Urban health and nutrition day or only immunisation day? barriers and bottlenecks in implementing Urban health and nutrition day in an Urban primary health centre of Nagpur, Central India

The study was conducted at Nandanvan UPHC, located in Nagpur, which caters to about 80,000 people, including 52,000 slum dwellers. The community-based outreach services of Nandanvan UPHC are provided through 28 UHNDs, which are held once a month on pre-specified dates. They are usually organised in Anganwadi centres (AWCs), primary schools or other suitable community spaces, where a package of services are provided by Anganwadi workers (AWW) and ANM, whereas community mobilisation is carried out by ASHA and MAS members. One nongovernmental organisation (NGO) also works in collaboration with health authorities to coordinate UHND activities. To get a broad insight into the study topic, professional diversity was considered in selecting the participants. ANMs, ASHAs, AWWs and an NGO representative involved in the UHND sessions were included as participants in the qualitative inquiry and are termed as CHWs.

Study design, tools and data collection techniques

This mixed-method study was conducted using a triangulation design, and data were collected between November 2019 and January 2020.

Sampling methods: In the selected UPHC, a total of 28 UHND sessions were planned in a month. Without any sampling, all these UHND sessions were visited for participant observation as per the schedule submitted in UPHC. Each UHND session was observed by a trained public health expert from initiation to the end of the session.

For the qualitative interviews, all ANMs, staff nurses involved in service delivery, were included, and ASHAs were approached based on their expressed willingness to participate in the study. An initial gap assessment was carried out quantitatively using an observation checklist as the first study tool to assess quality of care. The checklist was prepared according to the guidelines proposed by NUHM for conducting UHND [9]. Data were filled by trained epidemiologists for each observed session. Terms of references (TOR) included domains under the implementation of maternal and child health care; curative care for common conditions; screening and continuity of care for NCDs; raising awareness toward preventive and promotive health; provision of family planning services; and access to essential drugs and testing facility. To assess recent regularity and use of services, data on regularity of sessions, number of beneficiaries in each session, due list and follow-up details, availability of logistics and so on were obtained using a structured data extraction form from the last six months of reports prepared by ANMs.

After quantitative assessment, qualitative techniques were used to understand the bottlenecks and barriers in implementing the services. Researchers trained in qualitative methods collected the data. In-depth interviews (IDIs) were carried out among eight purposively selected ASHAs, eight AWWs, four ANMs and one NGO representative, all in the regional language, using a pre-tested, unstructured interview guide as second study tool. An IDI guide included questions related to all the terms of reference. Interviews were continued until data saturation. Field observations and IDIs were followed by focus group discussion (FGDs) among ASHAs. After the briefing on the objectives of the exercise, two free-listing exercises were conducted involving ASHAs on: (1) Activities carried out in their UHND session, and (2) activities expected to be carried out in UHND. After free listing, one FGD was carried out among 11 ASHAs present on that day with the help of a predesigned FGD guide (the third study tool). The domains unearthed in the IDIs were used in the FGD guide. Each TOR was discussed among the group, and for each domain, gaps were identified, possible reasons and ways to address such gaps as perceived by ASHAs were considered. Multiple probes were given in the vernacular language whenever clarification was needed. The entire FGD exercise lasted 90 minutes and was audio recorded; a transcript was prepared on the same day by the person who took notes in the FGD.

The flow of integration of qualitative and quantitative methods in data collection and analysis is depicted in Fig 1.

Figure 1

The proportion of UHND sessions providing each component of services was presented by number and percentage. The free listing exercise on expected and actual services delivered in UHND was analysed in Anthropac to get the salience score. Smith’s salience score is an index that indicates the importance and centrality of the specific item. A score close to 1 indicates high salience, and a score close to zero indicates less salience [10]. The audio-recorded clips were transcribed into English and read several times iteratively by two independent researchers. Identification of relevant codes and thematic analysis content was carried out manually to identify patterns of meaning across the transcripts.

