A MULTI NUTRIEHT PACKAGE FOR TEA PLANTATION WORKERS FOR BETTER HEALTH, PRODUCTIVITY AND PROFITABILITY
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- Title
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A MULTI NUTRIEHT PACKAGE FOR TEA
PLANTATION WORKERS FOR BETTER
HEALTH, PRODUCTIVITY AND
PROFITABILITY - extracted text
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A MULTINUTRIEHT PACKAGE FOR TEA
PLANTATION WORKERS FOR BETTER
HEALTH, PRODUCTIVITY AND
PROFIT ABILITY
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TARA GOPALDAS AND SUNDER GUJRAL
TARA CONSULTANCY SERVICES
BANGALORE, INDIA
1998
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CONTENTS
Acnowledgements :
Executive Summary :
Chapter One
: Introduction and Rationale
Chapter Two
: Overall and Specific Objectives
Chapter Three
: Participatory Plan of Action
Chapter Four
: Methods
Chapter Five
: Results
Section A
Section B
Section C
Section D
Chapter Six
: Discussion
Chapter Seven
: Recommendations
References
PAGE
Ill
Title of the Project : A Multinutrient Package for Tea Plantation Workers for Better
Health, Productivity’ and Profitability.
Contract Number
: This project was made possible through a research grant received frc
the Human Nutrition Institute of the International Life Scienc
Research Foundation (ILSI), USA under the Cooperative Agreeme
Number HRN-5122-A-00-3046-00(“CA”) with the US Agency i
International Development (US.AID).
Date of Initiation
: 1st April. 1996
Date of Completion
: 31 st March, 1998
Primary Contact at ILSI
: Dr. Paula Trumbo
Associate Director. Human Nutrition Institute. ILSI.
Washington D C, USA
Technical Monitor and
Adviser
: Professor Barry M.Popkin
Professor, Department of Nutrition
School of Public Health, University of North Carolina
Funder : Opportunities for Micronutrient Initiatives (OMNI) and the International Life Scienci
Research Foundation (ILSI) USA
Project’s Technical Teams
Study Estate
Dr. Vijay Kumar, Medical
Officer, Study Estate Plantation Hospital
Ms Claramma, Head Nurse
Mr. Micheal, Compounder
Mr. Ratnagar, Head Wardboy
Mr. Ramesh, Adhoc staff
Support Staff
The Administrative office in-charge
of MIS Systems
Tara Consultancy Services
Professor Tara Gopaldas, Project Director
Professor Sunder Gujral, Project Coordinator
Mr. K.K. Bansal, Director, Information Systems
Dr. Arati Singh, Research Associate
Dr. S.Ajeet, Research Associate
Dr A.Santosh. Research Associate
Mr. S.John Suresh, Lab Technician
Support Staff
Ms Malavika Sanadi )
Ms B.Kavita
) Secretarial Staff
Mr V.K.Murthy, Driver
(1)
exeeuzjvs summarv
A Multinutrient Package for Tea Plantation Workers for Better Health, Productivity and
Profitability
I. The Focus and Objectives of the Study :
=> To try and reduce the ‘Hidden Hunger’ for iron, iodine and Vitamin-A in the entire
workforce and their families on a Tea Estate in South India.
=> To intervene for nine months with a multinutrient package of supplemental iron and
Vitamin-A; and iodized salt.
=> To jointly plan and implement the Demonstration cum Research-Action Project with
the Management of the said Tea Estate.
=> To evaluate the improvement if any, in health, worker productivity and profitability.
II. The Plan of Action and its Implementation :
The Plantation District of Chickmagalur is endemic for Iodine Deficiency
Disorders(IDD). It also has high prevalence of Iron Deficiency Anemia (IDA); and
Vitamin-A deficiency (VAD). The intervention package consisted, therefore, of all the
three micronutrients.
The Study Design :
Balanoor Plantations and Industries Ltd., situated in Chickmagalur district of Karnataka
State, South Western India was our Study Estate. The entire workforce of 617 (pluckers
and non-pluckers) and their families (approximately 2000-2500 individuals) were the
beneficiaries of the micronutrient intervention of 9-months-duration.
The During Intervention period was from August’96 to April'97. The Internal Control
for the study was a Pre Intervention period of August'95 to April’96. In addition an
External Control Estate (Devon Plantations and Industries Ltd.) was included for the
comparison of key agricultural statistics of Rainfall, Crop Yield (kg/ Hectare) and
Average Tea Plucked/ worker/ day in the corresponding Pre and During Intervention
periods.
The Micronutrient Intervention:
The micronutrients consisted of 240mg ferrous sulphate delivering 60mg elemental iron
twice a week; 1600IU Vitamin-A + 400IU Vitamin-D once a week; and heavily
subsidized iodized salt (30ppm) for daily cooking for the whole family. The medicinal
(ii)
supplements of 250 tablets of iron and 125 capsules of Vitamin-A were filled in screw
top plastic containers to last a family of 5 members for 5 months. They were handed over
at the Baseline Survey in August’96 to each Worker; and refilled again in December’96
to last another 5 months. The cost of the micronutrients/ family/ year was Rs.61.50 or
Rs. 12/ family member. Except for Vitamin-A the other two inputs were freely available.
Self -Dosing:
The Workforce was empowered and held responsible for the dosing of self and all his/
rer family members.
[nformation-Education-Communication (IEC):
X simple IEC sheet was developed on the dosing regimen and benefits in Kanada (major
ocal language) and was distributed to the workforce and supervisors at frequent intervals
hroughout the Intervention period. The supervisors/ gang leaders were made responsible
o transmit the IEC to their workers/ pluckers.
The Division of Tasks Between the Study Estate and Tara Consultancy Services (The
tesearch Team)
Vhat the Study Estate Did
> Implemented the Micronutrient Intervention.
> Procured the Iodized salt and sold it at a subsidized rate of Rs.2/- kg Vs Rs.5.50 in the
open market.
> Maintained the necessary Registers and sent monthly reports to TCS.
> The Medical Officer continuously trained the implementing staff.
/hat TCS Did :
> Developed the Plan of Action in consultation with the CEO and Management.
> Developed a simple and sustainable research design.
> Oriented the CEO and Management; trained the medical/ health staff.
> Jointly developed the Information-Education-Communication (IEC) in the major local
language, Kanada.
Studied and made use of on-going data systems, namely, hospital registers and
computerized Management Information Systems (MIS) on crop yield, average tea
plucked, attendance etc.
Collected, analyzed and interpreted Primary and Secondary Source data.
_____ ILL
% Recieving the
Multinutrient Package
Pre
N
I
During
(2)
% Regularity of Use
During
(9 Months Intervention)
August ’96 to
December ‘96 (4-1/2
months)
99%
(N=334)
(4)
Hb Levels (g/dl)
_ Average Tea Plucked/ Plucker/ Day (kg)
Pre
Months
During
Pre
N
Regular
54%
(N=I8O)
L
December ’96 to
April ’97 (4-1/2
months)
99%
(N=334)
Overall 99%(N=334)
(3)
Regular
II 1g
(N=180)
Regular
120g*
(N=180)
August
327
September 313
October
326
November 324
December 326
January
313
February
311
March
305
April
322
Mean
N
Mean
25.7
24 8
29.2
27.7
22.4
17.3
176
16 1
24 8
315
322
315
321
315
268
317
288
302
27.4***
34 4***
25.9***
16 3*
20 5***
18 6***
24 2 Ns
Overall
22.90
2763
Overall
25 60*#*
Irregular
44%
(N=147)
Irregular
109g
(N=147)
Irregular
11 8g*
(N=147)
Stopped
2%
Stopped
11 0g
(N=7)
Overall
Stopped
H 3g
(N=7)
11 0g
11 9g***
2857
lm.~m.on ealeulat„g
Ave„8e Tea p|ucked
__________ (N=7)
Overall
About half were Regular
the p
Pi"
: ” XL’aur sample was available at both
“ ""
re
Overall
During
33 6***
27 6**
This is
Regular is
meanl ““ a "“k
m0,”hs u,Krvm“"
Iron and Vitamin.A "" ’ V'“,""'A oll“ ‘ ”'eek. "d iwiiaed sah daily m conking
Significant at p<0 01, * Significant at P<0 05, NS Not S.gnificant
I
i
i
i
[ thank OMNI-ILSI, USA for awarding us one of their prestigious research grants for
designing and executing this ‘Plantation Project’ in Karnataka, Western India. We could
lot have had a more warm-hearted and understanding primary contact at ILSI, than
Dr.Paula Trumbo, Associate Director of the Human Nutrition Institute, ILSI. We have
greatly appreciated the scientific acumen and prompt advice given to us by Professor
Barry Popkin, the scientific Monitor and Adviser from the OMNI-ILSI side for this
iroject.
fhis project would not have seen the light of day if my good friend and neighbour
vlr.Dev Mukerjee, former Chairman, Consolidated Coffee, had not introduced me to
vlr.Ashok Kurien, the young and dynamic CEO of Balanoor Plantations and Industries
Jd., in 1995. After many visits from Baroda to Bangalore, and many useful discussions
vith Mr. Kurien, my education on what happens on a Tea-Estate commenced. I have
bund this young CEO to be a straight shooter. He has kept his word regarding what he
nd his Management on Balanoor Estate could do and could not do. It has been a
Measure to work with him; the Balanoor Estate Manager, Jeevan Belliappa and his most
rilling and energetic staff; Eh. Vijay Kumar the Medical Officer of the Plantation
lospital at Balanoor and all his health staff; all the Supervisors or Gang Leaders and all
le 617 Workforce and their families who were the target population for this
Jemonstration cum Research-Action-Project. I am grateful to Mr.Vasudev, Manager of
)evon Plantations and Industries Ltd., who very kindly came to our rescue in September,
997 and provided us with key agricultural and/ other statistics on the Devon Plantations
nd Industries, which served as our External Control Estate.
his Project would not have been successfully completed but for the untiring efforts of
le Coordinator of the Project, Professor Sunder Gujral (my research comrade of
inumerable research projects spanning two decades); Mr. K.K.Bansal, Director of
iformation Systems, Baroda for the never-ending data processing and analysts that was
>sociated with this particular project; my excellent young doctors and the lab-technician
ho helped us at the Baseline and Resurveys; and the excellent support that the
lantation team obtained from its Management; as TCS did from its support staff.
would like to thank Dr.K.T.Achaya and Mr.Dev Mukeijee for kindly offering to review
e first draft of the report.
