|Year : 2017 | Volume
| Issue : 3 | Page : 571-579
|Assessing critical gaps in implementation of WHO and UNICEF'S 7-point diarrhea control and prevention strategy in Uttar Pradesh, India
Farhad Ali1, Om Prakash Singh1, Abhik Dutta1, Zaeem Ul Haq2, Arindam Ghatak1, Trupti Ashtankar1
1 Stop Diarrhea Initiative, Project Management Unit, Save the Children, Gurugram, India
2 Save the Children, 1 St. John's Lane, London, UK
Click here for correspondence address and email
|Date of Web Publication||21-Aug-2017|
| Abstract|| |
Context: Diarrhea is one of the leading causes of under-five mortality globally and also in India. In the state of Uttar Pradesh, the prevalence of childhood diarrhea is 12.43% and only around half of the children with diarrhea have access to health-care services. Aims: The aim of this study is to understand the critical gaps at the public health system and community levels for the effective implementation of comprehensive diarrhea control. Settings and Design: This study was conducted in the rural settings and data collection was done at health facility and community levels. Subjects and Methods: A mixed methodology was used to conduct this study. Quantitative data were collected through a household survey with 1350 households in four districts and qualitative data were collected through focused group discussions and in-depth interviews at health facility and community levels. Statistical Analysis Used: SPSS was used for quantitative data analysis. Thematic analysis was performed for qualitative data. Results: Mothers are largely aware of use of oral rehydration solution (ORS) but only a third of the children with diarrhea were treated with ORS. Only a fifth of the mothers knew about the use of zinc and just 7% of children with diarrhea were treated with zinc. Majority of the mothers do not wash their hands with soap at critical times. The use of toilet and safe drinking water were also found minimal. There were challenges related to procurement, supply chain of ORS and zinc and also with respect to health human resource capacity at facility and community level. Conclusions: For comprehensive diarrhea control and prevention, health systems and community-level barriers largely related to supplies, training of staff, and community behavior and practices should be addressed.
Keywords: Behavior change communication, diarrhea control and prevention, oral rehydration solution and zinc, 7-point strategy, wash
|How to cite this article:|
Ali F, Singh OP, Dutta A, Haq ZU, Ghatak A, Ashtankar T. Assessing critical gaps in implementation of WHO and UNICEF'S 7-point diarrhea control and prevention strategy in Uttar Pradesh, India. Ann Trop Med Public Health 2017;10:571-9
|How to cite this URL:|
Ali F, Singh OP, Dutta A, Haq ZU, Ghatak A, Ashtankar T. Assessing critical gaps in implementation of WHO and UNICEF'S 7-point diarrhea control and prevention strategy in Uttar Pradesh, India. Ann Trop Med Public Health [serial online] 2017 [cited 2019 May 22];10:571-9. Available from: http://www.atmph.org/text.asp?2017/10/3/571/213178
| Introduction|| |
Diarrhea is a major public health problem globally, and particularly in low- and middle-income countries. Diarrheal disease is the second leading cause of death among children under-five and is responsible for the deaths of around 760,000 children every year. The disease accounts for one in nine child deaths worldwide. Globally, there are nearly 1.7 billion cases of diarrheal disease every year. On an average, children below 3 years of age in developing countries experience three episodes of diarrhea each year. In 2010, the number of child deaths from pneumonia and diarrhea was almost equal to the number of child deaths from all other causes after the neonatal period, that is, acquired immunodeficiency syndrome, malaria, measles, meningitis, injuries, and all other postneonatal conditions combined.
Sub-Saharan Africa and South Asia are home to more than 80% of deaths due to diarrhea among children under 5-year-old. Just 15 countries, with India leading all, account for almost three-quarters of all deaths from diarrhea among children under 5 years of age annually.
