Department of Medical Research (Pyin Oo Lwin Branch)
Knowledge, attitude, practices and coverage of maternal, newborn and child health care at selected townships in southern Chin State
Dr. Kyaw Oo
Dr. Thida
Dr. Yadana Aung
Dr. Kyaw Thu Soe
Dr. Nyein Nyein Thaung
Department of medical Research (Pyin Oo Lwin Branch)
International Rescue Committee
February 2016
Contents
List of Tables
List of Figures
BACKGROUND OF THE PROJECT
Introduction
Rationale
Conceptual model
Behavioural Change Communication (BCC)
Objectives
Preparation for field activities
Ethical consideration
Data collection
Part I: Baseline Knowledge, Attitude and Practices about Maternal, Newborn and Child Health in Paletwa Township
1.Background
2.Objective
3.Methodology
4.Results
4.1.Personal and household characteristics
4.2.Antenatal Care
4.3.Complications of Pregnancy
4.4.Birth Preparedness
4.5.Intra-partum Care
4.6.Newborn Care
4.7.Postpartum Care
4.8.Contraceptive knowledge, perception and practices
4.9.Immunization
4.10.Nutrition supplements
4.11.Child health care practices during illnesses
4.12.Sanitation
4.13.Awareness of CHW/AMW or Mother Support Group (MSG) in village
4.14.Awareness of the village referral fund mechanism
4.15.Awareness of Roles and responsibilities of Villages Health Committee (VHC) or Village Health Committee (VHD)
5.Summary of findings
6.Discussion
Part II: Qualitative Behavioural Change on Maternal, Newborn and Child Health in Paletwa Township
1.Background
2.Objectives:
3.Methodology
4.Findings
4.1.Current practices
4.2.Knowledge of abnormal pregnancy, newborn care, and source of information;
4.3.Responses to abnormality and emergency
4.4.Referral
4.5.Availability of services at RHC/ sub‐RHC
4.6.Service Availability, Utilization, Quality
4.7.Quality of services in hospitals
4.8.Key Informant Interview with MNCH care provider (TTBA/AMW/MW/LHV/HA)
5. Discussion
6.Recommendation:
Part III: Baseline Knowledge, Practices and Coverage about Maternal, Newborn and Child Health in Kanpetlet Township
1.Background
2.Objectives
3.Methodology
4.Results
4.1.Background characteristics
4.2.Community awareness on sustainable community network
4.3.Disease Morbidity – Child Health
4.4.Micronutrient Supplementation & Immunization coverage
4.5.Nutrition Practices
4.6.Maternal health knowledge & practices
4.7.Health care seeking behavior for sick child
4.8.Environmental Health
5.SUMMARY OF RESULTS
6.Discussion
Part IV: Behavioural Assessment on Maternal, Newborn and Child Health in Kanpetlet Township
1.Background
2.Objectives
2.1.General objective
2.2.Specific objectives
3.Methodology
3.1.Data collection method
3.2.Data entry and analysis
4.Finding
4.1.Characteristics of respondents
4.2. Baseline knowledge on MNCH care and source of information
4.3. Knowledge on complications and emergencies of MNCH care
4.4. Information sources of MNCH complications
4.5. Current practice of MNCH care
4.6. Knowledge, practice and coverage of EPI
4.7. Responses to obstetric and newborn abnormalities
4.8.Referral practice for complications and emergencies of MNCH care
4.9.Service availability, utilization and perceived quality of services
4.10.Services from RHC/Sub-RHC: availability, utilization and perceived quality
4.11.Perceived basic needs for improvement of MNCH service utilization
4.12.Suggested interventions for improvement of MNCH in Kanpetlet Township
5.Discussion
6.Recommendations
CONCLUSION
List of Tables
Title / PageTable 1.1: Distribution of respondents according to geographical accessibilities / 11
Table 1.2: Age group distribution of the respondents according to geographical accessibilities / 11
Table 1.3: ANC services received by clients / 13
Table 1.4: ANC providers in different communities / 14
Table 1.5: ANC visits (at least 4 visits) / 14
Table 1.6: Planned Birth Attendant (last pregnancy) according to different areas / 15
Table 1.7: Reasons for not going to SBA according to different areas (N=81) / 16
Table 1.8: Immunization received by clients / 20
Table 1.9: Did you know CHW/AMW or Mother Support Group (MSG) in her village? / 21
Table 1.10: Is there any system for fund support for referral for a sick person/child to a health facility? / 21
Table 3.1: Background characteristics of respondent mothers / 37
