Experience with Under Fives' Clinic in Malavani, a slum area near Bombay.
3 models of Under Fives Clinics were tried successively at the Malavani Health Center beginning in 1978. Malavani is a village with a population of abourt 70,000 near the city of Bombay (India). In each model mothers were given a Road to Health Card for each child. Model I was a center-based model. The venue was the same center where outpatient departments were located for the convenience of the mothers. The staff comprised 1 pediatrician from the staff of the K.E.M. Hospital and rotating interns posted for 1 month at a time. Enrollment and follow-up of the children were done in the outpatient department. Model II, a subcenter-based model established in 1980, 5 satellite subcenters located in the community were established. The permanent staff consisted of a medical officer, a medico-social worker, and a records assistan. A detailed record of each child was maintained at the subcenter. The medico-social worker held group discussions with the attending mothers and an attempt was made to understand their views and beliefs about child care before trying to educate them. Model III, a community-based model, was established in April 1983. The staff was partly permanent (a medico-social worker, a student nurse, and local community health volunteer) and partly temporary (rotating interns). The staff visited different areas of Malavani village by rotation. An attempt was made to visit each area at least once in 2 months. Detailed recors were maintained as in Model II. In all models, the children were weighed at each visit. They were given oral polio and triple vaccines. Mothers were advised on foods to feed the children to improve nutrition and were given simple recipes and cooking demonstrations. An attempt was made to evaluate the regularity of attendance, weight gain in children, and immuniation coverage. With Model I 450 babies were registered in 6 months but only 48 of them were brought for further follow-up; only 21 of them completed primary immunization. 2034 babies were registered under Model II over a 2-year period. Of these, 1280 attended the clinic regularly for follow-up and completed the course of primary immunization. A striking feature was the weight gain in 1011 children. The number of family planning users increased significantly from 237 at the time of clinic registration to 384 after a few months. 856 babies were registered in 6 months under Model III and 764 attended regularly for follow-up. 613 of the 764 children gained weight and all 764 completed the primary course of immunization. The deficiencies of the center-based model, Model I, are evident. Models II and III proved effective in improving the care of children under 5.
Under Fives' Clinics, also popularly known as Growth and Development Clinics, are an important part of all comprehensive health care programmes. They permit not only delivery of health care to the most precious section of human community but also allow education of the parents in the matter of their children's health. One of the main problems in organising an Under Fives' Clinic is defaulting by the mothers. The default rate seems to depend upon distance of the clinic from the community and the personal rapport between the clinic staff and the attending mothers. The default rate is likely to be high particularly in a low socio-economic community that is largely illiterate. We describe in this paper our experience in the organisation of an Under Fives' Clinic in Malavani, a village with a population of about 70,000, near the city of Bombay. The details of the comprehensive health care programme in Malavani have already been described earlier.'
Three models of Under Fives' Clinic were tried successively at the Malavani Health Centre, beginning in 1978.
Model I: This was a Centre-based model which was established in 1978. The venue was the same centre where outpatient department was located for the convenience of the mothers. The staff comprised one paediatrician from the staff of the K.E.M. Hospital and rotating internes posted for one month at a time. Enrollment and follow-up of the children were done in the out patient department. A register for the new entrants was the only record maintained at the clinic. However, the mother was given a Road to Health Card (see [Fig. 1] on page 14 & 15) for each child. No attempt could be made to trace the defaulters because of paucity of records maintained by the clinic.
Model II: This sub-centre-based model was established in 1980. For this purpose, five satellite sub-centres located in the community were established. The permanent staff consisting of a medical officer, a medico-social worker and a records assistant attended these subcentres by rotation, one afternoon every week. A detailed record of each child, including his address and health record, was maintained at the sub-centre, in addition to the enrollment register. The mothers were given Road to Health Cards as in Model I. The medico-social worker held group discussions with the attending mothers and an attempt was made to understand their views and belief's about child care before trying to educate them.