In India, diarrhea is the third most common cause of death in under-five children, responsible for 13% of deaths in this age group, killing an estimated 300,000 children each year., The proportionate mortality due to diarrhea in children aged 0–6 years is 9.1%. Average estimated incidence of diarrhea in children aged 0–6 years was 1.71 and 1.09 episodes/person/year in rural and urban areas. According to Million Death Study, diarrhea as a cause of death in children aged 1–59 months was 8.9/1000 live births among boys and 13.4/1000 live births among girls. Further, diarrhea accounted for a greater proportion of total child deaths in lower income than in higher income states in India. Region-wise variation also exists in mortality rate due to diarrhea. The mortality rate from diarrheal diseases in Central India was three times than that in the West. In the state of Uttar Pradesh, the prevalence of childhood diarrhea was reported to be 12.43% and only about 56% of children with diarrhea have had access to health care. The reports suggest that only around a quarter of the diarrhea cases are treated with oral rehydration solution (ORS) despite the Government of India (GoI) recommendations. Similarly, despite the recommendations of the Indian Society of Paediatrics in the year 2004 and GoI adoption, the use of zinc remains minimal in the treatment of childhood diarrhea. In the state of Uttar Pradesh, some of the documented challenges in diarrhea control comprise nonavailability of ORS and zinc in the public sector due to procurement and supply chain related bottlenecks and lack of knowledge among the health functionaries (training and capacity building issues) related to diarrhea control and prevention which leads to mistrust of the community on frontline workers.
This study was commissioned by Save the Children's Stop Diarrhoea Initiative (SDI) program which attempts to test the robustness of WHO and UNICEF's 7-point strategy on diarrhea control, and investigates supply and demand-side constraints for diarrhea prevention and control among under-five children in four districts of Uttar Pradesh (Pilibhit, Behraiach, Shrawasti, and Balrampur) in North India. This study does not look into the policy level issues and challenges of interdepartmental coordination needed for integrated approach to health. The purpose of the study was to identify the gaps and bottlenecks at health system and community levels for comprehensive diarrhea control and assess effective implementation of the WHO and UNICEF's 7-point plan which comprise two treatment (ORS and zinc) and five prevention strategies (immunization, exclusive breastfeeding, handwashing, safe water supply, and sanitation).
| Subjects and Methods|| |
Mixed methods were used to collect qualitative and quantitative data from the four districts of Uttar Pradesh, namely, Pilibhit, Behraiach, Shrawasti, and Balrampur. Data collection tools including quantitative survey questionnaire, in-depth interview (IDI) schedules, focused group discussion guidelines and review, and data collection checklists for health facilities were used. The sources of data at the community level included the mothers and caregivers of children under-five, frontline workers including Accredited Social Health Activist (ASHA), Auxiliary Nurse Midwife (ANM), and AnganWadi Workers (AWWs). The facility level interviews were conducted with lady health visitors (LHVs), pharmacists, and medical officers. The health facility support staff and clerks were also included in the study who helped in sourcing health records. The health facility data comprising information about health human resources, training, infrastructure, equipment and devices as well as the government guidelines, reports, and modules were also sourced for information.
Based on the standard formula and accounting for 6% change in indicator value for practice indicators and 10% for knowledge indicators under SDI of Save the Children, the sample size for the study areas was estimated at 1350 households. For the purpose of survey, a household listing exercise was carried out, wherein the data collection team randomly selected lanes in a primary sampling units (PSUs). Within these lanes, households having children of age group 0–59 months in each village were identified. Then, from the list of eligible households, twenty households were selected randomly for quantitative survey. From each of the districts, one block was selected for quantitative data collection, and in each block, from the list of the villages, those villages which have high possibilities of having PSUs were selected. A total of 120 PSUs were identified and from 1350 households data were collected. The quantitative survey enquired about knowledge, behavior, and practices around diarrhea prevention and treatment.
The health facilities at the block and district levels were contacted, and for community-level health facilities, from each district, one facility within 5 km from the block headquarter and another within 5–10 km from the block headquarters were contacted. The community-level facilities where ANMs were available were included in the study and the remaining facilities were excluded from this study. IDIs were conducted with officials at the state, district, block, and community-level facilities. Documentation of the current system of procurement procedures and practices followed for ORS, zinc, Vitamin “A,” and measles vaccine were also checked at different levels.
Qualitative inquiry was made to learn the health human resource training and development issues. IDIs were conducted with the medical officers (n = 16), pharmacists (n = 16), LHVs (n = 8), and focus group discussions (FGDs) were held with ASHAs (6 FGDs), ANMs (12 FGDs), and AWWs (6 FGDs).
The qualitative component of data collection also involved FGDs with caregivers of children followed by IDIs with caregivers as well as providers of health services (such as ASHAs, AWWs, and doctors). The qualitative enquiry was made to elicit group and individual sentiments and ideologies on diarrhea prevention and management. To understand this, a total of eight focused group discussions (two in each district) and 40 IDIs (10 in each district) were conducted with carers of children under-five. The terms of reference (ToR) of the study was shared with the Department of Health and Family Welfare, State Government of Uttar Pradesh, and permission was obtained to conduct the study.
