Prepared by

Evaluation of awareness

cum advocacy project on mainstreaming

gestational diabetes mellitus in the

public health delivery system

Submitted to:Jagran Pehel – A division of

Sri Puranchandra Gupta Smarak Trust

Acknowledgement

We at KPMG in India would like to express our gratitude to Jagran Pehel, a division of Shri Puranchandra Gupta Smarak Trust for entrusting this study to us. We are thankful to the Jagran Pehel team, especially the senior management, for their continuous support and advice on different aspects of this assignment during the study.

The team would like to acknowledge the support and assistance provided by the state offices of Jagran Pehel, specifically the four project coordinators for each of the four states- Punjab, Delhi, Bihar and Jharkhand, covered under this study.

We are also greatly indebted to the various respondent groups that generously gave their time to provide the information that forms the basis of this report. They are not named in the report to maintain anonymity.

Table of contents

Disclaimer and notice to reader

Abbreviations used

Executive summary

Section 1: Context and overview of Jagran Pehel’s project

1.1 Context

1.2 Project overview

1.3 Implementation model

1.4 Feedback from project partners

Section 2: Study design

2.1 Objective of the assignment

2.2 Approach and methodology

2.3 KAP Scorecard

Section 3: Study findings and discussions

3.1 Changes in awareness and knowledge levels

3.2 Changes in attitudes regarding GDM

3.3 Changes in practices of stakeholders

Section 4: Jagran Pehel as a brand

Section 5: Conclusion and recommendations

References:

Annexure 1: Detailed KAP scorecards

State-wise scorecards

Stakeholder-wise scorecards

Annexure 2: Pre-test of data collection tools

Annexure 3: Data collection tools

FGD guidelines for the surveyor

Questionnaire for elected representatives and bureaucrats

Questionnaire for FGD with ASHAs

Questionnaire for FGD with ANMs

Questionnaire for FGD with Women

Questionnaire for Doctors

Questionnaire for media personnel

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Disclaimer and notice to readers

• The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. No one should act on such information without appropriate professional advice after a thorough examination of the particular situation.

• KPMG (herein after referred to as ‘KPMG’, ‘we’, ‘our’ or ‘us’ have prepared this report solely for the purpose of providing select information to the management of Jagran Pehel - A division of Shri Puranchandra Gupta Smarak Trust in accordance with the letter of engagement dated 21 April 2014 executed between Jagran Pehel - A Division of Shri Puranchandra Gupta Smarak Trust and us (‘Engagement Letter’).

• This report is for the benefit and information of Jagran Pehel - A Division of Shri Puranchandra Gupta Smarak Trust only.

• This report sets forth our views based on the completeness and accuracy of the facts stated to KPMG and any assumptions that were included. If any of the facts and assumptions is not complete or accurate, it is imperative that we be informed accordingly, as the inaccuracy or incompleteness thereof could have a material effect on our conclusions.

• While performing the work, we assumed the genuineness of all signatures and the authenticity of all original documents. We have not independently verified the correctness or authenticity of the same.

• We have not performed an audit and do not express an opinion or any other form of assurance. Further, comments in our report are not intended, nor should they be interpreted to be legal advice or opinion.

• While information obtained from the public domain or external sources has not been verified for authenticity, accuracy or completeness, we have obtained information, as far as possible, from sources generally considered to be reliable. We assume no responsibility for such information.

• Our views are not binding on any person, entity, authority or Court, and hence, no assurance is given that a position contrary to the opinions expressed herein will not be asserted by any person, entity, authority and/or sustained by an appellate authority or a court of law.

• Performance of our work was based on information and explanations given to us by the staff of Jagran Pehel – A Division of Shri Puranchandra Gupta Smarak Trust. Neither KPMG nor any of its partners, directors or employees undertake responsibility in any way whatsoever to any person in respect of errors in this report, arising from incorrect information provided by Jagran Pehel - A Division of Shri Puranchandra Gupta Smarak Trust.

• In accordance with its policy, KPMG advises that neither it nor any partner, director or employee undertakes any responsibility arising in any way whatsoever, to any person other than Jagran Pehel - A Division of Shri Puranchandra Gupta Smarak Trust in respect of the matters dealt with in this report, including any errors or omissions therein, arising through negligence or otherwise, howsoever caused.

• In connection with our report or any part thereof, KPMG does not owe duty of care (whether in contract or in tort or under statute or otherwise) to any person or party to whom the report is circulated to and KPMG shall not be liable to any party who uses or relies on this report. KPMG thus disclaims all responsibility or liability for any costs, damages, losses, liabilities, expenses incurred by such third party arising out of or in connection with the report or any part thereof.

• By reading our report, the reader of the report shall be deemed to have accepted the terms mentioned hereinabove.

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Abbreviations used

• ANC – Ante Natal Care

• ANM - Auxilliary Nurse Midwife

• ASHA – Accredited Social Health Activist

• AWW - Anganwadi Worker

• CHC – Community Health Centre

• CSO – Civil Society Organisation

• DFID – Department for International Development, U.K.

• DIPSI – Diabetes in Pregnancy Study Group India

• FGD – Focussed Group Discussions

• FOGSI - Federation of Obstetric and Gynaecological Societies of India

• GDM – Gestational Diabetes Mellitus

• GCT – Glucose Challenge Test

• HMIS - Health Management Information System

• IEC – Information, Education and Communication

• ICT – Information and Communications Technology

• IMA – Indian Medical Association

• MOIC – Medical Officer In-charge

• NGO – Non Governmental Organisation

• OGTT – Oral Glucose Tolerance Test

• OPD – Out Patient Department

• PHC – Primary Health Centre

• RBG – Random Blood Glucose

• UNICEF - United Nations International Children’s Emergency Fund

• WDF – World Diabetes Foundation

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Executive summary

KPMG’s Development Sector Practice (DSP), was engaged by Jagran Pehel to assess the performance of the project entitled ‘Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System’. Gestational Diabetes Mellitus (GDM) is a condition in which women not previously diagnosed with diabetes exhibit high blood glucose levels during pregnancy. GDM, as it is a matter of serious concern, can increase the risk of both mother and child developing diabetes later in life and can also lead to complications during child birth.

However, as 40 to 60 per cent1 of women do not demonstrate any risk factors, screening for GDM during pregnancy is essential for early detection and appropriate management of GDM. Jagran Pehel’s project aimed to increase awareness about GDM and advocated inclusion of GDM screening the public health system.

In order to achieve this, Jagran Pehel followed a multi-stakeholder approach that brought together key government and non-government actors whose participation is critical if GDM mainstreaming is to be successful. These stakeholders included:

• Elected representatives

• Bureaucrats from the public health system

• Government and non-government doctors

• Field Level Health Workers – ASHAs and ANMs

• Civil Society Organisations (CSOs)

• Media personnel

Key awareness and advocacy interventions were designed for each of these stakeholders ranging from consultations with doctors on appropriate screening protocols, to orientation sessions for field level health workers on the basics of GDM.

The aim of KPMG’s assignment was to understand what change the project has brought about on the awareness, attitudes and practices of the key stakeholders mentioned above. In order to do this, KPMG undertook a qualitative dipstick assessment in all four project states using a KAP (Knowledge-Attitude-Practice) methodology. The objective was to determine:

a. Change in the level of awareness regarding GDM as a result of the project

b. Change in the attitudes towards the importance of GDM as a result of the project

c. Change in actions taken by key stakeholders as a result of the project

The findings presented in this report are based on primary data collected from 284 respondents through a mix of focus group discussions and one-on-one interviews. The respondents were selected from amongst those identified by the project as key stakeholders. Overall, it was found that Jagran Pehel’s project has helped focus attention on GDM, and was able to solicit the positive participation of multiple stakeholder groups. Further, through its interventions, the project has also been successful in giving impetus to efforts to mainstream GDM screening.

1. Rahman MT, Tahmin T, Ferdousi S and Bela SN (2009).

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The findings are summarised as follows:

• Awareness about GDM has increased due to project interventions: The project has been successful in raising awareness about GDM across stakeholder groups. Even doctors who were already aware of GDM found the forums organised by Jagran Pehel to be a useful refresher. Overall, from the feedback received from respondents, the project has been instrumental in furthering the discussions about GDM in government circles as well as in the public domain. Circulars mandating GDM screening during ANC were released in three project states - Bihar, Jharkhand and Punjab.

• Stakeholders believe that GDM is an important issue that needs to be tackled: The project not only increased awareness about GDM, but also appears to have helped shape the attitudes of those covered by the project. Across stakeholders and locations, respondents expressed the belief that GDM is a critical issue that needs to be addressed. Further, a majority of the stakeholders attributed this belief to the information they received through forums/orientation sessions organised by Jagran Pehel, GDM related media coverage by the Jagran Group, and ICT material developed by Jagran Pehel.

• ICT campaigns and media coverage are critical in spreading awareness: The recall value of the ICT interventions in particular was seen to be high. Even though ICT intervention took place 2-3 years prior to the study, respondents cited it as one of the interventions they appreciated the most.

• GDM screening needs be strengthened: GDM screening is being carried out in the study states. In fact, notices/circulars to make GDM testing mandatory have been issued by the government authorities in three out of four of the project states. The project has played a significant role in giving impetus to implementation of screening measures on the ground.

Though efforts to incorporate GDM screening into the public health system have been initiated, there is scope for strengthening the system further. Constraints such as the availability of testing equipment and difficulty in ensuring pregnant women come for timely check-ups pose challenges in implementation. In this scenario, Jagran Pehel’s project plays an important part in ensuring that GDM stays on the agenda of state governments.

• Periodic engagement with stakeholders is important: The respondents were appreciative of the initiatives undertaken by Jagran Pehel and felt that they need to be continued. In particular, respondents felt that the media coverage should be repeated at regular intervals to reinforce the message. Similarly, civil society respondents felt that Jagran Pehel should engage with stakeholders on regular basis.

• High potential for Jagran Pehel to build a strong brand image: Jagran Pehel’s project on GDM has created visibility for them as an organisation, especially amongst bureaucrats and the civil society. However, scope to improve recall

among other stakeholders, especially field level health workers remains.

In conclusion, it was found that Jagran Pehel’s project has been successful in generating interest and fostering discussions around GDM. Further, the project has performed commendably against most of the parameters that have been assessed in the study. There are some areas, however, in which the project can be further strengthened. The following recommendations emerged from interactions with the key stakeholders:

• Communication with stakeholders: Interaction with most stakeholders was only a one-time activity; there is a need to establish regular and frequent communication with these stakeholders so as to keep them engaged and reinforce change in attitudes and actions.

• Strengthen adherence to screening protocols: It was found that screening protocols vary, and/or are not being followed stringently on the ground. This reduces the chance of successful detection of GDM. Advocacy efforts are needed to reduce discrepancies regarding testing by ensuring GDM screening is done as per laid down procedures.

• Direct interaction with the community: To ensure that GDM screening is carried out, demand needs to be created by raising awareness among pregnant women and their families. Therefore, it is suggested the project target pregnant women and their care-givers as well.

• Customisation of GDM interventions: The interventions, especially media campaign need to be tailored to the local context. For instance, in Jharkhand, stakeholders reported low instances of institutional deliveries due to superstitions and tendency to follow traditional delivery practices. Therefore, it becomes pertinent that interventions consider these cultural considerations. Further, for states like Jharkhand, IEC material should be in local dialects, especially in Jharkhand.

• Strengthen GDM reporting: There is no formal mechanism for tracking GDM cases. Hence, further policy advocacy efforts are needed to strengthen the GDM documentation and tracking mechanisms.

• Wider distribution of IEC material: Respondents found the IEC material and handbooks prepared by Jagran Pehel useful and informative. Some respondents requested that the IEC material be made available at government health institutions like PHCs and pathology labs where blood sugar tests are conducted.

• Strengthen orientations for ASHAs and ANMs: Respondents identified field level health workers as key in generating awareness and ensuring pregnant women have themselves screened for GDM during ANC visits. Therefore, orientation session for ASHAs and ANMs should be continued. Further, refresher courses would be useful in ensuring that the ASHAs and ANMs are well versed about symptoms, causes, management and screening of GDM

• Branding: While there was recognition of Jagran Pehel’s efforts amongst government stakeholders, there is a need to strengthen the branding during ASHA’s and ANM’s orientation sessions.

