<h1>Shree  Swami Samarth</h1>

Cleft Lip Project

Executive Summary

B.K.L. Walawalkar Hospital,Dervan , is actively involved in the treatment of patients with Cleft Lip and Palate. Cleft Lip and Palate Camp is held on Quarterly basis at this Hospital. This is the only Hospital in Konkan Area providing such a specialized plastic surgery service. This is possible only with the teamwork of renowned plastic surgeons, Dr. Lalita Naik and Dr. Sheetal Jagtap, anaesthetist visiting regularly and working in close co-ordination with surgeons,paediatrocoans and anaesthetist at the hospital.

With the availability of Doctors and Hospital for the camp, the question was how to get the patients to the hospital. For this it became necessary to raise community awareness as people in this area have many myths and superstitions related to congenital anomalies. They associate it with evil spirits and think of it as an incurable condition. For this lot of efforts had to beput by the community health department during the initial camps andmuch of it need to be continued even now. All health care workers, general practitioners and consultants are personally approached and information about the camp is given to them. Similarly, the community leaders in various villages are approached to identify the children with cleft lip and palate in their respective villages. Personal visits are made to the patient's house by our team members and the need of surgery explained. Media of newspapers is used to spread the message.In babies with cleft deformity upto the age of four months, repair of lip , soft palate and vomer flap is undertaken. Remaining treatment for lip deformity and rhinoplasty is completed before the child completes 1 year of age.

Todate, 147 patients have come for consultation and 88 patients have been successfully operated. The awareness is increasing in this area and the belief that it is an incurable condition is slowly disappearig,thanks to the good operative results seen by villagers in the nearby area. All types of repairs have been successfully done at Walawalkar Hospital because of teamwork and availability of well-equipped operation theatres. Close follow-up of patients after surgery is done by the surgeons of the Hospital. Also the patients are examined by the plastic surgeon on his next visit and advised accordingly.

Overall project objectives

The overall aim is to carry out preventive, curative and rehabilitative program for clef lip and palate patients. In addition to identifying , treating, and rehabilitating cleft li/palate patients this project's objectives include increasing community awareness of cleft lip/palate nd carrying out research to look into the causes of this disorder.

Work Plan Summary, including Target Population

This is a longitudinal interventional project to be carried out in districts of Raigad, Ratnagiri and Sindhudurg district. The hospital is situated in Ratnagiri district and comes under Swarda PHC jurisdiction. Ratnagiri district has population of 1,696,000 and SawardaPHC covers population of 34,000. Raigad and Sindhudurg district also cover population of approximately 1,500,000 to 1,600,000 each. Thus the total population to benefit from this project is approximately 4,800,000. This project will continue over a period of six years. The initial thee years is the intensive phase period and the remaining three years as the passive phase period.All the children in these three districts will be examined for cranial-facial abnormalities. The affected children will be treated with surgery. They will also receive paediatric reference,orthodontist treatment and speech therapist treatment as and when required.Also all the newborn children in the above villages will be surveyed for any other abnormality. Children are the primary beneficiaries of this program since their general health is in danger if corrective surgery is not perfomed. However, if older children or adults with cleft palates/lips are identified they will also be treated.

The project requires a multidisciplinary approach in order toachieve success. We require the help of villagers, the private doctors, government doctors and all level of health workers as well as school teachers in order to identify these patients and report them to the hospital. Also the Medical social Worder at the hospital is required to establish a co-ordination between these various levels of health staff. Monitoring of all these activities as well as carrying out research activities in the form of Epidemiological studies would be the responsibility of the Community Health Consultant. After the patient reaches the hospital , the patient would be evaluated by a team of hospital Surgeons, Paediatricians, Anaesthestists and later referred to Pathology for investigations. The patient is then followed by a paediatrician and surgeon regularly untilhe becomes fir for Surgery.Necessary Travel arrangements are made for the patient to arrive at the next camp. He is then operated on by the surgical team and monitored closely post-operatively. Patient is then discharged after 6 days.

