Healthy plan it

• 1. HEALTHY PLAN- ITShreejeet Shrestha(MPH, M.Sc.Medical Microbiology)

2. IntroductionJamyne is Very small developing country inSouthern Asia. It has the total area of 1,10,109 sqk.m. The population is around 20 million and ithas 6 provinces and 33 districts. The mainreligion of the country is Buddhism and Hinduismwhich are 85% of the population, 15%, havebelief on Islam and Christianity. The lifeexpectancy at birth is 59 years.In Jamyne, we want to focus everyones attentionin one community-Jamyka. 3. Jamyka shares a very difficult geography as thecommunity is situated in the hilly area. The main occupation of the people in thiscommunity is agriculture. But, there are very fewpeople who own land. Most of them work on adaily wage basis in others field for their survival. Because of its location, as it is somewhat isolatedfrom the other communities of the country, theowners dont get much price selling them in themarket so average income of the people of thatarea is not good. 4. It is male dominated community so women arenot involved in the decision making. Almost 75percent of women respondent reported thathusbands alone make decisions about womenshealth care. This exclusion compromises the health and wellbeing of all family members, particularly womenand children, and is often linked to high maternaland child mortality rates. 5. There are two schools in the village but very fewparents sent their children to the school. However, theteacher is trying to convince the parents to sent theirchildren to school but the families need their childrento take care of the younger siblings so they dont getto go to school. Women of this community are largely illiterate andsuffer from socio-cultural barriers to accessing healthservices, such as restrictions on leaving their homesor on interacting with strangers, and frequently do nothave access to a health center or health clinic. Illiteracy has also led to early marriage and earlypregnancy among women. The average number ofchildren is 4-5 per women because they also lackknowledge about family planning. 6. Women has to work at home, in the field anddont get much time to rest. They eat after theirfamilies eat, usually the left over of their husband.This has led to the poor nutritional status of themother. Again, after having children, they dont get tobreast feed the baby much as they have to work,that has lead to poor nutritional status of theinfants. Lack of hygiene and access to safe water oradequate sanitation has also increased the riskof children to have repeated diarrhea. Repeateddiarrhea has also led to malnutrition amongchildren. 7. The community has deep rooted traditionalvalues and beliefs. Their socio-culturalbackground have raised unresponsive andculturally inappropriate health and nutritionservices. There are many taboos related tobreastfeeding and weaning. They have the habit of eating stale food. Theylack the knowledge regarding personal hygieneand basic sanitation. 8. Situation Analysis As per survey done by UNICEF in 2011 it wasfound that the mortality of under 5 children wasas high as 82 per every 1,000 children in Jamyne. The report also showed that the major killerdisease in this group was Diarrhoea, Respiratoryinfections and Anemia. 9. However, it was found that Malnutrition was themajor underlying cause for the death of thechildren of under 5 years age as diarrhealdiseases, ARI , Anemia were found closelyassociated with Malnutrition. Prevalence of Malnutrition in under 5 children asper the Report in Jamyne:1stdegree Malnutrition - 55%2nd degree Malnutrition - 22%3rd degree Malnutrition - 4% 10. UNICEF has focused in its report that malnutritionshould be taken care of if we want to improve thehealth of under 5 children in Jamyne. 11. The Basic Priority Rating System(BPRS)109876543210DiaRrrehsepairatory InfectioHnIsV CancSetrroke, DM, HTNSize of Problem ASeverity of Disease, BEffect of Program, C 12. BPRS SCORE300250200150100500Diarrhea RespiratoryInfectionsBPRS Score=[A+2B] x CHIV Cancer Stroke, DM, HTN[A+2B] x C BPRS Score 13. Problem Statement Under 5 mortality was found to be as high as 149per 1000 which is 50% more than rest of thecountry and Malnutrition was found to be ascommon as 75% [1st degree] and 10% [3rddegree] in Province A, as of 2011. 