Indrajit Chaudhuri

Elimination of visceral leishmaniasis in the Indian subcontinent: a comparison of predictions from three transmission models.

We present three transmission models of visceral leishmaniasis (VL) in the Indian subcontinent (ISC) with structural differences regarding the disease stage that provides the main contribution to transmission, including models with a prominent role of asymptomatic infection, and fit them to recent case data from 8 endemic districts in Bihar, India. Following a geographical cross-validation of the models, we compare their predictions for achieving the WHO VL elimination targets with ongoing treatment and vector control strategies. All the transmission models suggest that the WHO elimination target (<1 new VL case per 10,000 capita per year at sub-district level) is likely to be met in Bihar, India, before or close to 2020 in sub-districts with a pre-control incidence of 10 VL cases per 10,000 people per year or less, when current intervention levels (60% coverage of indoor residual spraying (IRS) of insecticide and a delay of 40 days from onset of symptoms to treatment (OT)) are maintained, given the accuracy and generalizability of the existing data regarding incidence and IRS coverage. In settings with a pre-control endemicity level of 5/10,000, increasing the effective IRS coverage from 60 to 80% is predicted to lead to elimination of VL 1–3 years earlier (depending on the particular model), and decreasing OT from 40 to 20 days to bring elimination forward by approximately 1 year. However, in all instances the models suggest that L. donovani transmission will continue after 2020 and thus that surveillance and control measures need to remain in place until the longer-term aim of breaking transmission is achieved.

Continuum of Care Services for Maternal and Child Health using mobile technology – a health system strengthening strategy in low and middle income countries

BackgroundMobile phone technology is utilized for better delivery of health services worldwide. In low-and-middle income countries mobile phones are now ubiquitous. Thus leveraging mHealth applications in health sector is becoming popular rapidly in these countries. To assess the effectiveness of the Continuum of Care Services (CCS) mHealth platform in terms of strengthening the delivery of maternal and child health (MCH) services in a district in Bihar, a resource-poor state in India.MethodsThe CommCare mHealth platform was customized to CCS as one of the innovations under a project funded by the Bill and Melinda Gates Foundation to improve the maternal and newborn health services in Bihar. The intervention was rolled out in one project district in Bihar, during July 2012. More than 550 frontline workers out of a total of 3000 including Accredited Social Health Activists, Anganwadi Workers, Auxilliary Nurse Midwives and Lady Health Supervisors were trained to use the mHealth platform. The service delivery components namely early registration of pregnant women, three antenatal visits, tetanus toxoid immunization of the mother, iron and folic acid tablet supply, institutional delivery, postnatal home visits and early initiation of breastfeeding were used as indicators for good quality services. The resultant coverage of these services in the implementation area was compared with rest of Bihar and previous year statistics of the same area. The time lag between delivery of a service and its record capture in the maternal and child tracking system (MCTS) database was computed in a random sample of 16,000 beneficiaries. The coverage of services among marginalized and non-marginalized castes was compared to indicate equity of service delivery. Health system strengthening was viewed from the angle of coverage, quality, equity and efficiency of services.ResultsThe implementation blocks had higher coverage of all the eight indicator services compared to rest of Bihar and the previous year. There was equity of services across castes for all the indicators. Timely capture of data was also ensured compared to paper-based reporting.ConclusionBy virtue of its impact on quality, efficiency and equity of service delivery, health care manpower efficiency and governance, the mHealth inclusion at service provision level can be one of the potential strategy to strengthen the health system.

Epidemiologic Correlates of Mortality among Symptomatic Visceral Leishmaniasis Cases: Findings from Situation Assessment in High Endemic Foci in India.

