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Operational Manual
For
PHASE ONE: BASELINE ASSESSMENT
Supported by:
Ministry of Health and Family Welfare,
Government of India,
Departments of Health and Family Welfare
(Haryana, Karnataka, Madhya Pradesh, Maharashtra, Meghalaya, Rajasthan, Orissa, Uttar Pradesh)
UNICEF, USAID, WORLD BANK &
INTERNATIONAL CLINICAL EPIDEMIOLOGY NETWORK (INCLEN)
Investigating Team
Principal Investigator
Dr. Narendra K. Arora
Team Leader, IPEN
Professor
Division of Gastroenterology, Hepatology & Nutrition
Department of Pediatrics
All India Institute of Medical Sciences
New Delhi.
Co-Principal Investigators
1 Dr C. S. Pandav
Professor and Head
Department of Community Medicine
All India Institute of Medical Sciences
New Delhi
2 Dr R.M. Pandey
Professor and Head
Department of Biostatistics
All India Institute of Medical Sciences
New Delhi
3 Dr Rema Devi
Associate Professor,
Department of Community Medicine
Trivandram Medical College
Thiruvanantpuram
iii
Central Coordinating Team Members
iv
Extended Central Coordinating Team Members
Prof. Faruque Ahmed Dr. Rema Devi
Principal & Dean Associate Professor
Khaja Bandamawaz Institute of Medical Sciences Dept. of Community Medicine
Raza (B) Trivandram Medical College
Gulbarga Thiruvanantpuram
Karnataka Kerala
Dr. P.V Kotecha
Dr. K.R John
Professor & Head
Professor
Dept. of Preventive & Social Medicine
Dept. of Community Health
Govt. Medical College
Christian Medical College & Hospital
Vadodara
Vellore
Gujarat
Tamilnadu
Dr. Vishwajeet Kumar Dr. Thomas Mathew
Project Director Professor & Head
Rachna Shivgarh Project Dept. of Community Medicine
CARE India T.D. Medical College
Lucknow Alappuzha
Uttar Pradesh Kerala
Dr. Sandip K. Ray Dr. Lalit Sankhe
Professor Lecturer
Dept. of Community Medicine Dept. of Preventive & Social Medicine
Medical College Grant Medical College & J.J.Hospital
Kolkata Mumbai
West Bengal Maharastra
Dr. Shivananda Dr. Arun K. Singh
Director Assistant Professor & Head
Indira Gandhi Institute of Child Health Dept. of Neonatology
Bangalore SSKM Hospital & IPGIMER
Karnataka Kolkata
West Bengal
Dr. Saradha Suresh Dr. S.C. Mohapatra
Coordinator, Professor & Head
Unit for Evidence Based Medicine Dept. of Community Medicine
Medical Education Cell Institute of Medical Sciences
Madras Medical College Banaras Hindu University
Chennai Varanasi
Tamilnadu Uttar Pradesh
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IPEN-IMNCI Study Phase I (2006-2007)
National Experts
Dr. Abhay Bang Dr. A. K. Dutta
Director Professor & Head
SEARCH,Shrodgram Dept. of Pediatrics
Gadchiroli Kalawati Saran Children's Hospital &
Maharastra Lady Hardinge Medical College
New Delhi
Dr Dilip Mahalanabis
Director
Society for Applied Studies
Kolkota
West Bengal
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International Advisory Board Members
Dr. Robert Black
Professor
Department of International Health
Bloomberg School of Public Health
Johns Hopkins University
Baltimore
USA
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IPEN-IMNCI Study Phase I (2006-2007)
Table of Contents
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IPEN-IMNCI Study Phase I (2006-2007)
List of Figures and Tables
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IPEN-IMNCI Study Phase I (2006-2007)
List of Annexure
I- EXECUTIVE SUMMARY
Problem Statement
It is estimated that 2.1 million children in India die before reaching 5 years of age [1].
These children account for approximately one-fifth of the worldwide deaths occurring in this
age group. Infant mortality in India has declined over the past four decades, from 146 per
1000 live births to 72 per 1000 live births [2]; however this decline has slowed during the
past 8-10 years [1]. Most of the reduction in mortality over the last decade has been in
children between the age of 1 month and 5 years. Currently almost 2/3rd of infant mortality is
comprised of neonates, most of who die within the first week of life [1]. In an effort to
address high neonatal death rates, along with stagnating IMR and under-five mortality, the
Integrated Management of Neonatal and Childhood Illnesses (IMNCI) program will be
implemented in India. The IMNCI program aims to improve child survival rates by extending
the interventions/services in homes, communities, and the health care system. IMNCI will
focus specifically on the management of acute respiratory infections (ARI), diarrhea,
measles, malaria and malnutrition, which are the main causes of childhood deaths in India.
Furthermore, for the first time under a public health program special focus will be given to
the management of newborns. This will be an important endeavor for the India’s health care
system, as infant mortality is a sensitive indicator of inequities in health and health care in a
country.
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mortality, and related inequities in India. The study is also likely to emerge with useful
lessons for other lower and middle income countries.
Context of Study
The IMNCI strategy will be implemented in a phased manner in approximately 125
districts in India. During the implementation stage, some districts will not have the IMNCI
program at all, some will be in the training stages of IMNCI, and some will have fully
implemented the IMNCI strategy. The proposed study will take advantage of this natural
situation and identify two sets of districts: a set of districts where IMNCI implementation will
commence in 2007 (the Intervention districts) and another set of districts where IMNCI
implementation will commence in 2009-2010 (the Comparison districts).
Goal of Evaluation
The IMNCI program is to be implemented in rural areas of the proposed districts
under the National Rural Health Mission (NRHM). Hence the study will be undertaken in
rural parts of the intervention and comparison districts to tailor public health programs to
meet the needs of India’s children via policies, health system reforms, and community
interventions. The study will be accomplished in three phases. Each phase of the evaluation
study has different objectives that will contribute to the overall purpose of the study.
Childhood morbidity and mortality, health systems performance and community participation
in child survival activities will be assessed during Phase I and III. Attempts will be made to
capture the process of implementing child survival programs during Phase II
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Phase II (24-36 months)
Phase II will document different strategies adopted by the state health departments
and the process of implementation of the child survival programs in intervention and
comparison districts. Attempts will also be made to capture events or interventions (health
and non-health) that are likely to confound outcomes of child survival programs during study
period.
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Selection of the study districts
GOI has planned to implement IMNCI program in 125 districts in a phased manner,
which creates a unique opportunity for a natural experiment. Districts where the
implementation of IMNCI occurs in the first stage (2007) will serve as Intervention
Districts for the present study. Districts where IMNCI implementation occurs later (2009-
2010) will be termed Comparison Districts.
In order to minimize confounding by status of health systems and governance
variables, a pair of districts is selected from each selected study state.
Matching of the selected districts was done considering the following criteria:
1. Demographic profile: (a) Sex ratio; (b) Proportion of population (age 0-6 years); (c)
Scheduled caste (SC) and Scheduled tribe (ST) population (%); (d) Minority
population (%)
2. Literacy status: (a) Male; (b) Female
3. Population density
4. Health indicators: (a) Routine immunization; (b) Infant mortality rate (IMR).
The list of study districts selected in the eight states is given in Table-1 and represented on
map of India in Annexure-1. The comparative demographic features of selected pairs of
Intervention and Comparison districts according to state are listed in Annexure 2.
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IPEN-IMNCI Study Phase I (2006-2007)
Summary of Study Phases
Phase I
The baseline assessment consists of combination of qualitative and quantitative
methods. This phase of evaluation will be undertaken during 2006-2007.
Qualitative Component:
There are several aspects of health systems, program implementation and care seeking
behavior of clients that are context specific and currently not well understood. To explore
these, evaluation research methods will be used in the form of in-depth interviews and focus
group discussions.
Quantitative Component:
The study will be restricted to rural populations (as per the National Census 2001) of
the selected districts. Cluster survey design using probability proportionate to size (PPS)
technique will be adopted.
Phase II
Study teams will not be involved in the implementation of child health programs
under IMNCI. It is important to emphasize that study investigators will not be involved in
the process of implementing IMNCI in any of the study areas so as to minimize bias. In
addition to process documentation, a separate study on health economics will be undertaken
in the second phase. There will be two cycles of process evaluation: First in 2008 and second
in 2009. The primary data will be collected by conducting sample survey in all study districts.
Secondary data will be obtained from program managers. Based on information gathered
from primary and secondary data, (both qualitative and quantitative), saturation index for
IMNCI program in intervention districts will be determined before proceeding for end line
evaluation.
Major external events/ activities that are likely to effect health systems specifically as
they relate to child survival will be documented in all study districts during this phase. What
is observed and documented during the implementation process will be discussed when the
baseline is compared with the end line. In case of a natural disaster or civil disturbance an
additional baseline survey will be done in the affected area within a span of 6 months. This
will be done to document setbacks to the health system as a result of the event and also serve
as the comparison parameter for end line survey. It is assumed that industrial and economic
interventions are unlikely to have a major impact on the implementation of child health
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programs within the study period. NGO/ CBO and other civil society activities related to
health in the area will be documented and lists will be updated on yearly basis.
Phase III
Variables for the end line study will be identical to those used in the base line survey.
allowing the study to capture changes in the process of managing childhood sickness and
child survival indicators after the implementation of IMNCI in intervention districts and with
RCH-I strategy in comparison districts.
Intervention districts with IMNCI are not likely to be in the same phase of saturation
with IMNCI activities in 2009-2010. But as a principle, end line evaluation will be
undertaken only after more than 70% of the rural communities have access to IMNCI based
strategy of child sickness care for at least 12 months. Therefore, the end line evaluation is not
expected to begin before early 2010. Indicators of IMNCI-program saturation will be decided
in consultation with International Advisory Board and State Health Departments during
Phase II of the study
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quality of training and strengthening of health systems under IMNCI program. The primary
purpose of proposed regular interaction with program managers will be to review IMNCI
implementation process in intervention districts and identify steps for minimizing above
mentioned threats.
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II. Evaluation of Integrated Management of Neonatal and Childhood Illnesses (IMNCI)
Program in India: An IPEN Study
Overview
The World Health Organization has outlined the primary components of IMCI as [4]:
1. Improvement of case-management and referral skills of health staff through
provision of locally adapted guidelines
2. Improvement of the health system required for effective management of childhood
illnesses
3. Improvement of family and community practices related to managing childhood
illnesses
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2. Overviews of Multi-Country Evaluation (MCE)
WHO and the Johns Hopkins School of Public Health conducted ongoing Multi
Country Evaluations (MCE) of the IMCI strategy to identify its impact on the management of
childhood illnesses and the overall strengths and weaknesses of the strategy
(http://www.who.int/imci-mce). Specific site studies took place in Bangladesh, Brazil,
Tanzania, Peru and Uganda.
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districts. Therefore it was difficult to assess the overall impact in the given district in terms of
reduction in child mortality.
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2.5 Bangladesh [11]
The IMCI evaluation in Bangladesh began in 2000 and final assessments will
conclude in 2007. For the MCE site in Bangladesh 20 facilities were randomly selected for
IMCI intervention using a two-cell randomized design. A component was also added to the
study that documented the program and provided a summary of health facility utilization and
referrals. Instruments included a household demographic survey, a health and morbidity
survey on under-five children, a verbal autopsy survey, a social autopsy, and a health facility
survey at first-level facilities. The baseline assessment found that during the first two years of
IMCI implementation there was a fourfold increase in the number of severe cases seeking
care from IMCI facilities, but the rates of compliance with referrals was low.
*
Diphtheria, Pertussis, Childhood Tuberculosis, Poliomyelitis, Measles and Neonatal Tetanus
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improvement, especially if India is to reach the Millennium Development Goal regarding
under-five mortality by 2015. This alone would require a reduction from 87 to 41 deaths per
1,000 births [3]. .
The National Rural Health Mission (NRHM) was launched in April 2005 and will
run for 7 years (2005-12) as a strategy to improve the health system and health status of
India. The Mission seeks to provide universal access to equitable, affordable and quality
health care which is accountable and responsive to the needs of the people reduces child and
maternal deaths, as well as stabilizes population growth and the nation’s sex ratio. In this, the
Mission will help achieve goals set under the National Health Policy and the Millennium
Development Goals. It is anticipated that the National Rural Health Mission (NRHM) will
accelerate achievement in respect of MMR and IMR. The NRHM will target 18 States (Uttar
Pradesh, Bihar, Rajasathan, Madhya Pradesh, Chhattisgarh, Uttaranchal, Jharkhand, Orissa,
Assam, Manipur, Meghalaya, Nagaland, Mizoram, Arunachal Pradesh, Sikkim, Tripura,
Himachal Pradesh, and Jammu & Kashmir) all of which have weak public health indicators
and/ or weak health infrastructure. Mother and child health programs will continue to be the
major focus of public health activities under NRHM.
66
64
62
60
IMR
58
56
54
52
50
2000 2001 2002 2003 2004 2005
Year
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4. IMCI to IMNCI in India: Background and Rationale
It is not uncommon in resource poor settings for several diseases to go untreated due
to lack of first level health care services [6]. Thus, a program that strengthens the case-
management aspect of health care is required at the primary level. Presently, several
programs exist to address each of the five diseases within the IMNCI realm; such as the Oral
Rehydration Therapy (ORT) program which aims to avoid deaths due to diarrhea. However,
most children have two or more of the above-mentioned diseases simultaneously. An overlap
means that single diagnosis may not be possible or appropriate, and treatment may be
complicated by the presence of several illnesses in addition to malnutrition.
