Saumya Test file 2 text 1suppl

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'''Observation of PSBI cases-classified and managed at Primary Healthcare facilities''' '''xx'''

Of all the cases that were assessed, classified as PSBI and managed at primary healthcare facilities of the study block, 85% were directly observed by the IMNCI trained facility monitoring team. <s>The objective of these observations was to assess the quality of assessments by healthcare providers and ensure the availability of necessary equipment and consumables to manage PSBI cases at primary healthcare facilities</s>. The majority of cases (95%) were assessed at the Community Health Center (CHC), with Community Health Officers (CHOs) being the primary assessors in most of the cases (86%).

During the initial quarter of operationalization (post-training), digital thermometers were available in only 30% of cases. However, availability improved over time through indenting, and by the third quarter, all cases were assessed using a digital thermometer. Throughout the study period, all cases assessed at the CHC were weighed using an analog weighing scale. ARI timers were not available in the health system supply, so mobile phone timers were initially used to count the respiratory rate in young infants. Later, these were replaced by the IMNCI application, which has an inbuilt timer for respiratory rate counting.

Consumables such as injection gentamicin, syringes (1 ml, 3 ml), and needles (23 gauge) were available only at the CHC, whereas oral amoxicillin was available at all primary healthcare facilities, including Ayushman Arogya Mandirs (AAMs), Primary Health Centers (PHCs), and the CHC, at the time of case observation. The modified PSBI treatment card was properly filled out for approximately 91% of cases. However, for ~8% of cases, assessors did not mention all the required information in the treatment card, like the address of family and contact number, the infant's current weight (although it was measured), or the correct subclassification of PSBI. Additionally, for about 1% of cases, the PSBI treatment card was not filled at all, as the infants were referred immediately after birth.[[File:BJS_250_image6.png|451x288px]]

[[File:BJS_250_image7.png|438x288px]] Among the cases managed by CHO, e-sanjeevani for teleconsultation was utilized by only ~3% (2/74) of them, in which the consultation was done only in one case where MO was available for providing teleconsultation to CHO on e sanjeevani on the other side. 7% (5/74) among all CHO and 6% (4/72) among those who did not utilize e-sanjeevani, did teleconsultation with medical officers via call. During the initial phase of operationalization, the measurement of vitals in sick young infants (SYIs) was inconsistent (graph), with the implementation support team often stepping in, particularly for weight assessment. However, over time, adherence to vital assessments improved significantly. By the third quarter, nearly all SYIs had their weight, temperature, and respiratory rate measured as part of routine clinical practice.

Graphs (X) shows that while assessing infants according to the IMNCI protocol, assessors investigated feeding problems, chest indrawing, and lethargy in almost all sick young infants. In approximately 90% of cases, they inquired about the history of convulsions. Inquiry about jaundice and diarrhea was conducted in nearly three-fourths of cases. Although this improved over time, jaundice and diarrhea were still not assessed in 13% of cases each, despite adherence to the IMNCI protocol.

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'''Discussion'''

The study elicits the feasibility of implementation of community-based management of sick young infants (aged 0-59 days) with PSBI at primary healthcare facilities when referral is not feasible. The PSBI identification coverage during the implementation phase was 71%, which was comparable to the identification rates reported in Palwal, Haryana (70%) ([https://pubmed.ncbi.nlm.nih.gov/34234352/ <u>ref</u>]). It is higher than Ntcheu, Malawi (63.8%) ([https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229248 <u>ref</u>]), Pune (57%) ([https://pubmed.ncbi.nlm.nih.gov/32833993/ <u>ref</u>]), Lucknow (53%) ([https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234212 <u>ref</u>]) and Kushtia, Bangladesh (31%) ([https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232675 <u>ref</u>]) and lower than Zaria, Nigeria (95.5%) ([https://pmc.ncbi.nlm.nih.gov/articles/PMC7064229/ <u>ref</u>]), Pakistan (95%) ([https://academic.oup.com/jpubhealth/article/45/1/176/6524747 <u>ref</u>]), Mekelle, Ethiopia (87%) ([https://pubmed.ncbi.nlm.nih.gov/33544712/ <u>ref</u>]).