Background Visceral leishmaniasis (VL) is highly prevalent in the Indian state of Bihar and, without proper diagnosis and treatment, is associated with high fatality. However, lack of efficient reporting mechanism had been an impediment in estimating the burden of mortality and its antecedents among symptomatic VL cases. The objectives of the current study were to generate a reliable estimate of symptomatic VL caseload and mortality in Bihar, as well as to identify the epidemiologic and health infrastructure-related predictors of VL mortality. Methodology and Principal Findings Using an elaborate index case tracing method, we attempted to locate all symptomatic VL patients in eight districts of Bihar. Interviews and medical-record-reviews were conducted with cases (or next-of-kin for the dead) meeting the eligibility criteria. The information collected during the interviews included socio-demographic characteristics, onset of disease symptoms, place of diagnosis, pre- and post-diagnosis treatment history, type and duration of drugs received. In total, we analyzed data on 4925 VL patients—59% were male and 68% were less than 30 years old. There were 158 (3.2%) deaths and the incidence rate of mortality was 3.2/100 person-years. In the adjusted Cox-proportional-hazards analysis, treatment at public facility [Adjusted Hazard Ratio (AHR) = 0.61; 95% CI = 0.43–0.86], shorter (≤30 days) diagnostic delay [AHR = 0.62, 95% CI = 0.43–0.92], and treatment completion [AHR = 0.03, 95% CI = 0.02–0.05] emerged as significant negative predictors of mortality. Conclusion Mortality reduction efforts in Bihar should focus on improving access to early diagnosis, quality treatment and treatment-adherence measures, with special emphasis on marginalized communities.

The Influence of Seasonality and Community-Based Health Worker Provided Counselling on Exclusive Breastfeeding - Findings from a Cross-Sectional Survey in India.

Background Exclusive breastfeeding (EBF) during the first six months of life is considered a high impact but low-cost measure for reducing the morbidity and mortality among children. The current study investigated the association of seasonality and frontline worker(FLW) provided counselling with practice of EBF in Bihar, India. Methods We used the ‘Lot Quality Assurance Sampling’ technique to conduct a multi-stage sampling survey in 8 districts of Bihar. Regarding EBF, mothers of 0–5 (completed) months old children were asked if they had given only breastmilk to their children during the previous day, while mothers of 6–8 (completed) months old children were inquired about the total duration of EBF. We tested for association between EBF during the previous day with season of interview and EBF for full 6 months with nursing season. We also assessed if receiving counselling on EBF and complementary feeding had any association with relevant EBF indicators. Results Among the under-6 month old children, 76% received EBF during the previous day, whereas 92% of 6–8 (completed) months old children reportedly received EBF for the recommended duration. Proportion of 0–5 (completed) month old children receiving only breastmilk (during last 24 hours) decreased significantly with increasing age and with change of season from colder to warmer months. Odds of receiving only breastmilk during the previous day was significantly higher during the winter months (Adjusted odds ratio(AOR) = 1.50; 95% CI = 1.37, 1.63) compared to summer. Also, the children nursed primarily during the winter season had higher odds of receiving EBF for 6 months (AOR = 1.90, 95% CI = 1.43, 2.52) than those with non-winter nursing. Receiving FLW-counselling was positively associated with breastfeeding exclusively, even after adjusting for seasonality and other covariates (AOR = 1.82; 95% CI = 1.67, 1.98). Conclusions Seasonality is a significant but non-modifiable risk factor for EBF. However, FLW-counselling was found to increase practice of EBF irrespective of season. Scale-up of FLW-counselling services, with emphasis on summer months and mothers of older infants, can potentially reduce the impact of seasonality on EBF.

A Cross-Sectional Survey in Rural Bihar, India, Indicates That Nutritional Status, Diet, and Stimulation Are Associated with Motor and Mental Development in Young Children

Background: Many malnourished children in resource-poor settings fail to fulfill their developmental potential. Objective: The objectives of this analysis were to examine the nutritional, psychosocial, environmental, and household correlates of child development in Bihar, India, and identify mediators between dietary diversity and mental development. Methods: Using 2-stage cluster randomized sampling, we surveyed 4360 households with children 6–18 mo of age in the West Champaran district of Bihar. We measured motor and mental development with the use of the Developmental Milestones Checklist II. In a random subsample (n = 2838), we measured anthropometric characteristics and hemoglobin. Cluster-adjusted multiple linear regression analysis was used to examine the associations between nutrition indicators and development scores. Sobel’s test was used to assess significant mediators in the association between diet diversity and development scores. Analyses were stratified by children 6–11 and 12–18 mo of age. Results: In all children, length-for-age z score (LAZ), dietary diversity, and psychosocial stimulation were significant (P < 0.05) correlates of motor development scores [(β coefficient ± SE) in children 6–11 mo: LAZ = 0.46 ± 0.08, dietary diversity = 0.43 ± 0.09, and stimulation = 0.15 ± 0.04; in children 12–18 mo: LAZ = 0.73 ± 0.07, dietary diversity = 0.30 ± 0.09, and stimulation = 0.31 ± 0.05] and mental development scores [(β coefficient ± SE) in children 6–11 mo: LAZ = 0.57 ± 0.10, dietary diversity = 0.84 ± 0.13, and stimulation = 0.54 ± 0.07; in children 12–18 mo: LAZ = 0.54 ± 0.11, dietary diversity = 0.40 ± 0.16, and stimulation = 0.62 ± 0.09]. Stimulation, gross motor development, and fine motor development were significant mediators in the relation between dietary diversity and mental development. Conclusion: Strategies to improve dietary diversity and psychosocial stimulation could have important implications for child development of young North Indian children. This trial was registered at clinicaltrials.gov as NCT02593136.

