STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE Maternal-Child Health Well-Being A Mentorship Program for Interdisciplinary Scholarship at Stanford University STANFORD-INDIA: HEALTH, EMPOWERMENT, ADVOCACY, LEADERSHIP AND SELF (HEALS) Covenants for Maternal, Neonatal, Infant and Child Well Being: “ASK. It’s your right”. A PROP O SAL FOR A SCH OLAR PROGRAM IN THE INDIAN SUBC ONTINENT Final Report 2009 Co-Principal Investigators Vinod Bhutani, MD, Professor of Pediatrics (Neonatology), Division of Neonatal and Developmental Medicine, Department of Pediatrics Nihar Nayak, PhD, Assistant Professor, Director of Translational Research, Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynecology Jeffrey S. Gould, MD, Robert L. Hess Professor in Pediatrics, Director of Perinatal Epidemiology and Health Outco mes Research Unit, Department of Pediatrics Advisor David K. Stevenson, MD, Harold K. Faber Professor of Pediatrics Vice Dean and Senior Associate Dean for Academic Affairs Director, Charles B. and Ann L. Johnson, Center for Pregnancy and Newborn Services Department of Pediatrics Funding for this project provided by the Presidential Fund for Innovation in International Studies at Stanford University. All Rights Reserved. STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being Table of Contents 1. List of Co-Investigators and List of Partners [Pages 1 to 4] 2. Project Summary - Section A to I: Specific Aims and Background Materials [Pages 5 to 7] - Section J: Mentorship Programs [Pages 8-10]. i. Health and societal content development: Community Radio ii. Maternal Health and Societal Leadership Initiative. iii. Social Entrepreneurship Programs 3. Progress to Date [Pages 10-12]. Vinny Bhutani Page 2 10/27/09 STANFORD HEALS PROJECT CO-INVESTIGATORS Shalini Dev Bhutani, PhD Interim Director, Bechtel International Center Stanford University Usha Chitkara, MD Professor of Obstetrics and Gynecology Stanford University School of Medicine Ashok Deorari, MD Division of Neonatology, Department of Pediatrics, WHO Collaborating Center for Training and Research in Newborn Care, All India Institute of Medical Sciences (AIIMS), Maurice Druzin, MD Professor of Obstetrics and Gynecology Chief of Perinatology, Charles B. and Ann L. Johnson, Center for Pregnancy and Newborn Services Stanford University School of Medicine Dr. Susan Gennaro, RN, DSN, FAAN Florence & William Downs Professor in Nursing Research Editor, Journal of Nursing Scholarship New York University, College of Nursing Dr. Akhil Gupta, PhD Professor of Anthropology University of California Los Angeles Rohit Handa Common Cause (NGO dedicated to public causes promotes individual rights and access to information to redress grievances in a collective manner at an all India level), New Delhi, India Neelam Kler, MD President-Elect, National Neonatology Forum of India (NGO of neonatologists of India who have partnered with the Government of India for community-based programs. (Dr. Kler is the Chief of Neonatology, Sir Ganga Ram Hospital, New Delhi, India) Anjini Kochar, PhD Senior Research Scholar and India Program Coordinator, Stanford Center for International Development, and co-Director, South Asia Studies, Stanford University Linda Hess, PhD Lecturer of Religious Life co-Director, South Asia Studies, Stanford University Rahul Alex Panicker, PhD Graduate Student. David Packard Electrical Engineering, Stanford University His advisor, Professor James Patell, Stanford Institute of Design, and the Graduate School of Business) has been requested to participate in this endeavor. two STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being Vinod K. Paul, MD, PhD Division of Neonatology, Department of Pediatrics, WHO Collaborating Center for Training and Research in Newborn Care, All India Institute of Medical Sciences (AIIMS), John Pearson Director, Bechtel International Center Stanford University Nandini Sahai Executive Director Media Information Communication Center of India (MICCI) Manju Vats, PhD Indian Association of Neonatal Nurses Principal, College of Nursing All India Institute of Medical Sciences (AIIMS) Sumner Yaffe, MD Consulting Professor (Clinical Perinatal Pharmacologist) Division of Neonatology, Department of Pediatrics, Stanford University Other co-Investigators and Partners: Prospective Faculty to be invited (as indicated in the proposal) including Departments Anthropology, Culture and Social Anthropology (CASA), Center for Comparative Studies in Race and Ethnicity (CCSRE) and Engineering Faculty (to be identified). Partners in India: Department of Pediatrics, WHO Collaborating Center for Training and Research in Newborn Care All India Institute of Medical Sciences (AIIMS), New Delhi; National Neonatology Forum (NNF), Indian Association of Neonatal Nursing (IAAN), Media Information Communication Center of India (MICCI) and Common Cause, Vinny Bhutani Page 4 10/27/09 STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being STANFORD-INDIA: HEALTH, EMPOWERMENT, ADVOCACY, LEADERSHIP AND SELF (HEALS). Health and Societal Covenants for Maternal and Child Well Being: “ASK. It’s your right” PROJECT REPORT A. VISION. We have built partnerships with individuals