Prof. Tara Gopaldas
ate : March, 1998
Director, Tara Consultancy Services,
Bangalore
1
Chapter One - JNZKOOUCZJO^l AMD
KA ClOftACS
FOCUS OF THE PRESENT STUDY:
The focus of this OMNI-ILSI funded Demonstration cum Research Action Project
on ‘"A Multi-nutrient Package for Tea Plantation Workers for Better Health,
Productivity and Profitability” was the Workplace. Plantations are generally
bypassed by the Government’s Primary Healthcare system. Further, the focus of
this research project was to work as an equal partner with the Management of the
Tea Estate and to demonstrate to them the simplicity and cost-effectiveness of the
above intervention. The multinutrient package consisted of iron + Vitamin-A
supplementation + iodized salt.
India with a total tea production of around 780 million kilograms(kg) in 1996, is the
largest producer of tea in the world. It accounts for very nearly 30% of the global
production of tea. India also happens to be the largest consumer of tea in the
world. In fact domestic demand for tea has outstripped production inspite of
phenomenal technological advances in increasing tea-crop yield or its productivity.
The same zeal, however, has not been extended to increasing human productivity
although "plucking is a highly cost and labor intensive process of tea manufacture.
This step of the manufacturing process accounts for most of the employee costs
(IX
In the sub-continent of India, concentration of plantations, namely, tea, coffee,
rubber and spices are the strongest in South India followed by the North-East for
tea. Plantations are distinct entities which are managed by large Companies,
Corporations, or Single-owners, with management practices of efficiency flowing in
a descending order (2). The health and welfare of the plantation workers are
generally the responsibility of its Management. The plantation sector employs about
a million workers who support roughly another 5 million dependents. The Tea
Industry is unique in that it employs about 40 to 50% women workers. The
permanent work force live on the plantations. Hence, there is great potential to
design continuous and large-scale, micro-nutrient and related health interventions for
these large "captive’ and "accessible for services’ worker groups.
The United Planters of South India (UPASI) is a highly respected and powerful
association of Plantation Managers/ Owners of all types of plantation produce.
2
They are Worker and Welfare-oriented and are amenable to suggestions to improve
the well-being and therefore, the productivity of their workers. In the eighties,
UPAS I supported a “research-action” project in the tea-plantations of Kerala where
Rahamatullah (3) demonstrated that the Hb levels of female plantation workers
(mostly of the child bearing age) were very low by the Sahli's method (6 1g Hb/ dl).
Daily Iron supplementation with Ferrous Sulphate tablets (65 mg elemental iron)
significantly increased Hb levels and the average plucking yield of tea leaves per
supplemented worker also increased. The intervention did not consider the other
micronutnents such as Vitamin-A and iodme.
The classical studies of Basta et al (4) clearly demonstrated the relationship between
Iron Deficiency Anemia (IDA) and productivity of adult male, rubber plantation
workers in Indonesia. The Hb concentrations of these workers were 11.0 to 11.9
g/dl. Gardner et al (5) also established the interrelationship between physical work
capacity (PWC) and work performance among female tea plantation workers (26-62
years of age). A wide variation in Hb concentrations from 6.1 to 15.9 g/dl was
reported. In another Sn Lankan study Edgerton et al (6,7) reported very low Hb
levels in the tea plantation workers of 6.0 to 9.0 g/dl with substantial improvement
in plucking performance after iron supplementation. Kalita (2) also reported low Hb
levels among male and female tea plantation workers of Assam. She reported that
an intervention of anthelmentic, iron and vitamin C, had the best impact in raising
Hb levels among various combinations of the three inputs (8).
The intervention package of iron + Vitamin-A + iodine was selected due to its
epidemiological need on the plantations (9); and its cost-effectiveness and its
excellent success in improving the health and nutritional status of school children in
Gujarat, Western India(lO).
We would like to restate that the central focus of this study was Demonstration
cum Research Action. Its central purpose was to convince and empower the
management and the workers themselves to continue with the intervention after we
had phased out. Its central purpose was to prove to them and their medical/ health
staff that by using well accepted ‘Before’ and ‘After’ impact parameters such as
hemoglobin status, anthropometric status, dietary and nutrient intake status, clinical
status and morbidity status, that it was possible to improve the health and nutritional
status of the majority of the 600 odd workers and their families (tea pluckers and
non pluckers) on the Study Plantation. It was also possible to use the excellent
computerized data of the Study Estate on crop yield, rainfall, average tea-plucked
per worker per day, attendance etc. from their own on-going ManagementInformation-Systems (MIS) to augment our research data. This helped to
convince them as well as us that tea-plucker productivity had indeed gone up.
Especially so, as it had not in the Control Estate.
We were exceptionally fortunate to have obtained tremendous cooperation and
comradeship from our Study Estate - the Balannor Plantations and Industries Ltd.
located in the beautiful tea and coffee plantation district of Chikmagalur in Western
Karnataka, India. We were also very fortunate to have obtained the cooperation of
Devon Plantations and Industries Limited, a sister estate some 30kms away from
Balanoor, as our Control Estate for the comparison of some key statistics on rainfall,
average crop yield and average tea plucked. Both these estates were managed by
the same Corporate House located in Bangalore (the capital city of Karnataka).
In the following chapters we unfold our ‘plantation story’.
A
Chapter Zwo -
OKjeezjvss
SP8CJ3JC
OVERALL OBJECTIVE :
The overall objective of this Demonstration cum Action Research Project was to
demonstrate and evaluate if one could improve the health, productivity and the
profitability of the workers on a Tea Estate by delivering a simple, cost-effective
and sustainable micronutrient package of medicinal iron + Vitamin-A
supplementation and iodized salt to all the workers and their families over a 9months-intervention period.
PLAN OF ACTION OBJECTIVES
i. To Develop a mutually agreed upon Plan of Action with the Management of the
Study Estate.
ii. To empower and train the Medical and Health Staff of the Study Estate with
respect to the procurement and the dosing pattern of the micronutrients; in the
maintenance of registers/ records required for the Process Evaluation; and in the
conduct of the Impact Evaluation.
iii. To jointly develop a simple Information-Education-Communication System on
the Micronutrient Intervention, for the Management, Supervisory staff and the
Plantation Workers.
iv. To empower and train the workers to dose themselves and their family members
at the household level.
v. To scrutinize the ongoing computerized Management-Information Systems
(MIS) of the Study Estate for incorporation into the Plan of Action.
n. To compare the Study and Control Estates for the Key Agricultural Statistics of
rainfall, average crop yield and average tea plucked.
PROCESS, IMPACT EVALUATION AND COST
EFFECTIVENESS OBJECTIVE
PROCESS OBJECTIVES
ssues Important to the Management
Average Tea Plucked (kg/ worker per day) in the Pre Intervention Period
5
(August 1995 to April 1996) and the During Intervention Period (August ’96 to
April ’97).
ii. Percentage Tea Pluckers (matched data) who plucked more in each successive
month of the During Intervention Period relative to the Pre Intervention Period.
iii. Number of tea pluckers employed per month in the Pre and During Intervention
period.
iv. Month by month absenteeism among the pluckers in the Pre and During
Intervention periods.
v. The influence of gangs on the Average tea plucked (kg/ worker/ day) in the Pre
and During intervention periods.
vi. Reduction in referral to hospitals in the During Intervention Period relative to the
Pre Intervention period.
Additional Issues important to the Research Team
vii. Regularity of use of the Micronutrients in the During Intervention period.
viii. Distribution of the Information-Education-Communication sheet by the
supervisors to their workers.
ix. Knowledge of the supervisors and workers regarding the Dosing Pattern of the
micronutrients and their benefits.
IMPACT OBJECTIVES :
i. The Impact of the Intervention on the Nutrient Intake of the female pluckers.
ii. The Impact of the Intervention on the clinical signs of iron, vitamin-A and iodine
deficiency.
iii. The Impact of the Intervention on hemoglobin status.
iv. The Impact of the regularity of use of the micronutrients and Hb status.
v. The Impact of the Intervention on prevalence of Iron Deficiency Anemia (EDA).
vi. The Impact of the Intervention on the ‘plucking average’ by the Good, Moderate
and Poor Pluckers.
vii . The Impact of the Intervention on Body Mass Index.
viii. The Impact of the Intervention on Common Health Problems.
ix. The Impact of the Intervention on regularity of use of the micronutrients and
perceived health status.
x. The Impact of the Intervention on Hb status and attendance.
COST EFFECTIVENESS OBJECTIVES :
i. The cost of the Micronutrient Inputs Per Worker and his/ her family per annum.
ii. Cost of the Micronutrient Inputs per person per annum.
iii. Cost -effectiveness in terms of number of Tea Pluckers employed in the Pre and
During Periods of Intervention.
Chapter three - PAKCJCWACOKVPCJW
OJACCJO^
1. THE STUDY ESTATE :
Our Study Estate, namely, the Balanoor Plantations and Industries Ltd. is situated
in Chickmagalur district of Karnataka State in South-Western India. It is one of
the largest engaged in tea and coffee production.
