Experiences in the villages of Gujarat
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Experiences in the villages of Gujarat
Shree Chhotubhai A. Patel Hospital and
Community Health CenterMota Fofalia, Gujarat, India
Reena Patel
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Topics to Cover
General statistics
Nutrition statistics
Structure of malnutrition management Current changes in management
Shakti Krupa Charitable Trust and Hospital
My project Future management of malnutrition
Our future involvement
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Indias General Statistics
Currently (2013) there are 1,270,272,105 people in
India = 17.3% of worlds population
~13% are children 0-6 years (158.8million)
Projected to be the most populous country by 2030
The WHO, World Health Report for mortality rates
per 100,000 population (2008): non-communicable diseases: 685
communicable diseases: 363
injuries: 99 Indiaonlinepages.com
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Breakdown of India and Our Site
State Level (29) Gujarat
District Level (33)
Vadodara aka Baroda
Taluka Level (13)
Sinor
Village Level (43) Mota Fofalia
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Government ofIndia
(GOI)
National Rural HealthMinistry
NRHM
District Level
Health Survey(2007-08)
International Institute
for Population ScienceIIPS
National Family
Health Survey-3(2005-06)
Ministry of Family Healthand Welfare
(MoFHW)
Nutrition Statistics
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National Family Health Survey - 3
Surveyed 109,041 households from 2005-2006
29 states in India = 99 percent of Indias
population Two national-level fact sheets and 29 state
fact sheets that provide estimates of more
than 50 key indicators of population, health,family welfare, and nutrition
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District Level Health Survey (DLHS) and
facility survey
Surveyed 720,320 households from 28 Statesat the district level
It was used to assess the utilization ofservices provided by government health carefacilities and peoples perceptions about the
quality of services Facility Survey: Sub-Centres, Primary Health
Center, Community Health Center, and DistrictHospital
www.rchiips.org
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Underweight- Weight for Age Acute and Chronic malnutrition
Stunting- Height for Age Linear growth retardation, past growth failure Recurrent or chronic illness
Wasting- Weight for Height Acute malnutrition
Mid-Upper Arm Circumference- Measure of muscle wasting Acute malnutrition
Anthropometric Measures
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60
57
56
48
45
43
42
41
40
38
37
30
Madhya Pradesh
Jharkhand
Bihar
Meghalaya
Gujarat
INDIA
Uttar Pradesh
Orrissa
Rajasthan
Uttranchal
Maharashtra
Tamil Nadu
Indias Nutrition Statistics
Percent of children < 5years: underweight
DLHS-3 (2007-08)
NFHS-3, 2005-06
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DLHS-2, 2002-04
Gujarat
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Gujarats Child Nutrition Statistics
Weight for Age criteria Weight for Height criteria
Normal %[Green]
Severe Under
Weight %
(Red)
Moderate
Under Weight
% [Yellow]
Normal %
Moderate Acute
Malnutrition(MAM) %
Severe Acute
Malnutrition
(SAM) %
44.6%
55.4%
28.3
%
16.3
% 5.8%
12.9
%
55.4
%
18.7%
Wasting (%)
25.9
%
SUW/ MUW
NFHS-3, 2005-06
Underweight (%)
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Indias Nutrition Statistics
rural areas
50% of young children are stunted
~1/2 are underweight
20% are wasted
urban areas
40 % of young children are stunted
1/3 are underweight
17% are wasted
There is a strong inverse relationship between undernutrition in children and the
level of wealth of the households that they live in. However, even in the wealthiest
households (households in the highest wealth quintile), one-quarter of children are
stunted and one-fifth are underweight.
DLHS 3, 2007-08
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48
28
48
19
0
50
100
% 1. Initiation of Breastfeedingwithin 1 hour of birth
2. Exclusive Breastfeeding
upto 6 months of life
3. Children 6-9 months fedComplementary foods
1+ 2+3
Source: DLHS-3 (2007-08)
Most mothers (57 percent) gave their babies something
other than breast milk to drink in the first three days
after birth.