14. GOAL To reduce all form of Malnutrition by at least 50%of existing rate in Province (A) of JAMYNE by2013 15. Health Problem Determinants Direct Contributing FactorsMalnutrition inchildren under5 years old inJamyneNutritionalDeficiencyDecrease Intake of Balance DietRepeated DiarrheaParasiticInfestation +other infectionslike Measles andDiarrheaPoor Protective Practices likewalking barefootImproper Treatment of the underlyingconditionPoor Personal Hygiene and poorsanitationNutritional Statusof MotherInadequate intake of food by mothersMultiparityLow family incomeHealth Problem AnalysisIncreased workload of themothers 16. Determinant Direct ContributingFactorsIndirect ContributingFactors Level (1)Parasitic Infestation +other infections likeMeasles andDiarrhoeaPoor ProtectivePractices like walkingbarefootImproper Treatment ofthe underlyingconditionPoor personal hygieneand poor sanitationLack of safe drinkingwater facilityPoor Socio-economicConditionLack of Knowledgeand awareness aboutsanitation andpersonal hygieneLack of health careservices i.e. an accessto Anti-parasitic drugs 17. Determinant Direct ContributingFactorsIndirect ContributingFactors Level (1)Nutritional status ofmotherInadequate Intake ofnutritious food by motherduring pregnancy andlactationIncrease workloadMultiple pregnanciesTaboos and socio-culturalbackgroundi.e. avoidingLack of awarenessabout nutritious foodduring pregnancy andLactationUnavailability of nutritiousfood.Socio-economic condition.i.e. work as a daily wagelaborer in others farmMale dominatedsociety so female dontget much time to rest.Lack of knowledgeabout family planningIlliteracy/Low familyincome 18. Intervention pathway 19. Direct contributingFactorsIndirect Contributing FactorsLevel (1)IndirectContributing Level (2)DeterminantDecrease Intake ofbalance dietInadequate breast feedingFood CultureInappropriate Technique ofbreast feedingLack of knowledge andtaboos related to breastfeedingLack of knowledge andImproper Weaning taboos related to weaningNutritional DeficiencyLack of knowledge aboutstorage, preparation andcooking of foodUnavailability of nutritious foodFood TaboosLack of Knowledge regardinglocally available nutritiousfoodPoor socio-economic statusLack of Vitamins and mineralsupplementation 20. Intervention strategy and objectives 21. Inadequate breastfeedingTo increase thepercentage of womenwho breastfeed theirbaby adequately by 50%Improper WeaningPercentage of motherexclusively breastfeedingtill six months by 80%Food cultureTo raise awarenessregarding good practicesof food.Unavailability of foodsTo promote knowledgeregarding alternativefoodsTo providesupplementary nutrientsNutritional DeficiencyTo improve thenutritional status ofunder 5 children by 60%Decrease intake ofbalance dietTo increaseconsumption ofbalance diet by 60%Malnutrition in under 5childrenTo reduce theprevalence of all types ofmalnutrition of under 5children by 50%Indirect contributingFactors Level (1)Indirect contributingFactors Level (2)Determinant Direct contributing Factors 22. Intervention decision matrix 23. Possible Interventions (Activities) Impact(1-10)Easy to do(1-10)1. Mass media health education(Importance of breast feeding)5 92. FGDs (Knowledge and taboos relatedto breast-feeding8 53. Community Participation in breast-feedingweek event6 84. Health Education on proper weaning 8 75. Demonstration regarding appropriatebreast-feeding techniques7 76. Role-play to raise awareness of good-foodpractice7 67. Demonstration of locally availablenutritious food5 78. Community Meal Program 9 59. Vitamins and Mineral supplementationprogram8 5 24. Intervention design table 25. HEALTH PROBLEM:Determinant: Nutritional DeficiencyDirect Contributing Factor: Decrease intake of balance dietIndirect Contributing Factor ( Level 1) :Inadequate breast-feedingINDIRECTCONTRIBUTINGFACTOR 1a(LEVEL 2)WHO IS THE TARGETFOR CHANGE?WHAT WILL CHANGEIN THE INDIRECTCONTRIBUTINGFACTOR?(Outcome Objective)INTERVENTION DESIGN-HOW WILL YOU CHANGE IT?TYPE OFINTERVENTIONLOCATION SCOPEInappropriate breastfeeding techniqueLactating andpregnant womenPercentage ofmother properlybreast feeding babywill be increasedDemonstration CommunityDuring ANC visitAll lactatingmothers andpregnant womenINDIRECTCONTRIBUTINGFACTOR 1a(LEVEL 2)WHO IS THE TARGETFOR CHANGE?WHAT WILL CHANGEIN THE INDIRECTCONTRIBUTINGFACTOR?