and organizations who strive to improve the unacceptably high maternal and childhood morbidity and mortality rates in the Indian subcontinent. Our aim is to facilitate the implementation of known evidence-based interventions. The initiative goals included leadership training, interdisciplinary scholarship and mentorship by experts from Stanford University and the subcontinent. To improve the unacceptably high maternal and childhood morbidity and mortality rates in the Indian subcontinent we are facilitating the implementation of known evidence-based interventions through innovative strategies that bridge existing social and access barriers in the micro- and macro-health environment. These strategies included, but were not limited to, development of leadership skills, interdisciplinary scholarship and mentorship by experts from Stanford and the subcontinent. The anticipated societal messages based on a hypothesis: "ASK, its your right" or its local Hindustani version: "Aap ka Haq: sawaal ka sahhi jawab” relies on the health and societal principle of: E = S(T+M) where, empowered (E) healthcare decision making equals the product of societal facilitation (S) mediated transference (T) of empowerment (by healthcare providers) and media (M) communication-based education. B. OUTCOMES: We have initiated the validation of the health and societal principle of self-empowered decision making and the hypothesis of “ASK, its your right”. We initiated three innovative and interweaving projects to provide pilot data for large-scale national inquiry. We conducted an interdisciplinary symposium in India (in 2008) with our current partners from Stanford and India as well as reach out to potential NGO partners. With the development of a more formalized network and the conclusion of our ongoing projects (in 2010) we will plan to conduct a national [Stanford-India] maternal-child health and society symposium in India. Our specific mentorship programs are: 1. Health and societal content development for diverse rural and urban slum communities to address maternal, neonatal, infant and child health. In building a relationship with Ms. Nandini Sahai, of MICCI, we will expand the outreach Community Radio Network of India as a forum public maternal and child healthcare outreach. 2. Health and Societal Leadership Initiative and Its Impact on Maternal and Child Health Well Being. The mentorship initiatives with Drs. Neelam Kler, President-Elect of the National Neonatology Forum of India and with Dr. Vinod K. Paul, Chairman of Pediatrics at the All India Institute of Medical Sciences, we will network with their staff and organization to develop a network of leadership to address and promote evidence-based practice of neonatal-perinatal care in India. 3. Social Entrepreneurship Programs: A mentorship program to foster, promote and mentor the evolving programs initiated by Stanford graduate students to develop and market a portable self-sustaining warming device to facilitate the national goals to reduce infant mortality in rural and urban slum India. The Embrace program (http://embraceglobal.org) is one such example. STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being C. SIGNIFICANCE: Dramatic improvements in the overall socioeconomic conditions during the last decade have yet to impact the unacceptably high maternal and neonatal morbidity and mortality in the Indian subcontinent and other developing nations. Earlier experiences have led us to believe that building an interdisciplinary leadership approach (HEALS) would provide innovative strategies to bridge the existing social and access barriers in micro and macro-health environment. Thus, the two strategic goals are (i) to develop an inter-disciplinary mentoring program facilitating the training of future leaders, including junior faculties who are engaged in the advanced study and research of maternal child health that results in a pivotal clinical trial to enhance neonatal and well being in the Indian subcontinent; (ii) to lay the foundation for an interdisciplinary study group comprising of experts from US-based academic centers and the Indian subcontinent that could recommend and guide multi-faceted strategies for both practice and policy. Direct mentorship by both Stanford and affiliated partner faculty would help create a select network of regionalized academic centers and their related communities that could have the capacity and ability to conduct future pivotal clinical trial(s) that impact on national practice to reduce neonatal mortality and long-term morbidities. The current national neonatal mortality rate in India is 44 per 1000 live births and accounts for two-thirds of the infant mortality in India. Over one million newborn infants die annually in the Indian subcontinent before completing their first four weeks of life. This accounts for the highest burden of newborn deaths for any country in the world. Likewise, perinatal mortality continues to be unacceptably high due to maternal under- and malnutrition, anemia, hypertension, lack of basic antenatal care and deliveries by untrained personnel. Preventable maternal mortality also remains unacceptably high and is influenced by