Written informed consent was obtained from each participant before each interview. To ensure privacy, the confidentiality of the opinion and participants’ comfort, interviews were conducted at a place and time convenient to them, and no identifiers were included in the transcript. The transcripts and audio-recording clips were stored in password-protected files accessible only to the study investigators. The study was undertaken after obtaining clearance from the Institute Ethics Committee of All India Institute of Medical Sciences Nagpur (Reg No-EC/Dept of Comm Med/AIIMS/Nagpur, Dated 21/02/19).

Regularity and venue of the UHND sessions: Of the 28 sessions, two were not conducted on the scheduled date, as the ANM was on leave. Schedules of four more sessions needed to be changed due to the nonavailability of staff over the last six months. Missed sessions and changes of venue over six months were found in one and three sessions, respectively. Of the 28 sessions, 22 were organised at AWCs; five were in a private building; and one was in a community garden maintained by the municipality. No dedicated toilet or water supply was available at session sites. In none of the sessions were MAS members or Urban Local Body (ULB) representatives present.

Display of Charter and IEC materials: Fixed display boards were found in only one session, though that had only immunisation-related information. In other sessions, ANMs carried one poster of Mission Indradhanush [11], which described immunisation services only. Other services available (other than immunisations) were not displayed in any session. Health education materials were displayed in all the 22 sessions organised in AWCs, but not in any session organised in other settings.

Logistics issues: No contraceptives were found to be distributed to the beneficiaries in any session. At none of the session sites were essential items for examinations available, such as examination tables, screens for privacy, stethoscopes, inch tape, MUAC tape, and diagnostic kits. Details of drugs and logistics available at UHND are depicted in Tables 1 and 2, respectively. The adult weighing machine was available in 22 sessions, and 19 were functioning. Further, at 16 sites (57.1%), HCWs were using it to measure the weight of pregnant women. Salter’s scale or paediatric weighing machine was available in 22 sessions, and for 17 sessions they were in usable condition; nine (32.1%) were used for measuring the children’s weight. In two sessions adult weighing machines were used to measure the baby’s weight. Similarly, height scales were available in 20 sessions; however, in only five (17.9%) sessions were height measurement actually carried out.

Number of beneficiaries attending UHND varied based on location (slum vs. non-slum). Median (IQR) attendance in non-slum UHNDs was seven (4–15) as against 52 (18–65) in slum UHNDs. All sites offered services like registration of pregnant women, immunisation of pregnant women and children under five years of age, and distribution of iron folic acid (IFA) and calcium tablets to pregnant women. Details of key services provided at UHND sessions, as described in Fig. 2 revealed that antenatal services are predominately restricted to pregnancy registration and IFA tablet distribution, whereas among postnatal services only dietary counselling and registration of conditional cash transfer schemes were carried out. Among child health service components, only immunisation and filling of MCP cards were carried out. No reproductive health services were available except interpersonal counselling. Basic investigations such as testing for malaria, urine albumin/ sugar, haemoglobin estimation, screening for diabetes and hypertension, sputum collection and qualitative iodine test kits were not available in any of the UHND sessions. As depicted in the result of the free listing, most of the CHWs opined that the outreach sessions are organised to provide immunisation and registration of pregnant women (salience score of 0.786 and 0.510, respectively). Other components of UHND were grossly ignored by the providers. (Table 3.)

Figure 2

Thematic analysis of the transcripts revealed the following bottlenecks and barriers faced by the CHWs.

Striking variation in the number of beneficiaries per UHND session has been noted in the slum and non-slum settings. In all five sessions organised in non-slum-predominant areas, poor community involvement and compliance have been noted. One of ANM said, “Most of the people here prefer private practitioners. Even those who go to the government facility, they get all the facilities in the UPHC which is five minutes from here.” The ASHAs seconded this and added, “The number of beneficiaries who are not attending the sessions remain very high during every month. To cover this up, I need to make home visits for counselling and tracking their immunisation status. That increases my workload manifold.”