For this reason, India decided to adopt IMCI and address the overall health of a child
with interventions in homes, communities, and facilities for children under-five, and also
incorporate a neonatal component to it because neonatal mortality is extremely high at around
43 deaths per 1000 births [13]. Appropriate home care such as optimal feeding practices, use
of insecticide treated materials to prevent malaria, and appropriate treatment of infections can
help prevent childhood deaths in a setting like that of India.
In recent years, empiric evidence has emerged indicating the critical need for a
neonatal component in any child survival programs for meaningful impact. A field trial of
home-based neonatal care by Bang et al. (2005), found that interventions of home based
neonatal care such as the training of traditional birth attendants, group health education,
repeated home visits, and initiation of early and exclusive breast feeding reduced the NMR
from 62 to 25 over a period of two years Most of the decline was attributed to improved care
of low birth weight babies and improved care of sepsis [14].
Similarly, the Mitanin (meaning “a friend” in local dialect) program in Chhattisgarh
was an attempt to scale up the community health worker experience. The evaluation assessed
the Mitanin’s knowledge on treatment of diarrhea, fever, correct dose of chloroquine;
identified infant feeding messages; messages for neonate and children under-five; recognition
of grade II malnutrition, treatment of anemia; and refer high risk pregnancy case for delivery.
Results showed the utility of Mitanins in improving child health. For example, 70%
newborns were visited by Mitanin in first day or 1st week and 68.7 % of Mitanins had
provided advice on illness management in previous week [15]. India is diverse in traditions,
cultures, ethnicities, races, and languages. This diversity is reflected in child health care
practices found within communities throughout the nation. Therefore, in India, any health
care program that does not consider the influence of culture will be challenged to improve
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care. All public health strategies should also try to reduce the harm caused by some of the
prevailing practices by improving primary and secondary prevention practices.
India is the only country in the world to incorporate a neonatal component into IMCI,
creating IMNCI. The Integrated Management of Neonatal and Childhood Illnesses (IMNCI)
program will be introduced in at least 125 districts as part of the RCH II program. IMNCI
aims to reduce death, illness and disability; to promote improved growth and development
among children under-five years of age; and target acute respiratory infections (ARI),
diarrhea, measles, malaria and malnutrition, which are the five main causes of childhood
deaths. An important component for its success will be with active community involvement
and improving child care and health seeking practices at household level.
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to decrease income disparities, it will try to address the barriers of income disparities related
to child health.
Child survival inequalities in India are social as well as economic. For example,
women are disproportionately poor in India and have a hold a low social status compared to
men. Women’s position can be measured in terms of literacy, decision making, and social
access [20], all of which are an integral part of engaging in care seeking behaviors. There is
also a strong bias that exists in care taking and seeking practices for a female child, compared
with male children in India [19].
In India as a whole, child mortality between months 1 and 12 is 40 % higher for girls
than for boys [21]. There is great variance in female child mortality across India. For
example, while Haryana has the worst male to female child mortality than any country in the
world Tamil Nadu is only behind four other countries [22]. Yet, female infanticide, sex-
selective abortion, and neglect of female children are not uncommon. Therefore, addressing
gender disparities experienced by women and children in India will be necessary if the
country is committed to achieve MDGs Four & Five, respectively (reduce the under-five
mortality rate by two thirds between 1990 and 2015, and reduce the maternal mortality ratio
by three quarters between 1990 and 2015).
Children of women belonging to scheduled castes and scheduled tribes have higher
rates of infant and child mortality than children of women belonging to other backward
classes or “other” women. Children of “other” women have by far the lowest rates of infant
and child mortality. As expected, all indicators of infant and child mortality decline
substantially with increase in the household standard of living. There are 84.3 million
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members of Scheduled Tribes (ST) in India, which is about 8.2% of the total population [23].
Members of this group as well as those of scheduled and backwards castes are often
geographically and socially isolated from the rest of the population. Throughout India health
inequalities and health disparities between hierarchical caste levels are common [24]. Such
inequalities often result from the social marginalization and discrimination; and social
disadvantages such as a lack of economic and educational opportunity. These social
inequalities experienced by scheduled castes or scheduled tribes serve as a barrier to health
care and in turn contribution to an increased likelihood of mortality for members of these
groups.
NFHS data from 1998-1999 illustrates that for children and adults up to age 45 there
is excess mortality among indigenous people when compared to non-indigenous [24].
Regarding infants under-one year of age the same was concluded, but the statistical
significance was less. However, mortality differences were more attributed to socioeconomic
status than indigenous status. Also another study utilizing NFHS data from 1998-1999 that
examining mortality risk rather than just mortality, found that the mortality risk for children
under-one year in the lowest quintile of the standard of living index used was 2.73 times
higher than infants in the highest quintile, but that results for gender and caste were not
statistically significant [25]. For children between 2 and 5 years of age, children from
scheduled tribes and backwards castes did not have a mortality risk different from children in
other castes, but children from scheduled castes did have a significantly higher mortality risk.
Nevertheless, when comparing odds ratios controlled for standard of living and caste, there is
a greater decrease in mortality risk for caste than for standard of living for infants and
children under-five years. As despite increased spending on health, disparities in morbidity
and mortality indicators will continue to persist if utilization of health primary health care
services is hindered by income and cultural factors. To achieve MDGs related to child health
and improved equity, key interventions like IMNCI will have to give attention to increasing
service utilization among the poor. One way of doing this would be to engage other health
care sectors such as NGOs and CBOs.
Both economic and gender inequalities are compounded by reduced financial or
geographic access to preventive and curative interventions at the primary level. According to
the Bellagio Study Group, 2/3 of child deaths worldwide could have been prevented if
effective and child survival interventions had reached children and mothers who needed them
[26]. Jones et al. (2003) have also shown that available low cost interventions could
potentially prevent 63% of the child deaths. As despite increased spending on health,
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disparities in morbidity and mortality indicators will continue to persist if utilization of health
at primary health care services is hindered by income and cultural factors. To achieve MDGs
related to child health and improved equity, key interventions such as IMNCI must be scaled
up with a strategy so that health care service utilization among the poor can increase.
According to Bangdiwala and colleagues (2006), the decision to seek care for
newborns and pregnant mothers is primarily made by husbands, particularly so in rural and
tribal areas [27]. Additional reasons for not seeking care included lack of transportation, lack
of money, lack of time, and rumors about the health system. Rural and tribal communities
often practice harmful newborn care practices such as withholding early breastfeeding, not
feeding colostrum, application of unhygienic things, immediate bathing after birth, etc.
In addition to decreasing disparities in health care service utilization due to social,
economic, and gender inequalities efforts to improve home-based care have proven
successful at improving child survival as well. An example of a successful scale up home-
based care efforts that draw on community resources was implemented by the Society for
Education, Action, and Research in Community Health (SEARCH) in Gadchiroli,
Maharastra, India. An evaluation of the efforts found that home based neonatal care efforts
reduced NMR from 62 to 25 in intervention areas, which was 70% more than in control areas.
Under NRHM, the Government of India is planning to promote access to improved
health care at the household level through a female link volunteer, called Accredited Social
Health Activist (ASHA), strengthen Sub-centers, Primary Health Centers (PHCs),
Community Health Centers (CHCs); and devise new health financing systems [28]. The
health worker, ASHA will serve a population of 1000. The Government of India aims to train
more than 4 lakh trained women as ASHAs/ community health workers (resident of the same
village/ hamlet for which they appointed as ASHA).
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I. Care of newborns and young infants (under-two months):
• Keeping the baby warm
• Initiation of breast feeding immediately after birth and counseling for exclusive
breastfeeding and non-use of prelacteal feeds
• Cord, skin and eye care
• Recognition of illness in newborn and management and/or referral
• Immunization
• Home visits in postnatal period
III. Home visits: Home visits made by ANMs, AWWs and ASHAs and link volunteers
are an integral part of this intervention which help mothers and families to understand
and provide essential newborn care at home
IV. Training: IMNCI involves two categories of skill based training. One for medical
officers and a second for front line functionaries including ANMs and AWWs. For
ASHA and link volunteers if any, a separate package focusing on home care of
Newborn and children is being prepared.
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• Functioning referral centres, especially where health care systems are weak, referral
institutions need to be reinforced or private/public partnership need to be
established.
• Ensuring availability of health workers/providers at all levels.
• Ensuring supervision and monitoring through follow up visits by trained
supervisors.
VII. Collaboration/ Co-ordination with other departments, PRIs, Self Help Groups,
MSS etc.
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relies on inflexible input-based planning and expenditure controls that are centrally
determined, and do not adequately account for differences in needs or demands. It is
challenging to monitor quality of health care (both in public and private sector) and to
redefine standard of quality assurance and monitoring system.
In India, the private health sector refers to private, for-profit, medically trained
providers. Their range of practice varies from independent practice, small nursing homes
(inpatient facilities with usually less than 30 beds), to large corporate hospitals. There are
approximately 10,300 private hospitals in India, and about 225,000 private hospital beds [29].
The private sector also includes laboratory and diagnostic facilities, ambulance services, and
pharmacies. However, a much broader set of non-government actors is involved, that can be
categorized according to organizational type (profit or non-profit), size and scope of service
(solo practice, small nursing home, large specialized hospital), or system of care (Indian
systems of medicine- Auyervedic, Unani; or Western medicine- Allopathy). Many untrained
providers offer a combination of systems of medicine. It is estimated that there are
approximately 1.25 million informal providers practicing in India [29]. Because many are
not registered or work part time, this informality can be problematic when studying the health
system. However, indigenous, folk practitioners, and traditional providers constitute an
important part of the health system regarding infant and neonatal care because they are often
the first point of contact in rural areas [29].
Despite vast services provided by the public sector, there is an increasing use of
private sector health services in India. It is estimated that over 80% of the population uses
the private sector for outpatient curative services as a first line of treatment in both urban and
rural areas [29]. Nevertheless, the private sector in India has grown in an unregulated manner,
lacking in standards for quality of care and for pricing. The need to address issues related to
the growth of India’s private sector was acknowledged after the first formal national health
policy was adopted in 1983.
The recent National Population Policy 2000 also mentions the need to collaborate
with the private non-profit and for-profit sectors [30]. A variety of partnerships are pursued
under the existing programmes of the Ministry of Health, especially the RCH-II and
independently by the states with their own resources with non governmental partners. RCH-II
has developmental partners like UN agencies. Under this umbrella, States are trying contract
in, contract out, out sourcing, management of hospital facilities by NGOs, hiring staff, service
delivery, including family planning services, MTP, treatment of STI/ RTI, etc. NRHM
envisages to non-governmental sectors to provide high quality services in rural areas to meet
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the shortage of heath facilities there. Immunization, Polio eradication programs, the Janani
Suraksha Yojana has been involving private/ NGO facilities for delivery of promotive and
preventive service delivery. The non-governmental organizations are critical for the success
of NRHM. With the mother NGO (MNGO) programme scheme, 215 MNGOs covering 300
districts have already been involved. The mission aims at involving NGOs in capacity
building at all levels, monitoring and evaluation of health sector, delivery of heath services,
developing innovative approaches to health care delivery for marginalized sections or in
underserved areas and aspects, working together with community organizations and
Panchayati Raj institutions, and contributing to monitoring the right to health care and service
guarantees from the public health institutions.
8. Impact Model
This study hopes to generate evidence for policy makers and program mangers to
tailor child survival programs in India for improving skills of Health Provider’s related to the
management of childhood illness, health system logistics, more effective and equitable reach,
and community involvement in child survival activities. Child health programs in general and
IMNCI in specific aim to reduce under-five mortality, improve child health services with
particular focus on the care of neonates in the community and by the health system. The
study will take place in 16 districts of 8 Indian states covering different levels of health
infrastructure and governance, and cover diverse socio-cultural and geographic regions of the
country. This will allow results from the study to be generalized to all of India.
Taking into consideration the above factors an impact model (Figure-3) has been
developed which focuses on three important components of child health programs namely
Health Provider (Public/ Private), Health System and Community Perspective. It highlights
important issues influencing child health at various levels in the context of NRHM/ RCH and
equity. It also illustrates the interaction between communities, the public and private sector
and facilitating an enabling environment within the health system, as well as presents
assumptions of the implementation context. Thus this model shows inputs and outputs
mechanisms for achieving the objectives of the child survival programs in India including
IMNCI. Within the framework of this model some important and relevant indicators (input,
output, and outcome) could be derived which will eventually be helpful for evaluating
implementation of IMNCI and other child survival programs at all the three phases of this
study (baseline, concurrent and end line).
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The essential assumptions of the impact model are:
1. High quality training of health providers and strengthening of health systems on
their own will not be sufficient to improve effective coverage of program services.
2. Community participation and private sector involvement will further strengthen
health systems, service delivery and expand the pool of skilled health providers
rapidly.
3. Socio-cultural beliefs are significant influences and determinants of community
behavior in traditional societies and hence communication strategy must address
socio-cultural contexts as well.
4. Institutionalized mechanisms are required for:
(a) Monitoring of program activities by the community
(b) Involvement of private sector and regular assessment of their capacity to
contribute to public health activities for appropriate skill enhancement.
5. Effective coverage essentially includes the segments of the population that are at
highest risk for morbidity and mortality but are excluded from accessing and
benefiting from public health services for social, economic, and gender biases.
