Successful Growth Monitoring
Item
- Title
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Successful
Growth
Monitoring - extracted text
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u HU'iMgroM
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Successful
Growth
Monitoring
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SOME LESSONS FROM INDIA
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Prepared by—
Principal Investigators
Field Investigators
Dr. M.K. Bhan
Dr. Shanti Ghosh
Dr. N.K. Arora
Dr. V.K. Paul
For
UNICEF
REGIONAL OFFICE FOR SOUTH CENTRAL ASIA
NEW DELHI, INDIA. 1986
)
COM Mi in i’’----
LIST OF CONTENTS
■!
Contents
Page No.
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EXECUTIVE SUMMARY
1
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CASE STUDIES
11
Introduction
Methodology
PROJECT ONE
14
Integrated Child Development Services
(Beri, Dadri, Kathura and Rohtak (Urban) blocks.
District Rohtak, Haryana)
PROJECT TWO
34
(Tamilnadu Integrated Nutrition Project
(Madurai, Tamilnadu)
PROJECT THREE
63
Child In Need Institute
(Village Daulatpur, 24-Parganas, West Bengal)
PROJECT FOUR
Public Health Centre
(Mamblam, Madras, lamiInadv
90
ABBREVIATIONS
INTEGRATED CHILD DEVELOPMENT SERVICES
ANM
Auxiliary Nurse Midwife
CWG
Children’s Working Group
CNC
Community Nutrition Centre
CNI
Community Nutrition Instructress
CNS
Community Nutrition Supervisor
CNW
Community Nutrition Worker
DPNO
District Project Nutrition Officer
GIRH
Gandhigram Institute of Rural Health
GM
Growth Monitoring
HSC
Health Sub-Centre
KAP
Knowledge Attitude and Practice
MO
Medical Officer
MPHW
Multipurpose Health Worker
ORT
Oral Rehydration Therapy
PHC
Primary Health Centre
PC
Project Coordinator
PEM
Protein Energy Malnutrition
SSLC
Senior School Leaving Certificate
SF
Supplementary Feeding
TPNO
Taluk Project Nutrition Officer
TINP
Tamil Nadu Integrated Nutrition Project
WV/G
Women’s Working Group
TAMIL NADU INTEGRATED CHILD DEVELOPMENT SERVICES
ANM
Auxiliary Nurse Midwife
ATO
Anganwadi Worker
CDPO
Child Development Project Officer
GM
Growth Monitoring
ICDS
Integrated Child Development Services
KAP
Knowledge Attitude and Practice
LHV
Lady Health Visitor
NIPCCD
National Institute of Public Cooperation & Child Development
ORT
Oral Rehydration Therapy
PHC
Primary Health Centre
CHILD IN NEED INSTITUTE
GM
Growth Monitoring
MM
Mahila Mandal
PVOH
Project Voluntary Organizations in Health
PUBLIC HEALTH CENTRE
ANM
Auxiliary Nurse Midwife
GM
Growth Monitoring
OPD
Out Patient Department
ORT
Oral Rehydration Therapy
PEM
Protein Energy Malnutritior
PHC
Public Health Centre
EXECUTIVE
SUMMARY
1
FEATURES OF SUCCESSFUL GROWTH MONITORING LESSONS FROM INDIA
Growth monitoring, properly done, is an excellent tool for
assessing the growth and development of a child, for detecting the
earliest changes in growth and to bring about appropriate responses to
ensure that the growth continues uninterrupted.
As such, it contributes
to the promotion of child health and nutrition and is an educative tool
for the mother and the family.
It helps to bring about behavioural
changes in the mother with regard to child feeding, appropriate response
to Illness and an understanding of the various factors which play a role
in growth and development of the child.J
Growth monitoring is being used in several countries for the past
decade or so.
The concept of growth monitoring is frequently
misunderstood and is often confused with periodic nutritional assessment
i.e., the periodic weighing and classification by nutritional status
categories. "Jin periodic nutrition assessment the important element of
communication with the mother and transmission of appropriate practical
messages aimed at promoting growth are absent.
|The potential of growth
monitoring is not realized most often because it is not done.
Thus,
numerous countries describe failed growth monitoring activities because
of the lack of impact on mothers Without having ever recognized and dealt
with this important element.
What other strategies and methods that can
be used to improve quality of growth monitoring and increase the impact
of growth promotion?
UNICEF sponsored case studies of three rural based primary health
care programmes and one urban programme, of which growth monitoring is an
integral part.
The case studies were aimed to review the process of
growth monitoring within these programmes and to identify features that
might have contributed
to effective growth monitoring.
Growth monitoring is used on the largest scale in the Integrated
Child Development Services (ICT -’) programme which has been in operation
for ten years covering over one fifth of India’s administrative blocks
(approximately 130 million population) and is slated for rapid expansion.
2
Two other programmes chosen for the case stuay, though operating on
a smaller scale are of interest because of some innovative features in
design, training and implementation that might provide useful lessons tor
other programmes.
The Tamil Nadu Integrated Nutrition Programme (1INP)
covers 17.3 million people in 9 districts of Tamil Nadu state and is in
operation since 1980.
The nutrition programme was added to the existing
Maternal and Child Health services to strengthen and to increase
awareness of the crucial role of weight gain and, nutrition and functions
in more or less a vertical manner.
The Child In Need Institute (CINI) in West Bengal, is a
non-government
organization which provides a package of health and
nutrition services with other activities for social and economic
development to a rural population of 70,000.
The fourth project, the
Public Health Centre at Madras represents an example of the use of growth
monitorIng in an urban clinic setting.
FEATURES ASSOCIATED WITH SUCCESSFUL GROWTH MONITORING:
What are the key determinants of success for growth monitoring?
There are certain basic principles and prerequisites but the
modalities could vary from one setting to another.
Keeping this in view
and based on our observations of the four case studies, the following may
be considered the attributes of a successful growth monitoring programme:
1.
GM AS A PARI OF THE PRIMARY HEALTH CARE PACKAGE
Growth monitoring should be an integral part of the primary health
care services, as in 1CDS.
It proviues a basic monthly contact in
which not only is growth monitored and promotional nutrition
messages effectively transmitted to mothers, but also appropriate
public health centre (PHC) activities such as immunization, oral
rehydration therapy (ORT), birth spacing services are provided.
3
The PHC reinforces the growth monitoring and promotion activities ana
growth monitoring substantially improves the coverage and success of
PHC.
In TINP, where growth monitoring is more of a single vertical type
program, these synergistic and mutually reinforcing effects are not as
evident.
2.
COMMUNITY CENTRE AND HOME BASED
Growth monitoring is community centre and home based in both ICDS
and T1NP with iocus on the individual child.
be.
This is how it should
In CINI, a village clinic based approach has succeeded in
achieving only about fifty percent coverage for monthly weighing.
Even a village* based weighing point will not get the desired
coverage.
Home based growth monitoring is necessary and indeed
desirable to achieve the desired 80-90 percent coverage and to be
able to reach the very young child, who is not brought to the
centre because of other preoccupations of the mother.
3.
TARGET AGE GROUP
Growth and nutritional problems are most critical among children
upto 3 years of age even though they are also frequently seen in
subsequent years.
TINP has shown that children in the 0-3 years
age group can be attracted to the centre for weighing without the
inducement of a food supplement.
with household monitoring.
Effective coverage is achieved
It may be advisable to dispense with
growth monitoring after the age of 3 years to save the worker’s
time which can be used to maximise health ano nutrition education
of the mother and strengthen the various other components of
primary health care.
Maximum impact is also likely to be achieved
when growth monitoring is restricted to the initial 3 years.
4
4.
GROWTH MONITORING AS THE OBJECTIVE OF A PROGRAMME
To achieve the desired impact, that is, normal regular growth, the
objectives have to be clear and well defined and the training and
other activities should be geared to that.
In programmes like the
ICDS with the present objectives and orientation of training, the
exercise of weighing the children tends to be used to identify
beneficiaries for nutrition supplementary feeding and to improve
the nutrition grade rather than to recognize optimum growth and to
uetect early growth faltering.
It is necessary therefore, that the
planners and decision makers realise and are convinced of the basic
preventive ana promotional objectives of growth monitoring,
It is
only then that the training will become relevant and the worker
will respond appropriately as soon as growth begins to falter and
will look for the reasons why.
The ultimate objective of growth
monitoring is to achieve changes in mothers behaviour through
education using the growth card, which in turn will result in
better child health.
5.
HEALTH WORKER
There is one village level worker for 700-1000 population in these
projects, which seems satisfactory.
The worker should be a female,
preferably, a successful mother herself.
belongs to the village.
It is important that she
Education up to VIII grade is a great
asset in acquiring a high level of skills in growth monitoring.
The qualities of the worker are very important.
The worker needs
to be highly motivated, spontaneous and articulate and take pride
in the esteem that the job brings.
While voluntary mothers make
very useful contribution in TINP and CINI, a suitably paid and
satisfied worker seems an essential prerequisite of the programme.
A good growth monitoring worker clearly understands that the mother
is the focus of all her action.
She respects her ability and
5
skills and believes that able mothercratt is not related to literacy
alone.
hany workers in TINP ana C1N1 have graduatea from women’s working
groups ana this offers additional advantages.
The time distribution for
various activities should be such that it allows her sufficient time tor
home visits because that is crucial tor community involvement and
education.
Her skill in weighing, plotting, interpretation ana education
of the mother must be of high quality.
use the growth card for education.
She must know how to effectively
Her knowledge about feeding must be
practical, relevant and flexible enough to be adapted to the needs of the
individual child.
It is indeed creditable that even without the stated
objectives and with emphasis on nutrition assessment, some of the workers
in the IcDS programme have realised the value of growth monitoring by
observing the growth lines and discovered spontaneously that the
opportune time to respond is just when the growth begins to ialter.
The worker must know how to use the various health education
materials that she might have.
0.
TRAINING
TINT offers very useful lessons in training.
The brief initial
training of about 2 months is followed by intense, repeated,
purposeful, methodical and action oriented in-service training that
accounts for the excellent quality of workers in this project,.
The
workers actually participate in the predetermined number of problem
solving exercises during the 40 percent training time in the
field.
The learning objectives are well defined and known to the
staff.
There is emphasis on developing skills in education and
communication.
The batch size of 20 to 25 tor classroom and 5-7
for field training is optimal.
A training manual in local language
is given to all the workers for routine use at the time of initial
training.
It is meant for the staff at all levels.
instructions are task and action oriented.
The
The focus is on how to
achieve specific objectives (e.g. how to find the cause of growth
6
iailure in a child; how to launch a campaign).
The workers must be
taught the use of the growth card to explain the interplay between food,
illness and growth and use this as the foundation for giving messages on
feeding and response to illness.
7.
SUPERVISION
The quality of supervision is good when the ratio of supervisor to
workers is 1:10 as in TINP.
The supervisors in ICDS cover 20
Anganwadis each, which results in infrequent visits to those
farther away and lack of uniformity in the quality of supervision.
Some of the useful features of the excellent supervision in the
TINP are greater emphasis on technical rather than administrative
matters, check list of tasks to be done during each supervisory
visit and a well defined list of purposes.
Based on this clear and
objective check list of specific activities which should be carriedT^'
out, direct feedback is provided to the worker who immediately
understands where his performance is deficient and needs extra
attention.
A check list is thus a means of objective verification
and immediate feedback.
The supervision is not restricted to the
centre only, but extends to the household level which is the nodal
point of mother-worker interaction,
Further improvement could be
achieved by allocating time tor individual supervisory tasks for
each visit.
The first line supervisor is supervised by the
instructor at the block who again has
objectives.
clear cut methodology and
On the other hand, in the ICDS, the block level
supervision is more administrative rather than technical and
supportive.
Supervision of supervisors is as crucial as that of
the basic worker.
8.
COMMUNITY PARTICIPATION:
Excellent examples of community participation in growth monitoring
activities are seen in TINP and in C1NI.
Io achieve maximum
community participation, it is important that people become aware
of growth and are convinced of the benefit of growth monitoring.
I
7
An effective education and communication programme is essential to
achieve this objective.
The mechanisms of achieving these are several.
The growth card is used to promote understanding of relationship between
food, illness and child’s growth.
Providing other essential services
like ORT, deworming ana immunisation along with growth monitoring
promotes its acceptance and participation of the communityB
The innovative features o± community involvement in some o± the
programmes are:
I.
Formation o±*local women’s working groups:
a)
Members take responsibility for 5-10
neighbouring houses.
b)
Act as motivators, educators, organisers
and growth monitoring workers.
It is important that mothers are active participants.
They
should help with weighing, plotting, ORT, mass campaigns, group
discussions and in the functions at the centre.
This has been
achieved with considerable success in the TINP and CINI
projects.
II. Youth Club: Eaucators and Motivators.
Ill Teacher - children working groups:
a)
School as the base
b)
Growth monitoring and nutrition in school curriculum.
c)
Act as motivators ana educators tor the community.
8
EDUCATION AND COMMUNICATION
For education and communication to play an important role an
adequate emphasis, budgetary allocation and a clear strategy are
essential.
In TINP and to a considerable extent in CINI, educators
and communication experts play a major role in the programme.
Their strategy is to create a demand for growth monitoring among
mothers and leaders through person to person contacts and through
mass campaigns.
The educational messages are described and
recommended for their effect on growth, saying that if these are
acted upon, the child will get better growth.
The workers should
be involved in the development and trained in the effective use of
the education and communication aids. Up and down feed back, stress
on innovations and creativeness are important lessons from TINP. A
major contribution of communication activity is to sustain the
motivation among workers in growth monitoring which tends to
slacken with time.
Education needs to be targeted to a wide audience; mothers and
mother substitutes, opinion leaders, politicians, teachers, social
workers, school children and public at large.
The education
message must be based on prevailing KAP ana improved with frequent
evaluation.
Very effective use of local folk theatre, singing
during marriages, peep shows, slogan competitions, films etc. is
seen in TINP and CINI.
Radio programmes where the Anganwadi worker
is an animater and forming of listening clubs is evident in some
ICDS programme areas.
The educational messages need to be made
relevant in the local socio-cultural milieu.
NUTRITION EDUCATION
Conversations with mothers and workers brought out a major lacuna
among workers and supervisors in these programmes.
The workers do
not provide the mother with an understanding of the amount, bulk.
9
and frequency of diet appropriate for the child to achieve optimal growth
nor teach them how to make the family diet suitable for a child or to
increase energy density.
While there is emphasis on Vitamin A rich
foods, the emphasis on the major energy rich food is lacking. Very
careful attention should go into the design of the content of the
messages if we are to not only inform the mother but motivate her to
change her behaviour.
The messages should be simple, practical and
appropriate to the tradition and cultural milieu of the community.
Similar attention is required for messages regarding feeding during
illness•
11.
BACK UP HEALTH CARE SUPPORT
The two important elements of the response to early growth
faltering are education of the mother, search for the cause of
deviant growth and provision of appropriate remedial measures.
