Indigenous Health:
Access to healthcare among children
In tribal dominated villages of Simdega, Jharkhand
With reference to Acute Respiratory infections
Dr. Supriya Bonnie Minz
Dissertation submitted in partial fulfillment for the award of
Masters of Public Health Degree Year 2008
Achutha Menon Centre for Health Science Studies,
Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthpuram, Kerala
October, 2008 ACKNOWLEDGEMENTS
First of all I would like to thank my father Lieutenant Colonel (Dr) C B Minz who opened my eyes to the fate of the Tribes of Jharkhand. This inspired me to select such a topic. Sadly he passed away just before the data collection got under way.
I extend my sincere gratitude to my guide Dr. Biju Soman, Associate Professor,
AMCHSS, SCTIMST for his guidance at every step since I started working on this dissertation.
I thank Professor K. R. Thankappan, Professor Raman Kutty, Dr. Sundari
Ravindran, faculty at AMCHSS, for their valuable suggestions and inputs.
I’d like to thank all the people from the Government of Jharkhand, including my husband
Dr Rajeev Arun Ekka, IAS who extended support in various ways to put this work together.
I would also like to thank the field investigators who assisted me in data collection to the best of their ability against the odds of difficult terrain and weather.
Lastly, I extend my thanks to all the participants of this research for their cooperation
CERTIFICATE
Certified that the dissertation titled, “Indigenous Health: Access to healthcare among children in tribal dominated villages of Simdega district, Jharkhand with reference to acute respiratory infection” is a bonafide record of original research work undertaken by Dr. Supriya Bonnie Minz, in partial fulfillment of the requirement for the award of the Master of Public Health degree under my guidance and supervision.
Guide
Dr. Biju Soman
Assistant Professor
Achutha Menon Centre for Health Science Studies (AMCHSS),
Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST),
Thiruvananthpuam
DECLARATION
I hereby certify that the work, embodied in this dissertation titled, “Indigenous Health:
Access to healthcare among children in tribal dominated villages of Simdega district,
Jharkhand with reference to acute respiratory infections” is the result of original research and has not been submitted for any degree in any other university or institution.
Thiruvananthpuram
October, 2008 Supriya Bonnie Minz
CONTENTS:
Page no.
1. Introduction 1
2. Background 3
3. Rationale 8
4. Review of Literature 9
5. Objectives 14
6. Variables 14
6.1 Outcome Variable
6.2 Predictor Variables
7. Methodology 19
7.1. Study design
7.2. Study Setting
7.3. Sample frame
7.4. Study Population
7.5. Case Definition
7.6. Inclusion and exclusion criteria
7.7. Sampling procedure
7.8. Sample size estimation
7.9. Study tools
7.10. Ethical consideration
7.11. Data collection 7.12. Data analysis
8. Results 26
9. Limitations 44
10. Discussion 45
11. Conclusion 48
12. Recommendations 50
13. References 51
14. Appendix
1. Appendix-1
2. Appendix-2
3. Appendix-3
4. Appendix-4
5. Appendix-5
ABSTRACT:
Background: Indigenous people have worse health outcomes yet there is limited data on
their health status or healthcare access from developing countries. Acute respiratory
infections are among the leading cause of preventable deaths among under five children.
Objective: This study was to describe the healthcare access, identify barriers to access,
and estimate the prevalence and pattern of acute respiratory infections in children less
than five years of age.
Methodology: Using a multistage random sampling 1028 children 0-60 months were selected from 19 out of 117 villages that had 90-100% tribal population. Information on demographics, severity of ARI and access to health care was collected from mothers, village heads and health providers using a pre-tested structured interview schedule.
Results:
The study reveals that about 20 percent of these children belong to families that have ever visited the primary health center or a private clinic, while less than 50 percent have ever visited even a health sub center.
ARI was reported by 318 (30.9%) percent of which 89.6% belonged to cough and cold category, 6.6% to pneumonia, 2.8% to very severe pneumonia, and 0.9% to very severe disease . Access to healthcare was found to be significantly associated with distance to sub center< five km (OR 4, p<.001), availability of various resources at sub center (OR
2-8, p<.005), public transport to health facility (OR 5.6, p<.001), and mother’s perception of various aspects of the nearest Health sub center as favorable (OR 4-10, p<.001), mother’s perception of illness as serious (OR 3.4, p<.001), presence/regular visits of community level health workers (OR 3-5, p<.001), and IEC activity in village within six
months (OR 3.2, p<.001).
Conclusion: In our study prevalence of ARI was high and the major barriers to access
were – poor connectivity, ill equipped health facilities, low awareness of healthcare availability, low motivation among community level health workers, and distance to health facility. Efforts to bridge these gaps could improve healthcare access in indigenous populations.
CHAPTER 1
1. INTRODUCTION
2. BACKGROUND
3. RATIONALE
4. REVIEW OF LITERATURE
1. INTRODUCTION:
The World Health Organization fact Sheet on The Health of Indigenous Peoples states that the estimated 370 million indigenous peoples living in more than 70 countries worldwide, continue to be among the world’s most marginalized population groups and that there health status varies significantly from that of non-indigenous population groups
in countries all over the world. They differ in levels, patterns, and trends of health.
The gap in life expectancy between indigenous and non-indigenous populations has been
found to vary between 4-21 years in Australia, New-Zealand, Canada, and the United
States and in Australia, the gap in median age at death seems to have widened. Rates of
avoidable deaths among indigenous people tend to be much higher than for non-
indigenous people and can be reduced substantially by improving quality and access of
preventive, diagnostic and therapeutic services to these people.1
Lack of existing evidence about the state and determinants of indigenous health and their
access to health services and education have been important themes picked up at
discussions relating to these people (International symposium on Social Determinants of Indigenous Health Adelaide, 29-30 April 2007 & United Nations Permanent Forum on
Indigenous Issues, Fourth Session).
Access to appropriate health and other infrastructure or services are necessary to ensure equity in their health outcomes and there is an urgent need for more information on indigenous health 2 and there is an ‘overwhelming need for action on indigenous peoples health’. 3
India with 84.3 million people classified under scheduled tribes and its state Jharkhand with such people constituting 26.5 percent of its total population 4 deserves attention in this regard. Child health disparities between indigenous and non-indigenous groups are evident in India as per NFHS 2 and 3 reports.
Acute respiratory infections are a leading cause of morbidity and mortality in children less than five years of age. Despite the increasing availability and the use of antibiotics for the treatment of acute respiratory infections (ARI), global mortality from ARI, mainly due to pneumonia remains high since many children developing countries do not have access to appropriate healthcare.
2. BACKGROUND
Indigenous people make up about 6% of the world’s population in about 5000 separate groupings of languages and culture.5 and they differ in levels, patterns, and trends of health.
An official definition of “indigenous” has not been adopted by the UN system but a modern and inclusive understanding of indigenous has been developed and includes peoples who:
- Identify themselves and are recognized and accepted by their community as
indigenous.
- Demonstrate historical continuity with pre-colonial and/or pre-settler societies.
- Have strong link to territories and surrounding natural resources.
- Maintain distinct social, economic or political systems.
- Form non-dominant groups of society. And resolve to maintain and reproduce
their ancestral environment and systems as distinctive peoples and communities.
Situation in India: There are 461 ethnic groups are officially recognized as the
‘Scheduled Tribes’ in the Constitution of India fulfill these criteria and can be
considered as India’s Indigenous population. They are often referred to as ‘Adivasis’,
meaning the original inhabitants and make up 8.4% of India’s total population which
translates to 84.3 million people 4. Therefore it can be said that India houses the
largest number of Indigenous people. According to the International Institute of population sciences report-2000, the child health indicators in India are the worst
among the scheduled tribes when compared with any other group.
Table 1: Indicators of child health in different groups in India
Outcome Scheduled Scheduled Other Rest of Caste Tribes disadvantaged population classes Infant mortality(per 1000 live 83.0 84.2 76.0 61.8 births) Under-five mortality(per 1000 119.3 126.6 103.1 82.6 births) Children under 3 years 53.8 55.9 47.3 41.1 underweight (percent) Children under 3 years with 78.3 79.8 72.2 72.7 anemia (percent) Children under 3 years with ARI 19.6 22.4 19.1 18.7 (percent) Children under 3 years with 19.8 21.1 18.3 19.1 Diarrhea (percent) Source: National Family Health Survey Summary, India 1998-99.
Jharkhand is a small state in eastern India and is among its newest, having being carved out of the state of Bihar in 2000 after a long struggle for statehood. It forms a part of the central tribal belt of India and 26.3 percent 4 of its population belong to the scheduled tribes. There are about 31 different tribes residing here, varying in number between 400 and 2,000,000. Jharkhand originally comprised of 18 districts (at the time of last census) but with the formation of new districts, has 24 districts at present. Of these, only four districts have less than 10 percent tribal population, 10 districts have 10-30 percent tribal population, five districts have 30-50 percent tribal population, and five districts have more than 50 percent tribal population. Comparing the census 1991 and 2001 figures reveals that the tribal population as a proportion of total population in every district has declined. The same is true for most of its 211 blocks.