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IPEN-IMNCI Study Phase I (2006-2007)
Figure 3: Impact Model (IMNCI-IPEN STUDY)
Contextual Issue
o NRHM (RCH I/ RCH II) Implementation of Child Survival Programs (IMNCI/ RCH) with focus on Newborns
o Equity
Community
Component Strengthening Health Training Training and over sighting
System of Implementation
Effective Coverage
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IPEN-IMNCI Study Phase I (2006-2007)
Impact on Child Mortality/ Morbidity
9. Conceptual Framework of the Study Phases
The phased manner in which GOI is rolling out IMNCI is automatically creating
the intervention and comparison groups that will be used in this study. Some districts will
have IMNCI rolled out in 2007; while others have IMNCI programmed for 2009-2010.
This creates an opportunity for natural experiment allowing us to evaluate child health
services in two sets of districts using a baseline (Phase I) and end line (Phase III)
assessment. During the intervening period (Phase II), the processes of implementing the
various child survival programs will be documented with attempts to capture health and
non health events and/or interventions that are likely to confound outcomes of these
public health strategies. These include the introduction of new health programs, outbreaks
and epidemics, natural disasters, and major social developments. Data from Phase II of
study will help us explain possible reasons for changes in different child survival
indicators across study sites and between intervention and comparison districts with
greater certainty. The following framework (Figure 2) outlines how this study is
integrated with the rollout of IMNCI in India.
End line 2009-2010 Estimate end line child End line 2009-2010
By IPEN morbidity indicators By IPEN
and sickness
(Phase III) management practices (Phase III)
and compare with
baseline
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10. Expected Outcomes
The proposed evaluation study is designed to be an “action-oriented operational
research study” with built in mechanisms for constant feedback to decision makers and
program managers at various levels. The information collected from the baseline will be
shared with GOI for better implementation of child survival programs including IMNCI.
Particularly useful information will pertain to: skills of providers (including the health
workers) which need to be emphasized during training, feedback about the public health
infrastructure, role of the private sector and ways to strengthen public-private partnership,
as well as perceptions of program managers at district and state level. Equally important
are issues related to community perception and care seeking practices and equity as well
as access to public heath services.
The recommendations related to these areas will help redefine strategies for
implementing the child survival programs with special focus on the community
component for better utilization of services. The results will be shared with State and
Central program managers with follow up advocacy at all levels including district
officers. Efforts are being made to have a formal structure (a program managers group) to
share and engage policy makers and program managers so that findings can be translated
into action. We have requested Central and State governments to have meetings with
programme managers to share findings and take stock of implementation status.
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IPEN-IMNCI Study Phase I (2006-2007)
public health institutions). IPEN has successfully evaluated the Pulse Polio Immunization
Program for four consecutive cycles [1997-98, 1998-99, 1999-2000 and 2000-2001] and
was also involved in the evaluation of three rounds of Family Health Awareness
Campaign [1999, 2000, 2002] in the country. Additionally, this network has completed
the evaluation of Vitamin-A and Iron folic acid Supplementation Program(s) [2001-
2002]. Policy makers have incorporated several key recommendations made by this
network in the subsequent cycles of the respective programs, illustrating the relevance of
IPEN study findings. Most recently, a nation-wide Assessment of Injection Practices and
Routine Immunization had been conducted. Specifically, the results of this study
attracted wide attention and resulted in several policy level changes. Apart from
undertaking research activities, IPEN has tried to develop capacity of its network partners
to undertake policy and program relevant studies in their respective regions and states.
Members of the group have had the benefit of attending workshops on program
evaluation, qualitative research methods and continuous quality assurance.
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community leaders, and NGOs/ CBOs regarding their perspectives on existing child
health services; the role of civil society in promoting, providing, utilizing and monitoring
child health services, health beliefs; and clinical practices using qualitative methods.
Skills of health workers; sickness management practices at the household, community,
and health facility levels; manpower and logistic support available at health facilities;
health and care seeking behaviors of families; and the mortality rate and morbidity
density of the study sample will be assessed using quantitative methods. FGD of mothers,
frontline workers (ANM’s, AWWs) and their supervisors will also be conducted. This
study will also assess equity and equality issues related to child health services.
The information collected from the baseline will be shared with GOI so that
implementation of child survival programs including IMNCI can be improved.
Particularly useful information will pertain to: skills of providers in areas that will be
emphasized during training, unique needs of the private sector and methods to fulfill
those, as well as perceptions of program managers at district and state level. Equally
important are issues related to community care seeking practices and equity as well as
access to public heath services. The recommendations related to these areas will help
redefine strategies for implementing the community component of child survival
programs. The results will be shared with State and Central program managers with
follow up advocacy at all levels including district level. Efforts are being made to have a
formal structure (a program managers group) to share and engage policy makers and
program managers so that findings can be translated into action.
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baseline and end line assessments. In addition to process documentation, a separate study
on health economics will be undertaken in the second phase.
There will be two cycles of process evaluation: First in 2008 and Second in 2009.
The primary data will be collected by conducting sample survey in study districts.
Secondary data will be obtained from program managers. Based on information gathered
from primary and secondary data, (both qualitative and quantitative), saturation index for
IMNCI program in intervention districts will be determined before proceeding for end
line evaluation.
Major external events/ activities that are likely to effect health systems
specifically as they relate to child survival will be documented in all study districts during
this phase. What is observed and documented during the implementation process will be
discussed when the baseline is compared with the end line. In case of a natural disaster or
civil disturbance an additional baseline survey will be done in the affected area within a
span of 6 months. This will be done to document setbacks to the health system as a result
of the event and also serve as the comparison parameter for end line survey. It is assumed
that industrial and economic interventions are unlikely to have a major impact on the
implementation of child health programs within the study period. NGO/ CBO and other
civil society activities related to health in the area will be documented and lists will be
updated on yearly basis.
We have requested central and state governments to have meetings with
programme managers to share findings and take stock of implementation status. Some of
the major threats to Phase II will be: (1) different pace of implementation of IMNCI and
(2) variable quality of training and strengthening of health systems under IMNCI
program. The primary purpose of proposed regular interaction with program managers
will be to review IMNCI implementation process in intervention districts and identify
steps for minimizing above mentioned threats.
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major events taking place between baseline and end line surveys will help explain
changes observed.
Keeping in mind the seasonal variation of childhood illnesses, the end line survey
will be done around the same time of the year as the baseline study. The sample sizes for
primary outcomes will be recalculated for this phase because of following reasons:
1. As part of secular changes, morbidity and mortality density is likely to decline
over the study period in all districts.
2. Mortality rates (neonatal/ infant/ under-five mortality rates) may decline at
different rates in intervention and comparison districts.
3. Sample size calculation will also take into account difference in mortality to be
measured between two sets of districts.
Intervention districts with IMNCI are not likely to be in the same phase of
saturation with IMNCI activities in 2009-2010. But as a principle, end line evaluation will
be undertaken only after about/ more than 70% of the rural communities have access to
IMNCI based strategy of child sickness care for at least 12 months. Therefore, the end
line evaluation is not expected to begin before early 2010. Indicators of IMNCI-program
saturation will be decided in consultation with International Advisory Board and State
Health Departments during Phase II of the study.
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IPEN-IMNCI Study Phase I (2006-2007)
Phase I: Baseline Assessment of Child Survival Activities in Selected Districts
13.2 Objectives
Assess the current status of child survival indicators and process indicators for
existing program activities in Intervention (where IMNCI program will be implemented
in 2007) and Comparison (with ongoing RCH-I based child health strategy/ planned
IMNCI implementation in 2010) districts.
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IPEN-IMNCI Study Phase I (2006-2007)
ii. Community level
iii. Health facility level (Out-patient)
3. To assess health behavior at the
i. Household level
ii. Community level
iii. Health facility level
4. To assess skills and care providing competencies of the health care providers
i. Doctors (Public and Private)
ii. Heath Workers (AWW/ ANM)
iii. Other community level non-conventional service providers, including ASHA
and TBA (wherever in place)
5. To assess health system support for
i. Manpower
ii. Logistics
iii. Referral mechanism
iv. Intersectoral coordination
v. Social mobilization
vi. Monitoring & supervision
6. To assess the perspectives of state level policy makers and program managers and
health providers at district and state level regarding child survival issues.
7. To assess the client and health provider perspective on existing child health
services in terms of their
i. Availability,
ii. Accessibility,
iii. Perceived Affordability,
iv. Appropriateness,
v. Quality of care and
vi. Socio-cultural acceptability.
8. To determine the role of civil society (NGOs, CBOs, Community leaders) in
promoting, providing, utilizing and monitoring child health services.
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state for the study; Intervention and Comparison districts (Annexure 2). These districts
have been identified in consultation with the Division of Child Health, Ministry of Health
and Family Welfare, Government of India, State Governments and UNICEF taking into
account IMNCI implementation plan and study phases. The total rural population of the
sixteen selected districts is approximately 1.7 crore (Census 2001) (Annexure 2). Table 1
summarizes the states and districts to be included in the study.
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A pair of districts have been selected with matching demographic and health
indicators in order to minimize confounding by status of health systems and governance
variables.
Matching of the selected districts was done considering the following criteria:
1. Demographic profile: (a) Sex ratio; (b) Proportion of population (age 0-6 years);
(c) Scheduled caste (SC) and Scheduled tribe (ST) population (%); (d) Minority
population (%)
2. Literacy status: (a) Male; (b) Female
3. Population density
4. Health indicators: (a) Routine immunization; (b) Infant mortality rate (IMR).
As per the state planning for implementation of IMNCI program, districts have been
identified as Intervention and Comparison districts, which are listed in Table 1. The
detailed comparative demographic parameters of selected pair of districts in each state are
listed in Annexure-2
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IPEN-IMNCI Study Phase I (2006-2007)
validity, question framing, relevance, and sequencing before finalizing. The final version
of instruments are prepared with inputs from an International Advisory Board and Partner
Medical Colleges and Institutions, and then translated into local languages. Instrument
specific and general comments obtained during the pilot phase were also incorporated
into final instruments.
To ensure cultural sensitivity and appropriateness the following has been done:
• A multidisciplinary team from different parts of the country developed study
instruments
• Piloting has been done across the country to give attention to any issues of
cultural appropriateness
• Instruments will be translated into local languages
• Study implementation and administration of instruments will be done by local
[“Emic”] investigators.
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IPEN-IMNCI Study Phase I (2006-2007)
Table 2: Baseline Assessment of Child Survival Indicators: Qualitative Component
In-Depth Interviews Per Per State Study
District (For 2 districts) (8 states)
State Level Officers
Health Secretary, DGHS, State RCH/ IMNCI - 3 24
Officer
District Level Officers
District Magistrate 1 2 16
Chief Medical Officer 1 2 16
Medical Superintendent (District Hospital) 1 2 16
District RCH Officer 1 2 16
Rural Areas
Prescriber: Government 4 8 64
Prescriber: Private (Formal-2; Informal-2) 4 8 64
NGO’s/ CBO’s/ Community Leader 4 8 64
Focus Group Discussions
ANMS and ICDS supervisors 2 4 32
[@ 1 each in intervention district] and
Health Supervisors and AWWs
[@ 1 each in comparison district]
Mothers- Utilizers (who approached government 2 4 32
health facility for the last illness episode of their
under-5 child)
Mothers- Non-utilizers (who did not approach a 2 4 32
government health facility for the last illness of
their under-5 child)
Total 22 47 376
16.3.2 Design
Purposive sampling will be done keeping in view the relevance and involvement
of the stakeholders to the district child health services. General instructions for
conducting interview are given in Annexure 3. The information collected will help
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IPEN-IMNCI Study Phase I (2006-2007)
understand the process of child health program implementation, scope of program’s
coverage so as to ensure that target populations are reached, steps taken to address the
equity of services for all segments of the population, challenges faced, efforts taken to
overcome these barriers and suggestions to improve child health services in the area. The
information collected will complement the quantitative component of the study.
16.4.2 Design
A total of 4 FGDs with mothers of under-five children will be conducted in each
district; 50% will consist of mothers who utilized public health facilities for the most
recent illness of their under-five children (utilizers), the rest will consist of mothers who
did not utilize public health facilities for the most recent illness. One FGD with each of
the following groups will be conducted in each state: ANMs and ICDS supervisors or
AWWs, and health supervisors. FGD’s will be conducted to assess health promotion and
sickness behavior, client and health provider perspective about existing child health
activities and problems related to them, and suggestions to improve these services. The
guidelines for conducting FGDs are provided in Annexure-4.
17. Verbal Autopsy (VA) and Tracking of Events Before Death/ Recovery from
Illness
Verbal Autopsy relies on the assumption that most causes of death have
distinct symptoms and signs that can be recognized, recalled, and reported by
household members or associates of the deceased to a trained field-worker. Further, it
is assumed that deaths characterized through verbal autopsy possess a distinct set of
features that can be distinguished from other underlying causes of death [31]. Thus,
diseases with very distinct symptoms and signs, such as tetanus, that are recognized by
the local population may be more suitable for verbal autopsy than systemic diseases,
such as malaria, which has signs and symptoms common to other illnesse. Factors that
influence the validity and reliability of verbal autopsy include the verbal autopsy
instrument (mortality classification, diagnostic procedures), the data collection
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procedures (recall period, interviewer's characteristics, respondent's characteristics),
and the underlying distribution of cause-specific mortality in a given population. The
diagnosis of childhood illness by maternal health interview surveys is widely used to
estimate the prevalence of childhood morbidity in developing countries.
Although there is variation in the sensitivity and specificity for specific
conditions, verbal autopsy help classify the broad patterns of child mortality in
populations that are not covered by adequate medical services.
