Tag Archives: community health workers

Rehydration Unit

In the video, the Haitian child was listless: his eyes were sunken and his shriveled body was limp. His mouth curled, turtle-like, to prepare to cry, but no tears came. A gloved hand, arm hairs poking out, reached for the skin around the child’s abdomen. The hand of the clinician pulled gathered skin to form a sinusoid mound. Then, instead of snapping into place as skin normally does, the mound slowly melted back like silly putty. The words “SKIN PINCH” scrolled across the bottom of the video.

The skin pinch is one of the main diagnostic criteria for testing severe dehydration. In those severe cases in which the body has lost more than 15% of essential fluids, the little fluid left in the body rushes to the skin to cause the counterintuitive effect of swelling. Taped during a cholera epidemic in Haiti, the CDC video was showing how to best manage dehydration. The child had become severely dehydrated from the watery diarrhea that is a common and deadly symptom of cholera infection. By the end of the video, thanks to provision of the best possible treatment, the child was healthy and alert.

This “best practice” is something we are replicating in the slums of Fakir Bagan at Calcutta Kids with the new Rehydration Unit. The Rehydration Unit will allow us to tackle the terrible effects of diarrhea on the children under the age of three in our area. I reviewed over this CDC video to train our community health workers to diagnose and deliver key messages in the Rehydration Unit. One of our four main objectives at Calcutta Kids is to ensure that children age 0-3 grow normally. Diarrhea, the cause of fatal dehydration, is one of the central culprits in preventing normal growth, since it’s been linked to stunting and slower brain growth (1). Over the past six months, Sriya Srikrishnan (the other AIF Clinton Fellow) and I have been working to develop training modules for the health workers, a treatment protocol, and new counseling materials for the Rehydration Unit.

There is no reason any child should ever grow less or die from diarrhea. Yet this preventable and easily treatable disease takes 1.3 million under-five lives a year, a large proportion of those in India (over 1,000 daily on the subcontinent) (2). With counseling on hygiene practices, we can prevent diarrhea by stopping the root cause of microbial transmission. Additionally, the best treatment for diarrhea is the simple and cheap solution of “oral rehydration solution” or O.R.S.

photo

The Rehydration Unit is built on lessons learned from previous experiences with fighting diarrheal prevalence in Fakir Bagan. Back in 2010, analysis of the monthly growth monitoring and promotion weights showed a strong correlation between low weights and having had diarrhea in the two weeks before weighing. This connection spurred a desire to focus in on diarrhea, as both a cause and effect of malnutrition. After studying the highly successful model of the International Centre for Diarrhoeal Disease Research (icddr,b) in Bangladesh, Calcutta Kids opened up the Diarrheal Treatment Center (DTC) in March 2011.

This first foray into treating diarrhea was highly successful, but in creating the Rehydration Unit, we sought to learn from the weaknesses of the DTC initiative. Funded by a grant the World Bank, Calcutta Kids had rented a separate space with a separate staff roster dedicated to the DTC. For the Rehydration Unit, we’ve gone in a different direction. While retaining the essence of the DTC (O.R.S., Zinc, counseling), we wanted the Rehydration Unit to be an integrated part of the central initiative of Calcutta Kids: the Maternal and Young Child Health Initiative (MYCHI) in terms of funding and staff. Health workers, with whom the mothers of the community are familiar and have a rapport with, deliver the innovative BCC materials (from games to demonstrations) and conduct the follow-up visits in the home. Funding is no longer dependent on external grant cycles.

photo (1)

Each 90-minute treatment at the Rehydration Unit has been divided into prevention and treatment modules for counseling. Along with counseling, we have adapted practices from the W.H.O on how to best manage diarrhea with O.R.S. and Zinc while learning from our experience with the Diarrhea Treatment Center. This combination of counseling and the clinical treatment at the Unit (all administered by the community health worker) allows us to treat the short-term problem of diarrhea and dehydration in the most effective way possible while changing behaviors to prevent diarrhea from occurring in the future. The protocol and rehydration unit checklist has been designed to include all these facets and create a conducive environment for health worker-mother interaction.

We have deliberately called the new unit, attached to our daily health clinic, a “rehydration” unit rather than a “diarrheal treatment” unit. Calcutta Kids is seeking to change perspectives on what the ideal treatment should be for diarrhea. Rather than treating diarrhea with anti-diarrheals or anti-microbials (as is common in most of India), the treatment at the Rehydration Unit calls for replacing the lost fluids with O.R.S. to restore the body’s fluid balance. O.R.S. is nothing more than a carefully balanced salt, sugar, water solution that restores the natural transport systems of the intestines. Despite its simplicity, it remains the gold standard for treating diarrhea. It’s discovery, like many scientific advancements, was accidental but fortunate.

In the early 1970s with the Bangladesh War of Independence raging, refugee camps were overflowing and cholera was highly prevalent. The standard treatment was “intravenous fluids while starving the gut,” but the clinical staff ran out of IV therapy. In these desperate circumstances, one Calcutta doctor, Dilip Mahalanabis, decided to try an untested and new treatment: O.R.S. Miraculously, the mortality rates dropped to 3.6% instead of the normal 30% to 40% with IV fluids (3). Calcutta Kids has had the good fortunate to spend time with Dr. Mahalanabis on a number of occasions and he advised us with the DTC.