Table 2: Tribal population in few tribal dominated districts of Jharkhand (percent)
Districts Gumla Lohardaga W. Singhbhum Pakur Ranchi Dumka
1991 70.80 56.41 54.70 49.32 43.56 41.55
2001 68.36 55.79 53.36 44.59 41.82 39.89
Source: Census of India 1991, 2001
As may be expected, the scheduled tribes of Jharkhand are worse off than any other
group in various health indicators.
Table 3: Health indicators of tribals compared to other groups (percent)
Scheduled Scheduled Other Others Caste Tribe Backward Caste Children having vaccination card 14.9 12.1 18.1 20.7
Children (12-35months) with at least one 8.6 5.9 10.6 12.2 dose of Vitamin A Children <3years with ARI in preceding 25.7 24.9 19.2 22.8 2 wks Children with ARI taken to health 54.2 39.6 60.5 65.6 facility Children <3 years with diarrhea in the 41.3 60.1 37.1 30.8 preceding 2 wks Children with diarrhea taken to health 49.5 18.7 54.6 52.3 facility Births in last 3 years in govt facility 2.5 0.5 3.7 7.1
Births in last 3 years with home delivery 75.2 87.8 70.6 57.7
Source: NFHS 1998-99 (Bihar)
Simdega, among the new districts created, is a predominantly tribal district of Jharkhand, situated in the southeast part of the state bordering Orissa and Chattisgarh. Tribal population constitutes 70.2% of its total population 4. Seven out of the eighteen blocks that were originally in Gumla, now form Simdega district. These blocks are Bano, Bolba,
Jaldega, Kolebira, Kurdeg, Simdega, and Tethaitangar. In each of these blocks the percent of tribal population has declined over the last decade (Table 5). There are 117 villages across these blocks that have 90-100% tribal population. (Appendix 1)
Table 4: Decline in tribal population of all blocks of Simdega district, Jharkhand as per Census 1991 and 2001.
Blocks Total Scheduled Percent Percent population Tribe Population 1991 2001 1991 2001 1991 2001
Simdega 104212 126898 66440 79046 63.75 62.29
Kolebira 50907 60137 32960 38008 64.75 63.20
Bano 62563 72168 40959 45491 65.47 63.03
Jaldega 68742 74400 58815 61782 85.56 83.04
Thethaitangar 67822 76903 56534 62877 83.36 81.76
Kurdeg 67858 77025 49494 53905 72.94 69.98
Bolba 24317 26789 18223 19716 74.94 73.60
Source: Official website of GOJ, Department of welfare,
ARI and Child Health:
Acute respiratory infections are a leading cause of morbidity and mortality in children
less than five years of age. Globally, out of the estimated 10 million deaths in this age
group per year, 19% (nearly 2 million) die due to pneumonia 6. Despite the increasing
availability and the use of antibiotics for the treatment of acute respiratory infections,
global mortality from ARI, mainly due to pneumonia remains high since many children
developing countries do not have access to appropriate healthcare. Simple, effective, and
affordable preventive and curative interventions exist for ARI but their coverage is
inadequate and ironically leaves out the children who need them most.
According to the World Bank, immunization and vitamin A supplementation are two of
the most cost-effective public health interventions available today. Improving vitamin A
status can strengthen a child’s resistance to disease and decrease the likelihood of
childhood mortality. Vaccines against measles and pertussis (included in India’s
immunization programme) and Streptococcus pneumoniae and Haemophilus influenzae
(not included yet) can significantly bring down the incidence of ARI in the community.
The World Health Organization estimates that seeking prompt and appropriate care could reduce child deaths due to ARI by 20%.
3. RATIONALE
Though time and again the poor health status of indigenous peoples and the lack of
evidence from developing countries have been emphasized, little work has been done in
that direction.
Though India is home to nearly one-fourth indigenous people worldwide, the largest number in a single country, their health has received little attention despite glimpses of their dismal health status in the national health surveys.
In India, though some studies on topics relating to indigenous health have been carried out in states like Maharashtra, Andhra Pradesh, Rajasthan and few others, no peer reviewed & indexed studies from Jharkhand have been published in any standard Journal.
Jharkhand being a part of the central tribal belt of the country deserves attention in this area.
This study throws light on the healthcare access scenario among the tribes of Jharkhand with regards to healthcare needs of their children less than five years of age with acute respiratory infections, the leading cause of morbidity and mortality among children in this age group.
Such a study provides an insight into the extent and pattern of health deprivation among children in the study population, and in fact, reflects the status of access to existing healthcare interventions by the entire community itself.
It provides some idea on ways to make healthcare provision more equitable for better health outcomes in this underprivileged section of the society.
4. REVIEW OF LITERATURE:
Evidence shows that indicators of Indigenous health are consistently poorer than comparable indicators for non-indigenous communities within the same country and health differentials exist for a wide range of outcomes 7, 8, 9, 10, 11.
Poor health is possibly the most intractable problem among the many difficulties that
Indigenous peoples are forced to confront and there is need for concrete actions: to reduce health disparities between Indigenous and non-indigenous peoples, to raise their overall health status, and to collect better data about indigenous needs 12.
There is lack of clear definition of indigenous and this combines with systematic marginalization and isolation of such peoples. This in turn affects the availability of information about demographic and health status of Indigenous peoples, particularly in low-income countries. Access to healthcare is partly due to their geographic isolation, but more so due to their weak position within national priority setting and there is urgent need for further research and action internationally. 13
The major inequalities in health between Indigenous and non-indigenous communities within countries can be best illustrated by considering child health outcomes. Infant mortality rates are higher in Indigenous than in non-indigenous peoples in all countries but the difference is greater in the poorer countries. Indigenous people do not have easy access to basic western health care when needed and where services are available; they are often reluctant or afraid to use them because staff can be insensitive, discriminatory, and unfriendly. The quality of care available to them is also often compromised. 14, 15, 16,
17. Factors responsible for disparities in health between indigenous and non-indigenous populations can be broadly grouped under genetic and non-genetic ones with non-genetic factors further sub grouped into Socioeconomic, Lifestyle, Discrimination, and Access to healthcare. 18, 19. Access to healthcare has been found to have a possible role to play in creating a difference in health status between indigenous & non-indigenous populations and improving access to care has been found to be critical to addressing health disparities. 20
Access to quality health care along with socioeconomic and macropolitical interventions may improve the health status of indigenous peoples. 21
Millennium Development Goal-4 (MDG-4) commits the global community to reducing child deaths below age 5 by three quarters by 2015 from 1990 baseline. Each year 10 million children under 5 die in the world, mainly from preventable conditions that rarely kill children in rich countries. Most of these deaths could be prevented with simple low cost interventions feasible now, yet not reaching poor children. To reach MDG-4, massive increases are required in coverage of essential interventions. 22
Though existing and new interventions could prevent 63% child deaths, they are not enough unless they reach the children and mothers who need them most. Poor coverage is a result of weakness in both provision of and demand for services, and a consequence of malfunctioning health systems. Effort devoted to implementation of IMCI has not been sufficient, especially in relation to strengthening health systems and changing key behaviours at the family and community level. Achieving and maintaining high and equitable coverage would require planning of sound child health programmes requires relevant data at subnational level, selecting locally-defined key criteria for selection of effective interventions to be implemented, tailoring supply to match the demands and
respond to needs, and assessing alternative delivery strategies. 23
Acute respiratory infections are almost certainly the leading cause of morbidity and
mortality in children less than 5 years in developing countries accounting for more than
95% of all episodes of clinical pneumonia in young children worldwide. 24
World Health Organization (WHO) data from 88 countries representing 1/4 of the world's
population indicate that there are over 666,000 deaths annual from acute respiratory
infections. Assuming that non-reporting countries have similar mortality rates, it can be
calculated that there are at least 2.2 million deaths from acute respiratory infections
throughout the world each year. Little is known about the factors that contribute to these
deaths in children or adults, or about the extent to which they are due to unusual severity
of the disease, lack of access to the health care system, and institutional or social factors.
Knowledge is needed to mount an effective program for the prevention and treatment of
acute respiratory infections. Also needed is information on the availability and use of
adequate medical care. 25
It has been seen that the proportion of deaths attributable to ARI is higher in regions where under-5 mortality is high and declines as general mortality declines following a log
linear association. 26 Therefore since child mortality in India and particularly in
disadvantaged communities is high, effective interventions should be made readily
available and accessible to such communities.