Table 3.2: Micronutrient supplementation & Immunization coverage / 39
Table 3.3: Nutrition Practices of mothers to their child / 40
Table 3.4. Reasons for not using SBA at the last delivery / 42
Table 3.5: Knowledge on each type of birth spacing methods / 42
Table 3.6: Mothers sources of birth spacing / 43
Table 3.7: Types of best choice of birth spacing / 44
Table 3.8: Maternal Health Knowledge and Practices / 45
Table 3.9: Mothers health care behavior for their sick child / 46
List of Figures
Title / PageFigure 1.1: Source of information for AN / 12
Figure 1.2: ANC provider for the last pregnancy / 12
Figure 1.3: Planned birth attendant for the last pregnancy / 15
Figure 1.4: Reasons for not going to SBA / 16
Figure 1.5: Known required general care for newborn / 17
Figure 1.6: Meet the need of PNC / 18
Figure 1.7: Contraceptive method knowledge, attitude and practices / 19
Figure 3.1 Distribution of respondents by geographical location / 38
Figure 3.2: Get knowledge on CHW/AMW/MSG / 38
Figure 3.3: Source of knowledge / 38
Figure 3.4: Disease morbidity among children under 2 years / 39
Figure 3.5: Types of food amount when their child was ill / 40
Figure 3.6: AN care provider and geographical location / 41
Figure 3.7: Percentage of mothers delivered by different birth attendants / 41
Figure 3.8. Mothers’ knowledge and practice of contraceptive / 42
Figure 3.9: Type of birth spacing using / 43
Figure 3.10: Reasons for not using a contraceptives in different location / 44
Figure 3.11: PN care provider and geographical location / 45
Figure 3.12 : Environmental Health / 46
BACKGROUND OF THE PROJECT
Introduction
Maternal, newborn and child health (MNCH) is the largestcomponent of 3MDG’s (3 Millennium Development Goals) activities, covering maternal andnewborn health, child health, immunization, nutritionand health promotion. When the Fund was established in2012, the focus of this investment was to support townshiphealth planning and service delivery in order to scale-upand strengthen access to health services.The design of the Fund is underpinned by a strategy todeliver an essential package of MNCH (Maternal, Newborn and Child Health) services througha continuum of care approach. Working through and inpartnership with the Ministry of Health as well as stateand region health departments, 3MDG is supporting thework of basic health staff (BHS). Alongside support to strengthen facility-based healthcareservices, the Fund is providing significant financing forcommunity-based work as well as quality service provisionthrough the private sector. Economic modelling and earlydesign work undertaken by the Fund clearly demonstratedthat support to all these aspects of the health sector iscritical if the 3MDG is to reach targets set for lives saved.In areas where this approach to MNCH is supported, theFund therefore provides financing support to the publicsector, to international and local non-governmentalorganizations and to health care providers that use asocial franchising approach.
IRC has design a maternal and child health program to tackle the MCH care needs of communities in partnership with Ministry of Health –Township Health Department and LNGO (Local NGO) under 3 MDGs MCH Fund. The program will support for strengthening of community health care network and Maternal and Child Health care services of MoH through community participation. In Chin State, awareness raising sessions to sensitize the community on the benefits of safeguarding dedicated resource for MNCH cases are carried out in selected townships for a couple of years. CHWs and AMWs are the foremost responsible decision-makers for identifying the need for an emergency referral, with the exception of villages where there is a health facility in which case responsibility will belong to BHS.
The majority of cases will require financial support. During the effort, supervision visits to each village/tract, BHS and programme staff monitor and provide guidance and capacity building to VHCs (Village Health Committee) in order to ensure effectiveness and appropriateness of use of resources. The main reason preventing success is lack of capacity to identify need in time and prohibitive costs due to the remote locations.
