ADOLESCENT NUTRITION
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- ADOLESCENT NUTRITION
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Ileitis 1-19 of49
' trie page.
1: .AinJ Clin Null’2001 Jam7 3(1) :5 3-60
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Antlrelmintic treatment ofm al Bangladeshi chi 1 den: effect on
host physiology. growth. andUocliemical status.
Northrop-Clewes < 'A, Rousham EK, Mascie-Taylor CN. l imn PG
Human Nut t i ti on Research Group, School of Biomed cal Sci ei ices, University of
Ulster, Cbleraine, Noithei a Ireland United Kingdom
BACKGROUND: The effect of helminth infestation on the nutrition, growth, and
physiology of the host is still poorly understood .Anthelmintic treatment of children
in developing countries has had varying success in terms of growth improvements.
OBJECTIVE: Hie objective of this study was to assess the effect of regular
de worming on clrildgiowlli, (fiysioloey. and lioclienical status. DESIGN: The
study was a 12-mo longitudnal intenention in 123 Bangladeshi childr en aged2-5
y. Treatment (mebendazole) or placebo tablets were administered ever;? mo for 8
mo and again at 12 mo. Weight, height, mi (kipper ami circiunferenpe, in(e.dinal
permeability. plasma albumin. a!plia(l)-anticliymotiypsin, andtotal prolein
concentr ation were assessed evviy 2 mo. RESULTS: Treatment with mebendazole
reduced theprevalence of Ascarislumbricoid-'sfrom 7S"i..to tr;«. of T.richuris
tricliiura fi om65%to9l’C :mdoflioolo.TOnnfrom4"6toO' ,a There was no
signi licanl difference in tie growth of treated children compared with those given
placebo tablets. No charges in iule.-iinai permeability or plasma albumin were
olxeivedaiici dewotmiiig. Significant sL<leases in total potein (PAkOOl) and
i)-irrichyrnotryp-” 'i - • • ‘
— h--r ■ din
‘r-afm-n- —..... p,
inc.
t
.................................. .....
’
’■ nmiinoglobul in concentration
alter deworrning Asiguillcanl iucreas. .i htei
Ic.ic.;ofC
'
-•
hs(li<
4'. vic i
i:. ihe ti calment group was associated with a short -term reduction in
weiejif (P = 0.02) and higher intestinal jiermeability (P <0.001) in iiii'ccied subjects.
No long-term effects of G. intusiinalis on growth were observed CONCLUSIC’N:
Vw.-intensity hehrinlh infections. | xedonsnanlly of A himbricoicbs andT trichiiu
do not conhi Nile significantly io (liep-xn growth andliiochcmical status of rural
Bangladeslu cltilden
PtiH i cation Types:
hi
4^
lilBg
Publication T, pes:
Clinical uial
Randomized controlled tri al
PMliC 10694769
5: TropMedlnt Health 1999 Nov. 1(1 1)744-50
Related .Articles, Books, I inld sit
"Hie impact of population level dsworming on the haemoglobin
levels of scltod children in Tanga. Tanzania.
Beasley NM. Tomkins AM Hall A, Kihamia CM, Lorn W, .Nduna B,
Issae W, Mokes C. Bundy DA
Wellcome This! Centre jia th? Eprfentiology ofInfectious Diseases, University of
CM'oid
The inpact of albendazole (-100 mg) and praziquantel (40 mgdeg body weight)
t; ecmeni of schoolchild eu was compared with placebo according to the presence
of anaemia (IwemogloUn concentration 1.1.0 szd) and heavy (- 5000 epg) <x
light I'- 5000 epg) hookworm egg load. The stitch' was condictedin rural Tanga.
5 Li cation was admit li sterer! in Septemlter 1994 and chi! < ken wore followed up i n
January 1995. Overall, anthelminthic treatment reducedthe fall in haemoglobin
conciliation compared with that obsetvedmthe placebo group (- 0.11 g/d vs. 0.35 g/d: P — 0.02). Aiithelminiliic treatment was of greatest, benefit to tits 9%of
childen with both anaemia and heavy hookworm egg load (+0.67 g/d vs. - 0.67
gc?) and wns also of significant benefit tothe38%ofclrilden with anaemia and
light hookworm egg load (+0.07 g/d vs. - 0.21 g/d). It was of no significant
benefit to childenwho were not anaemic. Ihis study suggests tliat singje-doae
anthelminthic tiealmen! ds&ibuted in schools in this area achieves haematological
benefits in nearly' half of chilcken infected with S. haematobium and geohelminths
(3 7% of total popi tl ati on).
Publication Types:
Clinical trial
Randomized controlled trial
PMLD: 10588768
6: In! J Epidemiol 1999 Jun:28(3):591 -6
Related At tides, Books, [inletJut
.A controlled evaluation of (wo school-based anthelndntliic
:1 v-moilt-Tapy tegtriierts on intensity of intestinal helninth
infections.
Albonico M, Stoltzfe: Rl. Savioli L. ( hwaya HM, cfHaicourt Ii, Tielsch
Ivo <te ..'.jik , i Foundation, Milan, Italy.
BACKGRt L ND: School-based devrorning programmes have been p onioledas
a cost-efl'ective sti ategy for control of nematode infection in developing countries.
While nnmet ois efficacy’ strides have been conducted. there is little information on
actual prog amme effectiveness in areas of intense transmiss on. METHODS: A
randomized trial of a school-based ctewormi 11g pt og anime was conducted in 12
pimray schools on Pemba Island, Zanzibar. Four schools each were randomized to
control, twice a year deworming witli sinsje dose mebendazole or tliree times a
year ctewonning Baseline and J 2-month follow-np data on helminth infection using
the Kato-Katz techiiique, demographic irifonnalion raid nutritional status were
collect ed on 3028 cliilden irom March 1994 to May 1995. RESULTS Intensity
of infection measured as eggs pur gram of faeces (cpg) declined significantly fa
Ascaris haiiLicoides, Tiichtuis irichitua andiiookwonn infections in both treatment
groups. A hnnbricoides infection intensify cteclmed63.1" b raid 96.7“ bin the twice
and three times per year treatment groups compared to the controls. T trichura
iiitecti n tut rosily ctedined 40.4% and75.9%respectively raid hookworm intensity
declined??3’1 bard?7.2%respectively compared to control schools.
CONCLUSIONS: These results suggest that school-based programmes can be a
cc.-t-dffective aj-p oach fa controlling the intensity ofintestinal helnu nth infection
even in environments where transmission is high
Pubi i cation TVpss:
Clinical trial
Multi center stuck’
Randomized controlled trial
PMTD: 1O4O.-.869
7: AdvParasitol 1999;42:277-341
RfilatedAiticles, Books. UnkOut
Control strategies fcr human intestinal nematode infections.
Alborrico M, Crompton DW, Savioli L
Scientific Cbmmittee, Ivo de Gmieri Foundation, Torino, Italy.
In recent yeai s significant progress has been made in understanding the ecd ogy,
epidemiology andrelated moth city and development of now tods for the control of
soil-transiiitted helminths. Such knowledge has recognized the imjMct of helminth
infections on the health of infected groups and has created a rational basis for their
control. School chi 1 den binbour some ofthe most intense hdmintliic infectious,
which produce adverse effects on healtlr, growth and scholastic performance.
However, although great elici t lias been put into targeting school-age cliilci’en,
women of chi id-1 taring age and pre-school chilcken are two othei groups at high
risk of morbi rfty die to intestinal nematode infections. Hiejilv effective and
safety-tested ,-ingIe-dxre anthelminthic dugs are now avail able, [vsrnritling
periodcal deworming of sclnolchilden and other high-riskgronjis at affordable
prices. Foil authelniinlltics against all intestinal nematodes are inducted in the WHO
Essential Drug IJsl (albendazole, levamisole,mebendazole andiyrantel). Recently'
ivermectin has also been registeredfor use against Strongyioictes sterccralisin
..................
cw!i...
'....... ......
,L want iring inn I OVes
.ih>i»i>ishedpe.A.'iwoi < hi I den in eastern Zaire.
DotP.
■ .w D. Dramaix M Vert origen E zSliindilaM.
’• hdiainiii..': M.I-'
txtool oi'riiNic Heallli. Free I •nisei siiyol'Bius.scls(Ull)),Bru-s'els. Belgium
A randomized controlled tri al was conducted in eastern Zaire to assess the effects
of Itigh cose • i lamin A sundementalion andregular depara Station on Hie growth of
35S mochmi.-ly iiialu-otuidiedprescliool clald.cn, discharged Iran the haspiltil. ’The
treat men! groups received eithet viiamhi A (60 mg of oily solufiouofielinjl
palmitate. 30 mg if aged '12 mo) every 6 mo or mebendazole (500 mg) every 3
mo: (he control group received no supjrfementation. Anthropometric data were
gathered at baseline anti after 6 and 12 mo offollow-up. Serum retinol
concentr ations were measured at baseline and after 3 mo. Hie three groups cad not
drier in sociodemograpliic incicalois, age and sex composition, ni.itrilional status
and serum retinol concentrations at baseline. Tn children who were vitamin A
deficient al baseline, adj nsfed mean weight and mid-upper arm circiauference
(MUAQ increments were higher in the vitamin A-supplemented group than in the
control group [annual increment in weight andMUAC in vitamin A vs. control
group: 2.088 vs, 1.179 kg (P“ 0.029) and2.2-1 vs. 0.95 cm (P 0.012).
respectively], whereas growth increment did not dffer between the dswormed
group and the control group. In children who were not vitamin A deficient at
bas
?, growth increment ddnot dffer between the vitamin A-supplemented and
cculicl :icur.... whcre.i; weiglit gain was lower in tire dewonnedgrouptluuiinthe
coiitiol group, viiatuiii A-siipjJemeritedboys gainedma e weight andheiehl ihaii
control boys, whereas vitamin A-supflemented girls gained less height than control
dr! s. Pew™nti,'d toys in id girls gamed fess weight than control bojs and girls.
is to in^rove vitamin
tatustty high dose vitamin A siq^ianentation may
iiis.rov-.- growth of pteschcol cliilden who are vitainin A deficiert, whereas
de worn ling docs not.
■on I p.’’
G ini cal tri aS
Eiiu bruized conlioll..’d trial
I'MID: 9687551
if . .Am,! GinNuSr 1998.hd:68(l):179-S6
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Effecisofthe Zanzibar school-basedcbwomingpro&iain on
iron status ofclrilckeiv
Stoltzfus RT. Alton!co M. Gr.wva HM, Helsch JM Schulze KJ, Savioli I,
Center for Hunan Nutrition, Department of International Healllrlhe Johns
Hojfans School ofPuUic Health. Baltimore, MD 21205, USA rsloltzffriSjhsphedi
We evalurfledthe effects of the Zanzibar school-based (feywrning program on the
hon status of primary school diildeti. Parasitologic andnutritionai assessments
'2). I -shook in which students received twice-yearly djwormmgln-952),
and I schools in which students received ti trice-yearly devrormiug (n 970) with
tug generic mebendazole. Schools were randomly relcded tor evaluation and
allocated!© program groups. Relative to no treafitnerit, thrice-yearly deworming
caused significant decreases in pi otoporpityrin concentrations and both deworming
:reel metiscausedmat gin-ally significant increases in serum ferritin concentrations. Th
average rauiunl changes in protoporphyrin concentrations were -5.9 raid-23.5
i i ii cromoki t k>1 het re in the control arte11 hri ce-yeatiy dewon ri ng groups, respectively
(1' ■: ().'
Ute average changes in ferritin concentration were 2.8 and I.5
inicrog-l., respectively (P - 0.07). Dewonmtgliad no effect on annual hemoglobin
change or prevalence of anemia. However, the relative risk of severe anemia
(henipelobinc 70 g.'L) was 0.77 (95?i>confidence limits: 0.39. .151) in the
twice-yearly dewwiring group and0.-15 (0.19.1.08) in the thrice-yearly
deworming, group. Tire effects on
valence of high protoporphyrin values and
incidence of moderate-to-severe anemia (hemoglobin : 90 g/1 ,) were significantly■, <.;ei in child cu with 2000 hookworm uggs'g feces al baseline. We estimate
that this dewonnirig poet ran [revet fled 12.60 cases of mocks ate-to-severe anemia
and 276 cases of severe anemia in a population of 30,000 schoolchildren in I y.
Where hookworm is heavily endemic. deworming programs can improve iron status
and prevent moderate and severe anemia, but deworming may be needed at least
twice yearly.
PMID: 9665112
11: East AG Med J 1998 lair? 5(1): 16-8
Related Articles, Books, LinkOut
Prevalence of intestinal parasites in Kenyans with dyspepsia.
Cgutu E' .f ,Kanja (?, Kang’etiie SK, 5-Jyong'o A
Dejwrlment of Mcdciii ? nuiv.nsiiy ofNairola.Kenya.
Dysgt-psia an<l intestinal woim inlestation are both common clinical condlions in a
developingcountiy tike Kenya andthus this study was efesignedto look at the
coirelation between the two in arelenal gastroenterology clinic at Kenyatta
National Hospital. One liimded and twenty live patients with riyspepsia had their
.■.tool, dtodenal aspirate mid duodenal biopsy analysedfor evidence of imesthial
parisites. Seven (5.6'11) vwi v I'otuid lt> h;i>e vnious lyjX'S of intestinal jjarasitvs
with gi in d:i lamblia compri sug 42.8% of worms isolated 71.4% of patients with
ciys[iepsia and worm infestation had their syni[tons improved all er deworming, but
the low prevalence ofinlesiiual parasite in dyspe^ic patients makes routine
dswormingnot cost clleaive. Stool examination liadtlie bestyiddfer intestinal
praasites.
PMID: 9034529
12: Fur J Clin Nun 1997 Novpl Suppl 4:8.16-24
Re!ated Articles,Books. IJnkOut
2he ciiallengc of imp ovine h on nmrilimr limilnfinns- and
VV'-
-V? •>«»
i--.I TTVItr M- < t U .M'\ • M lit
t » (I 'ptWV >1'
MpR
division uf Nutrition and Physical .Activity. ('enters for Disease Control and
PrsrerioB. ■yhnla. Georgia. USA
Various: /p oach.: - to improving iron status are dscmsed Success in controlling
iron deficiency worldwide will requite the exjiaalien anddemonstralionof all
possible opiions. 'Hie approaches, which are not mutually exclusive, include iron
snnvdemenlaiion. nutrition education, reducing intestinal parasites ('panic-daily
iiocloAcnni. expandng fortification of processedfoorfet, and develop ng crops that
: : mote iron bioavailable. Coordnatibn with existing heal th and nutrition pograms
can enhance progress toward better overall nutrition. For example, iuthe
development of foodfortificafion or of crops with higher nutritional value, (lie
comhiKition of multiple micronutrients can be considered Within the primary health
care system. iron supplementation and dewonning can be coord naled with other
health care activities, lire ultimat e success in control of iron defici ency will depend
on how well the various intervention approaches can be integrated within the
current iramewotk of public healtu lbod|xoce$dng, and agri culture development.
Publication'types:
serial
1 'MID: P59S7S8
13: J Nutr 1997 Nov:127ill):2187-93
Rvl at<mI .Articles, Books. 111 ik< but
School-based dewotmittgprogt am yi elds small improvement m
growth of Zanzibari school children after one year.
StoltzfusRT, .Aibonito M,TQelsch JM, -'.hw-aya HM, Savioli L
Center for Human Nutrition, 1 -. v tm-ent of International Health lire Johns
Hopkins School ol Public Health. Baltimore, MD 21202. USA
Efficacy trials of airtihdnartlric therapies conducted in .Africa have reported
imnoremeiits in clnltyen's growth but nutritional evaluations of huge-scale
de worming programs are lacking. We evaluated the first-year effect on growth of a
chod-ba ed dzworming program in Zanzibar, where growth retarelation occurs in
school child en Childrenhi four priinniy schools were given Ihrice-yeariy
nii'-endazole <?i)0 ins) and compared with chilcken in low schools that received
t vice-yearly mebendizole aid child en in lour non-prog am schools. Evaluation
schools were i andomly selected and allocated to control, Iwice-yeariy or
ii :•: ce-ycai I y ■:; .• w?: muig
’ n oximately 1000 chi 1 d en in each program group
comjjetedlliel -y iollcw-iij?. t.hild en 10 y ddgained0.27 kgmae .'.eight (P
u.05) andi.'.i3 cm more heigirt (P = 020) in tiie tvvire-yearly group. andO. 20 kg
more w.-igirt (P - 0.O7) and0.30 cm more height (P <0.01) in the thrire-yearty
gi oup. compared with the control group. Cliildren 10 y old with higher
heigiits -ioi-age at baseline had higher weight and heiglit gains in response to
de worming. In cliild en ■ .-10 y old overall program effects on heiglit re weiglit
eains were riot dgnificarit. Bui in this age range, younger boy s had significant
mi>wv..menrs in height gain with t)nice-yearly dewuming, and cltilden with In/her
,f. ml'; :A
PXjiP:
i 'A-.-m
.
■. at n
!<Ionth ■. ■
:111 -I lliissUK'h-w::-' comp’ fed
■
17; Pediatrics 1996 Jun£)7(6Pt 1):871 -6
kGalect Articles. Books, Linki.iul
Effed ■. ft cnwit tg Am
schoolchild en
i s on the growth of Guatemalan
Watkins WF.. Pollitt E
Dept
ics. Univet ity of California, Davis 95616, USA
OBJE* A 11 ■ cfetetnane whether successful dewomiingfot 6 months in children
with lash levels ot A-caris improves physical growth. SUBJECTS. Two hundred
WU!t. -.;isi:: clukfen (mem n®, 9.7 years) in a highland Indan town in Guatemala
DESIGN. <’■' mien w-i-e randomly assieued to receive albendazole or jiacebo at
in; and 12 : .Ik.Children and field workers were both blind to the group
■ OUTCOME MEAiURES. CSiild en's heights,
Cis. and
ifei ■ y v'--;'rn circumferences were measured ar baseline and i 2 and24 weeks.
Feed egg counts were taken at 0.2,12,1-1. and24 weeks Io estimate tire hehrinth
ggspet gram of feces [epg]) RESULTS Baseline hdminthprevalences
were .A-;c~ :.;,910 . mdTiiclmris,82% Atcaris intensities were high half of the
ciiild en bad mod.rate Uu <.l?ns- (10 tXxi; to 50 O,X) epg), mu'i ? T" ohadherr>y
lindens i 50000 c[A;. fricrtinis hrrdens were liglit (7'2% ■ JtxX) epg). 'lire
dbendazoleandplacebogroups ddnot
at baseline in ej®. ^e,
: ■ orretry, or so< ioeconomic status. The two rounds ofheatment successfully
; diced the Ascaris bur dens but had l ess effect onlrichm is. At 6 months tire
treatment gioup showed a .small gain in weight (0.13 ke) comfw ed with the
placebo group but no improvement in height or mid-upper-arm circumference.
CT'N'.2LUS[ONS. The sticc.--IliI rcino-.al of ascar isiii a jxtjxilation of
school-aged child'enwithrelalivelyhiehloads may ht .. mod st effects on weight
gain
..wis is one of tire mo.-i common infections in school-aged cliildeu, but its
effect on the host may be less Ilian that ofotlw helmmths.
Publication Types:
ainical trial
Randomized controlled tri a!
PMID: 8657529
18: Tj ans R Soc Ti op Med Hyg 1
Mai'-.A|5r'.9|ji 2): 156-61
Related .Arieles, Books,
UnkOut
hie r ilex I.- ot <?:w» nmmg on inrs catots Ot school per loir nance m
Guatemala.
V'.hild.r ”1- ' t-o tn Pol lit l P
’.fl ■■ ■ v* • '■■ ■ ’ fl ■ ■. ■< u ■■i l ■>! - i fltali' 1 i flill < ’•< li< liiijn. Olli 16 it) '.'I
>
t■'•C' fl 5.A
■
coi n'tn infectionsin school ag ■ child m.
■
. . '
ged? 12 years, attendng school in rural Guatemala, 91%
cw i!
is Ibiifli- in.flflLs atoS2% earned Tri churis tiichiura. Tliese diikiett
■■. > ■ - ■ I-.- nly ."s-jenedto receive either albendazole or |4aceto at 0 and 12
in a .i-'ii; •: ?-! Ji nd stutiy off he effects of cfcwomwgon indicators of school
pe f<
izolesuccessfullyridthechildrenafAscarisbutitwasless
ug.:;:m Liidmi’. Q.e cliil den’s performance in tests of reading and
weabuk-.ty wi_-re measured al 0 and 24 weeks, the Peatodj'picluie vocabulttiy test
>v... ai ven a-; 24 weeks. and attendance was measured throughout the school year.
■ omii son o' the treaied and pl aceto gi oups showed no positive effect of
rfewoiiutK. The ti eased clrildeu were largely tree of Ascaris for at least 6 months,
; :.i ; Am.; tliat periodv.-e couldnot detect ay inuxoveinent in readtig, vocabulaiy,
or attend® ice. The effect s ol I« ng Tt i clitui s-free were not e.xai i liner 1 because of the
limited effectiveness of albendazole against this worm at the dosage used.
Publication Types:
Clinical trial
Rai flck'mi < i conu died ti i al
PMED: 8761577
9: Worin lierith Fonan I9to lfi ii:to/-a
Related All cles. Books, Linkt AU
?fl:fl?ii. ijifl«tii-iifl.s. fewefl- jrata.'ittoil...’ learning
Ciopal ct is T
tnsultancy Services, Ntteavarapalaya,Bangal ore, Ihda.
By 1997 it is it it ended that all of fnesa'.-; t <;'/ million isitnaty-scitod child en will to
given a tie? daily midday meal, ffince 1994 al most 3 million such children in
Gujarat, already benefiting, from thisinitiative,have toen receiving in adcition,
siiRieinents of iron, iodine and vitamiri A anddewormingtreatmmt with
a’itondazole. As a consequence tli^ic have toen signi ticant, highly cost-effective
and AKtainable improvement .sin growth rates and haemoglobin levels, and
decreases in the prevalence ol ocular signs ol vitamin A (feltdvtxy and tn intestinal
para-titicinfect ions.
PM I D: 9SS6G232
(■: .Ann D?!inanal Vetuneol 19%T2ii'4):2-K|-f'
Related Aliclcs, Books. linkOit
[Clflonic urlicatia andtoxocara canis infcction-Acase-conh'ol
•nxhj.
[.Article in FrenchJ
F
i. 'Vi' . V- 'c. ’<'■ •'
i' ’:my
[red’iiiiicmtly iisedly wohku living nearby in
. uhakand. ■ tecau e ol th? - .
hi,1 ocial coninis on female activities
11>.sue.»• ■ u.ei bom 11k ciniic. in Shekjxn a. ] veitilediosendtheii husbands
a ptanru-y in in? iiearty iowh to buy deworming treamt'iit. .-is a cotiseq icnc?.
. eta
swerea at lativedsadvantageinrespectofthelowexposureof
■
-i
■■ ci. '.i and the gt eater financial cost of deworming treatment.
The ■:nd. T_2:i g;:, the infiuenc?.; of social and cultural fad a;: on
. . I...::—~.'iv:.*.;!<>n. . .v>..... iii i.nil <ir.iv ci womensexpos.ae to livaitli
knowledge aflietainths. Further questions are raised,
ti on axI
however. on the u’ditvof raws to implement preventive measures and the impact
rat
ofp ■■ asitic infection.
■ ■
.. .-_p' • •. vi s ' >
kdin vii Altlvles. Decks,Link!.nit
.Ao I 8-month bud.- of the effect of peiiodc anthelminthic
tr eatment tin the growth andnutritional status of pre-school
child? iiu Biaiel-.idesh
Roi si an EK. M a«ci e-TRiyl or CG
Department of Bioloy.cal Aifin'opolcgy/Aiiversity of Cambdcfee, L2_
An 1 f'-mor.rh <iudy was conducted from Febnraiy 1989 to Ai’gnst 1990 to
mine the
.. '
' d :• • • ■
n mmo on chtldgrowthandnutritiand status. A
sami.’ie of 1102 cl til 4 en. from2 Io 6 yearn old. were dvdedinlo a treatment pronp
and a control group. The 688 children in the treatment group received a 500 mg
^1 nsue inios/ liicLa/hia./a.'K. ak
. > <-i<1 <11 111< the..-Ol... c. otij. .■..I.? ~‘I.Vi 1
'. ■ Aa<.v!.o. Heiela. '-vcigiit snidmid-’.in’ei arm circinnfererjcef MU AO v.ere
men.- itred on monthly households sits. Growth wmneasuredin terms of th?
change in Iieiglit-for-age. weieht-fcr-age. weight-for- bd ehi and Ml. AC over 18
months. Tlie initial pevnlence of infection wis estimated Irornaiandom sample of
96 cliild'cn (49 treated47 control). Tlu-initial overall jxevalenceof Ascaiis
hanbricoides, 'hi chi iris trichina arid hook worm was 71. i I and J. 0"-o respectively.
Hie final .Tevalence ot infection, estimated from a random samj.ie of26? ctiilden,
v-.’.i-. A 1111 ill i coi des 6n. <. T tri cl ii 11 a 6'1.. and 1 iookworn 12'1- i. i 111 he i neteiidazol e
group compai idwilioA 1, 18 and 19,'.'.r.,sj>eclively in the jlacel ■ •> group f)es|ite
th;
treatment of lidniiritlu, there was no significant imp G-.-emeut in the
soHtii of tresttedcliikieii comjKa d with tlieii’ untreated count ei puls in i.rm- of
tiie change in z-setrs of height-for-age, weight-for-age, weight-for-height and
ML'.-Vf. Tl:. factors tdii ch mav have contributed to this oui.coiiie are discussed
Publication Typ?.:
I ilnicai trial
Rm i cbir n ?..?'■! contr ci ied 11 i al
pytTD- Wt2^
26: .1 Tiopf edatr 1994 Febi iotl):49-51.
K.-ltti 'd Iriid
Docks, folild.nit
UDISHA SUMMARY
April 6, 2001
Introduction
The objective of UDISHA- the WB assisted ICDS Trg Programme is to develop all the
functionaries of ICDS into agents of social change (From April 1999 for 5 years). Additional funds
have been provided for staff honorarium including provision for guest speakers.
The staff
honorariums have been raised. Training teams for field trg of AWW will be constituted from
members of AWTC, DIET, Health Dept., ICDS, Mahila Samakya/FNB/WDP/DWCRA, DPEP
Gender Trainers
The training infrastructure is being upgraded- AWTC, MLTC. A State Resource Unit is
proposed to work under the ICDS Directorate
Three kinds of training are covered under UD1SFIA: Job Training Course (JTC), Refresher
Course (RC) & Orientation Course (OC)- See Table-1 for Summary. The Udisha activities are
followed up by the State Training Task Force
Training of AWW & Helpers
Institution based job trg at the AWTC and field for a period of 7 months. The number of
trainees will be 35 per batch. Each AWW will be paid an incentive of one months salary' on
satisfactory completion. Refresher Training of AWW every two years at AWTC or by Training
Teams. Training of Helpers will be done by the AWTC There are a total of 25 AWTC in Karnataka
all run by NGOs
Training of Supervisors
Presently, the Middle Level Training Centres (MLTC) organise a 80 day course for
Supervisors. Under UDISHA the Supervisors will undergo a refresher trg every 2 years
The
Karnataka MLTC is in Ujire (DK) and run by an Organisation of the Dharmasthala Temple.
Training of CDPO/ACDPO
The responsibility is with NIPCCD
Joint Training with the Health Department
ICDS-Health functionaries will undergo joint training. This is the responsibility of the Health
Department.
Training of Trainers
The training of the Instructors of AWTC & MLTC will be conducted by NIPCCD. Provision
is also made for training ofNIPCCD staff in other institutions.
Other Training Programmes
The objectives of the 1CDS will be communicated to Sarpanch, Panchayat members.
Other Financial Commitments
Provision has been made for the following:
Development, Printing, Distribution of all training and IEC materials and kits for AWW on
I.
early learning
2
Organisation of workshops, seminars etc.,
3.
Operational Research & Evaluation Studies; MIS on Training.
TABLE-DSUMMARY OF TRAINING COURSES
(Note Numbers in Parenthesis refer to trainees per course)
Institution
Course
Functionary
JTC
RC
AWW
3 months (35)
15 days (40)
AWTC
Supervisors
80 days (25)
11 days(25)
MLTC
CDPO/ACDPO
60 days (25)
12 days (25)
NIPCCD
Orientation
Refresher
Helpers
13 days (50)
7 days (50)
AWTC
MLTC Instructors
12 days (20)
8 days (20)
NIPCCD
Adolescent Health
The Karnataka Government provides facilities for improving health of adolescent youth
through its various departments viz. Health & Family Welfare, Women & Child
Development. Education, Women’s Development Corporation, Sports & Youth Affairs,
Rural Development and Panchayati Raj, etc. The main interventions are School health
programme. Health Education, Nutrition, income generation and other schemes. This
project will aim to strengthen the implementation of all these schemes. A sub committee
will be formed consisting of one member from each of these departments and with a
rotating he'ad. The sub-committee will be responsible to the project to implement the
various schemes which will have a positive impact on the health of adolescent youth.
Health &Family Welfare
Under the RCH Programme adolescent girls are being provided Iron supplements (to
combat Anaemia > 60%) and also deworming once a year (Albendazole 400 mg) to
improve their health. Through the arogya sanghas and anganwadis girls are given
Nutrition education on how to prepare and eat a balanced diet prepared from locally
available low-cost food. She is taught about personal hygiene, menstrual hygiene, and
also screened and treated for Reproductive tract infections (RTFs). She is also taught
about population education, gender sensitization, health facilities available and family
life education.