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Section 1 Context and overview of Jagran Pehel’s project

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1.1 Context

India is presently home to 62 million diabetics with significant prevalence in both the rural (34 million) and urban areas (28 million)2. The disease has reached epidemic proportions and the number of people affected is expected to cross the 100 million3 mark by 2030. Amongst other factors such as genetic predisposition, sedentary lifestyle and obesity, the increasing incidence of diabetes, especially amongst women in the child bearing age group, can also be partly attributed to Gestational Diabetes Mellitus (GDM)4. GDM is a condition in which women not previously diagnosed with diabetes exhibit high blood glucose levels during pregnancy.

Though it is not as widely known as other predisposing factors to diabetes, GDM can increase the risk of both mother and child developing diabetes later in life. Studies show that women with GDM have a 34 per cent higher chance of developing diabetes within 10 years of the pregnancy, while the risk of the child developing diabetes increases almost 6 fold5. Furthermore, offspring born to mothers with untreated gestational diabetes are at increased risk of excessive birth weight, early birth, respiratory distress syndrome – a condition that makes breathing difficult, low blood sugar (hypoglycemia), and jaundice. Mothers with GDM are also at increased risk of high blood pressure, preeclampsia and eclampsia6.

Research conducted in 2004-05 by Dr. V. Seshiah in Tamil Nadu found that while the overall prevalence of GDM was 13.9 per cent7, risks associated with GDM can be minimised if it is managed properly during pregnancy. As 40 to 60 per cent8 of women with GDM do not demonstrate any risk factors, it becomes pertinent to advocate screening (measuring blood glucose level) of all pregnant women for GDM.

It is in this context that Jagran Pehel undertook interventions aimed at mainstreaming GDM in the public health system. Jagran Pehel’s interventions were a mix of awareness and advocacy efforts carried out in four states – Delhi, Punjab, Bihar and Jharkhand.

The South-East Asian population is genetically different from American and European population; South East Asians have different BMI (Body mass Index) and visceral fat, hence the tests used in U.S. and Europe for detecting diabetes cannot be used in India. Therefore in 2010, DIPSI (Diabetes in Pregnancy Study Group India) issued protocols called DIPSI guidelines to test GDM in Indian women. The DIPSI guidelines were later approved by WHO for GDM testing in the Indian sub-continent.

- Dr. Anand (Diabetologist in Patna)

2. Website of Certificate Course on Evidence based Diabetes Management. Available at: http://ccebdm.org/news.php

3. ibid

4. Dabelea D, Hanson R L, Lindsay R S, et al. (2008)

5. As quoted by Dr Anand, diabetologist in Patna

6. Website of Not-for profit Clinic in USA. Avaliable at: http://www.mayoclinic.org/diseases-conditions/gestational-diabetes/basics/complications/con-20014854

7. Website of Jagran Pehel. Available at: http://www.jagranpehel.com/ContentPages/Programs/ProjectDetails.aspx?programId=1&projectId=41

8. Rahman MT, Tahmin T, Ferdousi S and Bela SN (2009).

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1.2 Project overview

Jagran Pehel’s GDM related interventions stemmed from an earlier diabetes awareness campaign carried out by them. Through their experience of implementing this nationwide campaign, the Jagran Pehel team came to recognise GDM as an important issue that needed to be addressed. However, in the context of existing maternal and child health scenario in India, GDM comparatively has a low priority level in the public health delivery system.

To focus attention on GDM, its early diagnosis and management, Jagran Pehel felt that a more intensive, issue-specific campaign was required. This campaign would also focus on integrating GDM as an integral component of the government public health system. In order to do this, Jagran Pehel launched a nationwide awareness campaign in 2010-2011 entitled “A Multi Media Approach for Awareness Generation on Gestational Diabetes and its Management in Selected Districts of India.”

The campaign built an environment for mainstreaming GDM in the government maternal and child health programme by:

• Creating awareness amongst the general public and key stakeholders about GDM and its causes, care and management through the use of various communication channels. This included the use of wall paintings, radio jingles, SMS, articles in print media, IEC equipped vans, and even a micro-site (www.onlymyhealth.com).

• Educating future mothers, i.e. high school and college going adolescent girls and women, on GDM so that they can act as peer educators within their community

• Advocating for the adoption of GDM screening as a component in the public health delivery system through multi-stakeholder forums at the district, state and national levels. An important issue discussed in these forums was the adoption of a standard screening protocol for GDM.

In order to take these initiatives forward, there was a need for technical support in capacity building of key stakeholders, and streamlining of systems and procedures for GDM screening. Therefore, Jagran Pehel decided to follow up the multimedia campaign with a project entitled “Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System”. This project was launched in four states: Delhi, Punjab, Bihar and Jharkhand with the following objectives:

• Follow-up with key stakeholders at the state level on previous commitments regarding GDM protocols being implemented in their states

• Sensitise and orient state level health service providers to facilitate effective implementation of government initiatives for mainstreaming GDM.

The key stakeholders identified in Jagran Pehel’s project – Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System are as follows:

• Elected representatives and bureaucrats who agreed to policy level incorporation of GDM related issues in the public health system of their states.

• Professional bodies like IMA and FOGSI who are extending health services to the community through their members or in association with the public health delivery system. These associations can act as advocates within and beyond their peers

• Field level health workers, such as ASHAs and ANMs, who are at the forefront of the public health delivery system. The project aimed at providing these health workers with relevant information regarding GDM

• Media Professionals from respective states.

Jagran Pehel engaged these stakeholders through a number of initiatives which included:

• Meetings with elected representatives for the purpose of advocacy

• Sensitisation of government officials/bureaucrats like civil surgeons, MOICs and other government doctors on GDM

• Sensitisation of non-government doctors working in private hospitals and professional associations like IMA and FOGSI

• Orientation of frontline health workers- ASHAs and ANMs - on GDM through sessions conducted in government health care institutions such as PHCs. These orientation sessions were focussed on creating awareness about GDM and motivating ASHAs and ANMs to get pregnant women in their assigned areas screened for GDM.

These initiatives were successful in raising the profile of the GDM and in engaging key decision makers from the government. For example, the forums were attended by Members of Parliament and Members of State Legislative Assemblies; Ministers of Health and Family Welfare (centre and state); bureaucrats; doctors (both government and non-government); civil society organisations, etc. As a result of these efforts, three of four project states have issued official orders and circulars to make GDM screening mandatory during ANC.

As per one of the respondents, the best aspect of the project is focus on frontline workers (ASHAs, ANMs and doctors in PHCs) as these people work on the grassroots and are the first point of contact for the women/patients.

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The project “Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System” was implemented using multi-stakeholder approach. This approach brought together key government and non-government stakeholders whose involvement in the project was crucial for successfully mainstreaming GDM in the public health system. These stakeholders included: State government health departments; CSOs like Indian Medical Association, Lions Club and Rotary International; and public and private healthcare institutions. The project was funded by World Diabetes Foundation (WDF) and technical support was provided by Medanta.

The intention of Jagran Pehel was not to create alternative systems and institutions for service delivery, but to strengthen existing systems. Therefore, the project’s interventions were delivered in close association with these stakeholders, especially the state government health authorities, with each stakeholder expected to play a clearly defined role in mainstreaming the efforts. Based on the identified roles, specific interventions were designed for specific stakeholders. These interventions focus on both awareness generation and advocacy. This model has been depicted below in Figure 1.

Stakeholder Expected Role Project Intervention

PartnersWorld Diabetes Forum Donor

Medanta Technical support

Advocacy

Elected Representatives • Make commitments for policy change to mainstream GDM in public health

• Advocacy meetings with elected representatives

• National level forums

• State level forums

• Discussions with doctors

• Engaging doctors as trainers

Bureaucrats • Ensure availability of medical supplies for GDM screening

• Releasing doctors for training

• Support the orientation of ASHAs and ANMs

Civil Society Organisations • Create awareness among their members/communities about GDM

Awareness

Doctors • Counselling pregnant women about GDM

• Recommending GDM screening

• Ensuring that ASHAs and ANMs are released for orientation on GDM

ASHAs • Inform community, in their area of operation, about GDM – its causes, symptoms & risks

• Motivate pregnant women to get tested and ensure that they go for counselling

• GDM orientation sessions for ASHAs and ANMs

• Distribution of GDM information kits

• Motivating ASHAs & ANMs to spread awareness amongst their communityANMs • Support efforts in increasing

awareness among the community

• Carry out field tests using glucometers

• Provide counselling services

Media personnel • Publish articles about GDM in print media

• Involve in GDM forums

1.3 Implementation model

Figure 1: Multi-stakeholder implementation model

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Interactions with project stakeholders

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1.4 Feedback from project partners

Feedback from WDF

World Diabetes Forum Foundation (WDF), the funding agency for the project, commended the Jagran Pehel team on their skills, efficiency and day-to-day management of the project. The monitoring and progress reports in particular were found to be well-written and satisfactory. Further, the WDF representative provided the following inputs on the project design:

• Ensure a strong focus on the postpartum period as well.

• Undertake follow-up on the distribution of IEC materials to see if they were actually used as intended.

My experience is that it is a well-run project with a highly qualified, professional and committed project team. The advocacy meeting and training session I participated in were well planned and executed.

- Karoline Kragelund Nielsen, WDF

Feedback from Medanta

Medanta was designated as the technical partner for the Jagran Pehel’s project. The team, headed by renowned endocrinologist Dr. Ambrish Mithal , played a vital role in conducting ‘training the trainer’ sessions with local doctors, informing the wider stakeholder group about GDM during the forums, creating relevant diet charts and translating IEC material into Hindi. Everybody in the team opined that they received the most enthusiastic response in Jharkhand from amongst the four project states. The team was of the opinion that though the project was well structured and managed, there was no subsequent communication from the Jagran Pehel on the follow-up and progress of the project.

Detailed feedback from the Medanta team is provided below:

Dr. Ambrish Mittal stated that the programme implemented by Jagran Pehel was well intentioned and targeted at making a difference to a section of community that is extremely vulnerable viz. pregnant women and new born children. He attributed the success of the project to the ability of the Jagran group to get buy-in from varied stakeholders and bringing them on one platform through the national and state level forums.

His recommendations regarding the projects are as follows:

• Quantification of the impact is of paramount importance so as to evaluate whether the intervention has really made change. In retrospect, it would have been ideal if baseline data was collected to provide reference points for measurement of outcomes.

• Further, since so much effort has gone into the planning and execution of the project, follow-up to build on the current achievements would be desirable.

• He also suggested that the project should now continue with specific targets focussing on smaller geographic areas and aim towards ensuring 100per cent GDM screening in those areas.

Dr. Beena Bansal made the following observations:

• Since GDM is a lesser known public health problem, it does not get as much focus as other conditions like anemia, hypertension, etc.

• TOT was only an empirical guideline. There is a need to create awareness beyond these guidelines. People at the community level need to be aware of the levels of blood sugar beyond which the mother and child are affected.

• Ideally a change in public health system should be aimed at ensuring GDM screening as a mandatory test during ANCs.

Dr. Jasjeet S Wasir was of the opinion that:

• Constructing a parallel system to the existing public health system has not been found to be effective in the past. Ideally new interventions should piggyback on existing projects and work in synergy with the existing system.

• ASHA/ANMs should know about GDM as they have close relationship with patients and patients need somebody to handhold and advise them correctly throughout the process.

• Bureaucrats play a critical role in the delivery and sustainability of an intervention.

Dr. Pooja Sharma opined that:

• It is important to prioritise GDM when there are limited funds as it affects two lives. The tag line of the programme was designed to reflect this – “Ek janch se bache do jaan”.

• Blood test should be ideally conducted during all three ANCs. If this is not possible, then at least one test should be conducted at the 24th week ideally.

• Awareness is the most important factor in detecting GDM. If media is working for disseminating positive information, it should be covered on the first page.

• Positive messages need to be reinforced regularly, like having a regular column in the newspaper on diabetes so as to enhance recall value.

• Other channels, in addition to, ASHAs and ANMs should be used for spreading awareness regarding GDM as ASHAs and ANMs are the focal points of many other interventions and may not be able to prioritise GDM.

Ms. Sweta Singh made the following observations:

• Received enthusiastic response for the workshops.

• Participants liked the interactive nature of the workshops.

• A campaign mode, similar to the polio programme is necessary to ensure 100 per cent GDM screening.

