Nandaris Marwein : A Journey of a Little Lamp
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- Nandaris Marwein : A Journey of a Little Lamp
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A JOURNEY OF A
LITTLE LAMP
NANDARIS MARWEIN
FELLOW
BATCH -10
SOCHARA,SOPHEA
BANGALORE
Acknowledgement
My first and foremost heartfelt thanks to Omniscience God for the wisdom bestowed upon me;
I’m so grateful for His unconditional love and His presence throughout my life, my field
internship and throughout my fellowship at SOCHARA.
I am so thankful to Dr Glenn Kharkongor and Revd E. Kharkongor of Martin Luther Christian
University for encouraging and recommending me to do my community Health learning
programme at SOCHARA.
I would like to acknowledge a number of people for the support provided during the fellowship
period and during my study of the research. My deepest appreciation to Dr Thelma Narayan,
Dr. Ravi Narayan, Mohammed, Prasannah, Chander, Kumar, Shani, Karthik for given me an
opportunity to pursue this Community Health Learning Programme and providing academic
guidance.
I warmly thank Ms Reenu Khanna, Ms Sunanda Ganju and SAHAJ team for their kindness and
recognised our needs while staying in Gujarat; most importantly for supports, guidance,
mentoring, acknowledging my ability and for making my study a successful and meaningful
one.
For assistance in translation from English to Gujarati, I would like to thank Parul. The study
would not have been possible without the continuous support and enthusiasm done by
Chetnaben, field worker who helped me in collecting data and oral translation with dedication
and of course to all the pregnant and lactating women who participated in the study are thanked
tremendously.
Furthermore I would like to extend my sincere and heartfelt appreciation to Sabu and Rahul
for their support, patience, hard work of getting my reports into useful shape. I also extend my
heartfelt thanks to Adithya for guiding me in writing about the observation on VHNDs held in
Gujarat.
My special thanks to Dr. Yuvaraj for his understanding and support during our difficult times
especially when we are down; also to Prahalad for taking me in the field for sanitation
programme. I am so thankful to Krishna for providing me valuable suggestions.
I would like to thank the following persons for their support and be part of my life: Samantha,
Madhavi, Anusha, Kanishka, Lekshmi, Banri, Sabeena, Chongneithem, Suresh, Job, Ganesh,
Sonu, Venit, Tejas and Anisha. It is not complete without giving an appreciation to Haribhaya,
Joseph, Tulsi, Kamalama, Vijayma, Maria, Victor, Naveen, Pushpa, Swami, Deepak, Mathew
and all fellows of batch 11.
My heartfelt thanks and appreciation to family for the continuous encouragements and prayers
that they extended to me during my field works and during my entire time of fellowship.
ACRONYMS:
SOCHARA
Society for Community Health Awareness Research and Action
SAHAJ
Society for Health Alternative
AYUSH
Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy
CEHAT
Centre for Enquiry into Health and Allied Themes
FEDINA
Foundation for Educational Innovation in Asia
NUHM
National Urban Health Mission
NGO
Non- Governmental Organisation
TB
Tuberculosis
ART
Antiretroviral Therapy
AAP
Aam aadmi Party
CMC
Christian Medical College
NACO
National AIDS Control Organisation
VHND
Village Health & Nutrition Day
VHAI
Voluntary Health Association of India
STDs
Sexually Transmitted Diseases
CID
Crime Investigation Department
Hb
Hemoglobin
WHO
World Health Oragnisation
ICDS
Integrated Child Development Scheme
NFHS
National Family Health Survey
MNCHN
Maternal Newborn Child Health & Nutrition
Contents
PART A ......................................................................................................................... 5
A BRIEF NOTE ON WHY I WISH TO JOIN THE PROGRAM ................................................... 1
MY LEARNING OBJECTIVES ARE ..................................................................................... 1
LEARNING FROM COLLECTIVE TEACHING SESSIONS: ................................... 2
FIELD VISITS: .............................................................................................................. 6
FIELD INTERNSHIPS:................................................................................................. 6
CASE STUDIES: ............................................................................................................ 7
READING LISTS AND INSIGHTS GET FROM READINGS .................................. 10
WATCHING DOCUMENTARIES WITH REFLECTIVE DISCUSSIONS : ................................... 12
METHODS FOR RECAPS .................................................................................................. 12
INVITING OF QUESTS IN THE CLASS ROOM ..................................................................... 12
OPPORTUNITIES IN PARTICIPATING OTHER PROGRAMMES : .......................................... 14
WORKSHOPS .................................................................................................................. 17
NEW INNER LEARNING WHICH I CONSIDERED THE BEST TO APPLY IN THE FUTURE ...... 17
OVERALL REFLECTIONS ....................................................................................... 19
CONCLUSION ............................................................................................................ 20
PART B ....................................................................................................................... 20
A STUDY ON THE DIETARY PRACTICES AND ANTE-NATAL CARE AMONG PREGNANT AND
LACTATING WOMEN IN BEDVA, RASNOL & S ARSA OF ANAND DISTRICT , GUJARAT ...... 20
PART C ....................................................................................................................... 43
VILLAGE HEALTH AND NUTRITION DAY: OBSERVATIONS AND REFLECTIONS FROM
EXPERIENCES IN GUJARAT ............................................................................................ 43
PART A
A BRIEF NOTE ON WHY I WISH TO JOIN THE PROGRAM
Health is understood not merely the absence of disease, it is a state of complete physical, mental
and social well being. Considering this statement in social work I would like to explore my
knowledge in health learning so that contribution to individuals, families, and communities
will be effective and meaningful. The practice of Social Work requires knowledge of human
development and behavior; of social, economic, and cultural institutions; and of the interactions
of all these factors. Generate knowledge from this program will help me as a teacher and as a
social worker how to enhance the skills in problem-solving, coping and developmental
capacities of people; also how to link people with systems that provide them with resources,
services, and opportunities.
Community Health will be my one of the subjects for Bachelor of Social Work students I
therefore felt the need and importance of having a clear concept and dept learning from the
training what community health is about so as to impart knowledge back to the students and
boosting my teaching career. I also interested in enrolling myself for PhD programme in my
near future on which my topic will be in line with health issue. By participating in this
Community Health Learning Program I hope that I will be able to deepen my understanding in
community health and to enhance my analytical skills as well. Field work activities are
immensely essential for increasing knowledge base and competencies in community health.
Our social work students have their field work placement in different settings. Health setting,
Social Welfare and Targeted Intervention projects to mention a few. By being a part of this
program I strongly believe that I will gain skills, interactions, understanding the diversities and
apply theories into practice. Importantly, I will be able to teach and supervise my students from
health perspective in health settings. Martin Luther Christian University introduces ‘Life Skills,
Human Sexuality and Personality’ as one of the activities and services for undergraduate and
postgraduate students. The life skills team consists of trained facilitators and a medical doctor.
My aim is to get involved in this activity so that I can teach the students, reach out to people in
the community for sensitization and creating awareness in health issues and change positive
attitudes towards health among them. In order to fulfil and achieve my aim is to join this
program and learn from this program. Apart from all the points mentioned above, Vision and
objectives of the SOCHARA inspired me to join the Program.
MY LEARNING OBJECTIVES ARE
•
•
•
•
•
To learn and understand about community health
To learn Social determinants of health through theory and field works (rural & urban
settings)
Enhance my knowledge various concepts such as Globalisation, Paradigm shift,
Knowledge translation, Alternatives, etc.
To visit public health facilities and experience field works in and outside Karnataka
Conduct a research study
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LEARNING FROM COLLECTIVE TEACHING SESSIONS:
Apart from other many topics covered in class the followings are the new terms/concepts for
me but through the fellowship programme I am able to perceive and understand which in later
life I will be able to use them in a meaningful way.
A) Community Health: Learning and gathering from class I understood that Community
means Self-organized network of people with common agenda, cause, or interest, who
collaborate by sharing ideas, information, and other resources. During my field works
I realised that my community that I was concentrating with was women who face
domestic violence, pregnant and lactating women, People Living with HIV/AIDS, and
Urban Slum dwellers. When I think about community health I would say community
health is the foundation for achieving all other goals because it addresses the health
needs of populations as a whole instead of individuals, it is prevention rather than
treatment of diseases. For me a healthy community reflects a sense of mental, physical,
spiritual and economical well being not just the absence of disease or illness in the
community.
B) Medical pluralism/ Alternatives: It is the adoption of more than one medical system,
or the simultaneous integration of both orthodox (Western) medicines with alternative
medicines. It is also the name given to the situation where a patient has a number of
choices when selecting a system of treatment. As learning in class, alternative means a
choice/option or available as another choice or shifted to another choice. Mind and
brain of a person is the main programme that brings the ability to choose, anything
he/she wants to change and choose is from his/her side not from someone else side. For
instance, alternatives in nutrition people always prefer modern food such as fast foods,
oily and spicy food, etc than traditional food items. Regarding health care, majority
would choose facilities that have more technology for treatment or they can choose a
kind of sustainable way of treatment, e.g. choosing knees modern replacement which
last only for 10-12 years or can also take alternatives, that is, walking, do exercise which
will last for long time.
In this medical pluralism there is interconnection of home remedies, local health
tradition, allopathy and AYUSH. Most of local healers in India are hereditary in nature
e.g. Dai, traditional birth attendance and all the traditional healers are always certified
and recognised by their community. In our daily life we always seek alternatives, we
can choose local healers for treating our sickness and we also can choose allopathy for
treatment. One of the reasons is that we have instinct, self regulating balance and
balance to get something of which we would go with our intelligent mind. Instinct,
intuition and intelligent should be allowed to operate in our life to have good health, if
these three tell us that we need alternative in health care then we go with it. In our life
we understand that every system of medicine can contribute to health care in their own
way but the most important to understand is that there should be no conflict so that it
can be utilised without discrimination.
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C) Social determinants of health: As per my understanding there is no single definition
of the social determinants of health, but there are commonalities, and many
governmental and non-governmental organizations recognize that there are social
factors which impact the health of individuals. The social determinants of health are the
economic and social conditions – and their distribution among the population – that
influence individual and group differences in health status. They are risk factors found
in one's living and working conditions (such as the distribution of income, wealth,
influence, and power). The World Health Organization says that “This unequal
distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon
but is the result of a toxic combination of poor social policies, unfair economic
arrangements [where the already well-off and healthy become even richer and the poor
who are already more likely to be ill become even poorer], and bad politics”(Marmot,
Friel, Bell, Houweling, & Taylor, 2008).”
Some of determinants of health that I have learned and linked direct or indirectly with
field experiences are :- water &sanitation, Education, Housing, Maternal and child
health, Caste system, social justice, Nutrition & Food supply, Health policy, Health
economics, Urban & Rural issues, substance abuse, Chronic disease, Mental health,
Health services, Discrimination, violence, aging, Disability, Ethnicity, Gender,
Environment issues, Immigration, income & social status, culture and employment/
working conditions. These social determinants of health are mostly responsible for
health inequities - the unfair and avoidable differences in health status seen within and
between countries. The unequal distribution of these conditions across various
populations is increasingly understood as a significant contributor to persistent and
pervasive health disparities. If attention is not paid to these conditions, we will most
surely fail in our efforts to eliminate health disparities. The question is what we as
community health workers do to collectively assure the conditions in which people can
be healthy.
D) Globalisation and Health: After brainstorming in class I understood that globalisation
has a ranges of meanings, it depend on a group or individuals how to define it. After
having many sessions on globalisation I understood that globalization is the flow of
information, goods, capital and people across political and geographical boundaries.
Many people would say that globalization has had an overall positive impact on
peoples’ health. In many ways, that is true. For instance, global transportation and the
communications revolution enable rapid response to epidemics and catastrophes,
saving thousands of lives. But there also is a downside to the health and well-being of
people as a direct or indirect result of globalization. For instance, Non communicable
diseases which I learned in class resulting from unhealthy lifestyles are now in places
in the world where they were either unheard of or rare just 50 years ago. Obesity,
hypertension and type2 diabetes are an enormous health problem today, and the
incidences are increasing in developing nations. This rapid increase again illustrates the
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globalized risks for conditions that are mainly caused by diet, even in less developed
countries that have coexistent under-nutrition. There is no doubt that due to improved
agricultural techniques and productivity combined with increased trade, malnutrition
decrease. But looking at genetically modified food production, for example, can
produce more food, but there are some negative aspects to it as well. The methodology
for producing those crops, such as the use of pesticides, can have a harmful
environmental side effect and if humans consumed these foods will definitely affect
their health. I believed that all these are because of globalisation.
E) Research (Qualitative and Quantative): Qualitative research is concerned with nonstatistical methods of inquiry and analysis of social phenomena by using detailed
descriptions from the perspective of the research participants themselves as a means of
examining specific issues and problems under study. After having session on this topic
I gained my knowledge understanding that conducting qualitative research will help a
researcher how many different causes and actions lead to specific outcomes, it helps
how the detail counts by recording attitudes, feelings and behaviours and it helps to
avoid pre-judgements.
As per the knowledge I perceived Quantitative research means that the quantitative
researcher asks a specific, narrow question and collects a sample of numerical data from
participants to answer the question. The researcher analyzes the data with the help of
statistics. Subjectivity of researcher in methodology is recognised less. The researcher
is hoping the numbers will yield an unbiased result that can be generalized to some
larger population. According to my experience in doing quantitative study in Gujarat I
understood that Quantitative research is more reliable and objective and can use
statistics to generalise a finding even though less detailed and miss a desired response
from the participants.
Learning about both Qualitative and Quantitative I would say that Qualitative methods
might be used to understand the meaning of the conclusions produced by quantitative
methods. Using quantitative methods, it is possible to give precise and testable
expression to qualitative ideas. This combination of quantitative and qualitative data
gathering is often considered referred good for more information.
F) Communitisation under NRHM: One of the main frame works and strategies of
NRHM is communitisation. Communitizing the health care was the ongoing process of
decentralization and people’s involvement for making health care services effective.