17.1 Instruments
WHO’s verbal autopsy instrument and instrument developed by Population Health
Matrix (Johns Hopkins University and Harvard University, USA) for their Global
Challenge GC-13 project, have been the basis of the verbal autopsy instrument developed
for the current study. Questions for tracking of events prior to death have also been
incorporated into the instrument. Separate instruments have been designed and developed
for tracking of events prior to recovery from common childhood sickness (as covered
under IMNCI) and for events taking place in the first 10 days of life of neonates 10-18
days old.
17.2 Participants
Mothers of children below five years who have died or recovered from illness or
neonates (10-28 days old) will participate in verbal autopsy and tracking of events. If
mother/ caretaker are not available repeat attempt to interview the key person will be
made before leaving the cluster.
17.3 Data to be collected in Under-five Child Deaths for Qualitative Verbal Autopsy
All deaths in children below 5 years (occurred in previous one year from date of
survey) in a given cluster will be included in the sample for verbal autopsy and tracking
of events. When 160 households are screened (covering approximately 750-1000
population) approximately 20 live births are likely to be captured within a cluster. Death
rate of under-five children in study states/ districts is estimated to be 50-90/ 1000 live
births and at this rate, we are likely to get 1-2 deaths per cluster.
Senior Investigator will administer the Verbal Autopsy instrument in the cluster as
according to the guidelines provided (Annexure 6). He/she however will not be involved
in assigning causes of death. A physician review process will be used to assign the cause
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of death. All the verbal autopsies will be independently reviewed by any two physicians
from a panel of trained physicians. These physicians will be members of the CCT. The
physicians will receive training on the cause of death assignment process. They will be
required to assign direct and underlying causes of death based on the International
Classification of Diseases version 10 (ICD-10). If two physicians agree on the direct and
underlying cause, that cause will be accepted. In the event of disagreement, the verbal
autopsy will be reviewed by the third physician on the panel. If his/her assigned cause of
death agrees with that of either of the other two physicians then that cause will be
accepted. If there is still disagreement, a “not determined” cause of death will be
assigned. The physicians will be allowed to assign “unspecified” as a cause of death if
they feel that there is not enough information to lead to a definite cause of death. If any
two physicians agree on “unspecified” as a cause of death then that will be assigned.
Senior Investigator will administer the instrument for tracking of events to the
mothers/ caregivers of following categories of children:
1. Morbidity–recovered and hospitalized (one per cluster): Child who was sick
anytime during last 3 months; sickness required hospitalization in a health facility
(public or private) for at least 24 hours, and is now asymptomatic for at least 72
hours.
2. Morbidity-recovered without hospitalization (one male and one female child per
cluster): Child who was sick anytime during last 2 weeks and is now
asymptomatic for at least 72 hours without the need for hospitalization.
3. Neonate (10-28 days) (one per cluster): First 10 days are critical for survival of
neonates. The purpose of tracking of events in neonates after they have completed
the critical period is to: (i) identify existing gaps/ inadequacies in the care to be
provided by pubic health system; (ii) explore family care seeking practices during
this period and (iii) health care facilities accessed by families during this critical
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period. [Neonates who die during first 10 days of life will be captured for tracking
events under verbal autopsy component].
17.5 Participants
Mothers/ caretakers will be asked details about the index child such as date of
birth. the pregnancy history of the mother including fetal losses and live births; details
about the birth of the child; what the newborn was fed and how it was cared for; and
details of the child’s sickness will be collected quantitatively. Details about interventions
at home and subsequent visits to health facilities will be collected qualitatively in
narrative form. All tracking processes will be done by Senior Investigators.
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19. Qualitative Research Teams at Regional Center
One Principal Investigator (preferably with social science background) along with
the Regional Coordinator and two Research Assistants will constitute a team at each
regional center/ state for qualitative component and organize interviews at district level.
In all 8 states, there will be 8 such teams (32 persons). They will be responsible for
conducting:
1. Interviews of program managers/ stakeholders/ prescribers.
2. Focus group discussions with mothers of under-five children and ANMs/ AWWs/
ICDS Health Supervisors.
The Verbal Autopsy and Tracking of Events associated with death and recovery
from childhood morbidity will be done by Senior Investigators of the field teams
(Annexure 6 and Annexure 7 respectively).
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However, in order to identify and survey 1500 live births, between 45,000 and
75,000 individuals total will have to be interviewed assuming a crude birth rate of 20-
35/1000. This will result in screening between 12,500 (with 6 people per household) to
15,000 (with 5 persons per household) household in each district. Taking into account
crude birth rates and rural household size in the study districts, a total of 12800
households will be recruited in every district at the rate of 160 households per cluster. A
design effect of one (1) was considered while determining the sample size, despite cluster
survey methodology, due to feasibility issues. However, design effect will be
reconsidered in Phase III when the sample size will be calculated taking into account
design effect observed during phase I and for expected changes in mortality resulting
from program implementation in intervention and comparison districts.
Table 3: Sample Size of Live Births for Estimating NMR, IMR and U5MR
Sample size
Sl. Estimated Admissible Estimated
Indicator (at 95%
no. prevalence error Sample Size
confidence level)
Neonatal ≈1500 live births
1 Mortality Rate 4% ± 1% 1454 [This translates into
(NMR) approximately
Infant 45,000- 75,000
2 Mortality Rate 7% ± 1.3% 1478 population residing
(IMR) in a sampling
Under-five universe with a birth
3 Mortality Rate 9% ±1.5% 1498 rate of 20-35/ 1000
(U5MR) population]
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20.2 Morbidity Survey
ARI, malaria, and diarrhea are morbidities that IMNCI is focusing on and will be
used as assessment measures for this evaluation. Cough, fever, and loose motion are
indicator symptoms for the morbidities ARI, malaria, and diarrhea respectively. Multiple
studies were consulted to arrive at a prevalence estimate for ARI, malaria, and diarrhea
before the sample size was calculated. According to NFHS II (1998-1999), in India the
prevalence of cough with fast breathing was 19.3%, fever was 29.5%, and loose motions
was 19.2%.
However, according to NFHS-II data for the eight states participating in the study,
the lowest prevalence of ARI was 7.9%, fever was 23.7%, and diarrhea was 13.9%.
UNICEF and MOHFW-GOI conducted a Multi Indicator Cluster Survey (MICS) in 2000
which surveyed all under-five children. This study found the lowest prevalence of the
indicator conditions in the eight states chosen for this study to be 18.8% for ARI, 21.3%
for fever, and 14.5% for diarrhea. Table 4 summarizes the prevalence rates of the child
morbidity indicators from different surveys (NFHS-II and MICS) and figures used to
calculate sample size.
Since there was a wide variation in the prevalence of ARI reported in NFHS II
and MICS studies an average was taken and a prevalence of 13.5% was used to calculate
the sample size with 20% admissible error. A design effect of 1.5 was used to calculate
the final sample size required to estimate density of three indicator morbidities.
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Approximately 923 under-five children will need to be surveyed to estimate morbidity
density (Table 5).
20.3 Sample Size to Estimate Under-five Accessing Government Health Facility for one
of the Indicator Illnesses (Cough with Fast Breathing).
Of the three indicator illnesses being studied in this evaluation, ARI has the lowest
prevalence rate in India. Therefore, the sample size for estimating the number of under-
five children accessing government health facilities for all the indicator illnesses was
calculated based on the ARI prevalence rate of 13.5%. Regarding use of health facilities,
(according to NFHS-II) 64% of children in India with ARI are taken to a health
facility/provider (either government or private). Therefore of the 13.5% of children
experiencing ARI, 9% are likely to be taken to a health facility/ provider (either
government or private), requiring a sample size of 621 with an admissible error of 25%.
This study also seeks to estimate the number of ARI children taken to government
health facilities. Assuming that out of the 13.5% of children experiencing ARI who are
taken to a health facility/provider (9%), 50% (4.5%) were taken to a government facility,
a sample size of 1072 with a 25% admissible error at 95% confidence level will be
needed. However, considering a design effect of 1.5, a total sample of 1600 under-five
children will be required in each district (20 per cluster) to estimate the number of
children accessing government health facilities when they are experiencing the indicator
illness (cough and fast breathing) with adequate power.
According to various surveys, approximately 50% of the under 5 population are
likely to be having one or more indicator symptoms at any time, but even if 1/5 of the
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sick children access a health facility/ provider, sample of 1600 under-five children per
district will be able to estimate the behavior with a confidence level of 95% and 20%
admissible error.
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21.2 Cluster Survey Team
In every district there will be eight cluster survey teams, each team will survey 10
clusters; thereby covering 80 clusters in the districts. Each survey team will consist of six
members: two Senior Investigators (SI), two Doctors/ Medical Officers (MO)/ Interns and
two Research Assistants (RA); preferably one male and one female (Table 7). All centers
are encouraged to co-opt one social scientist/ anthropologist of the institution as one of
the Senior Investigators into the team. Senior Investigators will mostly be faculty
members from partner institutions. Research Assistants with social science or social work
background will be preferred. It is estimated that each survey team would be able to cover
one cluster in 2 days. Thus senior faculty members along with the whole research team
will be in the field to undertake data collection which will be of highest quality.
SI MO RA Total
District 8 16 16 16 48
Total per state 16 32 32 32 96
(2 Districts)
Total in 8 states 128 256 256 256 768
(16 Districts)
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Table 8: Responsibility of Team Members during Cluster Survey
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21.3 Activities within Cluster
Activities within a cluster are carried out according to a pre-defined and consistent
strategy. Broadly each cluster will be divided into four quadrants to sample every
segment of population. In each quadrant, the team will decide about the first household
through a random process using the last two digits on the currency notes available with
Research Assistants/ Doctors. Thereafter the team will move clockwise and anticlockwise
in the alternate quadrants respectively. Flow diagram of field operations is given as
Annexure 8. An account of all the households visited will be kept by maintaining the log
sheet (Annexure 10 and Annexure 13). This will provide count of locked houses, refusals
and other incomplete information.
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considering crude birth rates (≈ 20-35/ 1000 population/ year); almost 1500-1600 live
births will be detected in every district during survey in rural areas.
Household screening will be done by both the Doctors and Research Assistants in
the cluster survey team. The screening will be done till 160 households are captured in the
given cluster. If there are more than one ever married female (15-49 years) in the given
household, then a separate instrument will be filled for each female. Research Assistants
will join the Doctor for screening after completing household survey to complete
household screening. A local seasonal calendar (Annexure 32) will be used to assign
approximate date while taking the pregnancy history, if exact dates are not known.
Therefore, dates on the instrument will be assigned by the interviewer. Detailed
instructions for household screening are provided in Annexure 9.
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22. Generic Health Facility Observation
22.1 Types of Health Facilities Included in the Study
In a district, a total of 40 rural health facilities will be selected for generic
observation; 20 government and 20 private health facilities. For every two clusters
surveyed, one health facility either government or private health facility will be identified.
Private health facilities will be identified in pairs of clusters that have cluster number
divisible by four. In remaining pairs, government health facilities will be recruited. Senior
Investigators will accomplish this task.
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23. Skill Observations
23.1 Skill Observations of Prescribers
23.1.1 Participants
One doctor (prescriber), delivering child health services, will be selected for
assessment of clinical skills from each of the selected health facility (government/
private) (refer to Section Para 22: Generic Health Facility Observation; Page no. 48).
23.1.2 Design
Out of 80 clusters in a district, we propose to observe the skills of health care
provider from 40 health facilities. Out of these, 50% health care providers will be from
government and rest will be from the private sector. Prescribers will be directly observed
by one of the Senior Investigators for management of five children (0-59 months) in the
OPD. The present intervention places emphasis on evaluating the process of assessing the
sick child. No cross validation of the process and key parameters inferred by health
provider will be done during the skill observation of the prescriber.
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23.1.3 Data Collection
Skills related to history taking and general physical examination related to
indicator symptoms other common and important sicknesses, feeding, immunization,
home care assessment, counseling of caretaker, prescription and referral (if applicable) of
sick child will be directly observed and documented. Three live cases and three
hypothetical case scenarios will be used for skill assessment of prescriber. Prescription
audit will be carried out as a component of skill observation for diagnosis and
classification for severity of illness. Guidelines for skill observations are found in
Annexure 16.
23.2.2 Design
Skills of one ANM or AWW per cluster (ANM from odd and AWW from even
numbered cluster) will be assessed for management of common childhood illnesses by
Senior Investigator and/or Doctor of the team. Management of three live under-five
children (including a neonate if available) and three hypothetical case scenarios will be
observed for each health worker (ANM/ AWW). During the time of survey the district
authorities will be requested to coordinate availability of ANM/ AWW in the respective
clusters.
NRHM is planning to have ASHA as a link person and depot holder for the
community. Therefore, their skills will be assessed during the study as and when they are
in position on the ground. Management of one live under-five child (it may be a neonate
if available) and three hypothetical case scenarios will be observed for each health worker
for every cluster one ASHA or non-conventional health worker will be selected for skill
observation. At all places ASHA will be the preferred over others for observation when
available.
Research Assistants will identify sick children (0-59 months; including a neonate
if available) during Household Survey and refer to Senior Investigator for the skill
Operational Manual 51
IPEN-IMNCI Study Phase I (2006-2007)
assessment of paramedical health providers. The three hypothetical case scenarios will be
same for all the prescribers and paramedical health workers, targeting at assessment of
common childhood illnesses and neonatal problems. During the survey of 80 clusters in a
district, we propose to observe the skills of 40 ANM and 40 AWW and 80 ASHA or other
non-conventional health workers (TBA/ Traditional Healer).
