The Concept Of A Nrc Health Essay
The present document has discussed the concept of a NRC and its adaptation in Madhya Pradesh. There is an attempt to get a rounded view of the structure and function of the NRC along with the basic understanding regarding the NRC beneficiaries, their knowledge and practices regarding child nutrition and health after discharge from the NRC, their experience at the NRC and the challenges they face in order to access the NRC. The impact of the activities at the NRC was assessed by analyzing the nutritional status of the children at various phases in the process of nutritional rehabilitation. The preceding chapters have dealt with these themes in detail. The following chapter attempts to interlink the structure and function of the NRC in the study area, to the beneficiaries, their experiences at the NRC and barriers faced by them to access the NRC as well as the impact of the NRC on the nutritional status of the children. The Concept Of A Nrc Health Essay.
Key findings and their interrelation
The following section views the findings from the qualitative and the quantitative data analysis in its entirety, thus shedding light on the objectives of this study .
6.1 The concept of nutritional rehabilitation centre in Madhya Pradesh
The concept of nutrition rehabilitation centres has undergone a lot of modifications since the time of its inception. The delivery system of nutrition rehabilitation, change with respect to the various contextual conditions. As seen in the review of literature, the nutrition rehabilitation centres globally can be broadly classified into day care nutrition centres, Residential centres, Primary health clinics and Domiciliary rehabilitation.
The residential centres are places where the children with malnutrition are helped to recover after they had been treated for their medical condition. These centres provide supervised feeding resulting in good recovery rates. The opportunity to educate the mothers regarding health, hygiene and nutrition is an additional incentive in such centres. This component is seen as the potential to prevent the problem of malnutrition in the long term. In countries where the primary health care system is fraught with problems, these centres can take the curative and rehabilitative measures for the malnourished children in one opportunity. However, this solution is sustainable in areas with a high prevalence of malnutrition. The Concept Of A Nrc Health Essay. The centre should be attached to a medical facility for treatment of medical conditions. Like in the case of day care centres, the residential centres also demand stay of the carer with the child which can be burdensome for the carer as well as the family and thus result in high default rates. Keeping in mind the infrastructural limitations in an institutional setting, there is a risk of low or selective coverage of malnourished children.
The Nutritional rehabilitation centres in Madhya Pradesh are a form of Residential nutrition centres. The choice of this type of nutritional rehabilitation centre for the state of Madhya Pradesh is justified due to the high prevalence of malnutrition in this area. These centres are located at block level and district level hospitals thus providing access to medical care along with rehabilitative care. The children with severe acute malnutrition are admitted along with their mothers/carers in these NRCs for at least 14 days. The stay at the NRC is followed by 4 follow up sessions 15 days apart continuing for 75 days after the discharge from the NRC. Thus one can identify a component of domiciliary rehabilitation included in the follow up phase in this programmatic adaptation of the nutritional rehabilitation centres in Madhya Pradesh. The domiciliary rehabilitation in this case is carried out without the supplementation of any form of RUTF (ready to use therapeutic food). This plan to include the domiciliary rehabilitation in the follow up phase however is based on the assumption that the family has adequate food resources, the carer or mother is present at home full time, and the children are regularly monitored by a CHW or clinic.
The findings of this study show that a very high percentage of the study population falls below the poverty line. Despite this less than half of the families had a BPL ration card. Among the families who had a BPL ration card not all were supplied with subsidized food. This situation leaves more than half of the respondent families facing food insecurity. A majority of the respondents were a part of the work force in the study area. Many of these working mothers were engaged in physically demanding work like daily wage labor. This left limited time for the mothers to be at home with the child and carry out the prescribed nutrition care. In the instances where the child was carried to the work place along with the mother, the child depended mainly on breast feed and the limited food brought from home. These two major hindrances preclude the success of the nutritional rehabilitation in the follow up phase. This is evident by the finding that in the study population the weights at the time of discharge from the centre and the time of fourth follow up were not significantly different. The Concept Of A Nrc Health Essay.
Thus this model of NRC adapted for the state of Madhya Pradesh shows possible hindrances in the implementation during the follow up phase due to the above mentioned contextual problems.
6.2 The Administrative structure of the NRCs
The NRC can be a 10 or 20 bedded structure within the campus of the CHC or District hospital. The staff at the NRC constitutes of a doctor, feeding demonstrator, nurse, caretaker and cook. The day to day activities at the NRC are financed by NRHM. The technical support for the programme is provided by UNICEF.