The Strengthening Local Capacities to Improve MNCH was launched in 2010 across 100 villages in Paletwa Township, Southern Chin State. The project trained community health workers (CHW), auxiliary midwives (AMW), and VHC to implement community health prevention and behaviour change communication (BCC) activities in collaboration with BHS. More mothers in targeted villages are able to identify warning signs of child disease and as a result seek more timely care for their children from trained health care providers (mainly CHW). Eighty nine percent of mothers seek care for their sick children from trained health care providers within 1.5 days of observing a warning sign of poor health. More mothers properly fed their sick children, but proper nutritional practices are still relatively uncommon and need continued health education efforts. Knowledge among mothers of danger signs of diarrhoea and pneumonia in children was improved. More than half of mothers correctly described preparation of oral rehydration salts (ORS) solution and 63% reported that they used ORS or homemade ORS to treat their child with diarrhoea. Use of ORS as treatment for children with diarrhoea is higher than baseline. Women’s behaviour concerning pregnancy and child care is strongly influenced by cultural and religious beliefs, which are inherently difficult to transform within a short period of time and require longer durations of programming. Strong geographic, cultural and social constraints, in addition to the scarcity of health care service providers in Paletwa, illuminate the importance of developing a “close to client health care system” and “community based health care network”.[1]
The BCC strategy have to be used to plan and implement advocacy, communication and social mobilization activities in order to increase knowledge and utilization of health services for improved health outcomes of the target population (reduction in child and maternal mortality in the target population). A MW and supportive staff will conduct individual support supervision visits to each village, focusing on improving service delivery of community case management, rational use of drugs, early detection and timely referral of MCH cases, health education, community mobilization for health promotion, reporting, recording, and diseases surveillance. CHWs/AMWs will have the chance to participate in MW outreach and health education actions as part of hands-on training but also to provide opportunities for strengthening the working relationship and linkages between CHWs, AMWs, VHCs and MWs, and health facilities. In addition to individual visits, supportive staff and BHS will conduct cluster visits, during which one village hosts supportive staff, MW, and CHW/AMWs from nearby villages. This approach greatly increases the monitoring coverage of CHW/AMW in remote areas like Chin State, and cluster visits enable exchange, peer learning, sharing of best practice/positive deviance cases, and strengthens the overall networking of the township health system. Also during these visits, MWs could identify CHW/AMWs who require more intensive individual support so that appropriate follow-up in subsequent months can take place.
It is very difficult for villages to get supports beyond the life of the programme. BHS and IRC programme staff carried out continuous support activities for CHW/AMWs, which foster sustainable capacity and improve the quality of services. A team consisting of the respective midwife and programme staff conduct joint support supervision that combines a debriefing meeting at each sub-rural health centre (SRHC); individual monitoring visits; and cluster-monitoring visits.
Rationale
After a period, the KAP about MNCH is necessary to evaluate again at the targeted township. It’s necessary to get qualitative behavior change status at the same township because of need to learn lessons from the previous implementations. Regular review of community beliefs, power structures and barriers to behaviour change will be useful in order to adapt activities so that they address deeply rooted cultural norms. The findings will reflect the change and differences in the target population.
To generate information that to be used to develop a BCC strategy and communication, knowledge, attitude and behavior including existing utilization and coverage of care on maternal and children health is essential for improvement of community and providers’ practices of MNCH.Exact information are also necessary to adapt the MNCH project design and strategies of MNCH intervention according to the results and findings of this study and to develop MNCH related IEC materials reflecting findings on needs in unhealthy behaviors. To adapt the project design and strategies of MNCH intervention according to the results and findings of this studywill be used for further intention of sustained action with proper MNCH system in the programmetownships. These will be adapted the 3MDG Program design, strategies and methodology of MNCH intervention.