Acute respiratory infections are the leading cause of death in children in developing
countries and the severity of ARI in 3rd world children has been associated with
malnutrition, diarrheal diseases, an increased parasite load, crowding, and other factors associated with poverty. How these various factors contribute to increased severity and
lethality is not well understood. 27
Indoor air pollution in the form of smoke from the combustion of biofuels such as wood, crop residues, and animal dung for cooking has emerged as an important risk factor for acute respiratory infections 28
But its importance in relation to other risk factors is difficult to establish and therefore
must be addressed in the context of broad based programs for several risk factors. 29
Immunization has been found to be effective in preventing morbidity and mortality due to pneumonia particularly important are vaccines such as measles, pertussis and haemophilus B and improving the coverage of these vaccines should be able to reduce the disease burden. 30
In a study of health seeking behaviour in ARI, it was found that mothers could correctly
identify fast breathing in 65% of the cases though most of them did not consider it a
reason to seek treatment outside of home and confidence in the provider, and
convenience particularly in time of operation were the major factors associated with
seeking care from private provider. 31
In a study to assess the role of management practices for acute respiratory infections
(ARIs) diagnosing and treating acute respiratory infections among children, it was found that in improving the competency of community health volunteers in Diagnosis and treatment of ARIs at the household level in developing countries are possible if intensive basic training and the close supervision of service providers are ensured. 32 A study done in Delhi slums reported ARI prevalence of 14.6% in children less than 5 years during the preceding 2 weeks of survey. Majority suffered mild symptoms like running nose and/or fever while only 4% had fast breathing. Yet 80% sought treatment. 33
Perception of severity of child's illness, Confidence in particular service/provider, and affordability of therapy has been found to be the major determinants of healthcare seeking from public and private providers. 34
Some of the barriers identified to accessing healthcare among indigenous people of
Australia are infrastructure, cost and transport 35
CHAPTER 2
5. STUDY OBJECTIVES 6. VARIABLES 7. METHODOLOGY
5. STUDY OBJECTIVES: a. To describe the access to healthcare among children in the tribal dominated villages of
Simdega district in the state of Jharkhand with reference to acute respiratory
infections. b. To estimate the prevalence and pattern of acute respiratory illness in the study
population. c. To identify factors associated with utilization of appropriate care and barriers to
accessing such care in the study population.
6. VARIABLES
6.1 Outcome Variable
Minimal access: It is being defined as the minimum level of healthcare a child with
acute respiratory illness should have in order to get the benefit of the known effective
interventions for ARI. It is based on the severity of illness and the action taken during the
current episode of illness and a child with ARI qualifies for having minimal access if
he/she fulfills the following criteria:
Table 5: Minimal access to healthcare
Severity of illness based on symptoms Action taken during the current episode reported during the specified period. of illness. Very Severe disease Consulted doctor Severe Pneumonia Consulted doctor Pneumonia Consulted doctor or Consulted ANM Cough or cold Consulted doctor or ANM or - took medicine from pharmacy - if educated on care of sick child by ANM/doctor or resorted to any other option..
6.2 Predictor Variables included:
6.2.1 Age
In completed months as reported by the mother
6.2.2 Sex
Boy or girl as claimed by the mother
6.2.3 Availability of immunization card
Availability of immunization card with the parents or the ANM as claimed by the mother
6.2.4 Duration of illness
Number of days that the child was continuously ill during the current episode as reported
by the mother
6.2.5 Symptoms of illness
As reported by the mother after being explained by the investigator what they meant.
6.2.6 Severity of illness: Bases on the key symptoms in the specified period as reported
by the mother the criteria for judging the severity of illness was as follows:
Table 6: Severity of illness in children more than two months.
Severity of illness Symptoms reported by mother Very severe disease Convulsions Abnormally sleepy or difficult to wake Unable to drink or breastfeed Severe Pneumonia Chest indrawing Pneumonia Fast and/or difficult breathing but no chest indrawing Cough & Cold No chest indrawing or fast breathing
In children less than two months, presence of fast breathing also classified them for
severe pneumonia even in the absence of chest indrawing, other criteria being the same.
6.2.6 Perception of severity of illness
What the mother said when asked if whether the child was seriously ill or not.
6.2.7 Birth order
The order of birth of the child as reported by the mother
6.2.8 Family size
Total number of children of the mother of the child under consideration
6.2.9 Age of Parents
Age of father and mother of the child in completed years as reported by the mother
6.2.10 Parent’s education
Parents’ education were recorded as reported by mother, recorded separately for mother and father. It was grouped as – no formal education, less than primary education (class 1-
4), completed primary education (passed at least class 5), middle school completed
(passed at least class 8), high school completed (passed class 10), and any further education. 6.2.11 Main source of income
The main source of income that the family depended on to sustain themselves. The
options offered were – monthly paid salary, daily wage, and agriculture or forest products.
6.2.12 Religion
Religion that the family followed as reported by the mother
6.2.13 Tribe
The tribe to which the family belonged, information taken from mother of the child.
6.2.14 ANM’s last visit
Duration of the ANM’s last visit to the family since the time of interview.
6.2.15 Ever visit to the health facility
Response of the mother when asked if she has ever visited any health facility specified.
6.2.16 Perception about healthcare facility
How the mother described the health facility she has visited, in terms of specified criteria.
6.2.17 Village health committee
Presence or absence of village health committee in the revenue village. Information
collected from the village head of the selected revenue villages.
6.2.18 ASHA selected and/or trained
Response from the village head of the selected villages on whether an accredited social
health activist (ASHA) has been selected and whether she has received any training.
6.2.19 ANM’s regular visit
If the ANM visited the village regularly (at least once in two months) during the last six
months as reported by the village head of the selected villages. 6.2.20 Aanganwadi worker
Whether or not the village has an anganwadi worker, serving the village as reported by the village head of the selected villages.
6.2.21 Availability of public transport
Whether any form of public transport facility to any health facility was available to any distance as reported by the village head of selected villages.
6.2.22 Health education campaign
Any health related activity other than ‘pulse-polio’ that took place in the stipulated time as per the village head of the selected villages.
6.2.23 Distance to nearest motorable road
Distance to the nearest pucca road from the village as estimated by the investigator by the
odometer of his two-wheeler if the distance could be covered by it. Where some distance
could not even be accessed by two-wheeler, a rough estimation of the distance was done
by the investigator.
6.2.24 Distance to health facility
Recorded by the investigator as per the odometer of his two-wheeler while traveling from
the village to the specified health facility.
6.2.25 Availability of resources at the health facility.
This was recorded as per the information from the person-in-charge of the subcenter and
the PHC closest to the selected villages. The availability of resources essential for the
management of ARI was asked and the recorded as – never available, available
sometimes, or always available.
7. METHODOLOGY
7.1 Study design
This study is largely a descriptive study done by community based Cross Sectional
Survey.
7.2 Study area
The area of study is Simdega, a small district in the south-west corner of Jharkhand sharing its border with Orissa and Chattisgarh. It is a new district having been carved out of the bigger Gumla district after the formation of Jharkhand in the year 2000. It has a population of about five lakhs of which nearly 70 percent belong to the scheduled tribes.
(Census 2001) It was chosen for the study as it has the highest tribal population among all the districts of Jharkhand. It has 117 revenue villages which are predominantly tribal with
90-100 percent population belonging to scheduled tribes. (Appendix 1)
7.3. Study population & Sampling Frame
The study population comprised of children in age group of 0-60 months reporting symptoms of acute respiratory infection in the two weeks preceding the survey. These children belonged to the 117 tribal dominated villages of Simdega district, Jharkhand.
The list of such villages was obtained from the official website of Government of
Jharkhand. (www.jharkhand.gov.in).
7.4. Sample size estimation.
The National Family Health Survey 2 (Bihar) stated that the percent of children aged less than three years from the scheduled tribe community reporting symptoms of acute respiratory infections in the preceding two weeks of survey was 24.9 percent and among
these who were taken to the healthcare facility was 39.6 percent.
The Census 2001, Gumla District (of which Simdega was a part at that time) states the
percent of children less than five years was 12.3 percent.
No of villages in Simdega district with 90-100 percent tribal population = 117
Total population of these 117 villages = 103795
Therefore no of children in the required age group (12.03 percent) = 12487
Children having ARI (24.9 percent of 12487) = 3109 (sample frame)
Of these, those taken to appropriate healthcare facility = 37 percent (less than 39.6 as
studies have shown that percent of children with ARI seeking healthcare decreases with
age)
So taking 37 as the expected frequency of the factor under study and 45 as the worst
acceptable result and population size of 3109, the sample size for survey calculated by
epi-info = 134
Doubling to compensate for design effect (cluster sampling) = 268
Adding 10% non response rate = 268+27= 295
Rounding up = 300
Therefore the minimum sample size required for analysis was calculated as 300 children
with Acute Respiratory Infection symptoms
To get 300 children with ARI, approximately 1200 children in the required age group
needed to be screened for symptoms.
7.5. Inclusion Criteria All the children in the 0-60 month age group in the selected villages were screened for symptoms of acute respiratory infection in the preceding two weeks of survey.
All the children reporting symptoms in this period were included for further data collection and analysis.
7.6. Sample selection procedure
Of the 24 districts in Jharkhand, Simdega was chosen for the study as it has the highest
(70.2 percent) tribal population. Sample selection was done by cluster sampling, taking each village as a cluster. Simdega has 117 villages with 90-100 percent tribal population spread across all its seven blocks.
Required number of villages was selected by simple random technique from the list of these 117 villages. Nineteen villages out of these were finally included in the study spread over six of the seven blocks.
Table 7: Geographic distribution of the study population Block Villages with Number of Number of Number of 90-100% tribal villages children children population included screened for reporting symptoms symptoms N=117 N=19 N=1028 N=318 Jaldega 39 5 224 89
Thetaitangar 24 5 256 98
Simdega 20 3 105 26
Bolba 7 2 56 14
Kolebira 7 2 117 23
Kurdeg 8 2 270 76
Bano 0 0 0 0
7.7. Data collection tools and technique
Data collection was done by Interview schedule using structured set of questions. Four
forms were used respectively to interview the mother of all children in the required age
group, mother of sick children, village head of the selected village, and the person-in-
charge of the health sub center and the primary health center nearest to the selected
villages. These forms were formulated keeping in mind the outcome variable and all
predictor variables that could be incorporated in the study design. A Framework for the
Study of Access to Medical Care, by Lu Ann Aday and Ronald Andersen, Center for
Health Administration Studies, University of Chicago, was used to formulate the set of
questions for the Interview schedules. The Forms were prepared in English and translated
to Hindi for the training of field investigators, and to four tribal languages spoken in the
study area. The interview schedule was administered in the language best understood by
the study participants.