Development of village health plan through Village Health and Sanitation Committee
(VHSC). Panchayat Raj Institutions (PRIs), self-help groups, and health, nutrition and
sanitation committees have been activated to seek local accountability in the delivery
of programs. During my field visit at Tamilnadu I can see that The NRHM also
establishes accountability structures like the Village Health Water & Sanitation
Committees (VHWSC) at various levels of facilities. Untied funds of all kinds under
NRHM also are a part of the overall design of strengthening of ‘Communitisation
Processes’ envisaged in the programme framework of NRHM, so they should not be
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seen in isolation. What helped immensely is that Accredited Social Health Activist
(ASHA)/Animators provide the link between monitoring and planning at the village
level as the two processes go together for positive change. Learning from collective
sessions and field visits I can say that the process of community involvement of the
health institutions itself would enhance accountability, which places community at the
central place in respect to planning and implementation. Involvement of voluntary
Organizations is critical to ensure the communitisation process. The idea is to realise
that decentralized planning, facilitation of implementation, oversight and monitoring
through community involvement is likely to be more responsive to the healthcare needs
of local communities and will be a step towards ‘Communitisation’- a hallmark of the
NRHM.
G. Knowledge Translation: Knowledge translation is defined as the use of knowledge
in practice and decision making by the public, people (patients), health care
professionals/Activists, managers, and policy makers. It is a relatively new term that is
increasing in importance and use in the field of public health and medicines as well.
Researchers have focused their attention on knowledge translation as both a process
and a strategy that can lead to utilization of research findings and improved outcomes
for consumers. Knowledge Translation in Health Care explains how to use research
findings to improve health care in real life, everyday situations.
During my research study period, I conducted a study on the problem of Aneamia in
three villages of Anand district, Gujarat. I was questioning myself what I’m going to
do with my study, in my mind, my study will be in my bookshelf only. But learning
about knowledge translation I realised that my study will be useful for health activists
of SAHAJ, public health providers of these villages and of course my study will bring
light to the participants. The significance of my study is to translate the evidence I have
collected into the knowledge for further actions. My findings will be translated by
health activists, health providers, field workers in to the knowledge of the participants
and even to other people in those areas so that pregnant and lactating women in
particular and other women in general will know their anaemic status and most
importantly they will know how and what to do in order to upgrade their health status.
G) Health economics: Economics deals mainly with money and spending on health can
be justified on purely economic grounds. Economics also helps in decision making how
to manage, generate and prioritisation of resources. It gives us a tool to prioritise what
is the most important for us whether it is primary care, surgery, etc. Health Economics
is a branch of economics concerned with issues related to efficiency, effectiveness,
value and behaviour in the production and consumption of health and health care. I also
can say that it deals with issues related to the financing and delivery of health services
and the role of such services and other personal decisions in contributing to personal
health. Health economics in health helps how to allocate resources between various
health-promoting activities and use for health purposes; it also helps in organising and
funding of resources to be used in health delivery. Looking at our Indian health care
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system it is characterized by low levels of public spending on health care; poor quality
in health care services, with adverse effects on the population‘s health status; a lack of
focus on preventative health care; and dependency of the population particularly the
poor, on private health care providers and consequently high Out-Of-Pocket spending.
Therefore learning of Health economics helps me in the future to know how to manage
and prioritise the available resources for effective and meaningful utilisation.
FIELD VISITS:
During the fellowship my co-fellows and I went to visit Siddapura and Old
Byapannahalli slums, Domasandra Public Health Centre, Well-being centre and
Sakkalawara Community Health centre of National Institute of Mental Health and
Neuro Sciences (NIMHANS), Foundation for Revitalisation of Local Health Tradition
(FRLHT), Snehadan, Association of People with Disability (APD) & Basic Needs India
(BNI). Field visits helped me interact with what I am learning; they also give me the
opportunity to experience new venues. The experience goes beyond reading about a
concept; I was able to see it and participate in it physically.
Together with co-fellows I also had fun while going to field and from these field visits
I realised that Learning and fun make a great combination. I was so touched by
facilitators who supervise fellows during a field visits carried a great amount of
responsibility on their shoulders. I realised that the connections established during field
visits encouraged fellows to come to the facilitators with any problems they may
experience during the fellowship. Most importantly field visits helped me to have an
in-depth understanding about health systems and services delivered by health providers
and also understanding more the health status of people, their social determinants and
their real life situation.
FIELD INTERNSHIPS:
Apart from having field visits the fellows had to do their internships according to their
area of interests. My first field internship was at Vimochana, Bangalore where I had
chance to learn about how women face domestic violence even if they are educated and
wealthy and how rehabilitating those women helps them to rejuvenate their health
problems which affect them physically and mentally. When I was placed at shelter
home, a home for women who face domestic violence I had an opportunity to do a case
work and also taught those women how to make greeting cards, sold those cards and
donate the amount to Vimochana which is mainly for those women at the centre.
Introducing this activity helped these women to switch off their tensions for a while
and switch on their joyful moment to a conscious mind by concentrating on the activity.
Another field placement was at SAHAJ, Baroda, Gujarat. In this organisation I had a
chance to learn about Village Health and Nutrition Day, services provided by health
workers and health seeking behaviour among the women in the villages. During my
field work I also have learned about entitlements (JSSK) that women get from the
government which helped them to have a better health care. Most importantly I had a
great opportunity to conduct a study on ‘The dietary practices and Ante-natal care
6
among pregnant and lactating women in Bedva, Rasnol & Sarsa of Anand district,
Gujarat’. From this study I understood that anaemia is still the problem not only in
Gujarat but also in the whole country.
My last field work was in St John Medical Hospital, Medico social work department
and at Swathi Mahila Sangha organisation. In St John I had a chance to visit in the
dialysis ward together with the students of Christ University. I also attended a gathering
organised by the Social workers of Medico Social Work department for the support
group of dialysis patients. During the process of treatments these dialysis patients faced
lots of challenges and problems as their family abandoned them due to financial
difficulties and loose hope on these patients. In order to make them feel accepted and
have hope in their life, social workers took initiative in forming a support group for
dialysis patients. On the day that I attended the gathering social workers and some
doctors facilitate these patients the discussion of how to improve their health status. It
so inspiring and interesting session because these patients came up with lots of
constrains they see during the process of treatment and at the same time they discussed
of how to solve the problems and achieve the gaps and constrains.
Another field work I did was at Swathi Mahila Sangha organisation (SMS). Its head
office is in Sanjaynagar and target interventions I visited are in Bommanahalli and in
Shivajinagar. SMS, a community based organisation of women in sex work formed in
2003. Experiencing in this organisation I have learned that it was initiated to holistically
address issues of women in sex work, with respect to health, risk of HIV infection,
various forms of crises and economic and social insecurity that increase their
vulnerability to HIV. Providing necessary support to these women who engage in sex
work industry helped them to overcome various challenges they face every day. This
will help building relationship among themselves and also maintain their regular
contact for effective services.
Reflecting these field internships I have learned that Internships are a proven way to
gain relevant knowledge, skills, and experiences while establishing important
connection in the field. Field internships make me understand that staying and working
with the community “It's not what I know, but who I know”. I also realised that
internships helped me how to apply knowledge from classroom to connect and relate to
the workforce that I will be undertaken. While observing the staff of these organisations
I have learned and realised that I will surely be able to do a networking with
professionals in the future. I really learn how to get to know the people, live with them,
learn from them with what they know especially those who are in the field; learn their
traditions, health status, their challenges, eating habits and their mindset at some point.
Apart from these above mentioned points I also gained my insights how to set my goals,
how to keep my positive attitude and try new things such as food, dress, language, etc.
CASE STUDIES:
The followings are some of the case studies conducted during my field internship at
Vimochana, Kolar district:
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1. A case study was conduct with Asha who is staying at shelter home (we conducted at
her room as she is not comfortable talking in front of other women in the shelter).
Originally she is from Mysore but after getting married she stayed with her husband in
Mumbai. Her husband was a manager at Air port; they have a flat where both of them,
their two daughters and a son were staying. After some years her husband got married
to another woman and left Asha alone because her children got married and they are
staying in their own place.
In order to kill her loneliness she decided to do a business, selling sari imported from
Kolkatta and transport to Mumbai. Her business was good enough so she employed two
boys from Kolkatta of whom she treated them as her own children. Greediness
penetrated the minds of these two boys. According to her sharing these two boys gave
her something to drink which make her weak, dizzy and sleepy. When she was in that
kind of condition these two boys graph their opportunities to let her sign the documents
of her flat and sold it to someone else, they also took all her jewellery and fled away
with a huge amount of money.
When she became conscious again she realised that she was betrayed by those two boys
whom she loves them as her own children. Without delay she informed her family and
her brother-in-law who is staying in Mumbai and working in CID department. They
filed a complaint to Kolkata police station and also to the court. The case on this issue
is still going on till now.
During the sharing she said that maybe because of that drink she consumed in Kolkata
her mentality is not right always, sometimes she spoke correct and nicely but sometimes
talked nonsense and not correct. Seeing her in such condition her family brought her
back to Mysore where they also ill treated her. She sadly said that when I was rich
everybody treated me well but now when I am in this condition they never accept me
and they even blame me for what had happened.
Her brother in-law knows one judge very well and he used to tell that judge about the
problem that Asha faces then the judge called her and listened her story. Fortunately,
that judge knows Ms Shakun from Vimochana quite well and the judge passes the same
story to Ms Shakun. Hearing this story Ms Shakun called Asha and let her come to
Vimochana by later encouraging her to stay in a shelter home which is in Bangalore
and after that she was transferred at shelter home, Kolar. She ended her story by saying
that her brother in-law called her back to Mumbai to stay with his family and continues
the case for justice. She is planning to go to Mumbai on the third week of the month of
November, 2013.
2. Bhagya an 18 year old mother hails from Mesahagatte completed her education till
class VII. She was once working in one house doing household works where she met a
man who she became to know that he has a family. In spite of knowing that he is married
she continued having an affair with him and got pregnant. When she got pregnant she
never had courage to tell her own family, she seeks help from the house owner instead.
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Fortunately the house owner is a very good person and she took Bhagya to St Martha
Church, Bangalore. In this church they help pregnant women but when they gave birth
to their babies they will send away the mother but keep with them the babies. So it
happened to Bhagya also, after 15 days of giving birth to twins (boys) the church is
taken care of the babies and sent away the mother. Even in this condition the same lady
(house owner) still helped Bhagya by telling to Ms Donna, Vimochana, Bangalore to
help Bhagya in any way she can. Bhagya was sent and admitted at Shelter home, Kolar
in August, 2013. She said that she is already talked to the staff of Vimochana about her
job after going out from the shelter but she doesn’t know what kind of job yet. Bhagya
said that after she is settle with the job she will go home but to visit her babies is not
possible right now as the church does not allow her to visit her children. But she still
have hope that she will be able to visit and meet her own kids in the future, she is happy
because her children are in the good hands, she said.
3. Another case study was conducted with Ms Rupa. The case was studied during evening
time at the office of shelter home as it was convenient for the client. Ms Rupa hailing
from Thalagudha, Kolar district was a repeated client (her third time in shelter home)
of shelter home. She completed her studies till standard IX. Without having admission
for class X she married a man (arranged marriage) from Bangalore who doesn’t have
any concern about her. Her husband was working as an electrician.
During her stay in Bangalore she went to a tailoring class but her husband and her inlaws never allow her to do the course. Pressurising by in laws she discontinued the class
and stayed at home where her husband and in-laws harassed her mentally and
physically. Since she is the daughter of a mother from the second marriage no one
bother her and her life. Ms Rupa does not know till now where & how her mother is (as
the mother married to another man whom Rupa don’t know). The father never considers
Rupa as his daughter because he has sons from his first wife whom he is staying with.
Fortunately Rupa has a grandmother whom she is always shared her problems with.
When her grandmother knows about the condition of Rupa she came to Vimochana
office to seek help from Ms Shantama. Since the place where grandmother and Rupa
are staying is not far from Vimochana, Kolar immediately Rupa was admitted at Shelter
home for the first time in 2012, second and third time was admitted in 2013. During
her stay in shelter home she was counselled by the counsellor and by the members of
the panchayat to go back to her husband house. She could stay there only for few days
because her husband and her inlaws continued harassing her every day. With the help
of Vimochana she is planning to continue her studies (class X) in government school
where books, uniform, accommodation and food was free of cost. She will join the
school in June 2014. At present she is helping in cooking and cleaning at shelter home.
Rupa proudly said that she is happy now, don’t want to go back to husband house but
continue her studies and become a teacher to teach others how to be strong in fighting
injustice.
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READING LISTS AND INSIGHTS GET FROM READINGS
Apart from many other books, articles, journals, reports, magazines, etc followings are the
readings which I found inspiring and relevant to health and social issues directly and indirectly:
1. “Behind Closed Doors: Domestic violence in India”, Edited by Rinki Bhattacharya,
published by Vivek Mehra for SAGE Publications India Pvt Ltd,New Delhi, 2004.
Rinki Bhattacharya is former victim of domestic violence, a well-known critic,
columnist, women’s rights activist, writer, freelance journalist and a documentary film
maker based in Mumbai. CHARDIWARI, her documentary film on domestic violence
received international acclaim. She has worked as a volunteer at the Nari Kendra
(Mumbai) and later founded a crisis hotline for battered women called HELP. Presently,
Rinki is Chairperson, Bimal Roy Memorial Committee, Mumbai. This book is
dedicated to women trapped in abusive relationships...and those of us who escaped,
Rinki said.
The book puts together the life stories of 17 women from diverse cultural, class,
education and religious backgrounds in India who were victims of domestic violence.
This powerful book is a tribute to the courage and determination of women who decided
to break their silence. It will inspire other victims of this ‘hidden crime’, to speak out,
share their plight and change their fate.
To be assaulted, abused and raped by someone as intimate as a husband, or lover is the most
degrading experience for a woman. Not recognised as ‘real’ violence, abuse of this nature is
experienced daily by countless women in every culture. Behind closed doors of family, custom,
values, traditions that are taken for granted and never questioned - are muffled voices of terror
and trauma, which do not reach beyond the threshold nor attract the attention of lawmakers or
redress agents.
2. Shepherd, Bruce. D and Carroll A. Shepherd “The Complete Guide to Women’s
Health”. New York: New American Library, 1985. This book offers a good amount of
practical information about such subjects as pregnancy, birth control, STDs,
menopause, sterilisation, hysterectomy, preventive health concerns, nutrition, exercises
and drug problems. Specialists assist women in choosing and using services within the
often-confusing health care system. In each of the chapters, step by step diagrams are
used to indicate whether home treatment or medical care represents the best choice.