Topography

Ratnagiri district is situated in western coast of Maharashtra State of India. Its latitude is 16.300 to 18.040 north and 73.030 to 73.520 of longitude in east. Ratnagiri district has border in north with Raigad and in south with Sindhudurg district. The natural beauty is added by Arabic sea in the western coast and Sahyadri Mountains in the eastern region.

The total area of Ratnagiri is 8326 sq. kms. It comprises of 9 talukas namely Ratnagiri, Guhagar, Dapoli, Mandangad, Khed, Chiplun, Sangmeshwar, Lanja & Rajapur.

The total population of Ratnagiri district is 16,96,000. The rural population in this district is 1,50,431. The males are 7,94,000 & females are 9,02,000 in number respectively. Averrage literacy rate is 75.35%. Out of which male literacy is 86.28% & female literacy is 65.98%. The ratio of female is 1135 per 1000 male.

Kokan Railway is boon for the people of this region for the last decade. However migration of population still continues in search of job to other metro cities.

The food habit of the people is mostly restricted to rice and fish, hence malnutrition with anaemia is quite prevalent in children under 5 years of age and adolescent group.

Since industrialization is less, the male population has tendency to migrate to larger cities for work like Mumbai & Pune. The main business of the persons of this Konkan region is fishing, agriculture and labourers. Average rainfall is 3000mm between June to October months. The maximum and minimum temperature is 34.20C & 18.70C. The relative humidity is more in summer as the Arabian sea is in west coast.

Aims & Objectives

I.General Objective

To prevent disorders of cleft lip & palate and promote quality of services in medical care.

II.Specific Objectives (Modified)

   

   b). To help parents for overcoming psychological stress and strain of the situation.

   c). To motivate patients for timely consultation with plastic surgeon for early correction through surgical interference at proper age.

   d). To rehabilitate the patients with dental and speech problems if it exists.

   e). To increase awareness through information, education and communication (I.E.C) in community.

   f). To carry out pre marital counseling amongst adolescent group in college / school.

Activities: (planned)

   1. Advertisement

      a). Through local newspapers

      b). Through health visitors / ANM / medical professional personnel in rural area.

      c). Through increasing awareness in rural population.

   2. Activities : (Proposed in future)

      a) Panel discussion proposal with All India Radio authorities and its relay eventually time to time.

      b) Focus group meeting in rural areas with parents and villagers.

      c) Slide show to increase awareness amongst rural and urban population.

Activities carried out

   i. Local doctors contact.

   ii. Contact with other effective personnel.

   iii. Village Mahila Mandal members awareness generation activities.

Reasons for difference

Since pilot study was not done earlier, it was not possible to record the problems. After my joining 30 cases studied during the past 2 months and discussion with parents was carried out. The sudden drops in cases were observed due to festival season and the work was affected in September 2002.

Social taboos and belief

Elderly children and parents have feeling that this illness is due to sin committed by grandparents. Others believed that this has happen due to cutting of vegetables during eclipse period by pregnant lady

Methodology

Area

The study area has been restricted to the talukas (9), that is within radius of 125 to 250 kms of area approximately. So far the coverage has been achieved from Dapoli to Rajapur.

Technique

Participatory Research appraisal technique (PRA technique) has been adopted to find out the cases in the rural area since the villages are quite remote and the population is scattered in hillocks and valleys. The villages are also situated at varied distance.

In addition to this, contact with doctors in nursing home wherever existing in villages of taluka places and general practitioners have been established to increase awareness amongst themselves for timely referral of a patient & proper selection of these patients.

Both parents of the patient have been given education through IEC & group meetings in this hospital when they bring the patient for consultation.

Data collected, compiled and analysed on EPI Info 5.0 software. The monitoring proforma was also developed simultaneously.