Under the IPP VIII (India Population Project urban) and IPP IX (rural) Health
promotion is provided to adolescent girls. The training covers the changes during
adolescence, nutrition, family planning and sex education, personal hygiene,
environmental sanitation and school health. It encourages enrollment in schools and
also targets school dropouts. These activities are organised through SHE (Social Health
and Environment) clubs. The SHE clubs (covering 5000 population) in urban areas also
provide vocational training like in radio repair, electrical and electronic work, and
tailoring.
The GOK has recently launched a pilot project in a few selected districts of supplying
sanitary pads for rural girls/women at subsidized rates (Rs 20/- for 10 pads).
Under a Border Cluster Programme covering few pockets in the border districts like
Gulbarga, Bidar, Bijapur, etc. UNICEF also through the health infrastructure is
providing Iron supplements to adolescent girls.
There are no specific schemes addressed to adolescent boys at present by the health
department, except for health promotion and school health program organised with the
education department.
Education
The education department focuses on improving health through education of girls.
It provides free education for all girls’ upto PUC in all government schools, along with
free uniform and books. It also has schemes to reach the school dropouts.
Under the World Bank DPEP (District Primary Education Programme) the backward
districts of the State have been covered to provide better education facilities to children
in primary schools (half the state covered).
The non-DPEP districts have also been recently covered under the Janashala scheme.
Under the School health programme all school children are medically examined once
in four years i.e in Std I, Std IV and Std VII. They are also given DT or TT
immunization.. These are done with the close cooperation of the Health department. •
Schemes to include life skill education, sex education and fortify the existing health
education/promotion activities are also being planned.
Women &Child Development
The WCD department has many programme targeting adolescent girls.
Under a scheme called Jagruti covering 15-18 years old girls in school the adolescents
are taught about health, nutrition, family planning, family/home making (home
science), vocational support, preparation for parenthood, and more about family life
skills. Each girl is given a first aid kit to take home and if she completes her education
upto VII Std is given a cycle and a NSS certificate of Rs 1000/-.
Under Vikasini girls above 18 years (<Rs 10000/- annual family income) are given
loans of Rs 10000/- with 25% subsidy (Rs 5000/- only can be spent on infrastructure
and the remaining used for rotation).
Child Labour Rehabilitation covers children under 14 years of age and the Deputy
Commissioner of Districts have been asked to strictly implement the same.
Rural girl child attendance scholarship provides Rs 25/-pm from Std V to VII and Rs
50/-pm from Std VIII to X as an incentive to the parents (<Rs 10000/-annual income)
to send their girl child to school. The child must get 40% marks to continue her
scholarship.
Daughters of commercial sex workers, prisoners, alcoholic fathers/husbands (<Rs
15000/-annual income) are also eligible to get scholarship to attend school @ RslOO/pm from Std V to VII, Rs 150/- pm from Std VIII to X and Rs 300/- pm from PUC to
Degree.
2
Namma Magulu, Namma Shakti covers girls from 6 to 18 years. Rs 2500/- is
deposited in LIC (Life Insurance Corporation) for the girl. From 6-9 years Rs 200/- pa
is given (from the interest), 10-13 years Rs 300/-pa and from 14-17 years Rs 400/- pa
is given to the family. If the girl has continued going to school till 18 years and atleast
passed VII Std and not yet married, then she will get a total of Rs 8400/- as a lumpsum
amount.
Balika Samruddi Scheme covers families, which have two girl children. Rs. 500/- is
given as a one-time grant and if the girl is regular till SSLC the entire education is
taken care of by scholarship cum Central government. This is applicable for girls born
after 15th August 1997.
Adolescent Programme This is under implementation. From 100 anganwadi centres
three girls will be selected in the 11-15 years age group. They will be given three days
training including health education from the health department. Then for 6 months they
will be beneficiaries of their anganwadi centres and will assist the anganwadi worker.
300 girls will be covered per district.
Women’s Development Corporation
They provide training for urban girls for self-employment (family annual income
<Rs 12000/-) in tailoring , embroidery, electrical and electronic repair.(@ Rs 100/-pm
during training and WDC will provide the materials necessary to start their work when
they finish).
Under another scheme Rs 5000/- to Rs 25000/- loan is given under self-employment
scheme. Devadasi Rehabilitation scheme assists Devadasi’s (Raichur, Bijapur and
Belgaum) through financial assistance.
Udyogini is also a scheme to assist girls above 18 years of age to start petty business by
giving Ioans upto Rs 50000/-(25% subsidy for all and 40% subsidy for SC/ST’s.)
Sports and Youth Affairs
Have a number of schemes for encouraging sports among adolescent girls and
boys. Low cost sporting activities like football, volleyball, basketball, kho-kho, kabaddi
and other games will improve the overall health of the adolescents and also increase
school attendance.
Rural Development & Panchayatiraj
Since more than one-third of the panchayat members are women, they have a
major role to play in the health of adolescent girls. They will be trained / sensitised on
adolescent health issues during the project period in a phased manner.
Role of NGOs
Since the government does not have the capacity to implement most of the above
mentioned schemes and neither has given adequate publicity for the same, the quantum of
beneficiaries has been abysmally low. The NGOs could play a proactive role in making
the beneficiaries aware of these various schemes and to bridge the gap between the
people and the government. Many NGOs are actively involved in providing specific
health interventions to the adolescent youth in rural and urban areas.
4
Role of NGOs
Since the government does not have the capacity to implement most of the above
mentioned schemes and neither have given adequate publicity for the same, the quantum
of beneficiaries has been abysmally low. The NGOs could play a proactive role in
making the beneficiaries aware of these various schemes and to bridge the gap between
the people and the government. Many NGOs are actively involved in providing specific
health interventions to the adolescent youth in rural and urban areas.
31st March 2001
o
Dr Sampath K Krishnan
Policy Fellow (Public Health)
Community Health Cell
Koramangala - Bangalore.
4
•Balika Samrttddi Scheme covers families which have two girl children. Rs. 500/is given as a one-time grant and if the girl is regular till SSLC the entire education is
taken care of by scholarship cum Central government This is applicable for girls born
after 15th August 1997.
a Adolescent Programme This is under implementation. From 100 an/ganwadi
centres three girls will be selected in the 11-15 years age group. They will be given three
days training including health education from the health department. Then for 6 months
they will be beneficiaries of their anganwadi centres and will assist the an/ganwadi
workers .300 girls will be covered per district.
Women’s Development Corporation
» They provide training for urban girls for self-employment (family annual income
<Rs 12000/-) in tailoring , embroidery,electrical and electronic repair.(@ Rs 100/-pm
during training and WDC will provide the materials necessary to start their work when
they finish).
. Under another scheme Rs 5000/- to Rs 25000/- loan is given under self
employment scheme«Devadasi Rehabilitation scheme assists Devadasi’s (Raichur,
Bijapur and Belgaum) through financial assistance.
• Udyogini is also a scheme to assist girls above 18 years of age to start petty
business by giving loans upto Rs 50000/-(25% subsidy for all and 40% subsidy for
SC/ST’s.)
Sports and Youth Affairs
Have a number of schemes for encouraging sports among adolescent girls and
boys. Low cost sporting activities like football, volleyball, basketball, kho-kho, kabaddi
and other games will improve the overall health of the adolescents and also increase
school attendance.
Rural Development & Panchayatiraj
Since more than 1 /3rd of the panchayat me/mbers are women, they have a major
role to play in the health of adolescent girls.
HEALTH FACILITIES FOR ADOLESCENT YOUTH IN KARNATAKA
Project “ Dimension for early pregnancy in urban & rural India”
Introduction
The Karnataka Government provides facilities for improving health of adolescent
youth through its various departments viz. Health & Family Welfare, Women & Child
Development, Education, Women’s Development Corporation, Sports & Youth Affairs,
Rural Development and Panchayati Raj, etc. The main interventions are School Health
programme, Health Education, Nutrition, income generation and other schemes. These
will be covered department wise.
Health & Family Welfare
® Under the RCH Programme adolescent girls are being provided Iron supplements
(to combat Anaemia > 60%) and also deworming once a year (Albendazole 400 mg) to
improve their health. Through the arogya sanghas and anganwadis girls are given
Nutrition education on how to prepare and eat a balanced diet prepared from locally
available low-cost food. She is taught about personal hygiene, menstrual hygiene, and
also screened and treated for Reproductive tract infections (RTFs). She is also taught
about population education, gender sensitization, health facilities available and family life
education.
• Under the IPP VIII (India Population Project urban) and IPP IX (rural) Health
promotion is provided to adolescent girls. The training covers the changes during
adolescence, Nutrition, family planning and sex education, personal hygiene,
environmental sanitation and school health. It encourages enrollment in schools and also
targets school dropouts. These activities are organised through SHE (Social Health and
Environment) clubs. The SHE clubs (covering 5000 population) in urban areas also
provide vocational training like in radio repair , electrical and electronic work, and
tailoring.
*
* The GOK has recently launched a pilot project in a few selected districts of
supplying sanitary pads for rural girls/women at subsidized rates (Rs 20/- for 10 pads).
Under a Border Cluster Programme covering few pockets in the/STstricts on tire
order like Gulbarga, Bidar, Bijapur, etc. UNICEF also through the health infrastructure is
providing Iron supplements to adolescent girls.
There are no specific schemes addressed to adolescent boys at present by the
health department, except for health promotion and school health program organised with
the education department.
Education
The education department focuses on improving health through education of girls.
It provides free education for all girls’ upto PUC in all government schools, along with
free uniform and books. It also has schemes to reach the school dropouts./Under the
World Bank DPEP (District Primary Education Programme) the backward districts of the
State have been covered to provide better education facilities to children in primary
schools (half the state covered).eThe non-DPEP districts have also been recently covered
under the Janashala scheme.
o Under the School health programme all school children are medically examined
once in four years i.e in Std I, Std IV and Std VII. They are also given DT or TT
immunization.. These are done with the close cooperation of the Health department.
o Schemes to include life skill education, sex education and fortify the existing
health education/promotion activities are also being planned.
Women &Child Development
7<—.
wcjj
c
o Under a scheme called Jagruti covering 15-18 years old girls in school the
adolescents are taught about health, nutrition, family planning, family/home making
(home science), vocational support, parenthood preparatioi?Tand more about family life
skills. Each girl is given a first aid kit to take home and if she completes her education
upto VII Std is given a cycle at® and a NSS certificate of Rs 1000/-.«-2~> .
• Under Vikasini girls above 18 years (<Rs 10000/- annual family income) are
given loans of Rs 10000/- with 25% subsidy (Rs 5000/- only can be spent on
infrastructure and the remaining used for rotation).
• Child Labour Rehabilitation covers children under 14 years of age and the
Deputy Commissioner of Districts have been asked to strictly implement the same.
♦ Rural girl child attendance scholarship provides Rs 25/-pm from Std V to VII
and Rs 50/-pm from Std VIII to X as an incentive to the parents (<Rs 10000/-annuaI
income) to send their girl child to school. The child must get 40% marks to continue her
scholarship.
* Daughters of commercial sex workers, prisoners, alcoholic fathers/husbands (<Rs
15000/-annual income) are also eligible to get scholarship to attend school @ Rs 100/- pm
from Std V to VII , Rs 150/- pm from Std VIII to X and Rs 300/- pm from PUC to
Degree.
* Namma Magulu, Namma Shakti covers girls from 6 to 18 years. Rs 2500/- is
deposited in L1C (Life Insurance Corporation) for the girl. From 6-9 years Rs 200/- pa is
given (^Interest), 10-13 years Rs 300/-pa and from 14-17 years Rs 400/- pa is given to
the family. If the girl has continued going to school till 18 years and atleast passed VII
Std and not yet married, then she will get a total of Rs 8400/- as a lumpsum amount
2
A Proposal for strengthening
the
Public Health Institute, Bangalore
Public Health Institute is an important arm of State Healtli Servmes.
Any Healtli problem affecting the community is the business of Public Health
Institute. Hence it is necessary that the Institute should develop skills U gather Health
intelligence, forewarn epidemics, diagnose diseases, find source of infection, suggest
methods to prevent the spread of the disease.
■To achieve these aims the Public Healtli Institute should have following three
wings.
1. Department of Epidemiological studies.
2. Diagnostic Laboratory and
3. A Surveillance set up
Department of Epidemiological studies: At present there is no meh wing under
Health Services. Whenever there is an outbreak of an epidemic an official of the rank
of Deputy Director / Joint Director is deputed to the area to make a study which is
hardly useful in containment of the disease in real terms. This is main}} due to the fact
that Epidemiological investigative skill can be developed only after a few years of
constant work in the field. The work has to be backed up by clinical studies by a
person who is preferably qualified in tropical diseases and by laborator, investigations.
Recommendations:- The Epidemiological Training Institute, Mindya (which is
defunct now) may be attached to Public Health Institute.
Diagnostic Laboratory: It should have facility to analyse Biological samples
and also non-biological samples like food, water and chemicals.
•’-*w
Under the NSPCD programme of Central Government a Regional lab for
communicable diseases is being established at PHI., during the curren year. Proposal
i
has already been submitted to establish a leptospira and Brucella lab and also Viral
diagnostic laboratory at PHI under this programme^
Ann I AdmtRept_Kmt
20
Constitution of Rapid Response Team: at Public Health Institute, a RRT will
have to be constituted for Rapid deployment to epidemic affected areas.
A field lab will have to be developed to assist the Rapid Response Team.
Personnel required:
A. Technician
B. Epidemiologist
C. Entomologist
D. Clinician
E. Group ‘D’
5
1
1
1
Laboratory kits for rapid diagnosis of the diseases will have to be made
available to the field lab.
A diesel vehicle with the sufficient space to carry the personnel and also act as
the laboratory will have to be provided.
The field lab should be equipped with the rapid diagnostic kits, florescent
microscope sample collection and transportation kits.
The Institute should constitute as rapid response team as envisaged by the
NICD, Delhi at its earliest.
Further, mechanisms for rapid control of vector population, rapid water
purification facility etc., should be available for rapid deployment to the sites of
epidemics. Such facilities should be developed and established for deployment, at
Public Health Institute.
Ami AdnuRept_Knil
22
Posting of Microbiologist to this Institute. The Health laboratory is another
name for Microbiology laboratory. There are two posts of Bacteriologists in this
institute and both of them are vacant. The work of the institute is hamstrung by the
absence of microbiologists. It is requested that two microbiologists be posted
immediately to this institute. There.is an urgent need for another two microbiologists
with sufficient experience in leptospira, Brucella, Viral Diagnostic procedures. These
two Microbiologists can be hired on contract basis immediately.
Ann! AdmiRepi Kmi
24
PUBLIC HEALTH INSTITUTE
SHESHADRI ROAD,
’
BANGALORE
ANNUAL ADMINISTRATIVE REPORT
2000-2001
Anni AdnuRepiJCmt
7
ANNUAL ADMINISTRATIVE REPORT
On
PUBLIC HEALTH INSTITUTE BANGALORE
2000-2001
Public Health Institute:- is the state level health laboratory in the department of
Health & Family Welfare Services. It is headed by the Joint Director (Laboratories).
The Institute houses the following laboratories :
1.
Diagnostic Bacteriology Lab:- Here stool samples of patients suspected to be
suffering from cholera are examined.
The section also conducts bacteriological analysis of food samples to determine
fitness for consumption under PFA Act. Samples are also received for examination, from
food processing industries and from general public.
2.
Water bacteriology Lab:- This is the biggest water testing laboratory in the State and
tests water for potability purposes. Samples collected under PFA and from industries
manufacturing mineral water and also from general public are tested here.
3.
Chemical Examiner’s Laboratory:- The samples received from Lokayuktha under
prevention of corruption act. are tested here.
Alcohol contents of drugs, samples from excise Dept., and narcotic samples are also
analysed here. Blood and Urine samples are analysed to find out the presence of
alcohol/Narcotic substance in them.
4.
State food laboratory:- State food laboratory is an important wing of Public Health
Institute. Food samples collected by food Inspectors from all over the state are analysed
here for adulteration.
5.
Laboratory for Chemical Examination of Water:- Chemical analysis of water is
done here. Samples are received from Industries, mineral water manufacturing unit and
from general public.
A
Effluents released from industries are also examined under factories act to prevent
/''' contamination of water by toxic substances in the effluents released by the factories.
’
Annl AdinlRept_K:nl
i
i
1
II Administration
2.1 Organisational set up / heirachial set up the Department from State Head
Quarters down to the lowest level.
A detailed report on organisational set up is enclosed herewith.
i r;
2.2.
'
Officer incharge during the year 1999-2000
Dr. B.Y.Nagaraj, Joint Director (Labs) upto end of February 2001.
Dr. Kamath, Deputy Director (Bact), is (I/C) Joint Director (Labs) from 1.3.2001.
2.3.
Additional Staff sanctioned during the year.
-Nil -
2.4.
Staff strength at the end of the year i.e. on 31.3.2000.
Statement enclosed.
2.5.
Promotions, Transfers, Postings - in brief
2.6.
Training of Departmental Staff
1)
Orientation Training has been given to 85 Food Inspectors.
2)
27 District Surveillance Officers have been trained to import the training to the .
Laboratory Technicians in their Districts.
55 Laboratory Technicians have been given in laboratory procedures to run
laboratories attached to Primary Health Centres.
2.7. Tours by the Head of the Institution:- Inspection of Surveillance Centres and PHC
Labs of Mangalore, Udupi, Chitradurga, Davanagere, Kolar ' was done by
Dr. K.R.Kamath, Deputy Director (Bact).
Ill
FINANCE
3.1 Revenue / Income during the year — Total and sourcewise, comparison
with corresponding figures of last two years and reasons for variations.
Ar.nl AdmtRepl_Knit
1
7J< 1. A BRIEF STATEMENT ON WORK TURNED OUT DU REW THE YEAR
1998-99, 99-2000 and 2000-01
Section
1998-1999
1999-2000
2000-2001
Diag.Bact.Section:
1. Stool Samples examined.
2078
2213
2341
2. Food samples analysed:
32
70
86
Water BactSection:
1.' -Water samples tested:
2143
2580
3467
Chem. Examinor Lab:
1. Spiritous drugs tested:
80
170
-
2. Alcoholic drinks
14
32
180
3. Blood and Urine
55
41
67
4. Lokayukta samples
108
101
154
5. Narcotic drugs
Food Laboratory:
1. Samples tested under PFA
-
-
5
1812
1722
638
2. Other food samples
1423
243
850
Water testing lab:
1. Sample tested
444
355
857
2. Effluents
•
20
-
4
Regional Food Laboratory:
273
192
200
Pesticide Laboratory:-
159
94
-
Training Programme:
1. Food Inspectors Training
-
-
85
2. Other Trainings:
-
-
82
2. Major herdless/difficulties met if any and remedial measures taken may be
indicated:- Alli the vacant posts to be filled up.
Joint Director (Labs)
Anri A.dmtRect Kmt
Nutrition of Lactating Mothers
z\ lactating mother requires 1000 calorics extra per day to meet the needs
of production of mother’s milk for the new born baby.
❖ A good nutritious diet prepared from low cost locally availab,' ; foods,
family support and cure, rind a pleasant atmosphere in the family helps
improve lactation and ensures health of both the mother and the baby.
Diet
.1
j
□
u
□
Include more uf cereal, pulse mid green leafy vegetable in daily diet
Take vegetables and one seasonal fruit a day
Take milk, butter milk, fluids and lot of water
Egg, meat, fish are beneficial
Energy dense foods like ghee/oil and sugar are necessary to meet the
increased energy needs. Traditional preparations like panjiri, laddoo are
useful
Rest
a
Breastfeed in a relaxed state. Any type of mental tension decreases milk
•;<■< reti<m
1FA tablets
_j
Take iron and folic acid tablets for first six months of lactation
£
HUMAN LACTATION - SOME FACTS.
By Dr. Asha Benakappa, MD,DNB,DCH,LMC
Asst.Prof. of Peadiatrics, Bangalore Medical College, B,lore-2
City Co-ordinator, Breastfeeding Promotion network of India
Phone:-6693173
A Landmark resolution recommending that infant be “ Exclusively
breastfed for 6 months” was passed by the full assembly at the 54 th
world assembly last May(WHA-54.2)
Exclusive breastfeeding is defined by WHO as no other food or
drink, not even water, except breast milk for 6 months of life, but
allows the infants to receive drops & syrups(vitamins, minerals &
medicines).
The resolution settles a seven years controversy over at least two
aspects of the baby food issue- the optimal duration for exclusive
breastfeeding and the marketing of complementary foods for infants.
It provides more clarity on the scope of the code: a breast milk
substitute is any food marketed for use before the age of six months,
ie. all milk, including infant formula, cereals, juices & teas
recommended for an earlier age may not be promoted.
The resolution recommends the introduction of safe and
appropriate complementary foods with continued breastfeeding from
6 months to 2 years of age or beyond. This means that, while
complementary foods may be promoted for after 6 months, the liquid
part of the child’s diet should still be breast milk. Any replacement is
a breast milk substitute ie. follow on formulas are substitutes and
may not be promoted.
HUMAN LACTATION - SOME FACTS.
By Dr. Asha Benakappa, MD,DNB,DCH,LMC
Asst.Prof. of Peadiatrics, Bangalore Medical College, B,lore-2
City Co-ordinator, Breastfeeding Promotion network of India
Phone:-6693173
A Landmark resolution recommending that infant be “ Exclusively
breastfed for 6 months” was passed by the full assembly at the 54 th
world assembly last May(WHA-54.2)
Exclusive breastfeeding is defined by WHO as no other food or
drink, not even water, except breast milk for 6 months of life, but
allows the infants to receive drops & syrups(vitamins, minerals &
medicines).
The resolution settles a seven years controversy over at least two
aspects of the baby food issue- the optimal duration for exclusive
breastfeeding and the marketing of complementary foods for infants.
It provides more clarity on the scope of the code: a breast milk
substitute is any food marketed for use before the age of six months,
ie. all milk, including infant formula, cereals, juices & teas
recommended for an earlier age may not be promoted.
The resolution recommends the introduction of safe and
appropriate complementary foods with continued breastfeeding from
6 months to 2 years of age or beyond. This means that, while
complementary foods may be promoted for after 6 months, the liquid
part of the child’s diet should still be breast milk. Any replacement is
a breast milk substitute ie. follow on formulas are substitutes and
may not be promoted.
20th NATIONAL NUTRITION WEE!
1-/September 2001
BREAK THE CYCLE OF MALNUTRITION AND IMPROVE
WOMEN'S HEALTH
Cycle of MalnutritioR
Maternal Malnutrition Perpetuates Intergenerational Malnutrition
Food and Nutrition Board
Department of Women and Child Development,
Ministry of Human Resource Development,
Government of li.Jia
Shastri Bhavan, New Delhi.
20th national nutrition week
1-7 SEPTEMBER ?001
THEME : BREAK THE CYCLE GF MALNUTRITION AND IMPROVE
WOMEN'S HEALTH
One of the major problem that India is facing today is the problem of
matnutrition. The latest National Family Health Survey 2 (1998-99) reveals that onequarter of children in our country are born with low birth weight, half the children
presently suffer from protein energy malnutrition, one-third of adults suffer from
chronic energy deficiency and three quarters of the population suffer from various
nutritional and micronutrient deficiencies. India has a high infant mortality rate of 67
per thousand live births and an extremely high maternal mortality rate of 437 per
100,000 births.
Women and children are the worst sufferers of the ravtiges of various forms of
malnutrition because of their increased nutritional needs and low social power.
Various achievements in other sectors like agricultural production, food sufficiency
and industrial capabilities do not seem to have influenced the nutritional status of
these vulnerable groups. Low literacy levels, lack of awareness about nutrition and
health, and poverty contribute to this dismal situation.
Nutiition ot women throughout their life cycle is not only important for their
own health but determines the nutrition and health of the future generations also. A
u-m.ik' ini.mt born with low birth weight, that is birth weight less than 2.5kg, is
already malnourished and hence starts life with a disadvantage. Intrauterine growth
retardation (IUGR) during pregnancy is the main cause of low birth weight, and
maternal malnutrition and nutritional anaemia during pregnancy is the major
determinant of the IUGR. Gender discrimination within home is often manifested in
uni'qtial access to food and inferior quality of food provided to girl children as
companxJ to male children in the family throughout the childhood.
The effects of years of neglect become visible during adolescence. A girl, therefore,
generally grows into a malnourished adolescent girl.
For various socio-economic and cultural reasons, girls are' married early,
invariably in their teens. The NFHS 2 (1998-99) reveals that the median age of girls
at marriage in India is 16 years and 61% of all women were married before the age
of 18 years. Thus, a large percentage of adolescent girls are forced to enter into
reproductive life even before they are adults themselves. Early pregnancy further
aggravates both under-nutrition and anaemia and results in adverse outcome of
pregnancy including a low birth weight baby. Under-nutrition and anaemia among
pregnant women and adolescent pregnancies are the main contributory factors for
low birth weight babies. A low birth weight baby girl will be subjected to similar
conditions and attitudes and will repeat this cycle, thus making the problem of
malnutrition an inter-generational cycle.
Thus, for preventing the low birth weight and breaking the inter-generational
cycle of malnutrition it is important to ensure nutrition and care of women
throughout their life cycle. Ensure nutrition, health and care of the girl child right
from birth through adolescence and adulthood by adopting the following measures:
□
Give the girl and the boy child equal nutrition.
□
Educate the girl child as much as possible.
'□
Give her adequate nutrition during adolescence as this is the second and last
growth spurt in her life.
□
Give her basic knowledge of food, nutrition and health to enable her to take care
of herself.
□
Do not mam/ her before 19 years and give her family life education.
□
First pregnancy should be after the age of 21 years.
□
Provide good nutrition, health care and family support during pregnancy and
lactation.
□
Encourage women to breastfeed immediately after birth so as to feed ''colostrum"
to the new born and to adopt proper infant feeding practices.
□
Reduce the workload of women by sharing the manual and household work and
adopting appropriate rural technology for making her work easier so as to
improve her nutrition and health.
Some nutritional guidelines for ensuring care of the low birth weight baby,
infant's nutrition through appiopriate feeding practices, nutrition of adolescent girls,
pregnant and 'actating mothers are annexed.
annexure
SOME NUTRITION GUIDELINES
Care of Low Birth Weight Baby
f'.-.v .01-11 baby with less than 2.5 kg weigh! is a low birth weight baby
w birth weight makes the child start lite with disadvantage as the child
.:, Trendy malnourished and requires extra care. Mothers milk is the only
food a low birth weight baby should be given
V In rural areas where the facility of the incubators may not be available,
mothers should be advised to keep the low birth weight baby close to the
chest, under a woolen garment in winter. This helps the baby in two
wavs, (i) the child gets warmth of the mother’s body and (ii) the baby can
suck the milk as and when he likes. In other words, he may not be strong
enough to suck the milk like a normal baby continuously for 10-15
mintties and may need to suck more often for shorter duration.
w birth weight baby should be given breast milk and nothing else for
first six months. Any other food, if introduced during early stages,
max cause infection in an already under weight child and may prove to be
i 3131.
Pre-lacteal feeds arc harmful and should be discouraged
Skin to skin contact between mother and child immediately after the
■childbirth helps early and successful establishment of lactation and
feeding of "colostrum" to the baby which provides natural immunity to
; be child.
Nutrition of Adolescent girls
*
■?
rm
imp“''a'’1 -°r “K hcallh of thc
rid suppleme"ts 1100
for the health of the ado!,.'seem girls.
"
Delaying the age o! marriage and the first HUta t
°f 19 ycars a"d nrsl preenancy
‘S ,,nPort£Un
■
“’<■ *
* s:^x^shea,th “d i fc should
: iff-f'T"fX'Xu“ds " — -
Educate the girls since female illiiiTnrv ;<•
,
<
“ -5 • an important determinant of
ton.
INFANT AND YOUNG CHILD NUTRITION
Infant Feeding: Breastfeeding arid Complementary Feeding
Breastfeeding
I
••• A child requires both exclusive breastfeeding for first six months and
complementary feeding from six months’ of age with continued
breastfeeding for 2 years and beyond for good health.
••• Eariy initiation of breastfeeding, that is’within half an hour of birth in
normal deliveries (and 4-6 hours in caesarean deliveries) is important to
establish successful lactation and feeding of “colostrum” (mother’s first
milk) to the baby.
<• Exclusive breastfeeding for the first six moths of life is important to
prevent infections in early infancv and reduce infant mortality,
particularly in low socio-economic strata.
<• Prolonged breastfeeding upto two years and beyond provides all the
benefits of the mother’s milk to the child like high quality protein, vitamin
A mid anti-infective properties.
World Health Assembly 2001 has passed a resolution adv eating
exclusive breastfeeding for the first six months of life for all segments of the
population. Complementary feeding with home based foods introduced from
6 months of age alongwith continued breastfeeding for 2 years and beyond
has also been recommended.
Complementary Feeding
Complementary feeding is extremely essential from six moths of age to
meet the growing needs of the growing baby.
Roasted Hour of any cereal mixed with boiled water .and sugar should be
the first complementary food for the child and should be started on the
day the child becomes six months old. An ‘Annaprashan’ ceremony is an
Indian tradition. 'Annaprashan Abhiyaan for promoting complementary
feeding should be taken at anganwadi level and in the community.
Family food without spices can be mixed and made into semi-solid
consistency suitable for the child. For instance, half a.roti soaked in half
katori of unspiced dal when mixed thoroughly, can serve the purpose of
khicheri for the young child, which is a nutritious food for the baby.
<• Leafy vegetables are important for the child as they provide iron, beta
carotene (vitamin A), folic acids besides other nutrients. Boiled and
mashed leafy vegetables should be given to the child atleast for 3-5 days
in a week.
Seasonal fruits like banana, papaya, mango should be mashed and fed to
the child.