Women seeking a complete and up-to-date health guide for the 1980s will find this
thoughtful, professional volume a most valuable resource. The Shepherds, a husbandwife, doctor-nurse team, have taken a humanistic perspective that is oriented to women
as informed users of health care services. The authors talk as people talking with other
people about medical issues that are important to all women concerned about their
health. The wide range of problems covered in this book will enable readers to identify
warning signs and take appropriate measures when health problems are in their early
10
stages. Use of this book will go a long way toward helping a woman better understand
her body, her health and her options when she needs medical care.
3. Pink Sari Revolution: A Tale of women and Power in India written by Fontanella
Amana Khan and published by Picador in London, 2013. Fontanella is a contributor for
The New York Times, The Financial Times, The Financial Times Weekend Magazine,
Slate Magazine, The Christian Science Monitor, The Daily Beast, Conde Nast Traveller
and is formerly a Contributing Editor at Vogue India.
This book is about fierce, frank and courageous work of the Pink Gang in freeing
Sheelu, a 17 year old girl from the clutches of a powerful local legislator who ended up
in jail. Shahbajpur, Atarra, Bundelkhand and Chitrakoot in Uttar Pradesh are the main
places in this book. The Times of India headline mentions “Even God can’t control
crime in UP”. In such notorious situation Sampat Pal, leader of the Pink Gang and her
20,000 strong all-women vigilante group operating from Bundelkhand crusading for
the rights of groups or individuals who were dealt an unjust hand. Sampat Pal's
extraordinary courage will inspire, delight and fill the readers with hope. In this book
the reader finds the story as an inspiring story of self-reliance and female grassroots
activism.
4. Genocide in Gujarat 2002 impact on health and women, produced by CEHAT,
Mumbai and prepared in May 2002. Reading this book there is a realisation that the
issue of sexual violence is grossly under reported, especially in rural areas. Women’s
health was physically and mentally affected. Till today Women continue to be markers
and cultural symbols of a community. To dishonour women is seen as an easy way to
dishonour a community, people need justice because justice still has not taken place for
the victims of this genocide.
5. Where there is no doctor: A health care handbook contributed by David Werner and
published by VHAI in New Delhi, 2010. Reading this book I understood that it is not
strictly to medical professionals only, it is for other health workers or even to ordinary
people who can take the lead in their own health care, it is like a first aid book. In this
book traditional forms of healing and home remedies are focused of which I personally
love to apply in taking care of myself and others in my future. I also have learned that
this book was written for anyone who wants to do something about his or her own and
other people’s health. I love reading this book because it explains in simple English
with drawings which is easy to understand.
6. Speaking tree, Women speak Asia-Pacific court of women on the violence of
development, Edited by Corinne Kumar, Donna Fernandes, Madhu Bhushan,Celine
Saguma, Gowramma, R.L Kumar, etc., produced by Asian women’s Human rights
Council and Vimochana, Bangalore, 1995.
Reading this book I understand that it talks about Asian Public hearing on crimes
against women related to the violence of development will hear women victims speak.
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It also talks about issues of dowry, female infanticide, devasis and sex trafficking and
witch hunting, displacement of people by mega-development projects like big dams,
migration and on shelter and homeless in the cities. The effects of nuclear radiation and
the violence of modern science and technology.
When I read these books, it feels great to put myself into a different world that the
writers have created. As I reflecting on what I read, I start forming my own thoughts
and values. Readings challenge my mind and my thoughts, customs and traditions that
I have grown up with. Through reading, I understand properly what I have read and
reflect upon it, I expose myself to new things, new information, new ways to solve a
problem, and new ways to achieve things. When I’m reading, I’m actually gaining the
knowledge and experiences of someone that inspired my life so as to inspire others as
well.
WATCHING DOCUMENTARIES WITH REFLECTIVE DISCUSSIONS :
Fellows were not confined to lectures and presentations only but also spent their time
in watching meaningful documentary films which are about health, environment and
social issues. Documentary films we watched were – violence against women, VHND
before going to Gujarat, Ramaka story, non- communicable diseases (Diabetes), Social
exclusions (caste), Climate change: heat wave/cold wave, disasters & GMO. During
class session there were topics which are difficult to grasp so Documentary Films are
like lectures that help in visualizing the contents we are trying to understand and
discuss. Documentary film helps me to enhance my knowledge, develop my analytical
and thinking skills.
METHODS FOR RECAPS
The fellows were very creative in doing recaps. They used to have a recap every
morning and sometimes in the evening. Most of the time the recap was oral recap where
each fellow had to produce key learning points and also reflect on those points learned
the previous day and previous week. The most creative way of doing recap is ‘role
play’. In this role play the fellows had to collect and gather learning points from all the
topics taught, combine and arrange together those topics and did a recap in the form of
role play. The role play was directed by Dr. Yuvraj, facilitator & programme
coordinator and was played by the fellows and watched by SOCHARA team.
INVITING OF QUESTS IN THE CLASS ROOM
Introduction: quest lectures are mostly sharing of experiences than power point
presentations which I love the most because by learning from other experiences we
speed up our own evolution. During these kinds of sessions we had sharing from both
the quests as well as from the fellows. Sharing session was also done during Kumar’s
class where all the fellows shared their experiences which are so emotional but
confidentiality is maintained.
Some inspired quest lectures and sharing are:
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Ms Vallarie Kaur: Ms Kaur is from USA, she came to SOCHARA with her friends to
tell stories about issues that need to tell. She shared about Civil rights and movements
in US context. She also shared about the shooting in Sikh community happened in the
temple at Oak Greek (USA), this incident which happened on August 5, 2012 was
known as a domestic terrorist type situation. Listening to her sharing I recollect back
the incident when I was at home watching the news on this issue and about condolences.
After shooting there were many condolences from government officials as well as from
general public. President Barack Obama offered his condolences calling the Sikh
community ‘a part of our broader American family’ but I think is not enough just to
feel pity without action. I hope that through the journey of Ms Valarie and her team in
playing their role to tell story on any particular event I believe actions will be more than
words.
From her session I realised that story telling should be told for the benefit of the
oppressed. The role of story tellers is to figure out the situation of the people who are
abandoned, who face harassment and who have no voice to raise for their problems.
Most importantly, storytelling is to tell the story that provokes universal movement
which provide a chance to experience a variety of emotions without the risk of those
emotions themselves. I also understood that storytelling provides the soil wherein
empathy for others takes root and grows.
Mr Elango: On the first day of resuming our class after coming back from field work
we had a sharing session shared by Mr. Elango who is working at Sam Raksha since
1993. He shared that he was found positive in 1988 but since no NGO working for
HIV/AIDS persons that he knew about and also because of stigma attached to HIV, he
was just kept silence about the problem until he met Mr Kumar, SOCHARA. Mr.
Elango reminded the fellows about the basic knowledge of HIV, he also mention that
in America AIDS only is identified not HIV but in 1983 in Fransisco the virus was
identified and the first case in India was in 1986 in Chennai (CMC, Vellore) and in
Karnataka the case was identified in 1987. The government started NACO in 1992 and
from 1995 onwards NGOs were coming up to work for HIV/AIDS. The first ART drug
(single drug) was provided in 1996 and from 2004 the government is providing ART
free of cost.
From Mr Elango’s sharing I have learned that people considered HIV/AIDS as a
dreadful and fatal disease which in fact is not, this is due to wrong and fearful messages
that Health providers and NGOs spread during awareness programme. This is the
reason why general public have lots of stigma and discriminate those HIV positive.
Reflecting to this issue, it is a high time for us as Community health workers to educate
ourselves first then give correct information to others. I feel that NGOs and health
workers have to motivate the particular community so that they will have self esteem
and strong enough to face any challenges.
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Reflecting to the real situation, majority of positive people would prefer to go to private
hospitals for treatment. It would be helpful if there is a private –public partnership as it
happens in St. John Medical hospital (govt provided kits) so that services will be
reaching out to many. Communitisation is very important, when positive people stand
together for a cause no one can take their rights and no one can discriminate them. One
inspire thing that this particular community had done is strengthening Labour policy.
According to this policy no one can remove from the job or position which a positive
person is holding. This is a good sample that other marginalized communities also to
take and follow for their future security. If the virus has a skill to change its shape we
humans also should have an extra skill to change and stop stigma and discrimination of
any sort. HIV positive persons should get more motivation and correct information. It
is a high time to the general public also to make an effort to get correct message on this
particular issue.
Basic Needs India: Dr. Mani Kalliath and Mr. Gururaghavendra, staff from BNI shared
their knowledge with the fellows about Mental health. During the session we had a
group discussion in which we had a chance to share our experiences related to the topic
we discussed within the group. Personally I’m so thankful to Dr Mani for giving me a
chance to share my personal life experience I faced several years ago which make me
feel relax after my sadness and anger is gone. My experiences were really affecting my
mental health but because of his class I’m Ok now.
OPPORTUNITIES IN PARTICIPATING OTHER PROGRAMMES :
Apart from class sessions and from any programmes that scheduled by SOCHARA there were
other programmes that fellows attended and participated which personally I gained my
knowledge on many issues related to health and social issues.
Mental health session at NIMHANS:
Under the guidance of Dr Yuvaraj fellows attended a session on mental health presented by Dr
Girish, Additional Professor and Mr Mathew Vanghese, MD, Professor of Psychiatry,
NIMHANS. Learning outcomes from this session were understanding of global key
determinants such as poverty, low education, unemployment, deprivation, homelessness are
the risk factors which affect the mental health of a person especially to vulnerable groups such
as women, children and elderly. The new learning from this session is brain injuries can also
cause mental disorders which directly affect the mental health of people. Hoping the Indian
government will give a strict enforcement of Helmet Law uniformly to all the Indian states not
just some parts of the country.
Mfc meeting:
During mfc meeting held in New Delhi in February 2014 I observed and graph some important
things which I understood mfc as a ‘current thought’ which discussed the topics that are socially
relevant such as cast, religion, gender, etc. Participants who attended the meeting feel relax and
flexible because children of some participants can also attend the meeting with their parents. It
14
was a nice thing to see that many background papers are circulated and presented for further
discussions. Gathering the key points from lectures, presentations, sharings, quest lectures,
group discussions I have learned that social exclusion and discrimination on the basis of caste,
class, gender and religious minorities is still rampant in our society. This kind of unfair
treatment affects the health of individuals physically, mentally and spiritually. Since mfc has
always supported in people’s movement for health, responding to such problems by the
members of mfc and by people themselves will bring a healthy environment and a healthy
society.
Mela:
During the fellowship I had an opportunity to attend two mela i.e, Mahila mela at Lowry
College Campus, Bangalore organised by Headstreams. Mr Naveen coordinated this mela
where 25 SHGs were taken part. Reflecting at how those women participated I would personal
say that they performed with enthusiastic spirit, their happy faces tell like they are saying ‘this
is my day, I enjoyed it, I strongly believed that when women are empowered, they really are
independent. Another mela is NGOs mela organised by Social work department students at
Christ University, Bangalore where all the NGOs had their stall for self presentation to those
who visit their stall. Having interaction with all the members/ staff of these 21 NGOs I realised
that running an NGO has lots of sacrifices to what things need to be done and achieved, I was
really impressed by their aim and objectives, their vision to extend their helping hands towards
underprivileged and marginalised groups.
Summer camp:
Headstreams organised a summer camp in May, 2014 in government school in A. Narayanpura,
Bangalore where SOCHARA fellows attended the programme. In this camp, children from low
economic background participated with the help of volunteers. Attending the closing ceremony
of the camp was interesting and enjoyable. Seeing those kids dancing I felt happy and most
importantly I understood that we the agent of change should keep in mind that these kind of
children need not only financial support but also psychological support for their bright future.
Protests:
The fellows are not confined only in class room, we also participated in protests organised by
NGOs such as FEDINA protesting against injustice done to unorganised sectors such as
construction & domestic workers and elderly.
Vimochana protests against all types of violence and harassments such as domestic violence,
it also conducted a protest against racist and sexist attacks against Ugandan women entertained
by AAP minister. Another NGO is Green peace protests against Genetic Modified Organism
which genetic foods are considered dangerous and harmful if people who consumed these
foods, farmers are bind by Monsanto’s regulations. Participating these protests I realised that
15
concern for others is important, it doesn’t matter we know those people who are the victim or
not. I was inspired by William Faulkner who says “Never be afraid to raise your voice for
honesty and truth and compassion against injustice and lying and greed. If people all over the
world...would do this, it would change the earth.”
Documentary film:
SOCHARA fellows attended a discussion session conducted at St John Medical College
Conference Hall, Bangalore. After watching a documentary film on ‘Empathy’ directed and
produced by Alex Gabbay. Medical professionals and fellows had a discussion that doctors
miss opportunities to express empathy in conversations with patients of which I also had a
chance to share my experiences on this particular issue. During the discussion I have gained
my understanding that clinical empathy is important because showing empathy can actually
save doctors time and improve patient satisfaction and even outcomes.
Launching of Nation Urban Health Mission:
NUHM was launched on 20th January, 2014 at Freedom Park, Bengaluru where Sri Ghulam
Nabi Azad inaugurated the function. Experiencing from field visits at urban setting and having
a chance to attend a launching of NUHM helped me to understand how government of India
should concentrate according to the needs at different context. By covering up the unorganised
sectors (slum dwellers, street children, homeless, etc) half of the problems such as clean water
and sanitation, housing, waste disposal, Anganwadi centre and other public infrastructures in
urban areas will be probably solved. But the most important thing I feel is people need to be
empowered for better accountability.
Chennai and Bangalore trips:
Under the guidance of Karthik SOCHARA team from Bhopal and Bangalore had a Chennai
trip where we visited Dr. Chandra Agency, PHC and Panchayat visits. From the visits I realised
that health care services and health status in this area differs from our state (Meghalaya).
People in Tamil Nadu are more involve in local institutions (Panchayati Raj Institutions) and
utilise public health system meaningfully, health is decentralised and localised. Due to this trip
a close relationship was build among the fellows and a sense of belonging to one family was
created in fellows’ mindset. Another trip was in Bangalore where SOCHARA fellows under
the guidance of Ms Shani visited some important places such as museum and shops run by
SHGs. Self reflecting on these SHG I gained knowledge on how strong the functions of SHG
are. Women are more financial independent which leads them to have better self-esteem and
better life in their future.