The quantitative data were analyzed using IBM SPSS 2015 version - Statistical Program for the Social Sciences and descriptive statistics was calculated and expressed as percentage responses. The qualitative data were analyzed manually using content analysis method. The method helped identify the patterns and themes for the sentiments, ideas, opinions, beliefs, and practices captured through note-taking during the qualitative interviews and focused group discussions.
Informed consent was obtained from all the respondents involved in the study and the approval for the study was sought from the government health department and senior management of Save the Children country office in India.
| Results|| |
Knowledge, practice, and coverage of preventive health
The data [Table 1] reflect an interesting fact that nearly half of the mothers were aware that diarrhea among the children is caused by the contaminated water and a quarter of all the mothers were also aware that diarrhea is caused by some kinds of infection. However, knowledge on correct treatment of the disease was low as majority of the diarrheal cases were treated with some kinds of pills and syrup as prescribed by the health practitioners. The children were also prescribed antibiotics drugs. Only a fraction of the children who suffered diarrhea were given zinc.
|Table 1: Knowledge about the causes of diarrhea among the mothers and management of diarrheal cases|
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A majority of mothers [Table 2] were aware of the usefulness of ORS in the treatment of diarrhea, but the awareness on use of zinc was low comparatively. Despite this awareness, the use of both of these treatments was reported to be low. The utilization of zinc was further lower compared to ORS.
|Table 2: Knowledge about oral rehydration solution and zinc among the mothers and its actual utilization during the disease episode|
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The data [Table 3] on the preventive aspects of diarrhea suggest that only around one-third of the children were breastfed within 1 hour of their birth and less than half of the children were exclusively breastfed for the first 6 months and complementarily fed after 6 months of their life.
|Table 3: Uptake and utilization of preventive health services for children|
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The coverage of measles vaccination was comparatively higher than other interventions (at 69%), coverage of the first dose of Vitamin A was comparatively low (45%), and rotavirus immunization coverage was found almost negligible.
Only around one-fourth of the households had access to some kinds of toilets. The piped sewer system was almost nonexistent. The data [Table 4] suggest that though majority of the women wash their hands with soap after defecation and after cleaning the feces of the children, very few women reported to wash their hands with soap before cooking, eating, and feeding their children.
|Table 4: Household access to sanitation and hygiene practices of mothers|
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Demand-side issues in prevention and treatment of childhood diarrhea
The mothers were found not only unaware of the importance of immunizing their children but also have some misconceptions related to child sickness following vaccination. They believe that immunization provides immunity to the children and hence protect them against the diseases; however with respect to knowledge about the relationship between immunization and diarrhea prevention, they were not very sure. The mothers shared that they immunized their children but it was found that the process was not self-initiated. Mobilization of the mothers and awareness generation by frontline workers such as ASHAs and AWWs were crucial in terms of bringing women and children to the immunization sites.
The mothers were aware of the importance of exclusive breastfeeding but unaware between the relation of diarrhea and exclusive breastfeeding. They shared that during diarrhea, the breastfeeding should continue but also reported wrong practices such as, if the mother's milk is not sufficient, cow's milk should be given to the child. They were also not aware of types of food that should be given to the children during diarrhea. The role of ASHAs and doctors in sharing the importance of exclusive breastfeeding and continued breastfeeding during diarrhea was found important as the mothers mentioned that they get the health information from them.
Handwashing with soap
The mothers were aware of the importance of handwashing with soap. They were also aware of its importance in diarrhea control and prevention. However, it was realized that the practice of the handwashing by mothers at critical moments was minimal. The mothers were not motivated to wash their hands and do it only when their hands are visibly unclean.
Water and sanitation in the community
The mothers were aware of the importance of safe drinking water, use to toilets, and safe disposal of child feces but the practice was minimal. Almost all the mothers reported defecating in open. They reported that external environment in the community is such that it is difficult to maintain cleanliness and thus unclean practices such as disposing child feces in open drain channels on the streets are easy. These mothers were not aware of the drinking water treatment, filtration, and boiling, but reported that during diarrhea, the children were given boiled water but otherwise untreated/unboiled water is given to the children for drinking which the family uses for drinking.
