<Emphasis Type="Italic">Priority Mental Health Disorders</Emphasis> of Children and Adolescents in Primary-care Pediatric Setting in India 1: Developing a Child and Adolescent Mental Health Policy,Program, and Service Model

India has a huge child and adolescent population. Psychiatric disorders are widely prevalent and the mental health needs of these children are well recognized. Nonetheless, there are no country-centric and child specific mental health policies, plans or programs. There is also a significant lack of human resources for child and adolescent mental health in India. This combination of factors makes the primary care a critical setting for the early identification, treatment, consultation and referral of children and adolescents with mental health and developmental needs. Even though the importance of primary care as a system for addressing the mental health care has been recognized for decades, its potential requires further development in India as the Child and Adolescent Mental Health Services (CAMHS) emerge and evolve. A country and child specific mental health policy, plan and program needs to be formulated as well an integrated, multi-tier CAMHS with a focus on the primary-care physicians as care providers for this population has to be developed.     

Priority mental health disorders of children and adolescents in primary-care pediatric setting in India 1: developing a child and adolescent mental health policy, program, and service model

India has a huge child and adolescent population. Psychiatric disorders are widely prevalent and the mental health needs of these children are well recognized. Nonetheless, there are no country-centric and child specific mental health policies, plans or programs. There is also a significant lack of human resources for child and adolescent mental health in India. This combination of factors makes the primary care a critical setting for the early identification, treatment, consultation and referral of children and adolescents with mental health and developmental needs. Even though the importance of primary care as a system for addressing the mental health care has been recognized for decades, its potential requires further development in India as the Child and Adolescent Mental Health Services (CAMHS) emerge and evolve. A country and child specific mental health policy, plan and program needs to be formulated as well an integrated, multi-tier CAMHS with a focus on the primary-care physicians as care providers for this population has to be developed.     

Health counseling of adolescents

Health counseling is a fundamental aspect of health care for adolescents and is a natural extension of the concept of anticipatory guidance. It is a dynamic process involving active participation by adolescents. Pediatricians are a valued source of health-relevant information, but must also recognize how their attitudes and beliefs can affect the counseling process. Knowledge of the multitude of changes occurring during adolescence and an understanding of the role of health-risking behaviors in meeting various developmental needs are critical to successful counseling. Particular attention must be focused on ways to help adolescents develop the skills necessary to maintain health-promoting lifestyles and to resist peer pressure to engage in health-risking behaviors.     

Mother-Neonatal Intensive Care Unit (M-NICU): A Novel Concept in Newborn Care

Health facilities in India are faced with the challenge of providing quality newborn care in the face of major skilled human resource shortage. A possible solution is the concept of Mother-Neonatal ICU (M-NICU), where the mother has her bed inside the neonatal intensive care unit (NICU) by the side of baby’s warmer. Our observations in M-NICU of a public sector hospital in New Delhi, India, indicate that mothers can be easily trained to follow asepsis routines and monitor the neonates, and are better prepared for their post-discharge care. Incorporating space for both mothers and their newborns in level-II NICUs may provide quality and developmentally supportive newborn care in coming years.     

Primary health care for developing countries

This article discusses implementation of the Alma Ata Declaration on primary health care in developing countries, particularly in India. Tasks are outlined in the areas of health indicators, training of health personnel, allocation of resources, integration of traditional health workers, drug policy, and health delivery strategies. The success of the primary health care strategy hinges on the support of the rest of the health system and of other social and economic sectors. Each country will have to specify its own health goals and priorities within the context of overall development policies, particular circumstances, social and economic structures, and political and administrative mechanisms. The training of health personnel, which is an essential part of primary health care, should be geared to the health needs of the community rather than patterned after the health services in developed countries. In particular, greater use should be made of community health workers. Traditional practitioners represent another potential reservoir of personnel for primary health care, and their integration into the modern system of medicine should be organized. The Government of India has adopted a strategy aimed at integrating promotive, preventive, and curative aspects of health care through a decentralized approach that involves the community in planning, providing, and maintaining the health services. 580,000 community health volunteers, as well as 1 traditional birth attendant for each village, are scheduled to be trained. A subcenter with 1 male and 1 female multipurpose worker is planned for every 5000 population; a subsidiary health center staffed by a doctor, 2 health assistants, and 2 multipurpose workers is proposed for every 25,000 population; and a primary health center is proposed for every 50,000 population, with 1 in every 4 centers to be upgraded to a rural hospital. The Integrated Child Development Services (ICDS) program delivers maternal and child health services at the village level. The number of ICDS projects is proposed to be increased to cover 913 of the 5011 community blocks and 87 urban slum areas by 1985.     