Though the capacity of the NRCs is to be decided based on the prevalence of that particular area or district, it is evident from the findings that the planning regarding the number of beds in each NRC has been done grossly underestimating the prevalence of malnutrition in the area. This is evident by the finding that the mothers were returned from the NRC when they had gone there for admission, due to non availability of beds. The personnel at the NRCs also seconded this issue by mentioning the prioritization of children for admission in case of inadequacy of beds.
The responsibility to refer SAM children to the NRC rests heavily on the AWW. The AWW is responsible for identification of the child with SAM and also for the follow up sessions of the child after discharge from the NRC. The identification of SAM children at the outpatient department of the hospitals and their referral to the NRC is rarely seen. The possible causes for this can be the lack of knowledge regarding the eligibility criteria for admission to the NRC or unwillingness of the mothers/guardians to get admitted at the NRC at a short notice.
The NRCs faced a serious issue of lack of human resource in terms of the nursing staff. This is the ramification of the shortage of the nursing staff at all the health facilities in the district. Nursing activities like administration of medication, timely clinical investigations and counselling regarding immunisation, family planning and ANC care suffer due to this shortage.
The educational qualification of the feeding demonstrator in two of the three cases did not show the essential training in nutrition. Though the recruitment of this crucial post is subject to the local availability of the prescribed qualifications, the post-recruitment trainings can orient the personnel regarding the technical knowledge as well as crucial job responsibilities. However, in one of the cases the induction training at the divisional level was not attended even after one year into the job. The Concept Of A Nrc Health Essay. The same observation was made in the case of the in charge doctors at the NRC who did not undergo any training in the past two years for their role at the NRC. These findings question the dependability on the technical knowhow regarding treatment of children with SAM and the process of nutritional rehabilitation at the NRC.
The feeding demonstrator carries numerous responsibilities managerial, procedural and technical. The documentation on the SAM chart of every child, the planning of individual diets of the children, the maintenance of various registers and preparation of reports takes up considerable time in the working day of the feeding demonstrator. This leaves very less time for the counselling and rapport building with the mothers. The doctors handle the NRC responsibilities along with the other tasks at the hospital. Considering the shortage of human resources in the rural public health institutions, their priority for the NRC rounds takes a setback.
These findings hint at the various issues in the NRCs at the administrative level.
6.3 Process of nutritional rehabilitation at the NRCs.
The process of nutritional rehabilitation when juxtaposed with the operational guidelines for the nutritional rehabilitation some inconsistencies were encountered which could possibly affect the outcomes.
The rapid screening of the sick children to detect medical conditions demanding immediate attention is an important activity once the child enters the NRC. The children are kept waiting for a considerable time for this procedure. There is possibility of an impending episode of hypoglycemia in these children during the waiting time.
The lack of training and reinforcement of the technical knowhow in nutritional rehabilitation is evident from the following findings. The appetite test is a means to detect a severe ongoing infection or underlying metabolic dysfunction in the child. The appetite test is conducted at all the NRCs, but the amount of RUTF to be administered to each child is not calculated individually. All the children are given 100 grams of RUTF for the appetite test. The decision to put the child on a certain phase diet rests on the child???s ability to consume this RUTF. The test gives false results in case of children who are unable to eat dry powdered food like the RUTF. Only the feeding demonstrators could give details regarding the appetite test. The Concept Of A Nrc Health Essay. The doctors were unable to tell the activities and implications of the appetite test. Thus the ignorance about the importance of the appetite test can lead to an incorrect diagnosis regarding the treatment protocol affecting the process of nutritional rehabilitation. The marginal knowledge of the doctors regarding the phased protocol for nutrition rehabilitation often leaves the feeding demonstrator in a dilemma regarding the treatment decision.
The clinical investigations involving withdrawal of blood and radiography are one of the reasons for defaulting according to the nurse at the NRC. The clinical investigations are to be done only after the child fails to respond to the treatment protocol based on the appetite test. The supplementation of micronutrients was found to be done as per the protocol at all the three NRCs. The nutritional supplementation was done according to the feeding charts displayed in the NRC. However the measurement of the actual feed taken by the child was approximate. This inaccuracy could be detrimental in the process of nutritional rehabilitation where gradual increase in the diet is done based on the daily intake capacity of the child. The timing of breast feeding vis a vis the feeding of the supplementary diet emerged as another issue with varied answers and evident confusion. The doctors and the other staff at the NRC face these limitations due to lack of training and reinforcement of the technical knowledge regarding the treatment protocol for the SAM children.