Common illnesses and infections are usually the precipitating
cause.
This, necessitates prompt referral to the health personnel
and indeed their active involvement in the programme.
to be a common weakness in the programmes reviewed.
This seemed
The latent
period before referral should be short and the guidelines and
logistics of referral should be clearly defined.
There should be
active Involvement of the health personnel in the whole growth
monitoring strategy.
12.
GROWTH CARD
Since the mothers involvement is essential in growth monitoring she
must become the keeper of a suitably designed, easily understood
growth card which would become her proud possession.
There is a
distinct difference in the mother’s understanding and perception of
growth monitoring depending on whether the card is kept by her or
by the worker.
In TINP the growth cards are retained by the
mothers and most of them could interpret the line trends.
This was
10
not so in projects where cards are kept with the workers.
If necessary,
a special card may be used at the centre for effective follow up of
growth faltering and malnourished children only till the time their
growth slopes assume normal direction,
be few, relevant and simple.
lhe messages in the card should
Often the cards are overcrowded and
messages are seldom absorbed by mothers,
lhe card should have 100 gm.
markings so that the weight can be charted accurately.
13.
WEIGHING SCALES
The programme can succeed only if the basic ingredients and tools
are available.
The weighing scales should be accurate, locally
manufactured, durable and easy to maintain, repair and transport.
It should be easy to use by workers and mothers.
100 gm. markings.
It should have
The readability on the dial or bar should be
easy, so that both the workers and mothers can use it easily and
correctly.
14.
LOGISTICS AND SUPPLIES
Efficient supply, maintenance and replacement of weighing scales,
growth cards and other items is crucial if optimum results are to
be obtained for growth monitoring.
In some situations, it may take
months instead of days to repair or replace a broken weighing
scale.
At times new types of scales may be introduced into a
programme without adequate training ana preparation.
The supply of
growth card should be regular so that their availability is never
in doubt.
Growth monitoring is useful only if it is impactful.
The
critical constraints are lack of clarity about the growth and
development role of growth monitoring, poor training?
supervision and support, lack of understanding of each workers
role and responsibilities, and insufficient and interrupted
supplies and maintenance.
5537A
CASE
STUDIES
11
I.
INTRODUCTION
.Growth is a key indicator of child health.
An interplay of
ignorance, inappropriate feeding practices, inadequate diet and
infection result in one third to half of the children remaining
undernourished in the developing world.
Malnutrition is a key
determinant of the high childhood mortality.' J
^Growth monitoring is advocated and used as a pivotal activity to
maintain children on the path of normal growth and development and
to recogniz^ early growth faltering. It has been appropriately
defined as:
"A process of sequential measurements for the assessment of
physical growth and development of individual and the community
with the purpose of promoting child health, human development
and quality of xife."
The process involves regular weighing for early identification of
growth faltering with appropriate and prompt follow up action,
The
ultimate target is to educate and achieve change in mother’s
behaviour towards normal growth and development of the child,
The
major focus is on child feeding and appropriate response to
illness.
Growth monitoring provides an excellent opportunity to
provide other primary health care services, to improve women’s
participation and status and interaction between mothers and workers
in a predictable and frequent manner.
Growth monitoring has been used in several countries during the last
two decades.
The purposes for which it. has been in use include
12
early detection
of faltering growth with followup action or of more
severe grades of malnutrition and rehabilitation.
There is now a
consensus that growth monitoring must become an activity by and for
the mother.
While there is agreement on its usefulness, there are
controversies and doubts among policy makers, health workers and
professionals as to itsfeasibility and implementation in different
countries, each with its unique primary health care system,
The
question often raised is, "Where has it been done?"
This case study was sponsored by UNICEF to review the process and
practice of growth monitoring in four health care projects in India
with a view to identify factors that may have contributed to the
success of the programme as well as identify operational constraints.
Three of the projects selected are large rural primary health care
programmes with growth monitoring as an integral part.
While the
design and implementation strategies are unique to each programme, an
effort was made to identify positive features that have a broader
application.
The fourth case study is an example of use of growth
monitoring in an urban public health clinic.
PROJECTS VISITED
Integrated Child Development
Rohtak, Haryana
Beri, Dadri,
Kathura, Rohtak
Services (ICDS)
(urban)
Kottampatti
Tamilnadu Integrated Nutrition
Madurai,
Project (TINP)
Tamilnadu
Child in Need Institute
Daulatpur,
Bishnupur I and
24-Parganas;
II, Tollyganj
West Bengal
Public Health Centre
Madras, Tamilnadu
Mamblam
13
II.
METHODOLOGY
The investigators visited each project location for a period of one week
during March-April 1986 to obtain an impressionistic view of the growth
monitoring operation in the project.
An overview of the programme was
obtained during discussions with the project leaders at the state and
district level.
Except for the initial forenoon, the rest of the time
was spent at the village level.
The mothers (50-100 at each project) were interviewed at several nodal
points of growth monitoring activities including at households.
households visited were selected by us.
The
These represented a fair mix of
households located near the centre and the periphery of the village.
investigators interviewed all the mothers together.
The
The assessment of
mothers and workers was done with the help of a pretested short question
naire.
Attempt was made to evaluate the level of exposure and awareness
of growth monitoring; their motivation and perception; knowledge of
optimal feeding practices during health and disease relating particularly
to their own children; and awareness of early faltering of growth or
severe malnutrition as a cause of real concern and their response.
The mother’s skills in weighing, plotting in the growth card, interpre
tation of growth lines were assessed using her own child’s card as also
three other cards showing normal growth velocity, growth faltering and
grade III malnutrition,
KAP about ORT and immunization was also
ascertained.
The activities at Community Nutrition Centres or Anganwadis, Health
Subcentres, Primary Health Centres and Clinics were observed during peak
working hours.
The growth charbs employed were carefully examined.
About ten front-line workers and 5-7 supervisors at different levels of
hierarchy were interviewed in each block visited.
The documents related
to the training and supervision procedures were examined,
leaders were met on the first and last day of the visit.
The project
14
PROJECT ONE
INTEGRATED CHILD DEVELOPMENT SERVICES
(BER1, DADRI, KATHURA AND ROHTAK (URBAN) BLOCKS, DISTRICT ROHTaK., HARYANA)
Contents
Page No.
1.
Background
15
II.
Organizational structure
16
111.
The role of key project staff
17
IV.
Growth monitoring activities
lb
Periodic weighing
Interpretation and follow up action
Supplementary nutrition
Maintenance and use of growth cards
Growth card as an educational tool
Objectives of growth monitoring
pursued in the projects studied
Impressions on AWWs
V.
Assessment of Mothers, role and participation
12
VI.
Community participation
26
VII.
Training
26
VIII.
Supervision
29
IX.
Communication and education
29
X.
Summary of salient features in growth monitoring
and suggestions for improvement
30
Epilogue
Annexures
15
I.
BACKGROUND
The Integrated Child Development Services (ICDS)
scheme was initiated in
1975 as a response to the recognition of the
impoverished economic, social
and environmental condition
surrounding infants and children in India.
The ICDS, India's most comprehensive and ambitious programme is both
preventive and developmental in design.
It aims to increase child
survival and improve the quality of survival among children,
reduce prevalence of malnutrition, improve the growth
It hopes to
status of children
and prepare them through non-formal education for
a more successful formal
promotes maternal health and nutrition
because there cannot be child health without
maternal health.
school education.
The ICDS also
The programme was started on <—
an experimental basis in 33 of India’s over
5,000 administrative blocks (each
-- 1 block has a population of about
100,000).
These blocks
were considered to be the most deprived and with
high representation by members of schedule castes and tribes.
The initial experience was considered successful resulting in rapid
expansion of the programme till about 1,300 blocks were covered by the enH
of 1985. The programme provides immunization
and health checkup to 10.4
million children, s upplementary nutrition to 6.1 million children and 1.2
million pregnant and nursing mothers,
and non-formal education to 3
million children. The: coverages included are expected to double during
the Seventh Five Year Plan by 1990.
The specific goals of the programme are:
reduce the incidence of low birth weight and severe malnutrition
among children;
bring down the mortality and morbidity
old;
rates among children U-6 years
16
reduce school dropout rates through early stimulation programmes for
children 3-6 years old;
provide the environmental conditions necessary for the mental,
physical and social development of children;
enhance £he ability of mothers to provide proper care for their
children; and
achieve effective co-ordination at the policy and implementation
levels among government departments to promote child development.
II.
ORGANIZATIONAL STRUCTURE
(Annexure I)
The ICDS projects are selected and approved by the Centre in
coordination with State Governments.
Their location and selection are
in need-based rural, urban or tribal areas.
It takes about 12 to 18
months after approval for the project to become fully functional in a
block.
The most frontline worker is an Anganwadi Worker, who belongs to the
village and is selected by the community to serve a community of 1,000.
About 20 Anganwadi workers are supervised by a Supervisor and both are
always female.
The Child Development Project Officer (GDPO) is
responsible for the entire block i.e. 100 Anganwadis.
The Anganwadi
Norker is assisted by a helper, who is often a local traditional birth
attendant, but could be anyone else from the village.
The health component consists of ANMs, LHVs and the Medical Officers of
the block Primary Health Centre.
17
III.
THE ROLE OF KEY PROJECT STAFF
Child Development Project Otficer (CDPO)
Provides link between ICDS and government administration.
Secures Anganwadi premises.
Is in-charge of 4-5 supervisors and 100 AWWs.
Identifies beneficiaries and ensures supply of food to the centre,
and flow of health services.
Monitors programme and reports to the State Government
Supervisor
Responsible for 20-25 Anganwadis.
Acts as mentor to AWWs.
Assists in record keeping, organizing community visits, visits of
health personnel.
Provides on-the-job training to AWWs.
Anganwadi Worker (AWW)
Selected from the community.
Provides direct link to children and mothers.
Assists CDPO in survey of community and beneficiaries.
Organizes non-formal education sessions.
Provides health and nutrition education to mothers.
Assists PHC staff in providing health services.
Maintains records of immunization, feeding "and pre-school attendance.
Liaises with block administration, local school, health staff and
community.
Assists other community-based activities, e.g. family planning.
18
The AWW assumes a pivotal role in the ICDS structure due to her
close and continuous contact with the community.
As the crucial
link between the village population and the government
administration, she becomes a central figure in ascertaining and
meeting the needs of the community she lives in.
iv.
Growth monitoring activities
Periodic weighing
One of the job responsibilities of the AWW is to weigh all children
0-6 years of age every month.
The weighing is done during the first
week of the month at the Anganwadi itself or whenever convenient.
Children under 3 years of age
who do not visit the Anganwdi
regularly are weighed at home.
The weighing at home is the main
mechanism which brings the Anganwadi worker and the mothers of this
nutritionally vulnerable group in contact with each other.
This is
also the only major opportunity for imparting nutritional education.
The coverage for monthly weighing in the 6 months to 3 years age
group is about 50 per cent of the eligible children.
Between 3 to
6 years of age about 70 per cent of the children are weighed
monthly.
There is a significant variation among different
Anganwadis in the extent of coverage.
Efforts are being made to record birth weight and periodic
weights in the 0-6 months age group but the coverage is still
low (15-20 per cent).
In some Anganwadis, weighing during 0-6
months is not being done as yet.
19
The weighing was previously done with Salter spring type scales.
Recently, the Anganwadis are being supplied with the Tansi beam type
scale.
In some Anganwadis weighing scales are either very old or
out of order.
maintained.
In most places, however, the weighing scales are well
All the workers assessed are skilled in measuring
weights both with Salter and Tansi scales.
None of the helpers
assessed can weigh with the recently supplied Tansi bar scale but
many did so with the Salter scale.
Interpretation and follow up action
The objective of the periodic weighing as understood by the whole
ICDS staff is to determine the nutritional status, eligibility for
supplementary feeding and need for medical attention. The
promotional
aspects of monitoring growth are not emphasized and so
an appropriate response to early growth faltering is not initiated.
However, in village Dhandla, all the four Anganwadi workers are
exceptionally skilled, knowledgeable and motivated.
They have
spontaneously discovered the utility of responding as soon as the
growth lines falter,
They recognise growth faltering as the
opportune time to respond.
They can recite the reasons for early
deviation in growth lines on several charts such as mothers being
busy at harvest time, illness, lack of diet and very interestingly
social factors such as female sex or mother being deserted by
husband.
Here is an outstanding example of the kind of understanding about
genesis of faltered growth in a child which can be achieved through
a growth card by an experienced worker. *Unfortunately, in most
20
Anganwadis, this role of growth cards is not clearly appreciated by the
workers and therefore, not transmitted to the mothers.
The shortcoming
lies in their training which has emphasized nutrition assessment rather
than growth promotion.
The followup action once grade III or IV malnutrition sets in is quite
effective; weekly observation and weighing at home by AWWs, intensive
nutrition education, a separate followup card and double the amount of
supplementary feeds,
The special cards for cases of malnutrition are
filled accurately in almost all cases, These provide for weekly weight
and record of morbidity.
It is difficult to assess how well the
referral for health check works, The ANMs and doctors visit the centre
periodically and see these children,
actually gets done is long.
The latent period before this
The description of what this health check
comprises of is also vague.
Table 1 : Growth monitoring in 1CDS
Centre/home based
Largely home-based for 0-36 months 6c Centre
based for 37-60 me nths age group
Indicator
Weight for age
Who weighs
Anganwadi worker
Periodicity
Monthly
Extent of coverage
50-70 per cent*
Time when weighing done
Any time of the month
Who records in card
AWW
Who keeps card
AWW
Scale used
Salter, now changed to Tansi bar
*0nly 10-20 per cent coverage for children 0-5 months old.
variation in different Anganwadis.
Great
21
Supplementary nutrition
Supplementary feeding should be an occasion for nutriton and health
education.
The contact with mothers at the Anganwadi, however, is
too short and infrequent.
Secondly, mothers of young children, most
in need of education, do not come to the Anganwadi.
Therefore, the
AWs will not reach the mothers of most of those in the nutritionally
crucial age group unless the home visiting is regular.
The utility
of the contact with the mothers can be increased by the effective use
of growth chart for nutrition and health education.
Maintenance and use of growth cards
The growth cards of all eligible children are maintained in the form
of a book at the Anganwadi.
The worKers carry the chart book with
them during home visits and record weights in them if weighing is
done.
At the Anganwadi, initially the workers used a register to
record weights but with increasing confidence, now the plotting is
done directly on the charts.
chart.
The mothers do not keep the growth
It is designed more for the workers.
In most of the charts, plotting is generally of good quality,
Most
workers can plot the age and dot position correctly. Several,
however, do not join the dots by a line, as they are not told to do
so either during their training or on the job.
It is apparent that weight charts tend to be used to locate a child’s
position according to weight for age in relation to desired weight
for that age.
