On this page we will post the summaries of CHW meetings.  Just as with the staff meeting notes page, if someone wants to make this page fancier with table of contents listing each date etc please feel free. 

 

6 September 2009:

CHW meeting

Meeting time: 1:25-3:00pm

Attendance: Kamal Koli (Mastamandu 2&3), Satya Sunar (Siddheshwor 2&6), Gauri sister, Astha, Shefali (NOTE: Kamala Kunwar (CHW) and Sunita Kumal (CHW) are both on maternity leave.)  Formatting of these notes is a bit weird b/c of tranfer from word to wiki - but readable so not fixing right now.  

 

1. Established general meeting etiquette, create opportunities for everyone to voice their thoughts and answers. Should be part of a routine process to begin the CHW meeting.

 

2. A major goal in the coming days with the CHW program is to initiate the process of oversight.  In this meeting we began by asking some very basic questions pertinent to their duties as Nyaya's CHWs, about the local health infrastructures and health services available in their respective wards. Tried explaining this new take on the program to the CHWs by saying "It is part of our program to now start collecting data in way that will enable us to see how well we really capture the reality of the health of our communities. You being Nyaya's major link to the communities here will play a vital role in doing so."

 

3. Began asking numerous questions that Piali, Shefali and Astha had come up with while setting up agendas for the CHW meeting.

• What are your actual catchments (in number of households)?

Kamala: 50 homes [Mastamandu, Wards 2 and 3]

Satya: 82 homes [Siddheshwor, Wards 2 and 6]

• As a CHW employed by Nyaya Health, and as a representative of this community hospital in your respective catchment areas, what do you consider to be part of duties? How long do the various duties take to be done?

Kamala : We spread information about the importance of cleanliness in order to prevent diseases like diarrhea.  We also disseminate information regarding malnutrition and actively look for malnourished children in our community. We also encourage pregnant women to take iron pills and get their shots on time. Also give out information about services that are made available by Nyaya Health.

Satya :  Other than duties already mentioned by Kamala. We dispense medications from our first aid box. Mostly ORS during the diarrheal outbreak that greatly impacted the Siddheshwor community. Recommend pregnant women to come for ANC visits

 

 

All of this information is dispensed  during their weekly rounds of the community.  

• How often does ‘general surveillance’ actually happen (twice a month, once a month etc)?

 Once a week.

•   How long do the various duties generally take (may not be totally accurate, but worth asking about)?

Kamala  -  Conducts general surveillance through weekly visits to homes in her ward. Spends about 2 days each week conducting these surveillances.

Typical surveillance schedule:  Ward 3 (50 homes that are sparsely distributed) on a typical surveillance day would be completed between 10 AM to 4PM.  Ward 2 (40 homes that are more clustered) on a typical surveillance day would be completed between 10 AM to 12/1PM.

 Satya -  Conducts general surveillance through weekly visits to all households in her wards.  Normally on days when she conducts her surveillance she remains out of the house for 2-3 hours at a time e.g. 12 AM - 2 PM or from 7AM - 10AM where she visits approximately 20 homes. Siddheshwor Ward 2 (52 homes) is farther away from her home and Ward 6 (30 homes)  is also where she lives.  During weeks when she cannot visit all of the households in her area within the 2 days she extends her 2 day surveillance to 3/4 days as necessary.

• How many malnutrition cases?

Satya  - 3 total (one severely malnourished + 2 borderline) 

CHW reported of the severely malnourished kid, Bhumika Auji, 1.5 yrs, came to OPD  2 weeks ago and was unable to give Sarbottam Lito because we were out of stock at the pharmacy. Currently have placed orders for Sarwottam Lito

Kamala-  0 total 

• How many pregnant women followed?

Satya -  4 pregnant

Kamala-  2 pregnant 

• How many immunizations (PNC)?

Kamala- All the kids in her wards  weighed and immunized at the health post or immunization center at airport bazaar. Currently no real count of number of children vaccinated. 