During the trip we also enjoyed travelling by Metro at M.G Road because it was so comfortable
and not crowded. While travelling in this Metro I was pondering to myself that this Metro rail
system adds to the beauty of Bangalore skyline and I hope it will reduce carbon emission
effectively and most importantly I hope it will function according to the need of people at large
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not just for sight seeking. These trips foster a sense of teamwork and community among fellows
as they experience a field trip together.
WORKSHOPS
Attending workshops both in St John and Ashirvad make me aware of various issues
connecting with health. These workshops conducted as part of the initiative where participants
discussed and reflected their experiences in depth and meaningful manner for possible
directions to be taken in the future. In a workshop ‘Social justice in Health’ there was one new
term which I considered another important aspect in our generation i.e,. Social vaccine. As per
my understanding Social vaccine is an encouragement the bio-medically oriented health sector
to recognise social and other determinants of health for improving health equity. Another
workshop conducted at Ashirvad, St Mark Street was about promoting patients rights and
ensuring social accountability of the private medical sector and Clinical establishing Act.
Listening to the discussions and final suggestions made in this workshop I understood that in
India privatisation is so rampant and health care is commercialised.
The noble profession which should be devoted to the service of human kind is now being
converted into a profit making industry. In order to bring health for all, public health systems
should be strengthening and should enshrine patients’ rights, there also should be a promoting
and upgrade of all the existing public health systems. There was another workshop I attended
was in Mumbai where maternal health and social autopsy were mainly discussed. Social
autopsy refers to an interview process aimed at identifying social, behavioural, and health
systems contributors to maternal and child deaths. It is often combined with a verbal autopsy
interview to establish the biological cause of death. Two complementary purposes of social
autopsy include providing population-level data to health care programmers and policymakers
to utilize in developing more effective strategies for delivering maternal and child health care
technologies, and increasing awareness of maternal and child death as preventable problems in
order to empower communities to participate and engage health programs to increase their
responsiveness and accountability.
NEW INNER LEARNING WHICH I CONSIDERED THE BEST TO APPLY IN THE FUTURE
Tap turner off: Even though I’m from Social work background I never realised what type of
social worker am I but learning this community health I came to senses that turning off the
flow of problems by addressing those problems appropriately will bring positive changes in
the health of a person. When Dr. Ravi was asking the fellows to think about one room where
there is an open tap in a basin with overflowing water. He asked us that when you enter the
room and see the floor full of water, what will be the first thing you should do? Turn off the
tap or mop the floor first?
All of us answered that we should turn the tap off first and then mop the floor, which is correct.
Then again he asked us Are you a Floor mopper or a Tap turner off? All of us just kept silence.
Interestingly he explained that the water that flows from the tap denotes various kinds of
17
diseases or illness that overflowing in our life whereas turn off the tap and mopping the floor
means to tackle the problems but the question is what kind of methods we will use, turn off the
tap or mopping the floor. Gaining knowledge from collective sessions and from field
experiences I realised that most of health professionals are just floor mopping due to various
reasons. One of the reasons, perhaps, is that we always think that only medicines/ drugs,
technology (floor mopping) can cure the illness but we failed to understand that concentrating
to other social determinants (turning off the tap) would even reduce the problem drastically.
Therefore preventive, promotive, rehabilitative care approach is important to use not just
curative alone if we want to tackle the challenges in health.
During my field internship I have learned about violence against women and the problem of
anemia among pregnant and lactating women. Reflecting on this floor mopping and tap turning
off I realised the government, health professionals, policy makers are tend to be the floor
mopper because Iron Folic Acid was provided to those women who are anemic and not
promoting or strengthening local nutritional foods available in kitchen garden or lower the
price of foods products in the market, education for nutritional conscious, water and sanitation,
etc. Looking at violence against women health providers tend to prescribe medicine for curing
the mental illness for curing wounds or any physical injuries of women instead of looking at
psychological health, Gender sensitivity, socio-economic and cultural condition of these
women. Analyse and examine from all angle of understanding and experiences I realised that
as Social worker and as Community health worker I should become a ‘tap turner off’ for better
action in the future.
Paradigm Shift: Paradigm shift is a fundamental change in an individual's or a society's view
of how things work in the world; it is a change from one way of thinking to another; it just does
not happen, but rather it is driven by agents of change. Paradigm shift in health is about
understanding from medicine/medical model to health/wellbeing model. When we say
medicine we only think of modern/western medicine/allopathy, of course bio-medical way of
thinking is not wrong but is not enough in every area of health system. In bio-medical we
always think at individual, patients, but if we understand health as overall wellbeing we have
to shift our way of thinking by showing and creating a sense of dignity from patient to person
or group of people.
To have a better understanding on this paradigm shift further explanations can be given such
as TB, Cancer, and mental retardation. When we think of TB, Cancer or mental illness in
women immediately in biomedical we think of her physical body or pathology that means
which part of her body that has cancer, which medicine to prescribe Mental illness, TB but in
health/social model we have to think about social, economic and violence against women. In
bio-medical we see virus, germs, bacteria, drugs, medicines, kit but in health model we have
to understand and concentrate on unhealthy sexuality, enabling environment and empowerment
that people themselves can do and bring positive changes in their lives as well changes in the
society.
Important thing which change me after learning from this programme is understanding myself
as a little light. I came to SOCHARA with the attitude of ‘chandelier’ but now I realised that I
18
am a ‘candle’ of which when I go back and work with community I will light other
candles/lamps that I can reach out at my level; I also realised that I have to be a ‘tap turner off’
and to be ‘agent of change’ to shift from negative thoughts towards others to positive thinking.
Learning about community health I believed that I’m able to change my way of thinking
towards the community that people in the community are wise even though some of them are
not literate, they know and understand everything, they have the ability to solve the problems
of their own but they just need somebody to guide and to show them the way what and how to
do. Motivation gets from VHND observations changes me to think things critically for the
welfare of the community and make me personally to be a determined person to succeed.
OVERALL REFLECTIONS
Class sessions are educative, informative, interactive and reflective sessions. Facilitators and
fellows followed a ‘teacher-student’ and ‘student-teacher’ approach which means facilitators
impart knowledge to the fellows and at the same time gathered knowledge from fellows and
fellows are not simply borrowed knowledge from facilitators rather collect insights from
facilitators and sharing knowledge with facilitators. Having multitalented facilitators and
fellows, who are from different background, different geographical area (South India, North
East, North India, US) makes the fellowship programme more effective, creative and
innovative and we can see this while performing in class and in the field.
I really love when Dr Ravi facilitating of how to be humble and down to earth person. When
we are in the realm of hierarchical structure be it in educational Institutions, Health sectors,
industrial sectors, religious realm, etc people who are in high position tend to feel superior of
themselves and considered others as low and unimportant people but here in SOCHARA
paradigm shift is applied by teaching & non-teaching staff and by fellows. Dr Ravi was always
mentioned that wherever we are we should work together with the community and we should
do the work in such a way the community will say to us “Namma (my) health worker”. We
also should be the ‘lamp and not chandelier’ if we want to become real community health
workers.
Another thing I was impressed by the member of SOCHARA is that every person at
SOCHARA is important and equal, facilitators and fellows are not considered higher than the
non-teaching staff and vice versa. When tea brought in the class everybody can stretch a helping
hand to serve and collect back the tea without waiting the one who brought the tea to do his/her
job. This is the biggest sign of positive attitude towards others.
All the members of SOCHARA are so approachable, friendly and caring. They create a sense
of belonging to me, they create an enabling environment that makes me to say ‘I have a freedom
to express anything whatever I feel necessary’. Another thing that I love is that we the fellows
were never confined ourselves to academic part only we also had meaningful fun by having
special celebrations and entertainments such as birthdays, best wishes to SOCHARA newly
married couples, coming back from trips in the form of getting food items or gifts, sending off
19
former fellows, singing, etc. These celebrations make us relax and rejuvenate our energy from
hectic schedule.
Apart from all the points mentioned above I find that giving presentations or attending others
presentations enriched my knowledge and my skills. Whenever we read an article/journal or
came back from NGO & field visits and did a study in the field all the fellows had to give
presentations. Throughout the fellowship programme I realised that presentations helped me to
be more confident, creative and knowledgeable.
CONCLUSION
Community health learning programme is one of the health learning programmes which a
learner should have an understanding in using the knowledge of the community to understand
health problems and to design activities to improve health care (interventions). Apart from all
the issues learnt in the class Research also is so important in order to spread awareness and
bring things into action. Research connects community members directly with how the research
is done and what comes out of it and it also provides immediate benefits from the results of the
research to the community that participated in the study. Community members are also
involved in promoting the use of the research findings. This involvement can help improve the
quality of life and health care in the community by putting new knowledge in the
hands of those who need to make changes.
PART B
A STUDY ON THE DIETARY PRACTICES AND ANTE-NATAL CARE AMONG
PREGNANT AND LACTATING WOMEN IN BEDVA, RASNOL & SARSA OF
ANAND DISTRICT, GUJARAT
Nandaris Marwein
Background
Anaemia is still considered a major public health problem in the world. It is a important
healthcare concern as it is estimated to affect approximately 2 billion people worldwide
(Carley, 2002). Anaemia is a disorder is due to the deficiency of folic acid and iron in daily
20
diets. According to WHO definition Anemia is a condition in which the Hb concentration is
lower than the normal level of Hb.(Nisha,2006).
It is one of the main nutritional problems affecting all sections of population especially
pregnant and lactating women. The world Health Organization estimates that 58% of pregnant
women in developing countries are anemic and out of different countries India was one of the
highest.(McLean, Cogswell, Egli, Wojdyla, & de Benoist, 2008)
Continental wise, Asia has the highest prevalence of anemia in the world and about half of all
anemic women live in the Indian sub-continent where 88% of them develop iron deficiency
anemia during pregnancy (Gillespie & Haddal, 2003). The National Family Health Survey-3
(NFHS- 3) revealed a high prevalence of anemia among children is 78.9%, ever-married
women is 56.2% and pregnant women is 57.9% in India. In Gujarat 61% of pregnant and
lactating women are anemic (NFHS-3).
In spite of the fact that the Health and Family Welfare Department in India has policies to
provide iron supplement to pregnant women to prevent maternal anemia; though the
government of Gujarat introduced ICDS programme to provide nutritious food to pregnant
women and children, evaluation from large scale programmes shows that maternal anaemia
has not declined significantly (NFHS 3).
Our country still experiences the situation of malnutrition which constitutes a major sociomedical challenge for the country. It seems that deficiencies of total dietary calories, proteins,
vitamins, iron, calcium and iodine are commonest in our country. Malnutrition is always being
a reflection of unfulfilled dietary demands which occurs mainly in the period of pregnancy and
lactating. It is natural to suppose that lack of nutrition is more prevalent among those who are
coming from low socio-economic status due to the restrictions of diet (Shukla,1982). The diet
of people who come from a low socio-economic status are predominantly based on cereals
which in fact have to be supplemented with other nutritional foods for more balanced and
adequate in all nutrients. But such foods are consumed only in small quantities and hence their
diets are inadequate with respect to many nutrients particularly iron. Therefore no doubt that
poor dietary can lead and cause anemia. In spite of having a chance to grow and produce
nutritional of food items in rural areas yet the intake of protective and body-building foods are
still inadequate in many respects. Even though anemia can be prevented by increasing of iron
dietary items, there are however certain problems in making people consume foods that contain
lots of iron due to cultural and economic barrier (Gopalan, 1991).
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In India, the majority of maternal deaths are attributing both to indirect and direct causes such
as haemorrhage, abortion. The main indirect cause is anaemia. VHNDs which are a major
initiative under the National Rural Health Mission (NRHM) meant for improving access to
Maternal, Newborn, Child Health and Nutrition (MNCHN) services at the village level. Gujarat
is one of the states in India which implemented this VHND effectively. In Anand district of
Gujarat VHNDs also known as ‘Mamta Diwas’ are organised in many villages where pregnant
and lactating women check their Hb level which is one of many services provided by health
providers. Sarsa (14200 population), Rasnol (8180) and Bedva (5444) are some of the villages
where VHNDs conducted regularly either in Sub-centre, Anganwadi centre or PHC. Majority
of people in these 3 villages engaged in agriculture, animal/cattle rearing, labour works and
business and their economic status is poor (SAHAJ 2014).
Even though VHNDs are conducted regularly in these villages but to the best of my knowledge
there is no studies conducted or published to know whether components of VHND package of
this programme is effective or not. Despite of receiving nutritional foods and ANC during
VHND women were not studied whether their anemia status is good or not. Thus, the aim of
the study is to understand the dietary practices and Ante-natal care among pregnant and
lactating women in Anand district, Gujarat.
Objectives
0. To assess the dietary practices in relation to anaemia and its prevention among pregnant
and lactating women in those three villages of Anand district, Gujarat
1. To find out prevalence of anaemia among pregnant women and lactating women
2. To document their awareness level about anemia and about their Hb level
3. To know the ante- natal care services received by pregnant and lactating women
Methodology
Study Area: Sarsa, Rasnol & Bedwa villages, Anand district, Gujarat
Study Design: Cross sectional study
Study Period: April - May, 2014
22
Study Population: Study population of the study are pregnant and lactating women in the
study area.
Sampling:
A sample size of 54 women (35 pregnant women, 19 lactating women) was selected as
convenient.
Data collection tools and procedures:
Semi- Structured questionnaire will be using for interview. Haemoglobin was estimated by
using mamta cards and registers. Data on socio-demographic characteristics, obstetrics history,
ANC and dietary intakes were collected.
Data analysis:
Data was entered on SPSS and analysed. Tables were prepared using Microsoft excel. WHO
(1968) cut offs for pregnant and non-pregnant women were used for classification of anemia
and the cut offs are shown in the result section.
Ethical Consideration:
Before filling the questionnaire women will be also asked for consent.
