|Year : 2022 | Volume
| Issue : 1 | Page : 10-16
A role of community nurses and challenges faced by them toward providing MCH services in selected blocks in West Bengal: A cross-sectional study
Swatilekha Pradhan, Uma Rani Adhikari
College of Nursing, Medical College Hospital Kolkata, Kolkata, West Bengal, India
|Date of Submission||09-Nov-2021|
|Date of Acceptance||04-Feb-2022|
|Date of Web Publication||20-May-2022|
Dr. Uma Rani Adhikari
College of Nursing, Medical College Hospital Kolkata, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Background and Aims: Community nurses have been providing health care to communities for many decades and have assumed a variety of roles, including community empowerment, the provision of services, and linking communities with health facilities. They face many challenges while providing community service. The present study has been conducted to assess the role of community nurses toward maternal and child health (MCH) services and to find out the challenges toward providing MCH services. Materials and Methods: After Institutional Ethics Committee approval, data were collected from 100 community nurses through multistage sampling. Data were collected through semi-structured and structured interview schedules. All tools were tested for validity and reliability before data collection. Data analysis was done through descriptive and inferential statistics. Results: Most of the community nurses adopted the role of educator (98.43%), administrator (97.63%), supervisor (95.5%), and coordinator (93.63%), respectively, toward MCH services; however, only 84.9% and 80%, respectively, performed a care provider’s and a collaborator’s role. The most common challenges faced by the community nurses were overburden, due to a high inflow of patients at the OPD (78%), the overload of handling written documents, and online data entry (69%). Conclusion: Administrators need to take proper steps to reduce the challenges faced by the community nurses, and there is a need for constant supervision and timely training for the community nurses.
Keywords: Challenges, community nurses, role towards MCH services, selected blocks
|How to cite this article:|
Pradhan S, Adhikari UR. A role of community nurses and challenges faced by them toward providing MCH services in selected blocks in West Bengal: A cross-sectional study. J Health Res Rev 2022;9:10-6
|How to cite this URL:|
Pradhan S, Adhikari UR. A role of community nurses and challenges faced by them toward providing MCH services in selected blocks in West Bengal: A cross-sectional study. J Health Res Rev [serial online] 2022 [cited 2023 Jun 7];9:10-6. Available from: https://www.jhrr.org/text.asp?2022/9/1/10/345549
| Introduction|| |
As per the Sample Registration System 2020, the infant mortality rate in India is 30 per 1,000 live births; as per the Sample Registration System 2016–2018, the maternal mortality ratio is 113 per 1 lakh live births in the country. So, MCH care is very important and community nurses are increasingly expected to take on a task in the area of MCH. The Sustainable Developmental Goals include a commitment to reduce the maternal mortality ratio to below 70 deaths per 1,00,000 live births by 2030.
The environment of MCH services always faces challenges in Indian communities. The situation is comparatively tougher within the rural parts of the country. The challenges are a mixture of complex issues encompassing the health system and community challenges. The importance of maternal health has been strongly emphasized in the Millennium Development Goals (MDG) and it is the fifth MDG goal. The state of maternal health in India is also alarming, though the nation has seen improvement in the state of maternal health through decades of endeavor. Recent evidence shows that almost two-thirds (70%) of all illiterate women receive no care, compared with 15% literate women. Women in rural areas are much less likely to receive antenatal care than those women in urban areas (43% and 74%, respectively). It has been stated that the high levels of maternal mortality might be prevented if women have adequate health services; this is why maternal mortality ratio in India is high. India’s maternal mortality rates are the highest in rural areas. From a global perspective, India accounts for 19% of all live births and 27% of all maternal deaths. It is stated that birth takes place in non-hygienic conditions or births are not attended by professionals; thus, these are more likely to have a negative impact on the mother and the child.
