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B : Programme Development
 
096
A STUDY OF SOME OPERATIONAL ASPECTS OF TREATMENT CARDS IN A DISTRICT TUBERCULOSIS PROGRAMME
MA Seetha, GE Rupert Samuel & VB Naidu: Indian J TB 1976, 23, 90-97.

The paper presents some aspects of domiciliary management of tuberculosis patients in a District Tuberculosis Programme (DTP) viz., the interval between diagnosis and initiation of treatment, regularity in collection of drugs, role of motivation of patients for collection of drugs and pattern of defaulter retrieval actions by health institutions. The treatment cards of 3089 patients of pulmonary tuberculosis belonging to Bangalore DTP diagnosed during 1964 were analysed. The cohort of 2479 patients was divided into 3 groups according to the place of treatment, viz., (i) those treated at District Tuberculosis Centre (DTC) where better trained staff motivated tuberculosis patients & took defaulter actions (ii) the Urban Peripheral Health Institutions (UPHIs) where motivation and defaulter actions were taken by specialised staff and (iii) rural PHIs where non- specialised general health workers along with general duties did motivation and took defaulter actions.

The study has shown that in the entire district about 94% of patients were put on treatment within 10 days of diagnosis. In rural PHIs, among 14.5% of patients the treatment was started after 10 days of diagnosis. For the 149 initial defaulter patients, actions were taken only for 39% of the patients, lowest being in rural PHIs (10.8%). The defaulter actions for 69% were taken in time, more promptly by DTC staff for DTC & UPHI i.e. 71.5%, whereas rural PHIs were poor in this respect and only 37.5% of the actions were taken on time. Sputum positive cases collected drugs more often than sputum negative and also more patients collected drugs on due dates at DTC in comparison with PHIs. Both the differences were statistically significant.

About one third of the lost patients came from those who made the first default. About 55-63% and 75-82% of this group defaulted by the second and third collections respectively. Defaulter actions were not taken by rural PHIs for 66.7 to 72.5% defaults, while DTC staff had not taken defaulter action for about 20% of defaulters and 67.8% of such actions were prompt in DTC, whereas it was only 19.3% in rural PHIs.

KEY WORDS: COHORT ANALYSIS, COMPLIANCE, CONTROL PROGRAMME, OPERATIONAL FACTORS.

099
ACCEPTABILITY OF BCG VACCINATION AMONG RURAL COMMUNITY
MA Seetha, N Srikantaramu & Hardan Singh: Indian J Prev & Soc Med 1980, 2, 57-63.

A study on acceptability of BCG vaccination, through specialised technicians in a population of 8350 residing in 8 villages of Channapatna taluk of Bangalore district, was carried out by National Tuberculosis Institute. Of the 1106 households satisfactorily interviewed, 956 (86.4%) had at least one child eligible for vaccination. For the purpose of analysis they were classified into three groups. Group I consisted of 312 (32.6%) households in which all children were vaccinated, Group II 270 (28.2%) where non-e of the children were vaccinated and Group III 374 (39.2%) households where only some of their children were vaccinated. Overall vaccination coverage was 52.7% with a range of 33.9% to 79.3%.

The reasons for refusing vaccination were studied. The caste, occupation, education etc., of the household did not have any influence on the refusals. When analysed according to the knowledge and opinion about vaccination it was observed that 55.9% of the children were not vaccinated because of the lack of knowledge in the group where no child was vaccinated. Even when 42% had favourable opinion about vaccination, 52% of the households did not vaccinate any of their children. The refusals were mainly due to (i) absence from the village on the day of vaccination, (ii) fear of prick. Among households where there was unfavourable opinion, all had refused due to fear. The reasons for accepting BCG vaccination were (i) the vaccination was done in the school and hence there was no option for the parents to accept or refuse, (ii) parents felt that the vaccination was good for children, (iii) parents knew that it would prevent TB.

KEY WORDS: BCG VACCINATION, ACCEPTABILITY, RURAL COMMUNITY.

099
ACCEPTABILITY OF BCG VACCINATION AMONG RURAL COMMUNITY
MA Seetha, N Srikantaramu & Hardan Singh: Indian J Prev & Soc Med 1980, 2, 57-63.