Use of oral rehydration solution and treatment of diarrhea
The mothers were largely aware of ORS, but majority of them uses different names such as water medicine, glucose, and electral. The mothers knew the role of ORS in the management of diarrhea and its preparation but reported that it tastes like soap water.
The major source of ORS stock was ASHAs and local rural medical practitioners (RMPs). The ORS was not available in local markets and the mothers had to be dependent on ASHAs at the time of need.
The children were treated at home first if they had diarrhea. They were given home remedies such as decoction and some other remedies such as Isabgal (flacks). If ASHAs visited home and got to know about a child who had diarrhea, she provided ORS and zinc. However, if the child did not improve and ASHAs did not visit home, the mothers and caregivers brought the baby to RMPs for the treatment who relied more on antidiarrheal and antibiotic drugs. It is only 5th–6th day of onset of illness that the child would be seen by qualified medical doctor at the primary health-care center if the child did not improve.
Use of zinc
Only few mothers heard about zinc tablets and largely they were unaware on its use and its role in the management of diarrhea. Since the general awareness on use of zinc was low among the mothers, its use was minimal in the management of diarrhea. The mothers were unsure about its benefits during the diarrhea. The use of zinc had been driven by the doctors and by the community health workers (ASHAs) in case it was used.
Supply-side issues in prevention and treatment of diarrhea
The infrastructure of the Central Medical Store Department at the district level was found to be in poor shape. The observations revealed that there was inadequate storage space for medicines and supplies and there were structural problems such as seepage in the building. There was inadequate furniture and whatever was available either required replacement or at least repair. The space for sitting was also cramped. In general, the infrastructure required repairs and maintenance not only at district level but also below district level.
It was found that the cold chain equipment was not functional and temperature monitoring of the vaccine freezers was not being done on a regular basis. There was inadequate space to store the cold boxes. At one of the three sites visited, it was found that only 135 out of 185 vaccine carriers were functional. At the same site, out of three thermometers, only one was functional and because of which temperature monitoring of the vaccine freezers was not being carried out.
Human resources and capacity building
In the areas where data collection was done, there had been reported shortage of support staff including loaders, sweepers, office attendants, and guards at district and block levels. At one site, the post of vaccine handler was vacant and its responsibilities were being handled by LHVs.
Demand assessment, indenting, procurement, and supply chain
Demand estimation of ORS, zinc, and Vitamin A was done based on the estimated population of children under 5 years by state-level Child Health Unit. In the indenting process, ANMs send indents orally to the pharmacists at the block level. Block pharmacist based on the block requirements send the indent to the district pharmacist in a handwritten indent. This was done on a monthly basis or whenever a need was felt. However, in contrary to that, supplies of ORS, zinc, and Vitamin A were done based on the stocks available rather than on the demand from a specific area.
Some other bottlenecks observed were improper indenting process, transportation-related challenges from district to below district levels, and poor distribution decisions such as distribution based on supply rather than demand of the products.
Health human resource capacity
All the sanctioned posts of the frontline health workers including ASHAs, AWWs, and ANMs were found filled at the time of data collection. The sanctioned positions of LHVs, pharmacists, and medical officers were also found filled. The health workers had good idea about their responsibilities with respect to the prevention and treatment of diarrhea. The frontline health workers responded that their tasks include social mobilization, communication on diarrhea and treatment of cases using ORS and zinc at the community level, and also referral of the cases at an appropriate level for those cases requiring inpatient treatment. Pharmacist reported about their responsibility of maintaining the stock and informing the patients about the treatment prescribed by the medical officers. However, more than 80% of participants who were responsible for the treatment of the diarrhea in the study area were not aware of the standard treatment protocols issues by the Government of India (GoI). Those reported knowledge about GoI protocols were not found well versed with these protocols. The doctors who participated in this research could not recall any training that they have participated on the management of diarrheal cases. The findings also suggest that the frontline health workers needed training on infant and young child feeding practices, breastfeeding, counseling, and prevention and treatment aspects of childhood diarrhea. The doctors working in the primary health centers require training on the management of diarrhea and management of the complicated and severe cases. They also need training on supportive supervision as they provide support to a range of health workers at facility and community levels. The qualitative enquiry revealed that the health workers need these training in local language, close to their workplace, and in a participatory manner so that they can learn the practical skills related to their work.