Association of Frontline Worker-Provided Services with Change in Block-Level Complementary Feeding Indicators: An Ecological Analysis from Bihar, India.

Background Insufficiencies in complementary feeding put infants and young children at increased risk of undernutrition. Till now, most Indian studies have looked at the individual level determinants of complementary feeding practices. We aimed to evaluate the association of frontline worker (FLW) provided nutritional counselling services, with change in community level indicators of complementary feeding practices among 9–11 month old children over time. Methods The study data was obtained from five rounds of ‘Lot Quality Assurance Sampling’ survey in eight districts of Bihar, an impoverished Indian state. The surveys were conducted as evaluation exercises for the ‘Integrated Family Health Initiative (IFHI)’–a multi-faceted program aimed at improving the maternal and child health outcomes in Bihar. The main outcome indicators were—current breastfeeding, age-appropriate minimum frequency of semi-solid food, age-appropriate minimum quantity of semi-solid food, initiation of complementary feeding at the right age, and dietary diversity. Repeated measures analysis was performed to determine the association of changes in the outcome indicators with coverage of FLW-provided counselling services. Results Visits by FLW, advices on age-appropriate frequency and handwashing were significant predictors of receiving age-appropriate frequency of feeding. The determinants of receiving age-appropriate quantity were—advices on age appropriate frequency and advices on handwashing. Receiving food support from AWC and FLW visits were significantly associated with initiating complementary feeding at the right age. Conclusions The present study identified the critical elements among the different types of FLW-provided services. The study findings, from an economically and socially underdeveloped region of India, would inform the relevant programs about the nutritional counselling services that need to be emphasized upon for reducing the burden of childhood malnutrition.

'We pledge to improve the health of our entire community': Improving health worker motivation and performance in Bihar, India through teamwork, recognition, and non-financial incentives

Background Motivation is critical to health worker performance and work quality. In Bihar, India, frontline health workers provide essential health services for the state’s poorest citizens. Yet, there is a shortfall of motivated and skilled providers and a lack of coordination between two cadres of frontline health workers and their supervisors. CARE India developed an approach aimed at improving health workers’ performance by shifting work culture and strengthening teamwork and motivation. The intervention—“Team-Based Goals and Incentives”—supported health workers to work as teams towards collective goals and rewarded success with public recognition and non-financial incentives. Methods Thirty months after initiating the intervention, 885 health workers and 98 supervisors completed an interviewer-administered questionnaire in 38 intervention and 38 control health sub-centers in one district. The questionnaire included measures of social cohesion, teamwork attitudes, self-efficacy, job satisfaction, teamwork behaviors, equitable service delivery, taking initiative, and supervisory support. We conducted bivariate analyses to examine the impact of the intervention on these psychosocial and behavioral outcomes. Results Results show statistically significant differences across several measures between intervention and control frontline health workers, including improved teamwork (mean = 8.8 vs. 7.3), empowerment (8.5 vs. 7.4), job satisfaction (7.1 vs. 5.99) and equitable service delivery (6.7 vs. 4.99). While fewer significant differences were found for supervisors, they reported improved teamwork (8.4 vs. 5.3), and frontline health workers reported improved fulfillment of supervisory duties by their supervisors (8.9 vs. 7.6). Both frontline health workers and supervisors found public recognition and enhanced teamwork more motivating than the non-financial incentives. Conclusions The Team-Based Goals and Incentives model reinforces intrinsic motivation and supports improvements in the teamwork, motivation, and performance of health workers. It offers an approach to practitioners and governments for improving the work environment in a resource-constrained setting and where there are multiple cadres of health workers.