The counseling services at the NRC form the most important component which will help the mothers to take proper care of the child and continue the process of nutritional rehabilitation on the domiciliary front. However, the findings suggest that the counselling sessions lack planning, regularity, coverage and scientific exactitude. The counselling sessions were not carried out as per the plan suggested in the operational guidelines. These sessions were held randomly without any fixed time or place or subject. The caretakers, the nurse and the feeding demonstrator conducted the counselling sessions at different times. The content of the counselling sessions appeared to be peripheral knowledge related to the subjects.The Concept Of A Nrc Health Essay. The most commonly mentioned topic was that of general hygiene. A majority of respondents also recall this topic to be discussed at the NRC. The other important topics which majority the respondents could not recall as being discussed at the NRC were immunisation and MCP card, making nutritious food at home with available resources, care of mother and family planning and introduction to structured play therapy.
The structured play therapy was the most neglected topic in the NRC. The motive of emotional development of the SAM child through active involvement of the mother in play activities with affordable locally made toys is not solved at the NRC.
The discharge criteria from the NRC are followed at the NRC. At the end of 14 days if the child does not gain weight, has a poor appetite, has oedema and /or other medical complications, the child is unfit for discharge. In this case the mother is requested to extend her stay at the NRC till the child fits in the discharge criteria. Discharge from the programme, after the fourth follow up , however has certain issues. At this stage the labeling of the child takes place. the study population shows that nearly 71 percent of the children were not cured. But these children were not followed up, were not advised readmission and were not investigated further. This finding reflects the limited focus of the NRC staff on the children who are admitted to the NRC. The domiciliary rehabilitation and its aftermath are largely neglected.
6.4 The health behavior and health status of the beneficiaries
The assessment of the knowledge and practices of the mothers was essential inorder to infer regarding the receipt of knowledge as well as the retention of knowledge regarding behaviors and practices that will prevent malnutrition. The findings in this study suggest that certain subjects like general hygiene and sanitation, antenatal care and immunisation and nutritious food were retained by majority of the respondents.
the activities covered under ???good hygiene and sanitation practices??? included hand washing, bathing , trimming nails, washing clothes and utensils with soap etc. the mothers mentioned these activities as components of good hygiene practices. On assessment of the actual practices the findings revealed that the knowledge regarding good hygiene was not being put into practice. This was further validated by the repeated infections in the children with the predominance of diarrhoeal diseases. The Concept Of A Nrc Health Essay. The probable reasons for the inability of the mothers to put the acquired knowledge into practice lie in the other findings from this study. Poverty precludes access to good living conditions. As most of the respondents fall below poverty line, the living conditions are abysmal and hence the susceptibility to repeated infections increases. we have seen in the analysis of the anthropometric parameters that, there is no significant weight gain after discharge from the NRC, thus the retention of the SAM status in these children is also a risk factor for repeated infections. Most of the mothers being a part of the work force, are not at home to supervise the hygiene habits of the children. In case of the mothers who carry the children to their work place , the unavailability of necessary facilities make the adherence to good hygiene and sanitation practices difficult.
The coverage of the topic of antenatal care and immunisation at the NRC was not satisfactory. Despite this fact the number of respondents having delivered a child at a health facility was high. This is a proxy indicator of the awareness regarding antenatal care services. The other channels for information regarding antenatal care and immunisation could be the ASHA, ANM or AWW. the knowledge and awareness creation regarding antenatal care and immunisation is key to thwart the intergenerational cycle of malnutrition and hence its reinforcement at the NRC is advantageous to all the beneficiaries , especially the reproductive age group.
The study revealed that more than half of the women believed in early initiation of breast feeding. There is a strong correlation between this belief and institutional delivery of the index child. However the misconceptions about colostrum feeding continue to exist in more than one third of the study population. This signifies the inability of the NRC to utilize this single most important opportunity to sensitise and educate every mother at the NRC regarding the importance of colostrum feeding. There appeared substantial confusion among the mothers regarding the age up to which exclusive breast feeding should be continued as well as the proper age for weaning. This supports the findings in this study regarding poor weaning practices observed among the respondents. Another finding in the study reveals the early age at which the child starts feeding himself. The nature of the occupation of the mothers, the domestic responsibilities, family size might be the possible explanations for this observation regarding the magnitude of young children feeding themselves on their own.
Inappropriate cooking practices and food taboos persisted among the mothers even after visiting the NRC. The details of the taboos regarding foods consumed during pregnancy and lactation among the women in the study population reveal the exclusion of food stuffs which are nutrient rich, cheap and locally available. Another inappropriate practice was that of preparation of a single meal in the day and consumption of stale food.The Concept Of A Nrc Health Essay. These findings reflect the failure of the NRC counselling services in making a dent on the existing misconceptions and malpractices regarding nutritious food and appropriate cooking practices. Another factor affecting the good nutrition practices is the inability of the mothers to follow the advice given at the NRC due to unavailability or unaffordability of the food stuff mentioned by the feeding demonstrator. Also the engagement of the mother in work, both at home and the work place precludes the time and energy to prepare more than one meal at home.