The Study Estate is situated at an elevation of 1200 feet above sea level. It gets an
average ramfall of about 100 inches/ year. It has a total area of 932 acres covering
the four villages of Yelemedalu, Murgadhi, Vetebachal Khan and Kulur. Out of its
total acreage, a little over 762 acres is under plantations - of which 552 acres are
given to tea cultivation and 210 acres to coffee cultivation. The Study Estate has a
Tea Factory located on the estate. The Head-Office of the Study Estate is located
at Bangalore, the State Capital of Karnataka. The Chief Executive Officer (CEO)
is Ashok Kurien who is responsible for the numerous Welfare Schemes for the
Workers. At the estate level, the day-to-day operations are carried out by Jeevan
Belliappa, the Manager. He is assisted by a Junior Manager, Supervisors,
Maistries and the male and female labor force.
The Study Estate employs over 600 workers (male and female; tea-pluckers and
non-pluckers). It has been in operation for over a century and possibly has third
and fourth generation workers hailing from the plains of Karnataka, coastal Kerala
and even the nearby State of Tamil Nadu. The permanent workers who live on the
estate have meshed and melled into a distinct ‘plantation community’ of their own.
Four mother-tongues, namely, Kanada, Tulu (a dialect of nearby Mangalore),
Malyal am (the mother-tongue of Kerala) and Tamil (the mother-tongue of Tamil
Nadu) are all spoken on the estate! The majority of women (about 350) are teapluckers in the tea-gardens. The men by way of contrast (about 300) are engaged
in the tea-factory, the estate office, for various agricultural duties, and in the
growing areas.
As per the Comprehensive Labor Welfare Schemes (CLAWS) proposed by the
United Planters of Southern India (UPASI) the Study Estate provides the following
to all its employees as under :
=> Free Medical Treatment
=> Free Creche Facilities
=> Sickness Benefit
=> Free Housing accommodation
=> Leave with wages
=> Way expense
=> Maternity Benefit
=> Family Planning Operation Incentive
=> Reading room with new-papers
=> A Canteen
=> Recreation Expenses
This enlightened estate Management has provided the majority of its workers with
free housing (three rooms and a toilet); free electricity; and free potable and piped
water. It has also provided for all its employees the following amenities.
=> A ten-bedded hospital managed by a fully qualified doctor. Dr. Vijay Kumar, a
Head Nurse (Claramma), a Compounder (Micheal); and a Head Ward boy
(Ratnagar).
=> Two creches with trained ayahs where the mothers can leave their ‘below 3s'
and come in at two breaks to breast-feed their infants.
=> An Anganwadi or pre-school to cater to the “three to six years-olds" with a
trained staff to look after the children.
=> A Primary School for the ‘above 6 to 12 year-olds' with trained primary
teachers.
=> A ration shop where rice is issued at a subsidized rate every week. During our
9-months intervention, the Management went out of their way to procure and
stock only a reputed brand of iodized salt which was also made available at a
subsidized rate (please see later for details).
=> A canteen with TV sets, radio, newspapers and various indoor/ outdoor games.
=> The managerial staff is provided with beautiful furnished bungalows.
As per the current Labor Acts inforce, a worker has to be paid a mimmum wage of
Rs.43/- day. A plucker, gets this minimum wage provided he/ she plucks atleast
14kg tea leaves per day. The tea plucker is given a cash incentive for tea-leaves
plucked over and above the minimum 14 kg as under :
15 to 20 kg
21 to 25 kg
26 and above kg
- 20 paise per kg
- 24 paise per kg
- 26 paise per kg
a
It is quite common to see almost all the tea-pluckers pluck well above 25 kg m the
crop-rich months of May, June, July, August, September, October and November
2. THE CONTROL ESTATE :
The Control Estate, namely, Devon Plantations and Industries Ltd., was our
Control Estate and was about 30 km away from our Study Estate. It was almost
identical in its Management and in the Benefits/ and Amenities given to its
employees. It was managed by the same Corporate Group (the well know MRF
group) as was the Study Estate. It matched the Study Estate in all infrastructural
respects. It also had a Tea Factory on the Estate. It provided the same wages,
incentives and all the welfare schemes that come under CLAWS.
It had a smaller area under cultivation with 406 acres under Tea Cultivation and
309 acres under coffee cultivation. It employed 390 women Tea-Pluckers and 150
men non-pluckers.
It was at more or less the same elevation and same geographic location as the Study
Estate but received much more rainfall of a little more than 200 inches per year, as
compared to the Study Estate (100 inches/ year). Please see a Comparative
Statement of both the Estates on 15 indicators, attached at Annexure A.
3. VARIOUS STATISTICS AND FACTORS CONSIDERED IN
EVOLVING THE PARTICIPATORY PLAN OF ACTION
i. Socio-economic characteristics of the Pinchers and non-Pluckers
From Table 3.1, we see that out of the 600 odd workers, the majority were in the
mid-age group of 30-50 years; followed by a younger age group of less than 30
years; half were literate (Sth to Sth class) and could very well read and understand
the simple EEC Sheet (please see Annexure B). The great majority did not have
young children. The great majority were permanent workers and stayed on the
estate; were married; had a mean monthly income of nearly Rs.3000/ month; and
took advantage of buying subsidized rice from the Estate’s Ration shop. In sum,
their standard of living was comparable to or even better than a Lower Middle Class
family in an Urban Setting.
ii. Management’s Views on the Health Problems of their Workers
Informal Participatory Research Assessment (PRA) interviews together with
structured questionnaires elicited the following views. Respiratory problems,
gastritis, acute acidity and general weakness/ aches/ pains headed the list; followed
by anemia (Table 3.2). The Management felt that absenteeism and productivity
were certainly affected by the poor health of the workers. This was why they had
provided an Estate Hospital with free medical aid, and expensive referral to the
nearby big hospitals at Shingeri and Manipal (Table 3.3). In the view of the
Management, atleast 21% of their workforce absented themselves from work
everyday, the major reasons being family responsibilities (100%, especially the
women workers); ill health and frequent illness (over 75%); and alcoholism among
the men (75%) (Table 3.4). However, the concept of ‘Preventive Care’ appeared to
be lacking, even at the Management level.
iii. View of the Medical Officer on the major micronutrient deficiency
disorders and health problems prevalent in the worker population.
The Estate Medical Officer, Dr.Vijay Kumar listed iron-deficiency anemia among
the women; and mild iodine deficiency disorders as the most prevalent micronutrient
deficiencies in the Estate population. Chikmagalur district where the Study Estate is
located, has been identified as one of the most endemic districts for FDD disorders
in Karnataka (9). He stated that gastritis (high acidity) was a very widely prevalent
problem. Intestinal helminthic infections were also common in man, woman and
child. He concurred with the Management that respiratory problems and general
weakness/ tiredness were also often stated reasons by the workers.
iv. Health Problems of the Workers as claimed by them :
fable 3.5 lists aches and pains (65%) as the most pronounced problem. This was
followed by helminthic infections (48%); general weakness (17%); obstetrical and
gynaecological problems among the women (13%); and infections of the upper
•espiratory tract (11%).
f. Views of the Supervisors/ Management on the Proposed Micronutrient
Intervention
\s per the supervisors 99% of the workers were willing to participate in the micro
lutrient intervention programme (Table 3.6). The management was convinced that
he intervention program was sustainable and then- workers would be willing to
>articipate in it even if they have to make part payment (Table 3.7). However 50%
>f the managers thought that they would promote the programme to neighbouring
states while the remaining 50% liked to be cautious until the impact of the present
ntervention was known (Table 3.8).
11
4. DEVELOPMENT OF THE ACTION-PLAN
i. Prelimnary meetings with the CEO and Management of the Study Estate
TCS met with the CEO of the Study Estate even prior to and during the
development of this OMNI-ILSI research proposal. TCS found him totally
committed to the idea of improving the health of his Workforce. He maintained
right through that if the project was even able to demonstrate that the health of the
workers had improved, he would continue with the micronutrient intervention.
ii. Prelimnary meetings with the Manager, Medical Officer and other staff of
the Study Estate
The Manager and his entire staff were very open to the suggestion of a
micronutrient intervention ’, but the Manager had greater expectations and
demands of the micronutrient intervention than did his CEO ! He voiced the
feelings of himself and his Management as under :
Issues important to the Tea Management
As a result of the ‘micronutrient intervention, in addition to the ‘improved health’
of the workers, the Management posed the following questions :
=> Would the average tea plucked/ worker/ day go up ?
=> Would the Moderate pluckers become Good pluckers ?
=> Would the Management be able to hire less workers to pluck more tea ?
=> Would absenteeism decrease ?
=> Would referral to the nearby hospitals decrease ?
These meetings proved extremely useful to both partners in fleshing out the details
of the Action Plan. TCS, in the bargain leamt to appreciate the concerns and
expectations of the Management. All the issues listed above, were evaluated in the
Process Evaluation (Please refer to Chapter Two on Objectives).
iii. The Micronutrient Intervention :
There was convincing evidence that iron deficiency anemia, iodine deficiency
disorders and Vitamin-A deficiency were widely prevalent problems in
Chickmagalur District which was home to most of the tea and coffee plantations in
Karnataka (9). Hence, the major thrust of the Micronutrient Intervention was to
12
deliver the above three micronutrients to every worker and his/ her family on the
Study Estate.
iv. Training and Capacity Building/ Information-Education-Communication
The Medical Officer of the Study Estate was identified as the chief liaison between
the Management and TCS. TCS and the Medical Officer jointly evolved the IEC
(Annexure B) and the Training Component.
v. Procurement of the Micronutrient Inputs:
TCS agreed to procure the iron supplementation and vitamin-A capsules from
Bangalore. The Management agreed to provide the iodized salt and sell it at a
subsidized rate in their Plantation Ration shop. One kg of Captain Cook iodized salt
was sold in the Plantation Rationshop for Rs.2/- kg packet Vs Rs.5.50/- kg packet in
the open market.
vi. Payment for the Micronutrient Intervention :
It was agreed that the cost of the package would be shared (50:50). The
Management would bear the full cost after TCS phased out. The cost of the
micronutrient intervention per worker and family came to about Rs.61.50/ year.