Satya-  Immunizations provided at the health post ( ~15 mins walk). 

• How many TB patients? 

Satya - HIV/TB coinfection outside of catchment, Ward 4 ( half an hour away from home). Patient lives outside of her catchment area.  

Kamala-  Zero TB patients; One HIV patient receiving treatment from Gangotri.

 

• How many OPD follow-upspatients? 

Currently no OPD cases being followed as they were not assigned before this meeting.  At the meeting next week the CHWs will receive OPD follow-up patients.

 

The clinical staff as well as CHWs need to be retrained on the OPD follow-up ticket (oversight) protocol.  Specifically on what types of cases should be categorized as those that need follow-up by CHWs and also emphasize to the CHWs to be more diligent about following up on cases and reporting back at every meeting regularly.  CHWs will be retrained during meeting on following Tuesday, and staff will be retrained Sunday/Monday prior to the CHW meeting. 

• Describe a typical visit to a home in your catchment area in the process of your general surveillance. This should include the typical questions you ask.

Kamala -  First greet them.  Address them as didi, bajai etc and ask them how they are doing? Ask if any kids in the household are sick? Ask if anyone is pregnant? If yes , ask if  they’ve been immunized? If kids are present, measure kid's arms using the malnutrition tape?  A typical visit to a single household assuming that there is someone present  may take  approximately 20 minutes to an hour.

Satya -   Greet them and then ask who is at home? Also ask how is everyone? Who is unwell?  How many household members? How many ANC cases? Send ANCs to the hospital? Give out information regarding Nyaya's services.   Visits range from 5 to 30 mins.   

 

4. Asked information on existing health infrastructure: 

• Ask our CHWs how many FCHVs are present in their catchment area? Who they are and where they live? How active they are in the community? 

Satya - 1 FCHV (Maheshwari Kunwar)

Kamala -Ward 2 (Sita Kunwar) Ward 3 (Ganga Budha)

FCHVs distribute anti-helmintics, iron pills, vitamin A and immunizing drops for polio. Vitamin A drops are 

given out in Magh while Polio is distributed in Jyestha/Baishakh. 

 

·         What about health posts and sub-health posts in your wards? What are their office hours? Who staff these posts? What services are provided by them?

Satya - 1 health post. 11 AM - 2 AM. Radha Kunwar, ANM (ex-employee of Nyaya) and senior aaiwa Mohan Sharma. 

They provide IV fluids for diarrheal patients, ORS and iron pills.  Medications provided by the government are received in weekly installments and are enough for a short period and often run out.

Kamala - 1 health post.  10 AM - 3 AM. Ma.Si.Ka.  alone staffs the health post.

Iron pills, some deliveries take place, IV fluids for diarrhea patients and few medications are also available. Health post is not really in the catchment region so did not have much information regarding the health post.

•  What about family planning? What kind of services are available? Are they themselves doing anything regarding it? Have they been disseminating info regarding Family Planning ?

§         CHWs have already received a training on family planning. They  have been distributing condoms which have been included in the first aid kit.

§         Condoms are generally distributed by NGOs involved in AIDS activities at airport bazaar.

§         There are not many services available for family planning in the communities.

§         They give out information while giving out condoms during the surveillance.

§         Also they are now very often  approached by community members asking for condoms as opposed to purchasing it from a private medical or going the freely dispensing AIDS organizaitons. According to the CHWs, they  feel  more comfortable talking to them about matters like family planning which often is a major hush hush.

• Why do you think services like CAC/PAC more popular than other family planning services? If yes, if there are other family planning services available in your community what are they and where are they available? (quick note since our CAC services have been made available appx 200 CAC procedures have already been performed.)

               Kamala - usually husbands are unwilling to use any family planning methods.  Although  family planning services                are not readily available there are camps held by the government during various times. This year the district will                conduct  a vasectomy camp and provide family planning services for women (temporary)   in Falgun at airport                bazaar.