Mohapatra and Gomare conducted a study on the critical appraisal of the maternal and child health scenario in India with regard to the achievements of MDG. The MDG 4 target involved reducing child mortality by two-thirds between 1990 and 2015. For India, this translates into a goal of reducing the infant mortality rate from 88 per 1,000 live births in 1990 to 29 in 2015. Under the MDG 5, the target is to scale back the maternal mortality ratio by three quarters between 1990 and 2015. This translates to reducing the maternal mortality ratio from 560 in 1990 to 140 in 2015. The Government of India has not undertaken any study to assess the ongoing program / scheme to reduce the maternal mortality ratio and the infant mortality rate. However, regular supportive supervision visits have been conducted to assess the progress of ongoing interventions for the improvement of infant and maternal health outcomes.
We all know that MCH services face challenges; thus, to beat the challenges, we need to analyze the condition of the infrastructural status, manpower status, services availability, equipment / logistic status, and patient care services in different sub centers / health wellness centers of selected districts in West Bengal by keeping in mind the ultimate goal to find out the challenges and providing effective and efficient maternal and child health services.
The aims of the study were to assess the role of community nurses toward MCH services, to find out the challenges faced by community nurses toward providing MCH services, and to find out the association between the role of community nurses toward MCH services and selected demographic variables.
| Materials and Methods|| |
Setting and design
The community-based cross-sectional study was conducted with community nurses who were posted in selected blocks in the selected district of West Bengal during the 02/01/2021 to 31/01/2021 period. In this study, community nurses denote all nurses (Auxiliary Nurse Midwife and Community Health Officer) who provide the MCH services in the subcenter and the Health Wellness Center. Her role toward MCH services refers to the following practices, that is, conducting clinic, periodical home visits, ensuring complete ANC and PNC, newborn care, screening of high-risk mother and child, referral, follow-up, etc.
Multistage sampling was done. At first, the district was selected conveniently; blocks were selected through simple random sampling; and subjects were selected through the total enumeration sampling technique. The inclusion criteria were: community nurses who were willing to participate with written consent and available during the data collection period. Community nurses who joined in those subcenters <1month were excluded from the study. A total of 100 community nurses were recruited for the study. A rating scale to assess the community nurses’ role was developed from the guidelines of job responsibilities of CHO and ANM released by the department of Health and Family Welfare, Govt. of West Bengal dated 19.06.2019 and 11.06.2013.
The rating scale consisted of 22 items with different role components, such as educator role, administrator role, collaborator role, supervisor role, and rehabilitator role. The score was: for always = 2, sometimes = 1, and never = 0. To identify the challenges faced by the community nurses, a checklist comprising 16 items was prepared: It consisted of two options, that is yes or no, and scoring was one (1) for yes and zero (0) for no. One open-ended question was also asked to identify any other challenges beyond the listed challenges. The validity and reliability were established before the final data collection. The reliability of the rating scale of the community nurses’ role was 0.91 through Cronbach’s alpha. The reliability of the checklist for challenges was computed through Kuder-Richerdson formula 20 methods and it was 0.87.
For data collection, the name list of community nurses was prepared with the help of Senior Public Health Nurses and those who had a fixed appointment for visiting subcenters and Health Wellness Centers. Subcenters and Health Wellness Centers were visited from Monday to Friday from 10 am to 4 pm. The investigator collected data from four to five community nurses per day and 30–40 minutes time was taken to collect data from each subject.
Data analysis was done through descriptive and inferential statistics. For the assessment of the role of community nurses toward MCH services, mean, standard deviation, mean %, and t value were calculated. Chi-square test was conducted to find out the association between the role of community nurses (ANM) toward MCH services and selected demographic characteristics. Chi-square with Yates’ correction was done where an expected frequency <5 was present for less than 20% cells to determine the association between the role of community nurses (CHO) toward MCH services and selected demographic characteristics. Statistical analysis data were entered into SPSS software version 22 (SPSS Inc., Chicago, Illinois).
| Results|| |
Regarding background information of the subjects, maximum (42%) of the community nurses belong to the age group 31–40 years; majority (76%) of the community nurses are ANM; maximum (49%) of the community nurses have distances less than 5 km between their working place and residence; the majority (62%) of them are involved in MCH services within a 6000–8000 population; 39% have working experience within 10–20 years; and most (86%) of them attended training on Integrated Management of Newborn and Childhood Illness. Overall, 71% nurses attended training on Antenatal Care and Postnatal Care, 52% nurses attended training on Reproductive Maternal Newborn Child + Adolescent Health, 21% attended training on Infant and Young Child Feeding, and 13% attended training on Skilled Birth Attendant training.