1 1 0 1 2 4 0
Instrument Code
Cluster Code
State Code District Code
Each instrument will have a Unique ID number and it will be specific for the state,
district, cluster and the nature of instrument. Same instrument designated for different
clusters will have the same last three digits of Unique ID, but different first four digits.
From a Unique ID, the type of instrument, and its data source including the cluster,
district, state and stakeholder/ nature of data can be identified. It will also help in linking
of data from the same household. The format of Unique IDs assigned to the states,
districts and instruments is given in Annexure 34.
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IPEN-IMNCI Study Phase I (2006-2007)
24.2 Data Management and Transmission for Quantitative Intervention
Collected data will be checked for completeness and quality at the cluster level by
the Senior Investigators. ICR (Intelligent Character Reading) sheets will be filled for
every quantitative instrument for rapid scanning and database formation. Guidelines for
filling ICR sheets are given in Annexure 17. The completed instruments along with filled
ICR sheets will be submitted to the Regional Coordinator. The Regional Coordinator will
dispatch all the completed instruments and ICR sheets from 80 clusters at one time to
CCO-Delhi for further data processing and analysis.
Operational Manual 54
IPEN-IMNCI Study Phase I (2006-2007)
The study team is a partnership between medical colleges (government and
private) and NGO’s in health. At all levels, IPEN team maintains its status of an external
evaluator and expresses and communicates the findings of the study in that capacity.
Operational Manual 55
IPEN-IMNCI Study Phase I (2006-2007)
draft protocol for the study and to discuss other operational details. The CCT facilitate
development of operational manual, study instruments, undertake quality assurance visits
to the study sites, supervise and conduct focus group discussions and provide inputs at the
time of project report writing. Additional investigators from partner institutions have been
inducted into CCT and are termed as Extended CCT members.
Operational Manual 56
IPEN-IMNCI Study Phase I (2006-2007)
Table 10: List of Regions and Corresponding Partner Institutions
S.No. State Partner Medical Colleges
Operational Manual 57
IPEN-IMNCI Study Phase I (2006-2007)
30. Network Monitoring
30.1 Regional Coordinator
A Regional Coordinator will be identified at each regional center to coordinate
activities in his/her state and streamline research activities. The regional coordinator will
be in constant touch with CCO, Delhi. Soon after the regional workshop, list of research
team members (Annexure 19), the plan of cluster/ field activities (Annexure 20) will be
sent to CCO. Thereafter regional center and CCO will remain in constant touch to
monitor progress of fieldwork and data collection. Regional coordinator will update CCO,
Delhi every alternate day (on every Monday, Wednesday and Friday) regarding the
progress of the fieldwork accomplished by their research teams and communicate
problems faced by any team (Annexure 25).
Operational Manual 58
IPEN-IMNCI Study Phase I (2006-2007)
10. To disburse funds for the field travel. Funds will be transferred to regional
coordinator office from CCO. The final audited accounts will be submitted back
to CCO for reconciliation by regional coordinators.
Operational Manual 59
IPEN-IMNCI Study Phase I (2006-2007)
Level 2: International Advisory Board
A one-day meeting consisting of members of International Advisory Board
will be held before the National Protocol Finalization Workshop to share
experiences from other parts of the world and get technical inputs for the present
study. Subsequently International Advisory Board will provide technical and quality
assurance inputs at all stages of program implementation and later during analysis
and report writing.
Operational Manual 60
IPEN-IMNCI Study Phase I (2006-2007)
The objective of these visits is to identify problems of methodology and logistics in
the field and find solutions in consultation with Regions Coordinators and CCO.
The CCT members will cross check authenticity of data that has actually been
collected and quality of interviews being conducted by researchers through direct
observation. CCTs will provide the feedback about overall cluster activities,
interview techniques, quality (correctness and completeness) of data collected, and
quality of transcription of data by the team members (Annexure 27 & 28).
Operational Manual 61
IPEN-IMNCI Study Phase I (2006-2007)
32.1 Challenges for Phase II and Phase III of Study
A major external threat to the study is speed, consistency and quality of
implementation of IMNCI for intervention districts across different states. If the program
is not implemented completely and/or dilution in the quality of these components of
IMNCI, the changes observed in intervention districts will not be truly reflective of
effectiveness of IMNCI as a child survival package.
To overcome this challenge, the study team is making an effort to set up an
institutional arrangement with State and Central program managers to discuss the above
issues. The purpose will be to encourage state program implementation machinery to
facilitate, complete and consistent implementation of IMNCI in the respective districts
within the time frame decided in the state implementation places.
Operational Manual 62
IPEN-IMNCI Study Phase I (2006-2007)
33. Timeline of IMNCI-IPEN Study Phase I (2006-2007)
Activity JUL 06 AUG 06 SEPT 06 OCT 06 NOV 06 DEC 06 JAN 07 FEB 07 MAR 07
Weeks 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
1. Development of study
instruments and
operational manual
2. Field testing
3. Finalization of Study
Instruments
4. Meeting of State Health
Secretaries and Program
Officers
5. Identification of Regional
coordinator and PMC
6. Preparation of National
Level Workshop
7. International Advisory
Board Meeting
8. National Workshop
9. Second Advisory Board
Meeting
10. Finalization of project
proposal and Instruments
11. District Level Workshop
12.Data Collection
13.Data Analysis
Operational Manual 63
IPEN-IMNCI Study Phase I (2006-2007)
References
1. Jones G, Schultink W, Babille M. Child Survival in India. Indian J Pediatr. 2006; 73:479-487
2. Mudur G. (2003). Neonatal deaths hamper India's infant mortality targets. British Medical Journal.
32. from bmj.bmjjournals.com/cgi/content/full/327/7426/1249.
3 Jones, G., Stekette, R.W., Black, R.E., Bhutta, Z.A., Morris, S., Bellagio Child Survival Study
Group. (2003). How Many Child Deaths Can We Prevent This Year? Lancet Child Survival Series.
361. 11-17.
4. World Health Organization. Towards Better Child Health and Development: Components of IMCI:
Website: www.searo.who.int/EN/Section13/Section37/Section2017/Section2038_10202.htm.
Accessed: December 2006.
5. Tanzania IMCI Mulit-Country Evaluation Health Facility Survey Group. (2004). The effect of
Integrated Management of Childhood Illness on Observed Quality of Care of Under-fives in rural
Tanzania. Health Policy and Planning, 19, 1-10.
6. Schellenberg JRA, Taghreed, A., Mshinda, H., Masanja, H., Kabadi, G., Mukasa O, et al. (2004).
Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in
Tanzania. Lancet, 364, 1583-1594.
8. Huicho, L., Davila, M., Gonzales,F., Drasbek, C., Victoria, C., Bryce, J. Policy contributions and
key messages from the Multi-Country Evaluation of IMCI : Peru Fact Sheet from Global Forum
for Health research, Ministerial Summit on Health Research.
9. Makerere University Institute of Public Health, Johns Hopkins University, WHO (Dept. of Child
and Adolescent Health and Development). Policy contributions and key messages from the Multi-
Country Evaluation of IMCI: Uganda Fact Sheet from Global Forum for Health research,
Ministerial Summit on Health Research.
10. Amaral, J, Gouws, E., Bryce, J., Leite, A., Alves da Cuna, A., and Victoria, C. (2004). Effect of
Integrated Management of Childhood Illness (IMCI) on health worker performance in Northeast-
Brazil. Cad. Saude Publica, 20, 109-118.
11. El Arifeen, S., Blum, L., Hopue, D., Chowdhury, E., Khan, R., Black, R., Victoria, C., Bryce, J.
(2004). Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a
cluster-randomised study. Lancet, 364, 1595-1602.
12. Baqui, AH et al. (2006). Rates, timing and causes of neonatal deaths in rural India: implications
for neonatal health programmes. Bull World Health Organ, 84,706-713.
Operational Manual 64
IPEN-IMNCI Study Phase I (2006-2007)
13. National Rural Health Mission: Government of India. (2006). Operational Guidelines for
Implementation of Integrated Management of Neonatal and Childhood Illness (IMNCI).
14. Bang, A., Reddy, H., Deshmukh, M., Baitule, S. and Bang, R. (2005). Neonatal and Infant
Mortality in the Ten Years (1993 to 2003) of the Gadchiroli Field Trial: Effect of Home-Based
Neonatal Care. Journal of Perinatology, 25, S92–S107.
15. Policy Reform Options Database. Outcome Evaluation of the Mitanin Porgramme: A critical
Assessment of the Nation’s Largest Ongoing Community Health Programme. Retrieved November
13, 2006, from www.prod-india.com/files/PROD49.
17. UNICEF. (2005). State of the World’s Children. New York. Retrieved October 2006, from
www.unicef.org/sowc06/.
18. Black R., Morris, S., Bryce, J. (2003). Where and why are 10 million children dying every year?
Lancet, 361, 2226-2234.
19. Victora, C.G., Wagstaff, A., Schellenberg, J.A., Gwatkin, D., Claeson, M., and Habicht, J. (2003).
Applying an equity lens to child health and mortality: more of the same is not enough. Lancet, 362,
24-32.
20. The World Bank Group. (1996). Summary of: Improving Women’s Health in India. Retrieved
October 2006, from http://www.worldbank.org/html/extdr/hnp/population/iwhindia.htm.
21. Desai, S., Rastogi, S., and Vanneman, R. (2005). Gender Differences in Child Survival in India:
What do we know? Retrieved January 15, 2007, from
iussp2005.princeton.edu/download.aspx?submissionId=51398.
22. Filmer, D., King, E.M., Pritchett, L. (1998). Gender Disparity in South Asia: Comparisons
Between and Within Countries. Retrieved January 16, 2007, from
www.worldbank.org/html/dec/Publications/ Workpapers/WPS1800series/wps1867/. (World Bank
policy research working paper No 1867.)
23. India Ministry of Tribal Affairs. (2004). The National Tribal Policy (draft). New Delhi: India
Ministry of Tribal Affairs. Available: http://tribal.nic.in/finalContent.pdf. Accessed: December
2006.
24. Subramanian, S., Smith, G.D., and Subramanyam, M. (October 2006). Indigenous Health and
Socioeconomic Status in India. PLoS Medicine. 3: e421, from 10.1371/journal.pmed.0030421.
25. Subramanian, S., Nandy, S., Irving, M., Gordon, D., Lambert, H., Smith, G. (May 2006). The
Mortality Divide in India: The Differential Contributions of Gender, Caste, and Standard of Living
Across the Life Course. American Journal of Public Health, 96, 818-825.
26. The Bellagio Study Group on Child Survival. (2003). Knowledge into action for child survival.
Lancet, 362, 33-38.
Operational Manual 65
IPEN-IMNCI Study Phase I (2006-2007)
27. Bangdiwala, S. Niswade, A., Ughade, S., and Zodpey, S. (2006). Integrating Results from
Formative Phase Studies for Informing the Design of Intervention Studies on Neonatal Health in
India. World Health and Population.
28. National Rural Health Mission. (2005). National Rural Health Mission: Mission Document (2005-
2012). New Delhi: Retrieved in September 2006, from www.mohfw.nic.in/NRHM/ 20Mission/
20Document.pdf.
29. The World Bank: South Asia Region, Health Nutrition, Population Sector Unit: India. (2001).
India: Raising the Sights: Better Health Systems for India’s Poor Overview. Retrieved September
2006 from lnweb18.worldbank.org/sar/sa.nsf/Attachments/ovr/$File/hOvr.pdf
31. Anker M, Black R, Coldham C, Kalter H, Quigley M, et al. (1999) A standard verbal autopsy for
investigating causes of death in infants and children. Geneva (Switzerland): World Health
Organization. Report Number WHO/CDS/CRS/ISR/99.4.