Thus, the slope of a child’s growth curve in relation
to reference lines is considered less important.
This is a
reflection of the programme policy wherein periodic weighing in the
project focuses on identifying grade III and IV malnutrition for the
purpose of nutritional rehabilitation.
This conceptual flaw needs to
be corrected if one aims at the optimum growth and development of the
children.
COMM’JNirr HtUTH CELL
*7/1. (First Fleer; St Merks R©ad,
BannpJnra .
' O01.
22
Growth card as an education tool
The workers feel that only the educated mothers can understand the
use and interpretation of growth charts..
Some of the mothers are
told the weight of the child or that he is healthy or weak. The
educational potential of the growth chart is not utilized fully in
the programme.
Objectives of growth monitoring pursued in the projects studied
Table 2 lists the potential objectives of GM being pursued in the
blocks visited by us.
Table 2:
Objectives of growth monitoring pursued
1.
Detection of malnutrition and followup care.
2.
Entry point for nutritional education and motivation of mothers.
3.
Entry point for health care activities.
4.
Monitoring impact of interventions
5.
Entry point for women’s participation in health and nutrition
programmes.
6.
Mechanism for promoting role and status of women in the community.
7.
Nutritional care of ante-natal and post-natal mothers.
8.
Analytical purposes.
Impressions on AWs
Most Anganwadi workers are well-motivated and enthusiastic.
They,
however, give high priority to preschool education and supplementary
feeding. They consider growth monitoring useful but not a pivotal or
key activity. They do not consider weighing children to be a burden.
48
Several of the women’s working group members are seen in and about the
The leadership quality is
centre.
The motivation is impressively high.
visible.
Their skills in weighing and growth charting are
considerable.
Most can weigh correctly and fill growth cards,
Their
interpretation of growth lines is generally flawless.
Their knowledge about infant feeding practices, diarrhoea management,
immunization, cause of deviant growth, vitamin A deficiency is uniformly
good.
CNWs feel that WWG is their most effective instrument.
major improvement in mothers understanding about feeding
The credit for
is essentially
due to the excellent performance of WWGs.
Children’s Working Groups
The idea behind CWGs was initiated by field workers, ancjl is an
illustration of the flexibility of the system and stress on initiative
and creativity at the grassroot level.
There are 100U CWGs in Madurai
district.
The teacher selects the best students of the classes V-X for
the group;
Leader is chosen by consensus.
motivating and educating mothers.
The CWGs are used for
They are involved with Vellupatti
(folk theatre) groups, drama groups, school functions and festivals.
They encourage other children to write essays on health and nutrition
subjects during campaign period.
We heard three groups in different villages reciting jingles.
members can recite these without the book.
programme activities.
Many
Most of them know about
They answer questions on use of periodic weighing
in children and infant feeding with reasonable accuracy.
47
weight.
There were several posters on the walls showing children being
weighed and about other T1NP activities, but when their children visit
the PHC, the doctor does not ask for the growth card,
They can weigh
accurately and interpret the growth curves in the card.
However, they
feel that weighing and plotting are essentially for purposes of
identifying children for supplementary feeding.
situation with the ANMs.
and guidance.
Similar is the
They have skills but lack proper orientation
The doctors informed us that they receive only an
occasional referral for children with growth faltering.
The weighing scale in the labour room (bar scale) is poorly maintained
but functional.
It is vital to involve the PHC staff in the whole
process of growth monitoring and referral for obtaining optimum results.
VII.
COMMUNITY PARTICIPATION
Wide and intense participation by the community is conceived to be an
important objective of the project.
The village elders, mothers,
children and school children are chosen as the key vehicle for acheiving
participation by the community.
Women's Working Groups
Most villages have a women’s working group.
are 1966 such groups.
In Madurai district, there
Each group comprises of 15-20 mothers, belonging
to households at different locations within the village.
The WWGs guide and educate 5-6 neighbouring mothers.
The WUG meetings
are held every fortnight for 2 hours at the house of one of the WWG
members.
A unique feature is that after the meeting, the whole group
marches through the village raising slogans on nutrition and health.
23
The skills in weighing and plotting are generally good,
most do not calibrate zero error before weighing,
the points.
However,
Many do not join
The interpretation of the growth curves is weak.
The knowledge about feeding practices is generally good but without
emphasis on amount of food appropriate for different ages.
The
quality of educational messages conveyed to mothers leave scope for
improvement.
Few have a clear understanding of how to achieve greater community
participation.
The workers clearly have the potential and skills to carry out a
very effective growth monitoring programme.
What is needed is
re-training in the proper use of growth monitoring, improvement of
workers skills in identifying early growth faltering, to investigate
its causes and to act promptly by promoting mothers understanding am
changing her behaviour through well thought-out educational messages
using the child’s growth card for the purpose.
V.
ASSESSMENT OF MOTHERS’ ROLE AND PARTICIPATION
The mothers are well aware of the Anganwadi and the AW.
Most of
them feel that the Anganwadis perform a very useful role.
There are
a few complaints about Anganwadis being closed the entire day or
sooner than scheduled and about misuse of the supplementary food by
workers and supervisors.
The mothers give preschool education and supplementary
feeding as
the major reasons for sending their children to the Anganwadi.
On
direct questioning (Table 3) growth monitoring is enumerated as one
of the functions.
The periodic weighing is linked more to
identification of beneficiaries for extra supplement,
their homes but often at more than a monthly interval.
AWWs do visit
24
Nutritional education is mainly imparted either when mothers visit
the Anganwadi or during household visits by the workers. The mothers
are also exposed to weekly radio programmes on health and nutrition
related subjects where the AW act as an animator and these seem
quite popular.
The exposure to growth cards among mothers is low. Some are aware of
the card but cannot relate to these . In all Anganwadis, mothers
cannot weigh children or plot findings on growth cards.
interpret growth lines or nutritional status.
They do not
Most mothers can list nutritious foods for infants and children.
Messages about breast-feeding and weaning at 6 months have reached
most mothers and seem to be well accepted.
The knowledge about infant feeding among mothers is fair but the
emphasis on bulk, frequency and amount of feeding is missing (Table
3). Many mothers agree that they reduce food intake when the child
has fever or diarrhoea for fear of aggravating the illness.
Almost all say that they would feed ’dal’ water rather than ’dal’ to
the child.
The awareness of the need to make infant diets more
energy dense is not apparent to the mother or the workers.
The need
to make education messages on nutrition more effective and practical
is evident.
Messages about diarrhoea management have reached more than half of
the mothers interviewed. Many can tell the correct method of
preparation of sugar-salt solution.
during diarrhoea
persist
Incorrect beliefs about
feeding
in almost 40 percent of the mothers.
Most mothers have had their children immunized.
25
Table 3:
Assessment of mothers’ KAP and skills
Variables
(a)
Percentages of mothers
Responding in Affirmative(n=60)
Growth monitoring
- Growth monitoring is useful for my child.
- Understand purpose of Gbi
- Approve of monthly frequency of weighing
- Eligible children in household are actually weighed monthly
70
50
90
50
(b) Growth card
- Produce growth cards during home visit
- Card locked up by husband/family elder
NIL
NIL
(c) Causes of deviant growth
- Lack of dietary intake
- Frequent or recurrent illness
- Failure of breast-feeding
60
75
30
(d) Feeding of children
- Correct duration of breast feeding
- Correct age for additional solid foods(6-12 months)
- Appropriate foods from 7 months to 2 years:
Excellent
Very Good
Good
Fair
Poor
100
80
10
15
20
30
25
(e) Diarrhoea management
- Aware of ORT
- Know correct preparation of sugar-salt solution
- Diet:
Same or more than that preceding illness
Decrease 'intake
Increase intake for 7 days after illness
Superstition about useful foods
50
40
30
70
20
40
(f) Correct interpretation of growth card
- Normal growth
- Growth faltering
- Malnutrition grade III
5
15
7
(g) Skills
- Weigh a child
- Plot a growth card
nil
nil
26
VI.
COMMUNITY PARTICIPATION
The awareness about the Anganwadis and growth monitoring is fairly
wide-spread but the involvement in the growth monitoring process is
lov;.
There are no organised groups of mothers, children or youth
helping the AWW with the GM activities,
They contribute a cake of
cowdung towards fuel for preparing the supplementary feed.
VII. TRAINING
The training courses for all levels of ICDS staff are designed and
curricula developed at the National Institute of Public Go-operation
and Child Development, New Delhi,
The basic core curriculum is
similar for all levels with additional managerial training for
supervisors and CUPOs.
The faculty involved with the development of
curriculum includes members of the various disciplines who possess
considerable work experience.
The details of training are given in Annexure 2.
The key features
are:
Anganwadi Worker (AW)
The AWWs are given sufficient skills in weighing,
Most of them were
made to weigh children and plot charts during field training,
The
emphasis on joining the dots and reading the slope of the growth
curves is lacking. The knowledge about initiating action for growth
faltering is not communicated.
These are consistent with the
lacunae found during assessment of the workers,
Some lacunae in the
training are summarized below:
No training manual is given to the worker but only some loose
notes.
27
The distribution of training time weighs heavily in favour of
non—formal education and administration of supplementary feeding
with less time being spent on growth monitoring.
The AWWs are not trained to realize the potential of using growth
cards as an effective tool for education of mothers.
Contents of educational messages leave considerable scope for
improvement.
Training component with regard to tecnniques in achieving
community participation is weak.
There are marked differences in the knowledge and skills achieved
by different AWWs.
This is partly due to the fact that many
centres are responsible for training and their standard varies a
great deal.
The individual capacity of the worker too is an
important determining factor.
Supervisors
Supervisors’ training also needs considerable reorientation.
Presently there are no well defined learning objectives.
There is
no training manual given to the trainees.
We were able to observe a batch of supervisors during their field
training.
During the field training the instructors spend little
time at the Anganwadis visited.
The supervisors are expected to do
most of the learning with the help of AWWs.
Instructors give
didactic lectures in the field rather than
solving exercises.
concentrating on problem
28
The number of children to be weighed and plotted is undetermined and
unspecified, being left to the initiative of the individual
candidates.
Most of the supervisors do not acquire a full
understanding of the potential use of growth monitoring.
Their
knowledge about infant feeding practices is often not practical or
relevant.
There is considerable interpersonnel and inter-batch variation in
the level of abilities.
Again this reflects lack of learning
objectives, uniform training manual and a system of evaluation.
Inservice training
Inservice training is provided dilring visits by Supervisors and
through refresher course.
All the Anganwadi workers interviewed had
attended a 8-day*s refresher course during the previous three
years. The emphasis during the refresher course was on toy making
and jingles. The workers feel that'the course was not well
organized and was not very helpful for their work.
The lack of
clear learning objectives and attention to organization details by
the trainers seems to be a considerable problem.
In Dadri block, the AWWs have superb skills, knowledge and
motivation which on exploring could be attributed to the on-the-job
training by the Supervisors.
Close linkage and greater emphasis on
on-the-job training seems to be the key to high professional
standards.
Similar problems exist with regard to the inservice training of
supervisory staff also.
Examples of good and less effective
training can be seen within blocks in the same district which shows
that high standards are achievable.
Greater uniformity in quality
of training can be achieved with carefully thoughtout and
implemented training.
29
VIII. SUPERVISION
There is one supervisor for 20 Anganwadis.
Supervisors are not
able to cover Anganwadis too far away from the headquarters, as
often as necessary for good supervision.
This creates a lack of
In some
uniformity in the performance of different Anganwadis.
villages where the workers are excellent, we discovered that the
frequency of visits by the supervisors is much more.
One
supervisor for about 1U Anganwadis may be more appropriate,
The
supervisors are motivated and sound in their knowledge but not in
the methods of supervision.
Some are not clear about how much time
they should devote to each task at the Anganwadi. Far too much
time is devoted to registers and supplementary feeding,
’Che
emphasis on checking the skills of the workers is less,
The
supervisors do not visit the households with the workers often
enough.
The quality of education given to the mothers by the
workers thus remains unchecked and unsupported.
There are no
checklists or job descriptions available or known to the
supervisors.
The quality of growth monitoring in the IUDS can be
substantially improved with more sustained and purposeful
supervision.
The islands of excellent work show what is possible
to achieve.
IX.
COMMUNICATION AND EDUCATION
This is one of the weak components of GM in ICDS.
community and mother on GM is weak.
Education of the
GM is considered in the
community as of a relatively lower priority in the service
package.
In Haryana State, radio is used effectively for reaching
the community through popular daily broadcasts on specific
subjects.
The mothers and community members interviewed were not
exposed to any other communication aid for GM.
1
30
X. SUMMARY OF SALIENT FEATURES IN GROWTH MONITORING
AND SUGGESTIONS FOR IMPROVEMENT
1.
In ICDS, growth monitoring is a part of a package of health and
educator service.
2.
Growth Monitoring is centre and home based.
3.
Children in age group 0-3 years do not usually visit the Anganwadi and
for them GM is the main entry point for mother-worker interaction for
nutrition and health education.
4.
Monthly weighing is achieved in 50-70 per cent children after 6 months
of age.
The coverage during 0-3 years is low and needs to be improved
through more effective home based activities.
5
The action response for children suffering from grade III and IV malnu
trition is prompt and effective.
given
However, early growth faltering is
less importance by the workers and no followup
action is taken
since the workers are not trained to do so •.
6.
The skills of workers in weighing and proper plotting are good.
Improvements in interpretation of growth lines and use of growth card
as an educational tool can be achieved through inservice training.
7.
There is considerable variability in the quality of growth monitoring
at different Anganwadis.
8.
The supervision of services is not uniform.
Improvements in training through development of learning objectives,
more exposure to problem solving exercises and pre and post training
evaluation will greatly enhance impact of growth monitoring.
9.
Supervision
(a) There is currently one supervisor for 20 Anganwadis.
many to cover.
A more appropriate ratio is 1:10.
These are too
31
(b)
The motivation and skills of supervision are generally sound but there is
lack of uniformity in coverage and quality.
(c)
Management aspects of supervision need strengthening.
Purposes of
supervision should be defined and reoriented more towards technical than
administrative issues.
10.
Logistics and Supplies: Supplies, repairs and replacements of weighing
scales in the programme have to be much more efficient if growth
monitoring is to be purposeful.
11.
Communication Support:
This appears to be the weakest component of the
programme. Strong communication strategies and activities can be used to
promote awareness of growth monitoring among community members, achieve
active involvement of village mothers and elders and to prepare them for
receiving educational and other inputs from the workers.
EPILOGUE
The LCDS programme has the potential of becoming an active instrument for
growth monitoring if the objective of the programme becomes growth
promotion rather than assessment of malnutrition.
This necessitates
shift of emphasis in the training of the AWs and other staff to growth
promotion rather than detection of malnutrition with a view to identify
the beneficiaries for supplementary nutrition.
Growth monitoring can
then become the core of the ICDS programme with a clear understanding of
the factors that promote growth and those which cause growth faltering,
so that appropriate strategies could be evolved to prevent deviant growth.