[Figure 1] depicts that community nurses have a higher mean percentage in terms of educator (98.43%), administrator (97.63%), supervisor (95.5%), and coordinator (93.63%) roles regarding MCH services; however, only 84.9% and 80%, respectively, performed a care provider’s role and a collaborator’s role. [Table 1] depicts that there is a significant difference between the roles of ANM and CHO in various subscales, such as care provider, educator, administrator, and coordinator role toward MCH services. Thus, this table reflects that the role of the ANM is likely to be better in these subscales.
|Figure 1: Bar diagram showing community nurses’ role in different subscale in terms of mean percentage|
Click here to view
|Table 1: Assessment of different community nurses’ role toward MCH services in terms of mean, SD, and t value n = 100 (nANM = 76, nCHO = 24)|
Click here to view
[Table 2] reveals that 100% of community nurses (CHO) stated that they could not perform a care provider’s role due to the shortage of time; that is why they are unable to provide 100% MCH care. Overall, 70.59% of community nurses (CHO) could not perform the educator’s role due to time constraints and 41.18% of community nurses (CHO) could not perform the coordinator’s role due to lack of experience.
|Table 2: Reasons for not performing the particular role toward MCH services as stated by the respondents nCHO = 17|
Click here to view
[Table 3] represents that the most (78%) common challenge faced by the community nurses is overburden with a high inflow of patients at the OPD. The majority (69%) of the community nurses were overloaded with written documents and online data entry, and maximum (47%) of the community nurses had inadequate training related to MCH services. [Table 4] reflects that there is a significant association between the role of community nurses toward MCHs services and demographic characteristics such as age, professional qualification, and distance of workplace from residence at 0.05 levels of significance.
|Table 3: Frequency and percentage distribution of responses of community nurses regarding challenges toward providing MCH Services. n = 100 (nANM=76, nCHO = 24)|
Click here to view
|Table 4: Association between role of community nurses toward MCH services and selected demographic characteristics, n = 100 (nANM = 76, nCHO = 24)|
Click here to view
| Discussion|| |
The current study showed that community nurses had performed various roles toward MCH services, that is, a care provider’s role through antenatal checkup, immunization, health assessment during home visit, and family planning services, and an educator’s role through providing health education on breast feeding, immunization, prevention and control of minor ailments and childhood diseases, etc. The present study is congruent with the findings of the studies, in which it was reported that community health workers serve a care provider’s role through identifying pregnant women, provide health education and screen for referral to higher centers, and also serve an educator’ role through providing appropriate and correct health information related to maternal and child care. The study by Srinivasan K and Sharma PS reported a workload of PHN and other women health workers and they mentioned that for field visits, the mean time spent during the previous month was 73 h; however, for immunization it was 26 h, for community interactions it was 52 h, for prevention activities it was 41 h, for mother and child care it was 41 h, and for family planning it was 34 h on an average. For IEC it was 36 h, for reporting the mean time spent it was 14 hours, for official meetings it was 15 h of their time, and for conferences and camps it was 11 h.
In this study, [Table 1] reflected that the role of the ANM is likely to be better in some subscales of MCH services. It may be explained that CHO have many more other responsibilities than ANM; that is why they exhibit low performance when they play the roles of a care provider, educator, administrator, and co-coordinator in MCH services. Further, it can be added that the number of community nurses (CHO) is very less in the present study so the findings cannot be generalized.