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© 2014 KPMG, an Indian Registered Partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.

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Section 2 Study design

2.1 Objective of the assignment

KPMG’s Development Sector Practice (DSP), was engaged by Jagran Pehel to assess the performance of the “Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System” project. The objective was to assess the change Jagran Pehel’s project has had on the awareness, attitudes and practices of key stakeholders; specifically the aim was to assess:

a. The role played by the project in changing levels of awareness regarding GDM across stakeholders including government and non-government doctors, field level health workers, bureaucrats, elected representatives and media personnel;

b. The role played by the project in changing perceptions/attitude of stakeholders regarding the importance of GDM; and

c. The role played by the project in mainstreaming GDM screening in the public health delivery system.

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2.2 Approach and methodology

To assess project performance, KPMG conducted a qualitative dipstick assessment in all four project states using a KAP (Knowledge-Attitude-Practice) methodology as depicted in Figure 2.

Figure 2: Methodology

Phase 1: Preparatory phase

Review of project documents and secondary literature

In order to understand the nuances of the project and its intended outputs, the KPMG team reviewed project related documents, including the project proposal, progress reports and various materials developed by Jagran Pehel. Simultaneously, the team also reviewed available secondary literature regarding GDM to gain an understanding of the context in which the project was being implemented.

Stakeholder mapping

An inception meeting was held with the Jagran Pehel team to define the boundaries of the study and identify the stakeholders to be consulted. Based on this discussion, as well as observations made during the data collection phase, the stakeholders were grouped into two broad groups: government and Non-government. There was some overlap in the case of doctors because the project reached out to both government and non-government

doctors. Further amongst government doctors, some have pure administrative responsibility, while others deliver clinical services to patients. With this in mind, doctors were classified as follows:

• Government doctors at the level of Medical Officer in Charge (MOIC) and below, who have both administrative and clinical role have been classified as Doctors. This group also includes doctors working with government medical colleges

• Government doctors who have a purely administrative role and are at the level of civil surgeon/chief medical officer have been classified as bureaucrats

• Non-government doctors have been classified under CSOs (Civil Society Organisations). This is because most of the private doctors participated in the project as representatives of various medical associations such as IMA and FOGSI.

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The detailed definition of stakeholder groups is provided below:

Elected Representatives

Central and State level elected representatives who were in office at the time of the GDM project and were covered by the project

Bureaucrats Senior health administrators, including government doctors who carried out a purely administrative role and were in office during the implementation of the GDM project & were involved in the project

Doctors Government doctors who had clinical role and participated in Jagran Pehel’s GDM forums or those involved in orienting ASHAs and ANMs on GDM

Field Health Workers

ASHAs and ANMs who participated in GDM orientation organised by Jagran Pehel

Civil Society Organisations

Professional medical associations and other NGOs that participated in the GDM workshop organised by Jagran Pehel

Media Reporters

Media personnel who reported on the GDM programme

Community Women

Women from communities, in areas assigned to ASHAs who were oriented on GDM as part of the project

Sampling

The qualitative dipstick study was undertaken in all four project states with respondents being identified based on purposive sampling. Purposive sampling is a type of non-probability sampling wherein the sample is determined with a particular purpose in mind. This type of sampling is best suited when the study intends to cover individuals with a particular characteristic/trait.

In this particular study, the intent was to determine the change in knowledge, perceptions and actions of individuals the project had reached out to. Therefore the study sample only includes individuals who had been covered, either directly or indirectly by the project.

A total sample size of 250 was decided upon for the study, in consultation with Jagran Pehel. Table 1 gives a break-up of the proposed target sample by stakeholder type:

Table 1: Study sample size

Stakeholder Number

ASHAs70 (10% of those whose orientation has been monitored)

ANMs 25 (10% of those whose orientation has been monitored)

Community Women

85 (included as indirect stakeholders)

Doctors 20 (5 from each state)

Bureaucrats 10 (2-3 from each state)

Elected representatives

5 (1-2 from each state)

Civil Society Organisations

30

Media Personnel

5

Total 250

Gove

rnm

ent

Non

-Gov

ernm

ent

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Phase 2: Data collection

Designing data collection tools and guidelines

Questionnaires, focus group discussion guidelines and interview guidelines were developed for each stakeholder group based on the specific project interventions they were exposed to. The questionnaires were structured based on the role the stakeholder was expected to play in mainstreaming GDM. These questionnaires were designed to cover all three dimensions of the study, viz. knowledge, attitudes and practices of the stakeholders. In addition, the questionnaires also tested whether the individual stakeholder was aware of the information source. That is, were stakeholders able to recall that Jagran Pehel was responsible for the interventions?

The questionnaires for ASHAs and ANMs were refined based on a pre-test carried out in Delhi. Details of the pre-test have been included in the annexure. The questionnaires and FGD guidelines used for data collection are provided in Annexure 3: Data collection tools.

Stakeholder consultations

Table 2 provides a break up of actual respondents covered per state. For ASHAs, ANMs and community women, focus group discussions were held. For the remaining stakeholders, viz. bureaucrats, doctors, CSOs, media personnel and the elected representatives, one-on-one interviews were conducted.

Overall, the KPMG team was able to interact with 284 respondents as against the target of 250. However, due to considerations outside the control of both Jagran Pehel and the KPMG team, only one respondent from the elected representatives’ category could be interviewed.

Table 2: Break-up of respondents

Punjab Delhi Bihar Jharkhand Total

ASHAs 18 20 30 30 98

ANMs 18 5 11 5 39

Community women 13 29 32 10 84

Doctors 10 5* 3 2 20

Bureaucrats 2 3* 2 9 16

Elected representatives - - - 1* 1

Civil society organisations 4 6* 6 3 19

Media personnel 2 2 1 2* 7

Total 67 70 85 62 284

* Consent letters not available for 7 out of 284 respondents

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Phase 3: Analysis and report writing

The study was designed to assess the effectiveness of the project at three levels, as defined in the hierarchy-of-effects model presented in the Figure 3.

Figure 3: Hierarchy-of-effect

Also known as Knowledge-Attitude-Practice (KAP) methodology, this is a means of measuring changes in behaviour and knowledge caused by a specific outreach intervention. KAP studies are particularly popular in measuring changes in behaviour and attitudes relating to health.

The focus of KAP studies on attitudes and practices is useful as knowledge by itself doesn’t necessarily translate to a change in action. Assessing what stakeholders ‘feel’ about the issue reveals attitudes, beliefs, and at times misconceptions that prevent knowledge from being put into practice. Further, information on actual practice gives a definitive understanding of what concrete actions have resulted from the intervention.

For the purpose of data collection, the boundary of the three levels was defined in Table 3. A score card was developed to allow for qualitative assessment of the project on the parameters defined in Table 3. The detailed scorecard has been reproduced in the following subsection. This report presents the findings of the study as per these 3 dimensions, viz. knowledge, attitudes, and practice.

Table 3: Dimensions of the study

Dimension Definition

Knowledge

• Do respondents know about Diabetes• Have respondents heard about the term ‘GDM’• Can respondents describe ‘GDM’• Are respondents aware about the symptoms of GDM, its risks, the tests required to diagnose GDM &

the steps to control/manage GDM

Recall of brand

• Can respondents identify the project coordinator • Can respondents identify the logos of the programme – Jagran Pehel & World Diabetes Foundation• Can respondents associate orientation/training programmes & advocacy forums with the Jagran

Group • Can respondents associate these interventions with Jagran Pehel

Attitude

• Do respondents feel GDM is a critical issue that effects both the mother and the baby• Do respondents feel actions need to be taken to address GDM• Would respondents recommend blood sugar test during pregnancy• Would women respondents get themselves and pregnant women in their families tested for GDM

Practice Actions undertaken by the respondents after being informed about GDM through the project. The actions expected from each respondent group are defined below:

Elected representatives • Make commitments for policy change to mainstream GDM in public health

Bureaucrats• Ensure availability of medical supplies for GDM screening• Release doctors for training• Support the orientation of ASHAs and ANMs

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Dimension Definition

Doctors• Counselling pregnant women about GDM• Recommending GDM screening• Ensuring that ASHAs & ANMs are released for GDM orientations

ASHAs/ANMs• Inform community in their region about GDM – its causes, symptoms & risks• Motivate women to get tested & ensure they go for counselling

Civil society organisations • Create awareness among their members/communities about GDM

Media personnel • Publish articles about GDM in print media

Community women • Undertake blood sugar testing during pregnancy and recommend the test to other pregnant women

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2.3 KAP scorecard

The change in knowledge, attitude and practice regarding GDM, because of the project- Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System, would be assessed using following score card.

Evaluation criteria

Grading

0 1 2 3 4 5

Knowledge

Respondents are unaware of GDM and its details

Respondents have heard the term GDM but don’t know details like effects of GDM or when to get tested

Respondents only know minimal details regarding GDM

Respondents know about GDM and knowledge can be partially attributed to Jagran Pehel

Respondents know about GDM and its details and the knowledge can largely be attributed to Jagran Pehel

Respondents know about GDM and its details and this knowledge can be fully attributed to GDM

Attitude

Respondents feel that GDM is not of critical importance

Respondents feel that GDM is somewhat important but feel that no action needs to be taken

Respondents feel that GDM is important but do not feel that immediate action needs to be taken

Respondents feel GDM is important and are willing to take some action

Respondents feel GDM is critical, are willing to take some action, and would recommend screening to others

Respondents feel GDM is critical & would strongly recommend blood sugar testing during pregnancy

Practice

Respondents have taken no action related to GDM

Respondents have taken limited action but this cannot be attributed to the project

Respondents have taken limited action which is minimally attributable to the project

Respondents have taken action and this can be partially attributed to the project

Respondents have taken action and this can be largely attributed to the project

Respondents take action and this can be fully attributed to the project;recommend blood sugar testing during pregnancy to others

Limitations of the study

The findings reported in the next section are subject to the limitations as described below:

• The scope of the assignment is limited to assessing the performance of the project and providing recommendations for its improvement, if any.

• The study is a qualitative dipstick assessment that was limited to capturing broad changes in the knowledge, attitude and practice of the key stakeholders post the intervention

• Respondents were selected from one district per project state. Hence, it is possible that the findings may not apply across all districts of the state.

• Limited respondents were available from two of the stakeholder groups, viz. CSOs and elected representatives, due to factors outside the control of Jagran Pehel or the KPMG team.

• As baseline data is not available, change in levels of knowledge, attitudes and perception of stakeholders has been attributed based on ‘before-after’ questions.

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Section 3 Study findings and discussions

Overall Jagran Pehel’s project appears to have been successful in providing impetus to mainstream GDM in the public health system. The project has reached out to a wide range of stakeholders including key decision makers such as elected representatives and officials in state health departments. Mr. Ghulam Nabi Azad, then Cabinet Minister for Health and Family Welfare participated in the national forum organised by Jagran Pehel.

The positive impact of the project has not been limited just to its reach; it has also been able to create real change on the ground. An area where the impact of the project is highly visible is in the attitudes of stakeholders towards GDM. Across respondents, there was a belief that GDM is a serious issue that needs to be addressed as a priority. Even in terms of change in knowledge and actions, the project has resulted in significant change, with its interventions being received favourably by all stakeholder groups.

This section provides the detailed findings of the change in levels of Knowledge-Attitude-Practice amongst key stakeholders, across the four project states. The change is measured with the help of a score card previously described in section 3. The score card rates the change on three parameters – awareness regarding the message (knowledge), change in beliefs of the respondent (attitude) and actions taken by the respondent (practice) as result of the awareness/knowledge provided through the project. Detailed stakeholder-wise and state-wise scorecards are provided in annexure 1.

Of the key stakeholders identified in Section 3, the findings in the subsections cover the responses of bureaucrats, doctors, field level health workers (ASHAs & ANMs), CSOs, and media personnel. The only other direct stakeholders targeted by the project were elected representatives. Unfortunately due to constraints beyond the control of Jagran Pehel and the KPMG team, only one elected representative was available for an interview from the four project States. As a result, it is not possible to comment on the knowledge, attitudes and practices of this stakeholder group.

The KPMG team also interacted with community women though these women were not directly targeted by any of the project interventions. However, being the ultimate beneficiaries living in areas covered by ASHAs and ANMs, FGDs were conducted with these community women.