The treatment seeking behavior among the respondents revealed strong dependence on the local traditional healers and herbal medicines for illnesses in children. The knowledge regarding ORS was mainly from the doctors when they were consulted for treatment. Despite the frequent incidence of diarrhoeal diseases in the study population, the NRC stay had not ensured the receipt of crucial information regarding ORS and care of child during sickness. The attitude of mothers regarding assuming responsibility for weight monitoring of the child is that of dependence on the AWW to a large extent. This indicates lack of sensitization of the mothers towards the importance of growth monitoring.
6.4 Experience of the beneficiaries at the NRC.
The experience of the mothers at the NRC is a factor which will not only influence the process of follow up but also the ???ripple effect??? of the benefits of attending the NRC. Hence in order to understand the perception of the mothers towards NRC some parameters like the overall ambience of the NRC, the communication and feedback from the NRC personnel and the perceived benefit from the NRC were taken into account.
Many respondents in this study were impressed with the cleanliness and the facilities at the NRC. This can be attributed to their poor living conditions at home, where they do not have access to electricity and hence fans/coolers and television. For the NRC personnel, the most important task at hand is to gain confidence among the mothers and build an effective rapport with her. Yet in the study population this component was seen to be deficient. The mothers were given cursory information regarding the child???s illness and the treatment measures.The Concept Of A Nrc Health Essay. This led to defaulting at the NRC or resorting to traditional medicine even during the stay at the NRC. The lack of confidence in the NRC and the treatment administered there is thus the result of the indifferent attitude of the staff towards the concerns of the mother. Sympathetic attitude and communication with the mother will go a long way in building confidence within the mother as well as promotion of behavior change.
The personnel at the NRC too take efforts to help the women to complete their stay at the NRC. They even resorted to indulge these mothers in their much believed traditional magic, just to retain them at the NRC. However this attempt is an indication of taking the easier way to influence the mother rather than bringing about a change in the belief and reasoning in the women at the NRC. These attempts might succeed on a short term basis but will hamper the long term attitude and behavior regarding treatment of illnesses and malnutrition in the community.
The experience of the mothers at the follow up sessions is limited to weighing the child and a physical examination by the doctor. Once again the component of nutritional counselling and support building is absent from these contact sessions. These opportunities to detect weight faltering in congruence with the problems faced by the mother are wasted due to the absence of effective communication and individual counselling sessions.
Thus the NRC experience of the mothers though apparently comfortable is marred by lack of empathy and communication from the service providers. Nevertheless, majority of the women in the study population decreed the stay at the NRC to be beneficial for the child and affirmed their willingness to advise other women in a similar predicament to come to the NRC.
6.5 Factors affecting the utilisation of the NRC services in the study area
It was found that in the study area, though the capacity of the NRCs was insufficient considering the prevalence of malnutrition, the NRCs did not have 100 percent bed occupancy throughout the year. In order to understand the possible reasons posing a barrier to access the NRC, focus group discussions were conducted with the mothers of children, who were suffering from SAM. The Concept Of A Nrc Health Essay.These groups consisted of mothers who had gone to the NRC as well as mothers who had not gone to the NRC despite the advice for the same.
Through the discussions, various factors emerged as possible deterrents to access the NRC. Household responsibilities weighed down heavily on the women in the study population. This, coupled with lack of family support made the stay at the NRC an unwelcome prospect for the mothers of children with SAM. Though the wage loss was covered at the NRC, opportunity cost of attending the NRC for 14 days in terms of loss of wages for the husband or another caregiver for the children at home was unacceptable to many women. This was also true in the months when the agricultural activities in the area were at the peak. These were the months of maximum earning for the daily wage laborers and farmers in the study area and hence the unwillingness to go the NRC for a long duration. Festivities in this region were also another reason for unwillingness to stay at the NRC.
Migration is an issue which has far reaching effects in the health status of the mothers as well as children in the study population. The families that migrate to neighboring states in search of jobs do not have access to any health programmes or subsidies due to unavailability of valid documents. This causes substantial out-of-pocket expenditure in case of illnesses of the mother as well as the child. Needless to say the antenatal care and nutrition both suffer due to this phenomenon. There are testimonies of the AWWs who gave numerous examples of children who were brought in extremely sick condition after returning from the migratory destination. This is also a factor which acts as a hindrance to the utilisation of the NRC services all year round. Thus the problem of migration represents a deeper malaise accentuating the problem of malnutrition in more than one ways. The Concept Of A Nrc Health Essay.