••• Roasted cereal and pulse mix like satin can be prepared and stored for a
month and fed to the child by reconstituting with boiled water or milk
whenever required.
A tea spoon of oil and sugar must be added to the food of the child so as
to make the food energy dense as child can not consume bulky foods but
requires more energy per unit of body weight.
••• Mixed foods alongwith breast-feeding should be continued upto two
years.
Ensuring adequate and frequent complementary feeding of infants will help
prevent onset of malnutrition during the period 6 months to 2 years.
Growth Monitoring and Promotion (GMP)
❖ Weighing the child regularly and plotting the weight on the health card is
an important tool to monitor the growth of the baby
Hygiene
v Hygiene in preparation of foods for the baby and in feeding is extremely
important to prevent infections.
F<• i'ding During Illness
v Continue feeding during illness as child requires more nutrition to make
up for the loss of nutrients during infections
Care of the Pregnant Women
A pregnant woman needs ;
o An adequate nutritious diet
o Adequate rest during last trimester
Iron and Folic Acid tablets throughout the pregnancy
Diet
□
u
a
-i
□
a
u
□
u
□
Increase food intake
Whole gram, pulses and legumes, sprouted pulses, leafy vegetables,
jaggery, dates, groundnuts, til are foods of plant origin having good iron
content. Include more of these in the daily diet.
Include green leafy vegetables in daily diet right from the beginning as all
foliage provide “folic acid” much needed during early months.
Consume one seasonal fruit daily
Milk, curd, butter milk, egg, meat, fish are helpful
Iodised salt should be consumed as pregnant women requires sufficient
iodine for brain development of the child in the womb
Take plenty of fluids/water
Take small and frequent meals
Heavy work should be avoided throughout the pregnancy
Rest (in lying down position) during third trimester is important to enable
adequate flow of nutrients from mother to the child
li oii and I'olic Acid tablets
u
□
□
u
IFA tablets should be consumed throughout the pregnancy
Iron tablets may cause black stools which are harmless
Iron and folic acid tablets prevent anaemia and helps a women to deliver
a normal healthy baby
1‘hc folic acid deficiency can cause “Neural tube defects’1 in the new borns
•I
7
Visit to Anganwadi Centres of 1CDS
near Hanur of Kollegal Taluk.
The Anganwadi centre of Chamaraj Nagar District in Kollegal was visited on the 26th of March.
The main purpose was to observe the supplementary feeding programme in operation at the
Anganwadi the quantity served and the ability of the children to consume the served portion, as
well as the issues related to the preparation of the food. I am thankful to Dr.Sr.Aquinas and
Sr.Anice who welcomed us and made arrangements for me to visit the Centre during the
operation of the feeding programme. The Holy Cross Comprehensive Rural Health Project covers
this village which was visited, and they have women's groups, Self-help Groups and the women
trained under Women and Health Project.
The Village visited was K.Gundapura. This village has two Anganwadi centres and both the
centres were visited by me one at the time of the preparation of the food and serving of the same
to the children present. The other centre was visited to discuss with the worker her routine and
the support services available..This village comes under Basappana Dotti Panchyat.
Anganwadi 1 (Actually this is the second centre started after a lapse of some years after the first)
Anganwadi Worker
Helper
Smt Suguna
Smt Parvathi.
Though Sr.Anice and self reached the village at 10 30,giving time for the centre to start the
activities, the teacher had not turned up,but few of the children were there with vessels in their
hand clutched closely, to take the cooked food home.The children were moving and running and
the helper Parvathi was not able to manage or even start the programme with them, utilising the
time we enquired about the food that was cooked by the helper and the supply made to the centre.
In the meanwhile Smt Suguna arrived and she had some personal problems to reach on time from
about 3-4- km away. The information gathered from the teacher are as under.
The Food Supply:
The Centre is supplied with Bags of Poorvaka Ahara (Energy Food)
and Rice, The ready mix ahahra and the rice are to be served alternatively.
The lable on the bag reads that this was designed by CFTR1 and the
composition of the Poorvaka Ahara is: Wheat, Groundnut cake ,Soy
Powder, Bengal gram dhall, Jaggery, with mineral mix and salt added. The
ratio with which these were mixed was not shown on the bag.This had
been produced by Agro-Kendra
The nutrition Factor
100 g of this Ahara has 12-14 g Protein
and 350-380 Cal.
Rice is also supplied along with Palmolein Chillies Mustard salt.
-2-
Per month The following ration is supplied.
Poorvaka Ahahara 75 kg
Rice
oil palniolein
chillies (red)
Mustard
Salt
70 Kg.
3 pkts
1/2 kg
1/2 kg
2 kg.
The fuel supply was supposed to be the responsibility of the Panchayat
but this is not being met by the Panchayat.
Suit Suguna informed as that for some time she personally paid for the fuel and now
along with the ration 2 1/2 maunds of fuel is being supplied by the CDPO. Whether this
is the latest policy and not pursuade the Panchayat to take up the responsibility is not
clear
This monthly ration had been fixed based on the number to be fed.
No: of Children taken into account
Allowance of Food per head
No of pre-school Children 3-6yrs
1-3 yr children
below 2 yrs
Mothers Pregnant & lactating 8+4
Children
23
31
08
12/
Energy Food
80 g
Rice
60 g
Adults interestingly in this
category the worker and the
helper are included as additional
Energy Food
160 g
Rice
120
As per the number specified and the daily ration allowed
the food calculation comes to
Energy food required for 62 children and 14 adults per day comes to 7.200 kg
Per month of 24 days feeding days the Energy food requirement is for
12 days only (the other 12 days are for rice)
86.4 Kg
while the supply for these feeding days is in the order of
75.0 kg
Rice
As per the allowance of 60g the requirment per day
For 12 days Feeding programme
5.4 kg
64.8 kg
-3The shortage is not felt by the Worker as not all children attend the class every day and they can
easily adjust l.The design is to feed the children in the class and make them take the cooked food
for the sibling and another quantity if the mothers included. Mothers do not come to the centre
as they cannot and the children do take the food and some time the helper goes to the door
step and provides.
The actual observation of the children : Amongst the 20 and odd atleast 12 of them were
between 1-3 yrs and very few were the 3-6 yrs.Evidentally the mothers sent them to collect
the food. 1 was there when the rice bhath (rice chithra anna) was being prepared, rice
cooked and seasoned. Office had supplied new plates and glasses for the children to eat Yet
the children were clinging on to their vessel and eagerly waiting for the food to be served in the
vessel.The serving portion appeared to me as 40g of raw rice only.Even this portion was too
much for the children of 1-2 yrs. Children were advised to start eating after the serving and they
were pecking at the food perhaps keen in taking the food home The teacher said that after serving
she would concentrate on record maintenance and children would ea by themselves. Obviously
she does not find it necessary to observe them eating and the quantity they can consume. It is
the helper who gives the additional serving
The helper had prepared , according to her, 4 kg of rice for that particular day.
I requested the helper to prepare the laddu which she normally prepares with Energy food of the
quantity of 40 g (weighed from the store near by) The resultant product was in the size of cricket
ball. The taste was of mild sweet. The Workers informed that the mothers do not eat the energy
food and give it to the children when ever the child wanted at home. The mothers thought that
they could well if the centre supplied uncooked flour for them to make rotis, almost demanding
the supply of flour for the week. It is also doubtful whether the mothers do consume the rice or
again give it the children.
Suguna had maintained the records of supp;ly and it was upto 23rd of March.the following two
days were holidays. While we were observing the children we wanted her to teach and it was the
normal pattern of saying some rhymes and the children repeating.
Growth Charts of the children
A thick booklet had been supplied to the centre as per the
pattern ! doubt whether the purpose of the growth chart
had been explained to Anganwadi worker or not.lt
appeared like routine plotting of the reading. This centre
has no weighin scale but takes from the other one, which
is understandable.She first notes down the reading on a
notebook every month along with attendance. When time
permits she plotson the chart.She had no time to look at
the growth trend of the children. But this is done regularly
every month
I was aurprised to see the pencil marking on the chart. When I enquired the reason she said that
she was asked to do so so that these recording could be erased and make a clean chart for the new
entrant in the class. When I checked with the weight of the child and the child that was present
it was found that the child was a healthy child to start but constantly had been on the grade II
status. Suguna could not answer our question on as why the child lost the weight. She could only
-4-
say that the child was sick but now she was eating.. The growth Chart had no meaning for the
Anganwadi worker, as it really takes a lot of time and effort to weigh all the childrne with only
the helper to assist. The Children appeared to be anaemic and stunted growth could be seen in
some of the children. I could not stay there to see the quantity that the worker would be
distributing to the mothers, as it would mean spending another hour or two with the worker,
as mothers do not come to the centre.
There are many related issues to be discussed and this will be done after the report on the second
centre. In the meanwhile we met few of the women of the sangha and the expectant mother.
This discussion was too find out as to why the mothers rejected the Ahahar Mix. According to
the women the laddu is prepared with cold water and they would rather have the atta to be given
to prepare their own roti. I donot give much weightage to their remark as there would always
some complain or other but still whether this mix is suitable for the adults is to be questioned.
The name itself sugggests that it is weaning diet. Mothers keep their share and give it to the
children when ever they are hungry.This also means that the children do not get any whole some
food at home. Are we not defeating the purpose of feeding at the Institution ?
THE SECOND ANGANWADI CENTRE in the same village. Actually this is the original centre
and the first visited was started later, This centre is equipped with weighing scale and the teacher
is much more experienced.
Teacher
Nagalakskhmi
Helper
Gowramma
The attendance at the centre was not full as the day was after Ugadi.The children were very
cheerful and Nagalakshmi has good relationship with them Apart from the ration amout that the
centre gets it was a news to us that the PHC at Ramapura supplies the iron tabs to be given to
the children.The strip contained Folic acid and ferrous sulphate and the Vitamin A is in the form
of liquid and concentrated. The teacher regularly gives these to the children before the food is
served. I requested the teacher to weigh a child to see the calibrations and the method of
weighing.She has n hook to hang but some how manages., the children were fairly healthy
Nagalakshmi expressed full cooperation with the Healthe department.She is an expereinced
teacher and is confident about her work. When we returned to the first centre to observe the
children being served, Sr.Anice asked about the medicine supply.Then the teacher pulledout the
carton from the store. Obviously this is not being utilised by the teacher ..
There are many question that came as a result of this visit and these need to be discussed
carefully.The intention of the Government is quite obvious but lack of supervision and entire
dependence on the teacher need todiscussed.
Addressing Adolescent Malnutrition to Improve Women’s Nutrition
Dr Farhat Saiyed, UNICEF, Hyderabad.
Adolescents form the largest and an important segment of our society,
with one-fifth of them constituting the total population. As per WHO
(1986), defines adolescence as the period of transition from childhood to
adulthood, in the age range of 10-19 years. Thus, it is the largest ever
generation in human history. Globally, they account for one-fifth of the
population and, in India, 21% of the total population comprises of
adolescence. (National Youth Policy, 2000).
is
Thiswise the period when second and the last growth spurt occurs in an
individual and therefore, their nutritional and health needs in particular
cannot be ignored. There is now data available, which shows that the state
of adolescent boys is equally vulnerable as the adolescent girls, from
nutrition, stand point. However, girls are at a greater nutritional risk due
to the added demand of reproduction. For a girl, especially from poorer
segments, low socio-economic status of the families compounds the
problem of under nutrition, with consequent effect on growth. In addition,
under nutrition reduces the reproductive, physical and mental capacities
of girls and continues to result in low birth weight and fetal loss. Thus, it
is quite evident that if India whishes to achieve the goals of Health for All
and adequate Nutrition for All, it must attend to the problem of under
nutrition among the adolescent girls. In this regard, the nutritional status
of a girl should be of a particular concern. The cycle appears simple but
the consequences are serious.
Nutritional status of a girl child will affect her own nutritional status
when adolescent and attains puberty. This in turn will influence the
nutritional status whenqs an adult woman of child bearing age. As she
enters into pregnancy and early childhood in this nutritionally deprived
condition, not onlyTier ability to perform the tasksa mother are affected/
but also the growth and development of the child are equally affected.
t
Thus^Tie girl child, whose growth is retarded in uterus and early years of
life, arrives to the stage of motherhood with poor nutritional status. And
the cycle continues. We must therefore, closely examine the outcome of
the intergenerational malnutrition cycle by understanding and analyzing
each of its components.
-2-
Food Intake: An important aspect of nutrition of adolescent girls is the
increased nutritional requirements during their growth spurt and also
during their reproductive age period, to account for the additional
function of child bearing and child rearing. Adequate nutrition during
adolescence implies adequacy of dietary intake and or body stores of both
macro as well as micronutrients. There is ample data to show that the
dietary intakes of nutrients of a majority of rural and underpriviledged
population of both sexes are below the desirable levels. However, women
and adolescent girls are much worse off than their male counter parts.
Thus-a girl continues to grow poorly with inadequate nutrient reserves.
The situation precipitates with the onset of menarche.
Menarche: Menarche is a physiological phenomenon, which marks the
onset of puberty. Menarche is generally delayed in girls from the poor
families and who are under nourished. In fact, this is Nature’s
compensation for growth-retardation suffered by these children during
their early childhood, because of under-nutrition. One important nutrition
consideration during menarche is in meeting the extra demand for iron
which, it imposes due to the loss of iron during the monthly cycle of
menstruation. When these demands are not adequately met it results in
iron deficiency anemia. With other nutrients also not being met, the
situation worsens to result in more serious future consequences.
Gender: It has been found that gender discrimination in intra-household
food allocation may limit the food intake of the adolescent girls. Gender
discrimination needs to be examine^ with a broader perspective. Inrlndia,
gender differences are mostly unfavorable to girls, and are far more
glaring with respect to, literacy, school enrolment and dropout, and
opportunities for vocational training. This is not so in case of health and
nutrition care, morbidity and mortality. Sporadic reports do point out that,
parents seek institutional medical attention more frequently for their sons
than their daughters. Severe malnutrition is more prevalent in girls than in
boys. The data also concludes that mortality rates in females throughout
childhood and reproductive periods are higher than in males. .
Thus, an adolescent girls nutritional status is influenced by these factors
and the situation deteriorates with the social stigma of a large percentage
of girls are pushed into early marriage, after menarche in India. We must
remember that the growth process in undernourished girls continues for a
longer period of time than those from the affluent classes.
-3-
A girl of 15 - 16 years is still a child, she enters adulthood only after she
crosses 18 years and her growth is complete only between 18 and 20
years. Therefore, it is even more important that conception is delayed till
about 18-20 years. These issues of early marriage and followingly early
child bearing are of concern because they affect a young mother’s
nutritional status a great deal, either directly or in directly. They thus
influence her education and employment which in turn exerts
considerable influence on household nutrition. In Andhra Pradesh, the
age at marriage is lowest with mean age of 14.9 years (MICS,2000).
Thus, considerable proportion of adolescents is of greater obstructive
risk, due to malnutrition and chronic illness during there early years of
life. As of now, there is little evidence to suggest that the growth
retardation suffered in early childhood can be compensated for, in
adolescence. Also, there are known studies to determine whether
malnourished children with growth-retardation, respond to nutritional and
health interventions, during adolescence.
Anemia: Adolescent is yet another vulnerable period in human life cycle
when nutritional requirements increase due to the adolescent growth
spurt. Recent data from UNICEF, Hyderabad, shows that 72% of rural
and 80% of urban adolescents suffer from varying degrees of anemia.
Anemia in severe forms is associated with increased maternal deaths
especially during pregnancy. It is also associated with an increased risk of
premature delivery and a higher incidence of low birth weight infants.
These in trim are at a greater; risk of perinatal and neonatal morbidity and
mortality and substandard growth and development in later life. .
It is becoming increasingly evident that control of anemia in pregnancy
may be more easily achieved, if satisfactory iron status of the adolescent
girls can be ensured prior to marriage. It is evident that growing
adolescents are likely to give birth to smaller baby than mature .women of
the same nutritional status. This is probably due to the competition
between! growing adolescent andthe ( growing fetus for nutrients.
Adolescent pregnancies also confer q higher risk of maternal and infant
mortality and preterm-delivery.
This discussion clearly indicates that while most direct interventions aim
at reducing young child nutrition, they may fail to prevent in early years
when it predominantly occurs. Prevention should start much earlier. An
increasing understanding of the importance of women’s nutrition is
important- both for the quality of her life as well as those of her children.
(Nutrition Week Celebrations-3rd September 2001)
PublichealthS-^
Evaluation of effectiveness of good growth monitoring in south
Indian villages
Sabu M George, Michael C Latham, R Abel, N Ethlrajan, EA FrongilloJr
Summary
We conducted a community intervention trial in 12 villages in
Tamil Nadu, India to evaluate the benefits of growth moni
toring. The villages were divided into 6 "growth-monitoring
package" of intervention villages (GMP) and 6 "non-growthmonitoring package" of intervention villages (NGM). A func
tioning primary health care system was in place in all 12
villages. One village nutrition worker in each of the 12 villages
implemented a set of interventions including health and
nutritional education. About 550 children under the age of 60
months were studied over 4 years in GMP villages and a similar
number of children in NGM villages. The interventions were
identical in the two sets of villages except for the use of growth
charts in education in the 6 GMP villages. The nutrition worker
In the NGM villages had the same contact time as in the GMP
villages but advisdd mothers without the benefit of growth
charts. The research team, independently of the nutrition
worker, did anthropometric studies on children in all villages
every 4 to 5 months. Comparisons were done by calculating
monthly gains in stature, and weight, and the significance of
differences observed was adjusted for age and sex. After 30
months of interventions, similar improvements in growth were
seen in GMP and NGM children. The interventions seemed to
have improved the nutritional status of young children in both
groups of villages. In view of the lack of additional benefit from
growth monitoring over other educational interventions, we
question Its use as part of child survival programmes in India.
Lancet 1993; 342: 348-52
See Commentary page 319
Introduction
The use of growth charts in developing countries was
started by Morley about 35 years ago in Ilesha, Nigeria.1
Morley now admits that the charts were useful for health
workers in the clinic but that mothers failed to understand
the growth curve.2 The Ilesha chart, and what later became
known as growth monitoring and promotion, was taken up
by others,3 and became part of UNICEF’s growth moni-
Program In International Nutrition, Division of Nutritional Sciences,
Cornell University, Ithaca, New York, USA (S M George pro,
M C Latham oee. E A Frongillo pod); Rural Unit for Health and Social
Affairs, Department of the Christian Medical College and Hospital,
Vellore, India (R Abel mph, N Ethlrajan mo)
Correspondence tu: Dr Sabu M George, Growth Monitoring Research
Project. South Asia Program, Uris Hall, Cornell University, Ithaca, New
York 14853. USA
348
toring, oral rehydration, breast feeding, and immunisation
(GOBI) strategy.4 Growth monitoring was advocated as an
effective, simple, and inexpensive way to prevent most
child malnutrition, but this view has recently been ques
tioned because of the lack of evidence that growth charts are
a better educational tool than health and nutritional
education without growth charts.5,6 Our research was
influenced by this concern. We studied the additional
benefit of growth monitoring (regular monthly weighing
and use of growth charts) conducted under the best possible
conditions. 12 villages were divided into 6 “growth
monitoring package” of interventions (GMP) villages and 6
“non-growth-monitoring package” of interventions
(NGM) villages. NGM villages received the same interven
tions as did GMP villages except for growth monitoring, ie,
education without growth charts.
Subjects and methods
This 4-year field study was conducted in the K V Kuppam block in
die state of Tamil Nadu, India. We describe here only the 12
intervention villages, but we also obtained limited data from 4
comparison villages where no interventions were introduced. The
complete study design is described elsewhere.7 For several years,
the Rural Unit for Health and Social Affairs (RUHSA) of the
Christian Medical College and Hospital, Vellore, has provided
primary health care in this block through rural clinics in each of the
18 peripheral service units. The 12 study villages were non
adjoining, poor agricultural communities that were distributed
among 10 peripheral service units. Each had a population of about
13 000. Growth monitoring had not been conducted in the villages
before. Our data showed that 70% of families lived in mud huts
with one or two rooms, about 99-5% defaccated in fields, and fewer
than 0-5% used kerosene or petroleum gas as the primary cooking
fuel (the rest used bio-mass).
Extensive field work was done over 9 months from September,
1986. From the data collected, 6 pairs of villages were formed so
that villages within each pair were similar with respect to caste
composition, access to a main road, cropping practices, and
distance from rural clinics. Some villages were served by more than
one clinic. GMP or NGM treatment was randomly allocated
within each of the 6 pairs so that villages served by a given clinic
received the same intervention. This ensured the independence of
the two treatments. One mother from each village was selected as
the village nutrition worker after consultation with community and
local primary health care workers. The nutrition worker was
responsible for the educational interventions. There were two
supervisors, one for GMP and one for NGM villages. We do not
believe that this was a source of bias because the performance of the
supervisors was similar. Preschool children in the 12 study villages
were eligible for inclusion and all children bom after initiation of
the interventions were offered enrolment in the study? Children
were dropped from the study at 60 months of age. Children with
severe congenital abnormalities (identified by a paediatric surgeon
who examined all children in the last year) were excluded from the
Vol 342 • August 7, 1993
Characteristic
Social
Harijan caste
Other castes
Nuclear family
Consanguineous
Landless
GMP
NGM
No(%)
No(%)
164(29 1)
400(70 9)
303(53-7)
237(50 8)
132 (28 3)
181(32 9)
370(67 2)
305(55 4)
248(55 5)
121(271)
Mean preschool children per mother
Mean birth order
Mothers reporting stillbirth
Mothers reporting abortions
Mothers reporting deaths of children
823 (1 5)
823 (2 8)
28 (5 0)
55(11 7)
164(29)
811 (15)
811 (2 8)
27 (4 9)
66(12-5)
144(26)
Senfcoiaja
Mother had 3 tetanus toxoids in pregnancy
Homedeilwy
BCG Immunisation
Tubal ligation In mother
335(40 7)
582(707)
583(70 8)
*80(319)
368(45-4)
562 (69 3)
646(79 7)
138(25 1)
Demographic
Table 1: Characteristics of the two treatment groups
data analysis? This exclusion did not affect the outcomes of our
study.
Data, including anthropometric measurements, were obtained
by trained field workers, not by the nutrition worker responsible
for the interventions.’ Baseline data are presented from interviews
with 1115 mothers who had 1634 preschool children bom between
April, 1982, and May, 1988. Children were weighed in all the
villages in April, 1987, to ascertain the willingness of the
communities to accept weighing. Baseline and final
anthropometric measurements were done in July, 1987, and
December, 1989, and intermediate anthropometric assessments
were done every 4 to 5 months. The take-up rate was about 90%.
Information on socioeconomic status was collected in August,
1989.
The following interventions were provided to both GMP and
NGM groups:
o The nutrition worker visited homes twice a month to provide
education on health and nutrition. Educational films were shown in
the villages.
o Immunisations were provided in the village, antenatal ser
vices at the rural clinic, and family planning services, at the rural
hospital.
• Curative care was provided at weekly rural clinics. If needed,
patients were referred to the RUHSA rural hospital or to the
reaching hospital in Vellore.
• Children aged between 1 and 5 years were dewormed with
albendazole or pyrantel pamoate about every 4 months.
• Vegetable and fruit seeds and saplings were distributed to
home gardens.
In GMP villages, growth monitoring was done by the nutrition
worker every month. Growth charts were used to educate mothers.
Growth monitoring was done in the child’s home to ensure high
take-up rates and the best possible understanding of the growth
charts by mothers. We have described elsewhere7 that growth
monitoring was successfully implemented in GMP villages, and
resulted in correct use of growth charts, good understanding by
mothers, and improved growth of children. Nutrition workers
visited the households the same number of times and spent the
same amount of time with mothers in NGM and GMP villages.
The content of educational messages in both groups was identical
but it was imparted to mothers in NGM villages without thc-use of
growth charts. The anthropometric assessments for research
purposes were done by an independent set of workers. Neither the
nutrition worker nor mothers in NGM villages were informed how
their children were growing with respect to weight.
The nutrition workers had 2 months of training from RUHSA
health educators. The interventions were started in July, 1987.
However, growth monitoring was not started when planned
because many community members were unwilling to allow their
children to be weighed. From July, 1987, to January, 1988, each
nutrition worker visited homes and weighed children with the
supervisor. These visits were used to motivate mothers to
Vol M2 • Angnst 7,1993
Age (mo)
Baseline
Final
GMP (%)
NGM (%)
GMP (%)
NGM (%)
3-11
12-23
24-35
36-47
48-59
16-3
219
19-4
20 2
22 1
150
192
202
196
25 9
15-8
22-2
21-7
215
18 8
179
21 7
202
20 6
19 6
Total no
515
505
558
535
Table 2: Age distribution of children
appreciate the significance of weighing. During this interim period
the nutrition worker imparted education without using the growth
charts in GMP villages. In January, 1988, the supervisor distri
buted growth charts to all mothers in GMP villages. Over 50% of
the charts had at least four weights already plotted and so most
mothers could see the growth of their child from the first month of
growth monitoring in February, 1988.7
Statistical analyses were done with SYSTAT (SYSTAT Inc,
Evanston, Illinois, USA) and SAS (SAS Institute Inc, Cary, North
Carolina, USA). Changes in nutritional status were analysed by
dividing the study children into three age groups: 3 to 23 months,
24 to 44 months, and 45 to 59 months, according to the age of the
child at the time of each assessment. These age groups were used
because the World Health Organization growth standards have a
discontinuity at 24 months,9 and the three age groups are
characterised by different growth rates. Infants under 3 months of
age were excluded because some were temporarily absent and
because prenatal factors have a major influence on their growth.
Comparisons were done by calculating monthly gains in stature
and weight at consecutive intervals. The significance of differences
in changes observed per month between the two treatment groups
was calculated after adjustment for age and sex. The above analyses
were done on the assumption that the child and the village each
contributed to random variation. These analyses were done with
the mixed-model procedure in SAS, which estimated the variances
and adjusted for the village effects.’ The inter-village variances
amounted to only 8% or less of the total variances. This sample size
of younger children is adequate to detect a mean difference of 22 g
per month in weight gain between the two treatment groups and of
0-8 mm per month in length gain. This study has the potential,
therefore, to detect differences that are of public health signifi
cance.
Results
The GMP and NGM villages were similar with respect to
caste, percent of nuclear families, mean birth order of the
study child, and mean number of preschool children per
mother (table 1). The study families in the two groups were
also similar with regard to consanguinity of the parents and
landlessness. The use of pre-existing services such as
antenatal care and childhood immunisation was 5-8%
higher in NGM villages, but use of family planning services
was higher in GMP villages.8 The duration of breast
MONTHS OF INTERVENTION
Figure 1: Mean Z-scores of weight for age In children aged 3 to
23 months In two groups by calendar month of intervention and
duration
GM - growth monitoring.
349
nil: LANCET
NGM
GMP
Jul 87-Oec 87
Dec87-Apr88
Apr 88-Aug 88
Aug 88-Dec 88
Dec88-May89
May89-0ec89
p
No
Mean (SEM]
length gain
(cm per month)
No
Mean(SEM]
length gain
(cm per month)
166
154
152
152
175
197
0 87 (0 03|
0 90 (0 03|
1 00 (0 04]
0 82(0 031
0 98 (0 03]
0 87 (0 02]
160
167
167
164
160
177
0 83 (0 03]
1 06 (0 03]
0 99 (0 03|
0 82 (0 03)
1 04 (0 03]
0 89 (0 02|
0-216
00001
0-814
0885
0056
0603
Table 3: Mean [SEM] length gain In children aged 3 and 23
Figure 2: Mean Z-scores of height for age In children aged 3 to
23 months In two groups by calendar month of Intervention and
duration
GM - growth monitoring.
MONTHS OF INTERVENTION
Figure 3: Mean weight gain (g per month) In children aged 3 to
23 months In two groups by calendar month of Intervention and
duration
Incremental weight gains for each Interval are plotted at the end of the
Interval. GM - growth monitoring.
feeding was longer and weaning was later in GMP villages.
GMP villages also used more traditional weaning foods and
less infant formula than NGM villages. The age distribu
tion of children measured at baseline and at the final
examination was similar (ub>; 2). The groups of children
were similar with respect to mean weight for stature, but the
mean suture for age and weight for age measurements were
lower in GMP villages.’ Consistent seasonal patterns in
growth’(attained suture and weight) in GMP and NGM
villages indicate the similarity of the two groups of villages
in terms ofresponse to seasons (figtires 1 and 2). The weight
gains were twice as large in the good growing season (last
interval of the year) compared with the poor growing season
(second interval of the year, figure 3).
months
Figures 1 and 2 show the attained weights and sutures of
children aged between 3 and 23 months measured at regular
intervals during the intervention. These figures indicate
that there were similar improvements in both treatment
groups over 30 months of intervention, and that improve
ments in GMP villages started even before growth moni
toring. Figure 3 shows the relation between monthly weight
gain and the duration of intervention. What is nouble are
the improvements in weight gain (figure 3), weight for age
Z-scores (figure 1), and suture for age Z-scores (figure 2) in
younger children of both GMP and NGM groups in the
period after the baseline examination and introduction of
interventions in July, 1987. The weight gain for younger
children in GMP villages was marginally greater than in
NGM villages between April, and July, 1987, before the
initiation of other non-growth-monitoring interventions.
However, the weight gain of young children in GMP
villages in the first interval after the initiation of non
growth-monitoring interventions was significantly less
than in NGM villages. The differences.in weight gain
between the two groups for other intervals were not
significant (p > 0-05, figure 4). The monthly gain in stature
showed similar patterns (uble 3).