Well-child care: effectiveness of current recommendations

Well-child care is the main source of preventive health care for children in the United States. Repeated examinations of healthy children during health supervision visits are used to assess biomedical health, development, behavior, and family functioning. In addition, well-child care serves to provide parent education through age appropriate counseling referred to as anticipatory guidance. Recommendations for well-child care are found in the Health Supervision Guidelines III, published by American Academy of Pediatrics, last revised in 1993, and a publication from the National Center for Education in Maternal and Child Health, The Bright Futures, Guidelines for Health Supervision of Infants, Children and Adolescents, revised in 2000. This article reviews the evidence for the effectiveness of the current recommendation for well-child care including the recommendations for the number of visits, history and physical examination as a screening technique, observation of parent-child interaction, and the recommendation for provision of anticipatory guidance. This article also summarizes the recent advances in well-child care and identifies an agenda for future research.     

‘Ayushman Bharat’ Program and Universal Health Coverage in India

India’s National Health Policy 2017 (NHP-2017) has its goal fully aligned with the concept of Universal health coverage. The Ayushman Bharat Program announced in the Union budget 2018–19 of the Government of India, aims to carry NHP-2017 proposals forward. The Ayushman Bharat Program has two initiatives/components – Health and Wellness Centers, and National Health Protection Scheme – aiming for increased accessibility, availability and affordability of primary-, secondary- and tertiary-care health services in India. Afterwards, the second component has been renamed as Pradhan Mantri Rashtriya Swasthya Suraksha Mission. The new program has received an unprecedented public, political and media attention; and is being attributed to have placed health higher on political agenda. This review article analyzes and provides critical reflections, suggestions and way forward for rapid and effective implementation of Ayushman Bharat Program. To be effective and impactful in achieving the desired health outcomes, there is a need for getting both design and implementation of Ayushman Bharat Program right, from the very beginning. If implemented fully and supplemented with additional interventions, the program can prove a potential platform to reform Indian healthcare system and to accelerate India’s journey towards universal health coverage.     

Training and education in perinatal and neonatal care

The Health Services program in Maharashtra, India has admirable plans, ideas, policies, and strategies for training and education in perinatal and neonatal care, but has not been able to implement them adequately. Therefore managers should undergo training to learn workable skills to effectively supervise and guide the maternal and child health (MCH) component of the program. Recognizing the inability to reach all women, despite the wish to do so, MCH services now concentrate their efforts to cover 100% of primigravidas and 1st born children. They have been neglected when MCH services attempted to provide health care for everyone. This approach reduces the workload of MCH personnel. Further, it allows for more time to educate mothers on prenatal care and care for their 1st child. This approach may encourage these mothers to seek care during subsequent pregnancies. Since age of marriage and female education play important roles in perinatal mortality, MCH workers educate the community about them. Specifically, they provide population education to females 12-24 years old. Health services need to train MCH workers from physicians to health workers at post partum centers. Presently training is done by individual institutions, but an integrated program needs to be created. Staff in institutions that provide MCH services should develop effective aids, however, before adequate training begins. MCH services emphasize quality in providing immunization (100 Point Programme) thereby building credibility and attracting more people to be immunized. Maharashtra state has developed a monitoring plan to evaluate MCH services and devise appropriate interventions. No studies had yet been conducted as of 1989.     

50 years of neonatology in India: Progress and future

India has made impressive gains in its child survival indices during the past half a century with infant mortality rates declining from 159.3 in 1960 to 44 in 2011 and neonatal mortality rate declining from 47 (1990) to 32 (2010). Neonatal health is now an integral part of the country’s flagship program — National Rural Health Mission. Facility based newborn care is not only available in large public and private sectors hospitals, but also in about 300 of India’s district hospitals. Complementing these efforts is home based newborn care being delivered by community health volunteers. The last two decades has also witnessed an increase in newborn research and its incorporation into medical and paramedical education as a major course component. Neonatology now is an independent superspecialty in India. The National Neonatology Forum has had a major role in spearheading reforms in neonatal care in India.     

