government supply at health facilities. Parents preferred syrup amoxicillin (which was available in government supply during the period when project was initiated) over amoxicillin dispersible tablets (provided through project in pneumonia drug kits) for their children. Demonstrations were given to the parents on preparations and administrations dispersible tablets of amoxicillin provided through PDK which increases acceptability.

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Distribution of treated Children by PDK and Govt. supply or self purchased medicines

80.00 73.40 67.90

70.00 67.16

60.00 50.21 49.21 50.00

40.00 32.84 32.10 30.00 26.60

20.00 Number Number Children of 10.00 0.00 Intervention_1 Intervention_2 Intervention_3 Intervention_4 Children treated by Pneumonia Drug Kit

Children treated by Govt. supply or self purchased medicines

Table 149: Availability of Amoxicillin (through government supply) at Government Health Facilities -Pre, Mid and Post project interventions period Pre intervention phase Mid intervention phase Post intervention (Feb 2016-May 2016) (Nov 2016- Jan2017) phase (Nov 2017-Jan2018) (Number of facilities (Number of facilities (Number of facilities

with availability of with availability of with availability of

Amoxicillin / Total Amoxicillin / Total Amoxicillin / Total

Number of a Govt. Number of a Govt. Number of a Govt. Intervention Health Facilities) Health Facilities) Health Facilities) [Pneumonia Drug Kit distribution by ANM or CHC or PHC] Intervention_1 9/10 9/10 [1774] 5/10 (Gosaiganj& MALL) Intervention_2 8/10 8/10 [2190] 4/10 (Kakori & Sarojini Nagar) Intervention_3 10/10 5/10 [2187] 6/10 (Malihabad & MohanlalGanj) Intervention_4 11/12 10/12 [1579] 4/12 (BKT &Chinhat)

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In pre and mid project intervention period, amoxicillin through government supply was maintained at health facilities. In the post intervention period it was found that there was a marked dip in of government supply of amoxicillin. 8.8.2 Primary Objective 2 Primary Objective 2 - To ascertain change, if any, in the types of health care providers’ service utilization for Acute Respiratory Illness (ARI)/CAP in last 12 months in children less than 5 years pre and post intervention. Intervention 1: Organizing Childhood Pneumonia Awareness Sessions (PAS) for caregivers of children <5 years of age during a routine immunization day, using self- developed and validated IEC materials, in PHCs and CHC monthly, conducted by a trained ANM and project facilitator. Intervention2: Organizing PAS on Village Health and Nutrition Day (V.H.N.D.) once a month by the ASHA worker trained for this. Intervention3: Combination of Both Intervention 1& 2 Intervention4: Usual Care

Table 150: Comparison of Children suffered from cough with fast breathing with or without chest in drawing (Possible pneumonia), by Intervention.

Child suffered from cough with fast breathing with or without chest in drawing(Childhood Pneumonia) Baseline Data(number Endline Data(number of children of children suffered suffered from possible pneumonia Interventions from possible /total number of children) pneumonia /total n=612 (%) number of children) n=824(%) Intervention_1 189/811(23.30) 147/849(17.31) (Gosaiganj& MALL) Intervention_2 217/852(25.47) 162/866(18.71) (Kakori & Sarojini Nagar) Intervention_3 203/848(23.94) 149/869(17.15) (Malihabad & MohanlalGanj) Intervention_4 215/840(25.60) 154/828(18.60) (BKT &Chinhat) Total 824/3351(24.59) 612/3412(17.94)

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Above table shows comparative distribution of childhood pneumonia among four interventions. Across the four interventions distribution was almost similar for childhood pneumonia from Baseline to End line. In comparison to End line Survey, where 612(17.94%) children suffered from possible pneumonia out of 3412 eligible children, 824 (24.59%) children suffered from possible pneumonia (out of 3351 eligible children), in base line survey.