In India, only 31% of doctors prescribe O.R.S. for diarrhea (4), and often antibiotics are overprescribed. The first component of the behavior change communication modules aims to change these perceptions in the mothers of Fakir Bagan, and hopefully enable the mothers to use O.R.S. themselves at home in cases of diarrhea.

Additionally, the causes of diarrheal incidence stem from improper health and hygiene behaviors as well as from lackluster systemic factors (in water and sanitation). Changing simple behaviors, including hand washing, food handling, toilet usage and disposal of feces, and exposure to open sewers and animal feces, can reduce diarrheal incidence enormously. Hand washing alone can reduce diarrheal incidence by up to 53% (5).

The Rehydration Unit is an example of the innovative and deep thinking way in which Calcutta Kids functions. Calcutta Kids is bringing the most effective, scientifically verified solutions to a community that needs them. Efforts like this will make child morbidity and mortality from diarrhea a fact of the past.–Pranav Reddy

Persuasion Dissected

Persuasion Dissected

(1)Checkley W, Buckley G, Gilman RH, Assis AM, Guerrant RL, et al. (2008) Multi-country analysis of the effects of diarrhoea on childhood stunting. International journal of epidemiology 37: 816–830.

(2) Santosham M, Chandran A, Fitzwater S, Fischer-Walker C, Baqui AH, Black R (2010) Progress and barriers for the control of diarrhoeal disease. Lancet 376: 63–67.

(3) Ruxin, JN (1994). “Magic bullet: the history of oral rehydration therapy”. Medical History 38 (4): 363–97.

(4) Taneja DK, Lal P, Aggarwal CS, Bansal A, Gogia V. Diarrhea
management in some Jhuggi clusters of Delhi. Indian Pediatr 1996;
33: 117–19.

(5) Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, Hoekstra RM. Effect of handwashing on child health: A randomised controlled trial. Lancet 2005;366(9481):225-33.

Child Health Counseling Training February

Since the last Calcutta Kids off-site training in May 2011, our staff members have frequently asked, when will we go away again for training? For our staff, training is more than just an opportunity to learn new skills, it is also a special and exciting opportunity to leave the office and their homes to spend a few days away– a much needed break from the daily grind. We held a long awaited training on protocols and child health counseling last week at Monobitan, a training center south of Kolkata in Pailan run by our friends at CINI. The training was a welcome opportunity to take a step back from our day-to-day work and enjoy some fun learning activities.

The first day of training was held on-site in our new community center in Fakir Bagan—Ma o Shishu Shiksha Kendra (MoSSK). The first task was to come up with an entertaining nickname name for each staff member, using an adjective starting with the same letter as their name. The name would be used throughout the training, and it proved to be a great source of amusement. The names ranged from simple— ‘Sincere Sima’ and’ Jumping Jayanta’—to more complex –‘Na sunne ka pasand nahi Nasreen’ (Doesn’t like to hear no Nasreen) and ‘Shundor moner odhikari Sumana’ (Soul with a good heart Sumana).

The goal of the first day’s training was to clarify protocols for program activities held in MoSSK. The day was spent learning about new protocols for Growth Monitoring and Promotion (GMP), our MYCHI Clinic, Immunizations, Nutrition Corner, Community Meetings, and Child Development Corner, all which are now carried out in MoSSK. The team members role-played each of the activities to internalize the protocol and enjoyed playing different parts such as patient, doctor, mother, and counselor.

The next morning the CK team piled into several Tata Sumo trucks and sped through the streets of Kolkata, heading south to our training site in Pailan. After a quick breakfast, we dove into the training sessions on child health. We focused on two new child health topics: Family Planning and Hygiene & Sanitation. They were not unfamiliar topics to our health workers, but they were new in the sense that we were introducing standardized education and training materials for them. Each topic session consisted of a lecture, videos, and the introduction of an innovative counseling technique. After the Family Planning session, Sriya, our AIF Fellow, who has been working on behavior change communication (BCC) for maternal and child health, introduced a technique called Forum Theater  an interactive form of theater that is used to demonstrate problem situations and involves the audience as part of the activity and resolution to the problem.

Chandan and Susmita participating in Forum Theater

Chandan, Malti and Susmita participating in Forum Theater

After the Hygiene & Sanitation lecture, our program coordinator Sumana, who has taken a formal training course on puppetry for community health and awareness, organized a puppet show on the topic performed by the AICs and CHWs in order to demonstrate another creative technique that can be used for counseling and BCC.

PuppetShow

It was incredible to see how quickly our staff members and, in particular, our health workers, adopted the new techniques. Performing both forum theatre and puppet theatre for the very first time, they successfully incorporated essential messages and both identified and found resolution to key problems using these two creative and interactive mediums.