(Outcome Objective)INTERVENTION DESIGN-HOW WILL YOU CHANGE IT?TYPE OFINTERVENTIONLOCATION SCOPELack of knowledgeand taboos relatedto breastfeeding(Not feedingcolostrums, feedinghoney etc.)FamilyParents +GrandparentsKnowledge aboutimportance of breastfeeding, importanceof colostrums will beimproved-FGD-Radio programs-Communityparticipation inbreast feedingweek eventsCommunityCenter/CommunityMeeting HallAll lactatingmother and herfamiliesIntervention Design Table 26. HEALTH PROBLEM:Determinant: Nutritional DeficiencyDirect Contributing Factor: Decrease intake of balance dietIndirect Contributing Factor ( Level 1) : Improper WeaningINDIRECTCONTRIBUTINGFACTOR 1a(LEVEL 2)WHO IS THETARGET FORCHANGE?WHAT WILLCHANGE IN THEINDIRECTCONTRIBUTINGFACTOR?(OutcomeObjective)INTERVENTION DESIGN-HOW WILL YOU CHANGE IT?TYPE OFINTERVENTIONLOCATION SCOPELack of knowledgeand taboos relatedto weaning ( earlyweaning before sixmonths or lateweaning after 2years, feedingsame food as theparent have forlunch or dinner)Lactating mothersand her familiesPercentage ofmother exclusivelybreast feeding tillsix monthsHealthEducationprogramCommunitycenterAll lactatingmother andher familiesIntervention Design Table 27. HEALTH PROBLEM:Determinant: Nutritional DeficiencyDirect Contributing Factor: Decrease intake of balance dietIndirect Contributing Factor ( Level 1) : Food cultureINDIRECTCONTRIBUTINGFACTOR 1a(LEVEL 2)WHO IS THE TARGETFOR CHANGE?WHAT WILL CHANGEIN THE INDIRECTCONTRIBUTINGFACTOR?(Outcome Objective)INTERVENTION DESIGN-HOW WILL YOU CHANGE IT?TYPE OFINTERVENTIONLOCATION SCOPELack of awarenessregardingImportance of locallyavailable foods(Preparation ofsuper flour fromgrains, vitamins andmineral sources tobe found invegetables andfruits.Household ofmalnourishedchildren andcommunity healthvolunteersAwareness will beraised about locallyavailable foods andimportance of themamong families andesp. families ofmalnourishedfamiliesDemonstrationDocumentarypresentationRole playCommunityCenterAll householdswithmalnourishedchildren andcommunityhealthvolunteersIntervention Design Table 28. INDIRECTCONTRIBUTINGFACTOR 1a(LEVEL 2)WHO IS THETARGET FORCHANGE?WHAT WILLCHANGE IN THEINDIRECTCONTRIBUTINGFACTOR?(OutcomeObjective)INTERVENTION DESIGN-HOW WILL YOU CHANGEIT?TYPE OFINTERVENTIONLOCATION SCOPELack ofknowledgeregarding storage,preparation andcooking of food(overcooking,washing foodsafter cutting,eating stalefoods, keepingsalt openly insunlight)Women as theyare one whocooks almost allthe timeIncreaseknowledgeregardingstorage,preparation andcooking of food.Demonstrationand FGDCommunitycenterAll women ofthatcommunity 29. HEALTH PROBLEM:Determinant: Nutritional DeficiencyDirect Contributing Factor: Decrease intake of balance dietIndirect Contributing Factor ( Level 1) : Unavailability of foodsINDIRECTCONTRIBUTINGFACTOR 1a(LEVEL 2)WHO IS THETARGET FORCHANGE?WHAT WILLCHANGE IN THEINDIRECTCONTRIBUTINGFACTOR?(OutcomeObjective)INTERVENTION DESIGN-HOW WILL YOUCHANGE IT?TYPE OFINTERVENTIONLOCATION SCOPELack of vitaminsand mineralssupplementationUnder 5 children To increaseaccess tovitamins andmineralsupplementationand fortifiedfoods.Communitymeal programVitamins andmineralsupplementation programsHousehold incommunityHealth centerAll childrenunder 5 years 30. Work breakdown system 31. Work Breakdown StructureIntervention design and WBSInterventionsProcess objectiveActivities TasksMass Media HealthEducation-To increase number ofradio programs on nutritionTo broadcast aboutimportance of nutrition onRadioDistribute flyersPrinting message in flexand hoarding boards Prepare Script Identify nutritionist and invitingthem to talk about nutrition Prepare material content forflyers and posters Print flyers and posters DistributionFocus Group Discussion-Number of FGDconducted per monthArranging a team for FGDInviting selectedparticipants to attend FGD Prepare for topic to be discussed Prepare questions Arrange for facilitator Decide on who will minute thediscussion Arrange for refreshment forparticipants Summarizing and preparing reportof FGD Evaluation and monitoringCommunity participation inbreast feeding week event-Number of participantsduring events-Number of events duringbreast feeding weekDoor to door breastfeedingawareness program Selecting one as coordinator ofthe event Inform community people toattend 32. Work Breakdown Structure cont.Intervention design and WBSInterventionsProcess objectiveActivities TasksHealth education on properweaning-Number of promotionprogramsWeaning food exhibitionMass education program onvaccine day Prepare materials for exhibition Arrange venue and time