Operational Manual 66
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE- 1
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI-IPEN Study 2006-2007)
Mathura
Kaithal
Kannauj
Mewat Morena
Ri-bhoi
Baran
Sonpur
Nayagarh
Amravati
Parbhani
Gulbarga Gadag
Comparison Districts
Intervention Districts
Operational Manual 67
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 2
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI-IPEN Study 2006-2007)
Karnataka
2 KARNATAKA GULBARGA GADAG
Intervention Comparison
Total Total Rural Total Rural
Demographic Profile (2001) % (#) %(#) %(#) %(#) %(#)
Total Population 100 5.9 72.7 1.8 64.7
(52850562) (3130922) (2278301) (971835) (629652)
Male Population 50.8 50.8 50.5 50.7 50.7
(26898918) (1592789) (1152343) (493533) (319629)
Female Population 49.1 49.1 49.4 49.2 49.2
(25951644) (1538133) (1125958) (478302) (310023)
Sex Ratio 966 977 969 970
Population (0-6 yrs) 13.5 17.1 17.7 14.1 14.5
Male (0-6 yrs) 51.3 51.6 51.4 51.2 51.2
Female (0-6 yrs) 48.6 48.3 48.5 48.7 48.7
SC Population 16.2 22.9 24.9 14.1 16.1
ST Population 6.5 4.9 5.9 5.5 7.28
Minority Population 16% 2400% 15
Total Literate Population 57.5 41.4 34.7 56.7 52.5
Male Literate Population 58 62.6 65.4 60.8 62.9
Female Literate Population 41.9 37.3 34.5 39.1 37
Population Density 275.56 193 209
Health Facility Profile HF/1 Lac HF/ 1Lac
Community health centres 19 0.8 6 0.9
Primary health centres 102 4.4 29 4.6
Primary health subcentres 507 22.2 183 29
Health Indicators
Routine Immunization (2005) 90.9 50.2 49.4
IMR (2001- IIPS) 58 60 59
Madhya Pradesh
3 MADHYA MORENA TIKAMGARH
PRADESH Intervention Comparison
Total Total Rural Total Rural
Demographic Profile (2001) % (#) % (#) % (#) % (#) % (#)
Total Population 100 2.6 78.4 1.9 82.3
(60348023) (1592714) (1249409) (1202998) (990265)
Male Population 52.1 54.8 55 53 53.1
(31443652) (874089) (687664) (637913) (525864)
Female Population 47.8 45.1 44 46.9 46.8
(28904371) (718625) (561745) (565085) (464401)
Sex Ratio 919 822 817 886 883
Population (0-6 yrs) 17.8 18.7 19.3 19 19.4
Male (0-6 yrs) 51.7 54.4 54.3 52.2 52.2
Female (0-6 yrs) 48.2 45.5 45.6 47.7 47.7
SC Population 15.1 21 21.2 24.2 25
ST Population 20.2 0.8 0.9 4.3 4.7
Minority Population 9 4 4
Total Literate Population 52.3 52.6 49.7 45 42.5
Male Literate Population 62.2 67.8 69.7 65.5 67
Female Literate Population 37.7 32.1 30.2 34.4 32.9
Population density/sq km 195.78 318.00
Health Facility Profile HF/1 Lac HF/1 Lac
Community health centres 5 0.4 4 0.4
Primary health centres 18 1.4 18 1.8
Primary health subcentres 196 15.6 158 15.9
Health Indicators
Routine Immunization (2005) 51.4 26.8 34
IMR (2001-IIPS) 86 118 142
Maharastra
AMRAVATI PARBHANI
4 MAHARASHTRA Intervention Comparison
Total Total Rural Total Rural
Demographic Profile (2001) % (#) % (#) % (#) % (#) % (#)
100 2.6 65.4 1.5 68.2
Total Population (96878627) (2607160) (1707581) (1527715) (1042529)
52 51.6 51.5 51 50.8
Male Population (50400596) (1345614) (880387) (780191) (529729)
47.9 48.3 48.4 48.9 49.1
Female Population (46478031) (1261546) (827194) (747524) (512800)
Sex Ratio 922 938 940 958 968
Population (0-6 yrs) 14.1 13.7 14.3 16.5 16.9
Male (0-6 yrs) 52.2 7 51.3 52 51.8
Female (0-6 yrs) 47.7 48.4 48.6 47.9 48.1
SC Population 10.2 17.1 18.6 9.9 10.4
ST Population 8.8 13.6 18.8 2.3 2.5
Minority population 28% 27%
Total Literacy Population 66 71.2 67.7 55.1 51
Male Literate 58.1 55.6 56.5 61.3 63.4
Female Literate 41.8 44.3 43.4 38.6 36.5
Population Density/ sq.km 315 213 229
Health Facility Profile HF/1 lac HF/lac
Community health centres 18 1 10 0.9
Primary health centres 56 3.3 31 2.9
Primary health subcentres 320 18.7 231 22.1
Health Indicators
Routine Immunization (2005) 78.7 82.4 80.8
Infant Mortality Rate (2001-IIPS) 50 51
Operational Manual
Source: Census 2001
69
IPEN-IMNCI Study Phase I (2006-2007)
Profile of Intervention and Comparison Study Districts ANNEXURE 2
Meghalaya
5 MEGHALAYA RI-BHOI JAINTIA HILLS
Intervention Comparison
Total Total Rural Total Rural
Demographic Profile (2001) % (#) % (#) % (#) % (#) % (#)
100 8.3 93.1 12.8 91.6
Total Population (2318822) (192790) (179610) (299108) (274051)
50.7 51.5 51.5 50.1 50.2
Total Male Population (1176087) (99319) (92563) (149891) (137629)
49.2 48 48.4 49.8 49.7
Total Female Population (1142735) (934714) (87047) (149217) (136422)
Sex-ratio 972 941 940 996 991
0- 6 Population 20.1 22 22.1 22.5 23
0-6 Male Population 50.6 50.7 50.6 50.1 50
0-6 Female Population 49.3 49.2 49.3 49.8 49.9
SC Population 0.48 0.1 0.1 0.15 0.15
ST Population 85.9 87 87.2 95.9 96.4
Minority Population 87 85 96
Literate population 49.9 51.2 50.6 40.1 37
Male Literate Population 53 54.1 54.2 48.3 48.1
Female Literate Population 46.9 45.8 45.7 51.6 51.8
Population Density (Per sq. km) 103.38 81 77
Health Facility Profile HF/lac HF/Lac
Community health centres 3 1.6 5 1.8
Primary health centres 8 4.4 16 5.8
Primary health subcentres 26 14.4 70 25.5
Health Indicators
Rotine Immunization (2005) 48.8 43 47.2
IMR (2001-IIPS) 61/1000 47.52
Orissa
6 ORISSA NAYAGARH SONAPUR
Intervenmtion Comparison
Total Total Rural Total Rural
Demographic Profile (2001) % (#) %(#) %(#) %(#) %(#)
Total Population 100 2.3 95.7 1.4 92.6
(36804660) (864516) (827450) (541835) (501767)
Male Population 50.7 51.6 51.5 50.8 50.7
(18660570) (446177) (426794) (275601) (254805)
Female Population 49.2 48.3 48.4 49.1 49.2
(18144090) (418339) (400656) (266234) (246962)
Sex Ratio 972 938 939 966 969
Population (0-6 yrs) 14.5 13 13.1 14.2 14.4
Male (0-6 yrs) 51.2 52.5 52.4 7.2 7.3
Female (0-6 yrs) 48.7 47.4 47.5 7 7
SC Population 16.5 14 13.8 23.6 23.5
ST Population 22.1 5.8 6 9.7 10.2
Minority Population 6 1 1
Literate Population 53.8 61.2 60.6 53.8 52.7
Male Literate Population 60.4 60.3 60.5 63.9 64.3
Female Literate Population 39.5 39.6 39.4 36 35.6
Population Density 236.37 222 231.00
Health Facility Profile HF/ 1 Lac HF/1 Lac
Community health centres 4 0.48 3 0.5
Primary health centres 8 0.9 6 1.1
Primary health subcentres 150 18.12 75 14.9
Health Indicators
Routine Immunization (2005) 70.4 62.3 65.2
IMR (2001-IIPS) 87 55 62
Rajasthan
BARAN CHITTORGARH
7 RAJASTHAN Intervention Comparison
Total Total Rural Total Rural
Demographic Profile (2001) % (#) %(#) %(#) %(#) %(#)
100 1.8 83.1 3.1 83.3
Total Population (56507188) (1021653) (849638) (1803524) (1514255)
52.1 52.3 52.2 50.9 50.6
Total Male Population (29420011) (535137) (445205) (918063) (767555)
47.9 47.6 47.6 49 49.3
Total Female Population (27087177) (486516) (404433) (885461) (746700)
Sex-ratio 921 909 908 964 973
0-6 Population 18.8 18.5 18.8 17.2 17.6
0-6 Male Population 52.3 52.1 52 51.8 51.6
0-6 Female Population 47.6 47.8 47.9 48.1 48.3
SC Population 17.1 17.7 17.4 13.9 14
ST Population 12.5 21.2 24.8 21.5 24.9
Minority Population 11% 7% 8%
Literate population 49 48.4 45.9 44.7 40.2
Male Literate Population 65.1 66.7 68.3 66.8 69.6
Female Literate Population 34.8 33.2 31.6 33.1 30.3
Population Density (Per sq. km) 165.11 146 166
Health Facility Profile HF/1 Lac HF/! Lac
Community health centres 8 0.9 12 0.7
Primary health centres 32 3.7 54 3.5
Primary health subcentres 201 23.6 391 25.8
Health Indicators
Routine Immunization (2005) 38.8 30% 23.30%
IMR (2001-IIPS) 79 77 92
Uttar Pradesh
8 UTTAR KANNAUJ MATHURA
PRADESH Intervention Comparison
Total Total Rural Total Rural
Demographic Profile (2001) % (#) %(#) %(#) %(#) %(#)
100 0.8 83.2 1.2 71.7
Total Population (166197921) (1388923) (1156951) (2074516) (1487493)
52.6 53.5 53.7 54.3 54.4
Male Population (87565369) (744170) (621751) (1127512) (809946)
47.3 46.4 46.2 45.6 45.5
Female Population (78632552) (644753) (535200) (947004) (677547)
Sex ratio 866 861 840 837
Population (0-6 yrs) 19 18.7 19 19.5 20.9
Male (0-6 yrs) 52.2 52.3 52.2 53.4 53.3
Female (0-6 yrs) 47.7 47.6 47.7 46.5 46.6
SC Population 21.1 18.4 19.7 19.5 21.9
ST Population 0.06 0.003 0 0.01 0.009
Minority population 19% 16% 9%
Total Literacy Population 27 50.2 49.3 49.5 45.5
Male Literate 64.5 63.3 64.4 67.9 71.5
Female Literate 35.4 36.6 35.5 32 28.4
Population Density/ sq.km 689.82 695 586
Health Facility Profile HF/Lac HF/Lac
Community health centres 2 0.17 5 0.3
Primary health centres 35 3 31 2.08
Primary health subcentres 180 15.5 207 13.9
Health indicators
Routine Immunization (2005) 37.90% 21.8 21.7
Infant Mortality Rate (2001- IIPS) 79 81 83
Operational Manual 71
IPEN-IMNCI Study Phase I (2006-2007) Source: Census 2001
ANNEXURE 3
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI-IPEN Study 2006-2007)
The Interview is primarily a product of the interaction between the interviewer and the
respondent. Competence in interviewing is acquired only after careful study of instruments and
practice of interviewing. However, there are some accepted, general guide posts which may help
the beginner to avoid mistakes and establish effective working relationships with the respondents
to accomplish what he/she sets out to do.
Operational Manual 72
IPEN-IMNCI Study Phase I (2006-2007)
11. If the respondent is uncooperative, do not get upset or show your anger. Talk very politely
and calmly to him/her. Explain the importance of the study. Remember, a smile always helps.
Also remember that you cannot and should not force anyone to respond.
12. Always use the brief introductory approach written into the questions which should include
an identification of who you are, why have you come, who do you represent, what will be done
with the information gained and promise confidentiality.
13. Listening is another important skill to be learned and practice. Always watch for additional
information or new leads in the casual remarks of the respondent as in their attitude, “body
language” (posture, expressions, etc).
14. Must be willing to listen with an open mind.
15. Ask questions just as they are written. Deviations from the prepared questions may serve to
promote the respondent into giving you answer (s)he thinks you may want to hear. In case the
question is not comprehended easily use relevant prologue.
16. Ask only one question at a time.
17. Ask questions in the order that they appear.
18. Adhere to the subject. If the respondent is not talking straight to the point, make a suggestion
or ask a question which will lead back to the general subject of the interview.
19. Be frank and straight forward rather than shrewd or clever. Do not talk down to the
respondent.
20. If a question is not easily understood, repeat it. Sometimes wrong or inaccurate information is
given because the question is not understood. If necessary use local terms to explain/clarify.
21. Get the full meaning of each statement. Make sure you understand each answer carefully
before recording it.
22. Generally, the first reaction to a question is the important or true one. Do not record any
changes in an answer to a past question if you already have gone into other items.
23. Do not record a ‘do not know’ answer too quickly. Sometimes the respondent might say, ‘I
do not know’ while stalling for time or arrange his/her thoughts. The words ‘do not know’
could be an introduction to a meaningful comment, so give the respondent a little time to think.
24. Record comments or remarks just as they are given. Use abbreviations that are
understandable, so in checking over the interview you can fill in the content of the answer.
25. Do not let the silence grow, the respondent might become distracted, bored, resentful, or may
even change his/her mind. Keep eye contact with the respondent.
26. Spend a few minutes checking the answers before you leave the respondent. Remember you
cannot supplement an answer after you leave.
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IPEN-IMNCI Study Phase I (2006-2007)
27. Do thank and extend your appreciation to the interviewee when the interview is completed.
Reassure that none of the answers will put the interviewee or his/her community at
any disadvantage.
Focus Group Discussions (FGDs)
Operational Manual 74
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 4
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI-IPEN Study 2006-2007)
Operational Manual 75
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 28
1. The respondent information will be treated as confidential and the identity of either the
respondent or health facility will be revealed to any one outside the research team.
4. Ask questions to mother/ immediate care provider of the child (Houseold Survey); specific
women in the reproductive age group (15-49 years) (Household Screening); doctor in-charge
of the health facility (Generic Observations).
6. After completion of cluster work, the Senior Investigator will fill up the ICR sheets.
Operational Manual 76
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 6
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI-IPEN Study 2006-2007)
Objective of Verbal Autopsy: Assigning cause of death and documenting events before death by
interviewing relatives of the deceased who are present at the time of death. The Senior
Investigator will conduct verbal autopsy. Coding and assigning the cause of death will be done by
trained CCT members. The CCT members will be trained in ICD-10 coding systems before
undertaking this exercise.
Instructions to Interviewer:
The Senior Investigator will speak to the mother or to another adult caretaker who was
present during the illnesses that lead to death. If this is not possible in the first contact, arrange
a time to revisit the household when the mother or caretaker will be home on same day/ next day.
Note: Written consent should be taken before proceeding further with the verbal autopsy.
Operational Manual 77
IPEN-IMNCI Study Phase I (2006-2007)
4. Read all questions exactly as they are written, and slowly and clearly so that the
respondent understands the question and does not feel rushed.
