Investigating violence against _Accredited Social Health Activists_ (ASHAs): a mixed methods study from rural North Karnataka, India

# Background Accredited Social Health Activists (ASHAs) are female community health workers who primarily work to improve local reproductive, maternal, neonatal, and child health across India. As ASHAs often hail from patriarchal environments and are positioned at the bottom of the healthcare hierarchy, they are vulnerable to experiencing different forms of violence from the various individuals that they interact with. There is a gap in knowledge about the violence ASHAs experience. The purpose of this study was to assess the working condition of ASHAs, the extent and types of violence they experienced, and the corresponding perpetrators of this violence in two districts of Northern Karnataka. # Methods Using a mixed methods approach, we first surveyed 396 ASHAs to characterize their experiences of violence. We then conducted in-depth interviews with 16 ASHAs to elaborate on survey findings. Data was analyzed using quantitative prevalence statistics and qualitative thematic analysis. # Results The majority of ASHAs reported economic (88%) or emotional violence (73%), while many ASHAs reported sexual (32%) or physical violence (26%). ASHAs reported high levels of economic violence from their beneficiaries and their beneficiaries’ families (64%), emotional violence from their co-workers (44%), and physical and sexual violence from their husbands (17% and 12% respectively). Mixed methods findings revealed that violence was often rooted from their low positioning on the healthcare hierarchy, a lack of respect from community members, and limited autonomy at home. # Conclusions Evidence from this study suggests that violence perpetrated against ASHAs is highly prevalent, diverse in forms, and often arises from the ASHA’s immediate circles. Interventions aiming to decrease violence against ASHA workers requires multi-level approach, with collaborative components empowering ASHAs, sensitizing ASHA families and co-workers, implementing regulations at the health facility level, and increasing community-wide respect for ASHAs and their role in the health care

Potential contributions of an on-site nurse mentoring program on neonatal mortality reductions in rural Karnataka state, South India: evidence from repeat community cross-sectional surveys

Abstract Background We assessed the effects of a nurse mentoring program on neonatal mortality in eight districts in India. Methods From 2012 to 2015, nurse mentors supported improvements in critical MNCH-related practices among health providers at primary health centres (PHCs) in northern Karnataka, South India. Baseline (n = 5240) and endline (n = 5154) surveys of randomly selected ever-married women were conducted. Neonatal mortality rates (NMR) among the last live-born children in the three years prior to each survey delivered in NM and non-NM-supported facilities were calculated and compared using survival analysis and cumulative hazard function. Mortality rates on days 1, 2–7 and 8–28 post-partum were compared. Cox survival regression analysis measured the adjusted effect on neonatal mortality of delivering in a nurse mentor supported facility. Results Overall, neonatal mortality rate in the three years preceding the baseline and endline surveys was 30.5 (95% CI 24.3–38.4) and 21.6 (95% CI 16.3–28.7) respectively. There was a substantial decline in neonatal mortality between the survey rounds among children delivered in PHCs supported by NM: 29.4 (95% CI 18.1–47.5) vs. 9.3 (95% CI 3.9–22.3) (p = 0.09). No significant declines in neonatal mortality rate were observed among children delivered in other facilities or at home. In regression analysis, among children born in nurse mentor supported facilities, the estimated hazard ratio at endline was significantly lower compared with baseline (HR: 0.23, 95% CI: 0.06–0.82, p = 0.02). Conclusion The nurse mentoring program was associated with a substantial reduction in neonatal mortality. Further research is warranted to delineate whether this may be an effective strategy for reducing NMR in resource-poor settings

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

Abstract Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions. </jats:sec

The why, what and how of preconception care: an exploratory descriptive qualitative study in Karnataka, India

Abstract Background Women’s health and nutrition are key to their reproductive health and are important for optimising pregnancy outcomes. Formation of most foetal organs starts soon after conception and much before the woman has her first antenatal visit. The provision of biomedical, behavioural and social interventions to couples to address health, nutrition, behaviour issues and individual environmental risk factors that could contribute to improved maternal and child health outcomes before conception is crucial. Most rural women in India, do not seek pregnancy care before the second trimester because of socio-cultural factors. Therefore, intervening in the preconception period is important. The objective of the study was to explore the challenges and opportunities of implementing preconception care interventions. Methods Individual, in-depth, semi-structured interviews (n = 25) were conducted with primary stakeholders (newly married women, newly married men, and family members) in Shorapur taluk of Yadgir district and Devadurga taluk of Raichur district. Thirty-one interviews were conducted with taluk, district, state officials and academicians. This descriptive qualitative study conducted four focus group discussions with front-line health workers. The in-depth interviews (IDIs) and Focus-group discussions (FGDs) used separate pre-tested semi-structured interview/discussion guides. Data analysis was carried out using NVivo software using a phenomenological approach with both inductive and deductive analysis. Results A strong influence of social and cultural norms shapes healthcare-seeking behaviour at the community level. Poor dietary diversity, lack of awareness, poor literacy levels, work pressure for women, lack of decision-making power and empowerment among women, pressure to conceive early, and gender norms are the roadblocks to successful preconception care programs in the rural Karnataka setting. The stakeholders expressed the need for interventions during the preconception period. The government functionaries recommended several interventions which could be potentially integrated into the existing Reproductive Maternal, Neonatal, Child and Adolescent Health (RMNCH + A) strategy to improve the health and nutrition of women before they conceive. Conclusion The study highlights the need for structured interventions during the preconception period to improve maternal health and pregnancy outcomes. The recommendations provided by government functionaries are indicative of the feasibility of integrating interventions in the RMNCH + A strategy

A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India

Abstract Background Low- and middle-income countries (LMICs) account for a higher burden of noncommunicable diseases (NCD) and home to a higher number of premature deaths (before age 70) from NCDs. NCDs have become an integral part of the global development agenda; hence, the scope of action on NCDs extends beyond just the health-related sustainable development goal (SDG 3). However, the organization and integration of NCD-related health services have faced several gaps in the LMIC regions such as India. Although the national NCD programme of India has been in operation for a decade, challenges remain in the integration of NCD services at primary care. In this paper, we have analysed existing gaps in the organization and integration of NCD services at primary care and suggested plausible solutions that exist. Method The identification of gaps is based out of a review of peer-reviewed articles, reports on national and global guidelines/protocols. The gaps are organized and narrated at four levels such as community, facility, health system, health policy and research, as per the WHO Innovative Care for Chronic Conditions framework (WHO ICCC). Result The review found that challenges in the identification of eligible beneficiaries, shortage and poor capacity of frontline health workers, poor functioning of community groups and poor community knowledge on NCD risk factors were key gaps at the community level. Challenges at facility level such as poor facility infrastructure, lack of provider knowledge on standards of NCD care and below par quality of care led to poor management of NCDs. At the health system level, we found, organization of care, programme management and monitoring systems were not geared up to address NCDs. Multi-sectoral collaboration and coordination were proposed at the policy level to tackle NCDs; however, gaps remained in implementation of such policies. Limited research on the effect of health promotion, prevention and, in particular, non-medical interventions on NCDs was found as a key gap at the research level. Conclusion This paper reinforces the need for an integrated comprehensive model of NCD care especially at primary health care level to address the growing burden of these diseases. This overarching review is quite relevant and useful in organizing NCD care in Indian and similar LMIC settings