Year : 2013 | Volume
: 2 | Issue : 1 | Page : 60--63
Experiences of junior public health nurses in delivery of maternal healthcare services to tribal women in Kerala
Jinu A Jose1, Sonali Sarkar2, Sitanshu S Kar2, S Ganesh Kumar2,
1 Department of Health Services, Ernakulam, Kerala, India
2 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry - 605006
Background: The maternal health care indicators are better in Kerala even in the tribal districts than the national averages. The tribal population scattered in hilly areas or other difficult terrains heavily constraints the MPHW female (Junior Public Health Nurse in Kerala) from providing services. The study was intended to describe the experiences of the Junior Public Health Nurses (JPHN) in delivery of maternal health care services to tribal women in Kerala. Materials and Methods: JPHNs posted in Thariode panchayat under the sub centers of CHC Thariode in Wayanad district of Kerala. This is a Qualitative study with in-depth interview of the JPHNs using an interview guide. Results and Inferences: The various difficulties experienced by JPHNs in delivering the services in tribal areas were lack of sufficient time for field work, travel difficulties faced due to the hilly terrain and lack of public transport facilities, more time spent on travel than actual time spent for field work, cultural and language barriers and extra inputs put up in service delivery to tribal women. Conclusion and Recommendations: The JPHNs serving in tribal areas overcame various constraints in service delivery like hilly terrain, limited public transport facilities, long hours spent in travelling, cultural and language barriers by putting in extra effort, time and personal money to fulfill their responsibilities. It is suggested that the JPHNs be given compensatory off to complete records and extra remuneration to cover their out of pocket expenditure on travelling to difficult areas.
|How to cite this article:|
Jose JA, Sarkar S, Kar SS, Kumar S G. Experiences of junior public health nurses in delivery of maternal healthcare services to tribal women in Kerala.J Family Med Prim Care 2013;2:60-63
|How to cite this URL:|
Jose JA, Sarkar S, Kar SS, Kumar S G. Experiences of junior public health nurses in delivery of maternal healthcare services to tribal women in Kerala. J Family Med Prim Care [serial online] 2013 [cited 2020 Feb 21 ];2:60-63
Available from: http://www.jfmpc.com/text.asp?2013/2/1/60/109948
Tribal people belonging to 698 communities, form eight percent of the total population of India,  inhabit predominantly remote areas; forests, hills and rough terrain in plateau areas.  In India, health indicators vary considerably between different states, regions  and caste groups  and also between tribal and non tribal populations.  According to the National Family Health Survey-3 (NFHS-3) data, the proportion of women delivering without any antenatal care and home deliveries are higher among tribal women as compared to others.  Most of the tribal populations have low coverage of Reproductive and Child Health services,  which contributes to high Maternal Mortality Ratio in India which is 212 per 1000 live births (SRS 2011). 
Maternal health care includes antenatal, intra-natal, and postnatal care services. Multi Purpose Health Worker female (Junior Public Health Nurse in Kerala) is an important provider of these services through the sub-centres.
The accessibility and availability of healthcare facilities in Kerala are higher as compared to other South Indian states.  Utilization of these services is also high in Kerala as proved by data from NFHS-3. The state has the lowest maternal mortality ratio  and second lowest infant mortality rate  in the country. Kerala has little more than one percent of the tribal population of India, 35% of which resides in Wayanad district constituting 17.4% of the district's population.  Even with about 1/5 th population in tribal areas, 95.4% women in this district delivered in institutions  compared to the national average of 38.7%.  As the multipurpose health worker female plays a crucial role in providing maternal health care services, especially antenatal care, the healthier indicators in Kerala highlights their performance. This study was done to understand the efforts and experience of the Junior Public Health Nurse (JPHN) in providing the maternal healthcare to the tribal women in Kerala as a motivational model for other states with larger tribal population to provide the Reproductive Child Health RCH services.
Materials and Methods
The eastern district of Wayanad in the state of Kerala is situated on the Western Ghats and has a tribal population 17%.  Thariode gramapanchayat in Wayanad district was purposively selected as the tribal population is 20% with more than 2,500 tribal people living in 28 colonies in 2010. The panchayat has five sub-centres each serving an average population of 2500 under Community Health Centre Thariode.
This was a qualitative study conducted in November 2010. All the five JPHNs serving Thariode panchayat through the sub-centers of CHC Thariode - Kallankari, Karalad, Kalikuni, Kavummandam and main center were interviewed in-depth using an interview guide to understand their efforts and also identify their difficulties in the delivery of antenatal, intra-natal, and postnatal care services in the area. The interviews were held at their respective sub-centres. Ethical clearance was obtained from the Institute Ethics Committee of JIPMER.