Breastfeeding Statistics
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Indicator: Child Mortality
Infant mortality is steadily declining
Still, > than 1:18 children die within the first
year of life, and >1:13 die before age five
Mortality rates are 50% higher in rural than
urban areas
Scheduled Class/Tribe (23.5% of population)
are at greater risk
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Poor nutrition as a contributing factor
to child mortality
NFHS-3, 2005-06
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So whats been/being done?
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ICDS: Government Stewardship
Integrated Child Development Services was first launched in 1975
Developed by the GOI to combat malnutrition and health problems inchildren below 6 years of age and their mothers
They started the concept of an Anganwadi Centre (AWC) located in thevillages
The following services are sponsored by UNICEF and the World Bank
Immunization, Supplementary nutrition, Health checkup, Referralservices, Pre-school non formal education, Nutrition and Healthinformation
ICDS provides $10-22 per year per child
As of Jan 1, 2013 there are 1,300,000 AWCs and mini-AWCs in India
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Anganwadi Centre: AWC
Courtyard shelter
Angan: is where people get together to discuss, greet, socialize, even cook
and sleep. In the home it is the heart and considered sacred.
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Anganwadi Worker (AWW)
Role: health worker chosen from the community
4 months training in health, nutrition and child-care
Importance: link to rural and healthcare needs, buildscommunity trust, good advocate, affordable/accessible
Each AWC covers 1,000 population, Each AWW covers 150-200
children
Supervised and trained by ICDS government officials/agents
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AWW & AW helper
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AWC services
Growth Monitoring* Supplementary Nutrition Program in the AWC for 6 month
to 6 yrs old:
a) Energy dense Bal Bhog (3.5kg)/ month to 6mos to 3 yrs
b) Hot cooked food to 3 yrs to 6 yrs
c) Energy dense Take Home Ration (THR) for severeunderweight children
Milk to children 3-6 yrs, twice a week.
Fruits to children 3- 6 yrs, twice a week
Nutri-Candy with micronutrients (Iron, Folic acid, Vitamin Aand Vitamin C) for age group of 3 to 6 years
Mobile Anganwadi scheme for NREGA/Migrants population.
Conditional Cash Transfer Scheme- cash incentive forpregnant mothers to have institutional births
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To create awareness about nutrition in the community.
To counsel on Infant and Young Child Feeding (IYCF)
practices.
To mobilize the community to access health and
nutrition services.
To escort mothers with malnourished children to
nearest care centers & to motivate mothers to stayduring the intervention
To ensure that children are followed up at care centers
AWC services
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Bal Bhog = supplementary foods
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*Growth Monitoring
In 2008, ICDS adopted the new WHO ChildGrowth Standards (launched April 27, 2006).
Weight-for-age
Height-for-age
Weight-for-height
Measure physical growth and nutritional
status of children from birth to 5 years ageusing anthropometric measures
Using a Mamta Card to keep record
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Despite >80% of children under age six years lived in enumeration areas covered by an
anganwadi centre in the 12 months prior to the NFHS-3
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Sub-Centres/AWCs (village level)
Mamta Abihyan Initiative,routine care
Community Health Center (CHC)
Primary Health Center (PHC)
Child Development and NutritionCenters (CDNC)
District Hospital/MedicalCollege
District Nutrition Units
Current Referral Scheme
Care centers
Nutrition centers
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Recent Changes
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In 2009, the WHO came out with updated
growth standards with new cut-off values, and
with anthropometric measures
The Government of Gujarat is now adopting
this model to propose a new measure of
growth monitoring and management
guidelines for malnutrition referral andintervention
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MUAC as a measure of growth
monitoring
Benefit of MUAC
Same specificity as W/H Cheap
Easy to do
Does not factor in age Indicator of acute issue
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Severe Under Weight
(SUW) if : Weight for Age < -3SD
Moderate Under Weight
(MUW) if : Weight for Age < -2SD to
-3SD
WHO Growth Standards, 2009
Severe Acute Malnutrition
(SAM) if :
W/H < -3SD&/or
MUAC
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Mission Balam Sukham
happy childGovernment sponsored nutrition program
Previously known as Gujarat Nutrition Mission Statement
September 12, 2012
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Mission Balam Sukham
Gujarat govt
Budget 60 million rupees
($1,500,000)
2,000 rupees ($400) to each
18,000 villages in Gujarat
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Mission
To strengthen growth monitoring and evaluationsystem and bringing in subject specialist.