Appropriate and Intensive health and nutrition education and community
involvement would be central to the success of the programme and these
aspects should receive adequate attention during training and refresher
courses.
The health system too should be reoriented and involved more
effectively in the whole exercise.
Special attention is necessary to ensure the constant availability of the
weighing scales.
strengthening.
Facilities for quick repair and replacement require
32
ANNEXURE I
ORGANIZATION STRUCTURE OF ICDS
GOVERNMENT OF INDIA
Ministry of Social
Welfare
Ministry of Health and Family Welfare, Ministry
of Education, Ministry of Agriculture, Ministry
of Works and Housing, Ministry of Information
and Broadcasting, Ministry of Energy, Ministry
of Food and Civil Supplies, Planning Commission,
All India Institute of Medical Sciences,
National Institute of Public Cooperation and
Child Development, national level Voluntary
Organizations.
STATE GOVERNMENT
Nodal Department
designated by the
State Government,
mostly the Department
of Social Welfare or
Health
Department of Health and Family Welfare,
Social Welfare, Education,Rural Development,
Public Health in the State Government,
Medical Colleges, Agricultural Universities,
Home Science Colleges, Voluntary Organizations,
and Training Institutions
DISTRICT LEVEL
Collector or other
Officer designated
by the State Govt.
District level Officers for Social Welfare,
Health, Nutrition, Education, Rural Develop
ment, Rural Water Supply, Medical Colleges,
Training Institutions, Voluntary Organizations.
BLOCK/PROJECT LEVEL
Child Development
Project Officer
Block Development Officer, Primary Health Centre,
ICDS Consultant, Block Advisory Committee,
Voluntary Organizations, Social Workers.
PRIMARY HEALTH CENTRE
for a population of 30,000
SCHOOL or a population
within a radius of 1 Km.
PRIMARY HEALTH SUBCENTRE
For a population of 5,000
ANGANWADI’for a
population of 1,000.
33
ANNEXURE II
Salient features of training key workers
Features
AW
Supervisor
CDPO
Place
Chandigarh
Ambala
Delhi
Duration
3 months
3 months
2 months
Institution
Home Science
College
Red Cross
Training Centre
NIPCCD
Course designer
NIPCCD faculty
NIPCCD faculty
NIPCCD faculty
Trainers
CDPOs, instructor
doctor, ANM and
staff at training
centres
Instructors at
training centre
NIPCCD faculty,
invited
consultants
Contents
Child development,
survey methods,
family planning,
nutrition,
health, growth
monitoring, nonformal education
Health, growth
monitoring,
community nutri
tion and Child
development
Child development,
accounting,finance,
management, survey
techniques, commu
nity organization.
Batch size
30-50
10-20
10-30
Class room: field
2:1 months
2:1 months
(in Anganwadi)
Stipend
Yes
Yes
Yes
Children weighed
Variable (5-30)
Variable (5-30)
No
Growth charts
filled
Problem solving
exercises
Variable (5-50)
Variable (5-50J
Yes
Few
Few
Communication aids
in training.
Slides, posters
Slides, posters
Specific learning
objectives
Not known to
supervisors or
instructors
Not known to
supervisors or
instructors
Pre and post
training
evaluation.
No
No
Yes
Previous
background
Class 10th
Graduates in Home
Science
Postgraduates
Training manual
given to workers
Notes given but
no manual
No organized
manual
No organized
manual
Slides, posters
34
PROJECT TWO
TAMIL NADU INTEGRATED NUTRITION PROJECT
MADURAI, TAMIL NADU
Contents
I.
II.
Project overview
Growth monitoring activities
1.
2.
3.
4.
5.
Supervision.
IV.
Impression on role and participation of mothers
V.
What is growth monitoring being used for?
Linkage with health Services.
1.
2.
VII.
39
44
45
48
49
MPHW and HSC
back up support from primary health
centre & medical officers.
Community participation
1.
2.
3b
Delivery of services
Response to growth failure
Weighing scale
Growth card
Observations & impressions of the
study team.
III.
VI.
Page No.
50
Women’s working groups
Children’s working groups
VIII.
Communication support
IX.
Training
X.
Monitoring and Evaluation
XI.
Areas in growth monitoring that need strengthening.
5b
XII.
Factors associated with successful
growth monitoring in TINP.
57
XIII.
Documents consulted.
XIV.
Annexures.
52
52
54
58
59
35
1.
PROJECT OVERVIEW
Concept and design
The Tamil Nadu Integrated Nutrition Project (TINP), started with
the assistance of World Bank in 1980, is aimed at evolving a
replicable model of a nutrition programme which would, through
adopting a risk approach, be cost effective, efficient and promote
better nutrition and health practices within the families. TINP is
a rural project adopting an integrated approach, combining
additional inputs for nutrition services with the optimum
utilization of the pre-existing maternal and child health services.
Two innovative features are the hallmark of TINP.
First, child
beneficiaries are identified and monitored through a monthly growth
monitoring system based in villages.
Secondly, supplementation is
continued only as long as required for a child to achieve adequate
nutritional recovery and is accompanied by intensive nutritional
education of key family—members to promote permanently improved
home feeding practices within the financial reach of their families.
TINP was initially intended to be a five years project started in
July 19bU. At present the project covers a total of 9 districts in
the state, covering a total population of 17.3 million,
The
project is providing services through 8965 CNCs and 2723 healtl
subcentres.
The project planners had anticipated that after 4 years of
completion of the project, the following goals would be achieved:
(a)
Fifty percent reduction in the estimated 60 percent incidence
of protein energy malnutrition among children under three
years of age.
(b)
Twentyfive percent reduction in the infant mortality rate
(then estimated at 125 per 1,000) and in child mortality rate
of 28 per 1,000 children.
36
(c)
Reduction to 5 percent, of the incidence of vitamin A deficiency in
children under 5 years of age (estimated at upto 27 percent at the
time of inception of the project).
(d)
Reduction of 20 percent in the estimated 55 percent incidence of
nutritional anemia in pregnant and nursing women.
Components
TINP comprises of the following four components:
1.
Nutrition (and Growth Monitoring)
2.
Health
3.
4.
Communication
Monitoring and evaluation
II. GROWTH MONITORING ACTIVITIES
Delivery of services
The nodal point for nutrition delivery is the Community Nutrition Centre
(CNC); one for about 1500 population.
The CNC is housed in a rented
accommodation of 1-2 rooms in the heart of the village,
The CNC is manned
by a Community Nutrition Worker (CNW) who is assisted by a Helper.
CNW is a local resident mother with preferably a healthy child.
about eight years of schooling.
Rs.y0.00 per month.
The
She has
She is paid an honorarium of about
She works for 6 hours a day for 7 days a week
starting at 8.00 A.M.
The CNW weighs children 3 days every month, usually in the last week with
the assistance of the Helper ana members of the WWGs using a Tansi Scale.
Weight is recorded simultaneously in a register and a card kept at the
centre.
It is then transferred to the card kept with the mother,
This
may be accomplished at the time of weighing when the mother has the card
with her or during household visits.
Other salient features of growth monitoring in TINP are outlined in Table
1.
37
Table 1. Salient features of growth monitoring in 1INP
0-5 months
______ Age Group
6-36 months
37-60 months
Centre based
70%
70%
70%
Home based
30%
30%
30%
Indicator
Weight for age
Weight for age
Weight for age
Who weighs
MPHW
CNW
MPHW
Periodicity
Once a month
Once a month
Once in 3 months
Extent of coverage of
monthly weighing
20-25%
92%
30-40%
Who records in card
MPHW
CNW
MPHW
Who keeps card
Centre
Mother and Centre
Centre
Type of scale used
Tansi beam type scales
Cradle scale for young
Children
Tansi beam type scale
Tansi or bath room
scale
Features
Comments
If child is not
brought to centre,
CNW/CNI/CNS visits
the household
Card is passed on from
MPHW to CNW and back
to MPHW
38
Response to growth failure
The action response to deviant growth in a child may consist of
active surveillance, supplementary feeding (SF), referral and
education of the mother.
Children who have growth faltering but do not fulfil the criteria for
SF, or those who are on SF, are subjects for more frequent contact of
the CNW with the family,
the households.
CNS and CNI reinforce these interactions at
Nutrition education is thus intensified both in
terms of quality and quantity of messages.
Supplementary feeding is indicated for children with FEM grade III
and IV, and those with no weight gain or weight loss (over previous 2
months in 6-12 months age group, and over previous 3 months in 13-30
months age group).
The minimum duration of supplementary feeding is
3 months and the maximum is till the age of 39 months.
Supplementary
feeding is discontinued when the child moves into grade II or higher
and following a weight gain of at least 500 gms registered over one
month in 6-12 months age group and in 3 months in the 13-36 months
age group.
Weighing scale
Tansi bar scale is used for weighing.
using this scale.
The CNWs face no problem in
They are conversant with correcting zero error and
have so far not encountered any accidents.
Scale is free from
significant breakdowns apart from tearing of the pants and on
occasional loosening of the screw meant for correcting zero' error.
39
Growth card
The growth card is designed for use during first five years,
There
is adequate space for illness record, immunization, deworming,
indications for special care, breast feeding but not for entering
start and conclusion of supplementary feeding.
features of special interest in the card.
There are two
The divisions for
recording weight are for 100 grams in consonance with the sensitivity
of the weighing scale.
There is a column for filling the month of
weighing and age when breast feeding is discontinued.
In the cards maintained at the nutrition centre, age and weights were
accurately plotted and the dots invariably joined.During our visits
to the households, fifty percent of the mothers produced the card.
Additional 40 percent claimed that the cards were kept locked by
their husbands or family elders.
An important issue related to use of growth cards is the extent to
which these are used for education of mothers, Although nutrition
and health education is also given directly to the mother and the
community, the cards seem to be used as an educational tool in this
project.
This impression is based on two observations.
Firstly,
most mothers interviewed can interpret the trends of growth lines and
early change in the normal upward trend.
Secondly, some of them
actually used the card to explain the effect of diarrhoea on growth
when asked a leading question.
It is however, difficult to ascertain
if the use of the growth card as’an educational tool is maximally
effective.
We are concerned that many mothers though claiming to
possess the card, do not produce it, claiming that it is locked away
by the husband or father-in-law.
Presumably, often even the workers
may not be using the card kept with the mother.
40
Observations and impressions of the study team
(a)
CNC
All the pedestrians in the village can locate the CNC.
premises are compact, clean and neat.
The
The weighing scales are
prominently suspended from the ceiling, the walls are full of
posters focussing the importance of weighing and its utility for
the child.
On the day of the visit children were being weighed by the
community nutrition workers alongwith members of the WWG in an
efficient manner and without confusion or chaos.
are arranged neatly.
Growth cards
Cards of individual children can be
identified in less than a minute.
Supplementary feeding is
given to children in a clean, orderly manner.
Most children are
with their mothers and some with mother-substitutes from the
family. The role of local mothers belonging to WWG is visible
and impressive.
(b)
CNW
The Community Nutrition Workers are widely known in their
communities; most mothers and children can identify them.
They
are proud of the special recognition received in the village for
their services.
They are highly motivated, articulate and
confident and recite their responsibilities and activities
precisely.
The degree of professionalism is unusual and
impressive.
Their rapport with mothers, school children,
teachers and the multipurpose health workers is excellent.
r
41
There is stress on linking illness with growth faltering using the
growth cards.
There is however, a lack of emphasis in the education given by the
workers on the bulk and amount of food appropriate for different
ages and frequency of feeding .
They also seem unaware of the need
for increasing energy density in the local infant diets, Indeed,
all the field staff share the perception of the mothers that oils or
fatty foods should be witheld during an illness like diarrhoea.
CNk/s possess remarkable degree of proficiency in skills of growth
monitoring.
They are at ease while handling children and using the
weighing scales.
Their recording of weight and plotting of cards is
uniformly of high quality.
Growth trend and not the grade of
malnutrition is given greater emphasis.
III.
SUPERVISION
The first level supervision in TINP is provided by the CNS.
There
is a vertical chain of staff playing a well defined supervisory role
including CNI, TPNO and DPNO at block, taluk and district level,
respectively.
(a)
There is one CNS for 10 CNWs.
The job description is explicit, clear and available in
writing.
42
(b)
A good check-list of supervision during each visit to CNC is
available.
(c)
The supervisory visit to CNC has two clear goals: supervision
followed*by inservice training.
(d)
Supervision is based on activities at the CNC as well as in
households.
The supervisors visit households of problem
children.
This allows them the opportunity to assess the
quality of nutrition and health education by the workers and
correct deficiencies through a problem-solving approach.
(e)
Refreshingly, supervisors
concentrate on technical matters
like accuracy in weighing, plotting, interpreting; while
considerabie attention does go to issues related to
supplementary feeding.
IV.
IMPRESSION ON ROLE ANU PARTICIPATION OF MOTHERS
The prime indication of a successful growth monitoring programme is
the extent of mothers’ participation.
The observation team
therefore spent more than half of the time in the field in an
attempt to absorb what the mothers had to say.
The salient objective findings in 65 mothers are shown in Table
I
43
Table 2: Assessment of mothers* KAP and skills
Variables
a)
Percentage of
mothers responding in
affirmative (n=65)
GM
Growth monitoring is useful for my child
Understand its purpose correctly
Approve of monthly frequency of weighing
Eligible children in household are actually
weighed monthly.
b)
e)
f)
82
95
85
Feeding of children
Correct duration of breast feeding
Correct age for additional solid foods(6-12 months)
Appropriate foods from 7 months to 2 years
100
89
. Excellent
. V. Good
. Good
. Fair
. Poor
15
51
22
b
b
Diarrhoea management
Aware of ORT
Knows correct preparation of Sugar & salt solution
Diet
100
80
Same or more than that preceding illness.
Decrease intake.
Increase intake for 7 days after illness
Superstition about useful foods.
b9
25
15
9
Correct interpretation of growth card
Normal growth
Growth faltering
Malnutrition grade 111
g)
51
40
9
Causes of deviant growth
Lack of dietary intake
Frequent or recurrent illness
Failure of lactation
d)
b9
Growth cards
Produce growth cards during home visit
Card locked up by husband/family elder
Lost the card
c)
97
85
89
95
85
69
Skills
Weigh a child correctly
Plot weight in growth chart
20
15
4
44
It is clear that the strong awareness and motivational drive in the
community has succeeded in breaking the resistance, common in the
beginning of the project to bring their children for weighing. This
is a considerable achievement.
The mothers seem to know and
approve of the CNk and the 14PHW.
Most understand the purpose and goals of the programme. Periodic
weighing is related both to supplementary feedings as well as to
finding out how well the child is growing.
The common causes of
growth failure are mentioned as illness such as fever, diarrhoea,
lack of breast feeding, poor diet and inability by the mother to
look after the child during harvesting,
The need to start weaning
food after 6 months is known to all.