Improvements in nutritional sutus of younger children
occurred in all 12 intervention villages. There were
improvements in children of both caste groups, especially
in Harijan children. In GMP villages the improvements in
mean weight for age Z-scores of younger children from
baseline to the final assessment were from - 2-20 to -1-82
in Harijans and -2-27 to -1;97 in other castes, and in
NGM villages were from -2-24 to — l-88 and —1-98 to
- 1-78, respectively. Similar changes were also observed in
suture for age Z-scores. In older children aged between 24
and 59 months the patterns of attained weights and suture,
and of monthly weight and suture gains, were similar in
both groups of villages but, as expected, gains were much
smaller than in younger children.7
MONTHS OF INTERVENTION
Discussion
Figure 4: Difference (GMP minus NGM) In mean Incremental
weight gain (g per month) In children aged 3 to 23 months In
two groups by calendar month of Intervention and duration
Difference for each Interval Is plotted at the end of the Interval. Values are
means and SEMs.
350
The observation that the gains in stature between
December, 1987, and April, 1988, in GMP villages were
significantly less than those in NGM villages, and the fact
that this followed the pattern of inadequate weight gains in
GMP villages for July to December, 1987, is consistent with
reports by others, which suggest that children need to put
on adequate weight before they gain much height.10 The
weight gains in the first interval after the initiation of
non-growth-monitoring interventions in July, 1987, were
significantly less in GMP villages than in NGM villages
because a substantial amount of the time of the nutrition
worker was spent convincing the families to accept weigh
ing. The finding that there were improvements in GMP
villages even before the introduction of growth monitoring,
Vol 342 • August 7, 1993
and that the gains were similar in both groups after die
initiation of growth monitoring in GMP villages (figures 3
and 4) over the entire duration of interventions, suggests
that no additional benefit resulted from the growth
monitoring component. The growth charts in our field
conditions did not seem to be a better educational tool than
education without charts. Doubts about the usefulness of
growth charts were raised in 1988 because of the marked
seasonal changes in the growth of older children in Nepal.11
Our data in young children support this observation. Even
with our optimal field conditions, the successful growth
monitoring efforts could not overcome the marked seasonalimpact on growth. This finding challenges the usefulness of
growth charts to promote growth of children in areas where
seasonal changes may have a substantial impact.
Until recently the main criticism of growth monitoring
was the appropriateness of the technology.12 Our study is
the first to evaluate the effectiveness of growth monitoring
with GMP and NGM villages. Why did the growth charts,
which mothers understood and used appropriately, not lead
to even better growth than nutritional and health education
without weighing and charting? Growth monitoring is
conceptually a very simple and attractive idea. Further
more, mothers’ perceptions of growth are inadequate.
Although it seems very plausible that sensitising mothers to
the faltering growth of their children (by looking at growth
patterns) could stimulate them to provide additional care,
child care is only one of the many responsibilities that a
mother has. There is also the assumption that mothers have
access to more resources (including time) and have more
decision-making powers to reallocate these limited re
sources towards providing better child care than they
actually possess. Our experience is that almost all mothers
desire to provide better care but are overwhelmed by their
workload and are often discouraged by the apathy of other
family members towards the well-being of their children.
In these villages mothers felt helpless on many occasions
because of frequent verbal abuse and, not uncommonly,
physical violence, alcoholism, and/or promiscuity of their
husbands.13 Our experience suggests that growth moni
toring can become an additional burden to an already
overwhelmed mother. Mothers do not seem to need such
visualisation to be persuaded to take necessary actions to
improve the growth in their children. The mother responds
to the worker’s suggestions and attempts to change her
practices when she is convinced that the worker does care
for her child. In our study area the mother gets additional
support from the worker to persuade the decision-making
members of her family to take action. The mother’s
improved self-esteem coupled with the confidence that she
can get support to provide better child care appeared to be
gained with or without the use of growth charts. These
improvements in self esteem of women seem to have
facilitated better growth in children belonging to the lowest
caste (Harijans) despite the higher socio-economic status of
families ofother castes. This appears to be due to the greater
autonomy Harijan women have compared with women of
other castes.14
In a centre-based nutritional programme the interaction
between mother and worker may be minimal and rather
impersonal with little or no participation from the mother.
In our study the entire community was involved because of
the home visits by workers. The practicality of a village
worker spending one hour per month with the mother of
every child in the home can be questioned. With our field
conditions, however, this seemed to be the least amount of
Vol 342 • August 7,1993
effort necessary to get the mothers and the community
really involved in growth monitoring.131'' Furthermore, the
effort of initiating growth monitoring in GMP villages
resulted in substantially lower weight or length gains in
younger children of GMP villages in intervals of the first
year (figure 3 and table 3).
Until now, claims of successful growth monitoring have
not separated benefits of the growth chart from benefits of
other interventions that have been implemented with
growth monitoring.17 Furthermore, the claims of successful
growth monitoring, as in the Tamil Nadu Integrated
Nutrition Program, have been based on anecdotal and
impressionistic evidence.16-18 Our study suggests that one of
the ways of achieving a greater sense of “community
ownership”*123456’ of government nutrition programmes is to
facilitate the transition from the “centre” to the home
based approach. In many parts of India this home-based
promotion of the growth of children without growth charts
and monthly weighing will be more acceptable to the
community because cultural prejudice against weighing is
recognised. Home visits can also influence the decision
makers in the family to provide better child care.
The effectiveness of growth monitoring in other coun
tries needs to be established. In other cultures where the
status of women may be better, where families have more
resources to take care of their children, where there is
greater community cohesiveness than in rural India, and
where there is a well-developed primary health care
infrastructure, growth monitoring may be effective.
This work was supported in part by grants from the Thrasher Research
Fund, UNICEF, India, and the Rockefeller Foundation. We thank
SmithKline Beecham (India) for the donation of albendazole and Ross
Labs for the arm circumference tapes. We are indebted to Dr R L Parker,
Dr B M Pulimood, Dr K E Mammon, Dr A V Puranik, Dr T J John,
Dr T Cherian, Dr C E Taylor, Dr J E Rohde, others,78
910
and the field staff
for their contributions. The paediatric surgeon’s visit was made possible
by grants from the CMC Research Committee and from the Department
of Paediatric Surgery, CMC Hospital, Vellore, India.
References
Morley D. Prevention of protein-calorie syndrome. Trans R Soc Hyg
1968; 62:200.
Morley D, Meegan M. A process df initiating the child, the family and
the community in ±e ability to comprehend and interpret
measurements. In: Cervinskas J, Gercin NM, George S, eds.
Proceedings of the Nyeri Colloquium on growth promotion for child
development. Ottawa: IDRC, 1993: 188-94.
3 Rohde J, Hendrata L. Development from below: transformation from
village-based nutrition projects to a national family nutrition program
in Indonesia. In: Morley D, Rohde J, Williams G, eds. Practicing
health for all. London: Oxford University Press, 1983: 252-71.
4 Grant JP. The sure of the world’s children. London: Oxford
University Press, 1985: 3.
5 Gopalan C, Chatterjee M. Use of growth charts in promoting child
nutrition: a review of global experiences. New Delhi: Nutrition
Foundation of India, 1985: Spec Publ Ser 2.
6 Editorial. What happened to growth monitoring? Lancet 1992; 340:
149-50.
7 George SM, Latham MC, Abel R. Successful growth monitoring in
south Indian villages. In: Cervinskas J, Gercin NM, George S, eds.
Proceedings of the Nyeri Colloquium on growth promotion for child
development. Ottawa: IDRC, 1993: 150-66.
8 George SM. The effectiveness of growth monitoring in south Indian
villages (dissertation). New York: Cornell University, 1993.
9 Diblcy JD, Stachling N, Neiburg P, Trowbridge FL. Interpretation of
Z-score anthropometric indicators derived from the international
growth reference. Am J Clin Nutr 1987; 46:749.
10 Nabarro D, Howard P, Cassels C, Pant M, Wijga A, Padficld N. The
importance of infections and environmental factors as possible
determinants of growth retardation in children. New York: Raven,
1988. Nestle Nutrition Workshop Series; 14:165-79.
1
2
351
THE LANCET
Nabarro D, Chinnock P. Growth monitoring: inappropriate promotion
of an appropriate technology. See Sei Afed 1988; 26: 941.
12
Editorial Growth monitoring: intermediate technology or expensive
luxury?
1985; ii: 1337-38.
13
Miller BD. Wife-beating in India: variations on a theme. In: Counts
DA, Brown JK, Campbell JC, cds. In sanctions and sanctuary: cultural
perspectives on the beating of wives. Boulder: Westview Press, 1992:
173-84.
14
Liddle J, Joshi R. Daughters of independence: gender, caste and class
in India. London: Kali for women and Zed Books Ltd, 1986.
15
Rohde JE. Editorial. Indian J Pediatr 1988; 55: SI.
11
Shckar M, Latham MC. Growth monitoring can and does work: an
example from the Tamil Nadu integrated nutrition project in rural
south India. Indian J Pediatr 1992; 59: 5.
17 Gopalan C. Growth charts in primary child-health care: time for
reassessment. Nutrition Foundation of India Bulletin 1992; 13 (3): 1.
18 Chatterjee M. On the nutrition component of TINP: some lessons and
issues. Workshop on Tamil Nadu Integrated Nutrition Project, July
31-Aug 3, 1989, Madras.
19 Balachander J. TINP, India, in managing successful nutrition
programmes. Geneva: ACC/SCN, 1991. State-of-the-Art series no 8:
97-107.
16
Deep-vein thrombosis and pulmonary embolism
John Black
The differential diagnosis between myocardial infarction
(MI) and pulmonary embolism (PE) is rarely discussed in
textbooks. My experience suggests that this is a serious
omission. PE should be considered, as well as MI, in any
patient with dyspnoea or atrial fibrillation of recent origin
for which there is no obvious cause.
In 1968, about 10 days after a transatlantic flight,
I experienced an aching pain in the left buttock and lumbar
region. 2 days later my left leg swelled up over a matter of
minutes, and the lumbar pain disappeared. I can find no
reference to lumbar pain as a premonitory symptom of
deep-vein thrombosis (DVT) but have since come across
another doctor with an identical history. The lumbar pain
may have been due to venous congestion from thrombosis
of a pelvic1 or lumbar vein, and this may have been relieved
when the venous return diminished, due to extension of the
thrombus into the femoral and great saphenous veins. After
initial treatment with heparin followed by warfarin the
swelling gradually subsided, leaving only some dilated
veins in the calf and round the internal malleolus.
Nothing further happened until 1987 when I noticed
mild exertional dyspnoea with a regular pulse. The same
night I was woken by a grossly irregular heart beat which
was confirmed as atrial fibrillation by a general practitioner
the next morning—and by an electrocardiogram when I was
seen in the afternoon by a cardiologist. The fibrillation was
intermittent, each attack lasting 2-3 hours. The provisional
diagnosis was paroxysmal atrial fibrillation due to an MI,
though the ECG showed no evidence of infarction. A
normal rhythm was rapidly restored by digoxin, and I
returned to London where I was seen by another cardio
logist who also thought an MI to be the most likely
diagnosis. Both resting and exercise ECGs were norm,al, as
were a chest X-ray and an echocardiogram. There had been
no change in the veins in my left leg.
Over the next two weeks I maintained normal rhythm but
the dyspnoea varied unpredictably in severity. At its worst,
usually after mild exertion, I experienced a bursting pain in
the precordium. One morning, after running for a bus, I
Victoria MUI House, Framllngham,'Woodbridge, Suffolk IP13 9EG
(J Black mef)
352
suddenly felt cold and clammy. Unwisely I continued with
my journey, but on the way back I felt so ill that I
abandoned the bus and took a taxi home, where I
telephoned my wife at work and our general practitioner’s
surgery. When she heard that I had taken a taxi my wife
knew at once that something was seriously wrong. The
doctor I spoke to was not our usual one and needed to be
convinced that I was not suffering from influenza before he
agreed to visit me. By the time my wife and the doctor had
arrived I was feeling better, and my pulse and blood
pressure were normal. An appointment was made to see the
cardiologist and I was admitted to hospital. Chest X-rays,
ECGs, and a coronary angiogram were normal, but a
pulmonary arteriogram revealed occlusion of the upper
branch of the right pulmonary artery. After a short course of
heparin I was given warfarin for 6 months.
2 months after stopping the warfarin, I went on holiday
on an overnight flight, with very little leg room. A week
later a small area of venous thrombosis on the dorsum of my
left foot developed. On my return to London I noticed
frequent extrasystoles, and after a few days I once more had
mild dyspnoea on exertion. A ventilation-perfusion scan
revealed three areas of hypoperfusion in the right lung. A
recurrence of PE was diagnosed and I was admitted and
given heparin for a week and warfarin indefinitely.
Lumbar pain as a presenting symptom of DVT may be
more common than its absence from published work
suggests. Aeroplane journeys, especially overnight flights,
are a well-known risk factor for DVT and PE. For some
weeks before the first episode of PE I had been editing a
book while seated on a wooden slatted chair. This probably
initiated a venous thrombus which lodged in the pulmonary
artery. The initial diagnosis of MI was justified though it
could be debated whether ah infarct severe enough to cause
dyspnoea and atrial fibrillation would have failed to
produce any ECG abnormality up to 3 weeks later. Atrial
fibrillation, and less commonly, atrial flutter occur in
7-10% of cases of MI2 but in only 3% of episodes of PE3 and
in many textbooks the association of PE with arrhythmias is
not mentioned. The development of extrasystoles during
the second episode may well have been an indication of
strain on the myocardium since it is well recognised that
extrasystoles often precede atrial fibrillation. Although
Vol 342 • August 7, 1993
Name of
pregnant woman
Age
Mother's education: illiterate/primary/middle/school final/graduate
Husband's name
Date of the first day of the last menstrual period
Expected date of delivery
/
/
Child’s Name
Date of birth
/
/
Mg
gms
Girl |____ |
Birth Registration: Yes/ No
Birth order: primi/not primi
Address
Anganwadi
SHC / Clinic
PHC / Town
Registration No.
1___
| Date I
Mother-Child
Protection
Card
ICDS
Name of
pregnant woman
Age
Mother's education: illiterate/primary/middle/school final/graduate
Husband's name ___________________________________________
Date of the first day of the last menstrual period
Expected date of delivery
/
/
/
/
Child's Name
Date of birth
/
/
Birth
Weight
gms
Girl |
Boy |
Birth Registration: Yes/ No
Birth order: primi/not primi
Address
Anganwadi_________________________________ _______
.
SHC/Clinic
PHC / Town
Registration No-[
---------------- --------------------------------------------
[Date [
|
|
Months
Regular chsckup is essential during
pregnancy
2nd
1st
3rd
4th
5th
6^
7lh
8tn
As soon as you see any of these
danger signs rush to the hospital
9th
'SO'??.
■
cL?
1
/'It
I
Heqisirauuii
A
ANC
Severe Anaemia with or
without breathlessness
Blood pressure
z
Weiqht
High fever during
pregnancy or within
one month of delivery
Convulsions or fits,
blurring of vision or
severe vomitting
Absent movements of
the baby or abnormal
presentations oblique or breech
Bursting of water bag
without any pain
T.T.Injection
Iron Tablets
•
Additional investigation and information about pregnancy
Care During Pregnancy
Place of Delivery
How families can help
Take more than usual
amounts of food, plenty
of green leafy vegetables
and use only iodised salt
& healthy child gains weight regularly
Continue breastfeeding and feeding of regular food during illness. On recovery, feed the child increased amounts of usual foods.
RECORD OF ILLNESS
Fever
In case of high fever, start
cold, wet sponge on the
forehead and limbs as you
take the child to a doctor.
Diarrhoea
Give increased amounts
of fluids to drink. If loose
motions do not stop, take
the child to a doctor and
continue feeding the usual
foods. Give ORS and
breastfeed.
ARI
If the child has rapid
breathing and/or difficult
breathing such as chest in
drawing, start antibiotics
prescribed by the worker
and take the child to a
doctor.
A
Details o f ImiTiunisation
1st year (0 to 12 months)
B.C.G.
/ /
Date
/ /
DPT-1
Polio-1
DPT-2
Polio-2
DPT-3
Polio-3
Date^a
Date^^
/ /
/ /
Measles
Vitamin A
cn
E
05
CD
it in Kilograms
.
We
Date
11 / / \\ // I
Vitamin A
\\\m
Vitamin A
leads sdlf, spi
3.0
imitates household work
2.5
2.0
indicates wants
9 10 11 12
I
I
I
unscrews bottle
puts 3 pebbles in a cup
gestures bye, bye
Special care is needed for the
baby if she I he
names 1 to 4 familiar objects
Smiles in response
o
scribbles spontaneously
points to 2 parts of body
1 .Was born prematurely
piCkE up
lor mtira mura
with! thumb & iridex linger
reaches for objects
2. Did not cry immediately at birth
says one other word
tracks a pencil
2.5 kg
3. Less than 2.5kg at birth^?^ j
says mama/papa
utters sounds
|
.vaiks backwards
4. Had severe jaundice in the first
week
c
walks well
turns to voice
stands alone well
5. Has convulsions
sits up from lying position
!©«.•
sits without su
•I ■
eloupng
head steady when helcnjpright
Birth to about 6 months
6 to 9 months
9 to 12 months
1 to 2
Along with breast milk start with 2 spoons of a
Put your child to breast within
mixture of mashed cereal or dal and
one hour of birth. Feed as many
vegetables. Increase to half a katori*4 times a
times as the child wants and at
day by 9 months, and to half a katori5 times a
least 8 times in 24 hours. Do
not give any other foods or fluids, day by 12 months
*katori measures
Feed when child shows hunger
approx 125 ml
not even water.
Continue breast feeding. Gradually increase L , Quantity of
the mixture so that between 1 to 1 1/2 years c ■ . aild consumes
almost half the quanitiy of the adult diet, including green leafy
vegetables.
Continue breastfeeding
during illness
The child needs extra
food after illness
Encourage child to eat independanily
1 -7 AUGUST 2001
7^ Si"® <Ez
tLifCz: S <£7j' ii D g
fi H's
th® Bnformation Age
........... and their advantages
Know these facts about breastfeeding
Ideally
Breastfeeding should co Initiated Immediately
after child birth (within half an hour).
BUT only 15.8% infants get breast-milk
within an hour of birth In our country.
This helps In establishing successful
lactation;
Enables feeding of 'colostrum' to the
baby, a concentrated source of vitamin A,
protein and antl-Infectlve constituents
that provides natural immunity to ths child; .
It benefits the mother also in several ways' ■’
Breast milk provides all the nutrients that a
baby ncods during tho first 6 months.
infant should bo breastfed exclusi vely for
first 6 months.
Any liquid or solid food othor than breast milk 7' .
given during this period causes diarrhoea
which may sometimes be fatal.
BUT only 19.4% infants ara exclusively
breast fed for first 6 months In India.
Any feed other titan breast milk suppresses lactation.
Infants should bo given homo baood complamsntary
feeds (dalla, khlcheri etc.) from 8 months of age
while continuing breastfeeding.
A growing infant's increasing requirements
can not be met by breast milk alono after 6
months.
\ '
' r-jTV-yr' •' ■
I .
BUT only 49.4% infants aro given soma
complementary foods from 6 months of age In India.
Infant requires adequate and frequent
complementary feeding alongwith breastfeeding
for optimal growth and development.
Breestfasdlng should bo continued upto two yoara
of .r.ge and beyond.
Breast milk provides valuable nutrients to the
child during this active growth period.
■ Elj F In India only 59% infants are breast fad upto
2years.
_
_
_ ___
_
___
DO YOU KNOW?
World Health Assembly2001 recommends excius'va urcastfcsdlng
/Jfpritfie first six months of life for aill segments of sosioty. :,
Knowing these facts about Breastfeeding and communicating the same to es ma:
people as possible Is our moral duty towards the future citizens of this country.
Food and Nutrition Board
Dopartmont of Womon and Child Development
Ministry of Human Resourco Development
Government of India
Shastrl Bhavan, Now Dolhi.
[iroaslfemlimj Promotion Network of India (BPNI)
7^’5 / / / i?//
is ir n i
S 1 tl ('t’111 C 11 !
OH:
jll'V iind JnCoiiC J’eedincj
Breastfeeding is the optimal way to feed an infant. It greatly/improves quality of life by pro
viding unique nutritional, immunological, economic, ecological, psychological and child spac
ing benefits. Breastfeeding also enhances maternal health.
Breastfeeding saves lives. Infant mortality continues to be very' high in India and artifi- •
cial feeding contributes to a major part of this. Malnutrition is rampant among infants
and this can be prevented to a significant extent by breastfeeding.
Il IV transmission ami infantfeeilinj;
Transmission via breastfeeding to uninfected infants born to women with HIV infection is
estimated to occur in I in 7 cases. The risk of III V transmission through breastfeeding is
highest among women who become infected whilst breastfeeding.
Mothers, health woikets and organisations such as Bl'NI ate faced with a dilemma concci ning
decisions about infant feeding. Given (he evidence regarding the risk of IIIV transmission
through breastmilk, it is \ ital for policies to be developed with regard to breastfeeding, by 11! V
positive mothers.
Recommendations
I. Priority should he given to policies and programmes, which aim to prevent women of
childbearing age and their partners from becoming infected with 1IIV in the first place. Ap
propriate preventive measures should be taken to reduce mother to infant IIIV transmission.
2. The genera! principle “irrespective ofl II V infection rates, breastfeeding should continue
to be protected, promoted and supported" as enunciated by UNAIDS1 should be followed.
?. Women should be "empowered to make fully informed decisions"1 about infant, feeding
and supported in their decision.
I
• I. Voluntary anil confidential counselling and IIIV testing should be made available lor women
of childbearing age and their partners. l;or those women who arc aware of their ill V status,
inlormation should include the heiu-lits of bre.i.'.lfeeding, additional risk of transmission of
1IIV via breastmilk, risks and possible advantages and disadvantages associated with other
methods o( (ceding. I his should he done in a supportive environment, which minimize.'; any
possible discrimination or stigmatization.
r
S, Women slmtdi: tie inietmcd about 'lie allot native methods ol Icfilin »• Mich at. using hcai-
»
tweed wd.V C ... 30 minutes) expressed breastmilk, wet nursing, etc. and the use of a c(up
;,..,.cr ll .a', bottle to minimize tisks ol arlilicial feeding.
o. BONI advocates adherence to the "//i/mir Milk Substitutes, Feedinp, Rotties and Infant
..'a (.Gyuiniitni o/ i'loiith lion, Supply and I'distribution) /I cl, / 79,?" nt id the World 11 calth
. issem/dy loOoi'mu'.'i, I'-'Vd1 which nlno re< nmineiidii (hut them me no domtlloiiH or low coal
supplies within any part of the health care system.
,
/
1. Research Needs
Ci) There is an urgent need for more research on HIV transmission through breastfeeding, and
interventions that may permit breastfeeding to be available to the infants of HIV infected
women in Indian situation.
(b) Research should be funded and conducted in a transparent and independent manner by
those who do not have a commercial interest in the outcome,. I'itimicitil support for research
and information ofHIV anil infant feeding matters should not create conflicts of interest.
January'11999
Rein enees:
|
UH' and Infant Feeding.')! Policy Statement Developed Collaboratively by UNAIDS, WHO and
UNICEF Mav 1997. " i
2. Infant Milk Substitutes, Feeding Hotties and Infant Foods (Regulation of Production, Supply and
Distribution) Aci, 1992, No 41 oj 1992.
3. H'HA Resolution 47.5, 9 May 1994. Eleventh Plenary IF./i.C. Geneva.
1.
Members of the Committee.on 11IV N Infant feeding, Bl’Nl
Dr.Amiiava SvmC<i/cmm,‘ Dr.Arim <iup(a-0i7/n,- f)r.Arini Vhnlak-Uaroda; Dr.RK Anand-Z?o/zi/?r"
Dr.Ai inida 1-eievAwSy.'.-llombay; Dr.AC Sai ma-lHihsi/mn'; Dr.GS 1 Islhi-lloinbay; iJr.KI’ Kui.liwalia ■
Gorakhpur; Dr.NB KmvCs-Hoinbay; Dr.NB Matlnir-/Jc7//r,' Dr.Rckhti U(Jani-/?o///Z)uy; Dr.S SrinivasanFondieherry and Dr.Sanjiv Kumar-/Je//ii.
' .I
CHALLENGE
Malnutrition is a multi-faceted problem interfering with all efforts
for development of human resources.
U
b-hlhltioH IM i'll impt’l I.Ill I mill.
I ' I
• • l> -pm* id
Imlidh I luman I Jvvvlupmenl Index (I II >1) Rank is 13.!
in the world reflecting a in.qor dchcivncy in the quality
of life of people.
a’i li
LI
Malnutrition in children and women i*. associalrd with
high morbidity and mortality.
_J
Malnutrition is le.spon.siblr lor low pimim livily
leading to poor social and economic progress.
(J
Chronic malnutrition in childirn insults in stunting,
poor cognitive drvolopini'nl and pool l.'.muug ahilily
malnutrition.
I ligh prevalence of low birth weight, high
malnutrition in 0-2 year olds, p»x»r nulution o(
and’
Even mild and moderate deficiencies of micronutrients
pai In 11lai Iy ol lion, \ itaimn A, folir acid ami iodine
result in pool growth, development and immunity in
tin* population
1 omlgram piodm lion has increased fourfokls during
the last live decades but food secuiily al the household
level i»s yel Io be a< him ed
U
Women and children aie woisl allecled by
i*nl git I .< «nii'll-,I Willi i .n Iy mao iapj ■
teenage piegnaiu les icmiII in an inlei gi’m'tatiomil
cycle of malnuli ition
......... . < ess Io sanitation l.iuhliv.s ami sale dunking
water leads to high rales of infection which further
peipelualvs malnutrition
Malnuli ition being invisible’ often gels neglected.
Malnutrition is a "Silent Emergency" which needs to be tackled on war footing
Determinants of young child malnutrition:l cinair Illiteracy
The Government of India
Poor null ilional status of girl children and adolescent girls
recognises malnutrition as an
l ady inariiagei of gills
impediment to national
teenage pregnancies
development and i:. implementing a
( luonli energy Mr fit irni y and niiaeini i hi piegnant women
number of Direct and Indirect
I ow liiilh weight I*.dries
Late initiation of breastfeeding
Nutrition Programmes to combat
Delayed and inadequate complementary feeding
malnutrition.
Ignorance about nutritional needs of infants
Pool hygienic practices in feeding infants
lute, lion <ioiI inlenliilion
Together we can make it work: A partnership between government and people
Malnutrition can be ei ad i rated by us he i i ng in "Nutrition Revolution"
Ministry of Human Resource Development, Departinent of Women and Child Development
Government of India
61
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ANNEXUKE
/4rJ 13
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KARNAtAPA
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with address
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NATIONAL INSTITUTE OF PUBLIC COOPERATION AND CHILD DEVELOPMENT
Dr. Usha Abrol
Regional Director
No.NI/SRC/GMD/WKS/2001-2002/ | X 0
Dear
3)^
9.4.2001
■ N—
Sub-- Workshop on finalisation of Growth Monitoring Card
(April 16 - 19, 2001)
In continuation to our earlier letter of even number dated 4th April 2001, this is to
further inform that the anticipated outcomes of the above mentioned workshop are as follows:
a.
The final version of the growth-monitoring card. We have received several comments
from other experts (including from the meeting of the Hindi card held in Delhi),
which need to be examined and finalised by the expert group and Karnataka/Andhra
Pradesh government (Day — I).
b.
The draft version of the 3 — 5 year old card will be ready for discussion and
finalisation (Day — I).
c.
The finalisation of the training modules on the card being prepared by the Osmania
Medial College and NIN (Day II — and III).
d.
Review and finalisation of the Dular Kit and similar material from other states to
form an additional information/support kits for frontline workers/village development
committees Day II and III).
e.
Finalisation of the entire package and the roll out plan for Karnataka and Andhra
Pradesh (Day I* IV).
You are kindly requested to go through the material and share your views in the workshop
in order to make the deliberations of the workshop more focussed.
As mentioned in the earlier letter also the board and lodging arrangements would be
made in the Institute’s hostel. You arc requested to kindly confirm your detailed
programme and requirement for lodging if any.
We look forward your valuable contribution in the workshop.
With regards,
Yours sincerely,
Dr. Ravi Narayan, Community Health Cell,
St. John’s Medical College, Sarjapur Road,
Bangalore - 34.
(Usha Abrol).
•T 18,
dUd'R,
HPf,
- 560 064
No. 18, New Town Yelahanka, Doddaballapur Road, Bangalore - 560 064
cTR : vl4«tlcR'H
Grams : NIPCHILD S : 8462818 / 8461355 / 8461793 Fax:080-8461793
E-mail : nipccdbl@bgl.vsnl.net.in
Monitoring of Maternal and Child Care Services at Block Level
12 Crucial questions for monthly monitoring the outreach of services at block level
1. No. and names of villages where there are pregnant women who have completed
8 months and are not immunized with TT.
2. No. and names of villages where 100% of children of 9 month age are not fully
immunized?
3. No. and names of villages with high risk pregnancy and nursing mothers (early
age, anemia cases, hypertension, history of caesarian, first delivery after 35)
4. No. of villages having more than 4 severely malnourished children (grade-III and
IV) for every 1000 population aged less than 6 years (175/100 children) to ensure
check up of fresh reported cases and arrange for medicines for this group.
5. Villages having an infant death to be visited for investigation.
6. No. of villages with even one of low birth weight for follow up investigations.
7. No. of villages having a maternal mortality
8. villages falling in the highest 25% in diarhoea/ARI incidence in children aged 0-6
years for follow up and arrange of awareness education.
9. No. of villages where feeding programme in AWC is less than 20 days for follow
up by ICDS/CDPO, Supervisor.
10. No. of villages where enrollment of children 5-10 years is less than 100% for
follow up by CRCs and BRCs.
11. No and names of villages where is enrollment of children 5-10 years is less than
90% for arranging special campaigns.