interacting social, cultural, medical, health access, as well as local political and economic barriers. This accounts for the highest burden of maternal and newborn deaths for any country in the world. Contribution of maternal mortality and pregnancy-related ill health to infant mortality and morbidities are seemingly evident, but have unique health and societal constructs. The geographic, cultural, ethnic, racial, caste, and social construct of the Indian subcontinent communities impact on maternal and infant health and well-being, as well as on the new and future citizens of India. Community-based access to medical care, public health leadership and education, efforts to improve literacy and community advocacy by non-governmental organizations has made inroads to selfempowerment and reduction of some societal burdens. Innovative strategies developed by individual communities offer unique opportunities for scholarship, evidence-based inquiry, and collaborative interdisciplinary mentorship. The potential for participating in the defining of future health and societal leadership that understands the “language of women” has the potential to have sustaining impact to enhance the health and well-being of women and their children. Recently, the National Neonatal-Perinatal Database (NNPD) published a report card for the year 2002-031. Initially launched by the National Neonatology Forum (NNF) in 1995, funded by the Indian Council of Medical Research, New Delhi and with data coordination at AIIMS, the NNPD comprised 18 participating neonatal centers at academic centers and leaders committed to academic neonatal endeavors. Data were obtained using standardized definitions (with mentorship by Dr. Jeffrey Gould, Stanford University), an electronic case report forms and included populations primarily cared for at these urban institutions and those who were 1 Reported at the Pediatric Academic Societies Meeting in 2003 and 2004. STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being referred from the neighboring rural and remote areas. Table I lists the latest perinatal mortality data evidenced for inborn population at these select centers and is distinguished from the higher rates out-born infants admitted these centers. Table I: Major Neonatal and Maternal Outcomes from NNPD: 2002 to 2003 Experience of Inborn Infants at Urban Academic Neonatal Centers in India Total births / Total live births Total neonatal deaths Early neonatal deaths Late neonatal deaths Post-neonatal deaths (but before discharge) Neonatal Mortality Rate (NMR) Early Neonatal Mortality Rate Late Neonatal Mortality Rate Maternal Mortality Ratio 151,436 / 145,623 3680 3230 (87.8%) 426 (11.6%) 24 (0.7%) 25.3 per 1000 live births 22.2 per 1000 live births 2.9 per 1000 live births 63.8 per 100,000 live births Rates are lower than national average in India and attest to capacity of improvement Specific neonatal mortality data, in Table II, illustrate the most common diseases encountered at Indian Level III centers caring for indigent communities. These conditions have been amenable to interventions in the context of evidence-based medicine in USA as reported by the Neonatal Network of NICHD. Table II: Common Causes of Neonatal Mortality Reported by NNPD: 2002 to 2003 Neonatal Morbidity Number Percentage Perinatal Asphyxia* 1060 28.8% Sepsis/Meningitis* 590 16.0% Respiratory Distress Syndrome* 508 13.8% Congenital Malformations 495 13.5% “Extreme” Prematurity (<32 weeks GA) 324 9.2% Pneumonia* 93 2.5% Birth Trauma* 5 0.1% Others 605 16.1% Total 3680 100% * these are usually preventable through and health and societal education D. MISSION. In an effort to foster interdisciplinary international research and collaboration at Stanford University with its partners in USA and South Asia, we proposed a program for scholars to be co-mentored by Stanford and US faculty in health and societal aspects of maternal and child health. Our goal has been to address reproductive maternal and child health that spans health and societal disciplines from a medical, nursing, public health, societal and community perspective. Innovative strategies developed by individual communities have offered unique opportunities for scholarship, evidence-based inquiry, and collaborative interdisciplinary mentorship. The potential for participating in the defining of future health and societal leadership that understands the “language of women” has the potential to have sustaining and beneficial impact on health and well-being of women and their children. We believe there are a “thousand points of light” that need to be enhanced, networked and coalesced through an array of interdisciplinary scholars mentored as a regional “think tank.” We intend to continue and demonstrate a successful implementation of national strategies based on scholarly inquiry led by Stanford Faculty and our counterparts from US and within India and lead preparatory (2008) and national health and societal symposia (2010). STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being E. STRATEGIES IMPLEMENTED: Our strategies included, but were not limited to, capacity building workshops and programs that: 1. Aid in the development and augmentation of leadership skills in India 2. Encourage interdisciplinary scholarship, debate and collaboration 3. Facilitate mentorship and knowledge exchange between experts from Stanford and those in India. 