The knowledge about
appropriate food is less impressive,
Overemphasis and a higher
ranking is given by mothers to
foods such as leafy vegetables and
tomato soup even though cereals, pulses are enumerated by most.
Care needs to be exercised in educating the mother about right
priority for foods.
The superstition about reducing foods in diarrhoea still persists in
uout 25 percent of mothers.
Most of these have been educated about
sustaining feeding during fever, diarrhoea and other illnesses by
the health workers,
almost all mothers admit that they will not add
oil to rice or ’dais* during diarrhoea and this perception is also
shared by most workers.
Most mothers find the recipe of supplementary food too cumbersome
and time-consuming and do not use it at home.
Only WWG members can weigh and chart it in growth cards accurately.
However, the interpretation of growth lines by mothers is
and impressive.
accurate
They can identify growth faltering, malnutrition
45
and a relapse with considerable skill and consistency.
The growth
card seems to serve one important purpose: it clearly explains the
relationship between illness and nutrition to them.
The mothers
spontaneously use the card while explaining reasons for deviant
growth.
This suggests an effective use of the growth card by the
workers.
Most mothers are aware of the messages of different posters, flip
charts, and have seen films on growth monitoring.
the monthly campaigns, WWGs and CWGs.
communication is evident.
They know about
The effectiveness of the
The programme seems to have penetrated
deep in the community reaching almost all mothers.
V.
kHAT IS GROWTH MONITORING BEING USED FOR?
There is a strong awareness in the field staff that the ultimate
and all important objective is to educate the mother and achieve
appropriate changes in her behaviour.
The communication strategy
employed also stresses on the process of monitoring growth than on
supplementary feeding.
The numerous posters at the centre focus on
healthy children being weighed and few show children eating the
supplementary feed.
The emphasis in interpreting the growth cards
is on early detection of growth faltering rather than detection of
malnutrition.
There is adequate emphasis on imparting nutritional
education to mothers of children with loss of weight or poor weight
gain.
The response to growth faltering has a major flaw in that the
referral to the health worker or higher level health functionaries
is done only if the child fails to graduate after three months of
feeding.
4b
VI.
LINKAGE WITH HEALTH SERVICES
The health component operates through the Multipurpose Health Workers
(MPHWs), one for 5,000 population in accordance with the nation-wide
scheme.
A Health Sub Centre (HSC) is established for every 5,000
population which is managed by the MPHW.
MPHW and HSC
We visited two sub centres of our own choice.
clean.
The places are neat and
Tansi weighing scale in excellent condition is suspended from
the ceiling.
They also have a bar-type cradle scale.
The few children
visiting the centre at the time of our visit were being weighed.
The
She was explaining the findings to a
worker looked calm and confident.
mother on the growth chart when we entered the room.
handling and weighing the children.
We observed her
She corrects the zero-error in the
scale and takes the weight accurately,
The plotting of weight is
correct and the dots are joined.
All the workers are knowledgeable about causes of deviant growth, infant
feeding and diarrhoea management,
growth lines are excellent.
The skills on interpretation of
The motivation is high, a feature common to
all other workers in the project.
Back up support from Primary Health Centre & Medical Officers
We were informed that regular weighing of children visiting the centre
is not done even though there are 2 ANMs on the staff.
doctors do not feel any need for it.
Indeed, the
About thirty births take place at
the primary health centre every month and the birth weights are recorded
but no special attention or care is taken of those with low birth
49
viii.
COMMUNICATION SUPPORT
A unique feature of TINP is an effective communication component.
It has succeeded in making growth of children, an important issue
among mothers, opinion builders, administrators, lay public and
the health workers.
The innovative feature of the communication
approach are:
(a)
Person to person contact, reinforced with monthly mass
campaigns on specific issues with regular pre-and-post
campaign evaluations.
b)
Use of traditional methods such as folk theatre (Vallipattu)
and jingles based on folk songs composed by workers and
mothers.
(c)
Use all possible communication aids and points of contact.
(d)
Sustain work motivation and intersectoral coordination
through regular meetings and workshops.
(e)
Prizes for slogan raising competition, best nutrition
workers, best essay in growth and nutrition.
IX.
TRAINING
1.
Training of health workers is a major factor determining the
extent to which programme objectives can be achieved.
2.
The CNWs are trained within the project and the supervisors
and instructors at the Gandhigarh Rural Training Institute.
Madurai ( Annexure IV).
50
3.
The faculty at the training institute in consultation with project
headquarter staff designed the curriculum and methodology of
training for supervisiors and instructors.
The faculty is well
represented by instructors from essential disciplines like
nutrition, child development, child health, education and
communication, and public health and sociology.
4. v
The duration of training for all levels is about two months with
major stress on reintorcement through in service training.
5.
The basic core curriculum for nutrition workers and supervisors is
similar but with few additions related to their specific job
function in the project.
6.
The instructors go through the entire process of developing and
implementing a complete programme for training a batch of CNWs.
The exercises include definition of general objectives and specific
learning objectives, development of audiovisual and other teaching
aids, evolving problem solving exercises, education and
communication and pre-and-post training evaluation systems.
7.
All levels of workers do practical, field training for about 30-40
percent of the training periods, more for CNWs and CM supervisors.
8.
There is a pre-training, mid-training and post-training
evaluation.
Significant number of children are weighed, findings
plotted on growth cards and explained to mothers.
GNWs are
involved in health and nutritional education exercises with mothers.
9.
Specific learning objectives for training are developed.
51
Training Manual
1.
A comprehensive, very well illustrated manual in Tamil
(vernacularJ is given to all workers.
2.
It is common to all workers; according to project leaders,
workers at all levels and in interrelated services know each
other’s job responsibilities and activities.
This ensures
uniformity in perception, quality of work and coordination at
peripheral and higher levels as well as between different
sectors.
3.
The manual was first developed during the first phase of the
project by the coordination office with the help of community
nutrition instructors.
4.
A workshop was organised to identify lacunae and suggest
modifications which were incorporated into the manual in .1983
and in the last revised edition of 1984.
X.
MONITORING AND EVALUATION
Input delivery, coverage of target population & input utilization.
The extent of delivery of key inputs and of the contact with target
population are recorded and analysed every month at the fie’ld
level.
(a)
The findings from six districts show that:
A higher proportion (82-96 percent) of children of the target
group (7-36 months) are being weighed monthly in December 1985
as compared to the earlier years.
COMM'JSilTY HEALTH CELL
(First Floor) St. Marks RWd,
<’
. t-r t r(5i.
52
(b)
Eighty percent of children in target group receive
supplementary feeding at one time or the other.
(c)
There is a decline in the proportion of children needing SF
from 30-42 percent in the beginning of the project to 25-29
percent in December, 1985 in different districts.
Mid-term evaluation (1984); key findings in study and control blocks
(a)
Among children 7-60 months old, the percentage of children in
normal and first grade increased by 9.7 percent points in
project blocks while declining by 4.2 percent points in the
control blocks.
This result was obtained in spite of the fact
that all children of age 24-60 months were given a noon-meal
both in the project and the control block (Annexure V)
(b)
The net decline in severe malnutrition achieved in the 13-36
months age group is 40 percent(Annexure VI).
This is based on
an actual decline of 23 percent in the project area and an
increase of 17 percent in the control area.
Key lessons from monitoring and evaluation data
(a)
Children under 3 years of age can be reached if a project is
specially designed for them.
(b)
Mothers do bring children for weighing even if they are not
given a supplement.
The initial resistance to weighing was
very effectively overcome with community education.
53
(c)
Community nutrition workers with some education can be trained
to correctly weigh children and interpret the growth lines.
(d)
TINP communication component puts heavy emphasis on the
importance of weighing children.
Children who do not come on
their own to the centre are weighed at home.
The WWG are a
highly effective instrument for motivating defaulters to bring
their children to the centre for weighing.
(e)
An issue of major concern is the high relapse rate,
This is
often linked to illnesses like fever or diarrhoea and to
mothers being away from home for work particularly during the
harvesting season.
(f)
The ill effects of infection on growth can be minimized or
reversed by prompt health attention.
The system of referral
both for illness as well as in response to growth faltering was
found ineffective.
XI.
AREAS IN GROV/TH MONITORING THAT NEED STRENGTHENING
1.
Improved coverage between 0-6 months with effective response to
low birth weight and growth faltering.
2.
Response to growth faltering should include prompt health check
and active search for infection.
3.
Strengthen GM activities at PHC
54
4.
Babies identified as low birth weight at PHC must be referred
to field workers for home follow up.
5.
Nutrition education messages must convey concept of bulk,
amount and frequency appropriate for the individual child.
6.
Supplementary feeds must be such that can be made by mothers at
home •
XII. FACTORS ASSOCIATED WITH SUCCESSFUL GROWTH MONITORING IN TINP
1.
Strong motivation among leaders.
2.
GM was added in a vertical manner to an existing primary health
care programme.
3.
GM used as a promotion tool with emphasis on mothers education,
judiciously supported by selective supplementation.
4.
Design oriented to target group (0-36 months).
5.
Home based GM focussing on individual child.
6.
Strong community awareness and participation,
Mothers actively
involved, WWG, CWG, teachers etc.
7.
Community nutrition worker, belongs to village, female,
educated, high motivation and skills.
55
8.
Training:
Short initial training backed up by purposeful, action
oriented, repeated, on the job, inservice training; stress on
developing practical skills through field training at lower
levels;
small batches (20-30); learning objectives well
defined; training manual, single for all levels, comprehensive,
well illustrated.
9.
Education and communication:
Targeted to all in the community; uses all available channels
and contact points; messages within social/cultural context;
messages designed according to prevailing KAP with frequent
impact evaluation.
10.
XIII
Well organised logistics and supplies.
DOCUMENTS CONSULTED
1.
Murthy, N. - Growth monitoring in Tamil Nadu Integrated
Nutrition Project. In: Proceedings of workshop on growth
monitoring as a Primary Health Care activity.
YogaJakarta,
Indonesia, August 1984.
2.
Tamil Nadu Integrated Nutrition Project:
Mid-term Evaluation Report, 1984.
Applied Research, Tamil Nadu.
Department of Evaluation and
56
ANNEXURE I
JOB DESCRIPTION OF COMMUNITY NUTRITION WORKER (CNW)
1.
Surveys the population in her area; records births and deaths.
2.
Monitors growth of eligible children.
3.
Identifies children for supplementary feeding; prepares and
administers supplementary feeds.
4.
Referrals.
5.
Nutrition and health education at the CNC and households,
at WWG, CWG and school meetings.
6.
Organizes community participation activities through WWG, CWG
and schools.
7.
Delivers other primary health care activities: diarrhoea
management, vitamin A administration, deworming; and assists
MPHW in giving immunization.
8.
Upkeep of the CNC, maintenance of records and registers,
preparation of monthly reports.
Also,
57
ANNEXUKE II
JOB DESCRIPTION OB' COMMUNITY NUTRITION SUPERVISOR (CNS)
1.
Visits to CNC
She visits each CNC thrice a month.
Assesses upkeep of the CNCs.
Supervises growth monitoring, checks weighing scale, corrects
zero error.
Observes spot feeding, whether eaten at centre or taken home.
Checks criteria for supplementary feeding.
Checks register entries.
Verifies age of children.
Checks referrals.
Visits 30 houses under each CNC.
Checks stocks.
2.
Supervisory and coordination meetings
Conducts meeting of CNWs under her charge twice a month for
beneficiary entry verification, review of work, problem solving
and data collection.
Attends WWG meeting (four times a month); gives family planning
advice, nutrition education and distributes papaya seeds.
Attends CWG meeting twice a month.
Attends coordination meetings at Taluk, Block and PHC level.
5b
ANNEXURE III
JOB DESCRIPTION OF COMMUNITY NUTRITION INSTRUCTRESS (CN1)
1.
Training of CNWs:
Initial training at the time of selection.
In-service training.
2.
Supervision of CNWs and CNSs:
Visits CNCs and households.
Attends review meetings at block level once a fortnight.
3.
Health education:
Attends at least four demonstrations at CNCs.
Participates in some of the WWG and CWG meetings.
4.
Coordination:
Serves as a link between CNV/s and CNSs on one hand and TPNO and
DPNO on the other.
5.
Administration:
Administers project at block level.
Indents supplies.
$
59
ANNEXUKE IV
Characteristics of initial training of nutrition and health personnel at IINP
Features
CNW
CNS
CN1
MPHW
SSLC
Essential
qualifications
8th class
Graduate
b.Sc.Home
Science
Place
Block
headquarter &
Model CNC
Madurai
Madurai
Institution
Within the
project.
GIKH*
GIRH*
Duration
2 months
2 months
2 months
Size of group
Initially 66
subsequently
20-30**
10-15
12
Course designei
PC, CN1,
faculty, of GIRH
training institute
Training institute
faculty
Training institute
faculty
Training institute
faculty, department
of health & family
welfare.
Trainers
CN1, CNS, TPNO,
MO, teacher
educator,
community educator,
health inspector,
health supervisor.
Nutrition,
communications,
sanitation, nursing
& sociology
experts.
Nutrition,
communications,
sanitation,
sociology and
nursing experts.
Medical, sanitory,
public health
officers, nursing
teachers
one and a half
years
Contd....
60
Features
CNW
CMS
CM
MPHk
Learning objectives
Yes
Yes
Yes
Yes
Trainer: trainee ratio
1:66**
1:20
1:20
1.12
2:1
2:1
2:1
2:1
No. of children weighed curing
training
10
10-15
Several
Several
No. of growth cards filled
100-200
10-20
10-20
10-20
Problem-solving exercises on
growth monitoring
Yes
Yes
Yes
No
Pre-and post-training evaluation
Yes
Yes
Yes
Yes
Training manual available and
given to trainees
Yes
Yes
Yes
Yes
Use of audiovisual methods
Yes
Yes
Yes
Yes
Medium of instruction
Tamil
Tamil
English
Tamil
English
Tamil
Class room
Field training ratio
*The Gandhigram Institute of Rural Health & Family Welfare
Trust, Madurai District, Tamil Nadu.