A study on acceptability of BCG vaccination, through specialised technicians in a population of 8350 residing in 8 villages of Channapatna taluk of Bangalore district, was carried out by National Tuberculosis Institute. Of the 1106 households satisfactorily interviewed, 956 (86.4%) had at least one child eligible for vaccination. For the purpose of analysis they were classified into three groups. Group I consisted of 312 (32.6%) households in which all children were vaccinated, Group II 270 (28.2%) where non-e of the children were vaccinated and Group III 374 (39.2%) households where only some of their children were vaccinated. Overall vaccination coverage was 52.7% with a range of 33.9% to 79.3%.

The reasons for refusing vaccination were studied. The caste, occupation, education etc., of the household did not have any influence on the refusals. When analysed according to the knowledge and opinion about vaccination it was observed that 55.9% of the children were not vaccinated because of the lack of knowledge in the group where no child was vaccinated. Even when 42% had favourable opinion about vaccination, 52% of the households did not vaccinate any of their children. The refusals were mainly due to (i) absence from the village on the day of vaccination, (ii) fear of prick. Among households where there was unfavourable opinion, all had refused due to fear. The reasons for accepting BCG vaccination were (i) the vaccination was done in the school and hence there was no option for the parents to accept or refuse, (ii) parents felt that the vaccination was good for children, (iii) parents knew that it would prevent TB.

KEY WORDS: BCG VACCINATION, ACCEPTABILITY, RURAL COMMUNITY.

101
INFLUENCE OF MOTIVATION OF PATIENTS AND THEIR FAMILY MEMBERS ON THE DRUG COLLECTION BY PATIENTS
MA Seetha, N Srikantaramu, KS Aneja & Hardan Singh: Indian J TB 1981, 28, 182-90.

A controlled study was conducted at Lady Willingdon Tuberculosis Demonstration and Training Centre (LWTDTC), Bangalore among 250 patients randomly selected urban patients of pulmonary tuberculosis of whom 155 were in the 'motivation' group and 95 were in the 'control' group. In the motivation group, patients were interviewed by National Tuberculosis Institute health visitor and motivated by LWC staff; a month of drugs (TH) were given. Within 3 days of initiation of treatment they were motivated along with their household members during home visit by NTI staff every month for a period of three months. Control group patients were motivated at the clinic as per the programme guidelines.

In the motivation group, 59.9% of patients had made all the three collections during the first three months compared to 27.8% in the 'control' group. During the remaining months also the drug collection was 47% and 35.6% respectively. The drug collection pattern among the patients in the motivation group was found to be better than among the patients in control group who did not have the benefit of home visiting. Sputum conversion was also found accordingly better among the motivation group as compared to control group.

KEY WORDS: COMPLIANCE, FAMILY MOTIVATION, CONTROL PROGRAMME, TREATMENT COMPLETION.

106
ACTIVE CASE-FINDING IN TUBERCULOSIS AS A COMPONENT OF PRIMARY HEALTH CARE
KS Aneja, P Chandrasekhar, MA Seetha, VC Shanmuganandan & GE Rupert Samuel: Indian J TB 1984, 31, 65-73.

Feasibility of introducing limited active case-finding in tuberculosis involving Multi-purpose Health Workers (HWs) to supplement the existing methodology of detecting the cases through chest symptomatics attending Peripheral Health Institutions (PHIs) on their own, was studied earlier with encouraging results. The present study was undertaken to understand the existing working system of HWs and within that the priority areas of input which may lead to better case yield.

The study revealed that the population available at any beat schedule of HWs was about 42% of the eligible population of age 20 years and above. Only 60-75% of the field days were utilized for routine multi-purpose duties. Of the total area, 25% to 40% remained uncovered. The effective tuberculosis work was done only on 5% of the beat schedule days and the work was not uniformly spread throughout the month. Even so, the contribution by HWs was twice the number of cases diagnosed at PHIs under study in one year. Had the HWs covered the entire area of their beat schedule, 80 against 26 cases would have been diagnosed. Moreover, there is possibility of detecting more cases among the elderly patients who normally do not attend their area health centres. However, the success depends upon meticulous supervision and regular flow of supplies.

KEY WORDS: HEALTH WORKER, PRIMARY HEALTH CARE, CONTROL PROGRAMME, CASE-FINDING, RURAL COMMUNITY.