Form 1: (Appendix 2) For screening the children for reported symptoms of ARI in the
specified period was applicable to the mothers of all children in the required age group in
the selected villages. It has just 8 questions regarding the child, their immunization status,
and presence or absence of symptoms of ARI in the specified period.
Form 2: (Appendix 3) this was the main form for data collection from the mothers of children with reported symptoms of acute respiratory infection in the specified period. It had three sections - current episode of child’s illness, Family & household, and knowledge and perception of healthcare delivery.
The section on child’s illness had 10 questions (S01 –S10) of which one had eight parts.
The section on family & household had six questions (F01-F06) and assessment of
Standard living index (F07).
The section on healthcare delivery had four questions (H01-H04) of which one had eight parts.
Form 3 and 4: (Appendix 4 & 5 respectively) There are some variables that must be taken into account for any study on access to healthcare, but due to the study design
(villages as cluster) these are common to the entire village. The information on these variables was therefore not collected individually for each child under study, but collectively from the reliable source.
Form 3 was applicable to the village head of the selected villages and had nine questions while form 4 was applicable to the person-in-charge of the sub-center and PHC nearest to the selected villages and had seven questions. One of these was on information regarding the availability of manpower resources and another one is on availability of other resources.
7.8. Training
Since the data was collected by the field investigators (graduates), it was important that they be trained appropriately. A training module was developed which incorporated lessons on their roles and responsibility, the study topic and its relevance, privacy and confidentiality, familiarizing with the data collection tools, familiarizing with the symptoms of acute respiratory symptoms, mock interview schedules using the relevant tools, and clarifications and feedback. Only those investigators who could administer the interview schedule satisfactorily were used for collecting data.
7.9. Data collection
The actual data collection was preceded by the investigators going to the selected villages, numbering each house and short listing the children in the required age group who would later be screened. This was followed by screening and further data collection from the mothers who reported symptoms. Both these process went on simultaneously and was done between July 1st and August 20th of 2008. The village head was interviewed soon after but the information from the person-in-charge of the health facilities was done almost ten days later due to their unavailability of the relevant person and their initial reluctance to cooperate.
The data collected over a week was handed over to me at the end of each week and any clarifications on these were dealt with the following week. The screening (using form 1) took about 15 minutes each and the detailed interview with mothers of sick children took about 45 minutes each. The investigators had to rough out heavy rains and difficult terrain, and had much walking to do as some of these villages were unapproachable by any other means.
7.10 Ethical consideration
The data collection was done in the language best understood by the study participants.
A written consent for participation in the study was obtained after reading out the details of the study in the language best understood by the participants.
The training of field investigators incorporated lessons on privacy and confidentiality. Care was taken to ensure privacy and cause least discomfort to the participants.
The names of participants were not recorded and all information provided by them has
been kept confidential. The names of selected villages are also not included in the report.
List of referral facility was prepared beforehand and appropriate advice and referral was made in case of children in the acute phase of illness who need outside care but had sought it yet. Assistance was provided whenever needed to do so. And the names of the selected villages are not included in the report.
7.11 Data analysis
Each form was examined once they were submitted and any discrepancy clarified the next week. Data entry was started once all the forms came in, and was done using
Epidata. Analysis was done using SPSS version 11.5 for windows.
-Severity of illness was calculated based on the presence/absence of various symptoms asked for.
-Based on the severity of illness and the action taken during the current episode of illness, the outcome variable was calculated as specified.
Univariate analyses of all variables were done to describe the situation and bivariate analysis of relevant variables was done using appropriate tests.
CHAPTER 3
8. RESULTS 9. LIMITATIONS 10. DISCUSSION 11. CONCLUSION 12. RECOMMENDATION
8. RESULTS
Out of the 1045 children in the required age group, 17 did not participate due to various
reasons yielding a response rate for screening 98 percent for screening for symptoms of
acute respiratory infection. All the children reporting symptoms participated in the study
yielding 100 percent response rate.
8.1 Univariate Analysis:
Out of the 1028 children screened, 318 reported symptoms of ARI in the specified period giving a prevalence of 30.9 percent, slightly more than expected (25% as per NFHS 2).
8.1.1 Sample Characteristics
The mean age of the 318 children who reported symptoms was 26.52 months. More than
50 percent of them were less than two years old and 53 percent of these children were
boys, while the average family size (total number of children in the family) was 2.84.
Table 8: Sample description 1 (N=318) Variable Mean SD (Range) Age of child in months 26.2 16.08 (1-60) Age of mother in years 28.90 6.03 (18-48) Age of father in years 33.99 6.78 (21-60) Family size (number of children/family) 2.84 1.37 (1-8)
Table 9: Sample description 2 (N=318) Variable Frequency (%) Age Group (months) 0-12 78 (24.5) 13-24 89 (28.0) 25-36 60 (18.9) 37-48 46 (14.5) 49-60 45 (14.2) Religion Sarna 99 (31.1) Hindu 28 (8.8) Christian 183 (57.5) Others 8 (2.5) Tribe Oraon 99 (31.1) Munda 69 (21.7) Kharia 74 (23.3) Others 76 (23.9) Main source of income Monthly pay 35 (11.0) Daily wage 46 (14.5) Agriculture/Forest products 237 (74.5) 8.1.2. Immunization status: Availability of immunization card for verification was claimed by 55.7 percent of the children and immunization status of the children more than 1 year, as reported by mother was as follows.
Table 10 : Immunization status in percentages Immunization Screened N=1028 Sick N=318 BCG 46.7 45.3 DPT 1st dose 50 53.1 DPT 2nd dose 42.5 44.3 DPT 3rd dose 39.8 40.6 Polio 1st dose 49.3 52.8 Polio 2nd dose 43.2 44.7 Polio 3rd dose 40.3 41.2 Measles 26.5 28 Vitamin A 26.7 23.6
8.1.3. Literacy in parents: Literacy among parents was low with mothers of 54.7 percent children and fathers of 28 percent children having had no formal education.
Table 11: Parents educational status (N=318)
Education Mother Father Frequency (%) Frequency (%) No formal education 174 (54.7) 89 (28.0) Less than primary schooling (class 1-4) 52 (16.4) 46 (14.5) Primary school completed (passed class 5) 36 (11.3) 64 (20.1) Middle school completed (passed class 8) 34 (10.7) 61 (19.2) High school completed (passed class 10) 8 (2.5) 28 (8.8) Higher education than above 14 (4.4) 30 (9.4)
8.1.4. Standard Living Index
All children belonged to SLI group 1 with the SLI score ranging from 4-14 and the mean being 9.63. Mostly they lived in katcha house with no toilet facility. Nearly 70% did not have a separate room for cooking and mostly (92%) they use wood for cooking and kerosene gas or oil (80%) for lighting. Though nearly 90% own livestock and almost all own land, just 5% have any irrigated land while very few are in possession of any other durable goods. The details of SLI were as follows:
Table 12: Standard Living Index (N=318)
Variable Frequency Percent House Type Katcha 315 99.1 Semi pucca 3 0.9 Toilet Type No toilet facility 318 100 Lighting Kerosene gas or oil 254 79.9 Other (no source of 64 20.1 lighting) Cooking Fuel Coal / charcoal 26 8.2 Other (wood) 929 91.8 Drinking water Pipe/handpump/well in 45 14.2 residence Public tap/handpump/well 76 23.9 Other water source 197 61.9 Separate room for cooking No 221 69.5 Yes 97 30.5 Agriculture land No land 8 2.5 <2 acre or acrage not 166 52.2 known 2-4.9 acres 104 32.7 > 5 acres 40 12.6 Irrigated Land No irrigated land 301 94.7 At least some irrigated land 17 5.3 Livestock No Livestock 3.4 10.7 Own livestock 28.4 89.3
8.1.5. Healthcare access:
Among all the children included, 60.1 percent belong to families that have never been told by any competent provider (doctor/ANM) about homecare of sick child and a high percent have never visited any health facility – health sub center (47.8%), PHC (83%), private clinic (79.6%) while the family of 69.5% of these children have never been visited by the ANM.
Table 13: Reasons for not visiting any health facility (multiple responses allowed)
Reasons H sub center N=154 PHC N= 264 Pvt clinic N=250 Frequency (%) Frequency (%) Frequency (%) Don’t know where it is 56(35.4) 90 (28.3) 87 (27.4) Did not need to 40 (26.0) 103 (32.4) 108 (34) Don’t trust provider 14 (9.1) 13 (4.1) 7 (2.2) Too far 44 (28.6) 60 (18.9) 48 (15.1)
8.1.6. Facilities at village: The facilities available at the village were as follows:
Table 14: Facilities available at the village (N=318)
Variable Frequency (%)
Village health committee present 145 (45.6)
ASHA selected 254 (79.9)
ASHA trained 166 (52.2)
ANM visits regularly 67 (21.1)
AWW present 188 (59.1) Public transport available from the village 116 (36.5) to any health facility
Health Education Campaign in the village rarely takes place with only 28 percent children belonging to villages that have had any health related activity in the last six months while for 44.7 percent of the children, it has never happened.