**After Phase I, 1:20
61
ANNEXURE V
Trend in the proportion (in percentages) of normal and grade 1 nutritional status
Age Group
Pilot
Baseline
survey
Oct.1980
7-12 months
77.8
76.6
-1.2
58.1
71.0
+12.9
13-36 months
41.7
48.4
+6.7
57.1
48.3
-8.8
37-60 months
46.8
59.9
+13.1
62.1
56.0
-6.1
7-60 months
46.6
56.3
+9.7
59.3
55.1
-4.2
Block
Mid term
evaluation
March 1984
Trend:
Decline (-)
Increase(+)
Control
Baseline
survey
Oct.1980
Block
Mid term
evaluation
March 1984
Trend:
Decline (-)
Increase(+)
62
ANNEXURE VI
Trend in the proportion (in percentages) of grade III & IV malnutrition
Block
Mid term
evaluation
March 1984
Trend:
Decline (-)
Increase(+)
Control
Baseline
survey
Oct.1980
Block
Mid term
evaluation
March 1984
Age Group
Pilot
Baseline
survey
Oct.1980
7-12 months
8.3
4.0
-4.3
21.6
6.6
-15.0
13-36 months
20.4
15.7
-4.7
15.1
17.8
+2.7
37-60 months-
15.6
6.8
-8.8
12.5
6.7
-5.8
7-60 months
17.3
11.1
-6.2
14.8
11.6
-3.2
Trend:
Decline (-)
Increase(+)
63
PROJECT THREE
CHILD IN NEED INSTITUTE
(VILLAGE DAULATPUR, 24-PARGANAS, WEST BENGAL)
Contents
Page No.
I.
Project Overview
64
II.
Health & Nutrition Services
66
III.
Growth Monitoring
67
Objectives achieved
Growth Card
Weighing Scale
Action Response to Faltered Growth
IV.
Observation of the Study Team
71
Clinics
Health Workers
Mothers
Training
Community Participation
Supervision
Education and Communication support
V.
Summary - Strengths and Constraints
81
VI.
Annexures
83
64
CINI - Child in Need Institute
I.
PROJECT OVERVIEW
CINI is a voluntary organization involved in the delivery of health
services at the community level and its integration with an all
round social and economic development of the people.
CINI was
founded in February 1975, and maternal and child health clinics were
set up in urban slums of Calcutta.
To optimise the benefits of
these services, inputs for social and economic development of the
area were added.
The project area has rural and urban components.
The programme
covers a rural population of 74,000 in 40 villages of two community
development blocks (Bishnupur I and II) in District 24 Parganas,
West Bengal.
The five urban slums receive services both from CINI
and ICDS programme.
For the implementation of various CINI
activities, the project area has been divided into four zones, each
with 10 villages.
The programme components at present ares
1.
HEALTH AND NUTRITION SERVICES
(a)
Community based
- rural
- urban slum
(b)
2.
Institutional
TRAINING of health and development workers and members of the
community in primary health care at CHETNA - the training centre.
65
3.
SOCIAL AND ECONOMIC DEVELOPMENT:
Income generating activities: farm and agro based
Child sponsorship and family helper project.
Training and extension programme for national project on
smokeless ’chullah’•
4.
RESEARCH on health and nutrition related subjects.
OVERALL PROGRAMME OBJECTIVES AND GOALS
(a)
Develop and implement a community based low cost
comprehensive health care programme for mothers and
children.
(b)
Organize women into effective groups (Mahila Mandals) that
will initiate group action programmes in mother and child
health.
(c)
Raise mother’s income and also of the family by family
level activities.
(d)
Train health and development workers from the government
and non-government sectors.
(e)
Conduct monitoring and evaluation of CINI’s on going
programmes as well as operational research in primary
health care activities.
66
II.
HEALTH & NUTRITION SERVICES
These consist of a package of primary health services which are used
as an entry point for other non health inputs. The health and
nutrition activities of CINI are presently being supported by the
Ministry of Social Welfare, Government of India under the Project
Voluntary Organizations in Health (PVOH).
The organizational
structure and job description of the key staff is provided in
annexures II and III.
The services provided are:
(a)
growth monitoring at the village level clinics;
(b)
home based oral rehydration therapy for diarrhoea cases;
(c)
immunization services for under 5 children and pregnant mothers;
(d)
prophylaxis programme for vitamin A deficiency;
Ce)
community based simple health care for under six, pregnant and
lactating mothers;
(f)
health and nutrition education; and
(g)
rehabilitation of severely malnourished children.
These services are provided through a number of out-patient clinics
(Table 1).
There are 10 clinics for the 74,000 rural population.
Within each clinic there are separate points (stations) for
registration, weighing and growth card plotting, ORT demonstration,
health and nutrition education, demonstration of supplementary feed
preparation, health check up and immunization, in that order.
is a separate antenatal station.
There
67
Growth card is used as an entry ticket for children 0-6 years. These
are retained by the mothers, A new growth card or replacement of the old
one costs the patient 50 paise.
A service charge of Rs.1.00 is collected
at each visit.
Table . 1: Health and nutrition clinics at C1NI
Mobile
clinics
Static
clinics
Population covered
Whole C1NI area
2-3 adjoining villages
Number
3
7
Frequency
Weekly
Fortnightly
Organized by
Health workers
Mahila Mandals or Youth clubs
Weighing
Health workers
Mahila Mandal or Youth club
members
Health component
Health workers
Health workers
Doctor
Present
Absent
III.
GROWTH MONITORING
Periodic measurement of weight is done at all the clinics.
During
which the children are weighed and issued growth cards and are
encouraged to visit the clinics.
At the clinics, after registration,
all the children go to the weighing station.
The worker or the MM
mother takes the weight on a Salter spring balance with 100 gm.
divisions and it is plotted on the growth card in front of the mother.
The mother is told the weight and also how it relates to the previous
measurements •
68
Health and nutrition advice is given to the mother at the next station
by the health worker/MM mother according to the weight record and its
trend.
It is estimated that in a‘village 40-50 percent children aged
0-6 years are weighed every month and a further 30 percent are weighed
Approximately 35-40 per cent children in 0-3
at 2-3 monthly intervals.
years are covered for monthly weighing.
Table - 2
:
Growth Monitoring at CINI
0-6 Years
Centre/home based
Centre
Indicators
Weight for age
Who weighs
Static clinics
Mobile clinics
Periodicity
health workers
MM mother/Youth club member
Monthly
Extent of coverage (monthly)
Static clinics
Mobile clinics
Time when weighing done
Who records in card
30-45%*
50-70%*
Every visit to clinic
Health worker or MM mothers
Who keeps card
Mother
Scales used
Salter
* The coverage is 15-30 percent, and 35-40 percent for 0-b month and
0-3 year age groups respectively.
69
The potential objectives of growth monitoring that
are being achieved at CIN1 include:
(a)
Detection of early weight loss and nutrition education.
(b)
Detection of established malnutrition for rehabilitation.
(c)
It is used as an entry point for other services related to
health and overall socio-economic development.
(d)
It is also used for promoting active participation of women in
health care and developmental activities and enhancing their
status in the community.
(e)
Research purposes.
Design? mainteilance and use of growth cards
Design:
The growth card used at CINI is essentially a Voluntary Health
Association of India (.VHAI) "Road to Health" card with some local
modifications.
The card is printed on a thick art paper mostly in
Bengali with some english words and numericals.
The card costs 50
paise to the mothers.
There are columns for immunization, indications for special care,
morbidity and the bio-data of the child.
Instruction for weaning,
infant feeding, breast feeding, sugar salt solution and
supplementary food preparation are printed on the chart.
chart is suitable for use upto 6 years.
weight is of 500 gms.
Growth
The smallest division for
70
Operation:
The plotting of weight is done most often by health workers and also by
Weight charting is done in front of the mothers.
some MM mothers.
They are told about the present weight and its relationship with the
last recording.
The doctors ask for-the growth card when the patient
is referred to. them for any ailment or nutritional problems.
Most of
the mothers, interviewed in various clinics possessed the card given to
them on their first visit.
Use of growth cards:
Most workers do not join the dots to form a curve.
is not identified.
Poor weight gain
In case of weight loss, mothers are explained on the
basis of the dot positions.
The card is used for explaining the
messages regarding feeding.
Weighing scale:
Salter "weigh bird" spring balances with 100 gm divisions are used in
all the clinics.
ago.
These are made in India ana were acquired 5-b years
In some the numericals on the dial are not easily visible,
The
pants are torn in some clinics.
Most balances have a zero error of 500 to 700 gms but there is no
external knob to correct it.
The health workers and mahila mandal
mothers know about the zero error and make the necessary adjustments
while measuring weight.
The clothes are not removed during weighing.
All the scales at the clinics we visited, were functional but when
repairs are needed, these have to be sent to the city.
71
Action response to faltered growth
In case of weight loss, the health workers and mahila mandal mothers
inquire about illnesses like diarrhoea, fever, worm infestation
etc.
The mother is advised to increase the dietary intake and is
encouraged to buy supplementary food provided at a subsidized rate.
There is no followup at the domiciliary level but they are advised
to attend the clinic fortnightly,
However, no special note is taken
of inadequate or no weight gain.
Indeed, since growth lines are not
drawn on the card, it is not possible to detect early growth
faltering.
In the children with grade III malnutrition , attempt is made to
identify illness and diet related causes.
These children are
referred to the doctor if (i) there is acute fulminant or chronic
infection; (ii) the child is severely anorexic or (iii) has edema.
The mother is given an intense individual education on health and
nutrition; child is followed up fortnightly in the clinic and mahila
mandal mother visits the home at least once a week to record the
progress till he starts gaining weight.
to buy the supplementary food.
The patients are encouraged’
The follow up of severely
malnourished children is quite good.
A select group of severely malnourished children are referred by the
doctor to the nutrition rehabilitation centre when: (a) the family
is very poor; (b) mother has lactational failure or (c) if the
general condition is bad, including presence of edema.
IV. OBSERVATIONS OF THE STUDY TEAM
Clinics
The static clinics are attended by over 300 and the village
72
clinics by over 50 mothers and children every day.
and tidy.
They are neat
The weighing balance hanging prominently from the
ceilingz tight at the entry point indicates the focus on growth.
The waiting time at the clinic is very well utilized for education
on diarrhoea management to groups of 4-5 mothers.
It is the
worker who is in command and supervises the entire growth
monitoring activity.
She seeks advice from the doctor when
required, who himself seldom sees a patient but is more of a
supervisor.
MM members manage the weighing and education with
enthusiasm and authority at the village level clinics,
Most of
the furniture in use at the village clinics belongs to the
neighbours which is an indication of community participation and
support.
Health workers
The workers are highly motivated and articulate.
They are skilled
in weighing and make adjustments for the zero error while
recording.
They mark the age and dot position accurately on the
card but often do not join the points to make a line.
Because the
points are not joined, inadequate or no weight gain is not noted.
This is a serious flaw as the opportunity to respond to early
growth faltering is lost.
The workers are able to judge the
weight loss by the relative position of dots and in such
situations, the response is adequate.
They investigate the cause
of weight loss in a child such as inadequate diet and illness like
fever, diarrhoea, measles, pneumonia and tuberculosis.
The workers are knowledgeable about feeding and illness
management.
However, they do not provide a clear and practical
advice on how much and how often to feed a child.
There is a need
73
to improve the contents of diet and nutrition messages,
Their
knowledge about ORT and immunization is good.
The health workers enjoy a very good rapport with the Mh mothers
and are seen sharing snacks after the clinic.
Impressions on mothers* role and participation
In CINI, substantial effort is being made to actively involve the
mothers in growth monitoring and other health activities.
The observation team therefore, spent over half of the time during
the visit, conversing with village mothers at the clinics and in
their homes.
The salient observations are provided in Table-3.
Every mother interviewed by us, without exception, considers
growth monitoring to be a useful exercise for the children and
understands its purposes well.
They are sufficiently motivated
to bring their children for regular weighing.
This is consistent
with the visible emphasis given to growth and its monitoring in
the total package of services.
Effective use of education and
communication services has succeeded, to a large extent in
creating a mass awareness about the importance of growth for a
child.
All other activities in the project are linked to growth
and growth monitoring.
Two third of the mothers interviewed had
actually been getting their children weighed at monthly
intervals.
More than half the mothers visited at home produced
the growth card.
Majority of mothers could interpret normal slope
of growth curve and malnutrition.
Some could identify early
growth faltering and consider growth faltering to be a problem
deserving a response.
74
Most mothers are aware of the causes for deviant growth and give
dietary inadequacy and frequent illness like fever, diarrhoea,
measles and tuberculosis as the causative factors.
The knowledge about feeding practices is good,
Over three fourth
of them could list appropriate foods for infants,
The
understanding of the amount and frequency of feeding is not as
clear.
This is because the workers themselves do not emphasise
this aspect while talking to the mothers.
Almost 85 percent of them do not decrease food during illness and
interestingly 10 percent responded that the food intake should
actually be increased after recovery.
Most mothers are aware of
ORT and know how to prepare it.
Fifteen percent mothers can weigh the children correctly.
are mostly MM members.
These
A few of these can also plot the weight on
growth cards.
The awareness and perception about growth monitoring is clearly
strong among mothers in this programme.
An index of their
motivation is that 50-70 per cent of them bring their children to
the clinics for regular weighing despite the time ana effort it
requires.
Because, the mothers keep the card, the understanding
of early growth faltering as the opportune time to act is common.
The messages about feeding during illness seemed to be well
absorbed.
Table
75
3 : Assessment of mothers’ KAP and skills
Variables
(a)
Percentage of mothers
responding in affirmative
(n=132)
Growth monitoring
- Growth monitoring is useful for my child.
- Understands purpose of GM
- Approves of monthly frequency of weighing
- Eligible children in household are actually weighed monthly
190
84
73
66
(b) Growth card
- Produces growth card during home visit/clinic
- Card locked up by husband/family elder
- Lost the card
58/98
7
(c) Causes of deviant growth
- Lack of dietary intake
- Frequent or recurrent illness
- Don’t know
57
80
15
(d) Feeding of children
- Correct duration of breast feeding
- Correct age for additional solid foods(6-12 months)
- Appropriate foods from 7 months to 2 years:
- Very Good
“ Good
- Fair
- Poor
100
91
68
11
11
0
(e) Diarrhoea management
- Aware of ORT
- Knows correct preparation of sugar-salt solution
- Diet
Same or more than that in preceding illness
Decrease intake
Increased intake for 7 days after illness
Superstition about useful foods
89
75
84
16
9
0
(f) Correct interpretation of growth card
- Normal growth
- Growth faltering
- Malnutrition grade 111
70
^+5
6b
(g) Skills
- Weigh a child
- Plot a growth card
X
Majority of these are Mahila Mandal mothers.
15*
4
76
Training programme
CHETNA is a separate wing at CINI for training of all levels of health and
development workers. The key features of training are shown in the table
below:
Table - 4 : Key features o£ training
Mahila Mandal
Mothers
Components
Health Workers
Duration
3 months
6 days (36 hours)
+ 3 months
Contents
- Concept of basic
human structure &
function
- Maternal care
- Child care
- Collection of
statistics & raaintainence of records
- Growth monitoring
- ORT
- Breast feeding
- Immunization
- Health & nutrition
education
10-12
5-6
20
6-7
Classroom: Field
2:1 month
1 WK:3 months
Specific learning
objectives
Yes
Yes
Training Manual
No
Yes
Problem solving
exercises
Yes
Yes
Children weighed
In-service
4-6
Growth charts filled
In-service
4-6
Post training
evaluation
No
Yes
In-service training
Yes
Yes
Educational
background
(Schooling)
8-12 years
5-8 years
(not essential)
Batch size:
Classroom
Field
77
The training programmes and manuals are designed by pediatricians with
community health background, nutritionist and serving health workers.