112
IMPROVEMENT IN CASE-FINDING IN DISTRICT TUBERCULOSIS PROGRAMME BY EXAMINING ADDITIONAL SPUTUM SPECIMENS
MA Seetha GE Rupert Samuel & N Parimala: Indian J TB 1990, 37, 139-44.

A study was conducted to augment Case-finding in the programme by increasing case yield through repeated sputum examinations by collecting 2-3 samples on the same day. The study was conducted in nine Peripheral Health Institutions (PHIs) of Bangalore district. They were all Microscopy Centres and were drawn on the basis of random allocation. A Health Visitor (HV), Laboratory Technician and Laboratory Attendants of National TB Institute (NTI) were posted at the PHIs during the entire study period. After collection of first sputum sample from the eligible chest symptomatics, 2nd, 3rd or 4th samples were collected at an interval of half an hour from those whose first specimen was negative. Separate smears were prepared from all the specimens for examination at NTI. The duration of the study was nine months.

From among 4233 total new outpatients, 458 chest symptomatics were identified. Of them, 451 gave the first specimen, 416 the second specimen and 379 and 332 the 3rd and 4th specimen respectively. There were a total of 25 smear positive cases; 18 were detected by the first specimen, 3 were added by second and the remaining 4 by the 4th specimen. Of the 451 chest symptomatics, 185 were selected by the PHI Medical Officers (MOs) and 266 were picked up by the NTI HVs from the remaining outpatients. Of the 25 cases detected, 10 came from the chest symptomatics selected by the MOs and 15 came from those selected by the NTI HV. The study has shown the feasibility of collecting multiple specimens of sputum from each symptomatic on the same day. A loss of 60% cases was due to casual symptom questioning by the MOs. It was further observed that the intensity of the physical suffering has influenced the behaviour of patients towards action taking. The sputum positivity rate was 5.5%

KEY WORDS: CASE-FINDING, CONTROL PROGRAMME, SPUTUM EXAMINATION.

 

 
  MISCELLANY  
 
B : Health Education
 
179
EDUCATIONAL & TRAINING REQUIREMENTS OF HEALTH CARE DELIVERY SYSTEM
SS Nair, MA Seetha & BC Arora: NIHAE Bulletin 1976, 9, 295-307.

The Health Care Delivery System (HCDS) consists of the governmental (public) and non-governmental (private) health agencies and the facilities they provide for one or more of the three main aspects of comprehensive health care viz., curative, preventive and promotive. The delivery of comprehensive health care in a country like India poses many problems. An adequate network of organisation, particularly governmental, has to be built up. This has to be primarily directed towards delivery of health care in the rural areas with considerable emphasis on preventive and promotive health. Such an organisational set up has to be manned by a large army of personnel with varying types and levels of basic professional education. At present both the know how for practical application of professional knowledge under varying conditions and proper attitude for the same are often inadequate among the health personnel. These can be improved and maintained only on the basis of a long term plan for job training. Permanent facilities should be available so that training of new recruits and staff on promotion/transfer can be taken care of regularly and systematically. Also, refresher courses have to be undertaken regularly to keep the staff abreast of the developments in delivery of health care. At present juncture, Multi Purpose Worker (MPW), community level workers and health assistants in the public sector of HCDS, also require the training.

To make such training more purposeful, it must be emphasised that planning for training has to come well ahead so that implementation of any programme is not unduly delayed due to absence or shortage of properly trained health workers. To illustrate this, the training requirements of the National Tuberculosis Programme (NTP) which is integrated with general health services have been dealt below: Governmental Agency: i)Programme workers who attend patients and community should be trained by the District TB Centre (DTC) key personnel as in service training or on the job training, ii)Programme supporter PHC doctors in addition to being programme workers, DHO, ADHO, ADHS (TB) etc should undergo orientation course for 8 to 9 working days. iii)Trainer Professors and lecturers of preventive & social medicine, tuberculosis and medicine of medical colleges, trainers of central training institute also undergo orientation course for 8-9 days. iv)Research Worker in research methodology for 4 weeks. v)Programme planners & Decision Makers a)Ministers of Health, Secretaries & Directors of Health both at state and central-levels By periodic meetings, personal discussions, participation in Central Council of Health meetings. b)TB Adviser, TB-Officer By periodic meetings, written communication, attending seminars. Similar estimates have to be made for other components of HCDS. Taking all these into consideration, the number of training institutions/facilities which are required to meet all the training needs can be worked out, keeping in view their proper regional or geographic distribution. The next step would be to organise the education and training of private health workers and health consumers. Adequate information for the detailed planning is not available for these two categories. But, a beginning has to be made as quickly as possible.