As the day came to an end, the staff took time to enjoy the last bit of sunlight to walk around the gardens and playgrounds of Monobitan, pushing each other on the swings and merry-go-round. In the evening, we did a ‘guess the baby’ game which included showing baby photos of staff members and having to guess who they were. The highlight activity was the eco-friendly newspaper fashion show, where we split into groups by topic—popular female leader, favorite political leader, famous TV advertisement, movie, book, or cartoon character, and Bollywood actor or actress. Each group dressed up one or more models using newspapers and then walked up the runway as a group, using song or dance. It was truly a hysterical experience and brought out the creative side of our team members. Arpita dressed up as the Chief Minister and sang Ekla Chole Re along with her group. Kalyan posed as Rahul Gandhi, and Chandan danced around as the Joker from Mera Nam Joker—much needed laughter therapy for all of us.

NewspaperFasionShow

The next day, the entire day of training was group work, focused on new strategies for BCC including the forum theatre and puppet theatre techniques from the previous day, along with counseling cards, interactive games, poster making, role-play, discussion groups, visual media, and demonstrations. Participants were divided into five groups and given child health topics–PNC and Care of Newborn, Immunizations, Care of Sick Child, Feeding Practices, and Child Growth and Development. All of these topics are familiar to the staff and our health workers already counsel beneficiaries on these topics. However the novel task was to identify key messages, challenges in changing those behaviors, and present solutions in a new counseling medium. Each group presented their topic and form of counseling technique to the rest of the participants, followed by discussion and feedback. All the techniques mentioned were effectively utilized—and at the end of the session, the whole team felt that they had really learned new skills in the BCC arena, and accomplished something very important. We will take this confidence building to our work in Fakir Bagan community, imparting essential health messages through effective delivery tools. The health workers commented how each of them had started at Calcutta Kids with virtually no knowledge of maternal and child health, and now they not only have internalized the information and the messages, but are able to teach the women they work with in new and exciting ways that will truly change the face of counseling and behavior change at Calcutta Kids.

GroupPresentation

As we left Monobitan that evening, I think that each of us felt a sense of triumph, that the training was a success and we came away from it with so much knowledge. We also felt a sense of peace, and sense of togetherness, as I think the training solidified relationships within the organization and really made us feel that we are working towards a common goal. Our Director Noah commented that the training was ‘a memorable few days which not only strengthened our team as a whole but also strengthened each individual working at CKT.’                          —Sumana Ghosh and Danya Sarkar

 

New BCC Techniques Introduced

At Calcutta Kids, community meetings are held to divulge health messages through meetings focused on various health topics. The community meetings also serve to promote interaction among the mothers of the community. Through the monthly meetings, Calcutta Kids promotes positive health-seeking behavior through the method of Behavior Change Communication (BCC). Women from the community have expressed the need for such a platform where they can share ideas, discuss challenges they face or simply sit along with other women from their community as they drink chai and listen to the health workers about life-saving practices they may adopt.

The health workers do a great job of getting the health messages across to the mothers, usually through an interactive lecture. They encourage mothers to ask questions, share personal experiences and initiate discussions. However, there seems to be a gap between the information that is conveyed during these meetings and the change in practices of the women. After a meeting, the women are able to repeat verbatim, some of the messages of “You must wash your hands before cooking” or “You must eat 6 times a day when pregnant.” Are they really adopting these practices in their homes though? In some of my visits to the community I found that this is not the case in all households.

For example, during my community visit with a health worker on the day of a religious festival, I observed 6 pregnant women who were fasting all day for the good health of their husbands in the future. In some of these cases pregnant women were fasting despite discouragement to do so from their husbands and mothers-in-law (both powerful family members who influence the actions of the mothers). These were mothers who had been to the community meetings and knew well the information about the importance of good nutrition for themselves and their children but continued this detrimental practice. Cultural and religious factors, domestic burden of having to work at home all day, and the simplicity of not having to take that extra step to eat one more meal or wash your hands one extra time often becomes the cause of poor health.

In order to initiate transformative change in the mothers of the community, it is necessary to create reflective processes in a safe space for women to explore their feelings. Providing them with health messages is necessary to build awareness, but in addition to this the health workers need to use approaches that encourage women to think about their behaviors. “Experts who study behavior change agree that long-lasting change is most likely when it is self-motivated and rooted in positive thinking.”(1) Additionally, the setting of a community meeting helps to “recognize the social nature, because it is the co-presence of others thinking alongside us that matters as much as the thinking itself, helping us change our attitudes and reflect on our values, while also acting as commitment devices.”(2)

In order to address this challenge and use different strategies to inculcate positive health behaviors, we are having an offsite training this week where we will introduce various counseling techniques to the health workers. A review of Child Health topics such as “Care of a Sick Child”, “Care of a Low birth Weight Baby, Child Growth and Development”, “Post natal care and Breastfeeding”, and “Feeding practices and Immunizations” will be carried out through the use of various activities to communicate the health messages. Two new topics will also be introduced 1) Family Planning and 2) Hygiene and Sanitation. These health topics will be reviewed using puppet shows, discussion groups, role-play, interactive games and ‘Forum Theater  to demonstrate the use of multiple techniques that can aid in communicating behavior change.