The
training is imparted by the same set of people as well as other medical
officers.
ICDS functionaries and workers from NGO’s are also trained here.
Health workers: Mort of them are working with CIN1 for over 5 years now.
All the mahila mandal and health coordinators are senior health workers
who have now assumed supervisory role.
Growth monitoring was not given adequate emphasis during initial training
of the health workers.
In line with the project objectives, growth
monitoring and ORT education were introduced as a part of the in-service
continuing education,
Weekly institutional meetings form the focal point
of such interactions.
Health coordinators and zonal coordinators actively
participate in the in-service training programme taking into account the
deficiencies of the health workers in their area.
Enough emphasis is
given to the field training and problem solving exercises.
The two major lacunae are lack of a training manual and post-training
evaluation.
Mahila Mandal mothers: The theme of the training is ’’Improved Child
Survival”.
Three to four mothers are selected from each mahila mandal.
Mothers with 5 to 8 years of schooling are preferred although it is not
essential.
The unique feature of the training is that the initial one week classroom
course is supported by three months of apprenticeship during which
through practical work under supervision, she develops into an effective
worker.
Learning objectives have been well laid out.
time is devoted to instructions in growth monitoring.
Almost 25 percent
78
She visits nearly 120 to 150 houses in her area and weighs several
children but the stress on plotting needs to be increased.
assists with the mobile clinic.
period of apprenticeship.
Weaknesses
She also
are rectified during this
A final evaluation is conducted at b months to
declare her suitablity for independent working by senior instructors and
area health workers..
The MM mothers are not paid any remuneration for
their contribution.
Trained MM mothers are evaluated at 3 monthly interval by coordinators.
Medical Officers: There is no formal training course for the medical
However an initial period of 2 to 3 months is used for
"de-schooling" at weekly institutional meetings, Subsequently the medical
graduates at CIN1.
officers attend classes and demonstrations along with health workers for a
period of 2-3 weeks.
All medical officers are sufficiently motivated and convinced about the
usefulness of growth monitoring.
Community participation
The major innovation in growth monitoring at CIN1 is the vigorous and
active participation of the community.
Their approach to achieve this by
organising Mahila Mandals at village levels is unique.
Youth clubs,
school teachers, panchayat leaders, traditional birth attendants and
village practitioners, have also been educated in growth monitoring and
nutrition education, for improved child survival.
79
Mahila Mandals: The women in C1NI project are organised into village
level "Mahila Mandals" (women’s club).
There are 17 MMs in the rural
area covered under PVOH programme and 5 in the urban slum 1CDS
Anganwadis. Each MM has 15-20 members,
These members are identified
with the help of local youth clubs and panchayat leaders.
Essentially these are women with a flare for social work,
percent of the members have some education.
About 50
Majority of the MMs
formed so far have been registered with the Registrar of Societies
making these accountable bodies.
The MM members weigh the children, educate the mothers on nutrition
and health and motivate them to utilize programme services.
They weigh children at the village level in mobile clinics and the
urban slums.
The skills of MM mothers j.n
Jn weighing are good.
cannot plot because they are not trained to do so.
They
However all of
them can interpret growth lines very well.
Each MM mother covers 4-5 neighbouring households,
Their
contribution to promoting growth and nutrition awareness among
members of the community is achieved through household visits
particularly for at risk, malnourished children and by organizing
periodic workshops for women.
The Youth Clubs are primarily involved in the education of their own
families and other community members on nutrition and health issues.
They occasionally participate in weighing activity at the mobile
clinics .and help during campaigns.
80
Supervision
The ratio of one supervisor to four health workers is appropriate.
The supervisors help with growth monitoring work, actually
participating side by side with the worker.
This allows an excellent
opportunity for supervisors to detect and correct deficiencies.
The
supervision in this situation is more intutive rather than through an
organised and objectivised manner.
The supervision of MH members is
primarily the responsibility of the health worker.
They check the
ability of the MM members in weighing correctly, giving education and
explaining findings on growth card to mothers.
The stress of supervision is not on administrative work but on actual
skills and the tasks involved.
Education and communication support
The programme has a separate communication division.
A significant
feature is the continued use of a professional advertising agency for
supporting communication activities.
They have succeeded in creating
an awareness about child growth and health promotion among the
community, mothers, teachers, village elders and lay public,
Key
activities and innovations are as follows:
*
Communication aids are developed with the active involvement of
the medical officers, health workers, nutritionists and other
field staff.
These are used within the project population and
sold to outside agencies to generate resources.
*
The methods used are relevant to the local social and cultural
milieu.
These include biscope (peep shows), puppet shows,
T-shirts, cassettes, posters and flip charts carrying messages on
growth and nutrition.
81
*
Mothers are actively involved in developing nutrition and health
messages through communication workshops.
*
Messages on nutrition and health are field tested periodically.
The field staff contributes actively in developing these.
*
MM mothers and health workers are trained in the use of
communication and education methods.
Communication support is an important feature of this project.
V.
SUMMARY: STRENGTHS AND CONSTRAINTS
1.
The project delivers a comprehensive package of primary health
services, in which Growth Monitoring is a pivotal activity.
2.
The nodal points of GM are a series of 10 clinics catering to a
population of 74,000.
There is no home based growth monitoring
activity.
3.
The coverage for monthly weighing in the 0 to 6 years age group
is about 50 percent,
Additional 30 percent are weighed at 2-3
monthly intervals.
4.
Nutrition education and periodic supervision is provided to
children detected to have loss of weight and severe malnutrition.
82
5.
Intense education targeted at the community motivates the
mothers to bring their children to the clinic for growth
monitoring.
In order to increase the monthly coverage and the
impact of GM, it is necessary to extend the activity to
domiciliary level.
6.
Skills in GM to health workers and Mahila Mandal members are
mainly provided as in-service training.
7.
The workers’ skill in growth monitoring is good.
Single major
lacunae is that trend lines are not made on the growth card.
8.
Women in the community contribute significantly towards
successful growth monitoring activity.
They serve as
motivators, educators, and growth monitoring workers for their
neighbours.
A similar contribution is made by youth club
members and school teachers.
9.
Growth monitoring receives appropriate communication support
with the assistance of a professional media agency.
10.
An innovative experiment has been started in an urban slum ICDS
block, where the local mothers are being used as growth
monitoring workers for neighbouring 4-5 households.
o
83
Annexure 1
CHILD IN NEED INSTITUTE (CIN1)
(Main Activities)
Health & Nutrition
Training
At CHETNA-CINI
1. Static clinics
l.ICDS Anganwadi
functionaries
-supervisors
2. Health workers for
CINI
3. Members of
community in
primary health
care and income
generating
activities:
* Mahila Mandal
Mothers
* Youth Club
Members
* School Teachers
* Practitioners
* TBAs
* Panchayat
Leaders
2• Mobile clinics
3. Mini clinic
4. Health campaigns
Income Generation
Agro and Farm
based
Child Sponsorship
& Family Helper
Programme
1. Agriculture
2. Poultry
3. Fishery
4. Dairy
Mainly from
foreign donations
National Training &
Extension Programme
on Smokeless Chullah
C1N1 Supported
Extension
Projects
- Moyena
- Halencha
- Sunderbans
Assistance
- Educational
Supports
- Clothing
- Health check up
- Income generating
activities
- Help in emergency
needs of family
(Continued)
84
Annexure I
Health & Nutrition
Training
AT CHETNA-CINI
5. Referral Services:
Institutional (CINI)
4.University
students
Intensive care
Pediatrict Unit
(ICPU)
- Nutritional
Rehabilitation
Centre (NRC)
Supplementary Feed
Production at
Institute
Headquarters
Integration with
ICDS Programme
(An experimental
effort to involve
mothers in growth
monitoring at
ICDS - anganwadi)
- Urban slum
Tollyganj, Calcutta
Research
- ICMR
- Nutrition
Foundation
of India
5 .Non-Government
Organization
Workers
6.Overseas Doctors
Income Generation
Agro and Farm
based
Child Sponsorship
& Family Helper
Programme
National Training &
Extension Programme
on Smokeless Chullah
C1NI Supported
Extension
Projects
Annexure I
85
2. ORGANISATIONAL STRUCTURE
£IN1- Chjld In Need Institute
DIRECTOR
I "
CHETNA-TRAINING CENTRE
HEALTH SERVICES
COMMUNITY NUTRITION 8c HEALTH
(PVOHO
~ I
Asst. Director
&
Pr i nc ipaI
Project Off i cer
URBAN SLUM
PROJECT
I
”
Project
Coord i nator
Project
Oft i cer
-------1.
Project Officers
(2)
Project Assoc. (4)
including
Nutr i t i on i sts(2)
Medical Officer (2)
I
Nurses (5)
Stat i st i c i an
(2)
Zonal Coordinator
(4)
Mon i tor i ng &
Eva Iuati on
MM Coordinator
(1)
HeaI th
worker
(1)
i
HeaI th
Coord i nator
(4)
HeaI th
Workers
(15)
Mah iI a
MandaIs
(17)
Mahi la
MandaIs
(5)
86
ANNEXURE III
JOB RESPONSIBILITIES OF KEY STAFF
Project Coordinator
Project Voluntary Organization in Health (PVOH).
Job Responsibilities:
- To plan, develop and maintain a data base for the surveillance area.
- Supervision and compilation of monthly and quarterly ’services’
report.
- To identify programme management indicators and monitor them.
- To identify health indicators and evaluate programme impact.
- Co-ordination of three major activities under PVOH namely - health
services, women’s organization and training of various community
members. It also jncludes financial supervision, administrative
responsibility and reporting.
Zonal Coordinator
Educational background: Science or Home Science Graduate
Job Responsibilities:
- Tmplements and coordinates programme activities in her zone
- Quarterly work plan for various village clusters
- Monthly work plan for each health worker
- Posting of health workers in her zone
- Supervises weekly zonal meeting held at CINI
- Compiles monthly reports
- Trains community members at CINI - Chetna
(Continued)
87
Annexure III
Health Coordinator
Job Responsibilities:
A senior and more efficient health worker of the zone
Supervises other health workers* activity in the zone
Organizes door to door survey for collection of demographic data
Attends all the clinics and camps in her zone and functions like a
health worker
Prepares monthly report
Trains mahila mandal workers at C1NI
Mahila Mandal Coordinator
Job Responsibilities:
A senior health worker or sponsorship case worker
Goes around the villages, meets youth club members, panchayat
leaders and influential ladies to organize mahila 'mandal in the
village
Registers mahila mandals with Registrar of Societies
Supervises the work of newly trained mahila mandal mothers
Co-ordinates the activities of mahila mandals
Helps in establishing mobile clinics
Participates in the clinics of the zone as health worker
Trains mahila mandal mothers.
(Continued)
8b
Annexure III
Nutritionist:
Educational qualification: B.Sc. Home Science and/or Diploma in
Dietetics
Job Responsibilities
Supervises health and nutrition education given by health workers
in various clinics
Organises food demonstration in clinics
Supervises dietary management of patients admitted for
nutritional rehabilitation
Trains health workers and community members
The Senior-Nutritionist is incharge of the communication wing
Organizes exhibitions in fairs and social get togethers
Principal
Chetna Training Centre - CIN1
Job Responsibilities:
Organizes training curriculum for all levels of health and
development workers in association with CIN1 Director
Participates in the training programmes
Clinical care of outpatients and inpatients
Medical Officers
Job Responsibilities:
Attend static clinics and camps
Care of patients admitted in intensive care ward and nutritional
rehabilitation centre
Train all categories of health and community workers
(Continued)
89
Annexure III
CINI Health Workers
Educational qualifications: Matriculate or S.S.L.C.
Job Responsibilities:
Organize and run various services at static, mobile and
mini-clinics and health camps, including treatment of minor
ailments.
May work as nurse in wards.
Collect demographic data by door-to-door survey in new areas.
Prepare monthly service reports for their village.
Field training of mahila mandal mothers and other community
members.
Health check-up of sponsored children.
May exchange role with child sponsorship case workers.
Total number of such workers in 25.
90
PROJECT
FOOR
PUBLIC HEALTH CENTRE
WEST MAMBALAM, MADRAS
TAMIL NADU
Contents
Page No.
1.
Overview
91
II.
Child health services
92
Services
Staff
III.
Growth monitoring activities
93
Delivery of Services
Tools
Impressions on GM activities
Objectives of growth monitoring pursued
IV.
Observations of the study team
1.
2.
3.
4.
99
Mothers
ANM
Dieticians
Pediatricians
V.
Training
104
VI.
Communications
104
VII.
Community participation
104
VIII.
Summary: strengths and constraints
105
91
I.
OVERVIEW
The Public Health Centre (PHC) is a multi-discipline health institution
situated in West Mambalam in the heart of Madras City.
It came into
existence in 1953 with the aim of serving the poor and low income groups
living in the surrounding areas.
The founders, who were all local
volunteers and later formed a trust, identified three major objectives of
the centre ”to provide high-grade medical help to the poor and the low
income groups; to involve the community in this service; and to depend as
little as possible on the government for help".
The PHC, which began as an out patient service run by two doctors in a
hut, has a well established set up for all major medical and surgical
specialities in a 60 bedded in-patient service and an out-patient service
with an annual attendance of over 36,000.
Both are supported by
reasonably well equipped diagnostic laboratories.
The Centre is managed by the Public Health and Welfare Society, a
voluntary organization and meets its financial needs through charges on
the services and voluntary donations.
Most clients of PHO are well educated and belong to the middle class.
II.
CHILD HEALTH SERVICES
Services
Child care was initially provided by a pediatric clinic twice a week.
1975, a full-fledged department was established under the aegis and
guidance of Dr S. Jayam.
department are:
At present the services provided by this
In
92
a)
Outpatient clinic
Daily outpatient services are provided in the morning and
afternoon.
day.
About 35 to bO children upto 12 years age are seen every
They mostly come from areas within a radius of 5-7 kms,
although some travel a long distance to avail of the services.
Children are seen by a pediatrician for ailments, growth monitoring
and immunization.
After being seen by the doctor, mother and child
go to the dietician who provides diet counselling.
services are also available.
Immunization
Interrogation with mothers revealed
that majority of children come for treatment of ailments (.55%),
followed by immunization (30%) and growth monitoring (15%).
b)
In-patient services
PHC has an embedded paediatric ward for sick children needing
inpatient care.
c)
Neonatal services
About 1500 deliveries take place in PHC every year,
are examined and weighed.
the lying-in ward.
All neonates
Common neonatal problems are managed dn
Emphasis is laid on the nutrition and health
education of the post-natal mothers.
bulk of outpatient attendance.