| Discussion|| |
The results show that a fairly high proportion of mothers have understanding about the causes of diarrhea but at the same time for the management of diarrhea, use of ORS (around 32%) and zinc (only around 7%) and continued feeding (in around 8% cases) during diarrhea seems poorly adopted. In a study conducted by Wilson et al. in urban India reveals similar trends in the use of ORS and zinc for the treatment of diarrhea. It shows that only 50% of children who suffered from diarrhea were treated with ORS, whereas the use of zinc remains extremely low. They also mentioned that the children suffering from diarrhea are also not given increased fluids during diarrhea. In another study, Gitanjali and Weerasuriya reported that in India only a third of the children with diarrhea receive ORS. Majority of these cases were prescribed pills and syrups by RMPs. They seldom prescribe ORS and zinc for the treatment of diarrhea and hence most of these cases are treated without use of ORS and zinc. In a study conducted in rural Uttar Pradesh, the authors reported similar trends. They found that only 9.8% RMPs prescribed ORS and advised continued feeding as standard treatment practice in diarrhea. One of the major reasons of this situation is that the childhood diarrhea cases are first treated at homes by mothers and caregivers using home remedies such as decoctions. Sometimes the cases are treated by ASHAs if there is an opportunity to visit home by them when they are on routine house-to-house visit or they get to know from someone that a child is sick. It is only when the children do not improve in a day or two, they are brought to RMPs who are not qualified and trained health providers practicing in the community and they often do not use ORS and zinc for the treatment diarrhea. As a result, the use of ORS and zinc is less. de Zoysa et al. in a similar study conducted in urban areas in India reported that mothers prefer to visit local, unqualified medical practitioners at the first place. They further reported that in want of rapid relief, mothers keep shifting to the providers and seek hospital care very late. The mothers visit the doctors and health centers only after 2–3 days are passed and children do not improve. Similar observations are reported in studies conducted elsewhere also.
The ORS is not available in the local market and hence despite knowledge of ORS, its use in diarrhea management is low. The qualitative data show that mothers are not very sure on what should be given to the child when they suffer diarrhea and this factor explains why only 8% of children were continually breastfed during diarrhea.
With respect to availability of ORS at the community level, if we look at the supply chain issues, the data suggest that availability of ORS and zinc in the community is constrained by the fact that supplies depend on the availability of stocks rather than demand of the commodity and there are challenges with respect to storage, transport, and distribution. The results also explain that training of health human resources is inadequate. The frontline workers did not receive any training exclusively on management of diarrhea, counseling, breastfeeding, and diarrhea prevention. All these factors, namely, training of frontline workers, inadequate supplies, nonavailability of ORS and zinc in local market, low acceptance of ORS taste, and low awareness particularly on the use of zinc in diarrhea management might be responsible for low use of ORS (despite high awareness on ORS use in diarrhea) and zinc in the management of childhood diarrhea. There are strong evidences available from different parts of India flagging the issues pertaining to the availability of ORS and zinc in public health facilities. The key issues highlighted in these research comprise challenges related to procurement, quantities of procurement, distributions bottleneck, and also policies concerning procurement and production , which are conformed in our findings as well.
If we look at the preventive health care, our findings show that only one-third of the children were breastfed within 1 hour of birth and less than half of the children were exclusively breastfed for the first 6 months of their life. The qualitative inquiry reveals that although mothers understand the importance of early and exclusive breastfeeding, they were unsure of what should be given to the children during diarrhea. Most of the mothers in the study area were unaware about the relationship between diarrhea and exclusive breastfeeding of the children and continued feeding during diarrhea. In several instances, they changed the feeding when their children got diarrhea. There are evidences from different parts of the world which suggest that during diarrhea mothers change the feeding practices of the children which support the above findings. These studies suggest that mothers usually reduced breastfeeding and at times interrupted breastfeeding and also reduced giving milk-based products to the children.
On Childhood immunization, the data suggest that the coverage of the measles vaccination looks good which may be because government ran mop-up rounds for improving measles's coverage  but coverage of first dose of “Vitamin A” looks poor at around 45%. The qualitative enquiry reveals that mothers were unaware about the relationship between immunization and diarrhea prevention. The immunization of the children at the community level is not self-initiated. It is driven by ASHAs, where she goes from house to house and mobilize mothers for the immunization of their children. However, it seems that she fails to make mothers understood that immunizing the children against measles will be useful in diarrhea prevention. The studies conducted in India reveal that demand generation is central to improve immunization coverage. Mothers are more likely to get their children immunized if they find it useful for their children and their concerns related to safety are addressed. Hence, mothers do not come forward themselves for immunizing their children. However, this may not be the only reason. The decision-making for immunization is complex. The global evidences suggest that there is hesitation related to vaccination of children. Vaccine hesitancy is a complex issue which is shaped by a variety of factors which are local and context specific. The hesitation also varies from vaccine to vaccine as well.