RESULTS
Table 1. Demographic Characteristics of Respondents
Demographic Characteristic
Village of pregnant women
Bedwa
Rasnol
Sarsa
Education of respondent
Non literate
Standard 1-4
Standard 5-8
Standard 9-10
Standard 11-12
College education (13-15 years)
Pregnant Women
N
%
Lactating Women
N
%
19
12
4
54.3
34.3
11.4
14
3
2
73.7
15.8
10.5
3
1
14
7
8
2
8.6
2.9
40.0
20.0
22.9
5.7
8
4
5
1
1
0
42.1
21.1
26.3
5.3
5.3
0
23
Religion of the respondent
Hindu
Christian
Muslim
33
1
1
94.3
2.9
2.9
17
1
1
89.5
5.3
5.3
Table 1 shows about the education, religion, and motherhood status of the respondents. There
were 35 pregnant women and 19 lactating women in the respondents. Majority of pregnant
women 54.3 % (n=19) and lactating women 73.7 % (14) are from Bedva whereas 34.3 % (12)
pregnant women and 15% (3) lactating women are from Rasnol. Only 11.4 % (4) of pregnant
women and 10.5% (2) of lactating women are from Sarsa.
Educational status of both pregnant and lactating respondents shows that majority are non
literate where 40 % (14) of pregnant women were completed till middle school and only 22.9
% (8) completed till secondary school. Majority of lactating women 42.1 % (8) have completed
their primary school and only 26.3 % (5) of them have completed their middle school.
Religion of the respondents shows that 94.3 % (33) of pregnant women and 89.5% (17) of
lactating women were Hindu. Only 2.9 % (1) of pregnant women and 5.3 % (1) of lactating
women were Christian where as 2.9 % (1) of pregnant women and 5.3 % (1) of actating women
were Muslim.
Table 2. Economic status of the respondents
Economic status (Multiple
Responses)
Occupation
Housewife
government employee
agricultural labour
cattle rearing
business(small shops, vendors)
work on family farm
daily wage labour
Pregnant women
Lactating women
N
%
N
%
35
0
2
9
0
1
0
100.0
0.0
5.7
25.7
0.0
2.9
0.0
15
1
4
5
0
1
0
78.9
5.3
21.1
26.3
0.0
5.3
0.0
Earners in the family
Male
24
1
2
3
4
5
Female
1
2
3
16
10
8
0
1
45.7
28.6
22.9
0
2.9
9
7
2
1
0
47.4
36.8
10.5
5.3
0
8
0
1
22.9
0
2.9
2
1
0
10.5
5.3
0
Table 2 shows about the Economic status of the respondents which includes occupation,
earners and family income. Majority of pregnant women 100 % (35) and 78.9% (15) of
lactating women were housewives. Around a quarter of the respondents, 25.7% (9) of pregnant
women and 26.3 % (5) of lactating women said that they also engaged in cattle rearing.
In about 45% of the households of both category of the respondents there was only one male
earning member and only 22.9 % (8) of the respondents among pregnant women and 10.5 %
(2) of the respondents among lactating women have only one female earner in their family.
Table 3. Monthly family income of the respondents
Monthly family
income
Pregnant women
(in Rupees)
N
%
0-3333
14
40
3334-6666
17
48.5
6667-10000
4
11.5
Lactating women
N
9
6
4
%
47.4
31.5
21.1
Table 3 shows the monthly income of the family where 40% (14) among pregnant and 47.4% (9)
lactating women earn up to Rs 3333 a month and only 11.5% (4) among pregnant women and 21.1%
(4) among lactating women earn up to Rs 10000.
Obstetrics history of the respondents
Table 4. Age of pregnant respondent when she got married
Age of the respondent when she got married
Age ranges in years
Below 18
18 to < 20
20 -23
Pregnant women
N
%
0
0
16
45.7
19
54.3
Table 4 shows age of the respondents when they got married. The age of marriage of pregnant women
ranges from 18 to 23. There are 45.7% (16) who are in the category of teenage got married at the age
<20. Whereas 54.3% (19) got married at the age ranges from 20-23 years of age.
25
Table 5.Age of lactating respondent when she got married
Age of the respondent when she got
married
women
Age ranges in years
Below 18
18 to < 20
20-24
Lactating
N
1
7
11
%
5.3
36.9
57.8
In table 5 the age of the respondents ranges from 17- 24 years of age. There are 5.3% (1) of lactating
women age 17 years got married before the legal minimum age of 18. Majority 57.8% (11)
got married at the age of 20-24 whereas 36.9% (7) got married at the age 18 to <20 years.
Table 6. Age of pregnant respondent during first pregnancy
Age of the respondent during first pregnancy
Age ranges in years
Below 20
20-25
Pregnant women
N
%
5
14.3
30
85.7
Table 6 shows the age of the respondents during their first pregnancy. The age at first
pregnancy among pregnant women ranges from 19 to 25 years. There are 14.3% (5) who are
in the category of teenage had their first pregnancy at the age < 20 and 85.7% (30) of the
respondents had their first pregnancy at the age ranges 20-25.
Table 7. Age of Lactating respondent during first pregnancy
Age of the respondent during first pregnancy
Age ranges in years
Below 20
20-25
26-28
Lactating women
N
%
4
21.1
14
73.7
1
5.3
Table 7 shows the age of the respondents during their first pregnancy. The age at first
pregnancy among lactating women ranges from 18 to 28 years. There are 21.1% (4) who are
in the category of teenage had their first pregnancy at the age < 20 and 73.7% (14) of the
respondents had their first pregnancy at the age ranges from 20-25. Only 5.3% (1) of the
respondents had their first pregnancy at the age ranges from 26-28 years of age.
Table 8. Age of the last born child
Age of last born child
Lactating women
26
N
1
4
6
3
2
1
1
1
Months
1.00
2.00
3.00
4.00
5.00
6.00
8.00
11.00
%
5.3
21.1
31.6
15.8
10.5
5.3
5.3
5.3
Table 8 shows the age of the last born child of the respondents which a ranges from 1 month
to 11 month of age. Majority 31.6% (6) of the respondents’ babies among lactating women
were in their third month of age.
Table 9. Number of months in pregnancy
Number of months in pregnancy
Pregnant women
N
5
5
4
6
4
9
2
3.00
4.00
5.00
6.00
7.00
8.00
9.00
%
14.3
14.3
11.4
17.1
11.4
25.7
5.7
This table 9 shows the number of months in pregnancy among pregnant women. Majority 25.7
% (9) of the respondents were in their eight month of pregnancy.
Table 10. Obstetrics history of the respondents
Number of pregnancies
1.00
2.00
3.00
4.00
5.00
number of miscarriages or abortion of the
respondent
1.00
number of live births
1.00
2.00
3.00
5.00
Pregnant women
N
%
22
62.9
6
17.1
5
14.3
2
5.7
0
0
Lactating women
N
%
3
15.8
8
42.1
6
31.6
1
5.3
1
5.3
2
5.7
1
5.3
4
6
1
0
11.4
17.1
2.9
0
5
8
4
1
26.3
42.1
21.1
5.3
27
Table 10 shows the number of pregnancies, number of miscarriages or abortion and number of
live births of the respondents. Majority 62.9% (22) of pregnant women and 15.8% (3) actating
women were in their first pregnancies only 5.7% (2) of pregnant women and 5.3% (1) of
lactating women experienced miscarriages. 17.1 % (6) of pregnant women and Majority of
42.1 % (8) of lactating women have two live births.
Table 11. Number of days working after delivery
Number of days working after delivery
Lactating women
N
%
1
5.3
1
5.3
8
42.1
3
15.8
2
10.5
4
21.1
2.00
20.00
30.00
35.00
40.00
45.00
Table 11 shows the number of days women started working after delivery. Majority of the
lactating women 42.1% (8) said that they started working after thirty days after the delivery .
Table 12. Kind of works (lactating)
Kind of works
Agricultural work
Animal rearing
Households animal rearing
Household works
Office work
Total
N
1
1
1
15
1
19
%
5.3
5.3
5.3
78.9
5.3
100.0
Table 12 shows kinds of workundertaken by the respondents. 78.9% (15) of them said that
household chores were undertaken by them some days after delivering their babies.
Table 13. Ante-Natal Care (ANC)
Place registered for ANC
SC
PHC
private hospital
anganwadi centre
CHC
Pregnant women
N
%
25
71.4
8
22.9
1
2.9
1
2.9
0
0
Lactating women
N
%
14
73.7
3
15.8
0
0
0
0
2
10.5
Table 13 shows the place where the respondents registered for ANC. 71.4 % (25) of pregnant
women and 73.7 % (14) of lactating women registered for ANC at Sub-Centre.
Table 14. Services received during ANC (Multiple responses)
28
Services received during ANC
per abdomen examination
Pregnant women
N
%
35
100.0
Lactating women
N
%
19
100.0
measure of weight
35
100.0
19
100.0
HIV testing
Malaria testing
HIV & Malaria testing
BP measurement
Counselling about pregnancy care
information about entitlements
17
2
16
34
35
35
48.6
5.7
45.7
97.1
100.0
100.0
10
1
8
19
19
19
52.6
5.3
42.1
100.0
100.0
100.0
nutritious supplements
height measurement
Hb examination
35
35
35
100.0
100.0
100.0
19
19
19
100.0
100.0
100.0
Urine examination
referral to other centre
counselling about nutrition
35
35
35
100.0
100.0
100.0
19
18
19
100.0
94.7
100.0
Table 14 shows the services received by the respondents during ANC. All the respondents
among pregnant and lactating women received. Majority of the required services during ANC
Only 45.7% (16) of pregnant women and 42% (8) of lactating women did HIV & Malaria
testing during ANC.
Table 15. Measurement of Hemoglobin
Number of Hb checked during
pregnancy
Once
Twice
Thrice
More than 3 times
Total
Pregnant women
N
7
23
5
0
35
%
20.0
65.7
14.3
0
100.0
Lactating women
N
0
5
11
3
19
%
0
26.3
57.9
15.8
100.0
Table 15 shows the place and number of times Hb was checked by the respondents during
pregnancy. Majority 65.7 % (23) of pregnant women and only 26.3% (5) of lactating women
have checked their Hb twice. 58% (11) of the respondents among lactating women and only
14.3% (5) of the respondents among pregnant women have checked their Hb thrice.
Table16. Place where Hb checked
29
Place Hb checked
Pregnant women
N
%
0
0.0
16
45.7
28
80.0
12
34.3
0
0
at home
at PHC
at Mamtadiwas/ VHND (SC)
at private clinic/laboratory
CHC
Lactating women
N
%
0
0.0
8
42.1
17
89.5
5
26.3
2
10.5
The above table 16 shows the place where the respondents checked their Hb. 80% (28) of
pregnant women and 89.5% (17) of lactating women checked their Hb level at SC during
Mamta diwas.
Table17. Hb level of pregnant respondents
Pregnant women
First time
Non anemia: (11g/dl or higher)
Mild: (10-10.9g/dl)
Moderate: 7-9.9g/dl
Severe: lower than 7g/dl
*N=33, **N=30
N*
%
N**
%
2
8
20
0
6.6
26.7
66.7
0
Most
recently
2
4
26
1
6
12.3
78.7
3
Looking at the Hb level of pregnant respondents in this table 17, majority of them are in
anaemic category and only 6% (2) who test for the first time and 6.6% (2) who test most
recently are non-anaemic.
Tables 18. Hb level of lactating respondents
Non anemia: (12g/dl or higher)
Mild: (11-11.9g/dl)
First time
N#
%
0
0
1
5.5
Moderate: (8-10.9g/dl)
Severe: lower than 8g/dl
15
2
Lactating women
83.3
11.1
2nd time
N##
%
1
5.2
2
10.5
15
1
78.9
5.2
Most recently
N*
%
1
7.1
3
21.4
10
0
71.4
0
#N=18, ##N=19, *N=14
Table 18 shows that majority of the respondents among lactating women are in the category
of anaemic and only 5.2% (1) who test for second time and 7.1% (1) who test most recently
are non-anaemic.
Table 19. Iron Folic Acid
30
Number of IFA taken during
pregnancy
less than 100
more than 100
Numbers of tablets taken after delivery
5.00
10.00
20.00
30.00
60.00
90.00
100.00
0
number of months taking IFA
0
1.00
2.00
3.00
4.00
Month of pregnancy received IFA
before 3 month
on the third month
four to six months
Pregnant
women
N
30
5
%
85.7
14.3
N
8
11
%
42.1
57.9
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
2
1
6
3
1
1
3
10.5
10.5
5.3
31.6
15.8
5.3
5.3
15.8
N
0
2
2
24
7
%
0
5.7
5.7
68.6
20.0
N
4
6
7
2
0
%
21.1
31.6
36.8
10.5
0
26
4
5
74.3
11.4
14.2
0
0
0
0
0
0
Lactating women
Table 19 show the number of IFA taken by the respondents during pregnancy and after
delivery. Majority 85.7% (30) of pregnant women and 42.1% (8) of lactating women took less
than 100 IFA during their pregnancy. There were 31.6% (6) of lactating women took 30 tablets
after delivery their babies. 68.6% (24) of pregnant women received tablets for three months
and 36.8% (7) of the respondents among lactating women received tablets for two months.
Majority 74.3% (26) of the respondents among pregnant women received IFA before third
month of their pregnancy.
Table 20.Number of months taking IFA after delivery
Lactating women
Month started taken IFA after delivery
1st month
2nd month
3rd month
15 days
Not taken
Frequency
Percent
11
3
1
1
3
57.8
15.8
53
5.3
15.8
31
Numbers of tablets taken after delivery
0
5.00
10.00
20.00
30.00
60.00
90.00
100.00
3
2
2
1
6
3
1
1
15.8
10.5
10.5
5.3
31.6
15.8
5.3
5.3
The above table 20 shows the number of months started taking tablets and numbers of tablets
taken after delivery. Majority 57.8 % (11) of the respondents started taking tablets during their
first month after delivery and majority 31.6% (6) of the respondents took 30 tablets after
delivery their baby.
Dietary practices contribute in anemia prevention
Table 21. Place getting nutritional foods (Multiples responses)
Place getting nutritional foods
Home
anganwadi centre
Market
PHC
Pregnant
women
N
%
29
82.9
35
100.0
0
0.0
1
2.9
Lactating women
N
10
19
1
0
%
52.6
100.0
5.3
0.0
Table 21 show the place where the respondents get their nutritional foods. There are 100% (35)
among pregnant women and 100% (19) among lactating women received nutritional foods
from Anganwadi centre and only 2.9% (1) among pregnant women are also getting food from
PHC.
Table 22.Nutritional foods received from Anganwadi (Multiples responses)
Nutritional foods received from Anganwadi
Upma
Sukhdi
Shiro
Pregnant women
N
%
19
100.0
19
100.0
19
100.0
Lactating women
N
%
19
100.0
19
100.0
19
100.0
The above table 22 shows about nutritional foods received by the respondents from Anganwadi
centre. 100% (35 +19) of the respondents among pregnant and lactating women received
nutritional foods such as upma, sukhdi and shiro from Anganwadi centre.