Table 15: Health education campaign in the village (N=318)
Last health education campaign in village Frequency (percent)
Never 144 (44.7)
< 1 month 22 (6.9)
1-6 months 67 (21.1)
6 month – 1 year 27 (8.5)
Don’t remember 60 (18.9)
The villages are also quite isolated with a road reaching till one km to the village being available to only 18.2 percent of the children
Table 16: Distance of nearest road to the village
Distance Frequency (percent)
< 1 km 58 (18.2)
2-5 km 182 (57.2)
6- 10 km 49 (15.4)
> 10 km 29 (9.2)
8.1.7. Availability of resources at the nearest health facility: The health facilities catering to these children are also poorly equipped as per the person-in-charge of the health sub center and PHC nearest to the selected villages. The average distance to the nearest HSC being 3.91(0-17) km and that to the nearest PHC being 12.77 (5-40) km.
Any staff trained in IMNCI at nearest HSC was available to only 103 (32.4%) children and at nearest PHC to 25 (7.9%) of the children.
Table 17: Availability of resources at the nearest health facility. (N=318)
Variable Availability at nearest HSC N=318 Availability at nearest PHC N=318 Frequency (%) Frequency (%) always sometimes never always sometimes Never Oral 103 (33.0) 213 (67) 0 (0) 296 (93.1) 22 (6.9) 0 (0) antibiotics Injectable 47 (14.80 178 (56.0) 93 (29.2) 145 (45.6) 173 (54.4) 0 (0) antibiotic antipyretics 230 (72.3) 88 (27.7) 0 (0) 307 (96.5) 11 (3.5) 0 (0) Disposable 123 (38.7) 111 (34.9) 84 (26.4) 217 (68.2) 101 (31.8) 0(0) needles/syn IV fluids 95 (29.9) 186 (58.8) 37 (11.6) 129 (40.6) 178 (56.0) 11 (3.5) ARI 58 (18.2) 0 (0) 260 (81.8) 11 (3.5) 25 (7.9) 282(88.7) management chart Oxygen in 0 (0) 0 (0) 0 (0) 15 (4.7) 117 (36.8) 186(58.5) running condition Ambulance 0 (0) 0 (0) 0 (0) 172 (54.1) 37 (11.6) 109(34.3)
8.1.8. Current episode of illness
Out of the 1028 children screened for symptoms of acute respiratory infections during the two weeks preceding the survey, symptoms were reported in 30.1% of the children and judging by the symptoms reported, nearly 90 percent had milder form of the disease that is cough and cold.
Table 18: Reported symptoms of acute respiratory infections (N=318)
Symptoms reported Frequency Percent
Running nose/cough 316 99.4
Fever 231 72.6
Difficult breathing 31 9.7
Fast breathing 30 9.4
Chest indrawing 9 2.8
Inability to drink or breastfeed 8 2.5
Unconscious/abnormally sleepy/difficult to wake 1 0.3
Convulsions 0 0
Depending on the symptoms reported and judging severity as stated earlier, the grading of illness was as follows:
Table 19: severity of illness (N=318)
Severity of Cough & cold pneumonia Severe Very severe illness pneumonia
Frequency 285 21 9 3
Percent 89.6 6.6 2.8 0.9
For the current episode of illness, only 4 percent consulted any doctor at the government health facility. Other options resorted to were as follows-
Table 20: Action taken during the current episode of illness (N=318)
Action taken Frequency Percent
Did nothing 64 20.1
Tried home remedies 99 31.1
Took medicine from local 40 12.6 pharmacy
Consulted traditional healer 26 8.2
Consulted ANM 38 11.9
Consulted government 13 4.1 doctor
Consulted private doctor 38 11.9
Considering the severity of illness and the action taken and calculating minimal access as per criteria adopted, only 52 percent of the children were found to have minimal access to healthcare. 8.2 Bivariate analysis
Chi square test was done to test difference in proportion and significant associations with Pearson’s chi square p value (<0.05) was seen with
8.2.1. Availability of immunization card: 59.3 percent of those who claimed availability of immunization card had minimal access compared to 43.3 percent of those who did not.
Table 21: Adequate access and availability of immunization card (N=318)
Immunization Access not adequate Adequate access Total P value card available Frequency (%) Frequency (%) Frequency (%) No 80 (56.7) 61 (43.3) 141 (100) Yes 72 (40.7) 105 (59.3) 177 (100) 152 166 318 .004
8.2.2. Mother’s perception of illness: 76.1 percent of the children had minimal
access to healthcare if the mother thought the illness was serious, compared to
48.7 percent if they did not perceive it as serious.
Table 22: Distribution of minimal access and mother’s perception of illness (N=318)
Was the Access not adequate Adequate access Total P value child Frequency (%) Frequency (%) Frequency (%) seriously ill No 141 (51.8) 131 (48.2) 272 (100) Yes 11 (23.9) 35 (76.1) 46 (100) 152 (47.8) 166 (52.2) 318 (100) .000
8.2.3. Main source of income: Minimal access was seen in 58.2 percent in those who reported agriculture and forest products as their main source of income as compare to
45.7 percent in those who reported daily wage and 20 percent in those who reported monthly pay as their main source of income Table 23: Distribution of minimal access and source of income (N=318)
Main source of Access not adequate Adequate access Total P value income Frequency (%) Frequency (%) Frequency (%) Monthly pay 28 (80.0) 7 (20.0) 35 (100) Daily wage 25 (54.3) 21 (45.7) 46 (100) Agriculture & 99 (41.8) 138 (58.2) 237 (100) forest products 152 166 318 .000
8.2.4. Ever visit to health facility: 63.3 percent of those who had ever visited the HSC had adequate access compared to 40.1 percent of those who had not, while the difference was more marked among those who had visited the PHC or a private clinic as seen in the table.
Table 24: Minimal access and ever visit to any health facility (N=318)
No adequate access Adequate access Total Frequency (%) Frequency (%) Ever visited health sub center (p < .001) No 91 (59.9) 61 (40.1) 152 (100) Yes 61 (36.7) 105 (63.3) 166 (100) Total 152 (47.8) 166 (52.2) 318 (100) Ever visited PHC (p <.001) No 146 (55.3) 118 (44.7) 264 (100) Yes 6 (11.1) 48 (88.9) 54 (100) Total 152 (47.8) 166 (52.2) 318 (100) Ever visited Private clinic (p<.001) No 134 (53.2) 119 (46.8) 252 (100) Yes 18 (27.7) 47 (72.3) 65 (100) Total 152 (47.8) 166 (52.2) 318 (100)
8.3 Binary Logistic Regression 8.3.1. Minimal access to healthcare was significantly associated with the following predictor variables and their odds ratio with 95% confidence interval is as follows: Those having immunization card were twice as likely to have minimal access as those who did not.
Table 25: Significant associations with minimal access.
Variable Groups Odds 95% C.I for OR p Ratio(OR) value Lower Upper
Immunization card Yes 1.91 1.22 2.99 .005 available No 1
Perception of severity of Serious 3.35 1.63 6.88 .001 illness Not serious 1
Main source of income Monthly pay 1 .019 Daily wage 3.36 1.22 9.23 .000 A/F products 5.58 2.34 13.28 Ever visit to Sub center Yes 2.57 1.63 4.04 .000
No 1
Ever visit to PHC Yes 9.90 4.10 23.93 .000
No 1
Ever visit to private clinic Yes 2.97 1.63 5.39 .000
No 1
Table 26: Perception of mother about sub center Variable Groups OR 95% C.I for OR p value Lower Upper Distance Not too far 3.72 1.85 7.48 .000 Too far 1 Provider behavior Good 4.78 1.92 11.89 .001 Bad 1 Timing Suitable 5.83 2.59 13.13 .000 Unsuitable 1 Availability of Medicines Available 10.0 3.48 28.74 .000 Unavailable 1 Benefit from visit Benefited 8.99 3.04 26.57 .000 No benefit 1 Overall experience Good 8.65 2.23 33.46 .002 Bad .002 Table 27: Village specific variables Variable Group OR 95% C.I for OR p value Lower Upper ASHA selected Yes 1.89 1.07 3.35 <.001 No 1 ASHA trained Yes 3.18 1.77 5.73 <.001 No 1 ANM,s Regular visit Yes 4.73 2.45 9.12 <.001 No 1 Aanganwadi worker present Yes 3.46 2.00 6.00 <.001 No 1 Health education Campaign <6mnths 3.19 1.88 5.42 <.001 >6mnths 1 Public transport available to Yes 7.15 4.17 12.25 <.001 health facility No 1
Table 28: Variables related to Health Facility
Variable Group OR 95% C.I for OR p value Lower Upper Distance to subcenter Up to 5 km 3.99 2.43 6.53 <.001
> 5 km 1
Public transport to subcenter Yes 1.86 1.10 3.15 .022
No 1
IMNCI training of staff Yes 2.52 1.54 4.13 <.001
No 1
Oral Antibiotics always Yes 7.53 4.26 13.29 <.001 available No 1
Injectable antibiotics always Yes 4.94 1.91 12.77 .001 available No 1
Table 29:Variables related to Health Facility
Variable Group OR 95% C.I for OR p value Lower Upper Antipyretics/analgesics always Yes 3.0 1.79 5.02 <.001 available No 1
Disposable syringes always Yes 2.28 1.29 4.02 .004 available No 1
I/v fluids always available Yes 7.84 3.27 18.77 <.001
No 1
ARI management chart always Yes 5.06 2.51 10.20 <.001 available No 0
Public transport to PHC Yes 5.58 1.15 27.09 <.001 available No 1
No significant association was seen between adequate access and age or birth order or sex of the child, age group, tribe or religion to which the child belonged, parent’s age, education, or knowledge of Hindi (language spoken by most healthcare provider), any specific symptom of illness, and interestingly it was also not associated with the distance or resources available at the PHC.