Forum theater  created by the Brazilian director Augusto Boal, serves as an interactive form of theater where dramatic sketches are created through discussion to show scenes where we see a problem that needs to be changed. When the play is acted out, members of the audience are allowed to step in and portray their solution in the given situation thus evolving from mere spectators into “spect-actors”. “The aim is not to find the best solution but to produce a variety of options that could be used in this type of situation.”(3) Forum theater functions by allowing the audience as well as the actors to experience real-life situations in a stage setting with the opportunity to offer multiple solutions to a problem they face. We aspire to introduce the concept of Forum theater to the staff of Calcutta Kids to build community and dialogue on the various problem situations that create obstacles for behavior change in the community. Through this training we hope to ignite the creative minds, especially our community health workers who can use such activities at the community meetings to aid in their counseling techniques.

The training begins at our MoSSK on Thursday 7th February and will continue at an outside training center where we will spend the weekend together.  There will be briefing about the various protocols, lecture sessions, leadership training activities and group work. Word on the street is that there is also an eco-friendly newspaper fashion show to encourage staff bonding and a little bit of fun! -Sriya Srikrishnan

References:

(1) Harvard Women’s Health Watch January 2007 issue
http://www.health.harvard.edu/newsweek/Why-its-hard-to-change-unhealthy-behavior.htm

(2) John, Peter and Smith, Graham and Stoker, Gerry (2009) Nudge nudge, think think: two strategies for changing civic behaviour. Political Quarterly, 80 (3). pp. 361-370. ISSN 0032-3179

(3) Séguin, Angèle Rancourt, Clémence The Theatre: An Effective Tool for Health Promotion http://whqlibdoc.who.int/whf/1996/vol17-no1/WHF_1996_17(1)_p64-74.pdf

US Consul General visits Calcutta Kids

On Wednesday 28th November, the United States Consul General Dean Thompson and his wife Jane paid a call on Calcutta Kids. They arrived at our office in full pomp and circumstance with an escort of 3 police jeeps. The Thompsons have been stationed in Kolkata since August 2011; have heard about the Calcutta Kids and its US connection; and have been anxious to see our growth monitoring and promotion (GMP) program in action. The visit was a great success and a major coup for Calcutta Kids.

Chandan leads the US Consul General, Dean Thompson to Ma O Shishu Shiksha Kendra

We began the visit by having tea around our lunch table while the senior management and CK Trustee, John Ambat, spoke with the Thompsons about the history; the objectives; the successes; and challenges of the organization. The Thompsons asked good questions and made several suggestions of potential collaborations we might pursue especially surrounding alternative mediums for behavioral change communication which they have seen work in various places, i.e. puppet shows and theater.

Gopal, welcomes Dean Thompson to Fakir Bagan

The next stop was Ma O Shishu Shiksha Kendra—our community center in the heart of Fakir Bagan. Wednesday was the second day of GMP—indeed the busiest of the three day program which takes place each month in which more than 550 children are weighed and measured. When the Thompsons entered the 1200 square foot center there were no less than 90 mothers and children. Mr. and Mrs. Thompson observed the weighing of the children and spent time with families waiting in line.

Danya and Sumana explain to the Thompsons about how data is collected at GMP

The Thompsons meet with beneficiaries waiting to be weighed and measured

We then organized a series of conversations so that our guests could interact personally with two of our health workers, Munni and Sima, and a few mother/child pairs. It was during these conversations that the Thompsons were really able to understand the power of the work Calcutta Kids does from the people who do it and from the people who benefit from it. After this series of conversations, Dean spoke to our health workers, about the importance of their work–that it is one thing to gain the knowledge, but the most impressive and most important thing is the transferring of that knowledge to lift up the other women in this community. Jane then mentioned that it was very evident from the way Munni and Sima spoke, how passionate and committed they were to their job—that it was good to see such empowered women in the community.

Some of the staff posing for a photo with the Thompsons in front of our office before they wrap up their visit

We are most grateful to Dean and Jane Thompson for their visit and we hope to welcome them back to Calcutta Kids again sometime soon. We are also most grateful to Danya Sarkar who encouraged and organized the visit. –Noah Levinson

Gov’t-assisted immunization training

In September, Calcutta Kids organized an immunization training program, which served as a refresher training for some of our team and a new experience for others.  The training was carried out by a colleague in the government sector, Dr. Swagata Mukherjee, the Assistant Medical Officer for the Howrah Municipal Corporation (HMC).  Despite his busy schedule, he volunteered his services to Calcutta Kids during his personal time.  During the training, participants learned about vaccine-preventable diseases and related vaccines, the proper vaccination schedule, and how to technically administer each type of vaccine.  The training comprised of two days of observation at the Municipal Health Center during immunization camps, and three days of theory, observation, and practice in the Calcutta Kids clinic.

Training with Dr. Swagata Mukherjee

The training is one of many steps in the process towards implementing a community-based health care model at Calcutta Kids.  Until recently, our curative health, nutrition care, and immunization components have been held in our health center, Swastha Kendra, situated outside of Fakir Bagan.  During immunizations, vaccines were primarily administered by our nurse under the supervision of our doctor.  But this month we are merging the health center into our community center Ma o Shishu Shiksha Kendra, so immunizations are also transitioning to the new space in the heart of Fakir Bagan.  This is part of our effort to bring cost-effective healthcare solutions closer to the community.