12. No. of villages where more than 10% of the enrolled children have the cumulative
attendance of less than 80% for immediate follow up by the BRC.
js
House / address
Basti
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o
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Member of Thrift Group
Name
of wife
A
________________________________________
(" 'k. Name of head of household
W
_______ Cooking Fuel
Housing
Thached house
Tiled house
Pucca house
Wood /Coal
'
~~
Kerosene
Details of infrastructure facilitie
co
Year
2000
2001
2002
2003
Drainage
Water Source
Lighting_____
Kerosene
Tap
Electric
Hand pump
Well
Tanker
Water let out
Drain
Year
2000
2001
2002-
2003
Garbage Disposal
Open
Year
2000
2001
2002
2003
“n
Dustbin
__________ Sanitation
Open defecation
House toilet
Open
Bathroom
2000
2001
2002
FAMILY FACT SHEET
2003
2000
2001
2002
2003
2000
2001
2002
2003
2001
2002
2003
I
I
T
NEIGHBOURHOOD MOTHER & CHILD DATA
Registration
B
z\b>
T.T.Injection
ANO
Iron Tablets
Place of Delivery
uuii'
I
Dai
| Age
House no
Date
1
I 2
3
1
2
I
Yes
No
11
1
I ’
2
J
3
I
4
I
I
I
1
1
1
1
I
I
I
1
1
1
I
No
.......
1
I
Yes
1
1
No
1
5
▼
X TBA
$ &
§3
Name of pregnant woman
Family Welfare
T. HOUSE
Hospital
o
Miscarriage/
Still birth
1
1
1
1
1
I
I
6
1
7
I
8
I
I
I
I
I
1
1
■ 1
1
1
1
1
1
PARENTING
CARD IA
The first three years after the birth of the child are times of rapid growth and
development. The foundation for future health and intelligence are laid at this time.The
care given by the family at this time will determine whether the child will live a
successful life or not.
Even as a child needs food for the body to grow .food is needed for the child’s mind to
grow . For the small child this food is made up of.
Love and affection
Being Talked to
Play
Love and affection
A baby is the greatest gift a family can have. Bringing up the baby is both a joy and a
responsibility meant to be shared by father, mother, grandparents and other family
members living in the home. In return the infant will learn to love and respect all those
who took part in caring for the infant**
The birth of a baby is a community event and a source of happiness. Elders may have a
great deal of wisdom to impart in helping you care for your baby, (picture of a naming
ceremony).
Use a lot of laughter and praise in encouraging your baby to do the things you want. A
child who grows up with love will also be loving and will have a good opinion about
herself or himself. This positive self esteem will prove a valuable asset in meeting the
difficulties of future life.
When correction is needed never beat your child. A firm “no” will serve the purpose.
Play
Play is the natural inclination of every child. Children learn through play. Play helps the
child develop concentration, vision and hearing .touch, imagination, concepts, movement
and expression. Parenting is fun and joyful. Playing together is a good way to enjoy the
company of your child. The precious days of early childhood never come back. Use them
well.
Play must be supervised to ensure safety. What does a small child play with ?
Everyday items in the house can be used as toys. Expensive toys need not be bought.
Talking to your child
Why should you talk to your child?
A child learns to speak by hearing others speak to him or her, the more you talk to your
child the more the child will learn to talk.
Language helps the child to develop understanding and will later help in studying well.
As family members your efforts in talking to your child give the child this special
advantage ***
When can you start talking to your child ?
Soon after birth a child will find the sound of the mother or father’s voice very
comforting.
How do you speak to a new born baby ?
Talk very gently when the child is lying quietly with eyes open and smile at the child.
You can say pleasant words.which will not have meaning but which sound loving.***
Softly sing the songs traditional for babies and small children
Later when your child begins making sounds or saying words, praise your child so he/she
may say the words again.
CARD IB
Birth to three months
G
o Being held securely gives the child great comfort .The feel of the mothers skin when
given the first feed soon after birth helps in creating the first bond between mother
and child . *As other family members become involved by carrying, talking and
playing with the infant, the infant learns who his or her own people are and begins to
smile at them and recognize them .
o Develop a regular routine for your baby. Have meals, baths, naps and bedtime at
about the same time everyday. (Picture with a clock)
° Respond immediately to your baby’s cries. Crying is the only way a baby can tell you
something is wrong.
o Gentle rocking or walking with the baby will soothe the baby. Carry the baby around
with you .**
(Picture)
T
8 Talk very gently when the child is lying quietly with eyes open and smile at the
child. Say pleasant words which will not have meaning but which sound loving like
telling the child how special the child is.
o Softly sing songs.
• The infant will respond to the tone of the voice and by the second month will be
smiling back at you.
8 By the third month the child may say ooh and aah sounds*.
P
® Tie a small colourful object on top of the baby’s bed. It could be made of colourful
cloth, ribbons or paper or a bought toy You will often see the new bom gazing at the
object and if you move it the child will follow its movement.**
o Place a small rattle in the hand and the child will hold it and shake it from 3 months
onwards***
M
0 The infant at birth has spontaneous movements of both arms and legs.
° Place the infant on the stomach and show the child a toy, the infant will be able to lift
his head up.*** Hold the baby in your lap in a sitting position. At 3 months the head
is held steady when in a sitting position.
0
Play Talk with your baby Play with your baby Show affection for your baby
CARD II A
Three months to six months
°
°
°
o
o
o
o
G
*
The baby is now settling into a routine ,sleeping and feeding at about the same time
every day
.Massage your baby gently before the bath talk soothingly during the bath and while
feeding the child
T A-3 •
By six months the child makes sounds like ga ga
By six months the child will be laughing aloud
Call the childs name softly behind each year -the child will start turning to sound
o
o
o
Pl<>.y
Place a toy in front of the child so that the child will try to reach for it and pick it up.
Offer two small toys to the child so that the child will transfer them from one hand to
another and later hold them each in one hand and later bang them together.
o
By six months the child will play peek a boo Cover your face with a cloth and then
remove the cloth The child will be fascinated when you reappear and will soon be
able to pull the cloth off even when placed on the child’s face. The child will laugh
and ask for this game to be played over and over
Let the baby feel objects of different textures
o
o
o
Mc>Hv
When the head is steady the child can be held in a sitting position so the baby can see
what is going on. ***
o
Roll a ball to your baby and get him or her to roll or toss it back to you.***
Play Talk with your baby Play with your baby Show affection for your baby
•
o
CARD II B
Six to twelve months
a
o
G
Stick coloured pictures from calendars ,newspapers old magazines ,on the wall Point
these out often*Paste some pictures in a n old note book and show the pictures
O
o
T
Imitate the child’s sounds and try to get the baby to make the same sounds back The
child will appear to imitate the way you talk by eight months As you smile and
encourage the child the first words take meaning like ama nana thatha ava and delight
the family Long before the child can say words the child can understand words like
***
where is thatha ,nana ?
where is your nose-your ears?***
where is the light ?
o P
o Show the child games like pat a cake , byebye ,how to find a hidden object by partly
hiding a toy and then covering it fully***
o Take a box or a plate and show how it can be banged with a spoon like a drum
o Show the child how to bang two toys together
o Take a katori and show the child how to put objects like nimbus in the container and
then empty them out ***
o Let the child pick up small bits of food with thumb and fingers like puffed rice(P)
See the child does not put harmful objects in the mouth
Your child will learn to drop an object several times on the floor and expect you to pick it
up. Be patient the child is learning that things fall when released.
°
o
«
o
o
o
o
M
Place your child in a sitting position in a corner to prevent falling over This will
help the child to sit independently by 7 months. (P)
Provide the child a secure support by sitting on the floor and placing the child’s hands
on your shoulders or knees so the child will gradually be able to stand
independently.**
While your baby is sitting, place a toy out of reach and attract the baby’s attention to
get the toy by crawling on hands and knees.***
When your baby can stand well alone, have your baby walk into your arms to get a
toy or a hug. This will encourage the bay to take a few steps.** If your baby is not
yet ready to walk alone wait a few weeks and try again.
Talk with your baby Play with your baby Show affection for your baby
CARD III A
0
°
°
°
3
°
°
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
«
»
»
One to two years
G
Show your child how to eat with his hands or with a spoon. Initially the child may
spill food but will gradually learn to eat independently. (Orissa card)
While you are washing clothes or dishes, making rotis or sweeping the floor, let your
child pretend to help you. (P)
Let the child take off his or her own clothes, shorts and shirt. Let him learn to start
putting on clothes. Give the child a shirt to practice unbuttoning and later buttoning
on. (P)
Take your child out with you, to the bus stop or market and talk about the things you
see. (RB)
Hide and let your child find you. At first make it easy for your child to find you. *
Teach the child to blow bubbles. (P)
T
Initially the child will say single words like “neeht”, “kukka" As you keep telling
him the names of different everyday objects. In the second year the child combines
words
“neelu ee kukka akda” and so on. Encourage your child to put words together.
Help your child learn to talk by having him or her name things you see like, dog,
goat, tree. ***
Have your child ask for things he wants instead of only pointing at them. ***
Ask the child to bring some item to you like bring the ball ***
P
Let the child play with a small amount of atta to roll into balls or rotis***
Show your child how bowls and dishes of different sizes can be put one inside the
other.***
Give the child a paper and pencil or slate and chalk and encourage scribbling **
Your child will like to throw things on the floor and expect you to pick it up each
time. Be patient as your child is learning how things fall.
M
Give your child a toy cart with wheels to pull. The child will learn to take steps
backwards as he pulls the cart along. (P)
If there are low steps near your house hold the child’s hand and help the child walk
up one step at a time. **
Hold your child’s hands initially and show your child to jump across a small piece of
cloth on the floor till the child gradually learns to do it independently**
Show your child how to kick a ball. The ball can be made of crumpled newspaper
enclosed in a rag. **
Talk with your baby Play with your baby Show affection for your baby
CARD III B
o
o
o
o
□
o
Two to three years
G
Tell children stories about themselves, about other family members***(group with
other kids baby on the lap)
Teach the child to say his or her name
o
T
Teach the child colours ,green like leaves, yellow like haldi, red like tomato, blue like
the sky. (Several mothers may not know colours) (Use earlier concepts pictures)
Words like up and down, in and out, under and on top eg “Put the red tomato in the
basket”. Teach the child to sort things “put the nimbus on the plate” “put the
tomatoes in the bowl ”***
Teach the child other opposite words like, hot and cold, day and night, big and small.
P
Teach the child to count using coins or stones or shells, one two three...
Show the child how to draw a line , a circle (P sibling)a face.
By the age of three the child can understand big and small, shapes and colours if
these have been told to the child
M
Show your child how to bounce and catch a ball.
Show your child how to stand on one foot and then the other, initially holding on to
you for support and later independently. By about 3 years the child can stand for a
few seconds at a time (P)
Teach your child to jump with both feet together
°
Talk with your baby Play with your baby Show affection for your baby
o
o
o
Same girl or boy growing up identified by dress /features
Diagrams =number of boys/girls
(P) only child in picture
°
* mother
o
** father
o
o
O
o
o
o
•
°
o
*** Grandmother =grandfather
o
SAFETY TIPS FOR YOUR CHILD
°
As your child learns to crawl and walk he/she will like to explore the
environment. Keep it safe
o
Keep small objects like beads or buttons which the child may swallow out of reach.
o
Keep sharp objects like knives, blades and sticks out of reach of your child.
o
Do not let your child play near the stove or with matches as he grows older
o
Keep all medicines locked.
o
Do not keep poisons like pesticides in the house.
o
Do not give the child bows and arrows, these could even blind the child.
Toys that may break easily could injure the child.
•
Do not let your child play with plastic bags, burst balloons or wires.
»
Protect your child from electrical sockets and wiring.
o
Windows should have bars and the child should be kept under close watch if the door
is open.
•
Do not let your child eat dirt.
•
Do not expose the child to loud noises.
CC L AX
i''ci(cl
/.fi (b
Recommendations from Consultation on:
Developing a Communication Strategy for ECC SGD for the Northern Region and
Consideration of a Home-Based Card
Consultation of NIPCCD and UNICEF
28-29,h Nov., 2000 Delhi
A meeting was held on 2S-29th of November, 2000 in Delhi with representatives of
5 states to define the role of communication in the ECC SGD framework. The
meeting vzas designed to sketch out a communication strategy, define the role of
a mother-held growth monitoring card in the process, evaluate whether it would
be useful or not, and develop plans for next steps.
Consensus items:
There should be some form of mother- or family-held card as tire core part of the
ECC SGD communication strategy. The card should define key elements of the
intervention. It will result in immediate feedback to being given to caregivers,
resulting in to use triple A in counseling them.
2. The format of the card can vary from state to state. However, each should meet
certain quality criteria, such as being field-tested and locally adapted, and should
be directed to all decision-makers.
3. Elements that should be added to the home-based growth card in use in several
states include the following: psychosocial care, feeding style, and care for girls and
women, plus sanitation/hygiene messages.
4. Growth monitoring and promotion and use of the card should be a part of the
regular work of the AWW and it should be positioned that way; it should not be seen
as a “new job” or additional burden for her1.
5. In order for this strategy to work, the supervisors and CDPOs need to be in
agreement (to be “on board.”), and advocacy efforts are needed.
6. The card has to be part of a larger communication strategy.
7. The card should be used as a support for communication and be a part of a normal
program, subject to programme monitoring from field to center and vice versa.
8. Training for the AWW is needed to strengthen the capacity of the AWW worker to
use the card. All functionaires need to be trained. The AWW cannot do it alone,
where needed, teams should regularly visit the villages to support these efforts
(within existing programmes).
9. States may decide whether or not to use the milestones, but all cards must contain
the Care for Development messages. States which choose not to use them in the
card may use them for materials for the AWW.
10. Implementation should be at least for one block. Cards should be given to all
children in the AWC, not just those receiving the supplement, as outreach of the
program is intended to be broader than just those with supplementary food.
Materials should be accessible for non-literate women. These issues will be dealt
with in pretesting.
1.
1 The home-based card will eventually replace the current growth chart (blue book) used by the AWW, the
Family Welfare immunization card, and the Antenatal Care card.
Recommendations for Actions:
1.
2.
3.
4.
5.
6.
7.
8.
NIPCCD will constitute a communication working group at NIPCCD HQ, including
other sectors and partners, including Family Welfare, DWCD, and UNICEF, World
Bank (add CARE since they have worked on cards in the past?). FEBRUARY 26"’ is
proposed as the meeting of the task force, to be called by NIPCCD.
NIPCCD will gather existing materials related to the use of a card that can be used
for developing communication materials, and will adapt these to the purpose of
supporting the card with information and training.
UNICEF/NIPCCD will support the setting up of communications working groups in
each state. States may develop resource centers and a state resource group.
NIPCCD/UNICEF will help organize 2 regional workshops or state workshops on the
communication strategy for ECC SGD.
NIPCCD/UNICEF will support the field testing of the card, as part of the
communication strategy, in 4 Hindi-speaking states (UP, Bihar, Rajasthan, and
MP) as well as Delhi. A protocol will be developed by NIPCCD with UNICEF input.
NIPCCD/UNICEF will support an evaluation study of the current Mamta and Dular
card strategy, in order to derive lessons learned.
NIPCCD/UNICEF to initiate the process for development of an ECC SGD card
prototype that can be adapted locally.
This effort must be done quickly; a timetable must be prepared for the first six
months of 2001 to complete the field testing. Field testing will be done in the three
stages: face validity, assessment of functioning in the field, and programme trial.
Components of a communication strategy:
°
o
o
’
«
•
o
Identification who one should communicate with - mother, parents in law, etc.
Information and materials that the AWW has that explains the card, with
specific recommendations for each milestone that are related to the care for
development recommendations.
Refresher training for the AWW, supervisor, and CDPO on how to use the card
and support materials.
Training in interpersonal communication for the AWW (as well as supervisors).
Advocacy for the importance of the Care for Development component: all have to
be convinced of its benefit and the risk of not using it.
Social mobilization strategies for increasing community involvement.
Folk plays, print, pamphlets, mass communication
Specific Recommendations on the format of the Card:
Many individuals, both at the conference and at other times have made (these
comments).
Page 1:
Title should be “family growth card” and include a picture of a father on the first
page.
2. Include sub-center/clinic/hospital address on card
3. State should have flexibility to incorporate local practices on this page.
4. This card should be a birth registration card and as such be launched by the
PM!!!
1.
Page 2: “regular check-up is essential during pregnancy”
1. Color code the boxes to indicate what it is that she should do - e.g., outline three
boxes for ANC check-ups to indicate that this is what she should do.
2. Indicate what normal blood pressure is, or at what level one should be concerned
3. For weight, indicate what the weight ought to be, and amount of weight gain per
month (1 kg per month)
4. Indicate when the TT injections should be done by color coding the box
5. Indicate how many iron tablets should be taken by color coding the boxes when she
should take them, and show the maximum number she should take (30 per month
for 3 months)
6. Add iodized salt intake to the chart (not clear how).
7. Instead of Place of Delivery, title this section Preparation for Delivery. Change the
items as follows:
List the five cleans in some way (show them all).
Triangle was not clear (family welfare)
Show some form of transport for safe delivery.
The heading over the picture with the purse should say ANM, not TBA.
Danger Signs:
Heading should say, “If you or anyone in your family sees these danger signs, rush
to the hospital”
Need a picture of Edema
Growth Chart Page:
1. Use colors to indicate grade 1, 2, 3, and 4 (or lines)
2. Question the value of the “record of illness: - would it be used? Could just have the
descriptions without the chart. Descriptions need more pictures, fewer words.
3. Instead of the risk factors listed under the “Special Care Is Needed” section, list key
newborn care practices. Some of these are:
» Weigh your child at birth.
» Keep the child warm.
° Begin breastfeeding within an hour of birth. (Show picture of good
attachment?)
= Do not bathe the child for the first 2 days.
» Protect the child from people who have coughs, colds, or are ill.
» Give no other foods or fluids except breastmilk.
4. For the milestones, the team in Bihar added color bars for each year, and the form
is much clearer. However, it becomes even more evident that there is a need for an
indicator that goes from 2 to 3.
5.
6.
Use only three dots instead of four (red, yellow and green) to indicate milestones.
Need a milestone that goes into the third year.
As children grow they need more food:
" Use bullet points instead of writing it out - too many words.
' In 6-9 month period, indicate need for consistency of purees.
= For micronutrient intake, in two places, indicate that the child needs green and
yellow vegetables. Perhaps here use the image or background of the Indian Flag as
a reminder?
*
The breastfeeding picture is still a bit troublesome.
•
The child from 6-9 months, and 9-12 months, is not shown being fed. Better to use
the picture of the child being fed for the earlier periods of time.
/
Playing and talking with the child helps her grow well
Change “her” to “the child”
A few of the Care for Development messages could be changed. The chart below
shows the relationship between the care recommendations and the indicators on the
other side. There is a pretty good correspondence except for some indicators, primarily
tire motor ones. With the card, one could make up a series of recommendations for
each indicator by turning to the care recommendation for that age group.
Pictures to change:
o Help your child to count - should have a series of pebbles, etc., to count.
» 6-12 months: child with pillow behind looks like he is in a sickbed - can you
have him sitting upright (common for 6-12 months)
» Add one more father in the pictures? Four mothers, the back of one father.
Care recommendations in italics are different from the ones shown on the chart. I
would recommend changing the first one.
Age
From birth
onwards
From 4-6
months
From 6-12
months:
From 12 to
24 months:
Care Recommendation
o Smile at your child, look into her
eyes
« Show your child that you love him or
her.
(card says, hug and cuddle your child)
o Have large colorful things for your child
to see and reach for
=
Talk to your child and get a conversation
going (not on the card)
° Give your child clean safe items to
handle, and things to make sounds
o Respond to your child’s sounds
»
°
From 24 to
«
Give your child things to stack up, to put
into containers and take out. (not on
card)
Play games like “bye”, and encourage
your child to name things (first part not
on card)
Help your child count and compare
Indicator
Smiles in response
Reaches for object
Tracks a pencil with eyes
Gestures bye bye
Turns to voice
Scribbles
Picks up with thumb and
finger
Says “mama, papa”
Utters sounds
Puts 3 pebbles in cup
Indicates wants
Names 1-4 objects
Says 1 other word
Unscrews bottle cap
V
36 months:
things; make simple toys for her.
Encourage your child to talk and answer
your child’s questions. Teach your child
stories, songs, and games
(no care messages related to these)
Points to 2 parts of body
•
Head steady sits without
support
Sits up from lying
Stands alone
Bladder control
Feeds self
Imitates housework
Walks well
NOTE FOR RECORD
FOLDER: 1 SAFE MOTHERHOOD
1.
The nurse should look healthier than the mother should.
2.
In the second picture, (after the title), which depicts the TT immunization, it may be noted that the
usual practice in AP is to take the first shot in the third trimester. Therefore, it was suggested it may be
shifted and placed after the illustration (over leaf) on IFA supplements.
3.
(Overleaf, again). The diet of the mother shown in the illustration needs no change except that the
picture of the live cock should be removed. Consumption of eggs can be encouraged by making them
more prominent, as they make small and out of focus.
4.
In the last picture, where a gap exists, show the picture of delivery kit as in folder II illustration I.
FOLDER: II CARE OF NEWBORN
I.
The second illustration can be done away with, as it may prove fatal and the doctors advice only on
technical training.
2.
Overleaf - the illustration giving prelacteal feeds should also mention and show ‘water’ and include it
in the message as not to be given, to promote exclusive breastfeeding.
3.
4.
To add-breast milk contains substances which help developing the brain and body of the baby.
To add-after delivery, mother needs good food and rest and she should continue breast feeding and
taking rest till the child is 2 years of age.
FOLDER: III COMPLEMENTARY FEEDING
1.
The picture of ‘nuts’ to be removed from Is' and 2nd illustrations.
2.
Put pictures of dal-rice-pulses in messages mentioning the diet of the mother..
3.
Also do not mention that ’ the toddler should be able to consume half of what his father eats’, as the
mothers are unable to estimate the quantity.
FOLDER: IV IMMUNIZATION
1.
The pictures of the child with six different diseases need to improvise to be more realistic.
2.
In the following illustrations, include picture of father along with the child’s mother, at the time of
immunization.
3.
Page 1, last picture, the site of injection should be correct and clear in the illustration.
4.
The hand holding the chin/neck should be made gentler.
5.
The ANM/nurse should in look healthy and cheerful. She looks more sick than the mother.
t
FOLDER: V VITAMIN ‘A’
1.
The sources of Vitamin A can have more pictures of locally available foods. Add guava as a source of
Vitamin A.
2.
3.
The picture of the Bitot’s spots and keratomalacia to be more clear.
-(Overleaf). In the first illustration- a line in the text to be included that ‘vitamin A in the food can be
made available to the baby through breast milk, when a lactating mother consumes these sources in her
meal.
FOLDER: VI IRON SUPPLEMENTATION
1.
The second illustration, showing picture of IFA tin, can be included in the folder on Safe Motherhood
and be placed over leaf, with the second Illustration. The message should also carried to this folder and
it can form part of the message already given.
2.
This folder on IRON SUPPLEMENTATION can then be deleted from the set.
FOLDER
1.
VII (DIARHOEA)
Picture of homemade ORS that can be prepared from salt and sugar in water to be added along with
other ORS that are shown.
2.
The illustration-giving picture of packet of ORS should also have 5 glasses of water and the message
should include that the contents of 1 packet to be dissolved completely in 1 liter or 5 glasses of water.
3.
If possible sketch showing dehydration symptoms such as the skin looses elasticity-the skin is pinched
with fore fingers, on removing, the pinch-mark remain.
FOLDER: VIII A.R.I.
1.
The child should look according to the age mentioned. In most pictures he/she looks older
than the age specified in the message.
FOLDER: IX ADOLESENCE
1.
(Overleaf), change the pitture of the mother placing her hand on the throat of her daughter.
2.
As the last illustration of this folder, add pictures of women who have made marked achievements as
doctors, engineers, pilot, police etc.
SAFETY TIPS
1.
All medicines, poisons, disinfectants, matches, small and sharp objects should be kept out of his reach.
2.
Check toys before you buy - ensure that they are safe and non-toxic.
3.
Your windows, doors and stairs should have gates or bars to keep him safe.
4.
Don’t let hem play with plastic bags, telephone and television cables and other wires.
5.
Avoid exposing to loud noises.
6.
Install electrical sockets at a height or make them child proof.
7.
Keep the child away from fire.
S.
Keep the containers filled with water covered and away from the child’s reach.
Early Childhood Care Practices: Twenty Key Actions
for Families and Communities
to Improve a Child’s Survival, Growth and Development*
16 March, 2001
UNICEF India Country Office
Action
Supported
_by_______
Pregnancy
1.Ensure that the pregnant woman receives timely health care services (ante-natal clinic checkups,
Tetanus Toxoid vaccinations, pregnancy registration by 16,h week, Iron-Folate tablets every day, and
ANM
access to adequate safe delivery facilities); gains at least 10 kilos during pregnancy; is provided with and
eats more food containing adequate micronutrients such as iron and folate, vitamin A, iodine; gets
adequate rest and relaxation; avoids heavy labour and stress; has at least a two year inter-pregnancy
interval; is informed about the advantages of exclusive breastfeeding for her own health and for delaying
ovulation, is provided with support for preparation for breastfeeding, and has access to information and
services for birth spacing
Birth through 3 years
2. Protect the infant from hypothermia immediately after birth; hold infant often and breastfeed
exclusively and on demand (a minimum of 6-10 feeds per 24 hours) from within an hour of birth to about
AWW,
ANM
six months.
3. Ensure that men and boys, as well as women and girls actively participate in early child care; touch,
hold, care for, feed, and bathe; maintain eye contact, interact with, communicate and play with the child
as often as possible
4. Complete the child’s full course of scheduled immunisations (BCG, DPT x 3, OPVx 3, and measles);
participate in preventative and promotive health care services such as growth monitoring and promotion,
ANM,
AWW
and de worming.
5. Promote child’s mental and social development; and respond to the child’s needs for care; stimulate the
child’s development through talking, playing, and engaging in other age-appropriate physical and
affective interactions with the child.
From birth onwards:
•
Smile at your child, look into his or her eyes
•
Show your child that you love him or her.
From 4-6 months
•
Have large colorful objects for your child to see and reach for
•
Talk to your child and start conversations with him or her (sounds or gestures)
From 6-12 months:
•
Give your child clean safe items and objects to make sounds with to play and handle
•
Respond to your child’s sounds
From 12 to 24 months:
•
Give your child objects that he or she can stack up; items to put into containers and take out.
Play games like “bye-bye” and “peek-a-boo”, and encourage your child to name people and
objects
From 24 to 36 months:
•
•
Help your child to count and compare things; make simple toys for him or her to play with.
Encourage your child to talk; answer your child’s questions; teach your child stories, songs, and
games.
6. At about six months of age, feed your child freshly-prepared energy and nutrient rich, locallyavailable, and age-appropriate complementary foods, while continuing to breastfeed up to at least two
years or longer, if possible.
•
7. From six months onward, give your child complementary foods frequently (2-3 times a day until the 8111
month, and at least 4 times a day thereafter); patiently, persistently and with good humour, help your child
to eat, responding to the child’s hunger cues and using meals and feeding as a learning opportunity.
AWW
1
Action
Supported
___ _____
Birth through preschool
8. Provide your child with adequate amounts of micronutrients (vitamin A, iron, iodine, zinc and others)
in his or her diet and through supplementation and through giving your child foods that are fortified;
AWW,
ANM
ensure that vour child and your entire family consumes only iodised salt.
9. If your child has diarrhea, continue to breastfeed him or her on demand; if the child is six months or
older, feed him or her more often, offer more fluids, and if the diarrhea persists, give your child ORS.
10. Recognise the signs that a sick child requires treatment outside the home (e.g., Acute Respiratory
Infections; fever; vomiting; persistent diarrhea); take him or her to a health facility that provides
appropriate services; strictly follow instructions for medical care and treatment upon returning home and
ANM
feed him or her more often following illness.
II. Dispose of feces (including children’s feces) safely; wash your child’s hands and your own with soap
and safe water after defecation; before preparing meals and before feeding your child or eating.
12. Provide a safe environment for your child, including a clean and danger-free home and play area;
prevent child accidents and injuries by removing dangerous objects and substances; provide your child
with safe water for drinking and bathing.
13. Teach your child to wash hands and use a toilet or another safe place for depositing feces and urine
from about 18 months.
14. Check to see if your child has slow development or low activity levels; talk to health service providers
(AWW, ANM, and supervisor) about this; provide a child who seems slow to learn with additional
AWW,
referral
encouragement and time for learning.
Young children, school-aged children and adolescents
15. Prepare household food to maximize nutritional value and store it hygienically.
16. In malaria- and dengue fever endemic areas, provide your child with an insecticide-treated mosquito
nets, and ensure that she or he sleeps under it each night; remove sources of stagnant water including tins,
ANM,
sanitation
worker
puddles and small pools; clean up cesspools in communities.
17. Ensure that your child’s environment is free from physical and verbal abuse and violence; protect your Community,
AWW
child from neglect; take appropriate action when abuse, violence, or neglect has occurred.
18.Support girls and women in the following ways:
Infant girls'. Ensure that girls have equal access with boys to adequate food, including breastfeeding,
Community
pressure
health care, and psychosocial care from birth.
school aged girls: Ensure that your daughter has equal access to school as a boy does; and that she is able
to complete at least primary school
adolescents: Provide your adolescent daughter with iron folate tablets, and ensure that she consumes them
weekly for 52 weeks per year; Enable her to delay her marriage and first birth until at least 18 years;
educate your son and daughter on birth spacing, nutrition, parenting skills, and care for children and
women.