The FGDs with women in the community revealed that they were not aware about GDM and only partially aware of diabetes. However, in most cases, they were aware of the importance of going for all ANCs and reported doing so. Some of the respondents were also able to name some of the tests carried out at the ANC. In one case in Bihar, one of the pregnant women interviewed recalled having had a blood sugar test as part of her ANC.

Findings of the interactions with the other stakeholder groups are presented below:

FGD with women - Jharkhand

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3.1 Changes in awareness and knowledge levels

This parameter assesses the change in levels of knowledge related to GDM by evaluating if stakeholders are able recall the information provided by Jagran Pehel.

The information provided by Jagran Pehel varied for stakeholder categories based on the role specific stakeholders were expected to play in mainstreaming GDM. For example, as doctors have clinical knowledge about GDM, Jagran Pehel did not focus on educating them about the disease. Hence, doctors were invited to forums where the importance of screening and the appropriate protocols for screening and management were discussed. Conversely field level health workers were trained on the details of GDM, including its causes, symptoms, and screening. Accordingly, the questionnaires differed according to the stakeholder category interviewed.

An important consideration with regards to change in knowledge is whether the stakeholder’s change in awareness/knowledge can be attributed to Jagran Pehel’s interventions or not. Knowledge about GDM obtained through sources other than Jagran Pehel is not relevant to this study. Keeping this in mind, the scores given for this parameter account for whether the knowledge of stakeholders is due to the message provided by Jagran Pehel or otherwise.

* As there was only one respondent from the stakeholder group Media Personnel in Bihar and the respondent was not directly linked with project, the response has been excluded from the study.

Figure 4: Project performance: change in knowledge

Figure 4 provides a snapshot of the performance of the project in changing the level of knowledge of key stakeholders in all four states. On a scale of zero to five (with zero representing no knowledge of GDM and 5 representing good understanding of GDM commensurate with the role of the stakeholder), it is seen that the project has been able to ensure a fair understanding of GDM amongst most stakeholder groups.

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3.1.1 Field level health workers

The project’s performance is particularly commendable when we examine the change in knowledge of ASHAs. Given that most ASHAs reported not knowing about GDM at all before Jagran Pehel’s interventions, the project’s performance has been praise worthy. This means that a majority of the ASHAs interviewed were aware of GDM due to the efforts of the Jagran Pehel project. In fact in Bihar and Jharkhand ASHAs were able to answer nearly all the questions related to GDM. Hence, the project’s performance was rated high in terms of change created in knowledge levels in these states.

It should be noted that in the case of Bihar, a GDM refresher course was held one week before interviews were conducted. Similarly in Jharkhand, the first orientation was held approximately three weeks before the interviews. By comparison, orientations in Delhi and Punjab were held two to three months before the interviews.

As a result in Punjab and Delhi, where an average score has been given, knowledge was found to be incomplete. For example, some ASHAs in Delhi claimed sugar test for GDM should be conducted in the 4-12 week of pregnancy9. On further enquiry it was found out that test being indicated was urine sugar test rather than blood sugar. The NRHM protocol during ANC mandate that urine sugar examination is done at 12th week of pregnancy. It seems that the ASHAs are under the impression that this test is adequate for the detection of GDM.

Based on this observation, it is pertinent to mention that regular refresher courses definitely play an important role in reinforcing the message and facilitating knowledge gain. In fact, the need for refresher trainings was a common comment made by both ASHAs and ANMs in all project states.

In contrast to ASHAs, ANMs appeared to be fairly knowledgeable regarding GDM. However, as the ANMs reported receiving information on GDM during their training as nurses, their knowledge cannot be fully attributed to the project.

For instance, in Punjab and Bihar, though the ANMs were fairly well versed on GDM, the project’s effect on change in knowledge has been considered average rather than high as the knowledge cannot be attributed solely to Jagran Pehel. Similarly, in Jharkhand, most of the ANMs knew about GDM and the quality of knowledge was also high, however, factoring in attribution the project performance is rated as high rather than very high.

Despite the questions of attribution, there is no doubt that the information provided through the project acted as a refresher for the ANMs.

ANMs in Delhi while aware of GDM, seemed to have incorrect/incomplete knowledge in terms of its details. For example, similar to ASHAs they stated that GDM testing should be carried out during the 12th week of pregnancy. Also, as the knowledge regarding GDM cannot be fully attributed to Jagran Pehel, the project’s performance has been rated lower in this state.

As a whole, the project appears to have increased the awareness of field level health workers. Periodic refresher courses may help in improving knowledge even further, and doing away with any misconceptions.

9. In Delhi, the MOIC stated that urine sugar levels are tested during 4-12 weeks of pregnancy as per NRHM guidelines. These tests are conducted to identify pregnant women with undetected type-II diabetes and not GDM.

An ANM in Jharkhand stated that, ‘We knew about GDM but weren’t consciously thinking about it. Training (conducted by Jagran Pehel) brought GDM to forefront and was a refresher’.

Interaction with ASHAs and ANMs - Punjab

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3.1.2 Bureaucrats

As defined in Section 3, bureaucrats are senior government doctors who perform an administrative role, e.g. Chief Medical Officers (CMO) or Civil Surgeons (CS). Bureaucrats interviewed in all four states were aware of GDM, its causes, symptoms, effects, and control. However, as they are trained doctors, it is difficult to solely attribute their level of knowledge to Jagran Pehel’s project. Nevertheless, it does appear that the project acted as a refresher course for them and helped focus attention on GDM as a condition that needed to be tackled separately from general diabetes and the National Non Communicable Disease (NCD) programmes.

Further, the national, and state level forums conducted by Jagran Pehel helped arrive at a consensus regarding the protocol for GDM screening. Thus, even among this stakeholder group, Jagran Pehel’s project played an important role in knowledge generation by helping build a shared understanding. Indeed, across all States, the project has performed fairly well.

3.1.3 Doctors

Most of the doctors, as expected, were well versed with matters related to GDM, its causes, symptoms, control, testing protocols and prevention measures. With this stakeholder group it would be incorrect to attribute knowledge regarding GDM to Jagran Pehel’s intervention. There are, however some exceptions:

• First, some of the doctors interviewed conceded that while they were aware of GDM before the intervention, they found the forums to be a useful refresher. They especially appreciated the discussions around forming standard GDM screening protocols

• Secondly, the forums were attended by doctors from across specialisations including medical associations like IMA (for example, ENT, plastic surgeon etc.)

Therefore, it can be said that the project performed moderately well in all project states. Further, in Bihar, the project’s performance has been rated slightly higher as some of the respondents explicitly credited Jagran Pehel with contributing to an increased understanding regarding GDM.

We (State Health Society) were working on GDM since 2011, but Jagran helped in intensifying the effort and spreading awareness across a wide spectrum of stakeholders.

- A bureaucrat from Bihar

Interaction with Doctors - Punjab

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3.1.4 Civil society organisations (CSO)

For this stakeholder group, levels of GDM related awareness/knowledge can only be partially attributed to Jagran Pehel’s project. This is because the majority of CSO respondents are doctors from medical associations such as the Indian Medical Association (IMA) and the Federation of Obstetric and Gynaecological Societies of India (FOGSI). As a result, they are already well versed about the details of GDM and its management.

However, for a few respondents who were not doctors, the knowledge on GDM provided through the project was new. Further, some of the doctors from IMA and FOGSI reported that the GDM forums delivered a more nuanced understanding of the topic. Keeping these factors in mind, the project can be said to have performed moderately well in the project States, as elaborated below:

• In Punjab, CSO respondents were from medical associations and were extremely well informed about GDM. As this cannot be attributed to Jagran Pehel, the project’s performance has been rated slightly lower.

• Similarly, in Delhi, those with good knowledge of GDM knew about the disease prior to the project, whereas those with low levels of knowledge did not show significant change in knowledge despite attending forums organised by Jagran Pehel.

• In Bihar while some of the CSO respondents were not doctors, they still seemed to be aware of GDM and appeared to have gained the knowledge independent of the project. For instance, one of the respondents was part of a joint DFID – UNICEF initiative to develop a national GDM testing protocol; however, he was not aware of Jagran Pehel’s efforts.

• Finally, in Jharkhand where project performance was relatively better, some respondents were doctors while others were from NGOs, like Humanity, NBJK (Nav Bharat Jagriti Kendra). Both stakeholder groups displayed a reasonable degree of knowledge about GDM and attributed this knowledge to the forums conducted by Jagran Pehel.

3.1.5 Media personnel

The response received from media personnel depended on whether the respondents were reporters who regularly covered issues related to healthcare or otherwise. In Punjab, for example, the journalist from Dainik Jagran was assigned to cover health related stories. He, therefore, had a greater understanding of GDM and played a significant role in implementing the project in Punjab. Due to this, the performance of the project is very high in the state.

However, while the reporters available for interview in Delhi & Jharkhand covered events such as the GDM forums, they were not as well versed with the details of GDM. Hence, the project’s performance amongst journalists in Delhi and Jharkhand is rated as marginally lower than that in Punjab.

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3.2 Changes in Attitudes Regarding GDM

Change in attitudes was assessed based on whether respondents expressed the belief that GDM is a critical issue. Additionally, respondents were asked if they felt they had a role to play in mainstreaming GDM screening; and whether they would have themselves screened/recommended screening for pregnant women.

Overwhelmingly, respondents from all stakeholder groups reported the belief that GDM was a critical issue that needed to be addressed on a priority basis. Further, these respondents also felt that screening pregnant women for GDM was important. This can be seen from figure 5 which provides a snapshot of the project’s performance.

The main reasons given for this belief included: the severe effects GDM can have on both mother and child; the long term harmful effects if GDM is untreated; the fact that diabetes is a silent killer.

* As there was only one respondent from the stakeholder group Media Personnel in Bihar and the respondent was not directly linked with project, the response has been excluded from the study.

Figure 5: Project performance: change in attitudes

An MOIC stated that, “There has not been much focus on GDM as compared to diseases like polio and TB. After Jagran Pehel’s intervention there is more discussion and focus on GDM.

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In addition to believing that GDM is a critical issue, the stakeholders also felt they could play a role in the process of mainstreaming GDM in the public health process. Specifically the following was observed during the field visits conducted by the KPMG team:

• ASHAs in all states claimed that their role was to spread awareness, and to motivate pregnant women to get screened for GDM. They were clear that the screening itself was to be done by doctors. ASHA’s role was thus limited to awareness and referral.

• The ANMs conceded that ASHAs have more of a role in spreading awareness, while doctors screen and counsel patients once diagnosed. The ANMs felt they could support these activities. In particular, they could contribute to the counselling of patients; and also carry out tests in the field if glucometers were made available to them.

• The doctors interviewed felt that they could contribute as resource persons in awareness workshops/trainings of field level health workers. Additionally, they expressed willingness to take part in screening camps

• CSO respondents agreed that the most effective channel for mainstreaming GDM was to include it in the public health delivery system. They saw the role of CSOs primarily in spreading awareness and organising screening camps.

• Media personnel, including health reporters and senior officials from Dainik Jagran, felt that continued coverage of GDM along with periodic IEC campaigns were essential to mainstream GDM. Some suggested that the message should be spread through mediums with wider outreach, e.g. the back of OPD slips or bus tickets. However, they were aware that this was dependent on having a budget allocated for the same.

• Other stakeholders including the elected representatives, bureaucrats, field level health workers and CSO representatives also felt that the media has a crucial role to play in spreading awareness and educating the public.

Overall, it can be seen that the interventions undertaken by Jagran Pehel did help raise the profile GDM and contribute to the sense that it is a condition separate from diabetes. Due to this, a very high score has been given nearly universally to all stakeholders in all states. The one outlier is in the case of media personnel in Bihar. However, this is based on only one response from a reporter who was not fully engaged with the project. As other reporters were not available for interview at the time of the field visit, the score is affected by this one response.

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3.3 Changes in practices of stakeholders

As highlighted earlier in Table 3, different stakeholders were expected to play different roles in mainstreaming GDM. The broad roles of the different stakeholders are recapped below:

• Bureaucrats – Ensure availability of medical supplies for GDM screening, release doctors for training, and support the orientation of ASHAs and ANMs

• Government doctors – Informing women about GDM, recommending GDM screening, and ensuring that ASHAs and ANMs are released for orientation on GDM

• ASHAs – Inform community in their area of operation about GDM – its causes, symptoms and risks. They motivate women to get tested and ensure that they go for counselling

• ANMs – Support efforts in increasing awareness among the community, carry out field tests using glucometers, and provide counselling

• CSOs – Create awareness among their members/communities about GDM

• Media personnel – Publish articles about GDM in print media.