The immunization camp will now be carried out in the community by the area in charges (senior community health workers) and the health assistant-counselors who are now qualified in immunizations as a result of the excellent training they received in September.  Where we once relied on one person to conduct immunizations every week (with the doctor as a back-up), we now have four trained staff members who are proficient in administering immunizations.  This will help ensure that immunizations are even more accessible for the families in Fakir Bagan, and provides Calcutta Kids the capacity to extend our immunization program to neighboring areas, thereby targeting more children in need of immunization.

Laxmi administering vaccinations after the training

Around the world, routine immunizations have reduced and even eliminated many childhood illnesses that once killed and debilitated many children.  Although many vaccine preventable diseases (VPDs) have been controlled, children are still dying from diseases that could be prevented by providing the critical vaccinations during the first few years of life.  The World Health Organization estimated that, every year, 1.5 million children die from diseases that could have been prevented by routine vaccination.  That staggering total represents almost one-fifth of all the children who died worldwide before reaching their fifth birthday. (1)

The Indian National Immunization Schedule includes the following six VPDs: Tuberculosis, Diphtheria, Pertussis, Tetanus, Measles, and Polio. For a child to be considered fully immunized, he or she must have received one dose each of BCG and Measles and three doses of DPT and Polio in the first year of life. There is still much more work to be done in terms of immunization coverage in India: Nationally, less than half (43.5%) of children 12-23 months are fully immunized. West Bengal is faring better than the national average, with 64.3% of children 12-23 months fully immunized. (2)

Waiting for immunizations at the Calcutta Kids clinic. Photography by Brett Cole, November 2012

Immunization in India must be sustained, not only to prevent VPDs, but also to reduce the incidence of measles and tetanus, and eradicate poliomyelitis. India, known as one of the greatest challenges for the global polio eradication campaign, has now been polio free for 18 months. (3) The last reported polio case was in Shahapur village in Howrah district, the same district where Calcutta Kids operates. Sustained immunization and coverage will ensure that polio does not make a comeback to this country.

Calcutta Kids is committed to help sustain immunization coverage in Fakir Bagan by ensuring that every young child in Fakir Bagan is fully immunized and therefore protected against vaccine-preventable childhood illnesses.–Danya Sarkar

1.http://www.who.int/immunization_monitoring/diseases/en/
2.NFHS-3, India and West Bengal Factsheets
3.http://www.un.org/millenniumgoals/pdf/UNGA%20Polio%20Event_Press%20Release%20and%20Quote%20Sheet_Final.pdf

AIF Fellow impressions 2012-13 (2 of 2)

On our first day working as fellows at Calcutta Kids, about a month back now, Sriya and I found ourselves rolling our pant-legs up and wading into dark, murky water. We were walking door-to-door with the community health workers in Fakir Bagan. The health workers, who form the foundation of CK’s mission, cajoled and persuaded, informed and explained, about the basic behaviors that were essential for their health and the health of the child in their womb. I realized then, as the gentle fans in the homes of the expecting mothers did a valiant effort to dry our monsoon rain-soaked clothes, that public health didn’t get more grassroots than this. Calcutta Kids worked, rain or shine, at the deepest and most essential roots of maternal and child health, in areas that are black holes in the larger Indian public health system.

Cleaning the drains in Fakir Bagan

Compared to the U.S., Calcutta is, of course, a risky place. One thing that I heard many times from family and friends was to take care of my health. But the truth is no matter how much riskier my life has gotten since I came to Calcutta from Ohio, daily life for an inhabitant of Fakir Bagan is laden with an immensely greater amount of risk. We can look to life expectancy (an admittedly crude indicator). Life expectancy at birth in the U.S. is 78.5 years, and in India it’s 67.1 years (CIA World Factbook 2012). These are averages though; estimates of life expectancy in slums across the globe, ones similar to Fakir Bagan have ranged from seven to fifteen years lower than non-slum urban areas. The risks begin at the very beginning of life and continue throughout, and are not far from what the average American would have faced a century ago.

A healthy CK child

In my view, all health providers at their core attempt to mitigate and prevent risk for their beneficiaries. At the most essential and highest impact stages of life, Calcutta Kids tackles this vast disparity for risk of death and illness. I’ve seen this done through a myriad of MCH programs, including nutrition for malnourished children, regular immunization, check-ups with an on-staff physician, and regular meetings with our health workers.

Immunizations about to be given

Over the next year, Calcutta Kids’s capacity to be involved and engaged within the community will increase, including the behavior change communication programs and community health meetings Sriya will be aiding with as well as the new child development corner. Additionally, Calcutta Kids will be transitioning the health clinic into the Ma o Shishu Shiksha Kendra community center, right in the thick of Fakir Bagan, and initiating a potential geographical expansion within the Howrah slums. I look forward to helping with these goals throughout the year and many more rain soaked home visits.–Pranav Reddy (AIF William J. Clinton Fellow 2012-2013)

AIF Fellow impressions 2012-13 (1 of 2)

I am so impressed and inspired by the motivation you see at Calcutta Kids. Every health worker I have been able to spend time with during my first month here is doing a wholehearted job to be a good resource to the organization and more importantly to the community they are serving. Thanks to our mentor Danya Sarkar, who helped us feel settled down, Pranav and I have been able to explore the community and learn all the various functions of the organization. As we make our visits into the field with the health workers, the community has noticed and recognizes us as new members of Calcutta Kids. We realized this as we looked a little lost while trying to find our way to the community center and two women immediately gave us directions before we even asked them!