Data from in-depth interviews were transcribed in Malayalam and translated in English. Content analysis was performed with the identification of themes and categories substantiated with the help of quotes from the interviews.
The JPHNs working under CHC Thariode were aged between 34 to 55 years, married and had family incomes more than 2.5 lakhs per year, belonging to upper class according to the Modified Prasad's classification. Three of them had two children each, one had three and the other had only one child. The youngest of the JPHNs had a 7-year-old child, all others in teens and twenties. The JPHNs had been working for periods ranging from two to 13 years catering to a tribal population of 12,480 residing in the rough hilly terrains. Each of them catered to an average population of 2500 and 556 houses. The various factors, which affected their service delivery as perceived by them were:
Lack of sufficient time for field work
Each JPHN had to visit all the 40 day blocks each with 12 to 15 houses, in her area every two months as per the guidelines. Due to immunization duties, conferences, trainings, and other duties; the actual days available for field work was 10-20 days (average of 15 days) as stated by them. All managed to cover their area in two months but admitted that the quality of their work suffered. They said that the beneficiaries also complain about the lesser attention they received. They insisted that this was due to the difficulty in reaching many houses in the hilly area and due to the time spent on extra attention paid to tribal people. Field work was completed compensating the time for office work.
"I will be able to cover 100-150 houses instead of 200-250 houses satisfactorily in the present working situation." (one JPHN responded)
Difficulties faced due to the hilly terrain and lack of public transport facilities
The area is hilly and difficult to access. Many houses need to be reached by foot even after hiring a vehicle. Public transport facilities were unavailable or were highly insufficient in many areas. Houses of many non-tribal women were also in areas with no public transport facilities and many of the houses were scattered in large land holdings. Tribal colonies were located in even more remote areas and needed to be reached by foot. JPHNs incurred out of pocket expenses for their travel to visit beneficiaries.
Time spent on travel and actual time spent for field work
Due to accessibility problems JPHNs tried to cover maximum number of houses in an area during a single visit. They had to travel an average of 20 minutes by bus followed one to two hours walk to reach some parts of their area to visit 15-20 houses. On being asked about the time factor, one JPHN said:
"I have to travel for a total of 5 hours (to and fro) to visit 15 houses. I spend only 15 minutes in a home. For four hours work I need almost nine hours."
Karalad sub-center has the most difficult terrain under CHC Thariode. JPHN posted there was not able to reach the farthest colony, which is located 35 kilometers into the forest to deliver maternal healthcare services.
Four out of five JPHNs said they had difficulties in dealing with tribal people in the initial days due to their varied life style, attitudes, and perceptions regarding health and disease. They found it difficult to gain acceptance of tribal women during the early stages of their career.
"I used to return from tribal colonies crying in my initial days as they used to laugh at me in their local dialect. But things have changed now. Now I can go to any tribal house at any time." (JPHN who has worked in the area for ten years responded)
Extra inputs needed in service delivery to tribal women
All the JPHNs felt that awareness on the need of maternal healthcare services was low among the tribal women and so they needed more time to convince them and to gain their acceptance. Each of the tribal antenatal women was visited four to five times in her house for ANC. This added to their work load and caused time constraints. At times they had to hire vehicles to transport them to sub-center for ANC or hospital for delivery. They had to accompany some tribal women for delivery. One JPHN said:
"They feel that it is our duty to hire them vehicles and accompany them. One bystander once scolded me telling that I was taking them through a damaged road."
Due to the insufficient time for field work, they were compelled to finish their field work in afternoons and office work on holidays and off duty hours. They felt that this affected their family life.
The JPHNs expressed that if the male health worker was also committed, they could improve the service delivery to their beneficiaries.
The response of a JPHN on being asked about the difficulties in delivering maternal health care services to tribal women was:
"We are under tension right from the time a tribal woman gets pregnant till she delivers; whether there will be any problems, will she deliver at home. If anything goes wrong we will be held responsible at the end and we will have to answer everybody."
To address equity in the delivery of healthcare services, the proposed population coverage of a sub-center in tribal areas is 3000. All the JPHNs in the present study had slightly lesser population to cover. They managed to provide services in their area but felt that the quality of their work suffered and insisted that this was due to the difficulty in reaching many houses and more time spent on paying extra attention to tribal people. Field work was completed compensating the time for office work and they were compelled to finish their office work on holidays and off duty hours. They felt that this affected their family life. Their dedicated field work could be the reason for the high utilization of ANC services in the area both among tribal and non-tribal women but could lead to improper record maintenance as well as decreased quality of other official duties.