The disappointment of some mothers who were returned from the NRC due to ineligibility for admission or due to unavailability of beds in the NRC served as a deterrent towards utilisation of the NRC services by other mothers. The mothers were unsure about their chances of admission at the NRC even after overcoming the other barriers to reach the NRC.
These factors appear different in isolation but when viewed in the entirety they represent the socio-cultural as well as economical barriers towards accessing health care in the Indian context. The widespread poverty, poor status of women, illiteracy, unemployment and lack of livelihood sources are the underlying reasons for these apparent barriers to accessing the NRC services.
6.6 Impact on the nutritional status of the children.
The most important objective of the activities at the NRC is to improve the nutritional status of the children attending the NRC. Accordingly the ability of the NRC to improve the nutritional status of the children is assessed by analyzing the anthropometric parameters of these children at the various stages of the nutritional rehabilitation programme.
The first phase of nutrition rehabilitation, which is carried out at the NRC shows significant improvement in the nutritional status of the children. It is taken into account that the average stay of the children in this study is 15.19 (??2.855) days. The second phase which is the follow up phase is domiciliary rehabilitation with intermittent supervision. It was found that in this phase there is no significant gain in the weight of the children. The third phase is the phase when the child is discharged from the programme and undergoes home based rehabilitation. It was found that there is no significant weight gain in this phase. On the contrary, there is weight loss seen in some cases. This could be due to the high morbidity rates seen in the children in the follow up phase as well as after the exit from the programme. The finding, that there is no significant difference between the weights at the time of admission to the NRC and at the time of interview suggests that most of the children are once again eligible to be admitted to the NRC.
The model structure for rehabilitation and treatment of SAM children in Madhya Pradesh is based on the Residential rehabilitation centres. A short phase of domiciliary rehabilitation is supplemented in the follow up phase. This adaptation is an attempt to choose from ???best of both the worlds??? in terms of efficacy and effectiveness.The Concept Of A Nrc Health Essay. However the contextual realities like high prevalence of malnutrition, lack of trained manpower, poverty, poor living conditions, lack of livelihood sources, illiteracy and lack of community support preclude the continuation of the effectiveness of this intervention.
Though domiciliary rehabilitation is considered more convenient to the carers and cost effective for the providers, the underlying assumption is the full time presence of the mother or the carer at home , presence of food security and continued medical and counselling support at home. In the absence of these factors the rehabilitation has little meaning. The stay at the NRC though life saving at a certain point, does little more than stall the advances of malnutrition temporarily. For the sustenance of improved nutritional status it is important to device a mechanism, where in the initial counselling and education of the mother is further strengthened by continued frequent follow up at the home level by a health worker. These frequent follow ups will serve as a mechanism to address the nutrition related concerns of the mother, will strengthen medical referrals where needed, and will act as a coordination mechanism between the mother and the various service providers in the area like the ASHA, ANM ,MPW and AWW.
Whether or not to provide RUTF, in domiciliary rehabilitation is an issue of long standing debate. However, primarily the acceptance and targeting of any such intervention has to be tested. Even in the case of the NRC in this study the mothers were not able to follow the advice and techniques imparted at the NRC because of lack of local relevance, affordability and availability. The ability of the counsellor to teach about acceptable, cheap, local food made nutrient rich will probably prove useful in the domiciliary phase.
The complex web of causation for malnutrition continues to affect the children even after they return from the NRC. Hence along with strengthening of the NRC programme in terms of capacity building and extensive follow up services, it is necessary to address the other determinants as well. Livelihood creation through self help groups can be a platform for continued health education and support. Timely access to medical services shortening the span of illness will prevent reversal of growth rate achieved at the NRC. A greater involvement of the AWW after the follow ups will ensure some contact of the beneficiaries with the program. However the current pattern of incentivisation in the study area concentrates on the finding of new cases rather than follow up of old cases. Strict adherence to the output indicators and their respective protocols, to be followed in order to avoid mortality and frequent morbidity.
The answer to the complex problem of malnutrition does not have a unique and definite remedy. The solution should be found context wise in intersectoral co-ordination and persuasive community involvement. As Gro Harlem Brundtland puts it, ???the dual scourge of hunger and malnutrition will be truly vanquished not only when granaries are full , but also when people???s basic health needs are met and women are given their rightful role in societies. The Concept Of A Nrc Health Essay.