The mission of Calcutta Kids can be understood through the manner in which the health workers communicate with the women of the community. Every child is important and can be given adequate care by simply monitoring them. If a child’s weight has not increased during the monthly Growth, Monitoring and Promotion Program, the health worker visits the mother in the following week and counsels her. The health workers express how they are really sad when they see no positive growth in the child. They encourage each mother to take more care of the baby, give her simple tips on how to create a healthy diet and also praise her when she has done a good job. Thus, the health workers have built a great relationship with the mothers of the community. The mothers are always happy to see the didis and welcome them into their houses. They also offer tea or lunch and ask us to spend time with them. When the health worker completes filling up her form and questionnaire, the women thank her for coming and tell her that they felt happy they got to chat with them. The women also trust the health workers as much as they trust a doctor. Even when the health workers are merely on their walk from one house visit to another, many women stop them with their babies and talk about how their child still has a cold or might have developed a skin infection.

Meeting for pregnant women lead by Laxmi Gupta

Meeting for pregnant women led by Laxmi Gupta

The success stories from Calcutta Kids are commendable and its establishment in Fakir Bagan is very apparent in the number of people who visit the clinic everyday or the manner in which we are received in each house. However, there is still work to be done. Although the women recognize the messages delivered by the health workers, many women still do not seem to be adopting a change in their habits. They usually quote too much housework and stress in their lives as reasons for not being able to follow the health workers advice. Even when they come to the community meetings, they listen to the messages or watch the videos but whether they are following the key points is something yet to be assessed. This is a project I plan to work on during my time at Calcutta Kids. I will be working out behavior change communication strategies using different methods of delivering messages to the community. I will be working with the health workers and the beneficiaries to find out why they are not able to follow simple, yet key health practices. Through the health counseling sessions, community meetings and discussions groups I hope to understand the needs of the women, analyze existing techniques of delivering health messages and find ways to improve them. Eventually, I hope to create a sustainable structure to monitor and evaluate changes in health behavior as put forth by the health workers.- Sriya Srikrishnan (AIF William J. Clinton Fellow 2012-2013)

CK Starts Routine Deworming

We introduced an exciting new component to our young child health initiative that we hope will help improve the health status of children in Fakir Bagan.  During our Growth Monitoring and Promotion (GMP) camp this week, Calcutta Kids carried out routine deworming of preschool age children. We have been discussing this idea for several months now after our data analysis showed a high prevalence of worm infestation in a group of malnourished children enrolled in our nutrition pilot program (YChiNG). At the time, we dewormed the children in the YChiNG program, but realized that there were many more children in our catchment area who could benefit from deworming.

Nasreen helping a father give deworming medicine

We were motivated in part by a Government of India mass deworming campaign in New Delhi earlier this year, which included deworming not only school-age children in government schools, but also pre-school age children in ICDS/Anganwadi (government health) centers. During last month’s GMP in Fakir Bagan, we conducted a survey with mothers of children 1-3 years old, asking them to report if their child had an incidence of intestinal worms in the past 6 months. A resounding 43% of mothers answered yes, which reflected a clear need for an intervention.

Intestinal worms, which are pervasive in India, can have devastating effects on a child’s physical and mental growth. In low-income urban areas like Fakir Bagan, where sanitation and hygiene are poor and many children walk around without shoes for protection, the most common type of intestinal worms are soil transmitted helminthes. Once in the body, these parasitic worms feed on host tissues, including blood, leading to a loss of iron and protein. They also hinder the absorption of nutrients. The result is diarrhea, anemia, and malnutrition, all which have a detrimental impact on child health, growth, and development. To counter the negative effects of worms, the WHO recommends periodic drug treatment (deworming) of all children living in endemic areas. (1) Studies have shown that routine deworming of children can have significant positive outcomes on nutrition, growth, and cognitive performance.

A child excited about the new deworming medicine

School-age children are thought to have a high burden of worm infestation. Fortunately, they are easy to reach for deworming because schools serve as pre-established distribution networks. The evidence shows that routine deworming makes a difference. One landmark study showed that deworming can reduce school absenteeism by 25%. Furthermore, children who are regularly dewormed earn over 20% more as adults and work 12% more hours, while those infected are 13% less likely to be literate. (2) Global campaigns now target pre-school age children, who are tougher to reach but also a vulnerable group in terms of exposure to worms. Studies conducted in Indian slums show that there is substantial weight gain in young children (pre-school age) who are dewormed regularly. (3)

Apart from the mass campaign in Delhi this year, which followed mass campaigns in Bihar and Andhra Pradesh a few years back, deworming campaigns have not been widely organized in India. Given that deworming is extremely cost-effective at only a few cents per pill, and provides both short-term and long-term physical and cognitive benefits to a child, India could see great benefits by ramping up state deworming campaigns, which can be effectively carried out through government schools and ICDS/Anganwadi health centers. The WHO includes intestinal worms among “the 17 neglected tropical diseases” which WHO Director General Margaret Chan described as “diseases that are largely silent, as the people affected or at risk have no political voice.”. The WHO launched its “neglected tropical diseases” campaign to raise awareness among policy makers and donors, in hopes of stimulating more action, like deworming campaigns. For Calcutta Kids, this new deworming initiative marks a proactive step to address the “neglected disease” that is most prevalent in our community.