If we look at the use of toilets and handwashing practices, the results show that only around one-fifth of the households have access to some kinds of toilets and less than one-fifth of the mothers wash hands with soap before cooking, eating, and feeding their children. Around 28% of mothers do not wash their hands after defecation and around 36% of mothers do not wash their hands after cleaning the feces of the child in the study area. A study conducted in South India also reveals similar trends. The study reports that handwashing with soap at key events was very rare in both the control and intervention areas of the study. The qualitative inquiry reveals that mothers were aware of the importance of handwashing but they did not seem to be motivated enough to wash their hands with soap. The study conducted by Biran et al. also suggest that knowledge of handwashing does not necessarily improve the behaviors of mothers related to hand wash. They concluded that interventions which are based on emotional drivers may be useful in improving the handwashing behaviors of the mothers. Our study reveals that mothers wash hands only when they feel that their hands are visibly unclean. This finding may help inform the appropriate communication designing. A social and behavioral change communication should take care of this aspect.
The qualitative inquiry found that almost all the mothers involved in the study were defecating in open and disposing the child feces in open drains. It is socially accepted and a normal way of life for them. They have been doing this because they feel that their built environment and surroundings are difficult to keep clean and the built environment is unsupportive for maintaining cleanliness and hence open defecation and open disposal of child feces is an easy option for them. Studies conducted in India reveal that construction and use of toilet is a complex behavioral issue and linked to high social and economic status. Those people who are educated, have higher income and belong to upper caste are more likely to use toilets. In rural society open defection is seen as an accepted social norm. People do not see use of toilets as a driver of good health but find it related social prestige. Hence, designing a health communication should consider making toilet use and hand wash a new trend and social prestige issue.
| Conclusions|| |
The challenges in the prevention and treatment of childhood diarrhea in rural Uttar Pradesh seemed multifaceted in the study and found interlinked. There are behavioral issues with respect to access to toilets and handwashing at critical stages and early and exclusive breastfeeding despite knowledge of its importance. There also seemed gaps in knowledge and awareness around links between immunization and diarrhea prevention, exclusive breastfeeding and diarrhea prevention, continued breastfeeding during diarrhea, and use of zinc in the treatment of diarrhea. Despite the fact that majority of mothers are aware of ORS use in diarrhea, only a third of children received ORS during the illness. This seems to be a condition due to unavailability of ORS in the local market and unawareness of the exact terminology used for the product. Since ASHAs and ANMs are the source of government supply of ORS in the community, inadequate availability may be attributed to the challenges in procurement and supply chain management. There have been issues, namely, indenting process, supplies based on stock rather than demand, storage problem, distribution and transportation, and lack of adequate human resources at district and below district levels. Another dimension that is found linked to awareness and use of ORS and zinc is the training and health human resource capacity of facility level staff and of frontline health workers. The health human resources were found unaware of standard treatment protocols of the government and did not receive any formal trainings on diarrhea prevention, control, and treatment. The frontline health workers need to be trained on engaging with mothers. The frontline staff also needs training on breastfeeding, infant and young child feeding practices, counseling of mothers, and identifying danger signs of diarrhea.
For effective diarrhea prevention and control in Uttar Pradesh, demand-side and supply-side issues as discussed above should be addressed. The National Health Mission should focus on social and behavior change communication for improving healthy behavior and practices pertaining to links between immunization and diarrhea control, continued breastfeeding and feeding during diarrhea, toilet usage, and handwashing at critical moments.
We acknowledge the technical support received from Save the Children, UK Office, in reviewing the methodology of the study and tools of data collection. We also gratefully acknowledge the support from the Department of Health and Family Welfare, State Government of Uttar Pradesh, for reviewing the ToR and allowing the data collection. We extend our gratitude to all the respondents, community members, doctors, and all the other health workers participated in this study and responded to our questions with lot of patience.
Financial support and sponsorship
Financial support was received from Reckitt and Benckiser.
Conflicts of interest
There are no conflicts of interest.
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Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]
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