Promotion of safe motherhood in India

In India, improvements in maternal health have lagged behind achievements in general health status. The maternal mortality rate is 500/100,000 live births, and most of these deaths are from preventable conditions such as toxemia, hemorrhage, anemia, sepsis, illegal abortion, and fetal malposition. Only a third of deliveries are attended by trained personnel, and high-risk pregnant women are not referred to appropriate facilities. 53% of pregnant women are not immunized, making neonatal tetanus a major contributor to infant mortality. Safe motherhood in India calls for a number of interventions in the health sector, including 1) the universal availability of trained medical personnel who can refer high-risk mothers and perform routine deliveries under aseptic conditions; 2) the provision of disposable delivery kits to all pregnant women; 3) the training of all members of the health delivery team to recognize high-risk mothers in the prenatal, intranatal, and postnatal periods; 4) the availability of graded expertise of manpower and logistics at the different levels of the health care system; 5) accessibility to pregnancy termination so as to avert deaths from illegal abortion; 6) strict monitoring and implementation of the National Nutritional-Anemia Prophylaxis Program; and 7) expansion of the Integrated Child Development Services Scheme into all areas of the country. The Child Development Scheme seeks to provide a high coverage of pregnant women with tetanus toxoid and folic acid tablets and to reduce the incidence of low birthweight and infant mortality. In India 94% of births proceed normally and do not require intervention. It is essential, however, that the remaining 6% of pregnancies be identified and given priority care.     

Passport to Health: An Innovative Tool to Enhance Healthy Lifestyle Choices

Obesity in children and adolescents has become an epidemic in the United States. The ramifications of obesity at a young age are longstanding and affect physical health, emotional health, and the economics of the health care industry. The Strong Pediatric Practice at Golisano Children's Hospital is a large inner-city practice serving more than 14,000 urban children and adolescents, the majority living below the poverty level. The Obesity Task Force, which comprises four nurse practitioners, two nurses, a nutritionist, and one physician, developed and implemented the “Passport to Health” tool in an attempt to encourage providers to assess and work with families around the issues of weight and activity, a need that was identified through chart audits. The Passport to Health supports the policy statements on prevention of overweight and obesity by the Centers for Disease Control and Prevention, National Association of Pediatric Nurse Practitioners, and American Academy of Pediatrics. Quality assurance standards for managed care that mandate body mass index (BMI) assessment and nutrition counseling in all children and adolescents also is supported by this tool. The Passport to Health also provides the same message as a current community initiative in the Rochester area that has received widespread media coverage. This tool includes a visual color-coded indicator of the child's BMI status and a synopsis of specific healthy eating and activity goals, and it permits an individualized goal to be established. The Passport to Health translates information that the provider knows about the BMI status into information that the family and child can embrace and understand. Chart audits as well as exit interviews have demonstrated that use of the Passport to Health has increased the assessment, identification, and counseling by providers in relation to healthy eating and activity. Chart audits found that nurse practitioners embraced this practice change more readily than did other providers. We also found that the use of the Passport to Health has increased the involvement of the child and adolescent in discussions about weight and activity status. Recommendations to encourage future practice changes have been established and will be implemented. The changes include intensive education with providers who were less likely to utilize the Passport to Health tool. The Passport to Health could be implemented easily in any pediatric practice setting.     

<Emphasis Type="Italic">Priority Mental Health Disorders</Emphasis> of Children and Adolescents in Primary-care Pediatric Settings in India 3: Psychotherapy and Other Non-pharmacological Interventions

The pediatrician is a primary column of support for children and adolescents with a myriad of mental health problems in low-mental health care resource countries like India. While majority of mental health consultations happen in primary-care, and only 10% are referred successfully for specialised help, there is a clear role for pediatrician psychotherapists in primary care. The primary-care pediatricians should be aware of the indications for psychotherapy, the various approaches that could be used in primary-care settings, the structure and the process of the psychotherapeutic technique involved, the suggested specific techniques for the Priority Mental Health Disorders and the evidence available to support their use as well as the developmental modifications that are required based on the cognitive development of the child or adolescent.     