8.3.2 Binary Logistic regression for other associations a. ANM’s visit to the family within six months: Distance of nearest road to the village, distance of sub center from the village, availability of public transport from village till some distance to the H. facility, and the presence were the main variables associated significantly with the ANM’s visit to the family.
Table 30: ANM’s last visit to family within 6 month.
Variable Group OR 95% C.I for OR P value Lower Upper Distance of nearest road from yes 3.22 1.61 6.43 .001 village less than 5 km
Public transport from village to yes 2.10 1.29 3.45 .003 any H facility
Village health committee present 2.32 1.41 3.80 .001
Traditional tribal religion yes 1.70 1.02 2.82 .041
Distance to H sub center <5 km 2.00 1.16 3.43 .012
Tribe Oraon 1
Munda 3.67 1.83 7.37 <.001
Kharia 1.14 0.53 2.45 .730 Others 2.94 1.48 5.84 <.001 b. Availability of immunization card: Associations were as expected
Table 31: Availability of immunization card
Variable Group OR 95% C.I for OR P value Lower Upper ANM’s regular visit to village Yes 3.56 1.90 6.67 <.001
ANM’s visit to family in <6 Yes 2.24 1.35 3.73 .002 mnth
ASHA trained Yes 2.86 1.58 5.15 <.001
Distance to road from vill <5 km Yes 2.19 1.30 3.69 .003
Public transport from village to Yes 4.91 2.91 8.28 <.001
H facility
Distance to HSC <5 km Yes 3.69 2.27 6.00 <.001
Ever visit to HSC Yes 13.23 7.71 22.68 <.001
Source of Income Mthly pay 1
D. Wage 3.36 1.22 9.24 .019
A/F pro 6.77 2.84 16.15 <.001
c. Ever visit to the health sub center: was also associated on expected lines. It is particularly evident that the OR increases as the distance of nearest road to village decreases.
Table 32: Ever visit to the sub center
Variable Group OR 95% C.I for OR P value Lower Upper ANM’s regular visit to village Yes 3.15 1.73 5.73 <.001
ANM’s visit to family within 6 Yes 3.36 1.99 5.68 <.001 months Trained ASHA in village Yes 2.40 1.34 4.29 .003
Public transport from village to Yes 11.73 6.49 21.21 <.001 health facility Distance to health sub center < 5 Yes 7.35 4.31 12.52 <.001 km Distance to nearest motorable < 1 km 10.67 3.51 32.45 . <.001 road to the village 1-5 km 5.73 2.10 15.67 .001
5-10 km 3.91 1.28 11.34 .017
> 10 km 1
Distance to health sub center < 5 Yes 7.35 4.31 12.52 <.001 km
9. LIMITATIONS
The field data collection was done by investigators who were not trained healthcare staff.
So most of the information collected were as reported by the mothers. This could be the reason for underestimation of severity of illness as clinical examination was not done in the field. The investigators were trained and could explain to the mother what they meant by each symptom, they were not to examine the child themselves due to ethical reasons.
Moreover many of the children had already recovered or on the way to recovery.
Nutritional status of the children was not assessed due to technical reasons. Any child with symptoms of acute respiratory infection and severe malnutrition needs to be graded as suffering from very severe disease even in the absence of symptoms specified for the same. It severe malnutrition was prevalent in the study population, this could be an overestimation of adequate access.
10. DISCUSSION
The study proposed to describe the healthcare access among the study population and reveals that just about 20 percent of these children belong to families that have ever visited the primary health center or a private clinic, while less than 50 percent have ever visited even a health sub center. One-third has not done so because they are unaware of its existence while less than 10 percent did not trust the provider. Just 30 percent of these children have been visited by the ANM in the last six months, even though she should be visiting them on a monthly basis. Other grass root level health workers like AWW &
ASHA is also available at the village to just half of these children.
The study also found that minimal access to healthcare (outcome variable) among these children with acute respiratory symptoms is present in only 52 percent among the study population even with very liberal criteria adopted
Mother’s perception of the illness as serious was found to be significantly associated with
access as has been seen other studies too. Mother’s earlier visit to any health facility in
the past understandably correlates with the minimal access during the current episode of
illness.
Mother’s perception about various aspects of the sub center visited earlier, with much
higher Odds Ratios ranging from 3.72 (95%CI 1.85,7.48) to 10.00 (95%CI 3.48, 28.74)
for minimal access if she perceived them as favorable shows that many don’t access
healthcare because they are not comfortable doing so. This opens up need for a qualitative study to interpret what exactly they perceive better in terms of cost, distance,
timings, provider behavior etc. Absence of any significant association of the outcome
variable was not true in case of their past experience at the PHC or a private clinic
probably because they mostly depend on the sub center for their healthcare needs and just
about 20 percent have ever visited any other healthcare facility.
Availability of resources essential for managing ARI at the HSC was also significantly
associated (OR 3-8) while that at PHC showed no association. This shows that this
community is mostly dependent on the health sub center for their healthcare needs and
that they access it more if it is well equipped.
The study reveals that the child is twice as likely to have adequate access if they possess immunization card probably because the same factors determine both variables.
Unavailability of public transport is one of the major barriers to access as can be seen in the result (OR 7.5) along with distance to the health facility particularly the sub center less than 5 km (OR 4).
Presence of community level health workers ASHA & AWW and regular visits by the
ANM (OR 2-5) reflecting the significant role they play in the healthcare access of these people, the presence of village health committee however did not have any significant association showing that the committee itself is insufficient in improving access to healthcare.
Factors like age, sex, severity of illness, parent’s age or education, birth order, family size, tribe, religion, duration or severity of illness or any specific symptom reported were not significantly associated with access. The apparently high immunization status can be explained by the fact that it is being
reported as claimed by the mother as actual verification of the immunization card could
not be done. It could also be due to the catch-up rounds for immunization that has been carried out in the state every six months from July 2004 to December 2006.
The average age for exclusive breastfeeding at 5.6 months does not reflect high
awareness among the study population about benefits of breastfeeding, but is probably
due to the fact that the breastfeeding practices is culturally better in this community. The
NFHS-2 data on Jharkhand revealed that the initiation of breastfeeding within the first hour and first day of birth was highest among the scheduled tribes, as compared to any other group.
As the same factors are significantly associated with adequate access and ANM’s visit to the family, like the distance to the nearest road from the village, availability of public transport, distance to the health facility etc, it can be said that the barriers to healthcare access are the same from the client as well as the provider side.
The prevalence of acute respiratory symptoms at 30.9% was somewhat higher than that
projected in NFHS-2. This could be because the study was carried out during the rainy
season and the prevalence has seasonal variation. It also could be because the study was
carried out in the remote tribal villages with higher risk of indoor pollution from more
frequent use of biomass fuel for cooking.
This study also reveals the poor economic status of the study population with all of them
belonging to SLI group 1. They are also geographically isolated with a motor able road
within one km present in less than 20 percent and scant public transport availability. Therefore it is unlikely for them to access healthcare from a facility situated any further than they can walk.
]
11. CONCLUSION
This study found that ARI prevalence was 31% as against 25% while those taken to facility was 28% as against as against 40% projected by NFHS 2 (Bihar) and minimal access to healthcare even by most liberal criteria adopted in the study, was present in only
52 percent of the children aged 0-60 months and reporting symptoms of acute respiratory infection in the two weeks preceding the survey in the tribal dominated villages of
Simdega district of Jharkhand.
The awareness regarding availability of healthcare is low in the study population, with more a third unaware of presence of any healthcare facility.
From the provider side too there is little attempt to reach out to this population, with just
30 percent of the children having had a visit from the community level provider in the last six months and 70 percent not having had any education on homecare of sick child by any competent source.
The facilities catering to these populations are situated far away with poor connectivity by means of road or public transport. They are also poorly equipped and lack adequately trained staff.
The prevalence of acute respiratory symptoms is slightly higher than expected at 30.1% but mainly those of mild form of illness.
The factors significantly associated with adequate access for these symptoms with p <.05 are - mothers perception of the illness as serious (OR 3.4), ever visit to any health facility like HSC (OR 2.6), PHC (9.9) or Private clinic (OR 3), mothers perception of sub center as favorable in terms of distance (OR 3.7), timing (5.8), provider behavior (4.8), availability of medicines (OR 10), benefit from last visit (OR 9), and overall experience
(OR 8.6), presence of trained ASHA (OR 3.2) & AWW (OR 3.5) in the village, regular
visits by ANM as perceived by the village head (OR 4.7), availability of public transport
till some distance to the health facility (OR 7.5), distance to sub center less than five km,
IMINCI trained staff (OR 2.5) and availability of various resources essential for
management of ARI (OR 2.3 to OR 7.8), and health education campaign in the village
within six months (OR 3.2).
