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A study on evaluation of health and nutrition day in urban slums of Berhampur, Odisha

In India, the rural areas have an organized three-tier health delivery structure. But in urban areas the health set up is ill-organized. As per Census 2011, population of India has crossed 121 crores with the urban population at 37.7 cores which is 31.16% of the total population, compared to 28.6 crore people as per Census 2001. 1 According to NFHS III (2005-06) data under 5 mortality rate (U5MR) among the urban poor at 72.7, is significantly higher than the urban average of 51.9, More than 46% of urban poor children are underweight. 2 Also the maternal health services utilization is poor in urban slums compared to the rural area, a recent study by Nimbalkar et al in Anand district in Gujarat supports this findings. 3

Despite the supposed proximity of the urban poor to urban health facilities their access to them is severely restricted. This is on account of their being "crowded out" because of the inadequacy of the urban public health delivery system. Ineffective outreach and weak referral system also limits the access of urban poor to health care services. The lack of economic resources inhibits/ restricts their access to the available private facilities. Further, the lack of standards and norms for the urban health delivery system when contrasted with the rural network makes the urban poor more vulnerable and worse off than their rural counterpart. 5 Keeping this in mind, the health of the urban poor (HUP) programme proposed to introduce urban health and nutrition day (UHND) in the urban areas on the lines of the VHND. 6 The National urban health mission (NUHM) framework highlights the need of convergence between ICDS and health where by MAS (Mahila Arogya Samiti)/urban ASHA in coordination with the Auxillary nurse midwife (ANM) would organize UHND in close coordination/collaboration with the Anganwadi worker (AWW). It is envisaged that UHND would serve as a common platform to deliver maternal, child health care, nutrition and WASH services to the urban poor population. It would help in delivering health care services at the door steps of the un-served and underserved urban population thereby leading to an improvement in the health status of the urban poor. 7 This study was formulated against this background with an objective to assess the availability of resources at the UHND under Berhampur Municipal corporation, to study the services provided and to determine the level of satisfaction by the beneficiaries of UHND.

METHODS
This was a cross sectional observational study carried out in urban slum of Berhampur from November 2016 to January 2017. Out of total 210 UHND sessions being conducted under Berhampur municipality, 10% of the session sites were randomly selected from the micro plan. Thus a total of 21 UHND sessions were observed for this study. The exit interviews from 4 beneficiaries from each session (10% of average of the daily attendance of UHND sessions) were done to assess client satisfaction. Also in-depth interviews of the service providers (all the ANMs) were taken for qualitative assessment of their experiences about the UHND sessions. Prior to the study, necessary permission was taken from the CDMO, Ganjam. A semi-structured checklist was prepared for data collection based on the guidelines for UHND in urban areas of Odisha. 7 Data were collected regarding the presence of service providers at the session site, availability of required equipments and supplies as well as the direct observation of service provision at the site. Each week UHND sessions are conducted on Tuesdays and Fridays. Hence the sessions were visited on Tuesday/Friday as per the convenience and done by single observer to avoid any possibility of observer bias. It was ensured that the data collection did not interfere with the on-going services. The staff members were briefed about the nature and purpose of the study and consent was taken from them before interview. Exit interview of the beneficiaries were conducted from each session with their informed consent. Regarding the quality of the services it was ranked as good depending on the perception of the beneficiary.
While collecting the information regarding availability of the essential items for providing the services, it was decided that if any item was not available in sufficient quantity as per the demand it would be considered as not available. Also item that was not functioning would also be considered as not available.
Data analysis was done in the department of Community medicine by using Microsoft Office excel for quantitative data and thematic approach for qualitative data.

RESULTS
The study includes findings from the observation of a total of 21 UHND sessions.
All sessions were held as per the microplan. Out of total sessions, 7 (33.3% ) of the sessions were not conducted in their own building and were conducted in the residence of the AWW or common meeting place of the community in the slum or verandas of local people. ANMs were present at all the sessions but Anganwadi workers were present only at 13 (61.9%) sessions. Anganwadi helpers and the urban ASHAs were present at 19 (90.5%) and 18 (85.7%) sessions respectively. In none of the session sites the supervisors from health and ICDS were present.   Figure 1). In all the visited sessions IFA tablet was available, but stock of calcium tablet was present in (85.7%) sessions and paracetamol in (90.5%) sessions. Chloroquin tablets were not supplied to any of the sessions. Oral contraceptives were available in 16 (76.2%) sessions (Table 1).

Figure 2: Observation of service delivery (n=21).
Regarding maternal services, registration of pregnant women and BP measurement was done at 90.5% of the sessions and weight of the pregnant women was measured at all sessions. The abdominal examination of the woman by abdominal palpation was not performed at any session site. Also no separate curtains or arrangements were available for ensuring privacy of women being examined at any of the session sites.
Weighing of children and plotting of weight on the card was done in 15 (71.4%) and 11 (52.4%) sessions respectively. Adolescent health education was not given at any session. Counseling on safe handling of drinking water was done in 7 (33.3%) sessions ( Figure 2). Exit interview of the clients revealed that 78.5% clients perceived the service provided to them at UHND sessions were of good quality. Waiting time was less than 30 minutes for 76% beneficiaries. Most of the clients were satisfied with the behavior of the staffs (82%) ( Table 2).  mobilisers like ASHA and MAS members. However AWWs were absent in many sessions. Before the session they prepare the beneficiary list and made sure that no one was left. Community leaders supported them. Few challenges faced by the service providers are shown in Table 3.