Women: Enable women in your family to engage in activities outside the home; protect them from verbal
and physical abuse and violence; treat them with dignity and respect
19. Adopt and sustain appropriate behavior that prevents the spread of HIV-AIDS; provide care for
HIV/AIDS affected people, including orphans, widows, elderly parents, etc.; educate your children and
other family members on ways to prevent HIV-AIDS, and how to care for HIV-AIDS patients
20. Strengthen your family’s ability to provide care through information and training, and through
supporting policies such as maternity leave; breastfeeding in the workplace, parental and paternal leave,
etc.
* an expansion of the 16 Key Family and Community Practices agreed upon in Durban in 1999 which
incorporates Care Initiative issues.
govt., civil
society
Could be added:
Actions bv Community;
Action
22. Monitor quality of services (health care, education, etc.) provided; raise objections
when services are inadequate: work with authorities to provide better services
Bv Whom
Community
boards
23. Monitor the well-being of pregnant and lactating women and malnourished children
Community
and provide support to families with young children
24. Prevent child abuse/neglect; protect women and children from abuse and neglect; and
committees
take appropriate action when it has occurred.
25. Ensure that men actively participate in early child care, including all dimensions of
the above - i.e. the responsibility for child care lies with men and women, boys and girls.
26. Adopt and sustain appropriate behavior regarding prevention and care for HIV/AIDS
Community
committees
How?
How and who?
affected people including orphans
Actions by Policy makers (could be a much longer list)..
Action
27. Strengthen the family’s ability to provide care through information, training, and
By Whom
govt.
policies such as maternity leave legislation
28. Protect women from exposure to breastmilk substitute advertising
Policy makers
29. Provide special support for mothers with low birth weight babies
ANM
30. Ensure that micronutrient supplements are available
Services
31. Ensure that iodized salt is available and right price
Services
Etc.
*List based on a combination of three sources: 1MC1 Family and Community Practices, practices listed in
the DWCD book of tasks for the AWC, and care practices and resources for care in the Care Initiative, also
for ECC for SGD.
CTETIJ®
The Beginning
CHETNA, which means
'awareness' in several Indian
languages, is an acronym for
Centre for Health Education,
Training and Nutrition Awareness.
It was established in 1980 as a
project to improve rhe impact
of supplementary feeding programmes for women and
children, in Gujarat, India.
Mission : CHETNA's mission is to
contribute towards the
empowerment of
disadvantaged women,
an* pjscents and children so
thK-rney become capable of
gaining control over their own,
their families' and communities'
health.
Presently, CHETNA works for
education, awareness and
empowerment, by supporting
and strengthening the work of
functionaries of Government
and Non-Govemment
Organisations (NGOs),
Individuals and Educators,
working to Improve the health of
women, adolescents and
children.
Geographical Outreach
CHETNA primarily works in the
States of Gujarat and Rajasthan,
In India.
CHETNA's Ideology
o Strengthening existing efforts
prevents duplication.......
CHETNA supports ongoing efforts
of Government and Non
Government Organisations,
health professionals and
community groups to Improve
their work related to health and
development concerns of the
community.
o Information leads to
empowerment.....
CHETNA realises that Information
is an indispensable input in the
process of development and is
critical In terms of policy making
and programming.
CHETNA makes efforts to bridge
the communication gap that
exists between the grassroots
and policy makers, funders and
programme implementors
ensuring that information on
experiences of innovative, viable
and relevant development is
disseminated widely.
• A participatory approach Is
the cornerstone of
empowerment and It Is
particularly essential at the
field level...
Participation enables people to
take greater control over their
lives, over the problems which
confront them and the solutions
which challenge them.
Community based development
requires that people define their
own health needs, and that
solutions come from their own
context. Focusing on health and
nutrition, CHETNA uses
participatory methods to
empower women and children.
• Drawing from the knowledge
of the community...
CHETNA makes efforts to
demystify modern health
knowledge and share factual
information with the community.
Strengthening existing health
systems, it also draws on the
richness of traditional health
knowledge and practices and
encourages people to use the
knowledge they already possess
to address their health concerns.
• Need-based education
respects people’s
differences...
CHETNA plans and develops
need-based education and
training modules and materials
which are responsive to priorities
of the people themselves. Every
training session, each
information package, and every
activity Is tailored to meet
people's felt needs.
• A life cycle approach...
CHETNA addresses the health
concerns of women from Infancy
to old-age Including, early
childhood, school age,
adolescence, adulthood and
old-age through the activities of
its two Resource Centres namely.
Child Resource Centre
(CHEITAN) and Women's Health
and Development Resource
Centre (Chalfanyaa).
CHEITAN
Committed to Children...
• A child centred and gender
sensitive perspective...
CHEITAN works with a childcentred. gender sensitive
perspective, valuing each child
and recognising her/his right to
blossom and grow as an unique
individual not merely as an
investment for future but, for
what s/he is today.
• Giving children a choice In
learning...
Curious and creative, children
quickly grasp health and
nutrition messages and can be
assisted to take control of their
own health, that of their families'
and communities'. Using a
’cafeteria approach’ to health
education, CHEITAN encourages
children to select the
Information most useful to them.
e Learning by doing...
Through games, puppet shows,
songs, drawing, painting, story
telling, children are encouraged
to take part in shaping their own
health and nutrition messages.
To make learning interesting,
CHEITAN develops and uses
activity-based, innovative
approaches.
» Children as partners In
health...
CHEITAN does not consider
children as passive recipients of
health care. Instead, It realises
that children are capable and
have a right to be considered as
partners In health, it recognises
that they are effective change
agents for the health and
development of the community
vision
CHEITAN envisages empowered.
healthy and happy children who
can contribute to the
development of the Nation.
affect women's ability to conlrol
and improve their health status.
Vision
Chaitanyaa envisages an
egalitarian and just society
where empowered women and
adolescents live healthy lives.
Mission
Its mission Is to enhance
women's and adolescents
health status by empowering
them to gain control over their
own health and development
concerns.
Mission
To empower children and
adolescents to become active
partners of their own health, that
of their families' and
communities', by equipping
adults working with them.
Areas of Intervention
Earty childhood care and
development (0-6 years) Health
and education of school age
children (6-14 years) Health &
development of adolescents
(15-18 years).
CHAITANYAA
Committed to Women....
• Health in the social context.....
Women's health problems
reflect the diversify of social,
cultural, economic and physical
environment. Efforts to improve
the health of women must be
linked with an understanding of
the underlying issues and
causes. Chaitanyaa's efforts to
improve women's health are a
part of the broader struggle to
Improve their overall status and
condition.
• Empowerment through
awareness.......
Chaitanyaa works to raise
women's and adolescents'
awareness through providing
opportunities and tools to reflect
on their social, political and
cultural status and encouraging
them to take action to improve
the quality of their lives.
o An Integrative and holistic
approach.....
Chaitanyaa recognises that
women's health encompasses
their social, physical and
psychological well being and
these need to be addressed in
an integrative manner.
Chaitanyaa does not see
women merely in their role as
mothers. As a comprehensive
approach, it considers focus on
all stages of women s lives
important.
• A gender sensltve and
realistic perspective......
Chaitanyaa recognises that
gender discrimination is one o
the important determinants or
women's low health status.
Therefore, understanding and
addressing the implications o
gender relations and enlisting
the participation of men and
the community, is central .
efforts in enhancing women
health and development.
In Its analysis and approach,
Chaitanyaa considers tne
totality of the political,
economic and social
that shape women's
environment particularly,
Area of Intervention
Health and development of
adolescents (12 -19 years).
Nutritional status of women (20
years and above). Violence and
Women's Health concerns,
Maternal Health, Reproductive
Health, Psychological Health,
Occupational Health, Promotion
of beneficial Traditional Health
Practices and Role of Panchyat
in Improving women's
adolescents' and community's
health.
Activities of CHETNA
* Training : Trainings are
conducted by CHETNA as a
strategy for sensitisation,
capacity building,
Information sharing and
networking. Capacity
building is done through
conducting short term & long
term trainings, workshops on
specific concerns of children,
adolescents and women
from time to time,
depending on the felt need.
Documentation of Innovative
efforts, development and
dissemination of IEC
materials :
Innovative methods of
Imparting health education
are tried out by both the
resource centres of CHETNA
at the field level. Such efforts
are documented to enable
sharing of experiences and
replication.
From time to time, education
and training materials ore
designed and developed after
extensive field testing for
creating awareness at the
community level and for
sensitising policy makers.
CHETNA has also developed
innovative and creative health
and nutrition communication
materials such as flash cards,
flip charts, booklets, manuals,
pamphlets, learning kits and
audio-visual material. These
have been found to be
effective to Impart health and
nutrition messages to children.
adolescents and women
particularly, among the illiterate
community.
For further Information please contact:
With the growing organisation
and user needs. CHETNA is now
preparing to supplement its
traditional channels of
communication such as.
personal contacts, reports.
newsletter, meetings and press
releases with computer based
communications.
' Advocacy: CHETNA
advocates on concerns/issues
critical to health and
development of women and
children through-sharing of
views, experiences and
documents at the state,
national and international
forms, eg.
— contributing in policy
documents of Government
of India or in country papers
to be presented at
International forums.
— providing input during
appraisal and evaluation
missions in Health.
Education and
Development Programmes
of Women and Children.
Newsletter: CHETNA publishes a
quarterly newsletter. CHETNA
News, in English. The objectives
of this newsletter are to provide
readers with information useful for
strengthening service delivery, to
share filed level experiences of
the CHETNA team, advocate and
promote innovative programme
interventions related to health
education, training, nutrition
awareness and above all to
serve as a tool for networking. It
covers all major activities of
CHETNA and some other
ogranisations. information on
new resources and sources for
further information.
CTEirm
Centre for Health Education Training and
Nutrition Awareness
Lilavatiben Lalbhai’s Bungalow, Civil Camp Road,
Shahibaug, Ahmedabad-380004, Gujarat, India.
Gram : CHETNESS Ph. : +91 (79) 2868856, 2866695, 2865636
Fax : +91 (79) 2866513, 6420242
E-mail : chetna@icenet.net
Website : www.icenet.net.in/chetna
February - 2000
CHETNA’s Documentation
and Information Centre
A Documentation and
Information Centre has also
been established at CHETNA
specifically, to address the
information needs of individuals.
Government and Non
Government organisations,
working in the field of women's
health and development and
child health and education.
Designed by Rashida
Networking : Networking to
share experiences, exchange
materials and ideas with
individuals and organisations
at the regional, state, national
and international level is
facilitated through.
— A quarterly newsletter
— Trainings
— Exhibitions
— Organising and
participating In Issue-based
events/meetings/work-shops/
semlnars/conferences.
Logical Framework Analysis ,
Si <x_ria t i v e’ S u in m a ry
Project goal
Reduce
all
form of
malnutrition
through
life
cycle
^kft_____ PurposeTo
Throve.
the
quality
Coverage and the use of
wdstion related services al
AW Cs
in
collaboration
jViriv and support
^sjflh sector
Expected Results
Performance
Measurement
Assumptions and Risk
Indicators
Impact
-Reduction in LBW rate
-Reduction in malnutrition in
children between 0-3 years
Indicators
-LBW rale
-% of undcrweighl'childrcn
-Political/social/cconomic
conditions continue to favour
of INP
-Sustained
community
interest
- Magnitude of die problem
and inadequacy of existing
interventions
-Reduction
in
anacmia/malnutrition
among
adolescent girls
-Reduction in anaemia in women
and children
Outcomes
- Improved package of service
based on community needs,
provided to mothers , adolescent
girls and children
from
-% of stunted children
-% of wasted children
-IMR
-% of children with anaemia
-% of adolescent girls with
anaemia
-% of pregnant women with
night blindness
-% of women with goiter
Means of VeriTicalion
-Establish baseline. Follow up
with implementation reports and
community
monitoring,
mid
term survey and final end line
survey
Indicators
-% of mothers bringing children
for growth monitoring every
month
-% of mothers taking and
feeding supplementary nutrition
-% of women who made three or
more antenatal visits
-number of contacts with health
and
nutrition
teams
for
counselling
-intake
of IFA tablets by
pregnant and lactating women
and adolescent girls
-% of cliildren getting Vitamin A
supplementation
-%
of families
iodized salt
.^kempower women so
-p5x they arc able to
(fxznand improved health
nutrition services for
^Kcmsclvcs
and
their
eWldrcn
-Number of SHGs formed and
operational
consuming
-number
of
functional
supplementary food producing
units
-good feeding practices in the
families
-good child caring practices
-good health seeking practices .
-number of specific actions
taken at community level to
improve health and nutrition of
women girls and children
-Districts continue to allocate
high priority lb improvement
of services
-Funding agencies provide
timely funds required
implementation
for
-Local support for change is
received and maintained
-SHGs arc able to sustain in
terms of production and
economic management
Risk Management
-encourage
linkages,
communication
and
collaboration between the
key stakeholders
-encourage districts/ blocks /
villages to have their own
best strategies
-District
core
group
/
nutrition
committee
will
develop
and
manage
activities
-Strengthen community capacity
to participate in and monitor the
progress of the project
-proportion
of
community
receiving technical assistance to
promote participation
Means of verification
Continuous assessment
Monthly monitoring by
SHGs
(Vo jcct Resources
■
•
•
■
■
Technical
Assistance
Training
Equipment
Materials
Management
Outputs
-Improved
capacities of key
functionaries
-Improved planning, monitoring
Indicators
-Extent of knowledge and skill
of functionaries
- Timelines and quality of plans
-WCD, GOK continues to
implement current project
-Full participadon of key
stakeholders
including
and reporting
-Development of Improved need
based training material
-Food production units
-Local specific EEC material
- Provision for food fortification
-Revision of school curriculum
-SHGs able to participate in
-Quality of training materials
and modules
-proportion
of
flour
mills
modified to fortify flour
-Quality of local specific EC
material produced and used
-Effectiveness
of
school
curriculum
for
nutrition
community
- Timely approvals and
clearances from DEA and
DFA
-Use of local expertise
-use of flexible approach to
GMP
sessions,
conduct
counseling sessions, and monitor
the nutrition situation
- Community has the knowledge
about low cost local nutritious
foods and their benefits
- Community is able to grow and
preserve fruits and vegetables
-Regular supply of IFA tablets
and Vitamin A
education
-% of SHGs participating in
GMP, Nutrition counseling and
monitoring
-% of functionaries received
JI '' j; i r
training
-% of women of SHGs received
training
-% of training
sessions
that
allowed participants to learn in
participatory manner and apply
into practice during training
- % of community members who
have Ute knowledge of good
child caring pracUccs
-% of severely malnourished
children treated
-% of Held workers who keep
track of G-l and II children and
provided help
-% of mothers who can interpret
growth chart
% .of families received seeds
and
provided
training
in
production and preservaUon ol
fruits and vegetables
% of children adolescent girls
and
women
who
receiver
supplements
adapt to cltanging needs and
circumstances
f total no offunclionaries-27860, total no of training programmes
for 30 participants/programme-929)
Rs 41,80,500x3
(d) 5 day training of SHGs @ Rs 5000/programme
(216000 members, 30 women from each AWC, 30 women in each
programme, therefore one programme for each AWC, therefore 7200
programmes)
Rs 3,60,00,000x3
3. Cost of 1FA to adolescent girls @ Rs 15/year/girl
for 14,48,700 girls
Rs 2,27,30,500/year
Cost of IF A to pregnant women for extra 90 days/year .
(33465 women)
Rs 7,69,595/year
5 (a) Hiring a consultant for preparation of IEC material.
(b)Translation and adaptation and reproduction of IEC
material,TV and radio spots
Rs37,00,000
6 Fortification of flour
(to be decided)
7(a) Base line and end line surveys
Rs 20,00,000
(b)Monitoring and Evaluation for 7200 AWCs @ Rs 500/centrc
Rs 36,00,000 x5
8 Cost of seeds and saplings to be distributed to community @
Rs 50/family ( Rs 5000/ village)
Rs 2,83,00,000
9 Establishing 4 NRUs , one in each district at PHC level
training to LHVs - Rs 1500
cost of medicine and diet (Rs 5+15) /day for 15 cliildren
Rs 20x15x30x12x4= Rs 4,38,000+ 1,60,000 (40,000x4 years)
10.Cost of setting up and running PMU'at State level
Rs 40,00,000 + 1,00,00,000 (@ Rs 20,00,000/year)
11. Cost of Vitamin A supplementation ' (if not provided under RCH)
Year- wise cost of the project: (# time schedule has been shown for year 1 only and likely to change )
Month#
Activity
Year 1
Oct-Dec
2000
Jan-Feb
2001
Jan-Jun
200!
Feb-Dec
200!
Jan-Jun
200!
Jan-Jun
2001
Feb-Jul
2001
Jan-.Apr
200!
Feb-Doc
200!
Feb-Doc
2001
Feb 200!
onwards
Aug2001
Jul 20001
Jul-Dec
2001
Year 2
Cost
Year 3
Year 4
Year 5
Government
Proposed Source
UNICEF
District level workshops
4,00,000
8 Block level
workshops
929 grass root level
training programmes
7200 training
programmes for SHGs
Basel intend line survey
1.60,000
1,60,000
1,60,000
•
41.80,500
41.80,500
41,80.500
•
3,60.00,000
3,60.00.000
3.60,00,000
•
10,00,000ssssss
s
•
Development and
printing of IEC material,
preparation of radio and
TV spots, includes
hiring of consultant too
Operationalising
Chakkia for fortification
of aaa
Setting up Programme
Management Unit
(PMU) at Slate level
Non recurring cost
Recurring co<
Establishing SHGs food
production units
Nutrition and health
education by SHGs
Initiatingproduction of
supplementary food
Initiating distribution of
1FA tablets to adol.
Giris and to pregnant
women for extra 90
days(*t preset govt
giving IFA to pregnant
women for 90 days
on ly)
Initiating monitoring
including community
based monitoring in
phases
Distribution of seeds
Establishing NR Us at
PHCs
Sub Total
Total
MI
•
10,00,000
*
•
22,00,000
10,00,000
5,00,000
•
To be decided
40,00,000
20.00.000
2,16,00,000
20.00.000
20.00.000
20.00.000
20.00.000
28,80.000
14.40.000
14.40.000
14.40.000
14.40.000
14.40,000
106J4.20.747
106.34.20.747
106.34.20.747
106.34.20.747
106.34.20,747
235.00.000
36,00,000
23 5.00.000
36,00,000
235.00.000
36,00,000
23 5.00.000
36,00,000
23 5,00,000
36,00,000
40.000
109.49,00.747
40.000
1 13,52.41.247
40.000
109,49.00.747
40,000
113.62,41.247
2.83,00,000
4,38,500
119.50.79.247
•
•
•
•
•
•
•
•
a
•
9. Risks
a)
The root causes of malnutrition in India are complex and
deeply
entrenched..
They- include
environmental,
cultural,
educational,
technological and political factors in addition to conditions of poverty, poor
health and illiteracy. The process of altitudinal change may be slow.
b)
Although tlie ICDS program has many accomplishments to its credit, its own
evaluations have pointed out many problems diat need policy and
institutional reform to be overcome. These might have repercussions on die
performance of die project.
c)
Failure to obtain die necessary approvals and clearances on timely basis
from DEA and Ministry of Finance may result in delays in project
implementation.
d)
At die community and district level, die project must continue to receive
strong community and political support'and participation if die SHGs and
NRUs are to function effectively. This to a large extent depend on local
leadership, IEC, political and administrative commitment.
The first three risks will best be managed by ensuring the active support and
involvement of die Government of Karnataka and die Zila Parishads, and by close
and harmonious working relationships between DWCD and MOFHW, with odier
government agencies and NGOs. The best way to make diis happen is die smoodi
functioning of the PSC, an effective IEC component and careful monitoring and
evaluation. The fourth risk will be managed by encouraging comm uni cation and
participation of local panchayat and community. Enabling die district core groups
and nutrition committees to develop and manage dicir own strategics and activities
to meet their local needs will also be helpful. However, die
Annex 1
PROJECT COST
1. Cost of Supplementary Nutrition
Total number of beneficiaries 19,42,321
(includes 0-2 infants, preschool children, adolescent girls, pregnant and lactating
women)
Cost of supplementary nutrition @ Rs 1.50/ ben/day for 365 days
Rs.l06,34,20,747/year(for 5 yrs)
{break up for supplementary nutrition for one kg energy and nutrition dense food
in the form ofpanjiri or bar will be -rice/ragi/jowar- 500 gms
Rs 3.00
pulse
nuts
-150 gms
50 gms
250gms
Rs 4.00
oil
50 gms
fuel
grinding+preniix
Total
1000 gms
Rs 3.00
Rs 1.50
Rs 2.50
Ils 0.50
Rs 0.50
• Rs 15.00
( cost will reduce with
the
bulk
purchase)
sugar
,
(food will be sold to each beneficiary at the rate of Rs 2.00/ kg)
2. Support to SHGs
(a) Setting up supplementary food units @ Rs 15000 per unit
Rs 2,16,00,000
(for total of 7200 AIVCs, one unit for a cluster of 5 AIVCs will 1
therefore 1440 units)
' '' '
I
(b) For nutrition education, demonstration for preservation, d nydration and cool
chambers @ Rs 2000 per unit one time grant and Rs 1000 per year
Rs 28,80,000
Rs 14,40,000/year x 5
( for 5 yrs)
Training
3.
(a) 4 District workshop's @ Rs 1 lakh/ workshop
Rs 4,00,000
(b)8 two days Block level workshops @ Rs 10,000/day/workshop
Rs 1,60,000 x 3 (includes 2 refresher trainings also)
(c) 3 day joint training of grass root level functionaries from
each sector @ Rs 1500/day/programme
The project will be audited annually by an external auditor. The audit reports
will be reviewed by the PSC.
8. Anticipated Results
Expected results at the impact level and indicators of progress towards
these results are in table -1
Expected Results (Impact)
Impact Indicators
* 30% reduction in LBW rate
’Reduction
in
malnutrition
in
children between 0-3 years within 5
years
LBW rate
’Infant mortality rate
*% of underweight children
*% of stunted children
*% of wasted children
*% of children with anaemia
*% of pregnant women with night
blindness
* % of IDD cases
*% of anaemia in pregnant and lactating
women
*% of adolescent girls (11-19 yrs.) with
anaemia
*Reduction in anaemia by 50% within 5
years
Project Purpose and Outcomes
The purpose of this project is to support and strengthen Government’s on going
programmes for improving nutritional status of tlie community by contributing a
substantial input in terms of community support through. SHGs of local women
and voluntary organizations and strengthen linkages with tlie health services.
Expected outcomes
Outcome Indicators
1. Improved package of services provided to
mothers and children at the district level, based
on community needs
1.Increase in appropriate use of nutrition and
health services such as:
- % of mother bringing children for GMP every
month
- % of children getting fully immunized before
one year.
- % of women getting -health and nutrition
counseling
%
of children
taking
Vitamin
A
supplementation
-% of pregnant and lactating women getting 1FA.
2. Women become empowered to demand and 1. No. of SHGs formed and operational.
provide improved nutrition to the children and 2. Good feeding practices (breastfeeding,
complementary feeding use of new foods in
themselves.
children’s diet, increase in the number, of times a
child is fed, active feeding etc.)
3. Good caring practices.
4. Good health seeking practices.
5. % of mothers with children under 2 years who
can interpret growth chart information.
6. % of mothers washing hands after use of toilet
and before handling food.
7. % of . adolescent girls consuming IFA
supplements
8. % of families consuming iodized salt
3. Improvement in knowledge and skills of field - % of field functionaries trained
- % of mothers counselled
level workers and their supervisors’ training
- % of training sessions that allowed participants
to put new knowledge and skills into practice
during training
4. Improvement in knowledge,
behaviour of women of SHGs
skills
and
5. Provide facility for fortification of local cereal
6. Establishing NRUs to manage severely
malnourished cases.
7. Strengthen community capacity to participate
in and monitor the progress of the project.
8. Strengthen the capacity at State, District and
Block level to provide high quality support and
training to functionaries of the project.
- No. of SHGs providing fortified supplementary
food to 1CDS
- No. of nutrition and health education sessions
conducted by SHGs
- No. of home visits conducted by SHGs
- No. or % of families eating fortified atta
No. of severely malnourished children (whose
condition has improved ) .
-Proportion of community receiving technical
assistance to promote participation.
-Proportion of functionaries provided training.
Number of institutions developed and
strengthened.
the child and child’s family would be paid follow up visits by the Lady
Health Visitor to prevent relapse.. She will monitor tlic progress of the child
and give practical advice. She will weigh and examine the child clinically
and refer the child bach to the unit if necessary, using specific referral
criteria. She will be assisted by ANM/AWW during the visit
6.6 Monitoring and Evaluation: Monitoring and evaluation of any
intervention programme is necessary to assess the progress and impact of the
project, to check if tire objectives are realistic and appropriate or if they need
be revised, whether the interventions being implemented as expected and
accepted by target population and having no undesirable side effects.
If the monitoring and evaluation is done together with the community it will
serve two purposes : Firstly, it is a management tool that helps people
improve their efficiency and effectiveness. Secondly, it is also an
educational process that helps participants increase their awareness and
understanding of tlic various factors that affect their lives. In so doing it
increases people’s control over the developmental process.
Proposed strategies: i) Baseline survey to assess the nutrition situation both
quantitative as well as qualitative, ii) mid term and end evaluation to
measure the achievement, iii) regular monitoring of the process and the
achievements. The existing monitoring formats of 1CDS may be reviewed
and modified if required for making them result oriented. A small number of
key indicators may be identified to help monitoring and management at each
level.
iv) A system of collating the information received from tire grass root area at
the district and state level for taking corrective actions
v) Introduction of community based monitoring.
Active community members can be part ofs the monitoring teams.( This
responsibility can also be given to SHGs ) In participatory monitoring
methods and indicators are simple and are designed to provide timely
information required for taking action at community as well as government
level. CDPO /supervisor can organize a monthly monitoring meeting where
problems and their possible solutions can be discussed. This information can
also complement the data collected by ICDS functionaries for MPRs and
will be collated at District level
7.0 Project Management
a)
Responsibility for the project within the Government ol Karnataka will lie
with the Department of Women’s and Child Development (DWCD/SW).
The Secretary' DWCD will be assisted by the PMU to ensure that the project
receives the necessary resources and facilities etc., authorizations, and
cooperation of the Karnataka government agencies.
b)
Overall direction of the project will be provided by a Project Steering
Committee (PSC) headed by tire Secretary, DWCD (GO1) and consisting of
Secretary DWCD (Karnataka Government); Director WCD GOK; the MI
Director/South Asia Region; Chief, CDN UNICEF-India; the Project
Manager; representatives of the four District Councils. The PSC will meet
every six months to consider and approve the strategies and work plans for
the project, review' and accept tire regular reports of tire Project Manager,
approve reports to the Government of Karnataka and the funding agencies,
and resolve issues that can not be settled at the working level.
c)
The project will be managed by an independent Project Management Unit
(PMU) established within /outside ???? DWCD/Kamataka and headed by a
Project Manager reporting directly to the PSC. The Project Manager will be
accountable for tlie implementation of the Management Strategy and
Workplan of tlie project, for the smooth functioning of tlie PMU and die
efficient administration of project resources, and for the preparation and
timely submission of narrative and financial reports to tlie PSC.
d)
Upon approval of tlie project and engagement of tlie Project Manager, tlie
Project Manager will prepare a detailed Management Strategy and a Project
Workplan for consideration and approval of the PSC. The Management
Strategy will set out the specific roles and responsibilities of all project
stakeholders, the management and decision-making systems, and a Work
Breakdown Structure for the various project components. The Workplan will
be reviewed and updated at each meeting of tlie PSC.
e)
The Project Manager will submit to tlie PSC quarterly financial reports,
semi-annual narrative reports, and a comprehensive annual report.
Uiat horticultural interventions can motivate families to produce some
vegetables and consume them too. Large scale production of vegetables and
fruits in Karnataka also makes it imperative to take simple techniques of
food processing, especially drying, to people so that vegetables can be dried
and preserved when are in glut. This will reduce post harvest losses as well
as ensure consumption of vegetables during off-season. Cash return may
also be obtained from the sale of surplus produce, which would make
horticulture a sustainable enterprise. Therefore the objectives of horticultural
intervention in the project are: (i) to develop nurseries in a cluster of villages
(ii) to supply saplings and seeds to SHGs at subsidized rates (in) to
encourage growing of at least one perennial and one seasonal crop in tire
homes, community, AWCs, schools (iv) to ensure consumption of fruits and
vegetables by community using nutrition counselling, and (v) to generate
awareness about home based food processing and use of low cost cool
chambers for preventing spoilage of food
Methodology: (i) SHGs and AWWs will be provided training in raising
fruits and vegetable plants suited to the taste and climate of different project
districts and in preservation of vegetables and fruits with the help of District
agriculture and horticulture extension centers in collaboration with
Horticulture Research Institute, Bangalore (ii) Seeds and saplings of plants
will be distributed to the community free of cost, (iii) Awareness generation
among community about preservation of fruits and vegetables in season and
use of low cost cool chambers. This responsibility can also be given to
SHGs which can work under the supervision of AWWs and Supervisors.
6.5 Health Services
6.5.1 Strengthening Linkages with Health System: Health and nutrition
arc strongly interlinked. Hence it is necessary that intervention for
prevention and management of tlie two sectors be delivered as a combmed
package at tlie community level. To do this, it is essential that functionaries
of health and ICDS work together as a team. They can work together to
empower families and tire communities to choose appropriate practices to
meet their health and nutritional needs at home and use appropriate facilities
when required.
