|Year : 2012 | Volume
| Issue : 2 | Page : 79-84
An evaluation of skill and knowledge in delivery of reproductive and child health services by female health workers in Jamnagar District and corporation area, Gujarat state, India
Naresh R Makwana, Viral R Shah, Sudha Yadav
Department of Community Medicine, Shri M. P. Shah Medical College, Jamnagar, Gujarat State, India
|Date of Web Publication||27-Sep-2012|
Naresh R Makwana
Department of Community Medicine, M. P. Shah Medical College, Jamnagar, Gujarat
Source of Support: Additional Director (ME), Government of Gujarat, Conflict of Interest: None
Background: Infant mortality rate and maternal mortality rate are key indicators of Health situation in India and also reflect the degree of achievement of Reproductive and Child Health (RCH) Program. Female health worker (FHW) is a grass-root worker and has key role to provide quality service and success of RCH Program. This study was designed to assess the skill and knowledge of FHW in delivery of RCH services. Materials and Methods: A cross-sectional study was conducted in the Jamnagar district during October 2008 to March 2009. All female health workers (FHWs) (n = 63) of 10 randomly selected Primary Health Center, one primary health care (PHC) from each Talukas and Corporation area, were selected and their skills and knowledge were assessed by observing and interviewing by the pretested oral questionnaire method. Results: Antenatal care achieve impressive coverage of more than 95% with regards to antenatal registration, tetanus toxoid to pregnant women, and iron-folic acid (IFA) tablet prescription to expectant mothers. Distressingly only half of the workers knew about "Five Cleans" and Resuscitation of new born child. Skills and knowledge regarding postnatal services and Family Planning services was variable among FHWs. Immunization service found to be good among all FHWs. Conclusion: Quality of services needs to be improved by train and re-train the workers on different aspects of the RCH program, so that their skills and knowledge can be utilized well. Support system of supervision and monitoring of activities of FHWs should be strengthened.
Keywords: Evaluation, female health worker, knowledge, RCH, skill
|How to cite this article:|
Makwana NR, Shah VR, Yadav S. An evaluation of skill and knowledge in delivery of reproductive and child health services by female health workers in Jamnagar District and corporation area, Gujarat state, India. Int J Health Allied Sci 2012;1:79-84
|How to cite this URL:|
Makwana NR, Shah VR, Yadav S. An evaluation of skill and knowledge in delivery of reproductive and child health services by female health workers in Jamnagar District and corporation area, Gujarat state, India. Int J Health Allied Sci [serial online] 2012 [cited 2023 Jan 29];1:79-84. Available from: https://www.ijhas.in/text.asp?2012/1/2/79/101688
| Introduction|| |
Reproductive health i.e. "state of complete physical, mental, and social well-being which enables the people to have satisfying and safe sex life, capability to reproduce and information and access to safe, effective, affordable, and acceptable methods of family planning of their choice", can be achieved only through delivery of reasonable quality of health care services.  As the National Family Welfare Program moved from target-based activity to client centered, demand driven, quality service program, subcenters are to be geared up to fulfill the aspirations of the people.  As female health worker (FHW) has key role for delivery of quality reproductive and child health (RCH) services through subcenters they are the backbone of the primary health care (PHC).  The spectrum of services has been enlarged and emphasis has shifted from the number of cases to quality and coverage of services as also client satisfaction. The full range of maternal and child health services has been the concerned with decentralized planning driven by client needs. 
Only those FHWs who have good knowledge, positive attitude, and proper skills can help the community regarding PHC and family planning.  The present study was, therefore, an attempt toward assessing the skills and knowledge of FHW in delivery of reproductive health care services. Skills comprise technical skill, supervisory skill, management skill, and communication skill. Several methods are available for assessing the skills of FHW for providing quality services ranging from direct observations, supervision, interview of the target clients as also examination of records, and facility survey. 
| Materials and Methods|| |
The purpose of present study was to assess the skills and knowledge of FHWs in relation to RCH services of Jamnagar District, Gujarat. The duration of study was 6 months from 1 October 2008 to 31 March 2009. Jamnagar district is divided into 10 Talukas and 1 Primary Health Center from each Taluka has been selected by a simple random sampling technique method. All FHWs (57) of 10 Primary Health Centers were enrolled in the present study. This load is almost 25% of the total load of FHWs in whole district. The same proportion of FHWs (i.e. 25% = 6 FHWs out of 24 workers) was also selected from the Jamnagar Municipal Corporation area and covered under the study. Thus, total 63 FHWs were evaluated for their knowledge and skills in delivering RCH services.