From [Table 2], it is reflected that 100% of community nurses (CHO) could not perform a care provider’s role due to the shortage of time; that is why they are unable to provide 100% of MCH care. Overall, 70.59% of community nurses (CHO) could not perform an educator’s role due to the time constraint, and 41.18% of community nurses (CHO) could not perform a coordinator’s role due to lack of experience. A qualitative study of Assam revealed that caseload has been perceived as a specific challenge in delivery and family planning service among medical officers. This study expressed that the shortage of staff is a challenge. This study also mentioned that inadequate training was a major challenge toward MCH services. Overall, 47% of our study participants also expressed that inadequate training is a challenge for providing MCH services [Table 3]. So, in spite of continuing many training programs in MCH care, inadequate training is evident in some health-care settings. Our study findings are also consistent with the studies conducted by Rawal et al. and Heller et al., in which they reported that health workers faced challenges due to a lack of infrastructure, lack of transport and communication facilities, high caseload, and inadequate training. The findings of the present study are congruent with the findings of the study by Tsolekile et al.,where they reported that community health workers could not provide comprehensive NCDs care due to lack of human resources, as well as lack of training services. The present study also found that being overloaded with written documents and online data entry comprised the second major challenge faced by the community nurses [Table 3]. Recently, the study by Brar et al.also found that a major amount of time was spent by both staff members (CHO and ANM) on data recording and reporting. The study by Sumankuuro et al. revealed that the main obstacles for maternal and newborn health services were inadequate medical equipment and essential medicines, infrastructural challenges, shortage of skilled staff, high informal costs of essential medicines, and general limited capacities to provide care. Fabienne et al. reported that the main work challenges related to overall workload, lack of training and support regarding a serious case mix, adverse working conditions, etc.
Our study also revealed that there is a significant association between the role of community nurses toward MCHs services and demographic characteristics such as age, professional qualification, and distance of workplace from residence at 0.05 levels of significance. There is a lack of published quantitative studies related to the role of community nurses in supporting the findings of the present study. It may be expected that subjects with a higher educational level should perform better than subjects with lower professional qualification. Self-efficiency and cooperation from each other increased the performance level of community nurses. One study from India showed that inadequate remuneration and lack of job satisfaction were the factors hindering ASHA workers’ performance. A study by Pyone et al. supports our study findings, and they revealed that one factor for governing the performance of ANMs at their workplaces was training and monitoring systems such as lack of quality supervision mechanisms and regular on-the-job mentoring and refresher training.
This study explored individualized challenges by using open-ended questions and further it was strengthened by a high response rate, which reflects the true representativeness of data. This study has limitation too. First, sample size is small. Second, because of the interview schedule, they (community nurses) may have given an expected response.
The ANM and CHO are working at the grassroot level to provide primary health-care services that serve as preventive aspects. This study will help the community nurses to identify challenges in their practice field and facilities and help them to take necessary steps to provide comprehensive MCH services. The nursing administrator should allocate an experienced supervisor for continuous monitoring of the services and identify the challenges faced by community nurses while performing their role; they should also allocate adequate resources for providing comprehensive nursing services to the community.
Qualitative research is needed in this area for the development of new policies based on scientific data about community nurses (ANM and CHO), subcenter, and Health Wellness Center related activities.
| Conclusion|| |
This study found that community nurses’ roles are quite satisfactory, except in terms of the collaborator’s and care provider’s role. They face many challenges, such as being overloaded with documentation and data entry, high flow rate of the OPD, and inadequate training. There is a significant association between the role of community nurses toward MCH services and the age, professional qualification, and distance of the workplace. Strategies to improve community nurses’ role can be planned by relevant stakeholders on the basis of these findings.
The investigators expressed their sincere gratitude to CMOH, BMOH, and PHN of the selected three blocks for their constant support and help throughout the study. The investigators are indebted to all community nurses for their kind cooperation and support.
Financial support and sponsorship
Conflict of interest
There is no conflict of interest.
Ethical policy and institutional review board statement
This study is approved by the Institutional Ethics Committee and Institutional Review Committee (IEC Ref. No.: MC/KOL/IEC/NON-SPON/691/03/2020, dated March 11, 2020).
Patient declaration of consent
Subject consent taken prior to data collection.
Data availability statement
Data are available with the author.
List of Abbreviations
Initially full form given then only abbreviation is used, so no need to provide list of abbreviations.
| References|| |
Sample Registration System Report 2020. India: Registrar General of India. Available from: http://pib.gov.in/sample registrationsystem
. [Last accessed on 2021 Feb].
Park K. Park’s Textbook of Preventive & Social Medicine. 25th ed. Pune: M/s Banarsidas Bhanot Publishers; 2019; p. 623.