The Border Cluster Strategy-Under GO1.0NICEF MPO has tlie objective of
strengthening RCH services in clusters of 4-5 districts located on tlie inter
state borders of 16 States with the goal to demonstrate a significant impact in
tlie reduction of IMR,MMR, and malnutrition. It is envisaged that clustering
will enhance tlie impact and cost effectiveness of activities that address
common problems in these districts. Gulbarga and Raichur districts of
Karnataka wliich are the project districts also have been identified for
implementation of this strategy. The following mechanism will be adopted
for building and strengthening teams:
-joint training of AWWs, ANMs, TBAs and SHGs
-joint communication drives
-AWW as depot holder for ORS, IFA tablets
-joint household visits for problem cases
-joint updating of records, immunization register or weight
records
- support of ANM in GMP sessions
-joint meetings with MSS or SHGs
-joint review meetings at block district and state level
Some more innovative activities can be identified at district level.
6.5.2 Setting up Nutrition Rehabilitation Units: In Karnataka 2.6% of
children suffer from severe malnutrition^ -3 sd weight for height criterion)
The presence of oedema or wasting indicates severe malnutrition. The
cliildren may or may not have conditions like dehydration, severe anaemia,
life threatening infections, hypoglycemia, hypothermia, severe vitamin A
deficiency, apathy and anorexia. Malnourished infants under 12 months of
age have a greater risk of dying than older malnourished children.
Residential care is essential for initial treatment and for the beginning of
rehabilitation of a child with severe malnutrition. The child should be
admitted to the hospital (CHC) with facilities for special nutrition care.
When child starts eating satisfactorily and gaining weight he or she can
usually be managed at non-rcsidcntial rehabilitation centre which can be set
up at a PIIC. Close cooperation between hospital and centre is necessary to
ensure continuity of the care. It may be relevant to point out here that it is
better to prevent severe malnutrition than., drain precious resources on
management.
Services to tackle severe malnutrition will be initiated at CHC/PHC level as
a pilot project in one block of each district. After a minimum stay in the
health centre, the mother will be taught about appropriate feeding, how to
adapt family foods , give frequent .feeds, continue breastfeeding to provide
enough energy and nutrition for rapid catch up growth. After the discharge,
form of either laddoos or bars. Food will be enriched with vitamin and
mineral premix. 100 grams of this food will provide 400 calories. For
infants die mixture can be reconstituted in warm water before feeding and
would not require any cooking. Acceptability trials of food will be done on
the local community before taking a final decision on die type of food. One
kilogram of food can be purchased from SHGs for Rs 15, which includes the
transportation cost also.
Since it will be logistically appropriate to provide the entire monddy quota
once a month as take home ration, die food mix may be packed in one kg
packets. Severely malnourished children will be fed at die site. Non
compliance can be checked to some extent by strengthening 1EC to mothers
and families
Production of food by locally placed SHGs will be cost effective due to
reduction in transportation cost of locally available raw food and distribution
of processed food. The food production units managed by SHGs will be
established in the accommodation provided by village panchayat. Except for
grinding of food, all otiier processing of food will be done by women of
SHGs. Grinding will be done at village flour mill which will have the
provision of mixing the vitamin and mineral premix also ( wherever possible
chakkis will be modified for mixing vitamin and mineral premixes to four.
Otherwise women will be trained to mix the premix manually). Extra food
produced in the food-producing units can be sold out in the market at an
agreed rate. This will be helpful in improving the economic situation of the
SHGs.
(The value of anything given free is not adequately appreciated. Therefore it
will be considered whether a nominal cost, say 2.00 p per kg for
supplementary food may be recovered. Having paid for the food, it will
directly ensure consumption by the beneficiaries. 77?e funds so collected can
be utilized as additional working capital for the SHGs. However, this
decision may be taken al the forthcoming meeting of Secretary WCD, GOK,
UNICEF and Ml.)
Fortification of Local Cereals: The rationale of fortification of flour
( cereals and millet flour ) is that it is widely consumed in fairly large
amount everyday. It can be fortified with lower levels of micronutrients
6.2.2
-r^'
''^^i'^‘xT^V-f^v » X*'
'*-i ; ‘ -
; >,: ■’ •''
’
(;25%t'df;;RDA-‘),;'\yhich-,helps]hi., preventing any discolouration or quality
problem. 'As ‘80% 'of/villages''in'project Districts have electricity operated
flour mills and most of the villagers get grinding of the cereal done from
those mills; this will be- a cheap and effective method for preventing
micronutrient malnutrition. It will also not require any change in food habits
of the people. The premix' ( containing iron, folic acid and vit A ) will be
mixed with,the flour at the end of milling process by a specially designed
mixer. Fortification of flour in the initial phase will be supervised by an
official designated by the Zila Parishad C.E.O, and later this responsibility
can be overtaken by SHGs.The consumer will be made aware of the
fortification and acceptability trials will be carried out.
6.3 Supplementation
6.3.1 Distribution of IFA supplements to under threes, adolescent girls,
pregnant and lactating women: IFA tablets are distributed to infants and
pregnant and lactating women under the govt programmes. Li order to
improve the health status of girls even before they are pregnant, tins project
envisages to include adolescent girls also in the beneficiaries of this service.
This also plans to improve efficiency and effectiveness of existing delivery
mechanism and counseling of women for better compliance. Pregnant
women will get IFA tablets for 180 days instead of 100 days.
6.3.2 Strengthening and support of the coverage of the current Vitamin
A supplementation programme for children upto the age of 6 years: The
present coverage which is about 80% at the first dose is not sustained later
particularly because the later doses are not linked to immunization. It is
therefore planned to strengthen IEC and educate SHGs to extend die
coverage and sustain die later doses.
6.4 Dietary Diversification
Intervention on Micronutrient-rich Horticulture Produces: A long term
and sustainable solution to combat micronutrient deficiencies is regular
intake of foods rich in diese nutrients. Efforts aimed at dietary
diversification can be sustainable only when die food sources of iron and
vitamin A are locally available. Food and agriculture policies thus need to
accord higher priority to improving production, preservation and distribution
of vegetables and fruits. It has been observed in different parts of die country
A consultant will be hired for preparation of IEC material specific for
Karnataka.
6.1.3 Training: Key to tire implementation of strategies of the project is
AWW and support to them is augmented through SHGs plus ICDS
supervisors CDPOs and District level officials will be a major component of
the project’s early stages. It is expected that ICDS functionaries, even
though have knowledge, will need to be introduced to community based
participatory activities. They also need to develop counseling skills.
Therefore, along with orientation to project interventions focused on the life
cycle approach they will also be provided training to develop counseling
skills. Other influential change agents who are in contact with women and
their families are ANMs, TBAs, primary school teachers, NGOs, PRI
members and rural development workers. Empowered with tire correct
information and communication skills, these change agents can play an
important role in changing tire nutrition situation. Teachers have the oilier
special role of influencing the young minds. Therefore combined training of
all key personnel will ensure transmission of the same information to the
target group, reinforcement of advice being given and minimal
contradiction.
The following training programmes will be organized for tire different
categories:
(i) Two days training of trainers for CDPOs, AWTCs, MLTCs,
DPOs, MOs, ICDS and health supervisors,NGOs
(ii) Joint training for 3 half days for AWWs, ANMs, MPWs,
school teachers, TBAs rural development workers, and NGOS
(iii) 5 days training of women of self help groups
Characteristics of training: All training should be participatory, on-going,
process oriented; skill oriented and practical; community-based and multi
targeted.
Four CFNEUs of FNB placed in Karnataka and Hyderabad will provide
training at block level. Training to grassroot level workers and SHGs will be
provided by 23 AWTCs of Karnataka and NGOs in die State and nearby
places.
6.2 Food Fortification
6.2.1 Distribution of Fortified Supplementary Food to Vulnerable
Groups-During Ihe last three decades a number of research studies and
evaluations of supplementary feeding programmes have been undertaken in
many countries. It has been shown that supplementary nutrition has
immediate as well as long-term effect on growth and development. Nutrition
care to pregnant women was found to be the most cost-effective means of
preventing perinatal deaths. Supplementary food is being distributed under
tire ICDS scheme for tlie last 25 years. However, tire quantum of
improvement in tlie nutritional status of women children is below tlie
intended level. Attrition could be due to irregular and poor supply of food,
poor participation of the beneficiaries, monotony of supplementary food
provided, or sharing and substitution of food in the family. It has been
planned to overcome some of tlie problems in tlie project so that tlie
beneficiaries get tlie advantage of supplementation.
gk
Supplementary food will be distributed to all tlie beneficiaries of ICDS
e.,children between tlie age group of 6m-2years, pre-school children,
i.
pregnant and lactating women for 365 days of tlie year. As tlie project is
adopting the life-cycle approach to address malnutrition, adolescent girls
will also be included in tlie beneficiaries of the programme. Pregnant women
will be entitled to tlie supplements from their first prenatal consultation and
12 months after delivery. More attention will be paid to children below 2
years as this age group is in chronic state of starvation for both macro and
micronutrients.
Type of food : The supplementary food to be distributed in the project
district will be carefully planned keeping in view tlie required nutrition
density, taste preference, low cost, cultural acceptability. Ready to use
precooked fortified mix based on locally available raw material would^p
used. This hygienically prepared RTE will be a combination of cereal, pimse
in tlie ratio of 3:1 with tlie addition of nuts, sugar or jaggery and oil.
However, the choice of raw material can be left to tlie Districts. A single
food mix will be prepared for all categories of beneficiaries initially.
However, it can processed later on according to local preferences for
different age groups. Different recipes will be suggested for adding variety
to the food for infants and small children. In order to improve tlie
acceptability by mothers and adolescent girls food can be supplied in tlie
strategies for working of SHGs can be worked out at Distt level as tire
strategy cannot be the same for the entire district and would depend on a
number of factors including geographical location of villages.
Each group can be provided a seed capital of Rs.15,000 for establishing the
units. Recurring expenditure needed is expected to be raised from sale
proceeds of products processed.
«,
Women of SHGs will be provided training in purchase of quality raw
ingredients, economy of wholesale purchase, safe storage, food processing
and fortification, hygiene and sanitation control and packaging. They will
also be oriented towards nutrition and health needs of vulnerable groups and
good cliild care practices. Hands on skill training for raising of annual and
perennial vegetable and fruit plants will also be provided. They will also be
provided skill based training in preservation and drying of fruits and
vegetables.
6.1.2 Information Education and Communication (IEC)
Many good practices are operationally simple and do not require heavy
expenditure or extra labour, but require change in behaviour of people. For
example, initiation of breastfeeding immediately after birth, feeding of
colostrum, timely introduction of complementary feeding for infants, minor
changes in food preparation methods and addition of some locally available
greens in the daily diets and care of girl cliild can bring about observable
changes in nutritional status of people.
Desirable behavioral changes related to nutrition and cliild caring practices
at household level and in the community can be initiated and sustained only
through effective communication support and demonstration of some
positive results of good practices adopted by tlie conununity. This broadly
aims to stimulate demand for the services, improve feeding and child caring
practices, encourage pregnant women for early registration and for availing
MCH services, prepare adolescent girls for safe motherhood and promote
community participation.
At present most of tlie programmes emphasize on awareness generation or
providing information only. Most of tlie field level workers are lacking
counseling skills and have weak communication skills; they also lack IEC
4
tools (e.g. counselling cards) to help them conduct EEC sessions more
effectively. IEC strategies in the project can be creative and can help in
taking advantage of all opportunities that present themselves to integrate key
messages into, ongoing events, '.including everyday unprogrammed
(opportunistic) encounters in tlie villages. These can be weekly markets,
health melas, specific health education days, religious functions, mahila
mandal meetings, home visits, baby shows, literacy programmes etc.
All the field level workers, formal and informal service providers can be
closely involved for enlightening the community and bringing out
behavioural change. Joint training programmes will be organized for
AWWs, ANMs, school teachers, rural development workers, SHGs,
members of VECs and TBAs. Additionally AWWs and ANMs will be
provided training in development of counseling skills so that they will help
tlie mothers to adopt nutrition friendly behaviour. They will also receive
training in PLA techniques which can help in moulding people’s behaviour
in participatory maimer.
a
Another strategy for establishing good nutritional .practices is to promote
sound nutritional practices in tlie young children. Nutrition topics will be
included in school syllabus after reviewing tlie existing one. Young children
can also become very responsible message carriers to the families and
community.
Interpersonal as well as mass media channels will be used for IEC. It is alsc
proposed that the roles of Supervisors from 1CDS and health sectors bi
further strengthened in interpersonal communication to support the efforts o
AWWs, ANMs, TBAs. For all communication themes to be addresset
interpersonal aids will be developed or selected from the already existing
ones and translated in kannada. These will include a set of counseling cards
meant to be used for one to one communication, a set of demo teachii^aids
Short messages for radio broadcasting will be developed to communicat
key behavioral issues to people. Cassettes of these massages can b
distributed at the block level also. Metal stencils with pictorial nutrition
messages will be prepared at District level and distributed to all CDPOs fc
painting messages on tlie walls of villages.
Based on community needs assessment and decentralized planning process,
it will lead to simultaneous improvement through these groups.
The project will be implemented tlirough the development of community
level teams of SHGs, AWW, ANM and school teacher for improved
outreach to ensure that beneficiaries of all the groups are receiving
counseling about appropriate nutrition, health and care.
SHGs formed in the Stree Shakti project will be established to produce
appropriate supplementary food, generate awareness and disseminate
messages to the community for developing healthy habits and monitoring.
The women panchayat members at village as well as taluk level will be used
as resource persons for advocacy and community mobilization.
The AWW, supervisors and ACDPOs will extend their help and cooperation
to the groups and liaise with them. At taluk level the programme will be
coordinated and monitored by CDPOs.
A District Nutrition Committee headed by C.E.O./ District Collector and
consisting of district level officers of the concerned departments, would
implement and monitor the progress of implementation every month.
A Programme Management Unit (PMU) at State level headed by Secretary
WCD and assisted by a Consultancy firm will have the responsibility of
management of the project.
It is very important to mention here that the project will require
strengthening, initiation and coordination activities including DWCD, Health
and Family Welfare, PRJ, Rural Development, Food and Civil Supplies,
Education, Horticulture, Agriculture and Forestry.. This can be handled best
at District Level. This project can also very well complement the Border
District Cluster Strategy in Gulbarga and Raichur districts in terms of
nutrition and childcare at family level.
•
6.0 Project Interventions
6.1 Information, Education and Communication
6.1.1 Support Women’s Self Help Groups (SHGs)
Experiences have shown that when a community is fully involved in design,
implementation and monitoring of nutrition and other development projects,
using a triple-A process (asscssment-analysis-action), these arc likely to be
more effective and sustainable. Such participatory efforts more often meet
the real needs of die people and achieve results diat can be continued witli
minimum external inputs. The prcsent<, project also envisages organizing
SHGs of women from the community and improving tlieir knowledge and
practices regarding health, nutrition and infant care and reduce die load of
AWWs. These women will play a critical role in carrying out die main
nutrition activities including:
(a) Setting up self-sustainable nutritious food production units ai^k
production of fortified supplementary food. Food produced in these units
will be distributed amongst beneficiaries of 1CDS scheme.
(b) Educating community about raising vegetables and fruits even in
landless households and the mcdiods of home based preservation and
drying of vegetables and fruits.
(c) Nutrition and healdi education. Acquired knowledge and skills related to
nutrition and infant care will empower them to- solve the local problems
and provide support to women and families. They will be able to identify
and optimize existing resources and solutions within the community to
solve community problems.
(d) Supervision of regular GMP sessions.These groups will also regularly
monitor the nutrition situation of the community.This will include home
visits for monitoring G-I and II malnourished children and counselling
care givers to prevent G-III and IV malnutrition.
Karnataka government has declared a programme called stree shakti w
rural women with a view to give special impetus to the empowerment of
rural women through SHGs. Under the programme each AWW will form
tliree SHGs in the limits of her centre. Each AWW will be given an
incentive of Rs 50/- p.m. for each group formation and supervisors an FTA
of Rs 200/- pm under the project. For production of supplementary food and
nursery development women can be selected from these SHGs. The
4.0 Summary Project Description
Concerned about tlie grim malnutrition situation in Karnataka amongst all the
southern states and to ameliorate the nutritional level of population, the Govt of
Karnataka has planned to initiate an IntegratedJNutrition Project (INP) in four
districts namely, Raichur, Gulbarga, Tumkur and Chikmagalur. The project will
address the problems of malnutrition including micronutrient malnutrition by
adopting intergenerational life cycle approach to reduce morbidity and mortality
due to malnutrition amongst the most vulnerable groups of the population namely:
children 0-2 years, adolescent girls and pregnant and lactating women.
An analysis of the causes of malnutrition reveals that the problem is the result of
multiple factors and no single sectoral programme input can address it effectively.
The programme, therefore envisages bringing in better intersectoral coordination
of various ongoing activities at all levels.
The total cost of tlie project will be Rs. 565 crores ( approx ) over five years. The
project will consist of seven components, organized as follows:
a) Information, Education and Coininunication(IEC)
•
support to women’s SHGs who will be educated and trained on (a)
promotion of child care at family level; (b) preparation of supplementary
food for infants, pre school cliildren, adolescent girls, pregnant and nursing
mothers; nutrition and health education; (c) growing fruits and vegetable
plants;(d) preservation and drying of .fruits and vegetables in peak season;
and (e) monitoring of nutrition situation in tlie village.
•
1EC and nutrition counseling, including nutrition-related topics in school
curricula
•
joint training of local Government and non-governmental functionaries
b) Food Fortification
•
distribution of fortified supplementary food to vulnerable groups
•
fortification of local cereals
c) Supplementation
•
distribution of Iron Folic Acid supplements to under-threes, adolescent girls,
pregnant and lactating mothers
•
Vitamin A supplementation to children from 9 months to tlie age of 6 years
d) Dietary Diversification
•
intervention on micronutrient-rich horticulture produces
e) Health Services
•
strengthening linkages with the health sector
•
establishing Nutrition Rehabilitation Units in each district for management
of severely malnourished cases
f) Project Management
•
establishment of a Project Management Unit and its efficient operation
•
establishment of a Project Steering Committee and support for its activities
g) Monitoring and Evaluation
•
on-going performance monitoring and feedback, and periodic external
evaluation
•
community-based monitoring and feedback, using the triple-A approach
5.0 Project Strategy
The strategies of the project will be on the lines of National Nutrition Mission,
that is,
a) Vigorous awareness campaign on malnutrition to reach all sections of the
society
b) Direct interventions for preventing onset of malnutrition among 0-2
years, adolescent girls, and reduce LBW and micronutrient malnutrition
c) Nutrition Mapping and Surveillance for monitoring tire nutrition situation
regularly.
The project has been designed based on assumption that it will support and^
strengthen government’s ongoing programmes for improving nutritional
status of the community. Local women of the Self Help Groups will be tire
key players in the project. Technical support will be provided to SHGs to
build up their own capacity to perform the required tasks. The project also
envisages to strengthen abilities of ICDS and health functionaries working at
field level as well as their trainers to actively support and assist SHGs.
An individual’s nutrition is determined by a number of factors acting
directly or indirectly. The causes of malnutrition are complex and include
®
•
0
®
°
Inadequate cliild caring practices, often governed by cultural and religious
beliefs and status of women in the families
Poverty and household food insecurity
Inadequate access to health care services and poor sanitation
Constraints to the physical and social development of tire girl during
childhood and adolescence
Heavy workloads, social and economic barriers compounded by gender
discrimination in the community and within tire family that influence
access to healthcare, intra-household food distribution and access to
information.
Malnutrition is transmitted across generations. LBW infants bom to severely
malnourished women, remain malnourished in the childhood and adolescence.
These effects are especially devastating in tire case of girls who are neglected
during infancy and childhood. Chronically malnourished girls are therefore, even
more likely to remain malnourished during adolescence and adulthood, and when
pregnant, to deliver low birth weight babies. Early marriage and teenage pregnancy
further deteriorate her nutritional and heal th status.
Household food insecurity also perpetuates across generations. Diminished work
capacity and work output result in low family income and household food
insecurity, thus perpetuating the cycle of household food insecurity and
malnutrition. Therefore, protection and promotion of health and nutrition of
women can be achieved through a combination of strategics involving concerted
actions by various sectors at different levels.
A depressing cliild nutrition and health scenario is common feature for most of the
states in the country. In Karnataka, it is estimated that 54 % of children below 4
years of age are underweight and 48 % are stunted or short for their age. Wasting,
which is the most serious nutritional problem, affects 19% of lire children in
Karnataka. According to NEHS I (92-93) about 22 % of the children in the state
were low birth, weighing less than 2500 grams at the time of birth. This clearly
indicates die poor nutritional status of modiers. Over 40 % of women suffer from
anaemia due to iron deficiency and close to 30 % women are suffering from severe
and moderate grades of CED. The degree of iron deficiency anaemia is highest in
12-23 months old children (78 %) in Karnataka (NFHS II)
Some of the contributing practices to this dismal-sitnation in Karnataka are:
• Intake of dietary energy, proteins, calcium, iron, vitamin A by children are
well below the Recommended Dietary Allowances (RDA).
• Cereals constitute tlie bulk of diets of women and children. Type of cereal or
millet varies with the region.
• Diets of women and adolescent girls are also deficient in most of nutrients especially iron and vitamin A. Tills is mainly due to tire reason that average
intake of GLV by women (15 grams) is far below tlie RDA, which is 100
grams.
• Only 27 % of rural women in Karnataka initiate breastfeeding on tire first
day. About 60 % of mothers discard colostrum and 85 % women give
prelactael feeds to infants. Tills practice which deprives tlie newborns from
getting benefits of colostrum, exposing them to dangers of infection.
• 22% of urban women introduce complementary food before 2 months of age
and 84% introduce it above 6 months of age.
Integrated Child Development services (ICDS) Scheme is implemented in all of
tlie Slates of India including Karnataka to improve nutrition, health and
psychosocial status of young cliildren and women. Services provided to local
population under ICDS are: distribution of supplementary nutrition to vulnerable
groups, immunization, health check upS, pre-school education and referral services.
The focal point of delivery of services is the Anganwadi Centre (AWC) - childcare
center in the village or urban slum. The centers are run by local community based
women childcare workers - tlie Anganwadi workers.
Child health is also addressed by Reproductive and Child Health Programme
which aim to reduce IMR, CMR & MMR. This programme is an extension of
earlier Maternal and Child Health (MCH) and Child Survival and Safe Motherhood
(CSSM) Programme. However, tlie improvement is not of tlie intended level,
which is quite apparent from the data discussed earlier.
Integrated Nutrition Project — Karnataka
1.0 Purpose
The purpose of this project is to support and strengthen tire Government of
Karnataka’s on-going programs for improving the nutritional status of the
community by reducing all forms of micronutrient malnutrition among vulnerable
population.
2.0 Objectives
The objectives of the project are:
To improve the quality, coverage and use of nutrition related services
namely, provision of supplementary nutrition and nutrition education
at AWCs in collaboration with and support from tire health sub-centre
• To create awareness education to the community for development of
proper nutrition habits with the use of low cost locally available
resources.
® To empower women through participation in Self-Help Groups. This
is intended to increase ownership of the project, and improve
knowledge and practices regarding health, nutrition and infant care.
• To establish Nutrition Rehabilitation Units for management of severe
malnutrition
3.0 Background
o
Malnutrition and morbidity are twin problcips affecting a major part of the
country’s population - especially women and children. They are undoubtedly tire
most crucial segment of the population, due not only to their sheer numbers, but
also their special physiological demands. Malnutrition is often associated with
morbidity and mortality thus adversely affecting life expectancy. Additionally, it
causes growth retardation and leads to functional impairment, disability,
diminished productivity and reduced resistance to diseases.
An individual’s nutrition is determined by a number of factors acting
directly or indirectly. The causes of malnutrition are complex and include
•
•
•
•
•
Inadequate cliild caring practices, often governed by cultural and religious
beliefs and status of women in the families
Poverty and household food insecurity
Inadequate access to health care services and poor sanitation
Constraints to the physical and social development of the girl during
childhood and adolescence
Heavy workloads, social and economic barriers compounded by gender
discrimination in tire community and within tire family that influence'
access to healthcare, intra-household food distribution and access to
information.
Malnutrition is transmitted across generations. LBW infants bom to severely
malnourished women, remain malnourished in tire childhood and adolescence.
These effects are especially devastating in the case of girls who are neglected
during infancy and childhood. Chronically malnourished girls are therefore, even
more likely to remain malnourished during adolescence and adulthood, and when
pregnant, to deliver low birth weight babies. Early marriage and teenage pregnancy
further deteriorate her nutritional and heal th status.
Household food insecurity also perpetuates across generations. Diminished work
capacity and work output result in low family income and household food
insecurity, thus perpetuating the cycle of household food insecurity and
malnutrition. Therefore, protection and promotion of health and nutrition of
women can be achieved through a combination of strategies involving concerted
actions by various sectors at different levels.
\
A depressing child nutrition and health scenario is common feature for most of tlie
states in tire country. In Karnataka, it is estimated that 54 % of children below 4
years of age are underweight and 48 % are stunted or short for their age. Wasting,
which is tire most serious nutritional problem, affects 19% of tire children in
Karnataka. According to NFHS I (92-93) about 22 % of the children in the state
were low birth, weighing less than 2500 grams at tire time of birth. This clearly
indicates tlie poor nutritional status of mothers. Over 40 % of women suffer from
^’ATEMENT SHOWING THE PERFORMANCE REPORT IN % OF SCHOOL HEALTH
PROGRAMME FROM JULY 2000 TO JANUARY 2001 & REVIEWED IN FEBRUARY 2001.
SI.
No.
Name of the
District
Med.
Exam, of
Students
Bangalore(LT)
Bangalore( R)
Kolar
Shimoga
Cliitradurga
Davanagere
Tumkur
GULBURGA DIVISION
95.83
82.13
97.74
93.60
95.10
94.00
78.21
89.82
90.05
75.26
93.74
86.77
93.80
429.64
128.40
88.53
110.96
98.98
61.48
86.60
98.60
125.55
89.00
132.46
98.94
116.82
40.72
78.93
84.44
89.55
82.13
91.92
81.26
99.02
64.83
71.12
44.91
85.31
80.85
85.72
85.58
104.74
64.54
78.64
120.58
83.33
68.47
84.90
73.62
41.20
66.08
86.43
73.65
61.10
61.45
66.25
76.20
65.15
77.92
62.55
73.80
71.95
95.50
76.88
63.75
97.56
94.40
63.52
85.85
80.30
101.18
73.68
80.55
80.23
93.21
384.28
91.30
82.38
101.80
81.20
65.00
74.59
80.13
91.62
60.09
82.71
76.42
98.22
84.62
93.70
63.28
74.70
86.32
grand total
95.23
74.76
84.72
01
1 02
03
04
05
06
r 07
12
13
14
15
Mysore
Cham araj n agar
Mangalorc(DK)
Udupi
Mandya
Kodagu
Hassan
Chikkamagalur
MYSORE DIVISION
16 Belgaum
17 Karawar(UK)
18 Dharwar
19 Gadag
20 Haven
!_21_ Bijapur
22 Bagalakotc
BELGAUM DIVISION
23
^4
25
26
27
T. T.
2nd dose
1st dose
Teacher'
Training
Remarks
"Marks /
Grade"
Marks
JIANGALORE DIVISION
08
09
£o
ru
D&T
Gulburga
Bidar
Bellary
Raichur
Koppal
100.78
59.91
106.26
150.50
147.00
30.23
91.33
87.80
67.00
107.15
68.55
69.26
88.06
223.69
136.47
112.42
91.95
102.97
99.54
126.87
93.14
263.55
113.62
206.66
128.80
240.98
200.67
134.84
145.31
159.78
185.10
11.13
46.97 1
10.72
60.07
03.35
01.56
85.02
31.41
00.93
62.83
84.35
43.98
00.00
97.28
28.40
64.27
38.01
15.05
33.84
35.65
14.42
67.70
03.95
38.00
26.52
05.71
00.00
216.58
64.59
24.27
37.34
84
80
80
92
80
70
96
88
80
88
96
84
76
100
88
92
88
80
82
80
84
92
76
84
80
80
78
92
88
80
84
Grade
A
B
1
B
A
B___
B
1
A
A
B
A
1
A___ |
A
1
B___ |
j
1
1
A
A
A
A
B
A
B
A
A
B
A
B
B
B
A
A
B
A
1
j
|
|
i
1
:
112.37
32.57
84
A
1
J_________
J_______
J_______ 1
> Note : 'A' - Good , 'B' - Poor , 'C - Very poor, 'D' - Extremely poor, 'E' - Bad performance,
> Note : 'A' - Marks- 81-100 , ’IP - Marks- 61-80 , 'C - Marks- 41-60, 'D' - Marks- 21-_40<
'E' - Marks- 10-20 & less
(DrS.B.Kurtakoti)
Addl.Director(HET)
tJKSOToqS — 1
CTc) c5§C5
j »nO•
’. i
1
i
<3«„ns?rt So?35 aoaSuad ‘82$ a»uonv aoaJfl
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05. as_fa jriF
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07. ^JOJSJDOJ
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09. aaaucra varies
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auontfuauo fa.5.)
11 . cot ja>
12- c3\JOC3 £
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1314. <5jD cxjF5
15- ajfaauritf jjoj
16. tJtfrrao
17- 530330 ((Alfa.)
18. jjraooas
1 9- non
20- coci se.o
21 • 2.125c) cjOO
22- 213 00303 5.0
23. FkJOon3F
24-- 05.30
25. 2J Vd f^O
26- OcsoJoS oaou
27- xJvJD
i
i
—,
—
750
1040
590
505
480
1025
615
335
525
165
590
240
755.
450
—
735
:
—
615
370
300
450
450
1 !
——
——
—'
—
—
—
—
—
—
——
—
—
—
—
—
—
—•
480
700 • •
450,
—.
—
— .