 

NOTES:

 

·         We also mentioned  that we will not be refilling the First Aid Kit with medications for now. We want to hold up on giving out medications like paracetamol until we have a better mechanism of oversight in place to ensure that meds arent being dispersed haphazardly. Instead, only provided CHWs with ORS, condoms, bandages and band aids.

 

·         After seeing first aid box, community members expect medications of all sorts from CHWs. But CHWs also seemed to be more fond of carrying the boxes around as it became an object that identified  them to the community as healthcare workers. While this maybe good in terms of improving their morale, we must be careful about how we dispense these medications until we create a solid method of oversight. 

 

·         Gauri Sister called in only one meeting during the time between Chhitij and Astha and even that was not conducted due to Gauri sister’s busy clinical schedule that day.  CHWs  also admit of losing motivation to work and reporting back to the hospital in the absence of program coordinator and the presence of only Gauri sister  who is already swamped with her clinical tasks (as there are only 2 ANMS on duty now). This is definitely not good for their morale.

 

• All four CHWs will be attending the meeting next week  i.e. two of them who were on maternity leave Santu and Pabitra will also be returning.  Next meeting will be held Tuesday.
• Mention of Dashain bonus for CHWs. Chhitij clarified in email that he had not promised this to them (as they claimed at the last meeting)

   

• Sidheshwor VDC  among all of  the CHW catchment regions appeared to be the hardest hit by the cholera outbreak.
• Checked logbook of the CHWs and noted how data has been entered. CHWs have not been entering the data in their logbook since the move to Bayalpata (during the summer they were recording information that was asked of them on forms that were handed out and some notes were put in their log books). They claim to have been asked not to collect data by Chhitij until we have transitioned into a newer version of the data entry system.  Chhitij has informed us that this is not true - we have had similar experiences with them regarding their claims of promises of umbrellas, dresses, etc.  We have emphasized to them greatly regarding the importance of collecting data and have asked to continue doing so in their current logbooks in the existing format until we have trained them to do so in a new and improved version. At the next meeting we are going to have a discussion about these issues where claims are made that Nyaya members confirm are not true.  

 

15 September 2009:

CHW meeting

Meeting time: 2:45-4:30pm

Attendance: Pabitra Kunwar, Santu Kumal, Kamala Koli, Satya Sunar, Shefali Oza and Astha KC

 

·               Maternity leave total - 2 months. Both Santu's and Pabitra Kunwar's maternity leaves will be over by Ashoj 22. 

·               Begin meeting by generally setting the mood, welcomed back new mothers and also set stage for all to participate and not for a couple to dominate all discussions (i.e. Kamala and Satya)

·               Announce that contracts will be renewed after Dashain

·               Inform CHWs that there will be no Dashain bonus as part time workers they get no bonus unlike fulltime hospital staff. Be polite. We appreciate your work etc.

·               Remind them that past coordinators are very much in touch and well communicated with so anything said can be verified.

·               If legit promises are made they will be done on paper. 

·               Did not have a personal chat with Kamala or Satya

·               Check their log books. Look at the process of data collection. See what was done by Satya and Kamala in the past week. 

·                     Have not collected data for the entire month of Shrawan.

·                     Santu forgot her logbook, Pabitra had data upto shrawan 3 2066, both Kamala and Satya have recorded no data for the entire month of shrawan.  

·                     Isha Sunar actually gotten better with

·                     Dhana Auji, Woman not in good shape after delivery. 1.5y Bhumika Auji (6 Kg)- severely malnourished.

 

·               Really discuss and confirm when all of the data was collected. Did they stop after move to bayalpata? If yes did they not collect any data over the summer? That should not have been the case because Chhitij regularly had meetings with them and verified the data were collected in a timely fashion.

Verification is not working very well. As far as logbook was concerned very little to no data was recorded in logbooks of CHWs for the month of Shrawan (which is also very crucial because of the diarrheal outbreak). When asked how Satya claimed during those weeks to have found 9 cases of diarrhea in the community, she replied "the count was based on the number of ORS packets that were given out."

