Effect of structured training programme on knowledge of stakeholders working for Particularly Vulnerable Tribal Groups (PVTGs) in twelve tribal districts of an eastern state of India

Particularly Vulnerable Tribal Groups (PVTGs) are the most marginalized tribal communities in the Indian society. The uptake of government led health & nutrition programme by them is low due to the geographical remoteness of their habitat, communication gap between service providers and PVTGs and their cultural believe. The objective of this study is to implement & assess the effectiveness of training programmes for stakeholders working for PVTGs in tribal districts of Odisha, an eastern state of India. A cross-sectional study was done in 12 tribal districts during April 2019 to January 2020. Six modules were developed for the trainings of different stakeholders like health ocials, ocials from Women & Child Development departments, NGO personnel, functionaries of Odisha Livelihood Mission (OLM) and Odisha PVTG Empowerment & Livelihood Programme (OPELIP). Three-day residential training programmes covered six thematic areas like child malnutrition, adolescent health, maternal health, communication in service delivery and about different PVTG communities and evaluation was done for 231 participants out of total 242 trained. Pretest and posttest knowledge assessment of the participants were done using a pretested structured questionnaire consisting of 20 items. various aspects related to adolescent health, antenatal & postnatal care, maternal & child health, malnutrition among under-5 children and communication. Six modules were developed by the researchers and vetted by the experts in the respective eld. These modules were used for training. Lecture, Group discussion, Group activities, practical demonstration (how to measure weight, height, Mid-arm Circumference), role play (for communication) were the different methods used in training. These modules were given to the participants for further reading. A comprehensive module covering all the above thematic areas was developed for the Frontline workers and this was translated to local language. are presenting here the implementation of the training program and results of effectiveness of this training program on knowledge related to adolescent health, maternal and child health issues, communication methods among different stakeholders.


Background
The aboriginal ethnic groups or indigenous peoples are culturally distinct societies and communities. Worldwide, approximately 370 million indigenous peoples are residing across some 90 countries, making up 5 percent of the global population [1]. They live in all geographic regions and represent 5,000 different cultures. The aboriginal ethnic groups of India are called "scheduled tribes". As per 2011 Census of India, 705 scheduled tribes (STs), constitutes approximately 8.6% of India's population [2]. Out of the total Scheduled Tribe population, approximately 2.6 million (2.5 per cent) belong to "Particularly Vulnerable Tribal Groups" (PVTGs). This classi cation is reserved for the most disadvantages of all the ST communities. PVTGs are distinguished from other tribal communities with regard to their pre-agricultural economy, extremely low level of literacy, isolated habitation etc. [3]. There are 75 identi ed PVTGs spread across 18 States and Union Territories in India [4]. And among them, Odisha, an eastern state of India with a population of approximately 41.9 million [2] has the distinction of having the largest number of PVTG-13. [5]. The PVTGs in Odisha are scattered over 541 villages in 12 districts of the state with an estimated 83,611 population.
In every part of the world, the aboriginal ethnic groups face discrimination and are forcefully evacuated of their ancestral land by large-scale deforestation, establishment of industries, factories in the name of economic development, which deprive them of their recourses for survival and cultural practices [6][7][8]. Studies across the globe have shown that the indigenous people experience enormous health disparities compared with the general population [9][10][11][12][13][14].
The health needs of the indigenous people and the health care utilization trajectory may be met if interventions would have some relevance with their culture.
In this context, Government of India implemented the Scheme of "Development of Particularly Vulnerable Tribal Groups (PVTGs)" exclusively for them through the Ministry of Tribal Affairs [15]. Under this scheme, Conservation-cum-Development (CCD) Plan for the PVTGs are to be prepared by each state and Union  [16]. Although signi cant success has been achieved in reaching many Scheduled Tribes (STs) in Odisha, the PVTG communities remain conspicuously unreached. In this project, we envisaged to do the orientation and training of all the stakeholders in Micro-project areas in twelve districts of Odisha who would be involved in implementation of these initiatives by providing technical support.
We are presenting here the implementation of the training program and results of effectiveness of this training program on knowledge related to childhood malnutrition, adolescent health issues, maternal and child health issues and effective communication among different stakeholders.