The iodized salt came to about Rs.31.50; the iron supplementation to Rs.5/-; the
Vitamin-A to Rs. 10/- and the plastic contamers to Rs. 15/- per worker and family (3
to 4 family members on an average) for two dosings per annum. Arrangements
were made to cater to 700 workers + their families for a five month period or an
expenditure of Rs.35,000/- per dosing round or Rs.70,000/- for the two dosing
ounds.
5. IMPLEMENTATION OF THE ACTION PLAN
there was a clear division of labour between the Study Estate and TCS. This
esulted in a very smooth functioning of the ‘micronutrient intervention’. The Study
estate; in addition, obtained an ‘on-the-job-training’ over the 9-months-intervention
vhich resulted in a smooth take over after TCS phased out in April 1997.
Vhat the Study Estate Did :
mplemented the Micronutrient Intervention.
tocured the Iodized Salt and sold it at a subsidized rate of Rs.2/ kg Vs Rs.5.50 - in
re open market.
Maintained the necessary Registers and sent a monthly report to TCS at Bangalore,
he Medical Officer continuously trained the implementing staff.
15
The Management at all levels conducted the IEC in Kanada, Malyalam, Tamil and
Tulu.
The Gang Leaders monitored and enthused their gangs.
Each worker was made responsible at the family level for dosing of self and family.
What TCS Did :
=> Developed the Plan of Action in Consultation with the CEO and Mangement.
=> Developed a simple and sustainable research design.
=> Oriented the CEO and Management; trained the medical/ health staff.
=> Jointly developed the IEC in the major local language, Kanada.
=> Studied and made use of on-going data systems, namely hospital registers and
computerized Management Information Systems (MIS) on crop yield, average
tea plucked, attendance etc. for the Process and Impact Evaluations.
=> Collected, analyzed and interpreted Primary and Secodory source data.
Brief description of the Intervention :
i. Approximately 600 odd Workers (Pluckers and non-pluckers) employed by the
Study Estate, and their families were the target population for the nine-monthsMicronutrient Intervention, (please refer to Table 3.1)
ii. The Micronutrient Package and its Dosing Pattern consisted of 240mg ferrous
sulphate delivering 60mg elemental iron twice a week (Tuesdays and Fridays)
after the evening meal. On the advice of the Medical Officer, it was decided to
give the Iron Supplementation two times a week. He felt, and rightly so, that
daily iron supplementation would receive a massive negative response due to the
high prevalence of gastritis and acidity in the worker population. Further,
evidence is now available that even weekly supplementation with 60mg
elemental iron is sufficient to raise Hb levels (11-13). Tuesdays and Fridays
were selected, as Hanuman the God of Strength is venerated on Tuesdays; and
Lakshmi the Goddess of prosperity is venerated on Fridays (Table 3.9) A
capsule of 1600 IU of Vitamin-A + 400 RJ of Vitamin D once a week on
Fridays. Both supplements were given to the Worker for himself/ herself and all
the family members over three years of age. Iodized salt (Captain Cook)
delivering 30 PPM was made available at the Plantation ration shop. Table 3.10
shows that nearly 85% received two health check-ups and the 5 month’s
supply (at a time) of the micronutrients. The first dosing was done in midAugust 1996 along with the Baseline survey. The second dosing was done in
end December 1996.
iii. TCS procured the above medicinal supplements from Pravin Pharmai Wholesale
Company) at Bangalore and transported the same twice to the Study Estate The
iodized salt was purchased locally by the Management. The Medical Officer
was oriented as to where to procure further supplies of the micronutrients m the
quantity and of the quality required.
iv. The IEC sheets were produced in the local language m quantity (Annexure B).
They were distributed to all the workers m advance; at the Baseline, in between
and at the Re-survey; and were put up at all vantage points. Gang leaders
reminded their gangs to take the supplements and handed over monthly reports
on responses/ regularity/ likes/ dislikes to the Medical Officer who took
immediate necessary action in counselling those workers who had complaints.
The countersigned reports were sent to TCS every month.
v. Preparation of containers for the “Take Home” micronutrients
Small attractive plastic containers with screw caps were purchased. Each
container was filled with 250 tablets of Ferrous-sulphate each supplying 60 mg of
elemental iron and 125 capsules of Vitamin-A each providing 1600 IU Vitamin-A
and 400 IU Vitamin-D. One kilogram of iodized salt (Captam Cook) came
packed and labeled by the company. Each worker received one plastic container
with the medicinal supplements and one bag of salt for the first intervention
period of 5 months. The plantation ration shop stored only Captain Cook’s
iodized salt. The workers bought it at subsidized rate of Rs.2/-kg. The market
price was Rs.5.50/ kg. The containers were refilled for the second dosing and
five months of intervention period.
|£
A PARTNERSHIP IN EVERY SENSE
THE ESTATE MANAGEMENT AND
THE TCS TEAM PLANNING THE
DEMONSTRATION PROJECT
THE GANG LEADERS - THE
KINGPINS OF THE ESTATE
I
THE CUSTODIANS OF THE DAILY
COMPUTERISED DATA
THE MOST IMPORTANT
WOMEN TEA PLUCKERS
■ ’.jyi
y-
THE EQUALLY IMPORTANT
MEN FACTORY AND
AGRICULTURALWORKERS
THE ASSISTANT ESTATE
MANAGER BEING INTERVIEWED
BY PROF. GOPALDAS
FREE FACILITIES FOR ALL ON
THE ESTATE
A 10-BEDDED HOSPITAL FOR ALL
FREE MEDICINES AND
MICRONUTRIENTS FOR ALL
1
r' *
A CARING AND HAPPY
HOSPITAL FOR ALL
A CRECHE FOR THE ‘UNDER 3S’
/
A PRESCHOOL FOR THE
‘3 TO 6 YEAR-OLDS’
THE ‘6-12 YEAR-OLDS’
ANNEXURE A
ITEMS OF COMPARISON
STUDY ESTATE
CONTROL ESTATE
MRF
MRF
Mr. Ashok Kurien
Mr K. Kurien
Salaries to Workers as per labour Laws in Force
Yes and Same
Yes and Same
Implementation of the Comprehensive Labour
And Welfare Schemes (CLAWS)
Yes and Same
Yes and Same
Plantation 10-bedded-Hospital with in-Residence
doctor and staff.
Yes
Yes
Number of W omen Tea Pluckers
350
390
Number of Male workers
267
150
Acreage Under Tea
552 acres
406 acres
Acreage Under Coffee
210 acres
309 acres
Elevation above Sea Level
1200 ft
1200ft.
Yes
Yes
2378 kg/ Het/ annum
2278 kg/' Het/ annum
2356 kg/ Het/ annum
2328 kg/ Kct/ annum
Average Tea Plucked (kg) 1995 - 1996
per worker per day
(August - April)
22.90 kg
20 80 kg
Average Tea Plucked (kg)
1996- 1997
per worker per day
(August - April)
25 60 kg
20 80 kg
Annual Rainfall
1995 - 1996
1996- 1997
99 inches
98 inches
211 inches
244 inches
1995- 1996
126 days
125 days
121 days
107 days
Corporate House, Bangalore
CEO of the Estate
Tea Factory
Crop Yield in
1995 - 1996
(April - March)
Crop Yield in
Rainy Days
1996- 1997
(April - March)
1996- 1997
cynanemethomoglobin method. A digital colorimeter was setup at the Estate
Hospital and was later handed over to the Plantation Hospital.
From station three, the subject was sent to station four to receive a 1kg packet of
iodized salt and 5 months supply of micronutrients in a container. Each subject was
advised to take after his/ her evening meal a black tablet (iron tablet) on every
Tuesday and Friday and the red capsule (Vitamin-A) on every Friday Also to give
the same to all his/ her family members (above 3 years of age) as described. The
subjects were explained the benefits of the micronutrients and iodized salt. They
were asked to report any ill effects if any, of taking the tablets particularly the iron
tablet.
Dosing pattern
The second round of dosing was done four and a half months after the first round.
The dosing procedure remained the same as in the first round. Each subject was reexplamed the benefits of taking the health inputs regularly and was asked if he/ she
had suffered/ suffer from the ill effects of these tablets particularly the black tablet
(iron tablet).
It was noted at the Baseline Dosing, that many families had two and sometimes
three pluckers per family. Hence adjustments were made in handing out the plastic
containers (with micronutrients) and the salt packet, depending on the need of the
family. This was duly noted in the Dosing Register.
Details of the procedures used
i. Anthropometric measurements :
Body Weight : The subject was weighed with normal clothing to the nearest 0.5 kg
using Krup’s weighing scale (16). The scale was adjusted to zero each time the
subject was weighed.
Body Height : Height was measured nearest to 0.1cm with the help of a non
Stretchable measuring tape affixed on a smooth surfaced wall.
Body Mass Index (BMI) . Waterlow’s classification (17) was employed for
nutritional categorization of the subjects based on their BMI. A cut off point of
squal to or above 18.5 indicated normal nutritional status. While a BMI of less than
18.5 was taken as indicative of under-nourished status. BMI was calculated using
he formula. Weight (kg) by Height2 (m).
ii. Clinical examination : All subjects were examined for eye signs of vitamin-A
deficiency using the “Field Guide to the detection and control of Xerophthalmia”
(18). The ocular signs of vitamin-A deficiency were classified as follows.
XN
Night Blindness
XIA
Conjuctival Xerosis
XIB
Bitots spot
X2
Comeal Xerosis
iii. Presence of Anemia : An anemia recogmtion card (cards were obtained from
the Voluntary Health Association of India) was used to determine the prevalence
of anemia.
iv. Iodine Deficiency Disorder (IDD) : The subjects were clinically examined for
the presence of clinical and subclinical manifestation of iodine deficiency (19).
v. Hemoglobin estimation : The cyanmethomoglobin procedure as described by
Oser (1976)(20) was used for hemoglobin estimations. Hemoglobin level of less
than 12g/dl in adult female and children aged 6-14 years, less than 13 gm/ dl in
adult male and less than 11 g/ dl in children below 5 years of age
was taken
to be indicative of iron deficiency anemia(21).