DISCUSSION
The UHND is a platform for the community people to access services for a package of preventive, promotive and basic curative care. Urban growth has led to rapid increase in number of urban poor population, thus putting greater strain on the urban infrastructure which is already overstretched.
Though AWC has been identified as a hub for service provision in UHND, in this study 66.7% of the sessions were conducted in the building of the AWC, but in rest it was conducted either in the residence of the AWW or common meeting place of the community in the slum or verandas of local people.
ANMs were present at all the sessions whereas AWWs were present only at 13 (62%) of sessions. But as per the norm, MAS/urban ASHA in coordination with the ANM would organize Urban Health and Nutrition day in close coordination/collaboration with the AWW. 7 Though AWW is one of the important health care provider who coordinates activities with the ASHA and the ANM, but was found to be absent in many sessions. 8 As per the plan for conducting UHND sessions, LHV, MO, CDPO, ICDS Supervisor are supposed to make supervisory visits to AWCs on UHND. 7 But it was observed that no supervisory visits were made during the study period.
A study by Mehta  Though privacy is essential to be maintained during health checkups, it was observed that bed with screen/curtain was not available at any sessions and abdomen checkup could not be done because of lack of privacy of women. So also urine examination kits, fetoscope, gloves were not provided to any sessions.
Saxena et al in their study on VHND services in the state of Uttarakhand also observed that blood pressure measuring instrument was available at 13 sites (54.17%), examination table at 3 sites (12.50%) and hemoglobinometer was available at 9 sites (37.50%) only. Adult weighing machine was not available at 10 sites and iron folic acid (IFA) large tablets were not available at 5 out of 23 sites. 11 In a study by Mehta et al in Vadodara city, Gujarat shows supply of MAMTA cards were available at most of the UHND sessions. Iron and folic acid (IFA) tablets and plain folic acid tablets was available only at 9 and 2 session sites respectively out of 17 sessions. 9 Regarding maternal service, registration of pregnant women, weight, BP measurement and provision IFA tablets were done at most of the sessions. In about 9% of the sessions registration of ANC was not done and for that the concerned health worker explained that due to proximity of the tertiary care centre and private practitioner in the locality many pregnant women did not come to the UHND session for ANC. Haemoglobin estimation done in 13 (61.9%) sessions only. The abdominal examination of the woman by abdominal palpation was not performed at any session site.
A study by Gandhi et al revealed that in majority of UHND sessions, pregnant women were weighed and weight was recorded. BP of pregnant women was measured properly and recorded in 65.57% of session sites. In 88.52% of session sites, abdominal palpation was not performed because of lack of privacy as separate rooms and curtains were unavailable. 12  Adolescent health education was not given at any observed sessions in this study and perhaps least focused by service providers. The reasons for non-attendance might be due to overlapping of school timings with UHND timings and lack of motivation & poor understanding about the services.
As per the guideline, WASH services like counseling on importance of safe drinking water, safe handling of drinking water, construction of individual sanitary latrine, usage of toilet facilities, hand washing, personal hygiene and household cleanliness is highly essential and need to be strengthened. 7 In this study counseling on safe handling of drinking water, on sanitation and hygiene were done in 33.3%, 57% and 62% sessions respectively.
As perceived by the beneficiaries, 76% opined that the waiting time of the service was less than 30 minutes, 82% clients were satisfied with the behaviour of the staffs and 78.5% perceived that they received good quality of service on the day of visit. Despite lack of adequate logistics at the sessions, the perceived quality of services by the beneficiaries was good. It might be due to the availability of outreach heath care services close to their dwelling place.
A recent study conducted in a block of Dibrugarh district of Assam on VHND concluded that satisfaction level with the quality and behavior of service provider was very good from the community perspective as evident from exit interview finding. 16 In a study by Saxena et al, exit interview of clients revealed that 64% clients took less than 15 min time to reach at VHND site and 60% clients waited less than 30 min to avail the services. Almost one third of clients rated the services "fair" (score -3) and good (score-4) on the scale of one to five of ascending satisfaction level. 11 In depth interview of the service providers (ANMs) revealed that though they were getting support of the Anganwadi helpers, social mobilisers like ASHA and MAS members as well as community leaders but few challenges were faced by them like lack of regular supervision, irregular supply of equipments and lack of sitting facility for the beneficiaries. In some sessions, there was no suitable place to conduct the sessions for which they manage it by conducting on verandas and houses of the local people.

CONCLUSION
This study shows that UHND sessions provided services to pregnant women and children regularly as per the plan and beneficiaries were satisfied with the services. But few challenges like lack of waiting facilities for beneficiaries, inadequate logistics and lack of supervision were identified. In addition no care was given to the adolescents. Hence strengthening of the infrastructure and regular supportive supervision is recommended to ensure provision of quality services in the sessions.