5. There are 13 sections in the instruments. Follow the instructions and skip patterns
carefully.
6. Be aware that some “close-ended’ questions allow for more than one answer.
7. If date of death is not known you can calculate the year by subtracting age from the year
of death.
8. If date of birth is not known ask the respondent if she remembers any social, religious, or
calendar event that could be related to the year the deceased was born.
9. If the respondent says that they do not know the answer or they begin to look
uncomfortable you can try probing for an answer by reframing the question.
10. If the participant becomes angry or says that they no longer want to participate, explain to
them the importance of their participation in the overall context of saving children. Re-
emphasize that all of their responses are confidential and that individual names will not be
known to anyone outside of the project. If this does not work, ask the participant if they
would like to take a break or reschedule a time to finish the interview.
11. No answer box should be left blank; if answer to a particular question is not possible/not
applicable, enter “Not Applicable”.
Linking the “Neonate”/ “Child” with the Household and Mothers Details:
Quote the unique ID of Mother’s Screening Instrument at the pre-designated place in
the Verbal Autopsy Instrument.
Operational Manual 78
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 7
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI-IPEN Study 2006-2007)
Objective of Tracking of Events: To find out the pathway of events before recovery from
sickness of children under-five years and their social, economic and contextual determinants.
All tracking process will be accomplished by Senior Investigators. The purpose is to record
relevant health and non-health events prior to outcome of interest (recovery from illness).
2. Please remember that “Tracking” instruments are mixture of quantitative and qualitative
type of questions (close-ended and open-ended questions respectively).
3. For “close-ended” questions, answers/ options are already provided and you have to
mark the responses as told by respondents in the appropriate box(es).
4. Read all questions exactly as they are written, and slowly and clearly so that respondent
understands the question and does not feel rushed.
5. For “open-ended” questions, please record the answers verbatim. Allow the respondent
(mother/ care provider) adequate time to reflect, and synthesize his/her answers. Answers
in “monosyllables” are discouraged.
6. Be aware that some “close-ended” questions allow for more than one answer.
Operational Manual 79
IPEN-IMNCI Study Phase I (2006-2007)
7. There are 6 (six) sections in the tracking instruments. Follow the instructions and skip
patterns carefully.
8. Ensure that events are recorded as per the location. As the child is taken from one health
facility to another, the events and related activities and reasons are to be recorded under
the health facility where these happened.
9. Similarly ensure events happening at home are recorded under home care.
10. “Reasons” and “problems” are the key issues that should be carefully listened to and
recorded appropriately.
11. If the respondent says that they do not know the answer or they begin to look
uncomfortable you can try probing for an answer by reframing the question.
12. No answer box should be left blank. If answer to a particular question is not possible/ not
applicable, enter “Not applicable”.
Linking the “Neonate”/ “Child” with the Household and Mother’s details:
Quote the unique ID of the Household Screening Instrument at the pre-designated place in
the Tracking of Events Instrument.
Operational Manual 80
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 8
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India (IMNCI-IPEN Study 2006-2007)
Summary of Field Operations
Duties of Senior Investigator 2 (SI-2)
After entering the cluster the team prepares a village map with the help of local volunteers.
They will then identify a central point where a Senior Investigator will be available.
First two quadrants: Doctor # 1 and Research 3rd & 4th quadrant: Doctor # 2 and Research
Assistant # 1 Assistant # 2 • Skill Observation of Prescriber
managing cases under-five (from
the health facility where generic
Identify the first house in each quadrant by using last two digits of the currency note from SI-1. health facility observation done)
This house will be the beginning of both: Household Screening & Household Survey • In depth interview of Prescriber
• Generic Health Facility Observation
DOCTOR: SENIOR INVESTIGATOR- 1 (SI-1)
9 Administer the Household Screening Instruments; 40 households in each quadrant 9 Receive and sort the children referred by the Doctor, and select to
or a total of 160 households in each cluster. administer the following instruments:
9 Refer appropriate cases to the SI-1 for the following: o Verbal Autopsy • At the end of day, scrutinize ALL
o All deaths of children under-five years in previous one year. (for verbal autopsy) o Tracking of Events: Morbidity (hospitalized & non-hospitalized) the instruments and assess for
o Households for Neonate aged 10- 28 days on the date of survey (for tracking). o Tracking of Events: Neonate quality & completeness.
o Recovered morbidity in children under-5 who were hospitalized in previous 3 o Skill Observation: ANM (odd clusters)/ AWW (even clusters) • Fill up ICR Sheets.
months. Only one such case (preferably female) will be included in the survey in o Skill Observation: ASHA or TBA or TH (one per cluster)
each cluster.(for tracking) 9 Scrutinize ALL the instruments at the end of the day and assess
for quality and send the completed instruments to regional
coordinator
9 Fill up ICR Sheets
Fill the appropriate referral sheet and refer to SI-1. 9 Sick children referred to SI-1 for tracking will be used for skill
assessment of health workers
RESEARCH ASSISTANTS
9 Administer the Household Survey instrument
9 Once the first household is completed, the one close to the first will be selected as the next household. This will be repeated until 20 children (10 male or 10
Operational
female) are includedManual
in the survey; 5in each quadrant. In two quadrants (i.e. one half cluster) only female children to be recruited; in the remaining two 81
quadrants (other halfStudy
IPEN-IMNCI cluster) only male
Phase children to be included.
I (2006-2007)
9 Recovered morbidity without hospitalization in children under 5 years (One male and one female in each half of the cluster). Children under-five with
illness in previous two weeks before survey, who recovered without hospitalization and are asymptomatic for previous 3 days will be included. These are
referred to SI-1 for tracking of events.
ANNEXURE 9
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI-IPEN Study 2006-2007)
The study will recruit 160 households in each cluster. Thus we will screen a population of
approximately 65,000-70,000 population residing in 12,800 household spread in 80 clusters.
Considering crude birth rates (≈ 20-35/ 1000 population/ year), almost 1500-1700 live births would
have occurred during the previous one year in the screened population in every district.
• Household screening will be done by both the Doctors and Research Assistants in the cluster
survey team.
• The screening will be done till 160 households are captured in the given cluster.
• The cluster is divided into four quadrants.
• The research team (Doctor/ Research Assistants) will recruit 40 households from each
quadrant starting with a randomly chosen house.
• Last two digits of currency notes available with research team will determine the first house in
each quadrant.
• If there are more than one ever married female (15-49 years) in the given household, then a
separate instrument will be filled for each female.
• Research Assistants will join the Doctor for screening after completing household survey to
complete household screening.
Operational Manual 82
IPEN-IMNCI Study Phase I (2006-2007)
• Socioeconomic and equity status of the household
During the screening process cases will be identified for
o Verbal autopsy (Death of under-five children in 2006)
o Tracking of events for Neonate (10-28 days old)
o Tracking of events for recovered hospitalized morbidity (under-five children)
These identified cases will be referred to Senior Investigator for appropriate action (Annexure 11)
Screening for recovered morbidity in children under-five years who were hospitalized
Field teams will also identify one child under-five years of age who was sick and hospitalized for
least 24 hours and recovered in 3 months prior to date of survey. Only one such case (preferably
female) will be included in the survey from each cluster for tracking events prior to recovery. If such a
child is not present in 160 households screened in a cluster, teams will not pursue further.
Operational Manual 83
IPEN-IMNCI Study Phase I (2006-2007)
Important note:
1. Instruments are to be filled up ONLY for those households where respondents are available
and agree to participate in the survey.
2. Do not fill up the instrument if the household is locked or if the person refuses.
3. It is necessary to mention details on refusal/ locked houses in the log sheet (Annexure 9).
4. If there is more than one eligible woman (15-49 years) in a household, fill up separate
instruments for each eligible woman (15-49 years).
5. Unique ID of the first instrument filled for a household is critical. This will be called “Unique
ID of First Female”.
6. All subsequent women interviewed from the same household have a “pre-designated” location
to record “Unique ID of First Female” for linking baseline demographic information about the
household.
7. Baseline demographic, social, economic, and equity related questions are asked ONLY from
“First Female”. Therefore unique ID of first Female will serve as link for subsequent females
from same household and also for other instruments such as: Household Survey, Verbal
Autopsy and Tracking of events.
8. For subsequent respondents from the same households, Section A is skipped. Only
“Pregnancy-related” questions. (Section B or C).
9. Table of Indian Calendar months and its corresponding English calendar and months is
provided. If the woman gives dates and month of their deliveries according to Indian calendar,
convert it to the nearest date and month of the English calendar. In case only Indian month is
mentioned, first-day of the nearest English month is to be entered.
10. Quantity of agricultural land (Q-25): Use the state specific conversion table to estimate
approximate ACRES of land (Annexure 33).
Operational Manual 84
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 10
Integrated Management of Neonatal and Childhood Illnesses:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI IPEN Study 2006-2007)
10
11
12
13
14
15
16
17
18
19
20
Name: _____________________________
Operational Manual 85
IPEN-IMNCI Study Phase I (2006-2007) Signature of Research Assistant: _________________
ANNEXURE 11
Integrated Management of Neonatal and Childhood Illnesses:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts
(IMNCI IPEN Study 2006-2007)
Household Screening Referral Sheet
Please give this slip to your Senior Investigator for tracking of events
Tehsil Address:
Village
Cluster No.
Team No.
This household has one or more of the following for further workup: (Tick if present)
Name ___________________________
Survey.
Screening for recovered morbidity in children under-five years who were non-hospitalized
Each team will identify first male and first female child of less than five years (in this half of cluster)
who have recovered of morbidity in their respective area (i.e. 1 male and 1 female in each half of the
quadrants of the cluster). These are children under-five year who had any illness in the previous two
weeks before survey, and now recovered without hospitalization and are asymptomatic for at least 3
Operational Manual 87
IPEN-IMNCI Study Phase I (2006-2007)
days (72 hours) prior to day of survey from any illness. This component is for tracking of events prior
to recovery. Event tracking will be done by Senior Investigator.
• It is necessary to mention details on refusal/ locked houses in the log sheet (Annexure 13).
• Plan for revisit for household survey, if the mother/ primary care taker is not available.
• Maintain the household survey monitoring sheet and the children identified and referred for
tracking of events/ skill assessment of health workers (Annexure 14).
Operational Manual 88
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 13
Integrated Management of Neonatal and Childhood Illnesses:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI IPEN Study 2006-2007)
10
11
12
13
14
15
* Reasons for Refusal
01. Locked Household/ No responsible adult respondent available
02. No one in eligible age group available at home
03. Individuals available but busy with household work/ function at home
04. Refuse to be interviewed
05. Mother/ Primary care provider not available [THIS HOUSEHOLD MUST BE REVISITED]
06. Any other Reason. Please specify
Name: ______________________________________
Operational Manual 89
IPEN-IMNCI Study Phase I (2006-2007)
Signature of Research Assistant: ___________________
ANNEXURE 14
Integrated Management of Neonatal and Childhood Illnesses:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts
(IMNCI IPEN Study 2006-2007)
Team No.
Name: ______________________________________
Operational Manual 90
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 15
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI-IPEN Study 2006-2007)
Operational Manual 91
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 16
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI-IPEN Study 2006-2007)
Operational Manual 92
IPEN-IMNCI Study Phase I (2006-2007)
(d) General instruction for skill observation
1. You will be assessing the skill of the health provider.
2. Please do not probe or ask any questions or guide during the observation.
3. For case scenarios, don’t guide them for response (history/ examination/ communication).
Record whatever they respond and note the responses in appropriate boxes.
4. Mark “X” in the boxes against the items if the doctor is observed doing it. If not, leave them
blank.
5. Cases for skill observation
Category of health Live cases for assessment per Hypothetical Case
provider Prescriber/ HW * studies per Prescriber/
HW
Prescriber 3 3
ANM/ AWW 3 3
ASHA**/ TBA/ TH 1 0
* Preference will be given to neonate if available.
** Preference will be given to ASHA over TBA/ TH.
6. Sick children brought/ identified for the first time for care are to be included for skill
observation.
7. Children brought for follow up visit should not be included.
8. Case studies: Read out the case study slowly in the language of health provider. Clarify and
repeat if asked for by the respondent.
• Doctor/ health provider asks for the frequency of feeding appropriate for age (breast feeding
for neonates and infants and especially about night feeding).
• Doctor/ health provider asks for additional/ complementary feeding other than breastfeeds
including the tme of starting, frequency, consistency.
• Doctor/ provider advises about the appropriate frequency and amount of feeds for the age.
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IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 17
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India
(IMNCI-IPEN Study 2006-2007)
1. In the evening, after filling all the schedules in the cluster, please open the packet containing
the ICR sheets.
2. The ICR sheets have unique serial numbers matching with the schedules of the cluster and
are arranged in a sequence.
3. Take the filled schedules one by one, open the ICR Sheet the matching unique serial number
and place the cross marks (X) and numbers in the appropriate boxes. The [X] mark should
not extend beyond the boundary of the square box X for accurate scanning.
4. Do NOT use tick marks.
5. To be filled and signed by the Senior Investigators only.
6. Only pencils are to be used for marking.
7. Only appropriate boxes are too be marked. Leave all other boxes blank.
8. Do not separate the ICR sheets from the folder.
9. Do not fold or stain the ICR sheets.
In case of incorrect entry erase the (X) mark/ number completely with the eraser and then
mark appropriately
Operational Manual 96
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 18
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity and Mortality in Selected Districts in India (IMNCI-IPEN Study 2006-2007)
INDICATORS
Operational Manual 97
IPEN-IMNCI Study Phase I (2006-2007)
institutional delivery in last one year. last one year.