II. Data Processing and Analysis
Data Entry and Validation
The Data were entered using Foxbase and data files were created. The data were
checked and validated for internal consistency. Separate files were created for
Attendance and Pluckability data.
Tabulation and Statistical Analysis
SPSS was used for tabulation and statistical analysis. SPSS commands were written
to describe all variables and specify missing values. SPSS commands to produce
tables were written and tested. SPSS commands were written to apply statistical
tests namely t-test, Chi square test, Pearson Correlation and Analysis of Variance.
Finally when the complete data set was ready. Tables were produced and Statistical
Analyses were carried out. All tests were considered significant at p<0.05. The
graphical presentation of data in the form of Bar and Line charts was done by using
Harvard Graphics.
NUTRITIONAL ASSESSMENT AND
MICRONUTRIENT DISTRIBUTION
II
THE PLANTATION DOCTOR AND
PROF.GUJRAL INTERVIEWING
A WOMAN TEA-PLUCKER
THIS PLUCKER HAD MILD GOITRE
THIS TEA PLUCKER HAD BILATERAL BITOT’S
SPOTS, WAS NIGHT-BLIND AND HAD A VERY
POOR DIETARY INTAKE OF VITAMIN-A
HEMOGLOBIN OF A MALE PLUCKER
BEING ESTIMATED BY THE
CYANMETHEMOGLOBIN METHOD
)
Ih
THE HEIGHT OF A WOMAN TEAPLUCKER BEING RECORDED
COUNSELLING AND DISTRIBUTION
OF MEDICINAL IRON,VITAMIN A
AND D SUPPLEMENTS TO LAST THE
WORKER AND FAMILY FOR 5 MONTHS
Chapter 3ive - Results
Section A : Comparison of Key Agricultural Statistics in the
Study and Control Estates in the Pre and During
Intervention Periods.
From Annexure A, Chapter Three, it is evident that the Study and Control Estate
were very similar in almost all the fifteen indicators of comparison.
In this chapter, we present comparative data on Rainfall; Crop Yield (kg/ Hectare);
and Average Tea Plucked (kg/ worker/ day) in the Pre Intervention Period (August
1995 to April 1996) and the During Intervention Period (August 1996 to April 1997)
in the Study and Control Estates.
From Table 5.1 one notes that the Control Estate was much better endowed with
rainfall in both the Pre and During Intervention periods as compared to the Study
Estate. The no rainfall or extremely scanty rainfall months for both the estates
commenced in November and continued upto March.
Table 5.2 and Figure 5.1 show that the overall crop yield m both the estates during
both the Pre and During Intervention penods were almost identical. The month by
month crop yield followed the rainfall pattern.
Table 5.3 and Figure 5.1 establish that inspite of the Overall Crop Yields being
almost identical (Table 5.2), the Average Tea Plucked in the Study Estate was
significantly better in its During Intervention Period as compared to its Pre
Intervention Period. The plucking average went up from 22.9 kg/ worker/ day to
25.6 kg per worker per day. By way of contrast the plucking average was 20.80 kg/
worker/ day in the Control Estate in its Pre-Intervention Period. It stagnated at
20.69 kg/ worker/ day in the During Intervention period.
fable 5.4, establishes that there is a significant relationship between Average kg
eaves plucked and Crop yield. The bountiful ‘plucking months’ on both the estates
vere August to December. The lean ‘plucking months’ on both the estates were
January, February and March.
Scrutiny of Table 5.3, however shows that in some crop-bountiful months such as
October (1996), the plucking average was less in the During Period, in the Study
Estate. This is even more apparent in the Control Estate, where the 'plucking
average’ was poor in the crop-rich months of August 1996 and October 1996. This
points to occasional and extraneous reasons that may bring down the 'Average
Tea Plucked/ worker/ day’.
A comparison of the Study and Control Estates on the three Key Agricultural
statistics shows the following :
=> Rainfall actually favoured the Control Estate.
=> The Crop Yield in the Study and Control Estates were almost identical in both
the Pre and During Intervention periods in both the Estates. Hence, this most
important factor is controlled for.
=> The Average Tea Plucked went up significantly in the Study Estate It stagnated
in the Control Estate.
Our conclusion, therefore, is that our ‘micronutrient-intervention’ of iron +
iodine + Vitamin-A did have a positive effect in increasing the labour
productivity and ‘average tea-plucked’.
We must bear in mind that the plucker received a package of micronutrients - not
iron alone. It must also be borne in mind that Chickmagalur is an iodine endemic
area. The consumption of the iodized salt must also have contributed to better
‘plucking averages’. Lastly the overall mean hemoglobin levels of the ‘pluckers’
were adequate at 12.0g/ dl at Resurvey. This has also contributed to better physical
work capacity and consequently to significantly better ‘plucking averages’.
3i
no
05740
I
w°i8
/
TEA CULTIVATION IS
SCIENTIFIC BUSINESS
1
d
T
w
Pl
;A- j .
WELCOME TO BEAUTIFUL
BALANOOR ESTATE
NURSERIES FOR TEA SEEDLINGS
A ?
■s
j-'
a-'' * >
THE TEA PLANTS HAVE
GROWN A LITTLE BIGGER
'-1 '* ft1'
IS
LIGHT, SHADE, TEA BUSHES AND
TREES - NATURE’S GREAT TEAM
MIGHTY RIVER BADRA
EVER FULL AND FLOWING
Section B : Results of the Process Evaluation.
This section will discuss data and results pertanung to the Study Estate only
Issues Important to the Management
i. Average Tea Plucked (kg/ worker per day) in the Pre Intervention Period
(August 1995 to April 1996) and the During Intervention Period (August '96 to
April ’97).
ii. Percentage Tea Pluckers (matched data) who plucked more in each successive
month of the During Intervention Penod relative to the Pre Intervention Period.
ui. Number of tea pluckers employed per month in the Pre and During Intervention
period.
iv. Month by month absenteeism among the pluckers in the Pre and During
Intervention periods.
v. The influence of gangs on the Average tea plucked (kg/ worker/ day) in the Pre
and During intervention penods.
vi. Reduction in referral to hospitals in the During Intervention Period relative to the
Pre Intervention period.
Additional Issues important to the Research Team
vii . Regularity of use of the Micronutrients in the During Intervention period.
viii. Distribution of the Information-Education-Communication sheet by the
supervisors to their workers.
ix. Knowledge of the supervisors and workers regarding the Dosing pattern of the
micronutrients and then- benefits.
i. Impact of the Micronutrient Intervention on the Average Leaves
Plucked (kg/ plucker/ day) in the Pre and During Intervention
periods in the Study Estate.
Tables 5.5 and 5.6 and Figure 5.2 clearly shows that the average tea plucked (kg/
vorker/ day) was significantly higher at 25.6 kg Vs 22.9 kg in the nine months of
nicronutrient-intervention. Furthermore, this significantly higher plucking level
vas sustained for six months out of the nine months of intervention, except for
he months of October 1996, January 1997 and April 1997, where possibly other
:onsiderations took precedence.
In the previous Section A, Chapter 5, we had presented data to show that the
significant rise in the ‘plucking average’ in the Study Estate, during the mne-months
micronutnent-intervention period was mdeed a true effect. The month by month
statistical analysis further substantiates this.
ii. Percentage Tea Pluckers (matched data) who plucked more in
each successive month of the During Intervention period relative
to the Pre-Intervention period.
Figure 5.3, shows that crop yield was virtually the same in both the Pre and During
Intervention periods. In fact it was slightly lower at 1608 kg/ Hectare in the 9months- micronutrient intervention period vs the Pre, where it was 1668 kg/
Hectare. In spite of this slight disadvantage to the pluckers, 64% of them on
matched data, plucked atleast one kg more as a result of the micronutnentintervention. Further, this was not a chance effect. Figure 5.1 shows that even in
the ‘crop lean months’ of January to April, 55% of the pluckers ‘plucked more’.
The question could well be posed as to How so ? and Why so ? Our data and
results point to the increased pluckers’ productivity due to the total package of
the micronutrients, namely, iron + iodine + Vitamin-A.
iii.Number of tea pluckers employed per month in the Pre and
During Intervention period.
Table 5.7 and Figure 5.4, shows that 2867 pluckers were employed from August
1995 to April 1996. In the Intervention period, 2763 were employed or 104 less
pluckers on a monthly basis. A scrutiny of the month by month data show that
except for September 1996 and February 1997, less pluckers overall were
deployed to pluck more tea leaves. September 1997 was a peak crop yield month,
with a better crop in this Intervention month Vs its corresponding yield in the Pre
month. Ninty three percent of the pluckers plucked more. The average tea plucked
was a whopping 33.6 kg/ worker/ day Vs 24.8 kg in the Pre-month. Possibly the
bounty of the crop entailed the employment of more pluckers, inspite of the
commendable performance of most of the pluckers. The largest number of workers
(45) were reduced in the month of January 1997. January is traditionally a ‘crop
bleak’ month. Figure 5.1 shows that the crop was also very poor.
But overall, the Management deployed 104 workers less which translates to quite a
fair amount of financial saving (please refer to Section D on Cost-Effectiveness).
34
A survey of the literature indicates that the highest productivity among workers was
achieved in the second month of iron or iron + helminthic interventions. (All these
classical studies had a duration of only 2 to 4 months intervention (4,7,22).
iv. Month by month absenteeism among the pluckers in the Pre and
During Intervention periods
Table 5.8 and Figure 5.5, reveal that the level of absenteeism did not change and
stood at a high 27% in both the Pre and During intervention periods. The month
where absenteeism peaks, more or less corresponds with the ‘crop lean’ months of
January, February and March. However, there does not seem to be any discernible
partem for taking leave. It would appear that the pluckers take all the leave they are
entitled to, regardless of their being in a fit or unfit state of health.
v. The influence of gangs on the average tea plucked (kg/ worker/
day) in the Pre and During intervention periods.
fable 5.9 does not reveal any significant difference in the average tea plucked (kg)
>er worker per day between gangs in the Pre and During intervention penods.