The first round of deworming this week marked the beginning of our commitment to ensure routine deworming every 6 months to each preschool aged child in Fakir Bagan. We reached each of the 311 children between 1-3 years old, but missed some children who had traveled to the village with their families, but they should be covered in future rounds. Between rounds, we will immediately treat any children who present with worms. Parents at the camp were positive about the deworming intervention. The results were telling. In the words of one father, “My child was feeling sick and her stomach was swollen from worms. I am happy that she is now getting medicine to make her better.” – Danya Sarkar

1. http://www.who.int/elena/titles/deworming/en/
2. http://www.dewormtheworld.org/why-deworm/the-evidence-for-school-based-deworming
3. Effects of Deworming on Malnourished Preschool Children in India: An Open-Labelled, Cluster-Randomized Trial. Shally Awasthi, Richard Peto, Vinod K. Pande, Robert H. Fletcher, Simon Read, Donald A. P. Bundy. PLOS Neglected Tropical Diseases, April 2008, Volume 2, Issue 4

The Story of Puja Yadav

I will never forget the image of Puja on that first day of YCHING (Young Child Nutrition Group) in April 2011: Her mother Rinku set her down on the ground, and she took off, a whirlwind of 11 month old energy, tottering on slightly bowed legs, eyes bright with promise, grinning ear to ear. She was a radiant child.

Puja in April 2011

Fast forward to January 2012: Puja’s family came back to Fakir Bagan after a 10 month stay in the village during which time Rinku delivered her fourth child, Prince. Rinku had conceived again when Puja was just 9 months old, and the family–which included Rinku, her husband, Puja’s older brother and sister, and Puja–decided to return to the village for the pregnancy and delivery and to be close to extended family at home. The next time we saw Puja in January, we were shocked to see her condition–gone was the sunny, energetic girl we knew a year back. The new Puja was sullen, lethargic, and irritable. There was a clear reason: after taking her measurements we found that Puja had dropped off her growth curve, plummeting from -2.2 in weight for age z-score (WAZ) in April 2011 to -3.6 WAZ in January 2012. She was severely underweight and obviously suffering from infection. We counseled her mother and urged her to bring Puja in for examination and treatment, but with the new baby, plus Puja and her older siblings, Rinku was overwhelmed and decided to return to the village before we could intervene.

The family reappeared in Fakir Bagan in June 2012 and we were dismayed to see that Puja, now at 27 months, had taken a turn for the worse.  She was now -4.8 WAZ, very severely underweight, and also severely wasted at -3.03 weight for height z-score (WHZ). She suffered from both chronic and acute malnutrition- she was very weak, had raspy, labored breathing, a swollen abdomen, and chronic fever. She urgently needed help. We were sure she would not survive if she continued on this downward spiral.

Puja in June 2012

The Calcutta Kids doctor examined Puja and we quickly put together a treatment plan for Puja. First, we referred and accompanied her to Hope Hospital in Kolkata where she could be seen by a specialist pediatrician. The pediatrician diagnosed her with severe protein energy malnutrition (PEM), severe anemia, and chronic infection, and suspected that she had TB. He ordered a battery of tests and we sent Puja to the local DOTS (Directly Observed Therapy) center for TB screening. Though her Mantoux test was negative, her chest x-ray showed severe infection in the lung.

In consultation with the Hope pediatrician, Puja is now taking a 3 month course of level I anti-tuberculosis drug for her lung infection and therapeutic micronutrient supplements. Rinku brings her to the Calcutta Kids clinic everyday for an energy and protein dense, nutritious meal. Our health workers visit her home regularly for follow up and counseling on care, hygiene, and nutrition with the family.

Puja and her mother Rinku, July 2012

Puja Yadav, like all our children at Calcutta Kids, was never just a ‘case’ to be managed. She was a child at risk, a child trying desperately to survive the odds around her–a life that would not only be lost, but discounted, if someone did not intervene. Our entire team rallied together with Puja’s family.  We had intense discussions, we shed a few tears, and we cheered when Puja started gaining weight, slowly but surely; started smiling again; and even laughing. We are very happy to report that Puja has started to blossom again, and is slowly starting to resemble the girl we met over a year ago. In two months, she gained 1.5 kg, and shot up from -4.8 WAZ to -3.5 WAZ. She has improved from severe wasting (-3.03 WHZ) to mild wasting (-1.38 WHZ), a remarkable turnaround. And all of this has happened with home-based care, which is much harder to adhere to and manage than institutionalized rehabilitation, an option that the family would not consider, because it would mean leaving the other children at home without a full-time caregiver.