Therefore it can be said that the main barriers to access to healthcare for ARI among the
study population are - poor connectivity, ill equipped health facilities, lack of awareness of availability of healthcare, low motivation among community level health workers, and distance to health facility.
12. RECOMMENDATION:
The healthcare access to the study must be improved to ensure vertical equity to this
disadvantaged population group.
As seen from this study, they homogenously belong to the SLI group 1 and have little
means to reach health facilities situated at a distance in the absence of proper road or
mode of conveyance.
-Ideally the health facilities should be situated closer to their homes with the health sub
center located within three km as per IPHS standard for sub center.
-The community level workers engaged in catering this population group should be
allowed special performance based incentives for motivation and should be trained on a
priority basis.
-Special efforts should be made to keep the facilities closest to them well equipped as per
IPHS standards, as they are unlikely to seek healthcare from any further.
-Connectivity to these villages must be improved by means of roads and public transport.
-Frequent IEC activities should be carried out in these villages at least once in every six
months to generate awareness regarding health and the healthcare system.
-Since the perceptions about the health facility are strongly associated with access, a qualitative study to interpret them would go a long way to tailor services as per their needs and aspirations.
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Appendix 1:
List of all 117 villages of Simdega district having 90-100% tribal population.
List of revenue villages of Simdega district having 90-100%ST population Thana S.No.ofVillage District Block No Village 1 SIMDEGA Bano 58 Chodordah 2 SIMDEGA Bano 86 Barbera 3 SIMDEGA Bano 83 Ketka 4 SIMDEGA Bano 74 Sumuibera 5 SIMDEGA Bano 87 Kauwajor 6 SIMDEGA Bano 28 Garra 7 SIMDEGA Bano 69 Chaklabasa 8 SIMDEGA Bano 67 Sijang 9 SIMDEGA Bano 45 Kusum 10 SIMDEGA Bano 34 Loasokra 11 SIMDEGA Bano 27 Konop 12 SIMDEGA Bano 65 Chorbandu 13 SIMDEGA Bolba 70 Gatigarha 14 SIMDEGA Bolba 59 Saraslongri 15 SIMDEGA Bolba 65 Behrainbasa 16 SIMDEGA Bolba 69 Baleyajor 17 SIMDEGA Bolba 52 Rengarbahar 18 SIMDEGA Bolba 68 Kasira 19 SIMDEGA Bolba 66 Naktikachhar 20 SIMDEGA Jaldega 3 Tilmibera 21 SIMDEGA Jaldega 19 Bardega 22 SIMDEGA Jaldega 25 Sakambahar 23 SIMDEGA Jaldega 26 Siharjor 24 SIMDEGA Jaldega 33 Semariya 25 SIMDEGA Jaldega 36 Hututua 26 SIMDEGA Jaldega 57 Titlingi 27 SIMDEGA Jaldega 58 Baribiringa 28 SIMDEGA Jaldega 42 Banjoga 29 SIMDEGA Jaldega 49 Ramjari 30 SIMDEGA Jaldega 56 Hutubda 31 SIMDEGA Jaldega 39 Robga 32 SIMDEGA Jaldega 13 Pomian 33 SIMDEGA Jaldega 9 Janoda 34 SIMDEGA Jaldega 37 Lamdega 35 SIMDEGA Jaldega 54 Barbera 36 SIMDEGA Jaldega 24 Bhukumunda 37 SIMDEGA Jaldega 34 Bhundupani 38 SIMDEGA Jaldega 50 Kutangia 39 SIMDEGA Jaldega 17 Dongapani 40 SIMDEGA Jaldega 14 Junadih 41 SIMDEGA Jaldega 68 Tengratuku Thana S.No.ofVillage District Block No Village 42 SIMDEGA Jaldega 30 Urte 43 SIMDEGA Jaldega 29 Lomboi 44 SIMDEGA Jaldega 66 Barkitangar 45 SIMDEGA Jaldega 62 Keluga 46 SIMDEGA Jaldega 63 Tangia 47 SIMDEGA Jaldega 11 Seharmunda 48 SIMDEGA Jaldega 31 Tikra 49 SIMDEGA Jaldega 38 Bhanwarchaba 50 SIMDEGA Jaldega 5 Menjurgara 51 SIMDEGA Jaldega 59 Mayamdega 52 SIMDEGA Jaldega 1 Pharsa 53 SIMDEGA Jaldega 15 Bendochuan 54 SIMDEGA Jaldega 43 Dhengurpani 55 SIMDEGA Jaldega 8 Sarubahar 56 SIMDEGA Jaldega 52 Tati 57 SIMDEGA Jaldega 18 Bansjor 58 SIMDEGA Jaldega 51 Tonian 59 SIMDEGA Kolebira 106 Kulasoia 60 SIMDEGA Kolebira 89 Setasoya 61 SIMDEGA Kolebira 86 Dom Toli 62 SIMDEGA Kolebira 90 Besrajara 63 SIMDEGA Kolebira 92 Bandarchuan 64 SIMDEGA Kolebira 131 Jurkela 65 SIMDEGA Kolebira 84 Jhapla 66 SIMDEGA Kurdeg 23 Karangaguri 67 SIMDEGA Kurdeg 43 Konskeli 68 SIMDEGA Kurdeg 31 Bhaimunda 69 SIMDEGA Kurdeg 29 Korkotjor 70 SIMDEGA Kurdeg 19 Hethma 71 SIMDEGA Kurdeg 26 Karrajhariya 72 SIMDEGA Kurdeg 24 Karuarjor 73 SIMDEGA Kurdeg 15 Jhunka Chhapar 74 SIMDEGA Simdega 9 Rengapani 75 SIMDEGA Simdega 13 Purnapani 76 SIMDEGA Simdega 20 Sirupardhia 77 SIMDEGA Simdega 55 Konbera 78 SIMDEGA Simdega 64 Belkarcha 79 SIMDEGA Simdega 71 Barpanichhota 80 SIMDEGA Simdega 73 Pindatangar 81 SIMDEGA Simdega 74 Koleadamar 82 SIMDEGA Simdega 46 Tumdegi 83 SIMDEGA Simdega 120 Belgarh 84 SIMDEGA Simdega 84 Kasaidohar 85 SIMDEGA Simdega 70 Bhanwarpani 86 SIMDEGA Simdega 39 Birkera 87 SIMDEGA Simdega 18 Gondlipani 88 SIMDEGA Simdega 28 Kewnddih Thana S.No.ofVillage District Block No Village 89 SIMDEGA Simdega 47 Semarbera 90 SIMDEGA Simdega 19 Katasaru 91 SIMDEGA Simdega 40 Sansewai 92 SIMDEGA Simdega 124 Muriya 93 SIMDEGA Simdega 67 Arani 94 SIMDEGA Thethaitangar 93 Galsera Barbera alias 95 SIMDEGA Thethaitangar 99 Chapamunda 96 SIMDEGA Thethaitangar 101 Latha Khamhar 97 SIMDEGA Thethaitangar 112 Jambahar 98 SIMDEGA Thethaitangar 100 Baghchata 99 SIMDEGA Thethaitangar 152 Kutniya 100 SIMDEGA Thethaitangar 154 Jampani 101 SIMDEGA Thethaitangar 145 Dharhibahar 102 SIMDEGA Thethaitangar 147 Koranjo 103 SIMDEGA Thethaitangar 150 Awrabahar 104 SIMDEGA Thethaitangar 155 Deobahar 105 SIMDEGA Thethaitangar 130 Kahupani 106 SIMDEGA Thethaitangar 92 Mundaltoli 107 SIMDEGA Thethaitangar 126 Ghutbahar 108 SIMDEGA Thethaitangar 129 Kesra 109 SIMDEGA Thethaitangar 157 Pandrpani 110 SIMDEGA Thethaitangar 153 Ambapani 111 SIMDEGA Thethaitangar 139 Japlanga 112 SIMDEGA Thethaitangar 128 Rajabasa 113 SIMDEGA Thethaitangar 149 Churia 114 SIMDEGA Thethaitangar 102 Gamharjhariya 115 SIMDEGA Thethaitangar 122 Bamalkera 116 SIMDEGA Thethaitangar 137 Jilinga 117 SIMDEGA Thethaitangar 123 Siringbera
Source: Official website of government of Jharkhand. Dept of Welfare.