Table 151: Table: Comparison of health seeking behavior for childhood pneumonia at the government health facilities (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS)

Children with Possible Pneumonia who utilize Intervention 1 & Intervention 2 & government health facility for Intervention 3 Intervention 4 treatment /Number of (ANM delivering PAS) (ANM not delivering children with possible (%) PAS) (%) pneumonia who had taken treatment from doctor

Base Line 19/290 (6.55) 12/305 (3.93) End Line 53/282 (18.79) 33/303 (10.89) Difference (%) 12.35 6.96 Improvement (%) 65.72 63.91 P value 0.055

Health seeking behavior at government health facilities for childhood pneumonia in Intervention 1 & 3 has increase by 12.35 % from baseline to endline. However intervention 2 & 4 shows only 6.96% increase towards the government health facility. The difference of health seeking behavior of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS is not statistically significant (p=0.055)

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Table 152: Comparison of health seeking behavior for childhood pneumonia at the government health facilities (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS

Children with Possible Pneumonia who utilize government health facility Intervention 2 & Intervention 1 & for treatment /Number of Intervention 3 Intervention 4 children with possible (ASHA delivering PAS) (ASHA not delivering pneumonia who had taken (%) PAS) (%) treatment from doctor

Base Line 12/311 (3.86) 19/284 (6.69) End Line 50/295 (16.95) 36/290 (12.41) Difference (%) 13.09 5.71 Improvement (%) 77.22 46.01 P value 0.006

Health seeking behavior at government health facilities for childhood pneumonia in Intervention 1 & 3 has increase by 13.09 % from baseline to endline. However intervention 2 & 4 shows only 5.71 % increase towards the government health facility. The difference of health seeking behavior of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS is statistically significant (p=0.006)

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Table 153: Comparison of health seeking behavior for Diarrhea at the government health facilities (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS)

Children with Diarrhea who Intervention 1 & Intervention 2 & Intervention utilize government health Intervention 3 4 facility for treatment (ANM delivering (ANM not delivering PAS) PAS) (%) (%)

Base Line 43/376(11.43) 38/362(10.49)

End Line 115/513(22.41) 76/530(14.33)

Difference (%) 10.98 3.84

Improvement (%) 49.0 20.9

P value <0.0001

Table 154: Comparison of health seeking behavior for Diarrhea at the government health facilities (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS)

Children with Diarrhea who Intervention 2 & Intervention 3 Intervention 1 & utilize government health (ASHA delivering PAS) (%) Intervention 4 facility for treatment (ASHA not delivering PAS) (%)

Base Line 37/390 (9.48) 44/347(12.68)

End Line 106/545 (19.44) 85/498(17.06)

Difference (%) 9.96 4.38

Improvement (%) 51.2 25.7

P value 0.007

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Salient Features for change in knowledge about childhood pneumonia of Mothers (from base line to end line)

Table 155: Change in knowledge of mothers about the illness called "pneumonia"? Interventions Have you ever heard about the illness called "pneumonia Baseline Data End line Data(number of mothers who (number of mothers who have have information about pneumonia ) information about pneumonia ) n=2465 (%) n=2469(%) Intervention_1 524/609(86.04) 596/616(96.75) (Gosaiganj & MALL) Intervention_2 549/617(88.98) 609/618(98.54) (Kakori & Sarojini Nagar) Intervention_3 543/622(87.30) 611/619(98.71) (Malihabad & Mohanlal Ganj) Intervention_4 566/621(91.14) 597/612(97.55) (BKT &Chinhat) Total 2182/2469(88.38) 2413/2465(97.89)

Comparision between information about pneumonia 100 98.54 98.71 97.55 98 96.75

96 94 92 91.14 90 88.98 87.3 88 86.04 86

84 Number Number Mothersof 82 80 78 Intervention 1 Intervention 2 Intervention 3 Intervention 4 Baseline Information about pneumonia Endline Information about pneumonia

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Table 156: Change in knowledge of mothers about any symptoms of Pneumonia from base line to end line facilities (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS)

Change in knowledge of Intervention 1 & Intervention 2 & mothers about any symptoms Intervention 3 Intervention 4 of pneumonia ( fast breathing (ANM delivering (ANM not delivering PAS) and difficulty in breathing and PAS) (%) (%) chest in drawing)

Base Line 253/1067 (23.71) 292/1115(26.18) End Line 747/1207(61.88) 729/1206(60.44)