United Nation. Resolution adopted by the general assembly. 55/2. United Nations Millennium Declaration. New York:United Nations; 2000. Available from http://tandfonline.com/doi/full/10.3402/gha.v7.23695
. [Last accessed on 2021 Feb].
International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), India, 2005–06. Madhya Pradesh, Mumbai: IIPS; 2008.
Jejeebhoy SJ, Saumya RR. Unsafe motherhood: A review of reproductive health. In: Das Gupta M, Chen LC, Krishnan TN, editors. Women’s Health in India: Risk and Vulnerability. Bombay: Oxford University Press; 1995.
Saha UC, Saha KB. A trend in women’s health in India–what has been achieved and what can be done. Rural Remote Health 2010;10:1260.
Mohapatra A, Gomare M. A critical appraisal of the maternal and child health scenario in a metropolitan city in India with reference to achievements of millennium development goals. J Family Med Prim Care 2019;8:995-1001.
] [Full text]
Guidelines of job responsibilities of CHO & ANM. (dated 19.06.2019 & 11.06.2013) West Bengal: Govt. of W.B., Department of Health and Family Welfare. Available from http://www.wbhealth.gov.in
. [Last accessed on 2020 Aug].
le Roux KW, Almirol E, Rezvan PH, le Roux IM, Mbewu N, Dippenaar E, et al
. Community health workers impact on maternal and child health outcomes in rural South Africa: A non-randomized two-group comparison study. Bmc Public Health 2020;20:1404.
Olaniran A, Madaj B, Bar-Zev S, van den Broek N. The roles of community health workers who provide maternal and newborn health services: Case studies from Africa and Asia. BMJ Glob Health 2019;4:e001388.
Srinivasan K, Sarma PS. Study on workload of Public Health Nurse and other women health workers. Trivandrum: Sree Chitra Trinunal Institute for Medical Sciences and Technology; 2012. Available from: www.sctinst.ac.in.
Samal J, Dehury RK. Challenges faced by health workers in providing maternity management and family planning services in Assam. J Health Res Rev 2015;2:90-3. [Full text]
Rawal LB, Kharel C, Yadav UN, Kanda K, Biswas T, Vandelanotte C, et al
. Community health workers for non-communicable disease prevention and control in Nepal: A qualitative study. Bmj Open 2020;10:e040350.
Heller DJ, Kumar A, Kishore SP, Horowitz CR, Joshi R, Vedanthan R. Assessment of barriers and facilitators to the delivery of care for noncommunicable diseases by nonphysician health workers in low- and middle-income countries: A systematic review and qualitative analysis. Jama Netw Open 2019;2:e1916545.
Tsolekile LP, Puoane T, Schneider H, Levitt NS, Steyn K. The roles of community health workers in management of non-communicable diseases in an urban township. Afr J Prim Health Care Fam Med 2014;6:E1-8.
Brar S, Purohit N, Prinja S, Singh G, Bahuguna P, Kaur M. What and how much do the community health officers and auxiliary nurse midwives do in health and wellness centres in a block in Punjab? A time-motion study. Indian J Public Health 2021;65:275-9. [Full text]
Sumankuuro J, Crockett J, Wang S. Perceived barriers to maternal and newborn health services delivery: A qualitative study of health workers and community members in low and middle-income settings. BMJ Open 2018;8:e021223.
Jaeger FN, Bechir M, Harouna M, Moto DD, Utzinger J. Challenges and opportunities for healthcare workers in a rural district of chad. Bmc Health Serv Res 2018;18:7.
Pal J, Roy S, Nandi S, Satapathy S. Assessment of knowledge and practices of ASHA workers related to maternal-child health and their performance affecting factors: A mixed method study in Deganga block, North 24 parganas district, West Bengal, India. Int J Res Med Sci 2019;7:3672-8.
Pyone T, Karvande S, Gopalakrishnan S, Purohit V, Nelson S, Balakrishnan SS, et al
. Factors governing the performance of auxiliary nurse midwives in India: A study in Pune district. PLOS One 2019;14:e0226831.
[Table 1], [Table 2], [Table 3], [Table 4]