 

·               Reinquire their week's schedules for Satya and Kamala. How long did the general surveillance take? How many households did they visit and the various cases that they have detected?  <This summer when Chhitij asked the same question they said it took 2 weeks for them to cover the entire catchment area.>

Satya - Ward 6 (20 homes with 50 household members) did not cover other ward. Covered in 2 days. 2 hrs per day. 21 community members were referred and 5 patients actually came to the hospital and were consequently followed up by CHW.  Bhumika Auji (1.5 yr, 6kg) severely malnourished kid in her catchment. Family are unwilling to bring her to the hospital because of transportation difficulties. Also the mother of the child recently gave birth to a son and is not in good shape because her limbs are quite swollen. Satya was sent home with a pack of Sarwottam Lito and was asked to try to convince family to bring patient back to the hospital. If that is not possible have arranged for Taraman to examine them (mother and child) if they are willing to bring them to sanfe at his wife's private medical. Important to note that patient was brought in to Bayalpata after being referred by the CHW but was not given lito because pharmacy did not have enough on hand. Same child was verified for the level of malnutrition by Ranju and Sushant when shadowing the CHWs.

Kamala - Ward 3 (30 homes and 40 members) Ward 2 (20 homes and 40 household members). Covered in 2 days. 1 hr per day.  Average 1-2 household members. Fewer people in homes because harvesting rice.  5 referred. None have visited.

 

·               Talk to Pabitra and Santu personally about their unwillingness to deliver at the hospital.

·                      We are trying to increase the number of in hospital deliveries. This is because as you all may know, life threatening complications may arise and MMR in Achham are amongst the highest in the world. It is not normal for so many women to die in the process of labor. And it can simply be prevented by taking a clever step such as coming to the hospital on time or making regular visits to a healthcare center. 

·                     As women in the community who know Nyaya the best and what services we provide and as our reps to the community we really want to understand from your perspective why women here are more willing to deliver at home but not at a hospital.

·                     We understand that the challenges are cultural, social, economic and logistical. But, asking you and trying to understand what you guys think is our first step toward maybe saving more lives of women in this region.

o                     Pabitra - delivery at a hospital is uncomfortable; economic reasons (paisa nabhayera);  family pressure - have older family members who insist on ideas like deliveries at home are just fine

o                    When asked if the level of discomfort would decrease had there been a female doctor delivering babies than males, most of them agree that women would be more comfortable. 

o                    Other reasons mentioned by the CHWs:

o                           difficult transportation;

o                          SHP deliveries have incentives from govt. of Rs.1000;

o                          Family members unable to accompany them to the hospital;

o                          Some women have very short lasting labor (eg. CHW Pabitra Kunwar gave birth to a son less than a month ago, and was only in labor for half an hour before the delivery was over. Said primary reason she decided not to deliver at the hospital was the hike from Mastamandu. Judging from her own past she knew her deliveries would only last for a very short period of time and so she did not want to risk having a baby midway had she decided to be brought to the hospital.

o                          Difficult to bring women in labor to the hospital

 

·         DON’T SAY  IT TO THEM BUT MAY NEED TO PROMPT IF THEY DO NOT SPEAK MUCH:

o  Hospital is uncomfortable?

o  Can't leave home for that long, have family/kids to take care of? Have work to do?

o  Too uncomfortable/difficult to walk after water breaks to the hospital

o  Family pressure to deliver at the home

o  Other cultural stuff? (things like blood is considered dirty and so husbands don’t want to touch the women or child immediately after birth or women birth in the cowsheds)

o  Belief that home delivery works fine

o  No one to accompany women to the hospital

o  Heard bad anecdotes about hospital deliveries

 

·               Ask all of the CHWs to list reasons why women in the community are unwilling to deliver at the hospital. Include all reasons that you might personally believe or even those that you have been told by community members.

  - Ask why pregnant women normally show up for first couple of their ANC visits but very few of them

     actually deliver at the hospital. Why does hospital tend to matter so little at the very end.