4. Support self-empowerment through knowledge creation and web-resourced for real time data on maternal, infant and child health as well as serve as forum for a) future health-societal campaigns and b) community level discussion and dialogue between health experts, advocates, activists and society, F. RESOURCES, LIAISONS AND PARTNERSHIPS DEVELOPED BETWEEN Stanford and Existing Partners in India a. Lucile Packard Children’s Hospital: Dr. Stevenson and Dr. Gould b. Stanford’s Women’s Health Program: Dr. Druzin, Dr. Chitkara and Dr. Yasser El-Sayeed. c. Stanford India Program Liaison: Anjini Kochar and Linda Hess d. Stanford BioDesign Liaison: Dr. Rajiv Doshi e. AIIMS (WHO Perinatal Collaborative) Liaison: Dr. Vinod K. Paul and Ashok Deorari. f. National Neonatology Forum of India Liaison: Dr. Neelam Kler. g. Nursing: Dr. Susan Gennaro (NYU), Manju Vats (IANN, AIIMS) and Ann Schwoebel (PENN). h. Education: Dr. Shalini Bhutani, PhD and John Pearson (Bechtel International Center, Stanford) i. Social entrepreurship: Dr. Rahul A. Panicker, PhD, Engineering graduate (Advisor James Patell) from David Packard, EE, Stanford. G. LIMITATIONS: Even though Stanford has a towering international outreach, there is an apparent visible gap for a working inter-disciplinary forum. There is a continued need to network for interactions and project collaboration among faculty with diverse interests and expertise. During our planning phase, I was fortunate to meet and interact with a vast number of faculty, staff and students on the Stanford campus who would value such a forum for health and societal area study. My personal focus has been maternal child health and I have elected, with counsel from co-investigators and partners, to focus on pertinent issues with intent to draw out potential partners. Several of these individuals have not previously dealt with maternal child health issues and we hope stimulate their participation. H. LESSONS LEARNED FROM THE PLANNING PROCESS (2007 PFIIS AWARD): The planning grant from PFIIS allowed for an ongoing dialogue among advisors, experts and liaisons from Faculty and Staff at Stanford University (listed above). Based on the feedback and review of available resources and interest of our peers and students, we convened an exploratory work-out session meeting with prospective partners in India: “Health and Societal Covenants for Maternal and Child Well Being: ASK. It’s your right” in New Delhi, India. Based on the outcome (see Appendix I), we selected and prioritized the following projects for our initiative over the next three years concurrent to India’s National Rural Health Mission (NHRM). The following were identified as unmet needs i) community education on maternal and child health wellbeing; ii) awareness of personal legal rights; iii) Awareness of Health and hygiene issues; iv) culture-sensitive and credentialed Health Care Providers; v) timely access to emergency care; safe water and sanitation. Several barriers were identified were identified at the societal level (family and community) such as a) woman against woman issues; b) personal motivation to seek health care; c) knowledge about how and when to seek help; d) information about and control over family planning decisions. Unmet needs at the resource level include a) lack of safe medical transportation; b) infrastructure does not match promised health care services; c) need for sufficient trained nurses sensitive to meet community expectations; d) need for on-site credentialed physicians work in urban areas; e) limited transparency for implementation strategies; f) limited community awareness and partnership STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being opportunities; g) limited transparency of resource utilization (need to build credibility); h) timely access to emergency care facilities. 1. Ongoing goals for national initiatives by the Government of India were reviewed by Dr. Vinod K. Paul and include a) national effort to promote institutional deliveries; b) a national effort to achieve 100% safe deliveries; c) implement effective reduction strategies of maternal and infant mortality; d) implement accurate birth and death reporting and e) improve doctor/nurse (healthcare provider) to patient ratio. The National Rural Health Mission was launched in April 2005 and is currently in its early adaptation phase in 18 high burden states and over 300,000 new community health workers (ASHAs) are being recruited in 10 states. To reach the poorest and remotest rural household with accountable, affordable and accessible public health system can only be sustained by improved local management and community action. Partnerships with NGOs to train health professionals are expected to address issues of safe water, sanitation as well as social and gender equality. As Indian public health community implement these projects, supplementation and expertise from Stanford partners could facilitate and modulate their acceptance and “buy-in” from the community. 