Like Puja, the family has started to change as well. Initially, both father and mother did not want to take Puja to the DOTS center three days a week for medication. They feared Puja would be labeled as a TB patient and ostracized by their neighbors. Calcutta Kids counseled them and gave them confidence to explain to their neighbors why they sought treatment for Puja. The community around them has also seen the changes in Puja and supports the family’s actions. Furthermore, as Puja’s health has improved, her younger brother Prince has also made remarkable strides. He, too, had been severely underweight when they came back from the village in June 2012. In the past 2 months, Prince moved up to the moderate category, gaining 1.2 kg, going from -3.47 to -2.4 in z-score (WAZ). We believe that this is another testament to change that has occurred in the family and especially in Rinku, who now seems less burdened, more confident, and proud of her children. When she brings Puja to the clinic she is delighted when Puja calls our health workers ‘amar didi’ (my elder sisters) and when Puja holds her hands to us in ‘namashkar.’

Puja now–August 2012

Puja is a true fighter. She is still the vibrant spirit who caught our attention long ago. She and her family just needed some extra attention. We at Calcutta Kids feel privileged that we were able to provide that additional help. We are committed to making sure that Puja remains on this trajectory of growth and nutrition, a critical foundation for a healthy and productive future. –Danya Sarkar

Puja’s Weight for Age Z score.
(Ideal is a straight line at 0)

Puja’s Weight for Height Z score.
(Ideal is a straight line at 0)

C-Section Blog Series (4 of 4)

The third part of our C-section blog series focused on the circumstances leading up to Calcutta Kids’ decision to stop partnering with private clinics for facility based deliveries, and instead (a) offer a Delivery Savings Scheme (DSS) which would provide financial assistance for beneficiaries to deliver wherever they prefer; and (b) up the ante on birth preparedness through a new home counseling curriculum. This week’s blog describes that curriculum, provides data on beneficiaries’ usage rates of the delivery savings scheme, and calls attention to the fact that more community involvement is necessary for the delivery savings program to succeed.

Throughout the pregnancies of our beneficiaries, our CHWs visit their homes at least once a month. During the last few months of pregnancy, the visits have become more standardized and focus on the following themes:

  • Danger signs. What to watch out for—especially pain in the lower abdomen, heavy white discharge or bloody discharge. In such cases, pregnant women are advised to go immediately to the facility with which they are registered, and to call their Area in Charge for support
  • What not to worry about: Many women become worried if the gestational age of their child crosses 37 weeks. The CHW’s counsel the women not to worry about this until around 40 weeks at which time they should visit their facility.
  • Preparation: The family is counseled to assure the availability of transportation to the facility regardless of the time of day or night, and to ensure that money is set aside for transport. They are also told what documentation to have ready to take with them to the facility.
  • To C or not to C: Pregnant women and their families are provided with knowledge about C-sections. They are informed of the recognized and accepted indications for C-sections; the potential risks for the mother after a C-section delivery; the potential risks for the mother during her next pregnancy; the immediate risks for the baby during a C-section delivery; and the potential long term risks for a C-section-delivered child.

The CK staff has gone through an intensive training focusing on these themes. (You can see these materials in the resources section of our website or you can click here for the Labor and Delivery Educational Session and here for the C-Section Education Session.)  They also have received refresher training on the labor and delivery process, fetal development, and complications that can occur during labor. And they are equipped with flip charts and other materials to facilitate their home-based counseling with pregnant women.

Delivery Savings Scheme Data:

  • Scheme began in July 2011
  • Since inception, 68 CK pregnant women out of 162 pregnant women in households registered with CK, have enrolled in DSS
  • Of those 68, 45 remain pregnant
    • Of the 45 who delivered, 2 had miscarriages; 29 had normal deliveries, and 14 had c-sections.
    • Of the 45 who delivered, 24 took place in private facilities and 19 took place in public facilities.
  • Currently (July 2012) there are 55 pregnant women involved with Calcutta Kids and 21 are participating in the DSS.

With a DSS user rate of around 40%, the scheme is not working as well as we would like. And the DSS is not working as a replacement for the services being provided earlier through private facilities.

Next week, Calcutta Kids will be holding a number of focus group discussions to try and figure out why it is that more pregnant women are not taking advantage of this scheme. The discussions will be held separately with those who have used the DSS and those who have not. We look forward to sharing what we learn from these discussions in a future blog.

From this data, however, some questions arise: Does this experience coupled with the micro insurance experience indicate that families (a) don’t have surplus cash on hand or (b) aren’t willing to use surplus cash for such a purpose or (c) that the men in the family are not willing to set such money aside for this or (d) there a is basic fear (based on the reality that there is a lot of huckstering that goes on in the slum) that they might never see their money again?

Clearly we have more work to do in facilitating a good option for safe facility-based delivery among our beneficiaries. We are confident that we will be able to find a solution which benefits our beneficiaries while at the same time protecting them—and also Calcutta Kids. -Sumana Ghosh, Danya Sarkar and Noah Levinson