Difference (%) 38.17 34.26

Improvement (%) 61.68 56.68

P value 0.029

Table 157: Change in knowledge of mothers about any symptoms of Pneumonia from base line to end line facilities (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS

Change in knowledge of Intervention 2 & Intervention 1 & mothers about any symptoms Intervention 3 Intervention 4 of pneumonia (fast breathing (ASHA delivering (ASHA not delivering PAS) and difficulty in breathing and PAS) (%) (%) chest in drawing)

Base Line 265/1092(24.26) 280/1090(25.68)

End Line 974/1220(77.62) 529/1193(44.34)

Difference (%) 53.36 18.66

Improvement (%) 68.74 42.08

P value <0.0001

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Table 158: Change in knowledge of mothers about all symptoms of Pneumonia from base line to end line facilities (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS)

Change in knowledge of Intervention 1 & Intervention 2 & mothers about all symptoms of Intervention 3 Intervention 4 pneumonia ( fast breathing and (ANM delivering (ANM not delivering PAS) difficulty in breathing and PAS) (%) (%) chest in drawing)

Base Line 56/1067 (5.24) 60/1115 (5.38) End Line 125/1207(10.35) 112/1206 (9.28)

Difference (%) 5.11 3.9

Improvement (%) 48.40 42.02

P value 0.155

Table 159: Change in knowledge of mothers about all symptoms of Pneumonia from base line to end line facilities (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS

Change in knowledge of Intervention 2 & Intervention 1 & mothers about all symptoms of Intervention 3 Intervention 4 pneumonia (fast breathing and (ASHA (ASHA not delivering PAS) difficulty in breathing and delivering PAS) (%) chest in drawing) (%)

Base Line 49/1092(4.21) 67/1090(6.1)

End Line 170/1220(13.93) 67/1193(5.61)

Difference (%) 9.72 1.0

Improvement (%) 69.77% 16.39

P value <0.0001

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Table 160: Change in knowledge of mothers about danger symptoms of Pneumonia from base line to end line facilities (on the basis of interventions where ANMs were conducting PAS to interventions where ANMs were not conducting PAS)

Change in knowledge of Intervention 1 & Intervention 2 & mothers about danger Intervention 3 Intervention 4 symptoms of pneumonia (ANM delivering (ANM not delivering (unable to drink and drowsy) PAS) (%) PAS) (%)

Base Line 11/1067(1.03) 9/1115(1.0) End Line 48/1207(3.97) 51/1206(4.22)

Difference (%) 2.94 3.22

Improvement (%) 74.05 76.30

P value 0.500

Table 161: Change in knowledge of mothers about danger symptoms of Pneumonia from base line to end line facilities (on the basis of interventions where ASHAs were conducting PAS to interventions where ASHAs were not conducting PAS

Change in knowledge of Intervention 2 & Intervention 1 & mothers about danger Intervention 3 Intervention 4 symptoms of pneumonia (ASHA delivering (ASHA not delivering (unable to drink and drowsy) PAS) (%) PAS) (%)

Base Line 9/1092(1.0) 11/1090(1.0)

End Line 71/1220(6.31) 28/1193(2.3)

Difference (%) 5.3 1.3

Improvement (%) 83.99 56.52

P value <0.0001

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Table 162: Change in source of information about pneumonia

Intervention Intervention_1 Intervention_2 Intervention_3 Intervention_4 Total (Source of (Gosaiganj & (Kakori & (Malihabad & (BKT & n (%) Information MALL) Sarojini MohanlalGanj) Chinhat) about n(%) Nagar) n (%) n (%) n (%) Pneumonia) ASHA 6/524 (2.79) 12/549 ( (4.48) 2/543 (1.14) 4/566 (1.74) 24/2182 (2.70) (Baseline data) ASHA 88/596(14.77) 399/609(65.52) 402/611(65.79) 41/597(6.87) 930/2413 (38.54) (Endline data) p value <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 ANM 1/549 (0.47) 4/549 (1.49) 4/543 (2.29) 5/566 (2.17) 14/2182 (1.58) (Baseline data) ANM 48/596(8.05) 97/609(15.93) 81/611(13.26) 11/597(1.84) 237/2413 (9.82) (Endline data) p value <0.0001 <0.0001 <0.0001 0.245 <0.0001