This study underscores the importance of addressing barriers to care seeking and a need for community engagement beyond the home visits by health workers which have reportedly been low in coverage even with substantial program support ([https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229248 <u>ref</u>]. A notable strength of this study was the active engagement of mothers and families as primary reporters of illness to improve the coverage and timeliness of care seeking. It also focussed on empowering these mothers around the decision making and hand holding in “stepping up” and seeking care . This intervention of introducing a Central Care Coordination System (CCCS) or SakshaMa helpline, filled the current need of encouraging uptake of the service by caregivers through community-based sensitization ([https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229248 <u>ref</u>], [https://www.bmj.com/content/339/bmj.b2826 <u>ref</u>], [https://pubmed.ncbi.nlm.nih.gov/35003714/ <u>ref</u>], ref, [https://www.example.com/study-kumar-2021 <u>ref</u>]). However, there is a need to further optimize this process for scalability and cost effectiveness. ASHA contributed to a substantial proportion (18%) of illness episodes and emphasizes their pivotal role in early identification and linkage to formal healthcare services. Her positioning, and potential of home based newborn is promising, however, improving its coverage and quality is an area that needs further exploration and innovation.

Another aspect highlighted through the study was the preferred utilization of primary health facilities (46.6%). The availability of quality services at these facilities was a major motivating factor for the community to seek care from these facilities. It is interesting to observe the trends of the referral acceptance, wherein, cases with Critical Illness had 100% acceptance while the referral acceptance was lower among cases of Clinical Severe Infection (CSI) at 36% (20/55), and notably minimal for severe pneumonia cases, with only 6.7% (1/15) referral acceptance.

This possibly indicates that caregivers only prefer tertiary care facilities and inpatient treatment pathway when they perceive the “severity of illness” to be high. There are other multiple aspects to this acceptance such as the effectiveness of counselling, fear of out-of-pocket expenses, distance etc. (ref). The helpline played a critical role in this piece by prioritizing patient admission through coordination with facility nodal, ensuring bed availability at the tertiary facility, and providing the necessary handholding support to these families in navigating through the “unknown” set up. Despite these interventions, there is a substantial population that is seeking care through informal practitioners and not seeking care outside home for newborn illness (10.3% and 14.4%, respectively) highlights the need to design more comprehensive approach for this population that was reported in other studies also as a missed opportunity for PSBI identification &amp; management ([https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-023-10065-x <u>ref</u>], [https://www.sciencedirect.com/science/article/pii/S2949856224000394?via%3Dihub <u>ref</u>], [https://preprints.jmir.org/preprint/36287 <u>ref</u>], ref, ref, ref). Although the study was designed to handhold the community to redirect the care seeking towards public health facilities, it was observed that nearly one-fourth (24%, 30/124) of cases were reaching the facility for care seeking by themselves once the services were established at primary healthcare facilities which were operationalised in the later part of the implementation phase, and the information spread through word of mouth in the study area.

The case fatality rate (CFR) found in the current study was 4% (5/124), which is considerably lower than the global pooled estimate of 9.8% for PSBI infants. Moreover, there were no reported deaths among the PSBI cases managed as outpatients at primary healthcare facilities with a simplified antibiotic regimen, indicating the potential effectiveness and safety of this approach in this setting. However, five deaths occured in infants that were referred and treated at tertiary care facilities out of which three infants that had comorbidities besides PSBI.

Another major progress which is significant programmatically and from a service delivery perspective is the inclusion of Community Health Officers for administration of antibiotics under the supervision of Medical officers as most of the previous study highlight at the limitation by the Auxiliary Nurse Midwives both in terms of their competency and operational challenge of not being able to operate from the sub-centres throughout the week. This inclusion is in line with the newly launched SAANS guideline as well as the AB-AAM initiative to improve the outreach of health system delivery. However, the treatment administration from AB-AAM for PSBI cases requiring injectable drug administration still remains a challenge at these centres and such cases need to be referred to CHC for simplified antibiotic regimen. CHOs hold promise for bridging the care gap in pediatric expertise at the community level, ensuring timely assessment, classification, and management of young infants' illnesses.

Unlike previous studies, this study adopted a bottom-up approach and did not rely on the Technical Support Unit for review and monitoring or technical supervision. On the contrary, this study relied on utilising existing resources at the block level and leveraged them under the leadership of the Medical Officer In Charge for complete ownership of programmatic implementation of case assessment, management and facility operationalisation. However, we acknowledge the scope of a monitoring body at the district and state level from a perspective of scale up across the district.

The limitation of this study is that despite intensive efforts with ASHA and other frontline workers, we could not establish a mechanism of follow up of young infants with PSBI in the community. This challenge was particularly notable among cases of PSBI with only fast breathing, crucial for adherence to the course of antibiotic treatment ([https://www.example.com/study-rahman-2017 <u>ref</u>]). Also, active efforts to improve care seeking through two strategies: the community outreach of the helpline, and ASHA workers' both of which emerged as a critical driver for formal care-seeking, are promising strategies can be scaled to other settings with limited healthcare access. But despite these strategies also, a significant population does not adhere to care seeking advice due to complex intertwined belief and information systems at the community level that are influenced by their understanding of disease etiology and the level of trust in public health facilitie'''<span class="mark">s.</span>'''



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