The effect of Jagran Pehel’s project on activities carried out by stakeholders was assessed based on whether stakeholders reported performing their role as described above. Further, the study team took into consideration whether these actions could be attributed to Jagran Pehel’s project or not.

Figure 6 provides an overview of the project’s performance in influencing actions of stakeholders in the four project states. It can be seen that overall, the project has been successful in prompting the stakeholders to take action. A sound foundation has been built from which efforts to mainstream GDM in the public health system can be further pursued.

* As there was only one respondent from the stakeholder group Media Personnel in Bihar and the respondent was not directly linked with project, the response has been excluded from the study.

Figure 6: Project performance – change in action

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3.3.1 Field level health workers

It was observed that in all project states, both ASHAs and ANMs are undertaking adequate action related to their role with regards to GDM. These actions, however, are hindered by constraints on the ground.

For example, a common response received from the field level health workers was that women from their communities are not able to understand details about GDM, and soon forget what is told to them. Further, since sugar levels are tested during the ANC (either through urine or blood tests), the health workers often only concentrate on ensuring women go for all their ANCs.

Another constraint, reported by health workers, is that GDM screening facilities (glucometers, needles, or strips) are not always available. In addition, an ANC involves a number of tests and not all can be carried out on the same day. In fact most peripheral health centres have specific days when blood sugar tests are carried out. As a result, often pregnant women have to come to the health centre especially just to have the sugar levels tested; this reduces the chances of tests being carried out.

Overall, it is noteworthy that ASHAs and ANMs in the project states have still attempted to ensure that women are screened for GDM despite significant constraints. As a result of these efforts, the project performance in all states has been rated as moderate to high. State-wise details are provided below:

• In Punjab, field level health workers reported that as part of the ANCs, urine sugar tests are conducted during the first trimester and blood sugar tests between 24-28 weeks of pregnancy. Further, as community members in this region have a stigma related to diabetes, health workers do not inform women about GDM. Instead, they ensure women attend all ANCs, which in turn ensures that GDM screening is done. This often becomes challenging as a large part of the population is migratory, making it almost impossible for the health workers to keep track of pregnant women

• In Delhi, both ASHAs and ANMs reported that they inform women in their area about GDM and motivate them to get tested. However, screening takes place during either the first trimester or during the 12th week of pregnancy rather than between 24-28 weeks, as recommended in GDM protocols

• In Bihar, though the field health workers inform the community about diabetes in general, but do not specifically cover GDM. Further, ASHAs and ANMs reported that the peripheral health centres do not have facilities for blood sugar tests

• In Jharkhand, it was observed that ASHAs and ANMs are informing community women about GDM. Also, it appears that blood sugar tests are conducted both at the time of the first ANC and again between 24-28 weeks of pregnancy.

There are systemic problems that make screening difficult. One of women from Shahjatpur village, Jharkhand said that “Friday is the day for blood test in our PHC. I went to PHC on Friday for blood test but nobody was there”. She further stated that, “ASHA are very helpful when they go for ANC tests. If they go to PHC without ASHAs, it is difficult to get any work done

List of Tests conducted at a PHC

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3.3.2 Bureaucrats

As stated previously, the project has successfully engaged bureaucrats and prompted them to take action. All bureaucrats interviewed by the KPMG team reported that GDM screening was underway in their state/district. Additionally, it was observed that notices/circulars have been issued to ensure GDM screening during ANCs in at least three of the four project states.

It is apparent that the project has played an important role in furthering efforts of state governments and at times catalysing action. State-wise details are as follows:

• In Punjab, the project played a role in the issuance of a circular for GDM screening; though this was issued only in four districts. Bureaucrats reported that glucometers and consumables are not always available at the PHC level, and ANMs are able to perform only urine sugar tests. Due to these factors, the project is seen to have performed only moderately well in Punjab

• In Delhi, it was reported that blood sugar tests have been a part of ANCs for the past eight to ten years as mandated in the NRHM guidelines. However, the tests are not recorded in the Mother and Child Protection Card (which only mentions urine sugar tests). Further, it could not be confirmed if a separate notification on GDM screening has been issued. Thus, in Delhi too the project has performed only moderately well

• In Bihar, the State government was already working towards mainstreaming GDM before Jagran Pehel’s interventions. A committee was formed by the State Health Society to determine an appropriate protocol for GDM screening, and the Health Secretary issued a circular in 2011 to make screening mandatory. However, the KPMG team noticed that blood sugar tests were still not being conducted in the PHCs visited. The project did help strengthen the Bihar government’s efforts by creating awareness. In particular, bureaucrats appreciated Jagran Pehel’s IEC campaign and GDM forums. As a result, the impact of the project on actions of bureaucrats has been rated as moderate

• In Jharkhand, a circular to conduct GDM screening as part of ANCs was issued in 2011 by the State government health authorities. All the stakeholders, including senior bureaucrats, attributed this to Jagran Pehel’s efforts. Further, ANMs in Jharkhand have been provided with glucometers to conduct random blood sugar tests and the new Mother and Child Protection Card (Jacha Bacha Card) has a section for recording results of the tests. However credit for this cannot be given solely to Jagran Pehel’s project. The issue of glucometers was done under the central government’s Non-Communicable Disease programme; and the change in the MCH card may be because blood sugar test is now mandatory as part of RMCH+A. Nevertheless, as the issue of GDM circular was explicitly attributed to Jagran Pehel’s efforts, the project performance has got a high rating in Jharkhand with regards to the actions carried out by bureaucrats.

Mother and Child Protection Card - Jharkhand

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3.3.3 Doctors

Across all project states, the government doctors interviewed by the KPMG team reported that they recommend blood sugar tests to all pregnant women as part of the ANCs. Furthermore, doctors in medical colleges also claimed that they ensure every pregnant woman under their care is screened for GDM. However, this may not be fully attributable to Jagran Pehel’s project. There are multiple interventions delivered through the public health system which require blood sugar levels of patients to be tracked. This includes the National Rural Health Mission and the National Non Communicable Disease Programme.

Further, doctors in government set-up have not been able to ensure blood sugar tests for all ANCs because of the systemic issues like:

• Non-availability of medical supplies and equipment such as glucometers

• Unwillingness of patients to get tested for reasons like distance of the testing centre and lack of awareness regarding GDM.

However, the doctors are making genuine efforts to ensure testing at their centres. Additionally, across states, government doctors do release field health workers for GDM orientations, and some of doctors even participate as trainers. Due to this, the project has been rated high in all project states in regards to impact on practices followed by doctors.

3.3.4 Civil society organisations (CSOs)

The project reached out to a large number of CSOs, and the respondents the KPMG team interacted with were appreciative of Jagran Pehel’s interventions, particularly the GDM forums and the IEC campaign. In terms of converting this to action on the ground, some efforts have been made, but these are often by an individual member of the organisation, rather than the organisation itself. At a group level, it is unclear if these organisations are taking up the issue in a concerted manner. Some CSOs like the Indian Medical Association do hold diabetes screening camps, but these are not specifically focussed on GDM.

Further, even for those associations who are actively carrying out awareness/training workshops and screening camps, it cannot be said that these efforts are fully attributed to Jagran Pehel’s project. In fact in some cases these efforts seem to predate the project.

Private practitioners who are members of medical associations claimed that all pregnant women they treated were screened for GDM during pregnancy using the appropriate protocols. A few of these doctors had also participated as trainers for Jagran Pehel’s awareness session at schools and colleges, as well as in orientations for ASHAs/ANMs.

However, beyond the project, these doctors haven’t undertaken any specific efforts to spread awareness about GDM (with a few notable exceptions). Most of the doctors, did, however, express willingness to participate in further interventions organised by Jagran Pehel.

For example, in Punjab and Bihar, respondents displayed keen interest in being involved in further efforts by Jagran Pehel to spread awareness about GDM. They offered their services as trainers for awareness workshops and even offered to be a part of screening camps. Due to this, a high score has been given to the project in these states.

In Jharkhand and Delhi, there was a mix of those who are taking some action in the form of screening camps and those who are not engaged with anything related to GDM; hence in these states the project performance has received a more moderate rating.

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3.3.5 Media personnel

The action expected from reporters was to frequently publish articles related to GDM in the print media. The reporters covered by the KPMG team had indeed covered the work undertaken by Jagran Pehel and written multiple articles on GDM. Hence the project has scored a very high rating across the project states with the exception of Bihar. In Bihar due to unforeseen circumstances, only one reporter was available during the visit of the KPMG team and he had only produced a sound byte on one of the GDM forums. As a result, in Bihar an average score has been given.

While the respondents did write articles whenever GDM forums were held, there was limited follow-up reporting. The reporters stated that readers would get disinterested with constant media coverage of one topic and that they needed to provide variety. However, they admitted that the message needed to be reinforced after a certain interval for it to have greater impact. They also stated that there was a good response from the public to articles that were written about GDM. This claim was based on an increase in the number of queries received by the newspaper on GDM and diabetes after publications of articles. Bureaucrats in Punjab felt that if more media houses got involved in covering GDM, a higher impact could be achieved.

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Section 4 Jagran Pehel as a brand

In addition to the three parameters discussed in the previous section, the study also assessed the recall value of Jagran Pehel’s brand amongst the project’s direct stakeholders. Overall, it was observed that the project has been fairly successful in creating visibility and recognition for Jagran Pehel and positioning it as an independent entity. Some key observations on branding are given below:

• Brand recall was highest amongst bureaucrats and doctors. These stakeholders were able to attribute the project interventions to Jagran Pehel and additionally could differentiate Jagran Pehel from Dainik Jagran.

• CSO respondents could identify both Jagran Pehel and Dainik Jagran. However, the recall value of Dainik Jagran appears to be higher than Jagran Pehel per se.

• Brand recall amongst ASHAs and ANMs varied from state to state:

– In Punjab, both ASHAs and ANMs were able to recognise the project coordinator and associated him with Dainik Jagran. Further, on prompting, they recognised Jagran Pehel’s name. Similar results were found in Jharkhand as well

– In Bihar, ASHAs and ANMs were not able to identify either Dainik Jagran, nor Jagran Pehel. The respondents attributed this to the fact that there are a multitude of trainings, both from the government and NGOs and as a result it is difficult to keep track of who organised the trainings.

– In Delhi, ASHAs were able to associate the project coordinator with Jagran Pehel, but ANMs couldn’t identify either organisation, but on being shown the IEC material, they appeared to recognise the GDM project logo.

– Field level health workers from across all four states could recognise the project tagline – ‘one test saves two lives’ – on being prompted

• As the reporters who were available for interview were mostly from Dainik Jagran they were fully aware of Jagran Pehel and thus brand recall data will not be relevant for this stakeholder group.

It can be deduced that Jagran Pehel has very strong brand recall among government stakeholders. However, there is potential to further strengthen its brand image among other stakeholders such as CSOs and field level health workers.

FGD with ASHAs and ANMs

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Section 5 Conclusion and recommendations

The project undertaken by Jagran Pehel has been successful in generating interest and fostering discussions especially among state government health authorities. Jagran Pehel’s effort, as observed by bureaucrats across states, was instrumental in bringing focus on GDM in the four project states.

Jagran Pehel took the initiative to orient ASHAs and ANMs and get buy-in of multiple stakeholders like bureaucrats, doctors, local NGOs, and private practitioners among others. One of the respondents appreciated the long-term commitment of the Jagran group towards tackling GDM.

The feedback and observations of respondents on the Jagran Pehel’s project are provided below:

• Most of the respondents stated that the IEC vans used in the Phase 1 of the project were hugely successful in generating awareness regarding GDM. The Jharkhand State Rural Health Mission wants to replicate the model (awareness generation through IEC Vans) for one of its projects.

• The IEC material and handbooks prepared by the Jagran Pehel were appreciated by all the respondents. The respondents stated that the IEC material was in Hindi and was easy to understand. Some of the respondents were of the opinion that IEC material and handbook should be made available at government health institutions where ANCs are conducted and pathology labs where blood sugar tests are done so that this is also accessible to pregnant women and their family members.