Children born here form the
The low birth weight.babies (birth
weight less than 2,500 gm) are identified and given special
attention on follow-up.
d)
Nutritional education
Three dieticians attached to this department provide nutrition
education to mothers in the lying-in maternity ward and in the
outpatient department.
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FHC has formulated a nutritious cereal-pulse ’Nandini Mix’
meant to be a weaning and supplementary food.
e)
Correspondence course on mother and child care (Aalochana)
f)
Sporadic activities
These include immunization campaigns, baby weeks, baby
competitions, etc.
As can be appreciated the services are only centre-based. No
outreach services are provided at present.
Staff
The key members of the staff include four paediatricians, three
dieticians and one Auxiliary Nurse Midwife (ANM).
III. GROWTH MONITORING ACTIVITIES
Delivery of Services
Periodic growth monitoring is carried out in the out patient
clinic.
The Auxiliary Nurse Midwife (ANM) weighs children and plots
it on the growth card.
to the doctor.
She does not give any advice which is left
The child is also seen by a dietician in the
adjoining room who performs other anthropometric measurements, viz.
head circumference, chest circumference, mid arm circumference,
length/height.
She also maintains a duplicate record of weights.
Nutrition education is. given by the doctors and dieticians.
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The recommended frequency of growth monitoring is: every fortnight
upto three months; then every month till 12 months of age.
The
frequency of GM is variable after this age and it depends on the
individual discretion of the physicians.
PHC cims at GM till the
age of 5 years.
The growth card and a health booklet are issued with initial entries
at the time of discharge in case of children born at the PHC. For
children born elsewhere the growth card is issued at the time of the
first visit. Growth card and the health booklet are ’tickets’ tor
seeking any service from the paediatric OPD of PHC.
In case a child is detected to have growth faltering or PEM, the
mother is educated to provide adequate calories and proteins through
a nutritious diet,
They are advised to make fortnightly visits for
monitoring growth,
The diet advised usually consists of ingredients
available at home except that PHC does recommend ’Nandini Mix* (a
cereal-pulse mixture developed, manufactured and sold at PHC) as an
additional nutritious, easily digestible food suitable for
children.
Supplementary feeding is not given at the PHC.
Although a great majority of children attending PHC belong to the
neighbouring colonies, there is no effort in reaching them through
extension services for the purposes of inducing mothers to bring
children to the centre for GM or conducting GM at the households.
Tools
a)
Growth card
PHC uses the ’Road to Health’ card.
years.
It caters to children 0-6
The card has space for advice on breast feeding, solid
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foods, immunization, family planning advice, reasons for
special care, description of other family members and the
problems on follow up.
As stated, periodic growth monitoring is available for low
birth weight,
The growth cards in use are not designed for
this group.
Since some of these babies may be premature, the
growth curve in the card must also incorporate trend during
last phase of third trimester.
b)
Health booklet
A health booklet prepared by PHC is issued to the mothers at
the time of discharge from the lying-in ward.
This has
provision for recording serial anthropometric measurements,
milestones, immunization and subsequent problems and
management.
c)
It does not have any growth card in it.
Anthropometry register
The dieticians maintain a duplicate record of the
anthropometric measurements in the register which is kept at
PHC.
It has a copy of the growth card.
Serial weights are
supposed to be recorded in a tabular form as well as plotted in
the growth card.
Other anthropometric measurements are
recorded in a tabular form.
d)
Weighing scale
The PHC uses a platform type [Tulaman
(R) ] machine made in
Hyderabad which is normally used for bulk weighing at the
godowns.
The machine has a platform of 65cm x 42 cm and the
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vertical bar of 111 cm.
The machine measures the weights
ranging from 100 gms to 300 kgs.
It is an all-metal heavy
instrument and cannot be transported from place to place.
The child is placed or made to stand over the platform of the
machine and balancing is done by moving the pointer block over
the beam.
The zero error is corrected only by the mechanic
sent by the manufacturing firm.
There is no practice of checking the accuracy of the machine
with standard weights routinely.
No significant breakdowns
have been reported since this machine was installed over three
years ago.
Impressions on growth monitoring Activities
a)
Weighing activity
The pediatric out patient department is a relatively crowded
part of the PEG.
Mothers wait for their turn with patience.
It may take upto 2 hours to have the child seen.
The waiting
period is not used for group discussions or any other form of
health education activities.
As soon as the mother and child arrive there, the ANN weighs ,
the child and plots it on the card.
Observations of over 20 children revealed:
(a)
Child is weighed with clothes on.
asked to remove shoes.
Older children are
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(b)
Mothers feel the weighing scales are safe.
(c)
Weighing machine is accurate and does not have a zero
error.
(d)
ANM is confident.
(e)
She does not interpret the growth lines and refers the
She weighs and plots accurately.
child to the doctor and through him to the dieticians for
nutrition and health education.
They interpret the growth
lines and talk to the mother regarding weight gain or
weight faltering.
(f)
Fifteen percent of eligible children attending the out
patient clinic do not possess a card.
(g)
Several anthropometric measurements besides weight are
recorded, but apparently these are not being used for any
definite purpose.
b)
Action response
The doctors advise feeding and the management of
morbidity, if any, in case of growth faltering or
malnutrition.
The dieticians reinforce the nutritional
education with regard to the actual foods which should be
given to the child.
According to the pediatricians, the children with deviant
growth are called for more frequent evaluation,
there is no separate clinic for them.
however,
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c)
Frequency of monitoring
An analysis of the Anthropometry Register kept at the PHC
(Table 2).
was done
The records of visits by 81
children, 7 to 9 month old at the time of the case study
were examined.
Each child paid a mean of 2.7 visits in
comparison to an expected number of 10.5 visits as desired
by the staff of the PHC.
As many as 54 per cent of them
had paid visits less than one fourth of the desired
number.
Thirty six per cent visited the PHC only once.
This poor follow-up, according to the physician, might
have been due to insufficient recording.
Our impression based on this data and the interrogation of
mothers is that usually monthly visits are achieved in the
first 3-4 months of life.
Thereafter, the frequency
declines.
TABLE 2
Break up of visits by 81 children aged 7-9 months
Number of
Visits
No. of children
who paid visits (n=81)
Per
centage
1
2
3
4
5
6
7
8
29
15
15
9
4
4
2
3
(35.8)
(18.5)
(18.5)
(11.1)
(4.9)
(4.9)
(2.5)
(3.7)
N.B.* Mean number of visits paid - 2.7 per child
* Number of visits desired by the staff of PHC = 10.5 per child
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d)
Objectives of growth monitoring pursued.
PHC pursues following objectives of growth monitoring in the
present set up:
i)
Early detection of growth faltering and malnutrition and
follow-up thereof.
ii)
Entry point and an effective vehicle for nutrition
education and motivation ui mothers, as well as for
comprehensive health care activities.
iii)
Identification and follow-up care of low birth weight
babies.
These children are the focus of more frequent
growth monitoring (fortnightly) and more intense education
of the mothers.
Their follow-up is also inadequate after
6 months of age, although it is better than other children
due to the extra effort.
However, even this short period
of regular growth monitoring serves a useful purpose; it
provides sustenance and support for unhindered growth
during a very crucial phase, thereby enhancing their
chances of survival.
Unfortunately, no domiciliary
follow-up lis attempted.
IV.
OBSERVATIONS OF STUDY TEAft
1.
MOTHERS
The study team interviewed 60 mothers at the outpatient department
(Table 2).
All except 3 were literate and as many as 80 per cent
were educated upto 12 class or more.
visits to the PHC.
They had paid a mean of 4.7
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It is noteworthy that none of the children attending PHC during our
visit had grade III or IV PEM.
Over half (55%) of them had normal
weight for age.
Mothers were shown 3 cards with simulated growth curves, depicting
normal, faltering and malnourished state.
Significantly, 75.0, 66.0
and 70.0 per cent mothers could correctly interpret these patterns,
respectively.
Interestingly, over half of even those mothers who
did not possess the growth card could also interpret the curves.
A
majority of mothers have fairly good understanding of the health
education messages shown on the cards,
The rationale of the
periodic growth monitoring was clearly understood by almost 80 per
cent of the mothers interviewed.
They showed a remarkable degree of
knowledge about normal feeding, duration of breast feeding, causes
of poor weight gain and immunization.
The awareness and preparation
of oral rehydration solution was not encouraging, as also
appropriate feeding during diarrhoea.
The mother-child pairs attending PHC belong to a relatively well-off
group of population.
It is indicated by the fact that they have to
pay at least Rs.3/- for each consultation.
They are also well
educated and reside in the heart of the city.
Thus, they have
access to other means of communication, including lay press,
television, radio, etc.
Then there is the team of doctors and
dieticians who lay special emphasis on growth and nutrition.
In the above scenario it seems but natural that KAP of mothers with
regard to GM and other primary health care modalities would be of a
high order.
When questioned, mothers admitted that they had
improved their understanding of child growth and feeuing through the
explanations given by the PHC staff.
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Table 2:
Assessment of mothers* KAP and skills
Variables
(a)
Percentage of mothers
Responding in Affirmative(n=bU)
Growth monitoring
Growth monitoring is useful for my child.
Understand purpose of GM
Approve of monthly frequency of weighing
(b)
Growth card
Produce growth cards
Understand messages printed on card
(c)
(e)
(f)
60
70
15
Feeding of children
Correct duration of breast feeding
Correct age for additional solid foods(6-12 months)
Appropriate foods from 7 months to 2 years:
100
80
Excellent
Very Good
Good
Fair
Poor
25
20
20
20
15
Diarrhoea management
Aware of ORT
Know correct preparation of sugar-salt solution
Diet:
60
40
Same or more than that preceding illness
Decrease intake
Superstition about useful foods
20
20
20
Correct interpretation of growth card
Normal growth
Growth faltering
Malnutrition grade III
Cg)
85
70
Causes of deviant growth
Lack of dietary intake
Frequent or recurrent illness
Failure of breast-feeding
(d)
90
80
65
75
66
70
Skills
Weigh a child
Plot a growth card
15
10
102
2.
ANM
The ANM was interviewed at length.
She has been working at the PHC
for over three years but has been involved in the weighing activity
only for a period of 5-6 months.
Her basic training of a total of 9 months is limited to maternity
On joining the PHC she worked in the pediatric wards and
care only.
acquired experience in looking after children.
Her training in
weighing and plotting growth card is in-service and informal through
interaction with the physicians and dieticians of the outpatient
department.
She is not involved in imparting health education to
Also, her involvement with mothers appears to be quite
mothers.
superficial.
On direct questioning, it was found that she has a fair idea about
virtues of weighing, causes and consequences of poor weight gain.
Her knowledge is unsatisfactory with regard to infant feeding
practices.
She considers orange juice and carrot juice superior to
She identifies normal and PEM growth curves but not
rice and ’dal*.
growth faltering.
She believes in stopping breast milk in
diarrhoea; curd in respiratory illness and buttermilk and rice in
fevers.
Her knowledge about immunization was excellent.
She does
not know the method of preparing oral rehydration solution, She is
good at taking weights and plotting them on the card accurately.
However, she does not have any concept of zero error,
These lacunae
indicate need for improved supervision.
3.
DIETICIANS
The study team interviewed the 3 dieticians.
They hold either a
postgraduate degree in nutrition (2) or a one year diploma in
nutrition (1).
They only have a theoretical exposure to GM and
growth cards.
All of them are with PHC for the last 8 months.
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The dieticians give correct interpretation of the sample growth
curves. Although their knowledge of childhood nutrition is
adequate, they do not know how to calculate the calories of common
foods•
ORS.
They know the composition and method of preparation of
They do not know the accurate method of taking mid-arm
circumference.
On direct questioning, they frequently admit that
they are not satisfied with the type of work being carried out by
them,.
They prefer prescribing therapeutic diets in various
systemic disorders, rather than feeding in infancy and childhood.
4.
PEDIATRICIANS
The trained pediatricians of the PHC are the pivotal personnel
responsible for the services rendered to the children, We
interviewed two of them (the other two, including their chief were
unavailable) .
The physicians have sound knowledge of their subject as a whole.
They sincerely believe in the role of GM as a critical tool of
primary health care and are committed to using it in day-to-day
care.
Their interpretation of normal and deviant growth is
impeccable.
Their action response is appropriate.
They emphasise
the role of the mother and overwhelmingly subscribe to the
philosophy of preventive and promotive health care.
However, their role in supervision and in-service training (of ANN
and dieticians) leaves much to be desired.
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V.
TRAINING
PHC does not organise any regular training programms.
The
training of different staff members is already discussed in
respective sections.
VI.
COMMUNICATIONS
Following tools of communication are employed at the PHC:
1.
Posters
Posters in Tamil and English are put up on the walls of the
outpatient department.
feeding.
2.
They deal with ORT, immunization and
There are none on growth monitoring.
"Aalochana"
This is a UNICEF supported correspondence course started in
1983.
The objective is to impart knowledge on mother and
child care to the target group of prospective mothers.
of Rs 75 is charged for 12 lessons.
A fee
The contents of the
lessons include antenatal care, childhood feeding care of low
birth weight babies etc.
VII.
COMMUNITY PARTICIPATION
A parents’ club consisting of about 15 mothers of children born at
the PHC was started about two years.
They meet once every 2
months informally with the pediatricians of PHC to have a dialogue
to solve problems encountered by them in rearing their children.
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VIII. SUMMARY: STRENGTHS AND CONSTRAINTS
Since the educational and socio-economic background of the
mothers is
of good standard, the Public Health Centre, Madras, is not found to be
an appropriate model for assessing the role and use of growth monitoring
in the setting of an outpatient clinic in a peripheral urban location.
The babies born at the PHC are introduced to the concept of growth
monitoring and the use of a growth chart for achieving optimal growth in
the lying-in ward when the motivation is very high.
The interrogations
of some mothers whose babies were born in Public Health Centre,
indicated that most of them do achieve an understanding of the growth
card and feeding.
A high GM coverage is achieved during first j to 4
months of life, the follow-up declines thereaafter.
All but a few
children who attend Public Health Centre outpatient clinic, are issued a
card and weighed.
clinic.
Nutrition education receives a key place in the
Those who do come for regular growth monitoring receive intense
education and fortnightly followup’s.
The low birth weight babies are
given more attention and emphasis but there is no domiciliary follow up.
Weighing at birth at PHC ensures identification of the low birth weight
babies.
Extra attention, more intense nutrition education to mothers
and a fortnightly growth monitoring especially for first few months
contributes significantly to enhanced chances of survival.
The
monitoring of low birth weight babies can be strengthened through
domiciliary visits.
The question arises - can growth monitoring be practiced in its true
sense in an outpatient clinic setting?
It is difficult to expect
children born at the Centre but living far away to visit every month for
weighing.
However, regular monitoring for growth can be extended to
the neighbouring locality.
The education targeted to these areas could
motivate them to bring children to the clinic for weighing and with some
rationalization of duties of the available staff, home based activities
are possible to incorporate.
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