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Study Design and setting: The analysis presented here is a part of the project "Jiban Sampark" which literally means "Connection with Life". This project was envisaged to enhance the uptake of health & nutrition programmes by the PVTG communities. For generating demand among the PVTGs and to provide quality services to them, the knowledge, skill and attitude of the stakeholders play a vital role. Hence, in collaboration withGovernment of Odisha and UNICEF, All India Institute of Medical Sciences, Bhubaneswar, an Institute of National Importance (INI), provided technical support and capacity building of different stakeholders working in 17 micro-project areas in 12 tribal districts (Fig-1). The details of the micro-project areas and PVTGs have been given in table-1. These trained stakeholders would be involved in implementation of government led programmes and schemes and they in turn would train the front line workers ( Lecture, Group discussion, Group activities, practical demonstration (how to measure weight, height, Mid-arm Circumference), role play (for communication) were the different methods used in training. These modules were given to the participants for further reading. A comprehensive module covering all the above thematic areas was developed for the Frontline workers and this was translated to local language.
We are presenting here the implementation of the training program and results of effectiveness of this training program on knowledge related to adolescent health, maternal and child health issues, communication methods among different stakeholders.

Outcome assessment
Pretest and posttest evaluation for knowledge assessment of the participants were done using a pretested structured questionnaire consisting of 20 items with four questions each from adolescent health, child malnutrition, new-born care & immunization, antenatal &post-natal care and communication respectively. The evaluation was done on 231 participants.

Statistical analysis
The data was analyzed using SPSS version 20.0. Normality of data was assessed using the statistical tests of normality like Shapiro-Wilk and Kolmogorov-Smirnov tests. Continuous variables with a normal distribution were presented as the mean ± standard deviation (SD) and qualitative data was expressed with frequency and percentages. Pre and post test score of an individual question as well as for a particular domain or thematic area was assessed using McNamara's test and comparison of cumulative pretest score and post test score was analyzed using paired t test. Comparison of mean values of pretest and post test score of different groups was analyzed using Analysis of Variance and p value less than 0.05 was considered to be statistically signi cant.
But analysis was done for 231 participants as six NGO functionaries repeated the training in subsequent batches and ve participants either missed the pre or post-test sessions, they were excluded. Questions were based on ve domain or thematic areas such as childhood malnutrition, adolescent health, antenatal and postnatal care, New-born care & immunization and communication. Each area contains 4 questions. The knowledge of participants was assessed by using pretested structured questionnaire. There was signi cant improvement in knowledge in different domains after training. The pretest results for communication in service delivery (44.04%) and new-born care & child immunization (46.7%) was relatively low but that of adolescent health was highest (52.4%). There was signi cant improvement in knowledge in all the domain/thematic area after training. The mean total score of knowledge was signi cantly improved (13.79 ± 3.78) after training as compared to before training (11.5 ± 5.2) ( Table-2).
A comparison between knowledge of different stakeholders in different domains was done (Table-3 & Fig-3). The pre-test result for the overall knowledge was low among OPELIP staff and health functionaries with mean score of 8.41 ± 3.03& 9.16 ± 2.49 respectively. But in post-test results, the highest score was obtained by the health functionaries (15.48 ± 4.19) followed by OLM staff (14.91 ± 3.26). In all the domains, the health functionaries had scored better than the staff of other department except for communication in service delivery, where the NGO functionaries had scored highest. Among all the stakeholders there was signi cant increase in the level of knowledge between pre-test and post-test results.
The knowledge of OPELIP staff was lower than any other stakeholders in every domain except for WCD functionaries whom knowledge was lowest in communication. The knowledge gap between the stakeholders of different categories in all domains was larger in pre-test results as compared to the post-test results.