*Table 163: Source of information about pneumonia? (Found only in ENDLINE Survey)

Interventions PHC CHC POSTER VIDEO RADIO OTHER Total Mother N (%) N (%) N (%) N (%) N(%) relative who have and Knowledge neighbors about N (%) pneumonia In Endline Survey n (%) Intervention_1 6(1.01) 15(2.52) 21(3.52) 15(2.52) 0(0.0) 277(46.48) 596 (Gosaiganj & MALL) (n=596) Intervention_2 2(0.33) 6(0.99) 85(13.96) 2(0.33) 2(0.33) 272(44.66) 609 (Kakori & Sarojini Nagar) (n=609) Intervention_3 16(2.62) 12(1.96) 88)(14.40) 24(3.93) 1(0.16) 266(43.54) 611 (Malihabad & MohanlalGanj) (n=611) Intervention_4 1(0.17) 2(0.34) 3(0.050) 0(0.0) 0(0.0) 305(51.09) 597 (BKT &Chinhat) (n=597) Total (N=2413) 25(1.04) 35(1.45) 197(8.16) 41(1.70) 3(0.12) 1120(46.42) 2413

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Comparision of Information about Pnemonia by ASHA at VHND

120 97.56 95.45 95.49 100 84.62 80 55.17 60

40 27.27 28.57

Number of Number Mothers 20 10.53

0 Intervention 1 Intervention 2 Intervention 3 Intervention 4

Baseline Information by ASHA Endline Information by ASHA

Comparision of Information about Pnemonia by ASHA on Immunization Day

120 97.98 96.51

100 80 79.17 80 66.67 60.87 60

40 33.33 Number Number Mothersof 20 6.67 0 Intervention 1 Intervention 2 Intervention 3 Intervention 4

Baseline Information by ASHA

Endline Information by ASHA

116

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THE WAY FORWARD PAS at villages are found to be most effective, which is evident by the increased knowledge of mothers about symptoms of pneumonia and increased case seeking at govt. health services for pneumonia, in the blocks where ASHA was delivering PAS. The repeated training of ASHAs about the symptoms of pneumonia, importance of immediate care seeking and place of care seeking along with structured training of explaining posters (provided by project) to the mothers, are found to be the key points. In turn ASHA , explained the mothers, about symptoms of pneumonia, importance of immediate care seeking and care seeking at government health facilities, which are now strengthened infra structurally for management of childhood pneumonia cases. Repeated reinforcement of these messages makes the impact. We are willing to do technology transfer (validated posters, case stories and story books). Government in association with agencies like UNICEF, Clinton foundation etc may continue the pneumonia awareness sessions at village through ASHA. The manpower deployment from project mode to program mode may be done as follows: PROJECT MODE PROGRAM MODE Investigator Medical Superintendent of Block Health Education Officer of Project Coordinator Block Block Process Manager (BPM) Field Investigator of Block Block Community Process Field Worker Manager (BCPM) of Block

Pneumonia Drug Kits are also very important component of this program. PDK were very much appreciated the Medical officers for the fact that kits were presentable, easy to dispense, ease of explaining usage to

118 parents by Medical officer/ANM. Parents also appreciated the kits for the fact that it contains complete course of medicines and the Instruction card is easy to understand, making use of PDK self explanatory. PDK many be supplied by the government through central drug repackaging in association with a bilateral partner. Government has huge resources in terms of both-infrastructure and manpower. This project may be easily transformed into a national program.

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Annexure 1: Institutional Ethics Committee, King George’s Medical University, approval letter for the study

120

Annexure 2: Letter from Mission Director, National Health Mission Uttar Pradesh, to conduct study in Lucknow district

121

Annexure 3: Letter from Chief Medical Officer Lucknow, regarding participation in study

122

Annexure 4: Instruction Card for Pneumonia Drug Kit

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Story Calendar 1 Story Calendar 2

Story Calendar 3 Story Calendar 4

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Story Calendar 5 Story Book 1

Story Book 2 Story Book 3

Story Book 4 Story Book 5

125

Poster 1 Poster 2

Poster 3

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