Model III: This community-based model was established in April 1983. The staff was partly permanent (a medicosocial worker, a student nurse and a local community health volunteer) and partly temporary (rotating internes). The staff visited different areas of the Malavani village by rotation. An attempt was made to visit each area at least once in two months. The staff maintained the same detailed records as in Model II, and the mothers were given Road to Health Cards. Group discussions in this set up were found to be difficult. Mothers in need of more elaborate education were referred to the sub-centres and the Malavani Health Centre for educative group discussions, which centred on the importance of regular attendance, proper nutrition, immunization, common childhood illnesses, child-parent relationship and family planning.
In all models, the children were weighed at each visit. They were given oral polio vaccine and triple vaccine. As a part of the effort to improve the child's nutrition, the mothers were advised to make increasing use of banana (a cheap and perennially available fruit), ragi (a cereal, rich in calcium and iron), germinated pulses, green leafy vegetables and groundnuts. The mothers were given simple recipes and cooking demonstrations.
An attempt was made to evaluate the following: (1) Regularity of attendance, (2) Weight gain in children, and (3) Immunization coverage. Further, an attempt was made to study the effect of attending the clinic regularly on the nutritional practices, and the association between improved nutritional practices and the health of the child. Body weight, clinical evidence of anaemia (pallor, of conjunctiva and tongue) and clinical evidence of vitamin A deficiency (xerosis of conjunctiva and Bitot's spots) were used as parameters of health.
Four hundred and fifty babies were registered in 6 months but only 48, of them were brought for further follow up; only 21 of them completed primary immunization.
Two thousand and thirty four babies were registered (1148 males and 886 females) over a period of two years. Of these, 1280, (832 males and 448 females) attended the clinic regularly for follow up and completed the course of primary immunization; 316 male and 438 female children attended the clinic irregularly.
[Table - 1] shows the change in the certain practices after these 1280 children started attending the Clinic.
[Table - 2] and [Table3] show the association between improved nutritional practices and certain parameters of health in 1280 children. A striking feature was the weight gain in 1011 children. Further, there was a positive association between the feeding of ragi and banana and the weight gain [Table - 2] and a negative association between feeding of dark green leafy vegetables and pallor/vitamin A deficiency [Table - 3].
It was found that the number of users of family planning methods among the 1280 mothers, increased from 237 at the time of registration at the clinic to 384 after a few months (p < 0.001).
Eight hundred and fifty six babies were registered in 6 months. Of these, 764 attended regularly for follow up. Six hundred and thirteen of these 764 children were found to gain weight and all 764 children completed the primary course of immunization. [Table - 4] shows a comparision between model II and model III.
The deficiencies of the Centre-based model (Model I) are brought out by this study. The reasons for the poor follow Lip probably are as follows: as this clinic was held in the Malavani Health Centre, the mothers were prone to bring only sick children rather than healthy children for follow up. Further, the rotating nature of the staff probably hampered the establishment of proper rapport with the mothers. Finally, due to inadequate records no defaulter action could be taken. In this respect, the sub-centre-based model (Model II) and the community-based model (Model III) proved distinctly superior to model I.
Model II was in use longer than the model III and hence more information was available about model II. Model II demonstrates the effectiveness of the group discussions with the mothers in improving the nutritional practices in the families and consequently the health of the children. Although less data are available for model III, improved nutritional practices and weight gain in children could also be demonstrated in this model. However, as expected, the follow up was much better in model III than in model II. Thus, model II and model III prove to be approximately equal in effectiveness. Model II requires space for running the clinic but makes the educative group discussions between the clinic staff and mothers possible; such group discussions are almost impossible in model III. Model III has the advantage of not requiring fixed space but places greater strain on the clinic staff who have to make door to door visits to the community. However, if trained local health volunteers are available, model III can work equally well. Thus, one has to choose between models II and III -depending upon the local circumstances in the community where one is going to work.
We are thankful to Dr. N. B. Kumta, Head, Department of Pediatrics, Seth G.S.M. College and K.E.M. Hospital, Dr. R. D. Khare, Reader, Department of Pediatrics, Seth G.S.M. College and K.E.M. Hospital and the Dean, Seth G.S.M. College and K.E.M. Hospital, for extending the help and allowing to publish the data. Thanks are also due to Dr. S. Sunder for extending the help.