Observation

The distribution of Cleft Lip & Palate cases has been observed maximum in Ratnagiri (84.0%) and minimum in Satara & Sholapur (3.0%) districts. However Raigad and Sindhudurg districts has 5.0% of prevalence each.

The taluka wise distribution revealed the highest contribution by Chiplun taluka, (26.0%) followed by Ratnagiri (21.0%) subsequently.

Religion wise contribution of Cleft Lip & Palate is 95% in Hindu community and only 5% in Muslim community. Similarly it has been observed that this anomaly is more common in first born child of a family (18 cases). The associated family history of congenital anomaly is not significant as only one case had deafness and dumb in the cousin of this family. Female outnumbers the male in this congenital anomaly by 51% as against 49% in males so far.

The anatomical site wise distribution reveals the pre-ponderance of left side anomaly in these cases. However this is only the first lot of patients and it needs further observations.

Monitoring proforma for evaluation of activities

Sr.No

Target

I/P indicator

Process

O/p indicator

Effect

K.A.B.P

Impact

1.

0 1 yr.

a).Parents assurance,

 

a).Counselling of parents.

% of parents received the counselling

 

 

 

Knowledge attitude behavior practice of parents.

Weight gain in patient.

b). % of called cases for surgery.

b). % of surgery performed

c).Feeding advice to patients

 

c). Use of spoon / wati or long teat vessel.

Monthly weight record of patient

Healthy appearance of child

Weight gain in patient.

2.

1 6 yrs.

Health education to ensure parents for follow up care

Counselling for speech

Progress of reduction in problem.

Actively mingling with other peers.

Scholastic carrier improvement

% of palate deformity cases

Dental surgeon consultation.

% of cases advised obturator

% of Speech improvement cases

Mixing with peers.

3.

6 yrs. And above

Cosmetic repair

Surgical interference

Cosmetic improvement

No social problem

Scholastic carrier improvement

Speech development

Speech therapist consultation

Speech improvement

No social problem

Scholastic carrier improvement

Changes in project during monitoring

1.Proforma modification to ensure proper indicators for evaluation of project.

2.To avoid psychological disturbances in family early detection and correction advised.

Local Community:

Local leaders, community workers and ANMs help to ensure early reference to tertiary hospital (BKLW Hospital)

Organization

BKLW hospital authorities have started feeding of data in computer and analysis is to be carried out by EPI Info 5.

Government linkages through M / O Incharge PHC and their workers in surveillance of patient through their staff involvement in periphery

Training activities

1. Training to nurses and doctors in BKLW hospital by Dr. A. Deodhar, plastic surgeon, Pune, regarding aetiopathology and management.

2. Proposed lecture by Dr. Ravin Thatte, plastic surgeon, Mumbai, India.

Age wise Distribution of Cleft Lip & Palate Cases

Cleft Lip Project

Taluka wise Distribution of Cleft Lip & Palate Cases

Cleft Lip Project

Taluka wise Distribution of Cleft Lip & Palate Cases (Pie Chart)

Cleft Lip Project

Birth order in Cleft Lip & Palate Cases

Cleft Lip Project

Religion wise distribution of Cleft Lip & Palate Cases

Cleft Lip Project

Anat. Site wise distribution of Cleft Lip & Palate

Cleft Lip Project

Family h/o Cong. Anomoly association

Cleft Lip Project

Data Analysis

District wise distribution is 84 % in Ratnagiri district.

Taluka wise distribution of Cleft Lip & Palate discloses Chiplun Taluka as highest 26 % (10 cases) till date. Earliest reporting is done during 1st year is in 27 % cases as directed by pie chart. Same chart indicates that in 11 % of cases, the reporting is as late as 20 years probably due to ignorance.

Hindus are highest in contribution. 95 % as far as religion wise distribution is concerned. Female and males are 51 % and 49 % respectively. There is no h/o congenital anomaly in other family members except in one (3rd degree consanguinity) family.

Left sided cleft lip is more common as noticed so far still further study is required.