2. Recommendations from the partnership participants to bridge the gaps between plans and implementation: 1.Need for real-time and region-specific data on maternal and infant mortality. 2. Need to build public awareness about issues of maternal and infant mortality. 3. Need to identify and network with existing stakeholders: governmental, nongovernmental and academic institutions.4. Need to create a working group willing to interact and develop a forum to seek evidence-based evaluation and implementation strategies: a) Need to develop a working model for national/regional implementation of project; b) Need to validate the successful adaptation and implementation of national/regional initiatives in diverse communities; and 5. Need to develop an identity for this working group. All India Institute of Medical Science’s WHO Perinatal Collaborating Center request to Stanford University’s included support and collaboration with specific project concepts that need development, structured and implemented in a collaborative manner. These are: a) education capacity and leadership skills development; b) Identify optimal information technology options to determine quality measures of optimal maternal and infant care; c) support development Centers of Excellence in nursing education: “Indian Institute of Nursing”; d) build an exchange program for research, bio-technology and innovation; e) develop exchange programs on hospital administration; f) Promote and support national “kangaroo mother care” initiatives; g) promote and support maternal and neonatal Transport/Ambulance system initiatives; h) develop web portal for MCH issues; i) help identify “hot spots” and NGO’s for infant and maternal mortality and i) assess feasibility of media initiative for national campaign to reduce maternal mortality. 3. Selection and prioritization of projects for our immediate attention: The planning process and the “work-out” sessions (at New Delhi and Stanford campus) led to identification to specific Health-Societal Projects that formulate our initiative over the next three years: Those selected for this application: 1. Identification and validation of sustainable communication mass and personalized media strategies that promote maternal and child health well-being in an urban, urban-slum and rural India. 2. Determination of the extent of societal-based gender empowerment among health-care providers prior to and subsequent to focused leadership-skill development interventions and determination of the role of a genderempowered health care provider who seeks to promote maternal-child health well-being. 3. Promote and support national social entrepreneurship initiatives. 4. Other concurrent and prospective projects that were deemed important to have an impact on the initiative and its sustainability are being pursued through other organizational and individual endeavors (see appendix II). 4. Identify the societal, cultural and religious determinants of health seeking behaviors among families who have had a recent encounter with maternal or infant mortality. 5. Social, educational and health determinants of maternal and infant mortality in sex health worker communities in high-risk Indian communities. STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being 6. Promoting regional quality performance surveillance for perinatal healthcare services. 7. Multi-center Neonatal Clinical Trials in India. 8. Develop and establish a Neonatal /Perinatal Research Network in collaboration with academic centers to explore clinical and pharmacology projects in India. 9. Promote development of perinatal biotechnologies that facilitate maternal and child health well-being in collaboration with Stanford’s BioDesign initiative. 10. Identification and validation of sustainable communication mass and personalized media strategies that promote maternal and child health well-being in an urban, urban-slum and rural India. 11. Determination of the extent of societal-based gender empowerment among health-care providers prior to and subsequent to focused leadership-skill development interventions and determination of the role of a genderempowered health care provider who seeks to promote maternal-child health well-being. 12. Promote and support national millennium development goal initiatives in conjunction with NHRM. STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being J. DESCRIPTION OF SPECIFIC MENTORSHIP PROGRAMS INITIATED THROUGH PFIIS AWARD Mentorship Program #1: Community Radio: Health and societal content development for diverse rural communities to address maternal, neonatal, infant and child health. India’s airwaves are public and not government property according to a 1995 ruling by the nation’s Supreme Court (http://www.indiatogether.org/campaigns/freeinfo/sc95.htm). In December 2002, after slow deliberation the Government of India finally approved Community Radios for Academic Institutions. Four years later (2006), pressured by several non-governmental organizations (NGO), the Government relented to allow societal organizations to access, manage and operate community radio [CR] stations. Each CR station has a range of 50 kilometers and is ideal for