Discussion
The uptake of health & nutrition programme by the PVTGs is very low. Cultural factors followed by the long distance to cover owing to the geographical remoteness and belief in indigenous system of treatment explain most of the reasons for non-utilization. Signi cant mistrust between tribal communities and service providers who are largely non-tribal, weak demand and non-responsive supply chain become barrier for the planners, programmers and functionaries in delivering the health care services to the PVTGs. Hence the interventions to enhance the uptake of different health & nutrition related programme by PVTGs should be sensitive enough to have some relevance to their culture. There is huge cultural difference among the PVTGs also. So, a particular approach that works for one PVTG will not work for others. Programmes should be designed according to their need and cultural context. Functionaries of different departments working closely with these PVTGs need to understand the intricacies of their culture as well as the technical stuff to render help to these communities at the time of need. Hence, training of these functionaries becomes necessary to build their capacity.
The present study was carried out to provide technical support and capacity building of different stakeholders working closely with the PVTG communities in 12 districts of Odisha. Through six intensive training programmes, 242 stakeholders were trained to be master trainers for the frontline workers.
In this study, the mean total score was signi cantly improved after training as compared to before training among all stake holders (13.79 ± 3.78 vs 11.5 ± 5.2, p value = 0.001). Study conducted by Nelson BD et al on frontline maternal, newborn, and child health workers in South Sudan observed that the scores improved signi cantly from 62.7%±20.1% pre-training to 92.0%±11.8% post training (p value < 0.001) [17] The pre-test result for the overall knowledge was low among OPELIP staff with mean score of 8.41 ± 3.03. As OPELIP staffs are involved more in livelihood programmes like agriculture, horticulture, sheries, animal husbandries etc, they have less technical knowledge in the eld of health and nutrition. On the contrary, the knowledge in OLM staff was quite good with mean score of 11.41 ± 3.42 even though their exposure to health & nutrition technicality is similar to OPELIP staff. The pre-test ndings for health functionaries (Public Health Extension O cers) were strangely lower (Mean score 9.16 ± 2.49) than other stakeholders except OPELIP staff. But, the post-test scores of health functionaries were highest in all domains and the overall increase in knowledge was statistically signi cant (pre-test 9.16 ± 2.49 Vs 15.48 ± 4.19, p < 0.0001). A study conducted by Khyati FN et el, amongst community health workers in Indonesia documented a signi cant improvement in knowledge regarding management of children with cough and breathing di culties amongst those were trained (p value < 0.05) [18]As ICDS supervisors work mostly for under-5 children, their knowledge in child malnutrition was better than other stakeholders in pre-test assessment and there was signi cant improvement in knowledge after the training. But their knowledge was low in the domain of communication in service delivery. This may be due to their less direct interaction with the bene ciaries like under-5 children and mothers. The knowledge regarding new-born care (kangaroo mother care) and immunization was improved signi cantly from 46.7-75%. Similar ndings were observed by Batra K et al where in the post test the participants improved their score to 100% [19]. The study by Taw q E et el have also shown that regular training of health care workers can improve quality of care of under-5 children [20]. Inservice and pre-service trainings are required by the stakeholders working in the eld of nutrition and health as these are ever evolving subjects. A study by Ameh et el recommended in-service & pre-service emergency obstetric and new-born care training for health care providers for better maternal health outcomes. But these emergency obstetric and new-born care trainings are lengthy and more intensive than the trainings we conducted for the stakeholders [21]. Study conducted by Bredfelt et el have found that training improved electronic health records (EHRs) skills of health care providers. The training sessions consisted of short lectures and demonstrations (20-40 minutes) were interspersed with hands-on directed activity. The training methods were similar to ours but the duration of training was shorter in their case. Another plus point in their trainings were that, those were conducted in live HER environment which might have resulted in better results in terms of outcome [22].
The strength of this study was that it was a rst of its kind of training for the stakeholders working for PVTG communities in 12 tribal districts of Odisha and also assessed the usefulness of the training modules speci cally developed for this training. The training module had covered all the aspects of child health, adolescent health, maternal health, communication strategies in service delivery and evaluated for the same. This training would equip the stakeholders with the required knowledge and skill to deliver quality health & nutrition services to the PVTGs and as Front-Line Workers (FLWs), local leaders and traditional healers would be trained subsequently, the communication gap between the PVTGs and non-tribal service providers would be lled up. The project has a component of monitoring of the trainings of FLWs. Hence the rolling out of the programme would be reinforced and quality of training would be good. Assessment of the participants immediately post training which might have resulted in an increase in the level of knowledge regarding different components of maternal and child health may be a limitation for the study.

Conclusion
Under Universal Health Coverage, provision of health services for all is the mandate of both state and central government. As the Particularly Vulnerable Tribal Groups (PVTG) are the most marginalized social category in India, many health & nutrition related programmes by state & central government are intended for them. But the uptake of these programmes by them is very low due to various factors. All the stakeholders working for PVTGs play crucial role in increasing the uptake of these programme by these communities. In this study, technical support and capacity building was provided to most of the stakeholders working in the tribal districts of Odisha where most of the PVTGs are residing. Signi cant increment in knowledge was observed for almost all domains and among all categories of stakeholders following trainings. As these master trainers would train the frontline workers in their respective areas, it is suggested that, there should be refresher trainings for these stakeholders at regular intervals to maintain the knowledge level. Therefore, we did not take separate informed consent from the participants for pre-test and post-test sessions.

CONSENT TO PUBLISH:
Authors give their consent to publish AVAILABILITY OF DATA AND MATERIALS: There is mutual understanding between the funding agency (UNICEF, Bhubaneswar, Odisha) and AIIMS, Bhubaneswar not to share the raw data with anyone. Apart from NGO functionaries, all other stakeholders are government employees. So authors cannot share the data with anybody except state government.

COMPETING INTERESTS:
None declared FUNDING: This program implementation was supported by United Nations Children's Fund (UNICEF).

AUTHORS' CONTRIBUTIONS
VB, PPG and MT conceived and designed the study. PPG and VB acquired and analyzed the data and prepared the initial manuscript. PPG, VB revised the draft critically. All authors have read and approved the nal manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.   Pre-test & Post-test Scores of different stakeholders