Priority mental health disorders of children and adolescents in primary-care pediatric settings in India 3: psychotherapy and other non-pharmacological interventions

The pediatrician is a primary column of support for children and adolescents with a myriad of mental health problems in low-mental health care resource countries like India. While majority of mental health consultations happen in primary-care, and only 10% are referred successfully for specialised help, there is a clear role for pediatrician psychotherapists in primary care. The primary-care pediatricians should be aware of the indications for psychotherapy, the various approaches that could be used in primary-care settings, the structure and the process of the psychotherapeutic technique involved, the suggested specific techniques for the Priority Mental Health Disorders and the evidence available to support their use as well as the developmental modifications that are required based on the cognitive development of the child or adolescent.     

Primary health care and child survival in India

The Primary Health Care (PHC) has been globally promoted as a comprehensive approach to achieve optimal health status and ‘Health for all’. The PHC approach, although, initially received the attention but failed to meet the expectations of the people in India. The child health programs in India had been started for long as verticals programs, which later on integrated and had been planned in a way to deliver the services through the PHC systems. Nevertheless, the last decade has witnessed many new initiatives for improving child health, specially; a number of strategies under National Rural Health Mission have been implemented to improve child survival- Skilled Birth Attendant and Emergency Obstetric Care, Home Based Newborn Care, Sick newborn care units, Integrated Management of Neonatal and Childhood Illnesses, strengthening Immunization services, setting up Nutritional rehabilitation centers etc. However, for a large proportion of rural population, an effective and efficient PHC system is the only way for service delivery, which still needs more attention. The authors note that although there have been improvements in infrastructure, community level health workers, and availability of the funding etc., the areas like community participation, district level health planning, data for action, inter-sectoral coordination, political commitment, public private partnership, accountability, and the improving health work force and need immediate attention, to strengthen the PHC system in the country, making it more child friendly and contributory in child survival, in India.     

National Rural Health Mission

The health related indices in our country are far from satisfactory and the country still bears an enormous share of the global disease burden. The lack of accessibility, scarce availability and the poor quality of health services and personnel in the remote rural and underdeveloped urban areas have been the major obstacles to the delivery of quality health care services in a vast and culturally diverse country with inter- and intra-regional variations and inequalities. The already over-stretched public health care system has been grappling with the deficiencies in linkage with the collateral health determinants, gross shortage and non utilization of infrastructure, financial and human resources. Revitalizing the existing primary health care infrastructure under the National Rural Health Mission (NRHM) will bring about the long overdue architectural corrections in the health care sector and be able to provide accessible, affordable, accountable, effective and reliable health care especially to the under-privileged sections of the society. NRHM is based on the principles of decentralisation of the health system, empowerment of the community and the panchayati raj institutions. Effective integration of health concerns with other health determinants like sanitation, hygiene and nutrition through district health plan is being made.     

Adolescents and sexually transmitted diseases.

Pediatricians with busy practices have limited time to spend with each patient. But because much of adolescent morbidity and mortality is related to behavioral issues, time and energy are crucial to providing effective counseling and care to adolescents. Many barriers to provision of services to adolescents exist, including time, space, décor, office hours, office fees, and support personnel. Despite these barriers to care of adolescents and, in particular, sexually active adolescents, the need for pediatricians to provide these services is clear. Services include anticipatory guidance and counseling about developing sexuality and sexual behaviors, as well as management of health consequences of sexual behavior. Primary care providers have an opportunity to assist adolescents to develop mature and healthy sexual relationships. This necessitates a full understanding of each patient's unique situation, listening to adolescents' concerns, and honest and straightforward discussion of sensitive information. Beginning the process of discussion of sexuality and relationships early in the pediatric years may help adolescents and their parents to develop healthy sexual attitudes and behaviors.     