Inform community people toattend exhibition Report Monitoring and evaluation ofeffectiveness of the programDemonstration regardingbreast feeding techniques-To improve the techniqueof breast feeding forpregnant and lactatingmotherBreast feedingdemonstration sessionDistribution of postersshowing ways of breastfeeding effectivelyRe-demonstration Organizing small groupdiscussion on how to breastfeed Involve volunteers todemonstrate using dummybabies 33. Work Breakdown Structure cont.Intervention design and WBSInterventions ProcessobjectiveActivities TasksRole play to raiseawareness of good foodpractices-Number of role playconductedStreet play Prepare scripts Arrange for volunteers Prepare and practice drama Decide on venue and time forstreet play Monitoring and Evaluation ofthe programDemonstration of locallyavailable nutritious foodsDistributing IEC materialsof locally availablenutritious food Survey for locally availablenutritious food Prepare materials content forIEC Print IEC materials anddistribute it Decide on venue and time toconduct health promotionprogram Select spokes person Prepare report Monitoring and evaluation ofeffectiveness of the programConducting healthpromotion program onlocally available nutritiousfood 34. Work schedule 35. Activities and schedulesIntervention strategy Activities Target populationSchedulesJan Feb Mar Apr May Jun July Aug Sep Oct Nov DecMass Media EducationTo broadcast about importance ofnutrition on RadioCommunity peopleDistribute flyers Community peoplePosters Community peopleFocus Group DiscussionArranging a team for FGD Community peopleInviting selected participants toattend FGDSeleced participantsfrom community peopleCommunity participation in Breastfeeding week eventDoor to door breastfeedingawareness programPregnant women andlactating motherHealth education on properweaningWeaning food exhibitionPregnant women andlactating motherMass education program on vaccinedayPregnant women andlactating motherDemonstration regarding Breastfeeding techniquesBreast feeding demonstrationsessionPregnant women andlactating motherDistribution of posters showingways of breast feeding effectivelyPregnant women andlactating motherRe-demonstrationPregnant women andlactating motherRole play to raise awareness ofgood food practiceStreet play Community peopleInviting selected participants toCommunity peopleattend FGDDemonstration of locally availablenutritious foodDistributing IEC materials of locallyavailable nutritious foodCommunity peopleConducting health promotionprogram on locally availablenutritious foodCommunity peopleDifferent color means different village, yellow means wholearea 36. Monitoring and evaluation 37. Objective Indicator Source of data Responsible Person Report due to Report toTo reduce malnutritionby 50%No of malnourishedchildren under 5 years ageRecord fromhealth postLocal healthworkersYearly Project ManagerTo improve nutritionaldeficiency by 30%Childs weight for ageChild height for ageChilds weight for heightRecords fromhealth PostANMHAQuarterly Project ManagerTo increaseconsumption ofbalanced dietNumbers of families takingbalanced dietNutritionalSurveyVillage HealthVolunteerHealth WorkerstraineesTwice a year Project ManagerTo increase the % ofwomen breastfeedingproperlyNo of women breastfeedingtheir children exclusivelyGroup interviewSurveyANMHATwice a year Project ManagerTo increase the % ofmother exclusivelybreastfeeding till sixmonthsNo of mother breastfeedingtill six monthsSurvey Community HealthVolunteerQuarterly Project ManagerTo raise awarenessregarding goodpractice in foodpreparationNo of households withmalnourished childrenCommunity Health workerObservation oftheir cookingpractice afterthe programSkilled healthworkersYearly Project ManagerTo providesupplementarynutrientsNo of children receivingvitamins and mineralssupplementationRecords ofhealth postLocal communityworkerTwice a year Project Manager 38. Budgeting 39. Program Budgeting [2nd Stage]:Program Mapping: Villages-6, Households: 801,Population: 5,300.Manpower: Project Manager: 1 Public Health Officers: 2 Nurses/Skilled Health Workers: 6 Vehicles/Drivers: 2 Office Clerks/Others: 4 40. Particulars Costs/Month1. Personnel 1,98,000/-2. Facilities 20,000/-3. Materials 15,000/-4. Communication 50,000/-5. Printing 15,000/-6. Travels 20,000/-7. Contingency Costs 30,000/-8. Overhead Cost 15,000/-Total 3,63,000/- per month 41. THANK YOU VERY MUCH