small communities such as rural, urban slum and geographically remote dwellings. They are similar to independently owned public radios and TV in the US. It is widely expected that in ensuing years, numerous CR stations will be licensed in India and could be incredible agents of change for the existing broadcast industry. Though an extraordinary opportunity, misuse, abuse and misinformation could hamper optimal and credible communications. Basic, understandable and evidenced health and societal messages need to be delivered by respected community representatives who are trained to be effective and credible communicators. Government guidelines for CR mandates require at least 50% of the programs be generated with participation of the local community in their own local language and dialect. A community led outreach would transform the awareness, the level of discussion and question the very nature of the deplorable status of maternal, neonatal and infant and child health well being in some regions. We will collaborate with, Media Information and Communication Center of India (MICCI http://micci.in.org) and National Neonatology Forum (NNF) to develop content for Community Radio. Goals: Using development of leadership skills for trainers, interdisciplinary scholarship and mentorship by experts from Stanford Faculty (and affiliated academic collaborators) and health experts from the NNF and MICCI, we will develop an innovative and creative content and core curriculum for the societal messages based on a hypothesis: "ASK, its your right". Through verbally illustrated dialogues of empowered healthcare decision we hypothesize societal facilitation and media transference of empowerment through CR-based media and communication education. we will facilitate and mentor MICCI Leadership: i) To develop a core-curriculum consistent with the national health care objectives of safe motherhood and integrated maternal and neonatal childcare initiative (IMNCI). ii) To configure the core-curriculum in a format that can be transformed and adapted by a community: as adjusted for local culture, language, social structure and gender values. iii) To develop sustainable economic models for CR stations (individual, networked or NGO-driven). Impact of Health and Societal Scholarly Discipline: To promote the development of evidence-based content that is culturally relevant and monitored during a trial implementation phase at select community sites, health and societal experts and students will participate and collaborate with MICCI to a) Identify new Community Radio forums and strengthen existing forums; b) develop a core-curriculum for Community Radio Trainers; c) development of training audio-visual and didactic materials; e) develop an implementation strategy; and, f) facilitate ongoing graduate research and evaluation. MICCI regional partners are in West Bengal, Karnataka. Kerala. Rajasthan, Chandigarh, Uttar Pradesh, Jharkhand, Andhra Pradesh, Maharashtra and Tamil Nadu.Asian College of Journalism (ACJ), Chennai; Bombay Bar Association (BBA), Centre for Media Research & Development Studies (CMRDS), Kolkata; Friedrich Ebert Stiftung (FES), New Delhi; ICON Communications, Dehradun; Indian Law Institute (ILI), Chennai; Indian Women’s Press Corps (IWPC), New Delhi; Indira School of Communication (ISC), Pune; Institute of Development and Communication (IDC), Chandigarh; Mahamana Madan Mohan Malaviya Institute of Hindi Journalism (MMMMIHJ), Varanasi; Media Education for Awareness and Cultural Transformation (MEDIACT), Kerala; National Institute of Social Work and Social Sciences (NISWASS), Bhubaneswar; Prabhat Khabar Institute of Media Studies (PKIMS), Ranchi; Seva Smriti Sansthan (SSS), Patna; Society for Media and Social Development(SMSD), Varanasi; South Asian Media Association (SAMA), Hyderabad; St. Andrews College, Mumbai; The Department of Mass Communication, Rajasthan University; The STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being International Centre, Goa.; The Kerala Press Union (KPU). The Press Club, Kolkata (PCK); The Press Club, Mumbai; UNESCO, New Delhi; VOICES, Bangalore and Write for Development (WD), Bangalore. Five educational institutions and NGOs who participated in the June workshop have already applied for licenses. A package of information on Community Radio from Applications to setting up of stations had been given to all participants in our workshop. Siddhartha Institute where the workshop took place has obtained a licensee, set up the CR station and test broadcast has also been started. The Karnataka Information Department has proposed to finance 25 deserving CR station remote areas and has decided to increase the numbers and the department officials who attended our workshop are using the information provided during the workshop for the promotional activities. STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being PROGRAM #2: Models for Leadership Development and Sustainable Empowerment for Health Care providers and Journalists Lifelong mentorship program. This key component will strive to match each individual with a life-long mentor who will support the process of lifelong learning and thereby achieve a sustainable