• All the respondents who were part of the workshops conducted by Jagran Pehel, found them very useful in bringing focus on GDM and refreshing their understanding regarding the disease. Most of the respondents found workshops interactive and stimulating. They appreciated the fact that a wide spectrum of stakeholders – government doctors, private practitioners, specialists like diabetologists, gynaecologists, obstetricians, etc., bureaucrats and representatives from CSOs/NGOs, were present in the workshops.

• Workshops were effective in advocating mandatory GDM screening, as is reflected by the remarks of a government doctor in Jharkhand. He stated that, “the Health Secretary of Jharkhand, was very impressed with the workshop and he issued orders to provide glucometers at the PHC level and conduct blood sugar tests during every ANC visit”.

• Most of the stakeholders reiterated that the success of the programme was largely dependent on involvement of the frontline workers, viz. ASHAs and ANMs, in project delivery.

• ASHAs and ANMs gave positive feedback on the orientation sessions. All the respondents from this stakeholder group

suggested that such orientation sessions should be conducted regularly and followed-up with repeat training sessions to reinforce their understanding of GDM.

• Most of the respondents who were part of the state and district level workshops were of the opinion that, though the workshop was very effective, a single workshop cannot result in adequate mainstreaming of GDM in the public health system and that follow-ups are required.

It is apparent that Jagran Pehel’s efforts catalysed state governments’ interventions to make GDM screening a mandatory part of ANCs, and also generated interest amongst other stakeholder groups.

However, there still remains some scope for improvement as suggested below:

• Interviews revealed that presently the blood-sugar test is done in the first trimester of the pregnancy when the pregnant lady comes for her first ANC as part of NRHM guidelines. This test is for detecting Type II diabetes mellitus and not for GDM. The ideal time for conducting GDM test is in the 24th - 28th week of pregnancy. Therefore, it is recommended that in addition to the test done during the first trimester as NRHM protocols, an additional blood sugar test be conducted in the third trimester for screening GDM. Jagran Pehel may advocate mandatory testing of GDM during third trimester on a National level and with various state governments.

• Screening equipment is not always available. In many health centres glucometers are not yet available, or where glucometers are present consumables like needles or strips are not available. Not all government healthcare centres have facilities for carrying out blood tests.

• In practice, at any point in time, government officials in the state health department have many other interventions to deliver, track and report on; many of these other interventions may be of higher priority than GDM. Generally in such cases these government officials need to focus on these higher priority areas (like polio drives, dengue,) and GDM falls low on the priority scale.

Therefore, further actions is required to strengthen the activities currently being undertaken to mainstream GDM.

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Some recommendations for the project are provided below:

Creating awareness by direct intervention with the community: The most critical factor to ensure that blood sugar tests are conducted in ANC during third trimester, is to generate demand for the same, through creating awareness among the pregnant women and their principal care-givers in the family. Some respondents (gynaecologists) have quoted instances where either the pregnant women or their guardians have refused to get the blood sugar tested, as they are not aware of the criticality of GDM. Therefore, pregnant women and their care-givers need to be counselled regarding GDM, in addition to the mass media campaign.

Additionally, direct interventions and mass media campaigns need to be adapted to the local context, which varies across and within the four states. For instance, in Jharkhand, as stated by some stakeholders, there are low instances of institutional deliveries due to high prevalence of superstitions and traditional delivery methods. Also, tribes in Jharkhand speak different dialects, therefore, it becomes pertinent that any direct interventions consider these cultural and language barriers.

Similarly, in Punjab there is a huge social stigma attached to diabetes. An ASHA narrated an incident where a man did not have intercourse with his wife for a considerable period of time after the wife was detected with diabetes because he was under the impression that diabetes was sexually transmitted. Therefore any direct intervention to promote GDM screening needs to be sensitive to these social issues and target at reducing the stigma.

Making GDM screening a routine activity: According to the ex-Secretary of Health in Bihar, GDM screening is a very simple intervention that can be easily done; however, it is a challenge to make any activity routine as it requires establishing a standard protocol for mandatory blood sugar testing during the third trimester. On the other hand, till GDM screening becomes a routine activity there will be problems like delay in procurement of supplies, non-availability of skilled human resources etc. This was further corroborated by an example narrated by a bureaucrat in Jharkhand. As per the bureaucrat, the strips purchased during the last procurement cycle, were not compatible with the glucometers available with the ANMs and hence those strips could not be used.

Therefore, it is recommended that policy advocacy needs to be targeted at ensuring that GDM testing is not only mainstreamed into the public health system but also becomes a routine activity like immunisation.

Reporting: There is no mechanism to track and report GDM cases. In Bihar, some of the respondents stated that a column is being added to the existing Health Management Information System (HMIS) to record GDM cases that have been detected. In Jharkhand, a column to record the results of blood sugar test has been added to Mother and Child Protection Card (Jachha Bacha Card) but GDM reporting is not part of HMIS. Similarly, in Punjab, urine test is conducted to check sugar levels and is recorded in the Mother and Child Protection Card but no further reporting is done. In Delhi, blood sugar test for pregnant women are done as part of NRHM guidelines but reporting and tracking mechanism is not clearly defined. To summarise, there is no clear mandate on reporting and tracking GDM cases across the four states. Hence, further policy advocacy efforts need to be aligned towards strengthening the GDM reporting and tracking mechanism.

Standard testing protocol: There is no standard testing protocol being followed across states for GDM screening. For instance, in Bihar, DIPSI guidelines are followed and Glucose Challenge Test (GCT) is conducted, while in Jharkhand, Random Blood Glucose (RBG) test is conducted followed by an Oral Glucose Tolerance Test (OGTT), if needed.

Timing for GDM testing: As GDM manifests only in the third trimester, any blood sugar test done in the first and the second trimester may not detect GDM. It is recommended that the timing of the blood sugar test for GDM screening needs to be reinforced as per DIPSI guidelines. A respondent suggested that blood sugar tests should be compulsorily done in the first trimester (to detect diabetes) and third trimester (to detect GDM). This will help in clearly diagnosing the cases of GDM indicating pregnant women whose blood sugar level is within normal ranges in the first trimester and has increased in the third trimester.

Communication with stakeholders: The project reached out to varied and huge number of people through mass media campaigns, workshops and orientation sessions. However, interaction with most stakeholders was only a one-time activity. There is a need to establish regular and frequent communication with these stakeholders so as to reinforce the behavioural change being brought about.

Branding: While there was recognition of Jagran Pehel’s work among bureaucrats and other government stakeholders, there is a need to strengthen the branding; especially among ASHAs and ANMs. As a suggestion, posters/wall hangings displaying Jagran Pehel’s logo and name can be put up during the ASHA/ANM orientation sessions.

Media coverage: Local language coverage of GDM forums and other activities can be strengthened further, especially in Jharkhand and Bihar.

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© 2014 KPMG, an Indian Registered Partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.© 2014 KPMG, an Indian Registered Partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.

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References

• Dabelea D, Hanson R L, Lindsay R S, et al. (2008), Intrauterine Exposure to Diabetes Conveys Risks for Type 2 Diabetes and Obesity. Available at: http://diabetes.diabetesjournals.org/content/49/12/2208.full.pdf

• Jain R, Pathak RR and Kotecha, AA (2014). Gestational Diabetes: Perinatal and Maternal Complication in 24-28 Weeks. Available at: www.scopemed.org/?mno=165463

• Kaliyaperumal K (2004), Guideline for Conducting a Knowledge, Attitude and Practice (KAP) Study, Available at: http://laico.org/v2020resource/files/guideline_kap_jan_mar04.pdf

• Plays, T, Purposive Sampling. From: Lisa M. Given (Ed.) (2008), The Sage Encyclopedia of Qualitative Research Methods. Sage: Thousand Oaks, CA, Vol.2, pp.697‐698. Available at: http://www.sfu.ca/~palys/Purposive per cent20sampling.pdf

• Rahman MT, Tahmin T, Ferdousi S and Bela SN (2009). Gestational Diabetes Mellitus (GDM): Current Concept and a short Review. Available at: www.banglajol.info/bd/index.php/BJPath/article/download/2877/2389

• Seshiah V, Balaji V, Balaji MS, et al. (2005). One step procedure for screening and diagnosis of gestational diabetes mellitus. The Journal of Obstetrics and Gynecology of India, Vol. 55, No. 6: November/December 2005, Pg 525-529

• Social Marketing and Public Health Pre-Conference (2003), Evaluating Your Social Marketing Programme. Available at: http://health.usf.edu

• Varcoe J (2004), Assessing the Effectiveness of Social Marketing, ESOMAR

• Website of Certificate Course on Evidence based Diabetes Management. Available at: http://ccebdm.org/news.php

• Website of Not-for profit Clinic in USA. Available at: http://www.mayoclinic.org/diseases-conditions/gestational-diabetes/basics/complications/con-20014854

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Annexure 1 Detailed KAP scorecards

State-wise scorecards

Punjab

Criteria Bureaucrats Doctors ASHAs ANMs CSOsMedia

personnel

Knowledge 3 3 3 2 5

Attitude 5 5 5 5 5

Practice 3 4 3 4 5

Delhi

Criteria Bureaucrats Doctors ASHAs ANMs CSOsMedia

personnel

Knowledge 3 3 3 2 2 4

Attitude 5 5 5 5 5 5

Practice 3 4 3 3 3 5

Jharkhand

Criteria Bureaucrats Doctors ASHAs ANMs CSOsMedia

personnel

Knowledge 3 3 4 4 3 4

Attitude 5 5 5 5 5 5

Practice 4 4 4 4 3 5

Bihar

Criteria Bureaucrats Doctors ASHAs ANMs CSOsMedia

personnel

Knowledge 2 4 4* 3 2 1

Attitude 5 5 5 5 5 1

Practice 3 4 3 3 4 2

*Some of the respondents were reoriented a week before the interaction with the KPMG team.

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Stakeholder-wise scorecards

Bureaucrats

Criteria Punjab Delhi Bihar Jharkhand

Knowledge 3 3 2 3

Attitude 5 5 5 5

Practice 3 3 3 4

Doctors

Criteria Punjab Delhi Bihar Jharkhand

Knowledge 3 3 4 3

Attitude 5 5 5 5

Practice 4 4 4 4

Civil society organisations

Criteria Punjab Delhi Bihar Jharkhand

Knowledge 2 2 2 3

Attitude 5 5 5 5

Practice 4 3 4 3

Media personnel

Criteria Punjab Delhi Bihar** Jharkhand

Knowledge 5 4 1 4

Attitude 5 5 1 5

Practice 5 5 2 5

Field level health workers

CriteriaPunjab** Delhi Bihar Jharkhand

ASHA ANM ASHA ANM ASHA ANM ASHA ANM

Knowledge 3 3 2 4* 3 4 4

Attitude 5 5 5 5 5 5 5

Practice 3 3 3 3 3 4 4

*Some of the respondents were reoriented a week before the interaction with the KPMG team. ** Only one FGD was held for a mixed group on ASHAs and ANMs

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Annexure 2 Pre-test of data Collection tools

A pre-test of the ASHA/ANM questionnaire was carried out on 24 April 2014 at Mandawali in the East Delhi District. The pre-test consisted of the following:

• A FGD with approximately 20 ASHAs

• A one-on-one interview with an ASHA

• A one-on-one interview with an ANM

As the pre-test was conducted immediately after the orientation programme for ASHAs, there were some limitations to the findings, especially regarding answers to questions on attitude and behaviour change. However, the pre-test still provided valuable feedback with respect to the questionnaire structure, flow and duration. Further, it also allowed us to gauge the pros and cons of conducting one-on-one interviews with ASHAs/ANMs vs. carrying out FGDs. As stated above, it emerged that FGDs would be preferable to individual interviews.

Some key observations from the pre-test are as follows:

• Repetition and length: During the interactions, it was observed that some of the questions in the questionnaire were repetitive and this affected the flow of the interaction and also took up more time. Based on this observation, the questionnaires were updated to remove the repetitive questions.

• Limited brand recall: Even though the interactions were held immediately after the GDM orientation, none of the respondents (FGD or interview) were able to name Jagran Pehel or Dainik Jagran as the organisation responsible for the training. It was observed that Jagran Pehel was

only mentioned once at the start of the orientation programme and subsequently there was no reference to the organisation. Further, as the orientation was held after the standard trainings given to ASHAs, the respondents believed it to be a continuation of their regular training and not a separate event. The lack of any fixed poster or banner with Jagran Pehel’s name/logo also contributed to the lack of recall of the organisation.