Proportion of pregnant women delivering at
11 Number of pregnant women delivering at home in last one year. Total number of pregnant women in last one year.
home in last one year
Proportion of deliveries taking place in Number of deliveries taking place in government facilities in last Total number of pregnant women in last one year in a
12
government facilities in last one year one year in a given population same population
Proportion of deliveries taking place in Number of deliveries taking place in private facility in last one Total number of pregnant women in last one year in a
13
private facility in last one year year in a given population same population
Proportion of pregnant women aware of Number of pregnant women aware of Janani Suraksha Yojana in Total number of pregnant women in last two years in a
14
Janani Suraksha Yojana 2005-06 same population
Proportion of pregnant women availing any Number of pregnant women availing any facility under Janani Total number of pregnant women in last two years in a
15
facility under Janani Suraksha Yojana Suraksha Yojana in 2005-06 same population
Proportion of women died in last two years
Number of women died in last two years during pregnancy or Total no. of pregnancy women in the same population
16 during pregnancy or within 42 days/6 weeks
within 42 days/6 weeks after delivery in last one year
after delivery
Proportion of literate ever married women
17 Number of literate ever married women (15-49 yrs) Total number of ever married females (15-49 yrs)
(15-49 yrs)
Proportion of ever married (15-49 yrs) Number of ever married female (15-49 yrs) working f or a cash
18 Total number of ever married females (15-49 yrs)
female working f or a cash income income
Proportion of ever married female (15-49
Number of ever married female member of any SHG or Mahila
19 yrs) member of any SHG or Mahila Total number of ever married females (15-49 yrs)
Mandal
Mandal
Proportion of child under-5 years sick in last
Number of child under-5 years sick in last three months, required
20 three months, required hospitalization and Total number of under-five children
hospitalization and now recovered
now recovered
Proportion of mothers (primary caretakers)
Number of mothers (primary caretaker ) of under-five child going Total number of mothers (primary care taker ) in the
21 of under-five child going out to work for at
out to work for at least 6 hours a day in a given population that population
least 6 hours a day
PROXIMAL INDICATORS
Improved Care of Sick Child
Percentage of children aged 0-59 months
Number of children aged 0-59 months with cough taken to a
22 with cough taken to an appropriate health Total number of children aged 0-59 months with cough
health provider
provider
23 Percentage of children aged 0-59 months Number of children aged 0-59 months with fever taken to a Total number of children aged 0-59 months with fever
Operational Manual 98
IPEN-IMNCI Study Phase I (2006-2007)
with fever taken to an appropriate health health provider
provider
Percentage of children aged 0-59 months
Number of children aged 0-59 months with diarrhea taken to a Total number of children aged 0-59 months with
24 with diarrhea taken to an appropriate health
health provider diarrhea
provider
Number of children aged 0-59 months who were taken to any
Proportion of children aged 0-59 months who Total number of children aged 0-59 months whose
health facility during sickness but died subsequently
25 were taken to any health facility during verbal autopsy was conducted
sickness but died subsequently
Proportion of sick children aged 0-59 months Number of sick children aged 0-59 months who were taken to Total number of sick children aged 0-59 months
26 who were taken to any health facility during any health facility during sickness surveyed for household survey
sickness
Proportion of neonates aged 10 – 28 days Number of neonates aged 10 – 28 days who were taken to any
Total number of sick neonates aged 10-28 days who
27 who were taken to any health facility during health facility during sickness
were tracked for neonate
sickness
Proportion of sick children aged 0-59 months Number of sick children aged 0-59 months whose caretaker
Total number of sick children aged 0-59 months
28 whose caretaker practice ANY form of home practice ANY form of home based care during sickness
surveyed for household survey
based care during sickness
Proportion of sick children aged 0-59 months
Number of sick children aged 0-59 months whose caretaker
whose caretaker practice ANY form of home Total number of sick children aged 0-59 months whose
29 practice ANY form of home based care during sickness and who
based care during sickness and who died verbal autopsy was conducted
died subsequently
subsequently
Proportion of sick neonates aged 10-28 days Number of sick neonates aged 10-28 days whose caretaker
whose caretaker practice ANY form of home practice ANY form of home based care during sickness and who Total number of sick neonates aged 10-28 days who
30
based care during sickness and who died died subsequently were tracked for neonate
subsequently
Proportion of children aged 0-59 months who
died & whose caretaker knew at least 2 signs
Number of children aged 0-59 months who died & whose Total number of children aged 0-28 days whose verbal
31 for seeking care immediately (child not
caretaker knew at least 2 signs for seeking care immediately autopsy was conducted
able to drink/breastfeed, child becomes
sicker despite home care)
Operational Manual 99
IPEN-IMNCI Study Phase I (2006-2007)
Proportion of neonates (aged 10-28 days)
whose caretaker knew at least 2 signs for
Number of neonates (aged 10-28 days) whose caretaker knew at Total number of neonates aged 10-28 days who were
32 seeking care immediately (child not able to
least 2 signs for seeking care immediately tracked for neonate
drink/breastfeed, child becomes sicker
despite home care)
Improved Quality of Care of Sick Child
Proportion of sick children Checked for ALL
ten danger signs (0 to less than 2 months)
convulsions, fast breathing, severe chest Number of sick children 0 to less than 2 months
Number of sick children aged 0 to less than 2 months seen who
33 indrawing, nasal flaring, grunting, bulged observed for management
are checked for ALL ten general danger signs
fontanelle, 10 or more skin pustules, axillary
temp. >37.5 C, lethargic, movements less
than normal)
Proportion of sick children Checked for
Number of sick children aged 2 to 59 months seen who are Number of sick children 2 to 59 months observed for
34 ALL three general danger signs (2-59
checked for all three general danger signs management
months) [convulsions, vomiting, lethargy]
Proportion of sick children (aged 2-59
months) seen who were assessed for the
presence of cough (chest in-drawing, nasal
Number of sick children (aged 2-59 months) seen who were Number of sick children aged 2-59 months observed
35 flaring, grunting), diarrhea (loose motions,
assessed for the presence of cough, diarrhea and fever for management
blood in stools, pinching skin on the
abdomen) and fever (temperature by hand,
temperature by thermometer)
Proportion of sick children aged 2-59 months
Number of sick children aged 2-59 months seen who were
seen who were weighed and whose weights Number of sick children aged 2-59 months observed
36 weighed and whose weights were checked against a
were checked against a recommended for management
recommended growth chart
growth chart
Proportion of sick children whose mother/
caretaker was explained care practices
Number of sick children whose caretaker was explained care Number of sick children under-five years observed for
37 (home care, signs for when to return, follow-
practices. management
up, how and when to administer drugs and
exclusive breastfeeding)
38 Proportion of sick children whose mother/ Number of sick children whose caretakers are advised to give Number of sick children under-five years observed for
Operational Manual 100
IPEN-IMNCI Study Phase I (2006-2007)
caretakers are advised to give extra fluid extra fluid and continue feeding management
and continue feeding
Proportion of mother/ caretaker who were
Number of sick children under-five years observed for
39 explained care practices (IFA tablets, Number of mother/caretaker who were explained care practices
management
nutritional advice & child spacing)
Proportion of sick children aged 0 to less
than 2 months referred (explained ANY of
Number of sick children 0 to less than 2 months
40 the following: the site of referral, feeding Number of sick children aged 0 to less than 2 months referred
observed for management
during transport, keeping baby warm and
referral slip given)
Proportion of sick children (0 to less than 2 Number of sick children 0 to less than 2 months
months) referred after being explained Number of sick children (0 to less than 2 months) referred after observed for management
41 ALL of the following: the site of referral, being explained ALL of the following: the site of referral, feeding
feeding during transport, keeping baby warm during transport, keeping baby warm and referral slip given
and referral slip given
Proportion of sick children (2-59 months)
referred (explained ANY of the following: Number of sick children 2 to 59 months observed for
42 Number of sick children (2-59 months) referred
the site of referral, feeding during transport, management
keeping baby warm and referral slip given)
Proportion of sick children (2-59 months)
referred after being explained ALL of the Number of sick children (2-59 months) referred after being
Number of sick children 2 to 59 months observed for
43 following: the site of referral, feeding during explained ALL of the following: the site of referral, feeding
management
transport, keeping baby warm and referral during transport, keeping baby warm and referral slip given)
slip given)
Proportion of Prescribers who Supervise the Total number of Prescribers interviewed
44 Number of government doctors who supervise the field staff
field staff
Proportion of caretaker whose
understanding was assessed before leaving Number of caretaker whose understanding was assessed before Number of sick children under-five years observed for
45
the Health facility (for periodicity & quantity leaving the Health facility management
of drugs and when to return)
Proportion of prescribers who have been Number of prescribers who have been trained in ANY child care
46 Total number of Prescribers interviewed
trained in ANY child care program program
Proportion of prescribers who have been ever Number of Prescribers who have been ever trained in IMNCI
47 Total Number of Prescribers interviewed
trained in IMNCI program program
Team Cluster
no
1 2 3 4 5 6 7 8 9 10
Team Cluster no
1 Date started
Date completed
Team Cluster no
2 Date started
Date completed
Team Cluster no
3 Date started
Date completed
Team Cluster no
4 Date started
Date completed
Team Cluster no
5 Date started
Date completed
Team Cluster no
6 Date started
Date completed
Team Cluster no
7 Date started
Date completed
Team Cluster no
8 Date started
Date completed
Team Cluster no
Date started
Date completed
Team Cluster no
Date started
Date completed
State……………………. District………………………………..
Sl. Cluster Date Date Date Sl. Cluster Date Date Date Sl Cluster Date Date Date Sl Cluster Date Date Date
no no planned done handed no no planned done handed .no no planned done handed .no no planned done handed
over over over over
RC RC RC RC
1
2
3
4
5
6
7
8
9
10
Team 5 Team 6 Team 7 Team 8
Sl. Cluster Date Date Date Sl. Cluster Date Date Date Sl Cluster Date Date Date Sl. Cluster Date Date Date
no no planned done handed no no planned done handed .no no planned done handed no no planned done handed
over over over over
RC RC RC RC
1
2
3
4
5
6
7
8
9
10
Cluster Survey Start Date…………… Date completed……………….. Week no……… (Date: from………….to …………..)
02 22 42 62
03 23 43 63
04 24 44 64
05 25 45 65
06 26 46 66
07 27 47 67
08 28 48 68
09 29 49 69
10 30 50 70
11 31 51 71
12 32 52 72
13 33 53 73
14 34 54 74
15 35 55 75
16 36 56 76
17 37 57 77
18 38 58 78
19 39 59 79
20 40 60 80
Date of Visit:
From: …….../………./2007 To:………./…………/2007
Region:.................................................................... District:..........................................................
………………………… ……………………………………….
(Please give your perception about all team members who are involved in data collection individually)
1. Interview Techniques:
2. Quality of data:
a) Completeness
3. Transcription of data:
Signature …………………………
If the medical officer in-charge refuses or is reluctant to share information; record accordingly.
Total Remarks
Scrutinized
1. Household Screening
(at least 25 instruments )*
2. Household Survey
(at least 5 instruments)*
3. Generic Observations at Health Facility
4.Observation of Skill-
Prescriber/ ANM/ AWW
5. Observation of Skill-
ASHA/ Other Non-Conventional
Community Health Provider
6. Verbal Autopsy (Under-five Deaths)
8. Tracking of Events-
Morbidity- Sick Child (1- 59 Months)
9. Tracking of Events-
Neonate (10-28 Days)
* Representing data collected by different team members
(Please give your perception about all team members who are involved in data collection individually)
2. Quality of data:
a) Completeness
Signature ………………………………………………….
Network Dynamics
(Cluster Survey)
CCO
District workshop
And Quality check
Team Members
(Senior Investigator- 2, Once the cluster-level task is
Doctor- 2, Research completed by the team, send the filled
Operational Manual Assosicate-2) schedules to Regional Centers. 120
IPEN-IMNCI Study Phase I (2006-2007)
ANNEXURE 30
Integrated Management of Neonatal and Childhood Illness:
Baseline Assessment of Childhood Morbidity & Mortality in Selected Districts in India (IMNCI-IPEN Study 2006-2007)
Senior
Investigator 2
Doctor 1
Doctor 2
Research
Assistant 1
Research
Assistant 2
1. Please list all children (either MALE or FEMALE- whichever is applicable in your case) less than five
years of age living in the household in descending order (eldest to youngest).
2. Assign a serial number to each child
3. If there is ONLY ONE child of eligible age and sex in the household,
No need to refer the random number table, recruit the child for household survey.
4. If there is more than one child, use random number table (below) for selecting the index child.
5. Process of selecting the index child:
a. Refer to column according to “SEX” category and “Quadrant” allocated to you.
b. Refer to first number of the appropriate column of the random number table. If the first number in this
column is less than or equal to the total number of listed children in the household, select the child
with the corresponding serial number as “Index child”.
c. If this number exceeds the total number of children in a given household, move down to the next number
in the same column till you find the number less than or equal to the total number of children listed in
the household. Select the child with the corresponding serial number as “index child”.
d. As you move down the column for selecting the index child, keep striking out the numbers which were
used/ not used for selecting index child.
e. Continue the process to select “index child” from subsequent households till desired number of
households are completed.
= 8 Kanal
= 4 Rood
Karnataka 1 Acre = 40 Guntha Meghalaya 1 Acre= 43560 sq. feet
State District
code code Cluster Instrument
code code
Cluster Code:
Instrument Code