32
Table 23. Animals that the respondents have at home (Multiples responses)
Animals have at home
Goats
Hens
Cows
Buffaloes
Nothing
Lactating women
N
%
2
10.5
1
5.3
9
47.4
11
57.9
4
21.1
Pregnant women
N
%
3
8.6
11
31.4
54.3
19
62.9
22
14.3
5
Table 23 shows what kind of animals the respondents have at home. Majority 63% (22) of
pregnant women and 58% (11) lactating women have buffaloes at their homes.
Table24. Foods available at home (Multiples responses)
Foods available at home
Fish
Eggs
Tomato
Lentils
Almond
Chickens
wheat flour
green leafy vegetable
Banana
Cabbage
Pregnant
women
N
0
9
34
33
8
0
34
27
29
27
%
0.0
25.7
97.1
94.3
22.9
0.0
97.1
77.1
82.9
77.1
Lactating
women
N
%
0
0.0
10
52.6
17
89.5
19
100.0
5
26.3
2
10.5
19
100.0
16
84.2
17
89.5
13
68.4
The above table 24 shows what foods available at home of the respondents. 100% (35) of
pregnant women have tomato and wheat flour apart from other food items available at home
where as 100% (19) of lactating women have lentils and wheat flour apart from other food
items available at home. None of all the respondents said that they have fish at home.
Table 25. Food consumed by the respondents (Multiples responses)
Food consumed
Greenleaf
Chapatti
Nuts
Eggs
Rice
corn ruti
Pregnant women
N
24
24
4
2
33
23
%
68.6
68.6
11.4
5.7
94.3
65.7
Lactating
women
N
15
18
4
7
19
7
%
78.9
94.7
21.1
36.8
100.0
36.8
33
Milk
bajara ruti
31
26
88.6
74.3
17
17
89.5
89.5
Table 25 shows what food items the respondents consumed. 100% (19) of lactating women and
94.3% (33) of pregnant women mainly consuming rice apart from other food items they used
to eat.
Table26. Certain foods that are not allowed to eat (Multiples responses)
Certain foods not allowed to eat
green leafy vegetable
Chappati
Nuts
Eggs
Rice
corn ruti
Milk
Fruits
# N=20, *N = 8
Pregnant women
N#
%
0
0.0
0
0.0
18
90.0
9
45.0
0
0.0
0
0.0
0
0.0
0
0.0
Lactating women
N*
%
0
0.0
0
0.0
8
100.0
0
0.0
0
0.0
1
12.5
0
0.0
0
0.0
Table 26 talks about certain foods which the respondents are not allowed to eat. There were
100% (8) among lactating women and 90% (18) among pregnant women said that nuts are not
allowed to eat whereas 45% (9) among pregnant women said that eggs are not allowed to eat
and only 12.5% (1) among lactating women mentioned that corn ruti is not allowed to eat.
Table 27. Consumption of eggs
How often eating eggs
once a week
twice a week
Every day
never eat
Pregnant women
N
%
4
11.4
2
5.7
0
0
29
82.9
Lactating women
N
%
6
31.6
2
10.5
2
10.5
9
47.4
The above table 27 shows how often the respondents eat eggs. Majority 83% (29) of pregnant
women and 47.4 % (9) of lactating women never eat eggs.
Table 28. Persons eat last at home
34
Persons eat last at home
Lactating women
Pregnant women
N
%
Persons eat last
parents-in-law
Husband
Myself
Together
wait till family finished
Yes
stop eating
Yes
N
%
3
7
6
19
8.6
20.0
17.1
54.3
3
1
0
15
15.8
5.3
0
78.9
7
20.0
1
5.3
5
14.3
2
10.5
Table 28 shows persons who used to eat last at home, who wait till family finished and who
stop eating if food gets over. Majority 54.3% (19) of pregnant women and 79% (15) of lactating
women said that they used to finish their meal together with the family and only 17.1% (6) of
the respondents among pregnant women said that they were the one who used to eat last. 20%
(7) of pregnant women and 5.3% (1) of lactating women used to wait till their family finished
their food. 14.3% (5) of among pregnant women and 10.5% (2) of lactating women said that
they stop eating if food gets over.
Table 29.Knowledge level about Anemia
Understanding the meaning of
anemia
Pregnant women
N
33
2
35
lack of blood
do not know
Total
%
94.3
5.7
100.0
Lactatingwomen
N
18
1
19
%
94.7
5.3
100.0
The above table shows the knowledge level about anaemia. 94.3% (33) of pregnant women
and 94.7% (18) of lactating women understand the meaning of anemia. Table 30. Knowledge
level on the causes of anemia (Multiples responses)
Causes of anemia
blood loss due to heavy menstruation
medical condition
regular blood donation
poor diet
Pregnant
women
N
3
%
8.6
N
2
%
11.1
1
2
30
2.9
5.7
85.7
0
0
18
0.0
0.0
94.7
Lactatingwomen
35
excessive blood loss during child birth
loss blood during surgery
10
0
28.6
0.0
3
0
16.7
0.0
Table 30 shows the level knowledge of the respondents on causes of anemia. Majority 85.7%
(30) of the respondents among pregnant and 94.7 % (18) among lactating women believed
that poor diet is one of the causes of anemia whereas 28.6% (10) among pregnant women and
16.7% (3) among lactating women believed that excessive blood loss during child birth also is
one of the causes on anemia.
Table 31. Signs and symptoms of anemia (Multiples responses)
Signs and symptoms of anemia
Pregnant women
N
35
10
tired and weakness
Dizziness
%
100.0
28.6
Lactating women
N
18
11
%
100.0
61.1
The above table 31 shows the level of understanding on what are signs and symptoms of
anemia. There are 100% both among pregnant and lactating women know that tired and
weakness are signs and symptoms of anaemia where as 61.1% (11) among lactating women
and 28.6% (10) among pregnant women said that dizziness also is one of the signs and
symptoms of anemia.
Table 32. How anaemia affect women’s health (Multiples responses)
How anaemia affect women’s
health
damage organs
affect fertility
Pregnant women
Lactating women
N
4
%
11.8
N
3
%
16.7
33
97.1
17
94.4
This above table 32 shows how anaemia affects women’s health. 97.1% (33) of pregnant
women and 94.4% (17) of lactating women said that anaemia affects the fertility of a woman
and only 11.8% (4) of pregnant women and 16.7% (3) of lactating women said that anemia
damage the organs in the body.
Table 33. Months women need to check their Hb
Number of months
3rd,7th & 9th
1st to 2nd month
Pregnant women
N
%
32
91.4
3
8.6
Lactating women
N
%
18
94.7
1
5.3
36
Table 33 shows the number of months that the respondents feel they need to check their Hb.
Majority 91.4% (32) of pregnant women and 94.7% (18) of lactating women knows that on the
third, seventh and ninth month were the months that women need to check their Hb level.
Table 34. Opinion which foods help prevent anemia (Multiples responses)
Opinion which foods help
prevent anemia
Fish
Eggs
Tomato
Lentils
Almond
Chickens
wheat flour
green leafy vegetable
Banana
Cabbage
Don’t know
Pregnant women
N
4
11
34
32
12
2
32
34
29
25
0
Lactating women
%
11.4
31.4
97.1
91.4
34.3
5.7
91.4
97.1
82.9
71.4
0
N
6
16
15
18
12
6
15
18
16
12
1
%
31.6
84.2
78.9
94.7
63.2
31.6
78.9
94.7
84.2
63.2
5.3
Regarding the knowledge level on food items which prevent anemia the above table 34 shows
that the highest response among pregnant women is 97.1% (34) saying that green leafy
vegetables and tomato can prevent anaemia and 94.7% (18) among lactating women believed
that lentils help prevent anemia where as only 5.3% (1) said don’t know.
Table 35. Opinion what can do for anemia prevention (Multiples responses)
Opinion what can do for anemia
prevention
eat veg fruits lentils
eat medicines
consume IFA regularly
go to temple and pray
Don’t know
Pregnant women
N
35
33
34
9
0
%
100.0
94.3
97.1
25.7
0
Lactating women
N
17
10
17
4
2
%
89.5
52.6
89.5
21.1
10.5
The highest proportion of pregnant women in table were aware that adherence of eating
vegetables, fruits and lentil 100% (35), having iron pills supplement 97.1% (34) and eat
37
medicines 94.3% (33) is necessary anemia prevention whereas only 25.7% (9) said that going
to the temple and pray can also prevent anemia. Among lactating women 100% (19) believed
that eating vegetables, fruits, lentils and consume tablets regularly will prevent from anemia.
The least response 21.1% (4) is going to temple and pray can prevent from anemia. Only 10.5
(2) said they don’t know.
Table 36. Food items that have high iron content (Multiples responses)
Food items that have high iron
content
green vegetable
corn ruti/chapatti
food eggs
Moongdal
food rice
food fish
Pregnant women
N
%
35
33
15
34
31
7
100.0
94.3
42.9
97.1
88.6
20.0
Lactating women
N
19
17
18
19
16
12
%
100.0
89.5
94.7
100.0
84.2
63.2
Regarding the level of awareness on food items that have high iron content all pregnant women
100% (35) and all lactating women 100% (19) believed that green vegetables have high iron
content. There are 100% (19) among lactating women said that moongdal is also one the food
items that have high iron content.
DISCUSSION:
According to Gujarat Human Development Report, 2004 the Alma Atta conference,1978
accepted nutrition and health as fundamental rights of people and as national concerns in the
developing countries. In India health is considered as the concern of state governments, though
some health programmes are funded by the central government (Gujarat report,2004).
Nutrition is one of the main areas that the government of India concentrated because it is
understood that nutrition focuses on how diseases, conditions and problems can be prevented
or lessened with a healthy diet. A poor diet may have an injurious impact on health, causing
deficiency diseases such as Aneamia. In order to tackle this problem many National Nutritional
Programs such as Integrated Child & Development Scheme, Nutrition Advocacy and
38
Awareness General Programs for Food and Nutrition Board, Iron and Folic Acid
Supplementation of Pregnant women, etc are implemented in many parts of India. In the study
conducted shows that 100% of pregnant and lactating women get their nutritional foods from
Anganwadi centre of which they also consumed them. Most of them also have animals like
goats, cows, buffaloes, hen that they can get best sources for iron such as milk and eggs. In
short, the study confirm that in spite of implementing Nutrition Programs, have animals at
home yet malnutrition and lack of Iron folic acid is still the main problem which contributes to
Anaemia.
In Gujarat Anaemia is one of major health problems, especially among women and children.
(NFHS -3). The 2005-06 National Family Health Survey (NFHS-3) is the third in the NFHS
series of Surveys. In Gujarat, NFHS-3 is based on a sample of 3,216 households that is
representative at the state level and within the state at the urban and rural levels. The survey
interviewed 3,729 women age 15-49 from all the sample households to obtain information on
population, health, and nutrition in the state. More than half (55%) of women in Gujarat have
anaemia. Since anemia is diagnosed by measuring the levels of haemoglobin in blood the study
tried to adopt WHO (1968) judgement of Hb level. Looking at the study the prevalence of
anemia in the study was high among pregnant and lactating women. Majority of pregnant
women are in anaemic category and only 6% who test for the first time and 6.6% who test most
recently are non-anaemic. Among lactating women majority of them are in the category of
anaemic and only 5.2% who test for second time and 7.1% who test most recently are nonanaemic.
In the report of NFHS 3 the median age at first marriage among women in Gujarat is 18 years
among women age 20-49 years, Almost two-fifth (39%) of women got married before the legal
minimum age of 18. Among young women age 15-19, 13% have already begun childbearing,
Young women in rural areas (16%) are more than twice as likely to be mothers as young women
in urban areas (7%). In contrast to the study only 5% of the respondents among lactating women
married at the age of 17 which is not the legal age for marriage. 14% among Pregnant and 21%
among lactating women had their first pregnancy at the age below 20 years which is considered
high risk for their health as well was for their child’s health. There are78 % rural mothers
received antenatal care from a health professional during their pregnancy and for their last birth
(NFHS- 3). Looking the NFHS 3 it is understood that there is utilisation of ANC before but
39
when comparing with the study visiting and utilisation of ANC increased after NRHM came
into existence especially after the implementation of VHND.
In the study, majority of pregnant and lactating women received ANC services which reach
100% in almost of the ANC services provided. This shows that Ante-Natal Care provided
during VHND improved in a massive way. Looking at individual characteristics of some
women like age and education there have been found out that these characteristics make a
significant impact on obstetric health care seeking behaviour and also facilitates utilisation of
public health facilities for complete health care of both women and children.
In India rules applied to nutrition of women are often related to the reproductive cycle such as
pregnancy and lactation are periods in which food taboos are very common .There are some
areas where there is a belief that a woman who was just delivered a baby should not eat certain
foods such as eat rice or chappaty with a water curry makes a woman weak and anemic. Of
course there are certain foods that cannot be eaten because of diseases such as too much salt is
not good for people with high blood pressure or too much greasy food, hot spices can make
stomach ulcer and so on (Werner 1943). Similarly, eggs should be avoided because the child
would be born bald. Customs and practices with regard to the quality of food intake have been
reported in literature (Hutter).
In the study pregnant and lactating women are having harmful ideas about diet; they are not
eating certain foods like eggs and nuts saying that if they eat they will have diarrhoea. 83%
pregnant women and 47% lactating women never eat eggs as eggs are considered as nonvegetable.94% pregnant women and 89% of lactating women are from Hindu background so
Non-vegetable items are never consumed. Even though 26% of pregnant and 53% of lactating
women have eggs at home they will not consume rather sell out those eggs in the market. Foods
available at home of these women should be consumed regularly like eggs, nuts for anaemia
prevention as they are the best source of iron and protein.
During pregnancy or breast feeding a woman requires various nutritional food items so that she
and her baby will grow strong and healthy. A new mother should eat lots of body-building
foods like lentils, various kinds of beans, vegetables, eggs, chickens, rice, flour, milk products,
meat, fish, fruits and All these foods are not harmful; all bring better health instead (Werner,
1943). The mother’s diet should have a combination of body building and high-energy foods
(oils and fatty food) not just rice or chappaties because fats also are used to make more milk
while a woman is breast-feeding. If the mother gets enough nutritious food during pregnancy
40
and lactating she and her baby will grow strong and healthy. Majority of pregnant and lactating
women of those villages carry out agricultural and other jobs in addition to household jobs. If
these physical tasks are taken into account the energy deficit in the diet of these women should
be high.