It should be noted that if the ASHA/ANM orientations are carried out in a similar manner in the remaining project states, it may not be possible to collect data on brand recall.

• Message transmitted to women: It was also learnt that the test for blood sugar has now been made part of the ante-natal checks conducted for all pregnant women at government health centres. As a result, ASHAs did not feel the need to tell the women about GDM separately. They continue to motivate pregnant women to visit the doctor at the health centre where the blood sugar test is done as part of the package of tests mandated by the government. Further, as ASHAs cannot recommend tests or advise the patients on treatment, their job is only to ensure that the women visit the doctor and it is the doctor who informs the women about possible dangers as well as appropriate diet and exercise regimes.

It should be noted that if a similar trend is found in other project states, it may be difficult to collect data on the behaviour change component of the project.

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Annexure 3 Data collection tools

This section provides the data collection tools and FGD guidelines used to collect responses from different stakeholder groups of the Jagran Pehel’s project.

There are significant similarities in the questionnaires for different stakeholders, particularly in questions that check for ‘knowledge’. These similarities are by design as the intention is to check how the knowledge conveyed through the programme to direct stakeholders is internalised and how this is passed on through direct stakeholders to indirect stakeholders – e.g. from ASHAs/ANMs to women in their locality.

While there are similarities, the questionnaires differ in their focus depending on the role a stakeholder plays in the programme. Further, the questionnaires also take into account the nature of the interaction (FGD vs. interview) and the likely time available for the interaction.

FGD guidelines for the surveyor

• The respondents in the FGD will be selected by Jagran Pehel. The respondents should have participated in the programme being run by Jagran Pehel

• The FGD group should be homogenous. In case there are sub-groups (like ASHAs and ANMs), separate FGDs should be undertaken

• The size of the focussed group should be 12- 20 members

• The duration of the FGD should be 30 to 45 minutes

• There should be two facilitators for the FGD. One facilitator should conduct the FGD and the role of other facilitator is taking notes during the FGD

• The facilitators should explain the nature of the study openly and honestly and in a way that is understandable to the respondents

• The respondents should understand that their participation in the FGD is voluntary and their prior consent on using the information collected during the FGD should be taken explicitly.

• Facilitators should ensure that:

– Majority of the respondents have an opportunity to participate in the discussion. Do not allow one or two people to dominate the group

– A structure is provided to the discussion and ensure that all key discussion points are covered as mentioned in the FGD questionnaire

– The discussion is not concentrated around one topic

– Bias is avoided and ensure that responses are recorded accurately and objectively

– Responses are not influenced by asking leading questions

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Questionnaire for elected representatives and bureaucrats

Jagran Pehel is undertaking third party evaluation of their programme – “Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System”. For this purpose, Jagran Pehel has hired KPMG in India, a consultancy firm to conduct the evaluation.

Interactions with Elected Representatives/Bureaucrats will be in the form of open ended discussions. The questions below are intended to guide the interviewer in his/her conversation and the objective is to gauge the levels of awareness, engagement and behavior change generated through Jagran Pehel’s advocacy efforts.

Consent to share and use the information collected through this questionnaire will be taken from each respondent.

This document is for the use of Jagran Pehel only. It is not to be distributed beyond the employees and management of Jagran Pehel and the respondents, nor is to be copied, circulated, referred to or quoted in correspondence, or discussed with any other party, in whole or in part, without our prior written consent, as per terms of business agreed under the Engagement Letter.

Date: Name of surveyor:

Name of respondent: Designation:

District:

1. Are you aware of Gestational Diabetes Mellitus (GDM)? If yes, please elaborate.

2. Do you feel diabetes and specifically diabetes during pregnancy are critical issues? Why?

3. Are you aware of Jagran Pehel’s efforts to mainstream GDM into the public health delivery system? [Show logos of Jagran Pehel and GDM project].

4. Have you participated in any of the GDM workshops held by Jagran Pehel? If yes, when?

5. Please provide feedback on the workshop? [Content provided, delivery, improvements if any, etc.]

6. What is your opinion on mainstreaming GDM screening into the public health delivery system? How do you think this can be best achieved?

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7. Who, according to you are the key stakeholders in mainstreaming GDM in the public health delivery system? [The options below are for benefit of the interviewer and will not be asked]

a. Elected representativesb. District level administratorsc. State health department officialsd. Doctors in govt. Health centrese. Ashas & anmsf. Civil society organisationsg. Media

8. What role can each of each of these stakeholders play in mainstreaming GDM?

9. Have you taken any steps to mainstream GDM in your district/state?

a. Is GDM screening mandatory in your district? If yes, when did it become mandatory?

b. Have any notices/circulars been issued to relevant authorities in your district to mainstream GDM screening? If yes, when were they issued and what is their content? (do they describe the roles of various stakeholders?)

c. Is diabetes testing a part of the ante-natal checks on the Jachcha Bacha card?

10. In your experience, what has been the level of engagement of State Health Department Officials on issues related to GDM? [Only for Elected Representatives

or

In your experience, what has been the level of engagement of Elected Representatives on issues related to GDM? [Only for Bureaucrats]

11. Have you faced any challenges in mainstreaming GDM in your district? Please elaborate.

12. In your opinion what further efforts are needed to mainstream GDM screening in your district?

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Questionnaire for FGD with ASHAs

Jagran Pehel is undertaking third party evaluation of their programme – “Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System”. For this purpose, Jagran Pehel has hired KPMG in India, a consultancy firm to conduct the evaluation.

This questionnaire is to understand the levels of awareness, engagement, and behavior change generated in ASHAs regarding Gestational Diabetes Mellitus (GDM) as a result of the orientation programme provide by Jagran Pehel.

Questions will be asked in an open ended manner; the options below the questions are to be used by the surveyors only as a guideline for the discussion.

Consent to share and use the information collected through this questionnaire will be taken from each respondent.

This document is for the use of Jagran Pehel only. It is not to be distributed beyond the employees and management of Jagran Pehel and the respondents, nor is to be copied, circulated, referred to or quoted in correspondence, or discussed with any other party, in whole or in part, without our prior written consent, as per terms of business agreed under the Engagement Letter.

Date: Name of surveyor:

Participants

Name District

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Knowledge on diabetes and GDM

Diabetes

1. Are you aware of diabetes? If yes, what do understand by diabetes?

2. Which parts of the human body can be affected by diabetes?

a. Heart

b. Nerves

c. Eyes

d. Kidneys

e. All of the above

f. None of the above

3. Are you aware of Jagran Pehel’s efforts to mainstream GDM into the public health delivery system? [Show logos of Jagran Pehel and GDM project].

a. Sudden increase in weight

b. Unusual tiredness/weakness

c. Increase in hunger and thirst

d. Non healing ulcers

e. Increased frequency of urination

f. All of the above

g. None of the above

4. How can sugar levels in the blood be tested?

a. Urine

b. Blood

c. Both

5. Who are at increased risk of being detected as a case of diabetes?

a. Those with family history of diabetes

b. Women who are obese

c. Those who have delivered premature or stillborn babies

d. Those who have delivered babies weighing more than 4 kg

e. Thos with high glucose level in urine

f. Random blood sugar level is more than 120gm

g. All of the above

h. None of the above

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GDM

8. Are you aware of Gestational Diabetes Mellitus (GDM)? If yes, what is Gestational Diabetes Mellitus?

a. Increase in sugar levels in blood

b. Decrease in sugar levels in blood

c. Increase in sugar levels in blood during pregnancy

d. Decrease in sugar levels in blood during pregnancy

9. When during pregnancy should the GDM test be undertaken?

a. In the first month

b. Within 8-12 weeks

c. Within 16-20 weeks

d. Within 24-28 weeks

10. What are possible effects of GDM on the baby?

a. The baby is larger than normal at birth

b. The newborn baby has low sugar levels in the blood

c. These children are at greater risk of getting diabetes in the future

d. All of the above

e. None of the above

11. What should the role of an ASHA be in spreading awareness about GDM?

a. To give pregnant women information regarding GDM

b. To give newly-weds information regarding GDM

c. To encourage pregnant women to get tested for GDM

d. To give pregnant women information about balanced and nutritious diet

e. All of the above

f. None of the above

g. Any other ……………………..

6. What is the name of the instrument used to measure blood sugar?

7. What kind of foods should be eaten and what kinds should be avoided in order to control sugar levels in the blood?

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12. Is the Diabetes test for pregnant woman available at your nearest government health centre? ( PHC/dispensary)

a. Yes

b. No

c. Not sure

13. Where do you advise pregnant women from your community to go for testing of diabetes?

14. What is the cost of the Diabetes test for pregnant woman?

[This question will help to gauge whether ASHA knows that diabetes test is included in the free tests by the government. This question will also be used to understand if the test is not done in government hospital, then how much do private hospitals charge]

15. In the mother and child health card (Jachcha Bacha card), is this test written/mentioned?

a. Yes

b. No

c. Not sure

16. Are any records maintained of the tests for future reference?

a. Yes

b. No

c. Not sure

17. If a woman is diagnosed of GDM, what is the next step taken by the ANM/recommendation given to the woman

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Practice

Feel

18. Do you feel prompt action needs to be taken when GDM is suspected?

a. Yes

b. No

c. Not sure

[Question 19, check whether the training had an impact on the personal views of ASHA. They might suggest the test for women but might not consider it important for themselves]

19. Would you get yourself or a family member tested for increased sugar levels in the blood during pregnancy?

a. Yes

b. No

c. Not sure

20. Do you feel there is greater awareness among pregnant women in your area about the dangers of increased sugar levels in the blood during pregnancy?

a. Yes

b. No

c. Not sure

Do

21. Have you provided information regarding GDM to women in your area?

a. Yes

b. No

22. Have you suspected any woman in your area of having GDM?

a. Yes

b. No

23. If yes, were these women tested for sugar levels in the blood?

a. Yes

b. No

24. What are the challenges you face in getting women tested for GDM?(from both demand and supply side - non availability of medical supplies, lack of family support, distance of testing centre from woman’s house, etc.)

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25. What messages do you give on diabetes in the community as a part of your health awareness programmes?

26. Do you report GDM cases to Medical Officer In charge (MoIC), if yes which format?

Sources of information

27. From where did you get the information regarding GDM?

a. Friends and family

b. Radio

c. Newspaper

d. Posters

e. IEC

f. Through training

g. Others______________

h. Doctors/MOs

28. If you have received orientation programme on GDM, please provide details (including date)?

29. Which organisation conducted the orientation programme for GDM?

a. Jagran Pehel

b. Doctor

c. Danik Jagran

d. Others _____________

[If the group is unable to answer, display the logo of the programme and Jagran Pehel, and IEC material]

30. What did you like about the orientation programme on GDM provided by Jagran Pehel?

31. What do you think could be done to improve the GDM orientation programme?

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Questionnaire for FGD with ANMs

Jagran Pehel is undertaking third party evaluation of their programme – “Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System”. For this purpose, Jagran Pehel has hired KPMG in India, a consultancy firm to conduct the evaluation.

This questionnaire is to understand the levels of awareness, engagement, and behavior change generated in ANMs regarding Gestational Diabetes Mellitus (GDM) as a result of the orientation programme provide by Jagran Pehel.

Questions will be asked in an open ended manner; the options below the questions are to be used by the surveyors only as a guideline for the discussion.

Consent to share and use the information collected through this questionnaire will be taken from each respondent.

This document is for the use of Jagran Pehel only. It is not to be distributed beyond the employees and management of Jagran Pehel and the respondents, nor is to be copied, circulated, referred to or quoted in correspondence, or discussed with any other party, in whole or in part, without our prior written consent, as per terms of business agreed under the Engagement Letter.