Ensuring growth monitoring and promotion byimproving
Survey efficiency
Weighing efficiency
Plotting of weights on growth charts, and
Identification of undernourished children and detection of
growth faltering and stagnation and focusing on the mostvulnerable- SAM, MAM, SUW and MUW
Amongst other mission statements not shown
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Developing and Integratingappropriate Referral and Practice
Guidelines as outlined in the WHO
child growth standards and the
identification of severe acute
malnutrition in infants and children.
Operational Structure: Three tier approach
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Children admitted
with defined SAM
criteria with Medical
Complications
Children admitted
with defined SAM &
MAM criteria without
Medical
Complications*
Children admittedwith defined SAM
criteria with severe
Medical
Complications/
Oedema
Operational Structure: Three tier approach
*Medical complication: infection, edema, failure of appetite test
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Village (Sub-centres)Village Child Nutrition Centres (VCNCs) at AWCs
Who qualifies: SAM & MAM criteria without Medical Complications
Duration : 30 days
Cost approx Rs 40/child/day
managed by AWW, AWH & ASHA.
Community (CDNCs)Child Malnutrition Treatment Centres(CMTCs)
Who qualifies: SAM criteria with medical complications
Duration: 21 days
Costs approx Rs 200/ child/ day
Daily visit by a Trained Doctor
Mother/guardian accompany onsite, compensated Rs 100/d forwage loss.
District Hospital/Medical College (Baroda)NutritionRehabilitation Centers (NRCs)
Who qualifies: SAM criteria with severe Medical Complications/Failed Appetite test/Oedema
Duration: 25 days.
Costs approx Rs 250/ child/ day
Daily visit by a Trained Doctor
Mother/guardian with child and compensated Rs 100/day forwage loss.
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For children admitted at -3 SD weight-for-height defined by the WHO standards, a
discharge at -2 SD and at -1 SD corresponds on average to a weight gain of 9% and 19%
respectively.
NRC CMTC
WHO Standard for therapeutic feeding programs
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Shakti Krupa Charitable TrustEmpowering Citizens to Strengthen the Roots of the Nation
www.shaktikrupa.org
P i t K 12 S h l
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Private K-12 School
50-bed adult hospital
Community Health Center
3 Ambulances Helipad
Farm for agricultural
empowerment
Government recognized
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Shree Chhotubhai A. Patel Hospital
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Dr. Singh (OBGyn) and Dr. Nilesh (internist)
with nursing staff.
Also pictured: Meghna and Dr. Maloney
The Staff
Dr. Pradeep (Internist)
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Swaddle technique
Avg birthweight ~2.5kg
Post-partum room
&
Well baby Nursery
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Community Health Centre
Second tier care center: Child Development
and Nutrition Center (CDNC)
In 2011, the AWWs in the surrounding Talukaof Sinor referred their children to Mota Fofalia
for a pilot program using new WHO standard
of care
They referred 144 children who were classified
as SAM for treatment
d h l b d f d
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10 day hospital based refeeding
program
Based on WHO treatmentstandards for SAMchildren
10 -21 day stay, until child
reaches target weight Components:
Initial management of thechild:
Management of co-morbidities: hypoglycemia,diarrhea, vomiting
Administering electrolytesolution: ReSoMal
10 d h i l b d f di
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10 day hospital based refeeding
program Feeding:
F-75 formula: 75kcal and 0.9gprotein/100ml
Amounts per reference card
Refeeding without laboratorymonitoring
F-100 formula: 100 kcal and2.9g protein/kg/100ml
Monitoring of vital signs and
Involving mothers in the care
10 day teaching program forfamilies: Hygiene
Food choices and preparation
Danger signs
SAM G j Pil M
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SAM program Gujarat Pilot Mota
Fofalia
144 children treated in 2011
Discharged when they reached target weight
Should be about 15% weight gain to go up 1SD
Long term outcomes ???