Facility Based IMNCI

India has the world’s greatest burden of neonatal and under- five mortality. In 2008, approximately 1.8 million under five children, including 1 million neonates, died. At the current rate of progress, India will not be able to achieve the MDG 4 target of reduction of under- five mortality to 38 per 1,000 live births by 2015. The Reproductive and Child Health programme (RCH) II under the National Rural Health Mission (NRHM) comprehensively integrates interventions that improve child health and addresses factors contributing to infant and under-five mortality. Under the RCH II National Programme—Implementation Plan, IMNCI approach is the major instrument of newborn and child health strategy. IMNCI clinical guidelines focus on assessment, classification and providing treatment according to disease severity. Severe illnesses (red classification) require urgent referral after pre-referral treatment. Further diagnosis and management is dependent on the skills of health workers of the referral hospital. Therefore, capacity building of professionals for providing optimum care for sick children in referral units is an obvious path to optimize the benefits of IMNCI on child survival. With these objectives, F-IMNCI (Facility based IMNCI) package was developed by a committee of experts constituted by the Ministry of Health and Family welfare, Government of India.     

Micronutrient powder use in Arequipa,Peru: Barriers and enablers across multiple levels

In Peru, nearly half of children aged 6–36 months were diagnosed with anaemia in 2017. To address this disease, the Peruvian Ministry of Health implemented a national programme in 2014, distributing free micronutrient powders (MNPs) to all children of this age. However, rates of childhood anaemia remain high. The aim of this study was to explore factors at all levels of the Social‐Ecological Model that affect MNP use and adherence in Arequipa, an Andean city with childhood anaemia rates higher than the national average. We conducted in‐depth interviews with 20 health personnel and 24 caregivers and 12 focus group discussions with 105 caregivers. We identified numerous barriers, including negative side effects (constipation, vomiting, and diarrhoea), poor taste of MNP, lack of familial and peer support for its use, insufficient informational resources provided by the health system, and limited human resources that constricted health personnel abilities to implement MNP programming successfully. Facilitators identified included concern about the long‐term effects of anaemia, support from organizations external to the health system, well‐coordinated care within the health system, and provision of resources by the Ministry of Health. We found that community or organizational and societal factors were key to limited MNP use and adherence, specifically the limited time health personnel have to address caregivers' doubts during appointments and the lack of informational resources outside of these appointments. Potential policy implications could be to increase informational resources available outside of individualized counselling by strengthening existing collaborations with community organizations, increasing media coverage, and providing group counselling.     

Overdiagnosis and consequent mismanagement of head louse infestations in North America

BACKGROUND: Lay personnel and many health care workers in the United States believe that head louse infestations caused by Pediculus capitis are exceedingly transmissible and that infested children readily infest others. Schoolchildren therefore frequently become ostracized and remain so until no signs of their presumed infestations are evident. Repeated applications of pediculicidal product and chronic school absenteeism frequently result. METHODS: To determine how frequently louse-related exclusions from schools and applications of pediculicidal therapeutic regimens might be inappropriate, we invited health care providers as well as nonspecialized personnel to submit specimens to us that were associated with a diagnosis of pediculiasis. Each submission was then characterized microscopically. RESULTS: Health care professionals as well as nonspecialists frequently overdiagnose pediculiasis capitis and generally fail to distinguish active from extinct infestations. Noninfested children thereby become quarantined at least as often as infested children. Traditional anti-louse formulations are overapplied as frequently as are "alternative" formulations. Pediculicidal treatments are more frequently applied to non-infested children than to children who bear active infestations. CONCLUSIONS: Pediculicidal treatments should be applied solely after living nymphal or adult lice or apparently viable eggs have been observed. Because health care providers as well as lay personnel generally misdiagnose pediculiasis, and because few symptoms and no direct infectious processes are known to result, we suggest that the practice of excluding presumably infested children from school may be more burdensome than the infestations themselves.     

Health services for homeless adolescents

This prospective review was designed to determine the effectiveness of a broad-spectrum health intervention program for homeless and runaway youth. Diagnosis, treatment, and counseling for drug use, sexually transmitted diseases (STDs), and other health issues were provided to all new admissions to a residential care facility during a 7(1/2)-year enrollment. Education was continued during a minimum follow-up period of 9 months based on the program entitled Bright Futures, previously developed and published by the National Center for Education in Maternal and Child Health. Fifty-four percent of the study residents had STDs on admission, and 9% developed new STDs after completing therapy and undergoing counseling. Drug dependence was reduced from 47% to 4%, and 46% achieved full-time or part-time employment. Sixty-three percent completed hepatitis B immunization with the 3-dose series. This experience suggests that an organized program of interventions in a residential care facility for homeless teenagers can significantly reduce drug dependence and STDs.