Date: Name of surveyor:

Participants

Name District

Jagran pehel | 70

Knowledge on diabetes and GDM

Diabetes

1. Are you aware of diabetes? If yes, what do understand by diabetes?

2. Which parts of the human body can be affected by diabetes?

a. Heart

b. Nerves

c. Eyes

d. Kidneys

e. All of the above

f. None of the above

3. Are you aware of Jagran Pehel’s efforts to mainstream GDM into the public health delivery system? [Show logos of Jagran Pehel and GDM project].

a. Sudden increase in weight

b. Unusual tiredness/weakness

c. Increase in hunger and thirst

d. Non healing ulcers

e. Increased frequency of urination

f. All of the above

g. None of the above

4. How can sugar levels in the blood be tested?

a. Urine

b. Blood

c. Both

5. Who are at increased risk of beigng detected as a case of diabetes?

a. Those with family history of diabetes

b. Women who are obese

c. Those who have delivered premature or stillborn babies

d. Those who have delivered babies weighing more than 4 kg

e. Glucose level in urine is high

f. Random Blood Sugar level is more than 120gm

g. All of the above

h. None of the above

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GDM

8. Are you aware of Gestational Diabetes Mellitus (GDM)? If yes, what is Gestational Diabetes Mellitus?

a. Increase in sugar levels in blood

b. Decrease in sugar levels in blood

c. Increase in sugar levels in blood during pregnancy

d. Decrease in sugar levels in blood during pregnancy

9. When during pregnancy should the GDM test be undertaken?

a. In the first month

b. Within 8-12 weeks

c. Within 16-20 weeks

d. Within 24-28 weeks

10. What are possible effects of GDM on the baby?

a. The baby is larger than normal at birth

b. The newborn baby has low sugar levels in the blood

c. These children are at greater risk of getting diabetes in the future

d. All of the above

e. None of the above

11. What should the role of an ANM be in spreading awareness about GDM?

a. To give pregnant women information regarding GDM

b. To give newly-weds information regarding GDM

c. To encourage pregnant women to get tested for GDM

d. To give pregnant women information about balanced and nutritious diet

e. All of the above

f. None of the above

g. Any other ……………………..

6. What is the name of the instrument used to measure blood sugar?

7. What kind of foods should be eaten and what kinds should be avoided in order to control sugar levels in the blood?

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12. What tests are undertaken for GDM? (let ANMs explain about GTC and OGTT and when are they undertaken)

13. Is the Diabetes test for pregnant woman available at your nearest government health centre? ( PHC/dispensary)

a. Yes

b. No

c. Not sure

14. Where do you advise pregnant women from your community to go for testing of diabetes?

15. What is the cost of the Diabetes test for pregnant woman?

[This question will help to gauge whether ASHA knows that diabetes test is included in the free tests by government. This question will also be used to understand is test is not done in government hospital then how much does private hospitals charge]

16. In the mother and child health card (Jachcha Bacha card), is this test written/mentioned?

a. Yes

b. No

c. Not sure

17. Are any records maintained of the tests for future reference?

a. Yes

b. No

c. Not sure

18. If a woman is diagnosed of GDM, what is the next step taken by the ANM/recommendation given to the woman

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Practice

Feel

19. Do you feel prompt action needs to be taken when GDM is suspected?

a. Yes

b. No

c. Not sure

[Question 19, check whether the training had an impact on the personal views of ASHA. They might suggest the test for women but might not consider it important for themselves]

20. Would you get yourself or a family member tested for increased sugar levels in the blood during pregnancy?

a. Yes

b. No

c. Not sure

21. Do you feel there is greater awareness among pregnant women in your area about the dangers of increased sugar levels in the blood during pregnancy?

a. Yes

b. No

c. Not sure

Do

22. Have you provided information regarding GDM to women in your area?

a. Yes

b. No

23. Have you suspected any woman in your area of having GDM?

a. Yes

b. No

24. If yes, were these women tested for sugar levels in the blood?

a. Yes

b. No

25. What are the challenges you face in getting women tested for GDM?(from both demand and supply side - non availability of medical supplies, lack of family support, distance of testing centre from woman’s house etc.)

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26. What messages do you give on diabetes in the community as a part of your health awareness programmes?

27. Do you report GDM cases to Medical Officer In charge (MoIC), if yes which format?

Sources of information

28. From where did you get the information regarding GDM?

a. Friends & Family

b. Radio

c. Newspaper

d. Posters

e. IEC

f. Through training

g. Others______________

h. Doctors/MOs

29. If you have received orientation programme on GDM, please provide details (including date)?

30. Which organisation conducted the orientation programme for GDM?

a. Jagran Pehel

b. Doctor

c. Danik Jagran

d. Others _____________

[If the group is unable to answer, display the logo of the programme and Jagran Pehel, and IEC material]

31. What did you like about the orientation programme on GDM provided by Jagran Pehel?

32. What do you think could be done to improve the GDM orientation programme?

75 | Jagran pehel

Questionnaire for FGD with women

Jagran Pehel is undertaking third party evaluation of their programme – “Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System”. For this purpose, Jagran Pehel has hired KPMG in India, a consultancy firm to conduct the evaluation

This questionnaire is to understand the level of awareness, engagement and behavior change generated in community regarding Gestational Diabetes Mellitus (GDM) as a result of the orientation programme provide by Jagran Pehel. The questions will be open ended and the options below are only for reference of the interviewer.

Consent to share and use the information collected through this questionnaire will be taken from each respondent.

This document is for the use of Jagran Pehel only. It is not to be distributed beyond the employees and management of Jagran Pehel and the respondents, nor is to be copied, circulated, referred to or quoted in correspondence, or discussed with any other party, in whole or in part, without our prior written consent, as per terms of business agreed under the Engagement Letter.

Date: Name of surveyor:

Participants

Name District

Jagran pehel | 76

Knowledge on diabetes and GDM

Diabetes

1. Are you aware of diabetes? If yes, what do understand by diabetes?

2. Which body parts can be affected by diabetes?

a. Heart

b. Nerves

c. Eyes

d. Kidneys

e. All of the above

f. None of the above

3. What are symptoms of increased sugar levels in the blood?

a. Sudden increase in weight

b. Unusual tiredness/weakness

c. Increase in hunger and thirst

d. Non healing ulcers

e. Increased frequency of urination

f. All of the above

g. None of the above

[Question to be asked in non-technical language, options to aid interviewer not to be asked]

4. How can sugar levels in the blood be tested?

a. Urine

b. Blood

c. Both

5. What kind of foods should be eaten and what kinds should be avoided in order to control sugar levels in the blood?

77 | Jagran pehel

GDM

6. Are you aware of Gestational Diabetes Mellitus (GDM)? If yes, what is Gestational Diabetes Mellitus?

a. Increase in sugar levels in blood

b. Decrease in sugar levels in blood

c. Increase in sugar levels in blood during pregnancy

d. Decrease in sugar levels in blood during pregnancy

7. When during pregnancy should the GDM test be undertaken?

a. In the first month

b. Within 8-12 weeks

c. Within 16-20 weeks

d. Within 24-28 weeks

8. If the mother has GDM, can it pose a threat to the baby?

a. Yes

b. No

c. Not sure

9. Is the Diabetes test for pregnant woman available at your nearest government health centre/ Diabetes test centre? ( PHC/dispensary)

a. Yes

b. No

c. Not sure

10. What is the cost of the Diabetes test?

[This question will help to gauge whether women know that diabetes test is included in the free tests by government. This question will also be used to understand is test is not done in government hospital then how much does private hospitals charge]

Jagran pehel | 78

Practice

Feel

11. Do you feel prompt action needs to be taken when GDM is suspected?

a. Yes

b. No

c. Not sure

Do

12. Would you get yourself or a family member tested for increased sugar levels in the blood during pregnancy?

a. Yes

b. No

c. Not sure

13. Have you ever recommend or motivated any other woman to get herself tested for GDM?

a. Yes

b. No

c. Not sure

14. Do you feel there is greater awareness among pregnant women in your area about the dangers of increased sugar levels in the blood during pregnancy?

a. Yes

b. No

c. Not sure

79 | Jagran pehel

Questionnaire for doctors

Jagran Pehel is undertaking third party evaluation of their programme – “Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System”. For this purpose, Jagran Pehel has hired KPMG in India, a consultancy firm to conduct the evaluation.

This questionnaire is designed to understand the levels of awareness, engagement, and behaviour change generated in Doctors regarding Gestational Diabetes Mellitus (GDM) as a result of the orientation programme provide by Jagran Pehel.

Questions will be asked in an open ended manner; the options below the questions are to be used by the surveyors only as a guideline for the discussion.

Consent to share and use the information collected through this questionnaire will be taken from each respondent.

This document is for the use of Jagran Pehel only. It is not to be distributed beyond the employees and management of Jagran Pehel and the respondents, nor is to be copied, circulated, referred to or quoted in correspondence, or discussed with any other party, in whole or in part, without our prior written consent, as per terms of business agreed under the Engagement Letter.

Date: Name of interviewer:

Name of respondent: Designation:

Name & place of hospital: District:

1. Are you aware of Jagran Pehel’s efforts to mainstream GDM in the public health delivery system?

2. Have you participated in any of the GDM workshops held by Jagran Pehel? If yes, when?

3. Please provide feedback on the workshop? [Content, delivery, improvements if any etc.]

4. How prevalent is GDM in your District/State? Do you feel it is a serious concern?

5. What is the course of action you recommend when a patient is suspected of GDM?

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6. Is blood sugar testing during the ante-natal period mandatory in your district? If yes, when did it become mandatory?

7. Have any notices/circulars been issued to relevant authorities in your district to mainstream GDM screening? If yes, when were they issued?

8. Do you face any challenges in conducting GDM tests (availability and operability of equipment, e.g. glucometer, needles, strips etc;)?

9. Do you feel GDM screening should be mainstreamed into the public health delivery system? If yes, how do you think this can be best achieved?

10. In your opinion, what is the level of awareness about GDM

a. Amongst pregnant women in your District/State

b. Amongst field level health workers (ASAH/ANM)

11. In your opinion how can awareness regarding GDM be improved in your District/State?

12. What role do you think you can play in this process?

13. How do you communicate the symptoms and consequence of GDM to pregnant women/health workers?

14. What kind of changes in lifestyle and diet would you recommend to a mother with GDM?

a. Changes in Diet

b. Changes in Lifestyle (including exercise)

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15. Have you provided any training to field level health workers (ASAH/ANM) on GDM?

16. If yes, please describe the process of organising and manner of delivering the training

17. What are the challenges involved in organising trainings for field level health workers?

Jagran pehel | 82

Questionnaire for doctors

Jagran Pehel is undertaking third party evaluation of their programme – “Mainstreaming Gestational Diabetes Mellitus in the Public Health Delivery System”. For this purpose, Jagran Pehel has hired KPMG in India, a consultancy firm to conduct the evaluation.

The questions below are intended to guide the interviewer in his/her conversation with media personnel. The objective is to gauge the levels of awareness, generated through Jagran Pehel’s advocacy efforts and assess whether this has led to increase in advocacy regarding GDM.

Consent to share and use the information collected through this questionnaire will be taken from each respondent.

This document is for the use of Jagran Pehel only. It is not to be distributed beyond the employees and management of Jagran Pehel and the respondents, nor is to be copied, circulated, referred to or quoted in correspondence, or discussed with any other party, in whole or in part, without our prior written consent, as per terms of business agreed under the Engagement Letter.

Date: Name of surveyor:

Name of respondent: Employer:

1. Are you aware of Gestational Diabetes Mellitus (GDM)? If yes, what is it?

2. Are you aware of Jagran Pehel’s efforts to mainstream GDM into public health delivery system? [Show logos of Jagran Pehel and GDM project].

3. Have you participated in any of the GDM workshops held by Jagran Pehel? If yes, when?

4. Were you aware of GDM before the Jagran Pehel workshop?

5. Please provide feedback on the workshop? [Content, delivery, improvements if any etc.]

6. In your opinion, what are the levels of awareness regarding GDM in the State/District?

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Questionnaire for doctors

7. Do you feel diabetes and specifically diabetes during pregnancy are critical issue that should be reported on?

8. Have you reported on diabetes during pregnancy? If so how many times and when?

9. If yes, what kind of stories on diabetes during pregnancy do you report?

10. Where do you hear about the story? [source could be workshop/meeting/individual doctor/ANMs or community]

11. What role can the media play in increasing awareness about GDM?

12. In your opinion what further efforts are needed to mainstream GDM screening?

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©2014 Jagran Pehel: A Division of Sri Puranchandra Gupta Smarak Trust. All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, any other electronic or mechanical methods, without the prior written permission of the publisher including in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. For any permission request/s, contact Jagran Pehel.

Mr. Anand MadhabChief Executive OfficerE: anand@jagranpehel.com