network for the training module. It will be based on mutual respect to share experiences, skills and knowledge. Through a fostered relationship it should allow for networking and counseling to support progress and achievement. Through a series of mentor orientation workshops and training sessions, specific attention will be paid to cultural, gender and social sensitivity such that the mentorship program would strive for excellence and consistency. ONGOING COLLABORATIVE HEALTH-RELATED PROJECTS IN INDIA WITH SOCIETAL IMPACT (led by Vinod K. Bhutani and may be included as concurrent scholarly activities to serve as resources for Faculty, graduate and undergraduate students) I. Promoted regional quality performance surveillance for perinatal healthcare services. Goal #1: To foster a formal networking, structural development, peer-review, and collaborative-organized venture to develop evidence-based compendium of intervention strategies that enhance maternal and infant survival and well-being for the Indian subcontinent, similar to the neonatal-perinatal network of the NICHD. Goal # 2: Invited 18 founding members of the NNPD to participate in a model and clinically relevant multicenter project with support and collaboration from the ICMR, NICHD, and participating US academic institution (Stanford University). Goal # 3: Developed a scholar training program to help rebuild the academic infrastructure to create a data coordinating center at the AIIMS. Ongoing Project A. Network for Maternal and Child Health Centers of Excellence: (Dr. Neelam Kler, Vinod K. Paul and Vinod K. Bhutani et al as an initiative of the National Neonatology Forum of India) 1. Aims and objectives • To standardize indices of neonatal morbidities and clinical practices and guidelines. • To identify evidence based and best practices and make recommendation for improvement. • To establish quality improvement process and implementation and outcomes surveillance. • To develop collaborative strategies to conduct multi-center clinical trials and health improvement research projects. 2. Guidelines: Standardization of definitions of risk factors and the outcome is integral to quality improvement and research. NNF (http://www.nnfi.org) will make an effort to reach consensus on important disease definitions and their management through discussions among its members. We will prioritize the neonatal issues and make practice guidelines, discuss through e-communication and have the final meeting at the time of annual NNF convention. 3. Quality Improvement. One of the goals of NNF would be to improve neonatal health and safety through coordination among Indian Neonatal Centers that meet good clinical practice standards. As recommended by Gould et al (www.cpqcc.org), reliable data that has been risk-adjusted would inform the Indian perinatal centers to specific action-oriented strategies. Studies that identify best clinical practices in centers with low morbidity indicators like nosocomial sepsis, hypoxemic-ischemic encephalopathy (HIE) chronic lung disease (CLD), Intraventricular hemorrhage (IVH and neuro-developmental disabilities (NDD) are needed to share their experiences. Translating these to evidence-based practices could enhance better outcomes for all infants in India while constraining cost. STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being 3. Outcome Research. Clinical practices and patient outcomes can vary in different units, among different physicians, geographic regions. Outcome research will identify and explain them by looking at mortality morbidity patterns. For example, frequencies of morbidities in very low birth weight infants include health care associated sepsis, IVH, CLD and NND serve as indices of best practice. Thus, interrelationship of clinical practice to morbidity, mortality trends need further study in the context of regional and national health care systems. Following projects serve as potential areas of common interest. a) Identifying best practice approaches for delivery room resuscitation. b) Effect of intrauterine growth retardation on morbidity and mortality on preterm infants. c) Identifying best practice models to reduce healthcare associated infections. For our own outcome data collection we need to identify the group of high-risk neonates (VLBW, IVH, HIE, Sepsis) individual variables to be collected to study morbidity mortality, trends and length of stay so as study impact of various clinical practices prevalent. 