A questionnaire was used after pre-testing, containing the process indicators for Community Need Assessment Approach (CNAA), sub-center action plan, and community consultative process. The questionnaire had three components - first part containing questions regarding the functions of FHW; second part was observation of records, and finally assessment of quality of care provided by FHWs. The questionnaire regarding the function of FHW sought information about the knowledge and awareness about CNAA and assessment of service requirement of sub-center. Various information regarding ANC care, intra-natal care, postnatal care, immunization skill, and family planning services was collected and "Quality of Care" Provided by FHWs in context of Clinical quality, quality of information provided by FHWs and prophylactic treatment given to mothers by FHWs.  Clinical quality was measured by ever performance of essential physical examination, tests, and services provided by FHWs. i.e. measurement of weight, fundal height, blood pressure, urine, and blood testing. Quality of information provided was measured by information provided on diet, danger sign, newborn care, and family planning. Quality of prophylactic treatment was assessed on the basis of percentage of mothers received antenatal tetanus toxoid (TT) and IFA tablet supplementation. 
Data collected was analyzed by the EPI INFO (version 6) statistical software.
| Results|| |
[Table 1] shows differentials in educational status of FHWs their work experience, whether they had taken training or not and how these differentials affects "Quality of Care" in context of clinical quality, quality of information provided to mothers, and prophylactic treatment given to mothers i.e. antenatal TT immunization and IFA tablet supplementation. These differences are statistically significant at all levels except educational status does not have positive impact for recording blood pressure, work experience for recording blood pressure and measuring weight of mothers, and work experience in providing quality information on family planning, otherwise table shows that higher education, more work experience and follow up training have positive impact on clinical quality, information quality, and prophylactic services provided by FHWs as shown by P value.
|Table 1: Differentials in quality of care provided by female health workers|
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[Table 2] depicts that quality of antenatal care services was found to be good in respect to essential obstetric care which is 60 (95.2%) for antenatal visits, 59 (93.7%) for TT immunization and 53 (84.1%) for IFA tablet. Other component of antenatal services i.e. weight measurement, blood pressure recording, HB estimation were satisfactory while skills for measuring fundal height, fetal heart sound, and edema examination was not satisfactory.
Data of [Table 3] reveal poor quality of natal services. 30 (47.6%) FHWs have no knowledge regarding resuscitation of newborn, 28 (44.4%) about five cleans, and only 11 (17.5%) FHWs knew about prompt referral of mothers.
[Table 4] shows that services rendered during post-natal period was good in respect to discouragement of pre-lacteal feeds, advice for exclusive breastfeeding (EBF), instruction on health benefits, and method of breast feeding, distribution of IFA to clients, etc. but only 18 (23.8%) FHWs had knowledge about post-natal complications.
[Table 5] shows that 60 (95.2%) FHWs gave correct advice on family planning to their clients. 28 (44.4%) asked about client's age, 36 (57.1%) about the details of previous pregnancy, and 30 (47.6%) for previous use of family planning methods and examined the clients for pelvic inflammatory disease (PID). More than 47 (75%) FHWs had described contraceptive options, explained correct usage of selected method, and place to go for resupplies. Only 21 (33.3%) FHWs had correct knowledge of medical termination of pregnancy (MTP).
[Table 6] shows good maintenance of cold chain i.e. 61 (96.8%). Knowledge component regarding Universal Immunization Program (UIP) schedule is strong 57 (90.5%) but the faulty technique and wrong selection of site for vaccine is found in almost one fourth of workers. Very poor knowledge and practice is seen for biomedical waste disposal in 23 (36.5%) and important four key messages given to parents in 18 (28.6%). Knowledge and skill for other elements at immunization session was satisfactory except "Shake Test" for DPT vaccine.
| Discussion|| |
This study indeed opened a vast window which will help us to peep through deficiencies of health system particularly in implementation of RCH-II Program which put emphasis quality of service rather quantity.
Qualification statistics of FHW showed that almost two-third (65.1%) FHWs educated up to higher secondary and/or above and 68.3% of FHW had work experience 10 years or more. These differences in educational status, work experience, and on-duty follow up training of FHWs are statistically significant in providing "Quality Care" in RCH services. This data suggest higher education level and better work experience than study conducted by Khan et al.  (2006), noted only 60% of Lady Health Worker were matriculate and only 16% of FHWs had work experience 5 years or more.