’tuckers in gangs 1, 4, 5 and 6 plucked 3 kg more in the During Intervention
icriod, as against gangs 2,3,7 and 9, who plucked 2 kg more. This difference was
lot found to be significant.
'JI that we can conclude is that the supervisors of the 9 gangs appeared to exert
lore or less the same influence over their gangs as far as ‘tea plucking’ went.
Ve agam draw attention to the fact, that the ‘plucking average’ did go up
ignificantly overall from 22.9 kg in the Pre Intervention period to 25.6 kg in the
hiring Intervention period. Since, crop-yield (the most significant factor for
plucking’ was the same) in the Pre and During intervention periods, we again
onclude that the significant increase in average tea plucked was due to the
licronutrient intervention.
{.Reduction in referral to hospitals in the During Intervention
Period relative to the Pre Intervention Period
able 5.10 reveals that illness or disorders that could have been influenced by our
icronutrinet intervention of iron + iodine + Vitamin-A did indeed decrease,
eferrals to the nearby hospitals such as Manipal and Shingeri, for conditions such
as general weakness/ aches/ pains; loss of appetite; GIT problems; gastritis; peptic
ulcer/ liver problems; goitre and anemia did decrease Referral for respiratory
problems and general check-ups did increase. However, overall there was a
reduction in referral to the nearby large hospitals by 26%.
Additional Issues important to the Research Team
vii.Regularity of use of the Micronutrients in the During
Intervention period
Table 5.11 depicts that the majority, namely, 58% of the subjects were regular in
taking the iron + Vitamin-A supplementation. Of the remaining, 33% were irregular
and 9% stated that they had stopped taking the supplements after 1 or 2 months.
The Table also brings out the gender variations in the regularity of use of the
supplements. Among the Pluckers, the few male pluckers were more regular in
taking the supplements (71%) than were the female pluckers (54°o). The same
pattern extended to the Non-Pluckers. The regularity of use among the males was
63% Vs 41% among the females. This pattern extended to the elderly male and
female dependents. However, what was very encouraging to see was that the
parents were very particular about dosmg their children as 83% were regularly
dosed. Our data show that it did not appear to make so much of a difference in
raising Hb levels, whether a subject took the iron and Vitamin-A supplements two
times (Regular) or once a week (Irregular) as the Hb levels rose by about one
gram in the women pluckers and by about two grams in the male workers (pluckers
or non-pluckers). In any case Baseline Hb levels were quite decent at about 11 g/ dl
and 12g/ dl respectively in the women and men. (Table 5.18 Section C, Chapter
Five). The ones who stopped taking supplements (30 to 40%) were the female
non-pluckers and the elderly dependents.
Fortunately, al! members of the family got the iodine on regular basis through the
fortified salt.
viii.Distribution of the Information-Education-Communication
(IEC) sheet by the supervisors to their workers
Table 5.12 shows that there was a lively interest among the supervisors in
distributing and explaining the IEC sheet (Annexure B, Chapter Three), to thenworkers. Almost all claimed to have done this. This was corroborated by the fact
that almost all the workers quizzed by the examination team at Resurvey, knew
3G
exactly what each micronutrient was expected to do for the improvement of their
health. But many insisted that their gastritis problem had been aggravated (Table
5.23).
ix.Knowledge of the supervisors and workers regarding the
dosing pattern of the Micronutrients and their benefits
Table 5.13 and Figure 5.6, depicts that the IEC sheet was a successful
communicator, as all the supervisors, and the sub-sample of workers had a very
clear perception of the dosing pattern of the micronutrients and the benefits they
would derive from the same.
37
THE DAILY LIFE OF WOMEN TEA
PEUCKERS
5
ixr*'
i
*4
f« 1
i -k :
i
15'-iW
WOMEN TEA PEUCKERS - BACKBONE OF
THE ESTATE AND THEIR HOUSEHOLDS
I
|T« ■
,
HEAVY LOADS OF PLUCKED TEA
LEAVES - A STRAIN FOR HEADS,
NECKS, BACK AND LEGS
. . j__
V'. '
'♦
**- ................
PLUCK, PLUCK, PLUCK FROM
DAWN TO DUSK
OFF TO WEIGH THE TEA LEAVES
AND EARN THEIR DAILY WAGES
‘------ rjli
Y
Si’*
THE SHEER JOY OF SUBSTANTIAL
DAILY WAGES
SOMETIMES WE CAN’T GO TO WORK
BECAUSE OF A SICK BABY
Section C - Results of the Impact Evaluation
In this section we will discuss data and results pertaining to the Study Estate only.
The Impact Results are presented as under.
i. The Impact of the Intervention on the Nutrient Intake of the female pluckers.
(Table 5.14)
li. The Impact of the Intervention on the clinical signs of iron, vitamm-A and iodine
deficiency.(Tables 5.15,5.16, 5.17)
iii. The Impact of the Intervention on hemoglobin status.(Table 5.18)
iv. The Impact of the regularity of use of the micronutnents and Hb status (Table
5.19)
v. The Impact of the Intervention on prevalence of Iron Deficiency Anemia (IDA)
(Figures 5.7, 5.8, 5.9, 5.10)
vi. The Impact of the Intervention on the ‘plucking average' by the Good, Moderate
and Poor Pluckers.(Tables 5.20, Figures 5.11 and 5.12)
I?6 Impact of the Intervention on Body Mass Index. (Tables 5.21 and 5.22)
viii. The Impact of the Intervention on Common Health Problems.(Table 5.23 and
Figure 5.13)
ix. The Impact of the Intervention on regularity of use of the micronutrients and
perceived health status.(Table 5.24)
x. The Impact of the Intervention on Hb status and attendance.(Table 5.25 and
Figure 5.14)
Nutrient Intake of the Sub-sample of Female Pluckers in the
Baseline and Resurvey in the Study Estate
Table 5.14 shows that the nutrient intakes of all the macro and micronutnents have
increased significantly. The ongoing informal Nutrition Education given by the
Hospital staff and Research team also had some beneficial effect. This is supported
by statements that ‘appetite had improved’ (Table 5.24) and by the Body Mass
Index also improving ( > 18.5), though not significantly, from 37% at Baseline to
42% at Resurvey (Table 5.21). However, the dietary nutrient intake of iron still
remained at a low 38%; and that of dietary vitamm-A at an even lower 27% at
Resurvey. Hence, it would appear that the only feasible way at the present time to
improve the iron and Vitamin status of Plantation workers, especially its women
Sluckers, is through supplementation or fortification
37
In informal discussions, the Management was of the opinion that multi-fortified
foods, such as double fortified salt, vitamin-A and D fortified cooking oil, which
could be easily procured and stored in the Plantation Ration Shop, would be the
best.
ii. a) Impact of the Micronutrient Intervention on Clinical signs of
Iron Deficiency in the Pluckers, Non-Pluckers and Children in
Study Estate.
Table 5.15, depicts that the clinical signs of pale conjunctiva and nails reduced
significantly in the worker population (plucker and non-plucker) from 47% to 10%;
the corresponding figures for children (6-12 years) was 65% to 20%. The
significant improvement in Iron Deficiency Anemia status is corroborated by
Tables 5.18, 5.19 and Figures 5.7, 5.8, 5.9 and 5.10.
ii. b) Impact of the Micronutrient Intervention on clinical signs of
Vitamin-A deficiency in the Pluckers, Non-Pluckers and children
in the Study Estate
Table 5.16 reveals that the pre-climcal and/ or clinical signs of Vitanun-A (Night
blindness, Conjuctival Xeroxis and Bitots spots) reduced from 19% at Baseline to
4% at Resurvey. In the Pluckers (almost all women) all the signs reduced
significantly i.e. Night Blindness reduced from 9 to 200; Conjuctival Xeroxis from 8
to 2%; and Bitot’s spots from 2 to <1%. In the non-Pluckers (mostly men) all signs
reduced significantly i.e. Night Blindness reduced from 10 to 2%; Conjunctival
Xeroxis from 9 to 1%; and Bitot’s spots from 3 to <1%. In children the non
significant reduction was 6 to 3%.
fhe nutrient intake data of the women Pluckers (Table 5.14) depicted the very poor
/itamin-A status of these women. At Baseline their nutrient intake of Vitamin-A
status was just 21% of RDA. The Research Team noted that the meals were
nonotonus and consisted of huge helpings of rice and lentil curry. Very little milk,
■egetables or fruits were consumed. Fish was eaten occasionally. On account of the
Nutrition Education and improved appetite, retinol intake went upto 27% of RDA.
Tie Vitamin-A supplement of 1600 IU, if it was taken weekly, would have added
30 IU or 69pg of retinol or Vitamin-A to the meager 165 pg retinol, from the daily
iet-bringing it upto 239pg or about 40% of the RDA.
urther, all the cases identified as Vitamin-A-deficient were ‘Active signs’. They
manifested night blindness (XN) in conjuction with conjuctival xeroxis (XIA) and/
or Bitot’s spots (XIB).
ii. c) Impact of the micronutrient intervention on Clinical signs of
Iodine Deficiency in the Pluckers, Non-Pluckers, and Children in
the Study Estate
Table 5.17, shows that overall 17% mamfested signs of mild iodine deficiency
(small nodules at base of the neck) at Baseline, which reduced significantly to 7% at
Resurvey. In the Pluckers the significant reduction was from 18 to 10%; m the nonPluckers the significant reduction was from 20 to 5%. No child manifested a
clinical sign of iodine deficiency at Baselme; one did at Resurvey
On the whole one could say that the use of iodized salt by the whole family did have
beneficial effects on its Iodine Deficiency Disorders status.
iii.a) Impact of the Micronutrient Intervention <on Hemoglobin
status of the Pluckers, Non-Pluckers and Children
— iin the Study
Estate.
