Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Yale Medicine Thesis Digital Library School of Medicine 2000 Childhood Pneumonia in Nuwakot District, Nepal: perceptions, management, and the impact of a community intervention Amy B. Levin Yale University Follow this and additional works at: http://elischolar.library.yale.edu/ymtdl Recommended Citation Levin, Amy B., "Childhood Pneumonia in Nuwakot District, Nepal: perceptions, management, and the impact of a community intervention" (2000). Yale Medicine Thesis Digital Library. 2850. http://elischolar.library.yale.edu/ymtdl/2850 This Open Access Thesis is brought to you for free and open access by the School of Medicine at EliScholar – A Digital Platform for Scholarly Publishing at Yale. It has been accepted for inclusion in Yale Medicine Thesis Digital Library by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale. For more information, please contact [email protected]. YALE UNIVERSITY CUSHING/WHITNEY MEDICAL LIBRARY Permission to photocopy or microfilm processing of this thesis for the purpose of individual scholarly consultation or reference is hereby granted by the author. This permission is not to be interpreted as affecting publication of this work or otherwise placing it in the public domain, and the author reserves all rights of ownership guaranteed under common law protection of unpublished Digitized by the Internet Archive in 2017 with funding from The National Endowment for the Humanities and the Arcadia Fund https://archive.org/details/childhoodpneumonOOIevi Childhood Pneumonia in Nuwakot District, Nepal: Perceptions, Management, and the Impact of a Community Intervention A Thesis Submitted to the Yale University School of Medicine in Partial Fulfillment of the Requirements for the Degree of Doctor of Medicine by Amy B. Levin Y»LE MEiffiV mm JUL 2 8 8000 i i UJ i tV sf I r A i t ^ c * i/ 1. CHILHOOD PNEUMONIA IN NUWAKOT DISTRICT NEPAL: PERCEPTIONS, MANAGEMENT, AND THE IMPACT OF A COMMUNITY INTERVENTION. Amy B. Levin (Sponsored by Michael Cappello). Section of Infectious Diseases, Department of Pediatrics, Yale University School of Medicine, New Haven, CT. Acute Respiratory Infection (ARI) is one of the major causes of preventable death among children in the developing world. Pneumonia accounts for the majority of these deaths. This two-part study was undertaken in the remote district of Nuwakot, Nepal to assess the management of pneumonia in children under 2 years of age. The baseline work was intended to provide a snapshot of the treatment of pneumonia in this population through the characterization of local health providers' and mothers' perceptions and practices. The findings were used to guide the design of a community-based intervention for Save the Children. In the second portion of the study, a follow¬ up evaluation of the pilot program was conducted. The tools for both studies included interviews, observations, record review and focus groups. Results of the baseline study demonstrate that the local government health infrastructure does not adequately provide care for respiratory infections. Health Post Workers lack pneumonia-specific knowledge; only 50% could site tachypnea and chest retractions as the 2 most important signs for diagnosing pneumonia. Health posts are understocked, often without the first-line antibiotic of choice to treat pneumonia. Mothers are uninformed about pneumonia signs and symptoms. They delay in seeking care at health posts, waiting an average of 3.7 days from symptom onset. Over 55% of mothers rely on traditional medicine, which contributes to this delay in care-seeking. The follow-up evaluation revealed that pneumonia training may improve knowledge and practices of Community Health Volunteers. However, the impact of the program appears limited due to lack of community participation. Implications of the study findings are discussed in the context of global ARI strategies. 11. Acknowledgements This work could not have been carried out successfully without the help of many dedicated individuals both in New Haven and Nepal. First, thank you to my thesis advisor at Yale, Dr. Michael Cappello, for helping to shape this project from the start and for guiding me throughout my years at Yale. I am also grateful to Dr. Robert Baltimore for sharing his expertise in international pediatric infectious diseases. Thank you to my Nepal supervisors, Chanda Rai and Naramaya Limbu, the Save the Children health staff both in Kathmandu and Nuwakot—particularly Bharat Panta and Roma Raut, and to the Health Post Staff and the Community Health Volunteers who are the backbone of care for children in Nuwakot. I was fortunate to receive funding from the Wilbur Downs International Health Fellowship and