Appendix 2: Form 1 (Interview schedule for screening for ARI)
FormNumber: FORM 1:Interview schedule with mothers for screening children with ARI Respondent’s (child) Identification number:
Serial Description Codes Response number G01 Interviewer code:
G02 Date of interview:
G03. Block:
G04. Village:
G05. House number:
Questions about the Child C01 What is the date of birth of the child? (DD/MM/YYYY) C02 How old is the child? (Record in months)
C03. Is the child a boy/girl? 1. boy 2. girl C04. Till what age from birth did the child have (specify months) mother’s milk as the only feed? C05 Has the child ever received Vitamin A 0. No dose? 1. Yes 9. Don’t know C06. Does the child have immunization card? 0. No 1. Yes 9. Don’t know C07 Is the immunization card available with you 0. No or the ANM ? 1. Yes C08. If yes, check entries for (tick in response column) BCG
DPT 1st dose 2nd dose 3rd dose booster
OPV 1st dose 2nd dose 3rd dose booster Measles Vitamin A (no. of doses) C09. Did the child have any of the following symptoms in the last 2 0. No weeks? 1. Yes (Cough/running nose, breathing difficulty, sore throat, ear 9. Don’t problem, inability to drink/feed, abnormally sleepy/difficult to know wake) IF YES, PROCEED TO FORM 2 Appendix 3: Form 2 (Interview schedule for mothers of sick children)
FORM 2: Interview schedule with mothers of children with ARI Questions on the current episode of Sickness (last 2 weeks) S.No. Question Codes Response S01. How long has the child been ill? ( number of days )
S02. Symptoms of current episode of illness (reported by mother) Did the child have the following symptoms? (Tick at appropriate place) Yes No Don’t know a. Running nose or cough b. Fever c. fast breathing d. chest indrawing e. Difficulty in breathing f. Convulsions g. Inability to drink/breastfeed normally (Could not drink at all/too weak to drink/vomited out everything) h. Unconscious or abnormally sleepy and difficult to wake S03. Do you think that the current illness was 0. No serious? 1. Yes 9. Don’t know S04. Was the child hospitalized? 0. No 1. Yes S05. How did you manage the illness? 0. Did nothing 1. Tried home remedies 2. Took medicines from the local pharmacy 3. Consulted traditional healers. 4. Consulted CHW/ANM. 5. Consulted doctor (at least MBBS) at Govt Facility 6. Consulted private doctor (at least MBBS) 7. Others (Specify)
S06. What best describes 0. Don’t know what else to do. the reason for your 1. It is the usual source of care for illness. preferred choice of 2. Have faith in the provider. treatment? 3. It is nearby. 4. Can afford it. 5. It is the appropriate choice. 9. Don’t Know/Can’t comment S07. What best describes 0. Don’t know where to seek such care the reason for not from. seeking care from 1. Didn’t think it is needed. Doctor/ANM? 2. Can’t afford/too expensive. 3. Too far. 4. Don’t have faith in the treatment. 5. Provider’s behavior not good. 9. Don’t Know/Can’t comment S08. Has any doctor/health 0. No worker ever told you 1. Yes how to care for a sick 9. don’t know child at home? S09. Who takes the decision 1. Mother regarding seeking 2. Father outside care for child’s 3. Mother-in-law illness? 4. Father-in-law 5. Others 9.Don’t know/Can’t comment S10. How is the child 1. Recovered today? 2. Sick 3. Dead Questions about the Family F01. What is the birth order (1st,2nd,3rd …child) of the child under study? F02. How many (Total number of siblings excluding the brothers/sisters does child) the child have? F03 Record separately for father and mother Mother Father a. How old are the (in completed years and date of birth) parents? b. How educated are the 0. No formal schooling. parents? 1. less than primary school(1-4) 2.Primary school completed(5) 3. Middle school completed(8) 4.High school completed(10) 5.more than above. c. Can the parents speak 1. Yes Hindi? 0. No
F04. What is the main 1. Regular employment (get monthly salary) source of income for 2. Daily wage earner. the household? 3. Agriculture /Forest products 4. Others (specify)
F05. What is the religion of 1.Sarna the family? 2. Hindu 3. Christian 4. Others(specify) F06. To which tribe does 1. Oraon the family belong? 2. Munda 3. Kharia 4. Others (specify)
F07. Standard Living Index(SLI)
Enter correct response from options given OPTIONS a. House type Pucca, Semi-pucca, Katcha b. Toilet facility Own flush toilet,Public or shared flush toilet, own pit toilet,shared or public pit toilet, No facility. c. Source of lighting Electricity, kerosene,gas or oil, other fuel d. Main fuel for cooking Electricity,LPG or biogas, coal,charcoal or kerosene, other fuel e. Source of drinking water Pipe,own handpump,own well,public tap, public handpump,public well,other source f. Separate room for cooking Yes, No. g. Ownership for agriculture land Specify in acres(1,2….etc) h. Ownership for irrigated land Some irrigated land,No irrigated land. i. Ownership of livestock Owns livestock,Does not own J Ownership of durable goods Car,tractor,two-wheeler, telephone,refrigerator,colour TV,bicycle,electric fan,radio,sewing machine, black&white TV
Healthcare Delivery. H01. When did the ANM 0. Never last visit you? 1. less than a month back 2. One month to six month back 3. more than six months 4.Don’t know For H02 to H04h Record separately for each facility Subcenter PHC Pvt.clinic H02. Have you ever 0. No visited any 1. Yes subcenter/ 9. don’t know PHC/pvt.clinic H03. If No, what is the 0. Don’t know where it reason? is. 1. Did not need to. 2. Don’t trust the care provided. 3. Others (specify) H04 How would you rate your last visit to the facility in terms of a. Cost involved in 0. Too expensive visiting it 1. Not too expensive 9. Don’t know b. Distance 0. Too far 1. Not too far 9. Don’t know c. Provider behavior 0. Bad 1. Good 9. Don’t know d Timings 0. Unsuitable 1. Suitable 9. Don’t know e. Availability of 0. Not available medicines 1. Available 9. Don’t know f. Benefit from the 0. No benefit visit 1. Benefitted 9. Don’t know g. Overall experience 0. Bad 1. Good 9. Don’t know h. Would you 0. No recommend it to 1. Yes your 9. Don’t know family/friends?
Appendix 4: Form 3 (Interview schedule for the village head)
FormNumber:
FORM 3:Interview schedule with Village head
Respondent’s (village head) Identification number:
Serial Description Codes Response Num.
V01 Interviewer code:
V02 Date of interview:
V03. Block:
V04. Village:
V05 Is there a village health committee in the 0. No village? 1. Yes 2. Don’t know V06 Does the village health committee meet 0. No regularly? (at least once in two months) 1. Yes 2. Don’t know V07. Has ASHA been selected in the village? 0. No 1. Yes 2. Don’t know V08. If yes, has she been trained yet? 0. No 1. Yes 2. Don’t know V09 Does the ANM visit the village 0. No households regularly? 1. Yes 2. Don’t know V10. . How would you rate the services being 0. Can’t comment. provided by the ANM to the village? 1. Bad. 2. Neither good nor bad. 3. Good. 9. Don’t know.
V11. Is public transport facility available from 0. No the village to reach any health facility? 1. Yes 2. Don’t know V12. When did any health education 0. Never. campaign last take place in the village? 1. Less than one month back. 2. One-six months back. 3. Six months to one year back. 4. Don’t remember/ more than one year back V13. What is the distance to the nearest 1. Less than 1 km. motorable road? 2. 1-5 km. 3. 5-10 km. 4. More than 10 km.
Appendix 5: Form 4 (Interview schedule for the person-incharge of sub center and PHC nearest to the village)
Form Nunber: FORM 4. Interview schedule with person in-charge of the nearest sub- center& PHC Respondent’s (ANM or MOIC of the facility) Identification number:
Question Question Codes Response number G01 Interviewer code:
G02. Subcenter/PHC Specify type of facility and location G03 Date of interview:
G04. Block:
G05. Village under study:
Q01 Approximate distance from To be estimated by the village under study in kms. investigator Q02 When did anyone from the 1. last one month facility last visit the village? 2. One to six months (specify who) 3.Six months to one year 4.More than one year 9. Don’t know Q03 What was the time taken to 1. Less than half hour. reach the village? 2. Half to one hour. 3. One to two hours. 4. More than two hours. 9. Don’t know Q04. To what extent is the public 0. No public transport. transport available from the 1. available till some distance. facility to the village ? 2. available for the entire distance. 9. Don’t know. Q05. How long would it take to 1. Less than half hour. reach the patient to nearest 2. Half to one hour. referral facility using available 3. One to two hours. modes of transport? 4. More than two hours. 9. Don’t know
Q06. MANPOWER RESOURCE AT THE FACILITY Q07 . OTHERStaff RESOURCES posted at the facility AT THE FACILITYDistance of Received Duration & place S.N (include all doctor, nurse, residence IMNCI of training LHV, ANM, Health from facility training (Days/hospital workers.) in kms. (Yes or name) No) 1.
2
3
4
5
6
7
8
9
10.
S.N Description Availability (Tick at appropriate space) Sometimes Never Always A. Analgesics/antipyretics for pediatric use. (specify generic name) A1
A2
A3
B Oral antibiotics for pediatric use (specify generic name) B1
B2
B3
C Injectable antibiotics for pediatric use (specify generic name) C1
C2
C3
D Disposable syringe/needles
E I/V fluids
F Oxygen(in working condition)
G Oral Salbutamol
H Standard case management guidelines chart I Ambulance/transport
Abbreviations used:
AWW Anganwadi worker ANM Auxillary Nurse Midwife
ARI Acute Respiratory Infections
ASHA Accredited Social Health Activist
NFHS National Family Health Survey
GOJ Government of Jharkhand
MDG Millenium Development Goals
IMNCI Integrated Management of Neonatal and childhood illness
WHO World Health Organisation
SLI Standard Living Index
PHC Primary Health Centre
HSC Health Subcenter
OR Odds Ratio
CI Confidence Interval