Table 5.18 shows that the mean hemoglobin levels m the females significantly rose
from 11 .Og/dl at Baseline to 11.9 g/dl at Resurvey. In the males it was even more
impressive, where there was significant nse of 12.1g/ dl to 14.Og/dl. Among the
children, there was a non-sigruficant rise from 10.8g/ dl to 11.6g/dl.
To restate, some facts regarding the iron status of this Plantation population
emerges:
=> The Baseline mean Hb values of the Pluckers (almost all women); non-pluckers
(almost all men); and children were not low to start with.
=> The empowerment of the workers to dose themselves and their families appears
to have worked well on the whole.
=> A very small percentage of the workers (2%) stopped dosing themselves or their
families. The rest dosed themselves with the iron and Vitamm-A supplements
either twice a week or once a week. Either schedule appears to have had a
similar impact on enhancing Hb levels.
=> This resulted in a mean rise of nearly I g/ dl among the women; and nearly 2g/dl
among the men. In the children (>3-12 years) who were most regularly dosed by
their parents, a mean rise of nearly 1 g/dl was agam noted.
4)
We conclude the micronutrient intervention jointly evolved by the Study Estate and
us (TCS), proved to be sunpie, effective and sustainable.
iv.a) Impact of the Regularity of use of the Micronutrient
Intervention and Hb status
Table 5.19 reveals that the Hemoglobin levels rose significantly among the female
pluckers and non-pluckers. In the female pluckers, it rose significantly from 11.1g/
dl to 12.0g/ dl among those who were regular in taking the medical supplements. It
rose from 10.9g/ dl to 11.8g/ dl among the female pluckers who were irregular and
took the medicinal supplements only once a week or off-and on. We, therefore,
conclude that it did not make an appreciable difference whether the subject dosed
herself once or twice a week. Among the few who had stopped taking the
supplements there was a non-significant rise from 11 g/ dl to 11.3g/ dl.
In the case of the men workers, who were much more regular than the women in
taking the supplements, their Hb levels rose by about 2g/ dl (non-sigmficantly) in all
the three groups of Regular, Irregular and Stopped taking.
v. a) Impact of the Micronutrient Intervention as Indicated by a
Reduction in Iron Deficiency Anemia (IDA) in Female, Male
Pluckers and Non-Pluckers and their Children in the Baseline
and Resurvey in the Study Estate
Figure 5.7 demonstrates that there was a highly significant reduction in Iron
deficiency Anemia among the Female, Male and Child population on the Study
istate. It was surprising to note that 98% of the Female and 100% of the Child
objects were anemic at Baseline, inspite of the mean Hb value appearing to be
airly adequate at a mean 11g and 10.8g/ dl respectively (WHO cut-off > 12g/ dl).
DA was widely prevalent at Baseline among the male population as well. (WHO
:ut-off > 13g/ dl) There was highly significant reduction in IDA in all the three
>opulation groups at Resurvey.
b) Impact of the Micronutrient Intervention on the shift in the
Hemoglobin Status Distribution Curve in Pluckers, Non-Pluckers
and Children in the Study Estate
igures 5.8, 5.9 and 5.10 clearly shows that there was a noticeable shift to
the right in all the three distribution curves.
r™e ml'e P^kuLre
m0S' bcnefi,ed hy ,he Micronutrient
Intervention. The WHO cut-off used was 13g/ dl
The Female Pluckers and Non-Pluckers came next; followed by the children. The
WHO cut-off was 12g/ dl.
The Women especially the Non-Pluckers were not very Regular in dosing
themselves. However, the Regular dosing was as high as 83% where the children
were concerned. The relatively subdued distribution curve for children mav suggest
a high level of intestinal helminthic infection or some other problem which may have
to be concurrently addressed.
vi. a) Impact of the Micronutrient Intervention on Average Leaves
Plucked (kg/ plucker/day) by the Good, Moderate and Poor
Pluckers and their Hemoglobin levels in the Study Estate
Table 5.20 demonstrates that the Good Pluckers (plucking more than 25kg/ day)
packed sigmficantly more, namely, an average of 29.3kg/ plucker/ day with a mean
Hb value of 11.9g/ dl than what they had m the Pre-Intervention penod In the
former penod the average tea plucked was 28.1kg with a mean Hb level of 11.1g/
dl. We clubbed the Moderate and Poor Pluckers (Moderate = 14 to 25 kg; Poor =
Less than 14kg/ day) as there were only 5 Poor Pluckers. The average tea plucked
went up sigmficantly from 19.9kg to 21.7kg. The mean Hb levels also rose
sigmficantly from 11.0g to 12.1g.
vi. b) Relationship between Hemoglobin status arid Average kg
Leaves Plucked/ Day as Stated by the Pluckers in the Resurvey in
the Study Estate
From Figure 5.11, Pluckers at the Resurvey with Hbs of less than 10g/ dl (N=16)
claimed to pluck as much as 27.9kg/ day; those in the range of 10 to 11 9 (N=123)
stated they plucked 30.5 kg / day; and those with Hbs of above 12g/ dl stated that
they plucked 32.2 kg tea leaves/ day (The Plucking Average figure were those given
just the previous day to the Hb estimations). Although there was a relationship of
more leaves plucked with higher Hbs, this did not reach a significant level.
vii. a) Percent Shift in Good, Moderate and Poor Pluckers from
Baseline to Resurvey in the Study Estate
Figure 5.12, clearly demonstrates the increased and significant shift from Moderate
(14-25kg/ worker/ day) to Good Workers (more than 25kg/ worker/ day). The
percentage pomts increased from 33% at Baselme to 49% at Resurvey. The
percentage pomts for Moderate Workers came down correspondingly from 65% to
51%. There were hardly any Poor Pluckers (less than 14kg/ day) to start with
(1.5%). This also reduced to 0.3%.
This analysis was the most convincing evidence to prove the positive impact of the
micronutrient intervention on labour productivity.
vii. b) Impact of the Micronutrient Intervention on Body Mass
Index (BMI) of the Pluckers and Non-PIuckers in the Study
Estate
Tables 5.21 and 5.22, depict that a larger percentage of female and male pluckers
lad a Body Mass Index (BMI) of equally to or greater that 18.5 at the Resurvey
han at the Baseline. (37% to 43%). A scrutiny of Table 5.22, shows that those
vith a BMI of more than 18.5, did tend to pick slightly more (though not
iignificantly so) than those who had a BMI of less than 18.5.
t was the female non-plucker who did not have to expend so much energy as her
ducker counterpart, that showed a highly significant improvement in her BMI,
amely, from 42% (Baseline) to 69% at (Resurvey). Overall, the BMI in the total
worker population did improve significantly!44% at Baseline to 55% at Resurvey),
lus was possibly due to a combination of better appetite and the general Nutrition
Education given by the Research Team to eat more. The Management stated that
lore subsidized rice was being purchased from the Ration Shop 1
iii.a) Impact of the Micronutrient Intervention on Common Health
Problems in Pluckers and Non-PIuckers as Perceived by them
on the Study Estate
able 5.23 shows that common health problems on the whole were perceived by
e Workeforce to have decreased from Baseline to Resurvey. This was found to
: highly significant. Perceived decreases were with respect to general weakness
7 to 7%); all aches (body/ head/ heck/ limbs/ joints/ shoulder) from 65% to 7%;
ssrx-xx'
?.±x:d sex
gastritis rose significantly from 7 to 32%. We feel gastritis is a veiy real problem
and may be caused by over-chlonnation of the potable water. This needs to be
looked into. We cannot explain the perceived rise in abdominal pam and giddiness.
ix.a) Impact of the Micronutrient Intervention on the Perceived
Improvements in Health by Regular, Irregular and ‘Stopped
Taking’ Pluckers and Non-Pluckers in the Study Estate
Table 5.24 reveals a clear and significant relationship of positive health perceptions
of ‘feeling better’ among the Regular Users of the iron + Vitamin-A supplements
(72%). This percentage slid to 37% among the Irregular Users; and still further to
6% among those who had ‘Stopped Taking’ the supplements.
Overall, 54% claimed to feel better; 9% said their appetite had improved; and 44%
perceived no change in their state of health.
x. a) Relationship between Hemoglobin Status and Attendance of
Female Pluckers in the Study Estate
Table 5.25 and Figure 5.13 sets out the relationship between monthly attendance
and hemoglobin status, the assumption or hypothesis being that better the Hb status
better would be the attendance. Although there was a distinct trend to support this
hypothesis, the relationship missed statistical significance.
A5
Section D : Cost effectiveness of the Intervention
This Section will refer to the Pre and During Intervention penods in the Study Estate
only.
The cost effectiveness of the Micronutrient Intervention will be discussed under the
following heads as under :
=> The cost of the multmutnent package consistmg of medicinal iron and Vitamin-A
supplementation + iodized salt per worker and his/ her family for a period of nine
months.
=> The cost-effectiveness in terms of total number of Tea-Pluckers employed in the
Pre and During Periods of Intervention.
i. The cost of the multiautrient package per worker and family
The cost of 500 tablets of the medicinal iron supplement (60mg elemental
iron) for 2 dosing rounds at 250 tablets/ round was Rs.5/-. The cost of 250
capsules of 1600 IU Vitamm-A - 400 IU Vitamin-D for two dosing rounds at
125 tablets/ round was Rs. 10/-. The cost of 9, 1kg packets of Captain
Cook’s iodized salt (30 ppm) for the nine months of intervention at Rs.5.50/
packet x 9 months was Rs.49.50. Since the worker paid Rs.2/ packet, the
cost to the Management was Rs. 3.50/ packet x 9 packets or Rs.31.50/-. The
cost of the screw -top containers was Rs. 15. container. Hence, the total cost
of the micronutrient intervention was Rs.61.50 per worker and family.