the Yale School of Medicine Office of Student Research. Finally, thank you to my husband, Jon, who has supported me along every step of this journey. iii. Overview of the Thesis I. The first chapter begins with an overview of ARI terminology, etiology, burden of disease and public health strategies. It then focuses specifically on current knowledge regarding respiratory infections in Nepal and provides background information on the local socio-economic conditions and health infrastructure. It closes with a description of Save the Children's activities in Nuwakot. II. The second chapter describes the aim of the work and the methodology of the baseline study including sampling and statistical analysis. III. The third chapter presents the results of the baseline study followed by a discussion of the findings. IV. The final chapter outlines the structure of the pilot program, follow-up study methodology, results and a discussion of those findings. It concludes with recommendations for future approaches to pneumonia management. IV. Table of Contents I. Introduction. 1 ARI—An Overview 1 ARI Terminology 4 ARI in Nepal 5 The Nepal ARI Control Program 6 Nepal Demographics 7 The Nepalese Health Infrastructure 8 The Nuwakot Health Infrastructure 10 II. The Baseline Study. 11 Statement of Purpose 11 Methods 12 Statistical Analysis 17 III. Results: Baseline Study. 17 Health Facilities 17 ARI Care Seeking Patterns 18 Caretaker Pneumonia Knowledge 20 Health Worker Knowledge, Attitudes, Practices 22 A Comparison of Health Worker Performance 25 The Impact of Literacy 26 Records 28 Discussion 29 IV. Pilot Program. 32 Background 32 Community-Based ARI Interventions 33 The Nuwakot Intervention 35 Statement of Purpose 36 Methods 37 Statistical Analysis 38 Findings 38 Discussion 41 Future Directions 43 References 46 V. Tables Table 1: Data Collection Baseline Study 16 Table 2: Mothers' Demographics 19 Table 3: Mothers' Knowledge of Pneumonia Signs/Symptoms 20 Table 4: Mothers' Knowledge of Home Treatment 21 Table 5: Mothers' Knowledge of Pneumonia Risk Factors 22 Table 6: Health Worker Background Information 23 Table 7: Pneumonia Knowledge Among Health Worker Types 24 Table 8: Comparison of Health Worker Knowledge 26 Table 9: CHV Pneumonia Knowledge by Literacy 27 Table 10: CHV Knowledge, Pre-Post Intervention 38 Table 11: CHV Management Performance, Post Intervention 39 Figures Figure 1: WHO ARI Algorithm Definitions 3 Figure 2: Organizational Structure of Nepalese Health Services 9 Appendices Appendix 1: Photographs Appendix 2: WHO ARI Algorithm Appendix 3: Sample Surveys Appendix 4: Charts A-D VI. List of Acronyms ARI Acute Respiratory Infection CHV Community Health Volunteer EPI Expanded Program on Immunizations HP Health Post HPW Health Post Worker MCH Maternal Child Health MOH Ministry of Health NGO Non-Governmental Organization SHP Sub-Health Post TH Traditional Healer USAID United States Agency for International Development VDC Village Development Committee VHW Village Health Worker WHO World Health Organization 1 I. Introduction ARI—An Overview Acute Respiratory Infection is one of the major causes of preventable death among children in the developing world, accounting for roughly 30% of the 14 million annual fatalities of children under 5 years of age [1-4]. Pneumonia leads to 3 million of these deaths each year [1-3, 5]. ARI-associated mortality is more than 30 times that in more developed countries, leading researchers to draw a link between pneumonia mortality and the immuno-suppressed state of children in the developing world [4,5]. This vulnerable state is attributed largely to diarrheal disease and/or chronic malnutrition [2-6]. Studies also indicate that ARI incidence is inversely related to age, peaking in the first 18 months of life [2- 3,7-8].' Traditionally, ARI is classified into 3 subgroups: upper, middle, and lower infections. Upper and middle infections include the common cold, acute otitis media, pharyngitis/tonsillitis, tracheobronchitis, and acute epiglottitis. While upper tract infections are frequently self-limited, they can progress to serious illnesses and are often found in conjunction with lower respiratory tract infections. Pneumonia and bronchiolitis are the most clinically significant lower respiratory tract illnesses and account for the majority of ARI fatalities. Studies in both developed and developing countries indicate that RSV and parainfluenza viruses are the agents most commonly associated with bronchiolitis. Pneumonia ‘The pneumonia trial conducted in Jumla, Nepal between 1986 and 1989 found that roughly 65 % of pneumonia episodes treated in children under 5 occurred in infants under 1 [7]; The 1995 Nepal Multiple Indicator Surveillance reported that ARI