1 • ■• <
450
425
—,
OHJj:
;
, i
I'
j i
i i
! I
1
I ;
i
1 4000
OTF5.ES 50
OjSj, gjbjoej sua^ra
rJe_flr(tfo^ jJonvoaoj.
GOVERNMENT OF KARNATAKA
Directorate of Health & F.W.Services,
Bangalore-9,
Dated: 02-03-2001.
No:HET/SHP/30 /2000-2001
TO:
The District Health & F.W. Officer,
District R.C.H. Officers/D.N.O. may please be instructed to contact the Deputy Director of
Public Instruction of their District to collect the following information as per the format given
below.
1. No.of Schools in Urban & Rural areas
2. No.of Students in Urban & Rural areas
These collected information should be sent to this Directorate by 3rd week of March 2001.
Statement showing the Schools and School Children in Urban & Rural areas of the
District
for Hie year 2000-2001.
SI.
No.
Name of
the
Taluk
No. of Schools
from 1st Std. to
7th Std.
Urb
Ru
To
an
tai
nd
No. of School Children from 1st Std. to 7th Std.
1
2
3
Urban
4
5
6
7
1
2
3
Rural
4
5
Re
marks
Total
6
7
District
Total:
Note:- l)Urban area means District Headquarter & Taluk Headquarter
2)Rural area means other than above.
3)Students from 1st Std. to 7th Std.
4)Schools : 1st Std. to 7th Std.
Additional DirectorfHET)
Directorate of Health & F.W.Services,
Bangalore-9.
1. Copy with best compliment to the Deputy Director Public Instruction,
......................................... District.
2. Office copy.
ANNEXURE- III
Government of Karnataka
Directorate of health and F. W. Services. Bangalore-9
The month! y progress report uniter the _____
School
health Prog
__________
<7 rani me d u ring the month of
: si.No.
N:imo of the Disrict
! Taluk i PHC /SC
i
Total of No. of
primary • higher
primary schools
No. of students* health
records opened for I*1
Std. Students
5
Cumulative
During
the
month
No. of students enrolled during the
period of 2000-2001
4
2
7“ Std.
4“ Std.
r* Std.
Total
Monthly target fixed for
visits to school by
Medical officer
6
Achieved
During the
month
Mont lily target fixed for
examination of students
7
During the
month
Achieved
____________ i
1
|
No . of students medically examined
8
f:0.1.
4'* Std.
7“ SOL
Total ;
Dental
No. of students found medically defectives
9
Ear
Eye
Skin Nutritional
Other
deficiency
1
1 No. of 1 " Std, students immunized
1 with the booster doze of D &T
i ...
During the
month
No. of
11
Cumulative total
______
'
Health education activities
1
r
1
No. of health
education talks
given in the senool
No. of health education
materials distributed to
the schools
1
10“ Std. Students
(2nd booster doze )
During
the month
: No. of PTA meetings
conducted by the
health personnel
“I
J
No. of teachers trained
5c 10“ Std. Students immunized with booster
doze of TT
12
-'n Std. Students
(T* booster coze )
During
. Cumulative
the month * total
Total
No of students treated / re ferred for the medical defectives
10
Referred
Others
Skin
Nutritional
Dental
Eye
Ear
deficiency
13
During the
month
No of schools
supplied with
medicine kits
14
No. of schools
provided with
mid-day meals
15
No. of schools
i
having sale drinking |
waler facilities
16
1
Cumulative
total
Cumulative
total
Environmental sanitation in the school & school Premises
18
No. of mini exhibition i
films shows arranged in
the schools
Urinals N latrines in the schools and their
maintenance Pieuse mentioned in number.
Having
Maintained
cleaned
__________________
Not maintained
cleaned
Maintenance ofSchool premises. Please
mentioned in number
1
Maintained cleaned
Not ain rained
cleaned
DIRECTORATE OF HEALTH AND F. W. SERVICES, BANGALORE-9
REVISED FORMAT
The Progress Report of the School Health Programme for the month of--------------------------------------------------Note * Medical Officers should examine, ** Health Assistant should examine, *** % to the yearly target, **•* Target should be fixed depending on the budget allotted
by ZP of respective Districts.
1
No. of students enrolled during the period of
2000-2001 ( This is the annual target to be
covered for the year under report )
4
Total
1st.. 4th. &
2nd, 3rd, 5th, &
7th. Std.
6h Std. students
•
*
Students *
Total of No. of
primary / higher
primary schools
Name of the District <
Taluk/PHC'SC
SLNo.
3
2
No. of students medically examined
6
Cumulative total starting from
Total
the mouth to the month under
the report
IsL, 4th. A
2nd, 3rd, 5th.
7th. Std.
A 6th Std.
Students *
students **
lb **•
Dental
Carries
Worm
Infestation
(»)
(b)
TB
Rheumatic heart Diseases
____ 0)____
(h)
No. of health
education talks
given in the school
DM
CT
Goitre
w
Health education activities
11
No. of health
No. of mini
education materials
exhibition / films
distributed to the
shows arranged in
schools
the schools
DM
CT
DM
No. of students examined medically
6
During the month
1st, 4th. &
2nd, 3rd.
7th. Std.
5th, A 6th
Students *
Std.
students **
No. of students found medically defectives' having the medical problems
7
URI
Anaemia
Vitamin- A
Scabies
Defective
Otlitis
deficiency
Vision
media
(C)
(d)
<e)
(0
Total
Defective
Hearing
(g)
(h)
No. of students found medically defectives.'' having the medical problems
7
Leprosy
____ 0)
Monthly target fixed for the
Medical examination of
students.
5
IsL, 4th. &
2nd. 3rd, A
7th. Std.
5th, A 6th
Students *
Std. .students
»•
CT
Others
(I)
No of students
treated for minor
ailments
8
No. of PTA meetings
conducted by the
health personnel
DM
CT
No. of students
referred to Taluk or
referral Hospitals
9
Training conducted for the school teachers (5) rate of
at least one or two teachers in each school
10
Annual Target ****
Environmental sanitation in the school A school Premises
12
Maintenance of School
Urinals A latrines in the schools and
premises in & around
their maintenance Please mention the
the school building
number.
Mention yes or No
Having
Maintained
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phone
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0091-80-5531518 75525372
Fax
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IQl&K COMMUNITY health CELL-CHC ,m°" :
No. 367, Srinivasa Nilaya, Jakkasandra I Main, I Block, Koramangala, Bangalore - 560 034.
REF: CHC/
/2001
17™ March, 2001
To;
Mr. T.M. Vijay Bhaskar, IAS
Commissioner Public Instruction,
Ambedkar Veedhi,
Bangalore.
Sub: Forwarding the minutes of Integrated HNP meeting held on 7th March 2001.
Dear Sir,
Enclosed herewith please find copies of the ‘Minutes of the Integrated HNP Meeting’
held on 7th March 2001 at your conference hall. We are in the process of integrating the
points, which came up for discussion during the meeting, into the project implementation
plan (PIP) of I INP on school health programme. This would be discussed in detail with
you and your officers before finalization.
Thanking you,
Yours sincerely,
DrCSampath. K. Krishnan,
/-'Policy Fellow (Public Health)
For Coordinator
Community Health Cel
Internal copy to Thelma Narayan - Coordinator.
Society for Community Health Awareness, Research and Action - SOCHARA
Registered under the Karnataka Societies Registration Act 1 7 of 1960, S No 44/91-92
Registered Office : No. 326, 5th Main, 1st Block, Koramangala, Bangalore - 560 034.
GOVERNMENT OF KARNATAKA
DEPARTMENT OF HEALTH & FAMILY WELFARE SERVICES,
ANANDA RAO CIRCLE, BANGALORE - 560 009.
THE FOLLOWING ARE THE IMPORTANT SALIENT FEATURES
TO BE STRICTLY ADOPTED BY SCHOOL AUTHORITY
STATISTICS
E
No. of schools
:
49,537
2.
School children
:
93, 48,666 (girls and boys 50 : 50 %)
SCHOOL SANITATION
1. Provision of sufficient lavatories @ one per 60 students (separate for girls and boys)
> 1,55,820 (77,910 for girls and 77,910 for boys)
2. Provision of sufficient lavatories @ one per 40 students.
> 2,33,716 ( 1,16,858 for girls and 1,16,858 for boys)
3. Provision of water (safe drinking and other purpose) @ 5 litres per student
> 46,88,940 litres ( 18,69,733 Ltr. for drinking and 28,19,207 Ltr. for other purposes
4. PROVISION OF HEALTHY ENVIRONMENT (IN AND AROUND THE
' SCHOOL BUILDING)
> Development of school garden by the students
> Keeping the school premises clean by disposing school waste in compost pits.
> Keeping the school premises clean and tidy always
> Keeping the school premises free from the flies and mosquitoes.
MIXI TES OF THE HNP DISCUSSION WITH DHO’s HELD ON 25™ JANUARY,2001
AT NEW CONFERENCE HALL, HEALTH COMMISSIONERS OFFICE.
The Commissioner H & FW briefly described the salient features of the HNP project.
He emphasized that the project covered the important aspects of Integration, Women’s
health (not just reproductive health), equity, Regional Disparities, Nutrition (which had
long been neglected) and other issues. He then asked the DHO’s (starting from the
category ‘C’ Districts) to give their suggestions/ views on the project proposal (which
had been distributed to all the 27 DHO’s the previous day itself). All the DHO’s
expressed that the Project proposal was well prepared and covered a large range of issues.
DHO’s of Koppal, Raichur and Gulbarga felt that in their districts there was no
requirement of new PHC’s.
DHO’s of Bagalkot and Bijapur felt that a few new PHC’s would be required as some
of their PHC’s were covering a population of above 45,000. Health Commissioner
advised them that they should review the distribution of population with all their PHC’s
and see if by re-distribution of area of responsibility could they avoid asking for new
PHC’s. (He felt that asking for new PHC’s posed a problem as Government, may
sanction PHC’s on political lines).
DHO, Bidar stated that 11 PHU’s in his district needed to be upgraded to PHC’s.
DHO Gulbarga stated that out of his 11 PHCs there was management problems and
also large number of vacancies in staff still required to be filled. He felt that government
should provide accommodation for health staff and staff should stay at their
Headquarters. Health Commissioner emphasized that it was left to the DHO to ensure
that staff resided wherever staff quarters existed.
DHO Koppal also emphasized the shortage of staff due to vacancies not being filled up
especially Lab Technicians and staff nurses and also the problem of having only 3 jeeps
for 43 PHC’s. Health Commissioner clarified that though some of those issues were
important they did not require a project to tackle them. He urged the DHO’s to come out
with concrete suggestions for the HNP project.
Dr. Krishnan stated that not having adequate vehicles definitely affected supervision of
health activities, but if vehicles were provided then MOs should ensure that these were
not taken over / misused by Zilla Panchayat staff.
DHO Raichur also reiterated that vehicles could definitely influence health indicators
positively. He pointed out that about 86 SC’s in his districts had no buildings, large
number of vacancies and the requirement of same funds for day-to-day maintenance of
PHC’s. Commissioner Health stated that under the PMJY for infrastructure these SC’s
could be tackled in a phased manner. He agreed that an annual maintenance fund of Rs.
20,000/- per PHC could be worked out for simple repairs but the exact modalities needed
to be worked out. Some of the DHO’s were in favour of a Junior Engineer under DHO’s
to carry out such works, (as ZP’s were busy with large projects more than Rs. 5 lacs).
Some DHO’s felt that Disposable Dai Kits needed to be provided to Dais so that aseptic
home deliveries could be conducted. Many felt that ANM’s found it'~dTff7cult to perform
deliveries without an assistant. It was felt that the Dais from the village should be
encouraged (through Health Education, IEC etc.) to bring cases to the SC and assist the
ANM in conducting the deliveries. An incentive of about Rs 50/- per case could be
given to the Dai and ANM for every delivery conducted in the SC’s. This would not only
bring down the incidence of home deliveries (with likely complications) as well as give
on the job skill based training'to the Dais in the villages.
One of the DHO’s agreed with the project proposal statement that the under 2’s were not
being reached in the Nutrition programme. It was stated that earlier under CARE ANM’s
were distributing tinned milk / powder to the under 2’s. Some felt that Nutrition
Education to mothers was adequate, others that SHG’s in villages could be involved in
preparation and distribution of weaning foods. PHC doctors and ANM should conduct
well-baby clinics during immunization days and actively monitor the nutritional status of
children. Also during these clinics once in a while nutrition demonstrations could be
conducted.
Regarding partnering with the private sector a lot of discussion was generated. Some
DHO’s felt that it would result in encouraging quacks to practice.
Health
Commissioner stated that whether the medical fraternity accepted it or not, 75% of the
patients in rural areas accessed private practitioners first. Some felt that Health Societies
could be formed at the village level with PP’s, NGO representatives, etc. and meet
regularly. PHC MO’s should have linkage / liaison with local PP’s (atleast once a month)
and they could be briefed about the National Health Programmes as well as inform about
disease outbreaks (surveillance).
There being shortage of time the discussion was concluded. The participants were asked
to read the project proposal in detail and submit written suggestion I strategies within a
week.
MINUTES OF THE MEETING HELD ON 07 MARCH 2001
AT THE OFFICE OF
THE COMMISSIONERATE OF PUBLIC INSTRUCTION ON
INTEGRATED HNP PROJECT
Mr. Vijay Bhaskar initiated the meeting by congratulating Dr Kurtakoti for the excellent
performance in the School Health Programme during the previous year.
Mr. Sanjay Kaul briefly touched upon the HNP project and CHC’s role in preparation of the
project proposal. He stated that the project was for about Rs 800 crores from the World Bank and
that a Project Preparation Grant had also been sanctioned. The main focus was on Primary
Health Care that should provide integrated services, and converge initiatives especially in
collaboration with other sectors on nutrition, health of children and women and other related
issues. He mentioned about the responsibility of the Dept of Health m provision of Nutrition
through the ICDS scheme of WCD Dept and similar commitment to the health of the children m
schools. While accepting the good efforts of the Chief Medical Inspector of schools and Dr
Kurtakoti in the School Health programme, especially where documentation is concerned, he still
felt that the school health programme was neglected. He commented that though the education
dept, had printed beautiful and useful health cards for the school children, these were not being
filled up while conducting the medical check up of children. Also the school registers were not
being updated. The components of Health Education and Education of Adolescents, especially
girls, (Life skills/ Sex education) was not being linked to the school health programme.
Coordination between the Health Dept and Education Dept had been initiated through joint
circulars, but this needed to be improved. He emphasized that counselling of adolescents (or
even post-pubertal girls) needed to be intensified. He felt that the health gains of the ICDS
programme, which covered children upto 6 years, should continue for the children in schools
also.
Dr Kurtakoti briefly described the school health programme achievements and gave handouts.
He stated that in 1998-99 only 25% children had been medically examined and this has steadily
increased from more than 80% in 1999-2000 to 95.23% in 2000-2001. He stated that he was
convinced of the validity of the data as they were reflected by the DHOs. The medical
examination was earned out for children of I, IV and VII standards (once every 4 years), as per
the guidelines of the Government of India. He also stated that DT was given for I Std students
and booster dose of TT was given to Std IV and VII students and almost 79% coverage had been
achieved. About 22% of children have defects of which majority were dental and malnutrition(5%). He felt that most of these could be avoided by simple health education alone. He also
submitted a proposal for about Rs 55 crores for improving the implementation of the School
Health Programme. Regarding training of teachers, he stated that this depended on the budget
received by each district, which varied from Rs 80,000/- to one lakh per year.
Mr. T.M. Kumar was skeptical that such a large number of school children had been medically
examined and expressed doubts regarding the validity of the statistics presented. He was of the
view that only a campaign mode was suited for carrying out medical check ups. He also stated
that ideally 3 days of training for teachers was required but only about one day training was
being given. Also modality for referral of school children to Taluk and District hospital needs to
be worked out.
1
Mr. Vijay Bhaskar briefed about the UNICEF project in Mysore District where schools were
being provided water supply, toilets, sanitation and training of school teachers on Health and
Environment. He also stated that the department has approached NABARD for assistance for
toilets and water supply to schools in all districts.
Mr. Sanjay Kaul stated that life skills training (including sex education) was required for
adolescents and felt that NCERT had a good booklet on life skills with practical tips.
Dr. Kurtakoti commented that students in the schools could take up tree plantation and the other
batches could maintain the trees. He also felt that this would help in Nutrition education. He said
that all schools would be provided first aid kits.
Ms. Jalaja stated that more than 80% of girls in schools suffer from anaemia. Since there were
roughly 4 million school girls, mechanism should be worked out to deworm them once a year
and provide elemental Iron weekly to them, as well as out of school girls. She also felt that
small doses of Vitamin A could also be administered rather than the mega doses being given by
ICDS.
Dr. C.M. Francis felt that as malnutrition was more in boys than girls, this problem also needs
to be tackled. He cautioned about the dangers of excess Iron administration. He disagreed with
Dr. Kurtakoti’s statistics (5%) and felt that malnutrition was a major problem in Karnataka.
Mr. T.M.Kumar was critical of nutrition education, as he felt that the ground reality was quite
different making it difficult for poor families to follow such advise. He stated that even in some
places in Kolar district, no vegetables were available for half the year.
Ms. Jalaja explained that even in poor families green leafy vegetables were always available.
Also nutrition education was necessary so that within their constraints they could provide a low
cost balanced diet to their school children.
Mr. T.M.Kumar expressed that as the text books for Std. I to V had already been revised, any
changes or incorporation of Health Education material would not be possible. However,
textbooks for the other classes could be suitably modified. Also the inside covers of the text
books could be used for printing Health Education messages. He felt that monitoring of school
health by school teachers needed to be strengthened and that DDPI or others should review this
regularly.
Mr. Sanjay Kaul clarified that the major part of the medical examination was done by the health
workers and only the children with defects were examined by Medical Officers. He projected the
requirement of mobility and also of referral of the school children. He also stated that additional
drugs would be catered for in the PHCs.
Mr. T.M.Kumar felt that there needs to be a curriculum review in the TCH programme. Also
over 2 lakh teachers would require to be trained in the Block Resource Centres. He commented
about the success of 'chaitanya' (in-service 1 days training) which had a package that included
what ailments teachers can handle, which cases they should refer, and also covered disabilities,
autism, slow-learning, etc.
2
Mr. Sanjay Kaul also emphasized a tighter monitoring of the school health programme. He
requested the Education Department to work out the modalities of monitoring at District, Taluk
and Village level, through DDPI, DPER and others. He felt the necessity of feedback for
identifying discrepancy in data. He also felt the need for closer cooperation between Health and
Education departments and said that already he and the Commissioner Public Instruction were
issuing letters under their joint signatures. Also joint review meetings once a month (like with
the WCD department.) should be organised at all levels.
Dr. Thelma Narayan emphasized on the implementation mechanism. She felt the necessity of
proper training of teachers, ANMs and health workers (male). Training of trainers (TOT) would
be a strategy of the HNP project. The need for screening of children on pre-fixed days, and
treatment and follow up of children with medical problems was important to make the school
health programme effective and credible. The issue of mental health in school age children was
discussed as were the possibilities of involving resource people from NIMHANS (such as Dr.
Malvika Kapur, and others).
Dr. Sampath K. Krishnan suggested that out of school children could also be reached through
the schools if the teachers understood that the school was the focal point to reach all children in
the village (Dr. Ravi Narayan’s concept). This was readily accepted by all the participants who
felt that medical examination, deworming and distribution of Iron supplements could be carried
out for all children in the villages (and not restricted to children within schools only).
Mr. Sanjay Kaul while agreeing to these suggestions wanted these to be budgeted for in the
HNP project. He wanted CHC to meet with DPI (Primary Education) and Jt. Dtr. DSERT to
work out the finer details of the school health programme and also with Jt. Dtr. Nutrition
regarding the Iron supplements. He then closed the meeting after thanking all the participants for
a meaningful discussion.
JDr.jSafnpath. K. Krishnan
"Policy Fellow (Public Health)
For Coordinator,
Community Health Cell
Bangalore.
3
Appendix 1
Date:
List of participants at the HNP Meeting
In Department of Public Instruction
07 March 2001
Name
Sl.No.
Department
1.
Mr. TM Vijay Bhaskar, IAS
Commissioner Public Instruction
2.
Mr. Sanjay Kaul, IAS
Commissioner Health & FW
3.
Mr. G.S. Hegde
DPI (Primary Edn.)
4.
Mr. T.M. Kumar
Jt. Director, DSERT
5.
Dr. S.B. Kurtakoti
Addl. Director (HET)
6.
Mr Kiran Kamal Prasad
Jeevika, Bangalore
7.
Dr. Sabu George
CHC, Bangalore
8.
Dr. Jalaja Sundaram
Jt. Director (Nutrition)
9.
Dr. Thelma Narayan
CHC, Bangalore
10.
Dr. Pushpa Madjani
CMI
11.
Dr. Sampath K. Krishnan
CHC, Bangalore
12.
Ms. S.N. Meera Devi
Principal, Bangalore Urban DIET
13.
Ms. B. Sushila
DDPI (Textbooks)
14.
Ms. Veena Naik
Sr. Lecturer
15.
Mr. M.R. Jagannatha
Sr. Jt. Dtr. DHERT
16.
Mr. H.S. Jayshankarmurthy
Sr Program Officer DPEP
17.
Dr. C.M. Francis
CHC, Bangalore
18.
Mr. S.T. Marulasiddappa
Jt. Director (IEC)
Urban
4
MINUTES OF THE MEETING HELD ON 07 MARCH 2001
AT THE OFFICE OF
THE COMMISSIONERATE OF PUBLIC INSTRUCTION ON
INTEGRATED HNP PROJECT
Mr. Vijay Bhaskar initiated the meeting by congratulating Dr Kurtakoti for the excellent
performance in the School Health Programme during the previous year.
Mr. Sanjay Kaul briefly touched upon the HNP project and CHC’s role in preparation of the
project proposal. He stated that the project was for about Rs 800 crores from the World Bank and
that a Project Preparation Grant had also been sanctioned. The main focus was on Primary
Health Care that should provide integrated services, and converge initiatives especially in
collaboration with other sectors on nutrition, health of children and women and other related
issues. He mentioned about the responsibility of the Dept of Health in provision of Nutrition
through the 1CDS scheme of WCD Dept and similar commitment to the health of the children in
schools. While accepting the good efforts of the Chief Medical Inspector of schools and Dr
Kurtakoti in the School Health programme, especially where documentation is concerned, he still
felt that the school health programme was neglected. He commented that though the education
dept, had printed beautiful and useful health cards for the school children, these were not being
filled up while conducting the medical check up of children. Also the school registers were not
being updated. The components of Health Education and Education of Adolescents, especially
girls, (Life skills/ Sex education) was not being linked to the school health programme.
Coordination between the Health Dept and Education Dept had been initiated through joint
circulars, but this needed to be improved. He emphasized that counselling of adolescents (or
even post-pubertal girls) needed to be intensified. He felt that the health gains of the ICDS
programme, which covered children upto 6 years, should continue for the children in schools
also.
Dr Kurtakoti briefly described the school health programme achievements and gave handouts.
He stated that in 1998-99 only 25% children had been medically examined and this has steadily
increased from more than 80% in 1999-2000 to 95.23% in 2000-2001. He-stated that he was
convinced of the validity of the data as they were reflected by the DHOs. The medical
examination was carried out for children of 1, IV and VII standards (once every 4 years), as per
the guidelines of the Government of India. He also stated that DT was given for I Std students
and booster dose of TT was given to Std IV and VII students and almost 79% coverage had been
achieved. About 22% of children have defects of which majority were dental and malnutrition(5%). He felt that most of these could be avoided by simple health education alone. He also
submitted a proposal for about Rs 55 crores for improving the implementation of the School
Health Programme. Regarding training of teachers, he stated that this depended on the budget
received by each district, which varied from Rs 80,000/- to one lakh per year.
Mr. T.M. Kumar was skeptical that such a large number of school children had been medically
examined and expressed doubts regarding the validity of the statistics presented. He was of the
view that only a campaign mode was suited for carrying out medical check ups. He also stated
that ideally 3 days of training for teachers was required but only about one day training was
being given. Also modality for referral of school children to Taluk and District hospital needs to
be worked out.
Mr. Vijay Bhaskar briefed about the UNICEF project in Mysore District where schools were
being provided water supply, toilets, sanitation and training of school teachers on Health and
Environment. He also stated that the department has approached NABARD for assistance for
toilets and water supply to schools in all districts.
Mr. Sanjay Kaul stated that life skdls training (including sex education) was required
adolescents and felt that NCERT had a good booklet on life skills with practical tips.
for
Dr. Kurtakoti commented that students in the schools could take up tree plantation and the other
batches could maintain the trees. He also felt that this would help in Nutrition education. He said
that all schools would be provided first aid kits.
Ms. Jalaja stated that more than 80% of girls in schools suffer from anaemia. Since there were
roughly 4 million school girls, mechanism should be worked out to deworm them once a year
and provide elemental Iron weekly to them, as well as out of school girls. She also felt that
small doses of Vitamin A could also be administered rather than the mega doses being given by
ICDS.
Dr. C.M. Francis felt that as malnutrition was more in boys than girls, this problem also needs
to be tackled. He cautioned about the dangers of excess Iron administration. He disagreed with
Dr. Kurtakoti’s statistics (5%) and felt that malnutrition was a major problem in Karnataka.
Mr. T.M.Kumar was critical of nutrition education, as he felt that the ground reality was quite
different making it difficult for poor families to follow such advise. He stated that even in some
places in Kolar district, no vegetables were available for half the year.
Ms. Jalaja explained that even in poor families green leafy vegetables were always available.
Also nutrition education was necessary' so that within their constraints they could provide a low
cost balanced diet to their school children.
Mr. T.M.Kumar expressed that as the text books for Std. I to V had already been revised, any
changes or incorporation of Health Education material would not be possible. However,
textbooks for the other classes could be suitably modified. Also the inside covers of the text
books could be used for printing Health Education messages. He felt that monitoring of school
health by school teachers needed to be strengthened and that DDPI or others should review this
regularly.
Mr. Sanjay Kaul clarified that the major part of the medical examination was done by the health
workers and only the children with defects were examined by Medical Officers. He projected the
requirement of mobility and also of referral of the school children. He also stated that additional
drugs would be catered for in the PHCs.
Mr. T.M.Kumar felt that there needs to be a curriculum review in the TCH programme. Also
over 2 lakh teachers would require to be trained in the Block Resource Centres. He commented
about the success of 'chaitanya' (in-service 7 days training) which had a package that included
what ailments teachers can handle, which cases they should refer, and also covered disabilities,
autism, slow-learning, etc.
2
Mr. Sanjay Kaul also emphasized a tighter monitoring of the school health programme. He
requested the Education Department to work out the modalities of monitoring at District, Taluk
and Village level, through DDPI. DPER and others. He felt the necessity of feedback for
identifying discrepancy in data. He also felt the need for closer cooperation between Health and
Education departments and said that already he and the Commissioner Public Instruction were
issuing letters under their joint signatures. Also joint review meetings once a month (like with
the WCD department.) should be organised at all levels.
Dr. Thelma Narayan emphasized on the implementation mechanism. She felt the necessity of
proper training of teachers, ANMs and health workers (male). Training of trainers (TOT) would
be a strategy of the HNP project. The need for screening of children on pre-fixed days, and
treatment and follow up of children with medical problems was important to make the school
health programme effective and credible. The issue of mental health in school age children was
discussed as were the possibilities of involving resource people from NJMHANS (such as Dr.
Malvika Kapur, and others).
Dr. Sampath K. Krishnan suggested that out of school children could also be reached through
the schools if the teachers understood that the school was the focal point to reach all children in
the village (Dr. Ravi Narayan’s concept). This was readily accepted by all the participants who
felt that medical examination, deworming and distribution of Iron supplements could be carried
out for all children in the villages (and not restricted to children within schools only).
Mr. Sanjay Kaul while agreeing to these suggestions wanted these to be budgeted for in the
HNP project. He wanted CHC to meet with DPI (Primary Education) and Jt. Dtr. DSERT to
work out the liner details of the school health programme and also with Jt. Dtr. Nutrition
regarding the Iron supplements. He then closed the meeting after thanking all the participants for
a meaningful discussion.
Dr^Safnpath. K. Krishnan
Policy Fellow (Public Health)
For Coordinator,
Community Health Cell
Bangalore.
3
Appendix 1
Date:
List of participants at the HNP Meeting
In Department of Public Instruction
07 March 2001
SI.No.
Department
Name
1.
Mr. TM Vijay Bhaskar, IAS
Commissioner Public Instruction
2.
Mr. Sanjay Kaul, IAS
Commissioner Health & FW
3.
Mr. G.S. Hegde
DPI (Primary Edn.)
4.
Mr. T.M. Kumar
Jt. Director, DSERT
5.
Dr. S.B. Kurtakoti
Addl. Director (HET)
6.
Ms. Kiran Kamal Prasad
Jeevika, Bangalore
7.
Dr. Sabu George
CHC, Bangalore
8.
Dr. Jalaja Sundaram
Jt. Director (Nutrition)
9.
Dr. Thelma Narayan
CHC, Bangalore
10.
Dr. Pushpa Madjam
CMI
11.
Dr. Sampath K. Krishnan
CHC, Bangalore
12.
Ms. S.N. Meera Devi
Principal, Bangalore Urban DIET
13.
Ms. B. Sushila
DDPI (Textbooks)
14.
Ms. Veena Naik
Sr. Lecturer
15.
Mr. M.R. Jagannatha
Sr. Jt. Dtr. DHERT
16.
Mr. U.S. Jayshankarmurthy
Sr Program Officer DPEP
17.
Dr. C.M. Francis
CHC, Bangalore
18.
Mr. S. f. Marulasiddappa
Jt. Director (1EC)
Urban
4
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