4. Research. NNF plans to develop collaborative protocols for collection of data (in intervention trial for providing intervention being studied) and coordinating centers to accomplish a randomized trial, observational study or quality improvement project. The value of multi-center studies is to provide and meet the large sample size requirement for timely duration of clinical trials. Such studies also address the need to include a heterogeneous and diverse population that is more representative of the Indian population. As an additional benefit, collaboration among experienced clinical investigators allows for the building of consensus and an Indian standard of care. 5. Societal Impact: Identify societal expectations and assess cost impact consequent re-distribution of healthcare costs due to increased biotechnology needs and potential increased burden ethical, economic, educational and social cost among neonatal survivors. B. Perinatal Health Quality Determinants for India based using state of the art collaborative Quality Improvement (Institute of Health) Methods: (Drs. Ashok Deorari, Vinod K. Paul and Neelam Kler (NNF, AIIMS), Jeffrey S. Gould and V.K. Bhutani (Stanford University). C. Committee of Fetus and Newborn for India to enunciate national policy and guidelines an initiative National Neonatology Forum of India: (Dr. Neelam Kler (NNF) and Ann R. Stark (COFN, American Academy of Pediatrics) D. Multi-center Neonatal Clinical Trials in India: Dr. Vinod K. Paul, AIIMS. Prevention of Meconium Aspiration Syndrome. STANFORD-INTERNATIONAL HEALTH AND SOCIETY INITIATIVE (SIHASI) Maternal-Child Health and Well-Being PROGRAM #3: Social Entrepreneurship Program such as one that uses a portable self-sustaining warming device to facilitate the national goals to reduce infant mortality in rural and urban slum India. (Rahul A. Panicker et al and a Collaborating team from WHO Perinatal Collaborating Center at AIIMS) About a third of all babies born in India have low birth weight. An important component of postnatal care is thermal regulation. Hypothermia (sometimes lethal) and caloric loss (essential for neonatal growth) can be prevented by use of incubators. Unfortunately, these devices can be expensive and energy dependent, and often not ideal for rural or urban slum environment. Local family-based solutions are needed to bridge the economic and health burden for families who have often have to resort to non-community-based hospital care. Panicker et al (Embrace) have proposed an alternate solution with a $25 portable and energy efficient “incubator”. An innovative phase-change material (PCM), safely inserted in a sleeping bag, has been designed to regulate a baby’s temperature (~37oC). To heat the PCM, the user simply needs to place a removable pouch in pre-heated hot water. The PCM’s physical properties ensure that, regardless of water temperature exposure, the baby is provided an ambient temperature of about 37oC. The PCM is also embedded with a thermochromatic ink, which changes color to indicate its optimal heat status. This “incubator” does not use electricity, has no moving parts, and lasts about 4 hours and is reusable. Our expectation is that the device will augment the national drive for kangaroo mother care (an integral component of the “essential newborn care” for NHRM. It has the potential to bridge the gap in healthcare available to both urban and rural newborn and allow the mother to attend to daily chores while caring for her infant. We believe that this is an enabling technology to aid governments towards achieving the UN millennium development goal of reducing infant mortality by 2/3 by 2015. “Embrace” evolved out a class at the Institute of Design, at Stanford University. Early work was done in partnership with Medicine Mondial from Nepal, and Design that Matters, from MIT. The team comprises Stanford Engineering and MBA students, and students from Harvard University’s Kennedy School of Government. Our advisors include Prof. Vinod K. Bhutani (Neonatologist, Lucile Packard Children’s Hospital, Stanford), Prof. James Patell (Stanford Institute of Design, and the Graduate School of Business), and Colleen Cotter, IDEO, Palo Alto (Product Design). 2. Specific Aims: i) To facilitate the testing of the device by a neonatal research network group in India ii) To provide scholarly support to better understand the community acceptance of kangaroo mother care and the potential beneficial value/limitations of the augmentation provided by the test portable device iii) To network the community education of thermoregulation of newborns (prevention of hypothermia) and facilitate the acceptance KMC and the role of the augmented device (once tested to safe and effective in clinical trials). 3. Immediate Objectives are to a) establish liaisons between the Panicker group, AIIMS-based investigators and review the regulatory requirements in India for testing and use of an investigational device; b) Facilitate the development of a strategic plan for clinical trials to demonstrate performance and safety at tertiary and specialized neonatal centers and follow-up validation of community acceptance and device performance in a home setting (rural and urban-slum). 4. Impact of Health and Societal Scholarly Discipline: from this project will serve as a template for testing a new investigational device in both the clinical settings (specialized and primary) as well as measuring the community acceptance in the context of social, cultural and personal values. Publications 1. Bhutani VK. Developing a systems approach to prevent meconium aspiration syndrome: lessons learned from multinational studies. J Perinatol. 2008 Dec; 28 Suppl 3:S30-5. 2. Bhutani VK. Covenants for Maternal-Child Health, Empowerment, Advocacy, Leadership and Self: “ASK. It’s your right” Indian Journal of Pediatrics (submitted).
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