RECOMMENDATION
-
Most of those women were taking IFA less than 100 tablets. Taking IFA regularly along
with the motivation and encouragement on kitchen garden will be more effective in
perverting anemia
-
There is a need to educate women about dietary supplement based on locally available
foods can bridge the gap to a large extend.
-
Determining food intake during pregnancy and lactation due to cultural and religious
factors might be important food items for both the mother and the child. Diet of most
of those women lack many kinds of other nutrients. Thus, using home iron sources
(green leafy vegetables, sprouts, chickens, Fish) will help preventing anemia.
-
Some of those women have constraints on food intake; few of them used to either stop
eating or start eating the leftover food only after their family members have finished
their meals. It is more effective if they are sensitised to prepare enough food for
everybody at home or to cook again or to get food from Anganwadi centre.
-
Malaria blood test is one of the services that those women received. But it seems that
very few of them get themselves tested for malaria as they had to go to Sub-centre and
PHC. It will be more effective if malaria testing could be done at Anganwadi centres.
-
Nutritional goals in Gujarat is Reduction of iron deficiency anaemia in pregnant and
lactating women from existing 50% (estimated) to less than 10% by 2000. In order to
eliminate the problem, Health care services and distribution of nutritional food at health
centres during VHND needs to be continued and promoted up to the extent that the
nation is free from anemia.
-
It is necessary to carry out further studies especially on the factors or reasons why
pregnant and lactating women are anaemic in spite of receiving regular health care
services and nutritional food during VHND.
41
CONCLUSION
Anemia during pregnancy is associated with multiple outcomes for both mother and infant.
Adequate nutrition and taking regular IFA tablets is a vital need for everyone especially for
pregnant and lactating women who are more prone to malnutrition that leads to anemia. The
study focuses on the dietary practices and Ante-natal care among pregnant and lactating women
so that haemoglobin level will be determined for their anemia status. According to the study
findings, most of women are anaemic, therefore women are needed to be sensitised to be more
nutrition conscious and to have a heath seeking behaviour.
BIBLIOGRAPHY
Abel, R., Jolly Rajaratnam and V. Sampathkumar (1999). Anemia in Pregnancy: Impact of Iron
Deworming and IEC. Vellore: RUHSA
Carley, A. (2002). Anemia: when is it iron deficiency? Pediatric Nursing, 29(2).
Marmot, (2008). Commission on Social Determinants of Health: "Closing the Gap in a
Generation: Health Equity Through Action on the Social Determinants of Health" (PDF).
World Health Organization. Retrieved 2013-03-27.
Gopalan, C., B.V. Rana Sastri & S.C Balsubramanian (1991). Nutritive value of Indian food.
Hyderabad: National Institute of Nutrition, Indian Council of Medical Research
42
Gujarat Human Development Report (2004), Mahatma Gandhi Labour Institute,
Ahmedabad.Availableat:www.in.undp.org/.../human_develop_report_gujarat_2004_report.pdf
Hutter, I. Being pregnant in rural South India: Nutrition of women and well-being of children.
PDOD publication
Mclean, E., Mary C., Ines Eglis, Daniel Wojdyla and Bruno de Benoist (2008). Worldwide
prevalence of anaemia,WHO Vitamin and Mineral Nutrition Information System 1993-2005.
Geneva: Department of Nutrition for Health and Development Available at:
www.who.int/nutrition/publications/micronutrients/PHN
Nisha, M (2006). Diet planning for Diseases. Delhi: Kalpaz Publication
National Family Health Survey -3 (2005-2006). Key Indicators for India. Available from:
http://www.nfhsindia.org/pdf/India.pdf.
SAHAJ unpublished Report, 2014
Shukla, P.K (1982). Nutritional problems of India: Prentice Hall of India private limited. New
Delhi
Stuart, Gillespie, Lawrence J. Haddal (2003). The double burden of Malnutrition in Asia:
Causes, Consequences and solution. New Delhi: SAGE publication
WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity.
Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization,
2011 WHO/NMH/NHD/MNM/11.1 Available at:
http://www.who.int/vmnis/indicators/haemoglobin.pdf
Werner, D. (1943). Where There is No Doctor: A Health Care Handbook.New Delhi:
Voluntary Health Association of India
PART C
VILLAGE HEALTH AND NUTRITION DAY: OBSERVATIONS AND REFLECTIONS
FROM EXPERIENCES IN GUJARAT
Scope of the report:
43
As an intern I had an opportunity to go to the villages named Ruparel, Baria block , Dahod
district, Khanpur, Anand block, Anand district and Jabuvania, Ghogamba block, Panchmahal
district to observe Village Health and Nutrition Days (VHNDs) together with the staff and
field workers of Society for Health Alternatives (SAHAJ), Anandi and Prerna Organisations.
This report will cover the observations and reflections from these experiences and the relevance
of this to health systems in Meghalaya.
Background:
Maternal Mortality Rate and Infant Mortality Rate in particular, are problematically high in
many places in India. The National Rural Health Mission which was launched on 12th April
2005, approved in July 2006 and fully operationalised in 2007-2008 marked an attempt to
remedy the situation as regards quality of care in public health care facilities. But the aim of
the government today is not just focusing in public facilities only but also beyond the facilities
that is to provide universal access to health care. Therefore mission and vision of NRHM seeks
to provide accessible, affordable, quality health and envisaged provision of effective health
care to rural population throughout the country. In order to bring successful results NRHM
focuses also on decentralisation and communitisation where outreach approach, an effective
measure is applied to boost coverage of core maternal and child health interventions. In
accordance with NRHM’s goal, the goal of the State Health Mission, Gujarat also is to improve
the availability of and access to quality health care by people, especially for those residing in
rural areas, the poor, women and children in the state.
In Gujarat, the NRHM which is national program implemented health activities/ programs
through the State Health and Family Welfare Dept. The Village Health Sanitation & Nutrition
Committees (VHSNC) set up at the village level under the NRHM have been known to carry
out activities, such as Sanitation drives and VHND. VHND also called Mamta Diwas’ is one
of the outreach approaches of the Indian government as well as the government of Gujarat
which could help boost coverage by increasing coverage of basic health and nutrition services
and by bringing services closer to communities. Importantly, it provides the first point of
contact for essential primary health care. The main objective of VHND is to provide essential
and comprehensive health & nutrition services to pregnant & lactating women, children (below
6 yrs) and adolescent girls.
VHND is conducted usually at Anganwadi centre or other suitable location once a month
preferably mainly on Wednesdays which will ensure uniformity in organizing the VHND.
Under this initiative, basic components of primary healthcare services provided by ANM, Male
worker, ASHA and Anganwadi worker & helper to pregnant women, lactating mothers,
adolescent girls and children under-five years of age include registration, counselling
(breastfeeding, nutrition, hygiene, entitlements, etc), blood testing, distribution of IFA and
supplementary food, identification and referral of high risk cases of children and pregnant
women, as well as basic ANC and PNC. Apart from these above services, Mamta cards also
44
are provided to women so that they will know their own health status and it is easy to health
workers to cross check women’s health such as Blood pressure, weight, anemia status and
referrals during complications.
Roles of Non-Government Organisations:
Communitisation is one of the pillars that bring positive changes in health status of the people.
According to National Health Mission, NGOs and other civil societies have a great role to play
in order to facilitate community based monitoring. Their main roles are to be as members of
monitoring committees, as resource groups for capacity building and facilitation; and as
agencies helping to carry out independent collection of information. During my internship
period at SAHAJ and Anandi, Non- Government Agencies expands their services in monitoring
of VHND with regular observation and on-site supervision. As part of the project titled
'Enabling Community Action for Maternal Health' funded by MacArthur Foundation, SAHAJ
involved in observing VHND day for monitoring the quality of Maternal health Care in three
districts of Dahod, Panchmahals and Anand. To monitor and evaluate the quality of services
provided during VHND a certain Checklist was followed which is adopted from the Guidelines
for Community Processes” introduced by the NRHM. Using checklist will enable to find out
the gaps and achievements. This check list can be used by the community to dialogue with the
health system sthat there is improvement in services It also enables the operationalization of
NRHM’s vision that the frontline workers and VHSNC are part of a continuum to strengthen
community engagement for health and social determinants.
Objectives of the report
- Provide an account of the experience of VHND in three villages in Gujarat
- Reflect about the relevance and impact in Gujarat
- Reflect about the relevance to the state of Meghalaya
Methodology
- Experience of VHND was captured through: interactions, checklists, and observation
- Reflection was done through SWOC
Case study of the VHND in Gujarat:
Why VHNDs observations conducted in Dahod, Anand and Panchmahal districts.
VHNDs were implemented after the inception of NRHM but according to the situation analysis
report regarding condition of maternal health in these districts especially in Panchmahal and
Dahod districts are one of those backward areas where government’s health services are very
poor and irregular.
The report said that in villages, ‘Mamta Divas’ is not being conducted in a regular manner and
no guidelines are being followed when it is carried out at all, e.g. A pregnant female is never
examined as far as her HB, urine and height are concerned. At present, supply of BCG’s and
TT’s vaccines is never adequate in stock at ‘Anganwadis’. As a result kids and pregnant women
45
have to leave without getting their vaccinations done. BP checkups not so regular because
measuring instrument is not working, PHC is far from the village and doctors are mostly found
absent therein, because of this situation villagers normally have to leave without meeting
doctors. Doctors normally explained such situation to be a result of work overload on them as
they have been assigned 2 to 3 PHCs per doctor along with the load of administrative work
because of which they are unable to provide sufficient time to each PHC. In absence of doctors,
patients from nearby villages are compelled to visit private facilities. Moreover medicines and
ivies are being sold at government clinic. If a group of people protests this practice, situation
seems to get better for few days and then it gets back to its normal course of action again. No
staff can be found till 12 noon in primary health centers which are supposed to stay open for
24 hours. Thus is absence of the doctor and staff members, patients are left with no option but
to visit the private clinics.
Looking at the analysis, it is felt that there is a need to observe VHNDs in some villages under
these mentioned districts so that gaps and achievements will be identified and what action
should be taken for improvement. As part of this observation, I did an observation during
VHND in three villages mentioned earlier. Certain objectives of the field visits during VHNDs
are: To identify the quality of service package provided on VHND, to examine the role
coordination between health workers during VHND and to observe the level of participation
of beneficiaries.
Report of what observed during VHND:
Checklist is used during the observations of VHNDs (refer annexure). The observations were
done in three villages, i.e., Ruparel, Khanpur & Jabuvania where staff and field workers of
NGOs played a vital role in translating the information gathered from Mamta diwas.
The followings are the parameters/services provided during VHNDs:
1. Presence of health workers during VHND:
a) According to the checklist ANM, ASHA, Anganwadi worker & helper are frontline
health workers that should present during VHND. During observations all these
health workers were available in all three centres.
b) In sub- centre, apart from these health workers mentioned there were additional
health providers such as Doctor, Male health worker, Female health worker, ASHA
supervisor were also available during Mamta diwas.
c) Venue: Ruparel Anganwadi centre, Khanpur Sub-centre and Jabuvania Anganwadi
centre.
Day: Wednesdays in all the three centres
46
Services delivery and roles done by ANM during VHNDs in these villages are:
a) ANC checkups
b) Tetanus toxoid injection was given only in Khanpur
c) Blood pressure was measured only in Ruparel & Khanpur where in Jabuvania No
BP measurement (as no blood pressure monitor available).
d) Weighing of pregnant women, blood test was supposed to do by ANM but in these
3 centres ANM did not measure weight those women
e) Blood test for anaemia using Haemoglobinometer done only in Khanpur by Male
health worker not by ANM. In Ruparel Hemoglobinometer is available but no blood
test. In Jabuvania only malaria blood test was done by ANM
f) Abdomen examination done by only in Khanpur, no bed and no separate room in
Jabuvania and Ruparel.
g) Counselling on diet, rest and for institutional delivery in Ruparel and in Jabuvania.
In Khanpur counselling did by FHW.
h) Danger signs such as swelling in whole body, blurring of vision, severe headeache
were supposed to inquire by the ANM, unfortunately there was no inquiry about
danger signs in all the three VHNDs.
i) Vaccination provided to children only in Jabuvania and Khanpur.
j) In all the three centres ANM provides medicines for common illness to those who
come during VHND.
k) In Khanpur ANM referred a pregnant woman to Management Information System
because her Hb level is low (8g/dl) and also referred a child with severe
malnutrition. In brief, this MIS which is in CHC is where people get information
about Village Child Nutrition Centre.
l) Prescribed IFA tablets to pregnant, lactating women and even to Adolescent girls.
IFA available in all the centres
Services provided by ASHA
a) ASHAs of all three villages did help both ANM and AWW in organising the Mamta
diwas
b) Only in Khanpur ASHAs motivated most of the beneficiaries to attend VHND
c) In Jabuvania and Ruparel ASHA did additional work by helping ANM in providing
counselling on diet, rest, hygiene, family planning.
d) Extra work inWeighing of pregnant women and children below 5 years with AWW
& helper.
e) Extra work in measuring of BP with ANM
Services provided by AWW & helper
47
a) Provided supplementary foods in Ruparel only
b) Distributions of take –home- rations were done in Jabuvania and Ruparel
c) Weighing of pregnant women and children below 6 years
Performance by other Health workers during VHND (sub-centre):
a) Male health worker did Blood test for anaemia using Haemoglobinometer
a) Female health worker did counselling on diet, rest, hygiene, entitlements, family
planning, institution delivery given to pregnant &lactating women even to
adolescent girls
b) ASHAs’s Supervisor helped ANM in keeping the records in the register
Whom to share the gaps with?
SAHAJ in collaboration with partner NGOs such as Anandi contribute to the collection of
information relevant to the monitoring process of child and maternal health in those rural areas
by observing the quality of health care during VHNDs. In spite of organising these VHNDs
regularly yet there are gaps in delivering services. Based on observations of the VHND the
organisations shared the gaps with the health system but now that a check list has been
prepared, they plan to share the gaps with both the health system and the community
systematically based on evidence.