This was covered. See above.

 

·               ANC knowledge quiz (look more into CHW course book and where there is no doctor books). Ask questions to them individually.

 

1.       गर्भवती आामाको स्याहार कसरी गर्ने? गर्भवती महिलाले कस्तो खालको खाना खानु पर्छ? Santu with pabitra together answered this question. Santu listed out most but Pabitra had to help out with the last couple.

 - शक्ति दिने खाना खाने (चामल, घिउ, कोदो, तेल आदि)           

 - शरीर व्रिद्धि र बिकास गर्ने खाना (गेडागुडी, माछामासु, दुध, दही, फुल)

            - रोगबाट बचाउने खाना खाने (सागसब्जी, फलफुल र अरु तरकारीहरु)

 -  सन्तुलित आहार बाहेक: थप आइरन, आयोडिन, भिटामिन आदि खानुपर्छ

 

     2.  गर्भवती महिलाले सु्त्केरी नहुने बेलासम्म स्वस्थ जाँच कति पटक गराउनुपर्छ?

·         ४ पटक

पहिलो पटक:  गर्भवती भएको थाहा पाउने बित्तिकै

दोस्रो पटक: ५ देखि ७ महिनाको बीच

तेस्रो पटक: ९ महिना पुगिसकेपछि

चौथो पटक:  गर्भको अवधिको अन्त्यमा वा बच्चा जन्मने

 

     3.  गर्भ अवस्थामा गर्न नहुने कुराहारु केके हुन् ?

·         धेरै ठूलो भारी नउचाल्ने

·         धुम्रपान, रक्सी वा अरु लागु पदार्थको सेवन् नगर्ने

 

4.       स्वास्थ्य संस्थानमा गर्भको जाँच गराउदा केके गरिन्छ?

·         महिलाको जाँच गरिन् ANM बाट वा डाक्टरबाट

·         रक्तचापको जाँच गर्ने

·         टिटानसको सुइ लगाउने

·         गर्भको चौथो माहिनापछि, १.५ महिनाको लागि आइरन चक्की ख्वाउने

·         भिटामिन ए र जुकाको औषधि पनि एक मात्रामा ख्वाउनुपर्छ

·          भिडियो एक्स-रे वा खुन चेक जस्ता कुराहरु सामान्य रुपमा गराइदैन

 

5.       गर्भवती अवस्थामा हुन सक्ने खतराका लक्षणहरु केके हुन्?

·         ज्यादै टाउको दुख्ने

·         रगत बग्ने

·         मुर्छा पर्ने गरी हात खुट्टा अररो हुने

·         हातखु्ट्टा सुन्निने

·         तल्लो पेट दुख्ने

 

खतराको लक्षण देखिएमा के गर्नु पर्छ?

 

6.       सु्त्केरी अवस्थामा हुनसक्ने खतराका चिन्हहरु केके हुन्? Satya unable to answer successfully.

·         बच्चा जन्माउनु अघि वा जन्मि सकेपछि धेरै रगत बग्ने

·         पहिले नै साल निस्किएमा

·         पहिले खुट्टा निस्किएमा

·         पहिले हात निस्किएमा

·         लामो सु्त्केरी बेथा लागेमा

·         साल बाहिर ननिस्कने

 

यस्तो अवस्थामा केके नगर्नाले आमाको ज्यान जान सक्छ?

 - परिवारले समयमा स्वास्थ्य संस्था लैजाने निर्णय गर्न ढिला गरेमा

            - स्वास्थ्य संस्था पुर्याउनमा ढिला गरेमा

 -  स्वास्थ्य संस्थामा उपचार गर्नमा ढिला भएमा

 

·               Obtain ethnographic information from Pabitra Kunwar re: Ekendra Kunwar' s DOTS therapy; the first TB patient who successfully completed his therapy.

 

Could not get to this agenda at this meeting. Have asked CHW Pabitra Kunwar who was on maternity leave to bring her nephew Ekendra Kunwar along with her in another meeting.