Recording of fetal heart sound, fundal height, and examination of edema feet was found in almost half of the health workers. Antenatal care was confined to Antenatal visits, distribution of IFA tablet, TT injection immunization, blood pressure measurement, and hemoglobin estimation of client. No single FHW had distributed insecticide-treated mosquito nets (ITMN) to beneficiary. 92.1% and 88.9% of FHW explained about Janani Suraksha Yojna (JSY) and Chiranjeevi Yojna, respectively. Khan et al,  (2006) reported required level of knowledge, attitude, and skill regarding antenatal care. Study findings are consistent with findings of Agrawal et al. (2001) reported antenatal care confined to antenatal visits, TT immunization, and IFA distribution. Lal  (2001) reported a near universal coverage level of 95% in respect to antenatal registration but only 5.8% of mothers were distributed full course of IFA tablet suggest high coverage level as observed by key maternal and child health service did not correspond with quality coverage as only 28% of ANC received three antenatal check-up and only 3.5% of them were registered early (in the first trimester of pregnancy).
All elements of natal services were performed poorly. Only half of Female FHWs had knowledge of five cleans and resuscitation of new borne. Surprisingly only 17.5% FHWs knew when to refer a mother to higher center. Almost three fourth (76.2%) of FHWs knew about the importance of weighing a new borne. Agrawal et al. (2001) on the contrary reported good performance in natal services. Lal et al. (2001) reported only 29.4% of new borne babies have been weighed after birth.
Despite of having knowledge regarding frequency and importance of postnatal examination of mother and baby, very few mothers and new borne got adequate attention. 93.7% of FHWs discouraged mother for prelacteal feeds, 98.4% advised for exclusive breast feeding, and 77.8% of FHWs explained about health benefits of Breast Feeding and instructed mother for the right method of breast feeding. The level of performance in postnatal service was low in a study conducted by Agrawal  (2001) who reported that 35% of clients were told about health benefits and only 1.3% of clients were explained about right method of breast feeding. Good knowledge regarding breast feeding, practices, and methods in the present study may be attributed to Integrated Management of Neonatal and Childhood Illnesses (IMNCI) training of FHW in Jamnagar District.
Family planning services were good in the context of some elements i.e. 90% of FHW gave correct advice about spacing methods, 77.8% explained correct use of selected method, and 84.1% of FHW inserted IUD by the right method. Only disappointing finding was as much as 66.7% of FHW didn't have correct knowledge of MTP. Khan et al. (2006) reported 94% of workers were quite aware of importance of family planning; they also reported that in the context of practice in relation to the method of use of contraceptive (70%). A report on evaluation Program initiated in 1999 carried out by Oxford Policy Management demonstrated that the performance of about 17% of FHW was poor and 35% were below average. 
Quality of immunization services found to be good except biomedical waste disposal and key messages after vaccination (36.5% and 28.6%, respectively). These results are consistent with the findings of Lal et al. (2001).
| Conclusion|| |
This study reveals that higher education, work experience and follow up on duty training have positive impact in quality of RCH services provided by FHWs in context of clinical quality, information quality, and prophylactic treatment to mothers.
The present study also reveals that quality of antenatal service provided by FHWs was good in context of essential obstetric care and clinical examination of antenatal women. Poor quality of intra-natal service has been noted among FHWs which is an alarming signal because it is risk factor for early neonatal mortality and thus infant mortality. Delivery of post-natal services was excellent in terms of discouragement of pre-lacteal feeds and exclusive breast feeding. Delivery of immunization services for under-five children was satisfactory but at the same time practice for biomedical waste was poor.
This study opened a window to peep through the deficiencies in quality RCH services. It showed that most of female health workers had optimum knowledge and optimistic attitude and skill in some areas of RCH i.e. antenatal services, immunization services, and family planning services while the quality of intranatal and postnatal services are needed to strengthen.
Improvement in various skills of female health workers and thus improvement in the quality and coverage of maternal and child health and family planning services at subcenter and PHC level can be achieved by interventions i.e. reorientation training of health functionaries for improving their managerial, technical, and supervisory skills for comprehensive RCH and FP services, community education and improving data recording, reporting and feedback system at PHC and subcenter level. An adequate support system of primary health center must be ensured on sustainable basis through fixed tour program and supervisory visit.
| Acknowledgment|| |
Our special thanks to Additional Director (ME), Government of Gujarat for funding this research activity.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]