KEY WORDS: EDUCATION & TRAINING, HEALTH CARE DELIVERY, CONTROL PROGRAMME.

181
HEALTH EDUCATION IN NATIONAL HEALTH PROGRAMMES
MA Seetha & GD Gothi: NTI Newsletter 1977, 14, 41-45.

This paper critically describes the place of Health Education in National Health Programmes. Health Education is one of the recognised ways of health promotion in the primary prevention of diseases in the community. Probably it may be required even at secondary and tertiary prevention levels. This implies that health education has to be directed towards the community for accepting the health services provided and participate in all activities which promote their own health. Health education is part of any health programme and its component and implementation depend on the nature and organisation of the health programme itself. Integrated programmes are more acceptable to the community and economically feasible. Health education of the community under the integrated health services has to have new dynamics and priority over the conventional approach hitherto adopted in vertical programmes. Health education in all national health programmes has to be made into a comprehensive one, rather than planning individually for each programme. Community health education should go along with the "health education" of the health workers. The efforts to do former alone without improving the latter, has not been able to give good dividends.

KEY WORDS: HEALTH EDUCATION, NATIONAL HEALTH PROGRAMMES.

182
EFFECT OF SHORT TERM INTENSIVE HEALTH EDUCATION ON CASE-FINDING IN A RURAL COMMUNITY
MA Seetha, Rajani Gandha Dei & N Srikantaramu: NTI Newsletter 1979, 16, 1-7.

As a part of the supervised field training of the students of health education from Rural Health Training Centre, Gandhigram, Tamil Nadu, a pilot project of short term intensive health education was undertaken at 11 selected villages under Primary Health Centre (PHC), Hesarghatta. The objectives were to measure the impact of an intensive health education effort in increasing the attendance of patients with symptoms suggestive of pulmonary tuberculosis at a PHC and to study the impact of health education in terms of increase in knowledge and change of attitude of the people towards the PHC. For participation of the community all the three health education approaches viz., individual approach, group approach and mass approach were planned along with audio visual aids as and when required. Application of a specific approach depended on the level of awareness about tuberculosis and the availability of services which was measured by a base line survey conducted in the selected villages.

As expected this short term intensive health education has shown that the knowledge on tuberculosis in the population increased, following it. When it was measured by the yardstick of increase in the proportion of out patients with chest symptoms, attending the PHC, no significant change was noticed during the period of observation. The likely reason could be that it was too early to measure the effect of health education within a period of 6 weeks. In this project the intensive health education work was done almost continuously for a short time which was probably not appreciated by the people. Though in all the villages following the health education programme, the people had understood the importance of getting the chest symptoms examined to rule out tuberculosis, they have not approached the PHC for the same. The other possible reason could be that the people are not satisfied with the services provided by the PHC. It goes without saying that when the services provided by the PHC itself are not upto the expectation of the people, the outcome of health education could only be

minimal.KEY WORDS: HEALTH EDUCATION, RURAL POPULATION, CASE-FINDING.

183
SOME CONCEPTS IN CURRICULUM FORMULATION IN JOB ORIENTED TRAINING
MA Seetha: NTI Newsletter 1979, 17, 53-59.

Some important aspects for consideration at the time of formulating the curriculum of orientation training programme for tuberculosis have been discussed in this paper. At the time of formulation of District Tuberculosis Programme, planning for training of manpower was taken simultaneously. The essentials of job orientation training are to change with the change in the requirements of the programme. Defining Objectives in clear terms is one of the important aspects to be considered while formulating the curriculum. This helps in preparing the contents, methods of teaching and developing effective assessment. Profile of Trainees is another important aspect. Factors which have to be considered at the time of formulation of curriculum are age, educational qualifications and professional experience of the trainees. Changes occurring in the general health services, introduction of multi purpose workers scheme and participation of community health workers in the health services, would require a thorough revision of the training organisations and contents of training.

KEY WORDS: CURRICULUM FORMULATION, JOB TRAINING, DTP.
 
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