The geographic boundary of each UHND location was not clear-cut to the service providers. When data collection was done for this study, they did not have a line list of beneficiaries. For ease of work, CHWs divided the population catered to by the said UPHC arbitrarily into some “areas” catering to 1,000 to 1,200 people, roughly based on the number and residence of ASHAs. However, due to constant in-migration, such areas have been expanding, posing great challenges to existing manpower. Often, the CHWs were not being updated regarding slums included or excluded. This resulted in some unserved and left-out pockets as well as some duplication of beneficiaries. When ASHAs were asked about their beneficiary lists, it was observed that in four areas the number of beneficiaries was much less (<50%) than expected (i.e., as calculated based on area population and age distribution) [12]. ANMs also reported that many people come to UHND sessions from adjacent slum areas, outside the catchment area, where no UHNDs are carried out. The ANMs/AWWs had to provide services to these attendees without entering it in the record or portal. Thus a true picture is not being reflected in the records.

As depicted in the free listing (Table 3), most of the CHWs opined that the outreach sessions were organised to provide immunisation and registration of pregnant women (salience score of 0.786 and 0.510, respectively). Other components of UHND were grossly ignored.

Though the basic Module of ASHA [13] was expected to cover the scope for UHND, some ASHAs said, “We did not undergo any formal training on different components of UHND.” Many of them are not aware of all the components of UHND. In free listing their perceptions on the services that need to be available, very few participants listed components like supplementation of iron syrup to children or deworming (salience score of 0.042 and 0.028, respectively). Also, few ASHAs reported that “they felt UHND as a separate program organised on a different date in AWCs.”

A tendency to complete all the sessions before the 15th of every month was observed. On exploration, they replied, “We plan our sessions to complete within the initial two weeks so that we can utilise the remaining days of the month for preparing the reports. Further, if I can finish up my quota, I can take charge of that of one of my colleagues, who might be on leave or deputed for some other work, which happens very commonly.” Except for two sites where the supervisor from the central immunisation team had visited for quality assurance, none of the other sites had regular supervision and monitoring. A medical officer of UPHC commented, “Since some of the days in the first two weeks do have even three sessions on the same day, monitoring or logistic adjustment becomes challenging.”

With the majority being located inside slums, the UHND session sites are plagued with a space crunch. Nine out of the 28 sessions could barely accommodate five or six adults and those sessions conducted in open places had privacy issues. One ANM said, “We cannot carry out any abdominal examination for the pregnant ladies. We conduct sessions even in an open park/courtyard, which does not have privacy or logistics. How will it be possible then? Moreover, during monsoon, it becomes almost impossible to carry out the sessions.”

The supply of supplements (like IFA, calcium and vitamin A) were found to be irregular and inadequate. “The amount of calcium tablets supplied gets over within one to two sessions and most of the beneficiaries don’t get it. … [S]upplies of iron tablets are not adequate. If beneficiaries are already taking iron tablets from private, we have to ask them to continue so,“ commented one ANM. Due to insufficient supply, sometimes CHWs distributed fewer tablets than should be according to norms. Home delivery of iron and calcium tablets by ASHAs to pregnant and lactating women were not carried out.

No MAS member was found to be present in any UHND session. On exploration, the coordinator for the MAS replied, “Development of MAS is in a very primitive stage in most of the slum areas. The liaison between the ASHAs and the MAS members are not in place and we are in process of addressing this issue, sometimes by redistributing the MAS members.” ASHAs and ANMs have no idea about the role of MAS in UHND. Representatives from Urban Local Bodies (ULB) did not interact with CHW in coordinating UHND activities. Lack of community awareness on services provided in UHND and very poor community engagement were observed.

Frequently, ASHAs and ANMs were involved in other survey/ services, which resulted in discontinuation of routine services. Numbers of ASHAs present were much fewer than required per the NUHM norm. Lack of coordination between ASHA, AWW and ANM and internal conflict about job distribution among them was also noted. Currently, contraceptives are expected to be distributed and monitored through Family Planning–Logistics Management Information System (FP-LMISF).¹⁴ Training on this online portal was given to only select CHWs. According to one ANM, “ASHAs are unable to use this system as they did not have training and they do not understand its functionality. All don’t have a smartphone to use this application. The IT support team did not provide user-ID for everyone.”