Conceptual model
Behavioural Change Communication (BCC)
BCC is an effective tool for dealing many community and group related problems. BCC has been adapted as an effective strategy for Community Mobilization, health and environment education and various public outreach programs[2]. Enhanced knowledge about the behavior change process has facilitated the design of communications programs to reduce the risk. A wide variety of health promotion strategies use communication as either an educational or norm-forming strategy. In addition, specific strategies must be designed for high-risk groups such as women.Behavior change communication (BCC) is an interactive process of any intervention with individuals, communities and/or societies (as integrated with an overall program) to develop communication strategies to promote positive behaviors which are appropriate to their settings. This in turn provides a supportive environment which will enable people to initiate, sustain and maintain positive and desirable behavior outcomes.[3]BCC is the strategic use of communication to promote positive health outcomes,
Objectives
To explorestrength, weakness, opportunity and threats on MNCH care system in Paletwa Township.
To measure baseline status of the key MNCH knowledge and practices and the coverage of selected MNCH intervention in Kanpetlet Township
Preparation for field activities
Prior permission from MOH was received at second week of December 2015.Technical discussion with Director (MRH) was made for further coordination of DOPH.Two data collection teams were form with DMR (POLB) staff. Two experienced researchers lead each team. Six interviewers in each team were recruited and trained for interviews.Three days training including pretesting of questionnaire were carried out.Questionnaires were revised accordingly to pretest experiences.During preparing the teams, official communication with local authorities (State Public Health Director, Township Health Departments) were made for permission, sampling and local travel authorization to health facilities.
Activities / Dec 2015 / Jan 2016 / Feb 2016Ethical clearance
Permission to proceed field visits
Interviewer training and pretest
Preparation of questionnaire and materials
Field data collection
Data entry
Data analysis
Draft Report
Ethical consideration
Health staff,community key informants and women were clearly informed the objective, confidentiality and expected benefit of the study not to reluctant to express their existing situation and practices not using local health staff and denial to referral and use of untrained birth attendants. Confidentiality and protection from risk for individual respondents were also guaranteed them before interview. Informed consent was taken prior to interview. They had autonomy, anonymity and right to withdrawal from participation before or during interview.The interview was about 40 minutes. All procedures followed the guidelines for research ethics regarding human participants. The proposal was submitted to Department of Medical Research Ethics Review Committee and Ethical Clearance has been approved at 28-12-2015.
Data collection
Data collection activities were carried out from 22 Jan to 21 Feb of 2016. Quantitative and qualitative portions were arranged appropriately with local situation, timeline, transportation and availability of respondents, local health staff and translators. Data checking, coding, transcript writing, thematic coding were done during the days of field activities. Project timeline was shown in the table below.
Data entry and analysis
Quantitative data entry was done in Epi Data software 3.01. Analysis was used SPSS 20. Descriptive statistics were used to summarized background characteristics, and main variables. Frequency tables for main indicators of conceptual variables and cross-tabulation for those indicators with background characteristicswere made. The statistical significance was determined if p value of the test is less than 0.05 (allowed type 1 error).
For qualitative information, narrative record were transcribed into text and typed into word file in computer. Atlas Ti software was used at analyze text data. Content analysis was made. Various types of practices were explored.
Part I:Baseline Knowledge, Attitude and Practices about Maternal, Newborn and Child Health in Paletwa Township
(Kyaw Thu Soe, Kyaw Oo, Yadanar Aung)
1.Background
IRC has worked with local NGOs such as Karuna Myanmar Social Service (KMSS)[4]and Myanmar Christian Council (MCC)[5] in Paletwa Township, Chin state in last 6 years and has done baseline and midterm KPC surveys on Reproductive Health interventions. In Paletwa a pilot programme was launched for effective referral support systems. However, sustainability needs community contributions and interest gained from that is used to replenish the resources.It’s necessary to conduct baseline KAP survey about MNCH at the township because of evaluating the previous MCH project implementations and also taken as baseline for the present MNCH funded by 3 MDG. The objectiveof this part is to describe the knowledge, perception, attitudes and practice of MNCH care in Paletwa Township and to generate information that to be used to develop a BCC strategy and communication messages on maternal and children health. Based on the findings, the BCC strategy wiould be used to plan and implement advocacy, communication and social mobilization activities in order to increase knowledge and utilization of health services for improved health outcomes of the target population (reduction in child and maternal mortality in the target population).