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Established Follow-up
There hasnt been any.hadnt
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My Project
h l f ll h h ld
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The Plan: To follow up on the 144 children
treated at the CDNC at Shree Chhotubhai
Hospital for 10 days in 2011 The Follow-up: weight, MUAC, dietary history,
recent illnesses
The Team: 1 driver, 1 sister (nurse), 1 ward-boy, myself
The Equipment: 1 electronic weight scale,
MUAC tape, 1 heavy duty vehicle, and a lot ofpatience
The Route: 7 day adventure to 28 of 36
villages in the Sinor Taluka
Hashmuk (not shown), primary driver
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Parul, Nurse
Ashok, Ward
Boy
Bhagu, Driver(hes usually more happythan depicted here)
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AnganwadiCenters
step one
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Village-to-Village
step two
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House-to-Housestep three
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Visited 28/36 villages in Sinor Taluka
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Were able to find 85 of 144 children = 59% Children not accounted for:
12 children in those 8 villages we did not go to
2 children passed away* Children were out of town for Holi celebration
Children were with their parents in the farm
R lt
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Results
Of the 85 children found and measured by MUAC:
63 were green (74.6%)15 were yellow = moderate acute malnutrition (17.4%)
7 were red = severe acute malnutrition (8%)
No child had edema on exam
One child with a mild skin infection
*2 children expired, cause unknown, unrecorded
- 1 was taken to a nearby hospital the other was not hospitalized.
- From word of mouth, they both had an infection
Reported Illness in past 2 weeks:
ARI: 36/85, (42%)
Diarrhea: 20/85, (23.5%)
Fever: 22/85 (26%)
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Successes and Attributes
Majority of children were green!
Parents seemed educated appropriate
nutrition
Intra-village and inter-village awareness of
community members
Respect for Mota Fofalias hospital
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Shortcomings, Improvement needs
- Efficiency of growth monitoring records and interpretation- Efficient referral systems and communication
- Follow-up structure and plans
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Future Malnutrition Management
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At the Local Level
Growth Monitoring:
Using MUAC as a marker for acute wasting and a
criteria for referral
Making appropriate referrals
Education
Workshops for teaching new VCNC guidelines at to
the village workers Improve approach of teaching feeding practices to
families
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Training Day
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At a Taluka Level
Electronic Data Collection as a means for:
Efficient and simple ways to record anthropometricmeasures
Quick reference Ease of follow-up
Database for research
Current idea is using a mobile data entry system To allow quick transfer of communication for
appropriate referral
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At a District Level
Building NRCs in more accessible locations
while providing adequate treatment, with
appropriate resources and management
Advantages: closer outreach to the ruralpopulation, decreased transportation cost,
ease of navigation, trust in a community
stronghold
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New Pediatric Center
Equipped w/ a: NICU, PICU, an operating room, 4 general wards and 4 special rooms
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2nd floor: Pediatric OR2nd floor: Nursing area
Main entrance Connection to Adult Hospital
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Nutrition Rehabilitation Center
The Shree Chhotubhai A. Patel Hospital will soonprovide a new NRC for the district of Vadodara
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Our Involvement
U of U Pediatrics Department and the
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U of U Pediatrics Department and the
SKCT partnership?
For residents
Opportunity to learn how to
build from the ground up
Clinical experience rotationfor residents
Public health project
development
For the university program
potential global health
fellowship site
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Potential Project Ideas
Developing and researching public healthinterventions Anemia, Vitamin A follow-up research
Smoke exposure in homes
Diarrheal disease Genetic syndromes
Malaria research
Defining outcomes and accountability QI projects
Developing appropriate care processmodels and overseeing integration
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References
International Institute for Population Sciences (IIPS) andMacro International. 2007. National Family Health Survey(NFHS-3), 200506: India: Volume I. Mumbai: IIPS.
WHO child growth standards and the identification of severeacute malnutrition in infants and children. World Health
Organization, United Nations Children's Fund. Publication2009.
District Level Health Survey 3 (DLHS) website: rchiips.org
World Health Statistics 2012. Global Health Indicators.www.who.int/healthinfo
Guidelines on Facility Based Management of MalnourishedChildren. Commission of Health, Government of Gujarat,Gandhinagar. 2012.
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Questions?
Every revolution has to originate from villages; only then can it be successful.
Mahatma Gandhi
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Thank You!