Action taken?
As per the follow up conversation with SAHAJ staff, some actions have been taken in some
areas. Anandi, a co-partner agency of SAHAJ was constantly in dialogue with the Medical
officers, in many Anganwadis, weighing machine has been brought where there were none, BP
machines have been repaired or replaced, and cheques for entitlements are being issued to
women. This is a continuous process- recently many women had not opened their bank
accounts and their cheques(dated 6 months to one year back)were not deposited. So, Anandi is
now trying to get their accounts opened.
Reflection on observation at the three villages:
-
Before the programme begun, ANM & AWW made ready and arranged everything in
place. This is very appreciative.
-
VHND are observed on Wednesdays once a month. This is very good plan, no need
for health workers to remind people again and again to come on this day, people
remember the day for VHND. When interacting with ASHAs they proudly said that
they don’t need to inform the beneficiaries a day before about the date of VHND, they
know and remember when to come for Mamta diwas.
48
-
Role coordination between/among among health workers (ASHA, AWW, ANM) is
highly appreciated, there was really a good coordination especially between frontline
workers in all the three centres.
-
Overall attendance during Mamta diwas was good but observing the attendance of
women who registered for ANC is low comparing to the total number and the number
of attending for ANC. In Khanpur the total ANC women registered was 32 and total
ANC women attended was only 7, in Ruparel total registered was 14 and total attended
was only 7 and in Jabuvania total registered was 10 and none attended for ANC. As
told by the ANM and ASHA, the main reason is because women are still celebrating
their Holi. During Festive seasons women hardly come to the centre. I personally feel
that arrangement of vehicle from PHC/CHC level during VHND day, which means
VHND that happened during festive period only will perhaps helpful to those women
who need to come to the centre spending sometimes for services than not coming at
all.
-
In Jabuvania all lactating mothers who came on this day were given new Mamta cards.
The reason is that Mamta cards were not available since April 2013, they got this month
(March) only. Government’s fault needs to address in a serious manner as it is a matter
of life and death of pregnant women.
-
In Khanpur, provision of nutritional supplement distributions were not available as part
of the VHND service because Mamta diwas was conducted in Sub-centre where only
health care services will be provided, not food. After having an interaction with one
of the ASHAs it was understood that food never distributing in sub-centre, women
should go to Anganwadi for supplementary foods any day they feel like.
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In Ruparel, the quality of supplementary food distributed on this day was only puri
which I personally felt that its quality is not that good; there were no other nutritional
food items available.
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In Jabuvania Things provided by the governments are only rations, oil and small
amount of salt but most of the things such as weighing machining (adult),medicines
(paracetamol, cough syrup, ORS, Zinc tablets),etc provided by Village Health
Committee. If the govt can extend its service up to the mark that all the basic needs
(water, BP measurement, scale for height, bed & separate room for abdominal
examination, etc) are availed regularly and extensively in each and every Anganwadi
centre there is no doubt that half of the problems in the community will be solved.
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In Khanpur, the doctor was available at the centre but his role in this event was
remained unclear, as it appeared that he didn’t do any checkups or interact with those
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women who came on that day. In Khanpur there was a mixing of roles by health
workers which is not according to the check list e.g FHW played the role of ANM in
counselling and in giving information about schemes and so on. In fact there was no
shortage of human resources, there was a mutual understanding among themselves that
they can play their own role and also they can help each other according to their own
capacity. Another example is that the ASHAs’ supervisor helped ANM in keeping
records on that day where in Ruparel for example was done by ANM. Personally I feel
that mixing of roles with no negative consequence is useful because as in the case at
Khanpur ANM had to provide medicines, did ANC check up, gave injections, etc and
if she had to keep records or give counselling I believed that she will not be able to
finish everything on time.
Reflecting those VHND observations there are of course some differences between the services
provided at Anganwadi centres and in Sub-centres. Sub-centres are far better in having
facilities, infrastructures and giving services to women, children and adolescents. For example,
in Khanpur there are two rooms, bed for abdominal check up where as in Ruparel and in
Jabuvania there is only one room, in Ruparel bed is used for displaying medicines and other
stuff. In sub-centre there are buckets for waste and syringes destroyers to destroy all syringes
used. In Anganwadi centres such as in Jabuvania there is no measuring scale for height and no
weighing machine for infants, infants had to measure altogether with the mother. Again when
we think about nutrition Anganwadi centres are better place to conduct VHND because those
who come on this day will get both nutrition and health care services.
Eventhough the observation was done only to three centres yet I can see a positive impact in
the life of people there. Mamta diwas has been an effective way in reaching out to the people
in those three villages to bring about the much needed behavioural changes which is from not
taking IFA to consuming IFA or taking TT injections for instance. During the observation there
was a health seeking behaviour among women because on those VHNDs women came along
with their children, with their mothers and even with their husbands.
As per the information got from some of the health workers saying that there are some families
have one meal a day but due to Mamta diwas those families could have two supplementary
meals a day. Regarding institutional delivery, health workers said that women now starting
coming out to deliver in hospitals due to awareness they got from ASHA & ANM during
Mamta diwas. Thus there is no doubt to say that Mamta diwas has a positive impact in the
community’s life which in later life will lead to a better health outcomes.
Summary of SWOC analysis:
Strengths:
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1. Availability of of mamta cards
2. Organised VHND on a fixed day
3. Good coordination among health providers
4. Distribution of IFA
Weaknesses:
1. Low awareness on entitlements (JSY/ JSSK,etc)
2. Wasting of human resource
3. Poor allotment of responsibilities
4. Provided health care without nutritional foods
5. Poor provision of facilities and adequate infrastructure (water, bed, number of rooms,
etc)
Opportunities:
1. Integration with ICDS for supplementary food
2. Collaboration with NGOs in monitoring the quality of care using checklist
3. Support from Village health committee
4. Linkages with health providers of public health system
5. Networking with MIS at CHC for referrals
Challenges/Threats:
1. Non availability of certain equipments (measuring scale &weighing machines)
2. Poor quality of supplementary food
3. Poor attendance for ANC
4. Young age for pregnancy and lactation
5. No enquiry about danger signs
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My overall reflection: Relevance to Meghalaya
Health status of women and children is still low in our country of which Anemia is one of the
problems faced by all the states of India including Meghalaya not only Gujarat. Reflecting from
the observation of VHND I would like to mention that most of women and children are
anaemic. Since this problem can be prevented it is good perhaps if health workers spend more
time in counselling about proper diet and discussing in utilising of resources (e.g vegetables)
available locally not just providing them IFA tablets. It will also be prevented if nutritious
foods are distributed both at Anganwadi centres and in sub-centres because in sub-centre food
was not provided. In addition, I would like to think in a way that giving awareness on taking
tablets is so important because providing repeated information makes them relate the tablets
with the purpose. As per interaction with health workers another factor which contributes to
anemia might be the age of those women who came for services because majority of them are
in the age of 18 – 23 which is still considered as vulnerable age for pregnancy and lactation.
Regarding the food items and home rations distributed at anganwadi centres were according
to the food that local people used to eat, it happens and applies in Meghalaya also where at
present rice which is a staple food of local people is distributed, this is appreciated. But the
only problem is that at Anganwadi centres there is no store room to keep all the food items. As
per my experiences in visiting few Anganwadi centres in Tamil Nadu, Karnataka, Gujarat and
Meghalaya I would say that none of Anganwadis in these mentioned states have store room or
store house, foods get rotten easily especially in hot places. Another important thing which was
observed was that in Anganwadi centres there is no separate room for ANC checkups or any
partition of rooms for that matter. If the government wants that every state in India is free of
malnutrition and ill health, sanctioning of building of Store room for food items and a separate
room for ANC check up needs to be done with great responsibility. Information, Education and
Communication (IEC) materials in local languages are very helpful in educating and providing
information to women. It is commendable to say that most of health centres especially
Anganwadis and Sub-centre in those villages as well as in Meghalaya are lacking in providing
IEC materials to those concern people who need to understand the whole process of health care
services providing to them. In spite of having weaknesses the government can still improve a
lot of things and one of its strategies could be developing and providing more IEC materials
such as in sub-centre and Anganwadis for the effectiveness of services especially for the
behavioural changes among those target groups.
Reflecting about the doctor who was not playing any roles, one question that crosses my mind
is why human resource is wasted? According to my experiences in other parts of Gujarat
doctors are the main persons in delivering health care services, they even do counselling as
well. In fact in India the major problem in Public health facilities is shortage of medical
professionals. It is important therefore that this small but important issue should be analysed
and rethink properly not only in this particular public health system (Khanpur SC) but also to
other Public health systems in Gujarat, Meghalaya and in all other states of India.
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The government of India wants to strengthen institution delivery. Therefore Janani Shishu
Suraksha Karyakram (JSSK) & Janani Suraksha Yojana (JSY) are the schemes/ entitlements
that were introduced for the welfare of the people. JSSK is an initiative of Govt. of India &
Govt. of Gujarat to assure completely free and cashless services to pregnant women including
normal deliveries and caesarean operations and sick Infants (up to 1 year after birth) in
Government health institutions. This scheme is for all pregnant women. JSY is a safe
motherhood intervention. The objective is to promote institutional delivery among the poor
pregnant women. The Scheme has contributed immensely in increasing the Institutional
deliveries among the BPL, ST and SC population. According to the observation, some women
in sub-centre were informed about JSY but not JSSK. Some of them they don’t even aware of
what these schemes meant for. If pregnant women were not informed about entitlements
definitely there will be less number of pregnant women who would opt for institutional
delivery.
Out of pocket expenses in health care are the main challenges especially in the state like
Meghalaya where Public health systems are low in performance and where various schemes
and entitlements are not properly utilised. Therefore implementation of entitlements which
aimed at mitigating the burden of out of pocket expenses incurred by pregnant women and sick
newborns will be a major factor in enhancing access to public health institutions and help bring
down the MMR and IMR. In order to reach out to people who need these schemes, VHND is
the main platform in giving awareness on these entitlements for institution delivery because
besides financial benefits they get, women can also be assured of preventing complications that
can arise later
Experiencing VHNDs in Gujarat brought lots of insights realising that On the VHND, the
villagers can interact freely with the health personnel and obtain basic services and information.
They can also learn about the preventive and promotive aspects of health care, which will
encourage them to seek health care at proper facilities. Since the VHND is being held at a site
very close to their habitation, the villagers will not have to spend money or time on travel which
is more or less to say health services is provided at their doorstep. The Village Health
Committee such as in Jabuvania and VHSNC in other state of India comprising the ASHA, the
AWW, the ANM, and the PRI representatives, if fully involved in organizing the event, can
bring about dramatic changes in the way that people perceive health and health care
practicesThere was a realisation from those observations made at those three villages that
Anganwadi centres are the main and nearest centre that people can access health care services
and get supplementary foods. In Meghalaya, since 1975 the Integrated Child Development
Services program was implemented to combat malnutrition and to provide basic health care
and Anganwadis are as part of the ICDS and as part of the Indian public health-care system.
In Gujarat also ICDS plays a very important role in providing supplementary and nutritional
foods at Anganwadi centres during VHNDs.
Analysing and commenting at organising of VHNDs, Gujarat is far ahead than Meghalaya
since the inception of NRHM. As per the outcome of mission of Meghalaya ANC coverage is
just 68%; about one-third of women received no antenatal care. In 2008-09 IMR is 58. Instead
of declining it is getting increased in each year, which shows the measures taken is not effective
in the grass root level. Moreover accessibility to Sub-centre where it is considered as primary
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contact for health care is the challenge due to distance and lack of transportation because of
difficult tarrain, costs because of distance. Therefore it is felt thatthe idea of conducting of
Mamta diwas needs to be applied and strengthened in Meghalaya as well especially in all 3864
(as in 2010) existing Anganwadi centres of the state where ASHAs and Angawadi workers will
be the main frontline health workers at Anganwadis especially during VHNDs.Even though
India is suffering from a shortage of skilled medical professional yet when it comes to grass
root level an Anganwadi worker and ASHA are also skilful in tackling some health issues, they
even better equipped than professional doctors in many ways especially in reaching out to the
local population, since the workers live with the people they are in a better position to identify
the cause of the various health problems and hence counter them.
Reflection on methodology:
Interaction with health workers was one of the methods used during the VHNDs. It is
immensely important for gathering maximum information but unfortunately there was no
interaction with women and adolescent girls who attended this programme. The main reason
was language barrier. Apart from observation of what is happening during the day, translation
is needed (English to Gujarati for women and Gujarati to English for me). The field workers
find difficult to help two tasks at a time, i.e., translating on what things happened during service
delivery and translating of what those women have to say. In spite of having this barrier,
observation was done successfully. In effect, there is scope for additional observations and
interactions to enquire about the perceptions of the beneficiaries of the program. That will help
get a more holistic understanding of the value of the program and associated challenges.
CONCLUSION:
Organising VHND raises nutrition and health consciousness among women who are living in
rural areas and prevents both women and children from any sickness which leads to serious
illness and even death. In conclusion, although VHND services take place regularly and health
seeking behaviour from women’s was good; there is still a long way to deliver truly convergent
service and efforts should be made at policy level and sufficient resources allotted to deliver
more and better services through VHND program.
References:
Jan Swathya Abhiyan Universalising health care for all: oppose corporate health care
strengthening the public health system (2012). New Delhi: Jan Swathya Abhiyan
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Improving the Coverage and Quality of Village Health and Nutrition days: Technical Brief
(2012). Intra Health Available at: http://www.intrahealth.org/files/media/improving-thecoverage-and-quality-of-village-health
Evaluation Study of ICDS programme in Meghalaya (2010-2011). Available at:
megpied.gov.in/evaluation/ICDS_Evaluation_study.pdf
Evaluation of NRHM in Meghalaya (A Report),. Prepared by AMC Research Group, New
Delhi. Available at: megpied.gov.in/evaluation/evaluation_NRHM.pd
NRHM in the Eleventh Five Year Plan (2007_2012). Strengthening Public Health Systems.
New Delhi: Ministry of Health and Family Welfare, National Health Systems Resource
Centre Available at: nhsrcindia.org/index.php?option=com_dropfiles&task=frontfile
Guidelines for Community Process (2013) Available at:
http://nrhm.gov.in/communitisation/village-health-nutrition-day.html
SAHAJ. Unpublished data 2014
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