JPHNs incurred out of pocket expenses for their travel to visit beneficiaries as the area is hilly and difficult to access with limited public transport facilities and has scattered houses. They had to spend more time on travel than actual time spent for field work. The situation is similar to that in other tribal areas as reported by Saha PK on the evaluation of the status of family welfare services in tribal areas. This study pointed out that Auxiliary Nurse Midwives (ANMs) in tribal areas are heavily constrained from providing adequate maternity care services due to geographic constraints in these areas. 
Majority of JPHNs had difficulties in dealing with tribal people in the initial days and found it difficult to gain acceptance of tribal women during the early stages of their career. ASHA under NRHM from the same society may help in overcoming these barriers faced by the JPHNs. 
All the JPHNs had dedicated more time to convince tribal women and gain their acceptance though this added to their work load and caused time constraints. In another study, Suman et al. observed that immunization among tribal people were higher than non-tribal people due to frequent visits of health workers in tribal areas.  The acceptance of medical services in these areas emphasizes the importance of their work. However, the JPHNs expressed that if the male health worker was also committed, they could still improve the service delivery to their beneficiaries.
Soudarssanane et al. reported about the work overload of health workers especially in tribal areas and suggested to bring down the population coverage under a sub-center to 1000.  Additional ANMs can be appointed in much needed areas under NRHM to increase the coverage as well as quality of all services including maternal health care services.
The JPHNs serving in tribal areas had difficulties due to insufficient time for field work as well as due to the hilly terrain and limited public transport facilities. They had to spend more time in travel than actual time spent for field work and had also encountered cultural and language barriers. JPHNs spent a significant amount of time in paying extra attention to tribal people to be able to motivate the tribal women to accept maternal care services under the programme. The indicators of maternal healthcare are better in tribal areas of Kerala due to the sustained efforts of the JPHNs, which need to be recognized and awarded by the state government authorities. Their problems also need attention for the purpose of further improving their functioning. It is suggested that the JPHNs be given compensatory off to complete records and extra remuneration to cover their out of pocket expenditure on travelling to difficult areas.
|1||Register General and Census Commissioner, India. 2001 census. Available from: www. censusindia.gov.in. [Last accessed on 2012 May 28].|
|2||India Ministry of Tribal Affairs: The National Tribal Policy: A Policy for the Scheduled Tribes of India, New Delhi: Ministry of Tribal Affairs; 2004.|
|3||International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3); 2005-06. Vol. 1. India: 2007.|
|4||Dilip TR, Mishra US. Social divide in maternal health care use in rural India: The relative impact of education and economic status. International Population Conference of the IUSSP; 2009.|
|5||Population Policy of India 2000. Department of family welfare, ministry of health and family welfare, govt. of India. Available from: http://www.populationcommission.nic.in/npp.htm. [Last accessed on 2012 May 31].|
|6||Registrar General of India. Maternal and child mortality and total fertility rates. Sample registration system, July 2011. Available from: http://www.censusindia.gov.in/vital_statistics/SRS_Bulletins/MMR_release_070711.pdf. [Last accessed on 2012 May 31].|
|7||Navanetham K, Dharmalingam A. Utilization of maternal health care services in south India. Center for development studies, Thiruvananthapuram. Available from: http://www.unpan1.un.org/intradoc/groups/public/documents/apcity/unpan012686.pdf. [Last accessed on 2012 May 31].|
|8||National Rural Health Mission. 2 nd common review mission, NRHM, Kerala state report 2008. Available from: http://www.nhsrcindia.org/pdf_files/resources_thematic/Health_Sector_Overview/NHSRC_Contribution/182.pdf. [Last accessed on 2012 May 31].|
|9||Sample registration system. Registrar general of India. SRS Bulletin January 2011 - Census of India 2011;45. Available from: http://www.censusindia.gov.in/.Bulletins/SRS%20Bulletin%20-%20January%20.pdf. [Last accessed on 2012 May 31].|
|10||International Institute for Population Sciences. District level house hold and facility survey- 3, 2007-2008: India.|
|11||Saha PK. The status of family welfare services in Tribal Areas: Highlights of the evaluation process. Indian J Community Med 2003; 28:141-4.|
|12||Ministry of Health and Family Welfare, Govt. of India. Mission Document. National Rural Health Mission (2005-2012). Available from: http://www.mohfw.nic.in/NRHM/Documents/Mission_Document.pdf. [Last accessed on 2012 May 31].|
|13||Suman VS, Asari VG. Reproductive health care of women in rural areas, an exploratory study in Nilgiris district in Tamil Nadu. J Fam Med 2006;47:50-5.|
|14||Soudarssanane MB, Thiruselvakumar D. Overcoming problems in the practise of public health among tribals of India. Indian J Community Med 2009;34:283-7.|