The cost of the micronutrient intervention for 700 workers (some buffer stocks
were calculated), came to Rs. 43,050.
A worker and his/ her family generally consisted of the worker, spouse, two
children and an elderly dependent or five members. Hence the cost of the
micronutrients was Rs. 12.30 per family member.
i. Cost - effectiveness in terms of total number of Tea Pluckers employed in
the Pre and During Periods of Intervention
iundred and four less workers were employed in the nine-months Intervention as
ompared to the Pre-Intervention. A worker generally works 25 days per month.
per the current Labour Act, the minimum daily wage/ worker per day is Rs.43.
Hence the Management has made a financial saving of 104 workers
x Rs.43 daily
minimum wage x 25 working days per month or Rs. 1,11,800/-
Hence the Management more than recovered the actual cost of the three
micronutrients which was Rs. 43,050.
We are very happy to report that the CEO of the Study Estate decided to
continue with the Intervention on the basis of the improved health of the
majority of his Work Force and their family members.
Al
Table 5.1
Comparison of Average Rainfall and Rainy Days in the Study and Control
Estates in the Pre and During Intervention Periods
STUDY ESTATE
CONTROL ESTATE
Vlonths
PRE
DURING
PRE
DURING
Rainfall
(inches)
Rainy
days
Rainfall
(inches)
Rainy
Days
Rainfall
(inches)
Rainy
Days
Rainfall
(inches)
Rainy
Days
Aug
21.53
26
25.97
31
62.70
28
48.41
30
Sept
14.47
14
8.50
20
25.00
13
21.15
15
Oct
3.61
12
4.49
8
10.10
11
16.30
8
Nov
0.91
6
0.57
4
2.06
3
0.20
1
Dec
0.00
0
0.79
4
0.00
0
2.10
3
Jan
0.00
0
0.03
1
0.00
0
0.00
0
Feb
0.00
0
0.00
0
0.00
0
0.00
0
Mar
0.43
2
1.99
3
0.00
0
3.50
3
Apr
2.83
5
2.93
5
8.17
7
8.64
4
otal
43.78
65
46.71
76
108.03
62
100.3
64
PRE : August 1995 to April 1996
POST : August 1996 to April 1997
Ae
Table 5.2
Comparison of Crop Yield in the Pre and During Intervention Periods in the
Study and Control Estates
STUDY
CONTROL
Months
PRE
(kg/ Het)
DURING
(kg/ Het)
PRE
(kg/ Het)
DURING
(kg/ Het)
August
213
193
190
120
September
204
248
178
253
October
241
244
268
200
November
249
237
261
229
December
177
181
170
227
January
112
99
104
91
February
131
119
109
150
March
151
97
122
169
April
190
189
168
169
Total
1668
1607
1570
1607
4?
Table 5.3
Comparison of Average Tea Leaves Plucked (kg/ Plucker/ day) in the Pre and
During Intervention Periods in the Study and Control Estates
STUDY
CONTROL
Months
PRE
DURING
PRE
DURING
August
25.7
27.4
29.02
17.33
September
24.8
33.6
20.88
30.05
October
29.2
27.6
28.07
22.11
November
27.7
34.4
24.92
25.16
December
22.4
25.9
19.29
22.87
January
17.3
16.3
13.51
10.71
February
17.6
20.5
14.99
18.06
March
16.1
18.6
12.52
15.71
April
24.8
24.2
19.22
20.54
Average
22.90
25.60*
20.80
20.69
ndicates that the value of 25.6 was significantly better than 22.9 m the Study Estate
p < 0.001 level.
ere was no significant difference between 20.80 and 20.69 in the Control Estate.
So
Table 5.4
Relationship between average kg Leaves plucked and Crop Yield in the Pre and
During Intervention periods in the Study Estates
Correlation coefficient
Significance level
0.8077
0.01
0.9145
0.001
Pre Intervention
(Aug 95 to Apr96)
During Intervention
(Aug96 to Apr97)
Table 5.5
Impact of the Micronutrient Intervention on the average Leaves
Plucked (kg/plucker/day) in the Pre and During Intervention
periods in the Study Estate
Pre Intervention
During Intervention
r
______
N
Mean
SD’
N
Mean
August
327
25.7
5.69
September
313
24.8
6.75
October
326
29.2
6.65
November
324
27.7
6.26
December
326
22.4
5.48
January
313
17.3
5.47
February
311
17.6
4.45
March
305
16.1
4.20
April
322
24.8
5.78
315
322
315
321
315
268
317
288
302
27.4 **♦
33.6 ♦♦♦
27.6 ♦*
34.4 ♦**
25.9 ♦**
16.3 *
20.5 ***
18.6 **♦
24.2
4.66
7.28
7.43
6.93
5.65
6.28
6.28
4.54
5.88
August to April
2867
22.9
7.26
2763
25.6 **♦
8.51
—L__
Comparison between Pre and During Intervention periods
Significantatp<0.001, ♦♦ Significant at p < 0.01, ♦ Significant at p < 0.05, NS
SD
Not Significant
Table 5.6
Impact of the Micronutrient Intervention on the average Leaves Plucked
(kg/plucker/day) by the same Pluckers who were present at the Pre
and During Intervention periods in the Study Estate
Pre Intervention
During Intervention
N
Mean
SD
N
Mean
SD
August
310
25.9
5.68
304
24.9
6.77
306
29.6
6.45
November
313
27.8
6.30
December
305
22.7
5.38
January
254
17.3
5.76
February
293
17.7
4.46
4.66
7.23
7.46
6.93
5.68
6.26
6.25
March
276
310
304
306
313
305
254
293
276
285
27.4 **♦
September
October
16.2
April
285
25.2
______ _______________ ___________ _____________
bmparison between Pre and During Intervention periods
** Significant at p < 0.001.
Significant at p < 0.01
4.27
5.63
05740
34.0
27.7
34.6 ♦**
26.0
16.4 *♦
20.8 ♦♦♦
18.6 ♦♦♦
24.3 ***
}
.Z
■
Table 5.7
Number of tea pluckers employed per month in the Pre and
During Intervention periods in the Study Estate
No. of pluckers employed
Month
Pre Intervention
During Intervention
Difference
August
327
315
-12
September
313
322
+9
October
326
315
-11
November
324
321
-3
December
326
315
-11
January
313
268
-45
February
311
317
+6
March
305
288
-17
April
322
302
-20
Total
2867
2763
-104
Table 5.8
Month by month absenteeism among pluckers in the Pre and
During Intervention periods in the Study Estate
Pre Intervention (Days)
Months
Present
eptember
•ctober
ovember
ecember
inuary
ibruary
arch
oril
Work
Days
27
26
26
26
26
27
25
26
26
/era 11
26
lUgUSt
During Intervention (Days)
Absent
Present
18
5
7
5
6
10
8
7
8
"26
19
27
19
23
37
32
27
31
Work
Days
" 27
25
27
26
27
27
24
26
26
19
7
27
26
No.
%
20
21
19
21
20
17
17
19
Absent
No.
%
20
19
22
19
20
17
16
18
20
6
5
7
7
10
8
8
6
"26
24
19
27
26
37
33
31
:23
19
7
27
Table 5.9
Average Leaves Plucked (kg/plucker/day) by the 9 gangs in the Pre and During
Intervention periods in the Study Estate
Pre Intervention
During Intervention
Gang
N
Mean
SD
N
Mean
SD
1
2
3
4
5
6
7
8
9
43
37
41
39
36
41
38
21
23
24
23
23
22
22
22
25
23
24
4.0
5.3
5.1
5.0
3.9
4.4
4.8
3.8
3.6
43
38
41
39
38
40
38
21
22
27
25
25
25
25
25
27
25
26
4.2
5.4
4.7
4.8
4.7
4.4
5.2
3.9
3.6
Total
319
23
4.6
320
26
4.6
Comparison within Pre and During Intervention periods
Gang effect not significant at p < 0.05
Table 5.10
Changes in number of patients who were referred for various nutrition related
problems from Estate hospital to other hospitals during
the Baseline and Resurvey in the Study Estate
Baseline
Health Problems
N
Resurvey
N
%
%
General weakness/aches & pains
Loss of appetite
GIT problems/Gastritis/Peptic
ulcer/Liver problems
Respiratory problems
Goitre
Anemia
General checkup
31
2
21
27
2
18
14
0
8
16
0
9
5
1
1
55
4
1
1
47
19
0
0
45
22
0
0
52
Total
116
Total decrease
Spmparison between Baseline and Resurvey
’• Significant at p < 0.01
86
26%
Table 5.11
Regularity of use of the Micronutrients by the workers as stated by them
in the Study Estate
Regularity
Subjects
Regular
Irregular
"Stopped Taking"
N
%
N
%
N
Grand Total
410
58
235
33
62
9
Plucker
Female
Male
181
54
71
144
43
29
10
3
4
41
12
58
22
28
20
20
37
10
9
45
6
2
30
40
8
12
4
6
Non-plucker
Female
Male
10
22
132
63
Dependants
Female
Male
3
25
60
Children
57
83
%
Regular = Iron tablets taken twice a week
Irregular= Iron tablets taken off & on /once a week
"Stopped Taking" = Stopped after taking for one to two months
Table 5.12
e
Distribution by the supervisors of the ’’Information Education Communication”
sheet before the Baseline and Resurvey survey in the Study Estate
Baseline
Resurvey
Sample size
7t
"79
Sheet
Distributed (%)
Explained (%)
94
94
95
95
'otai
100
100
Sti
Table 5.13
Knowledge of the Supervisors and Workers(subsample) regarding the dosing
pattern of Micronutrients and their benefits in the Baseline and Resurvey
in the Study Estate
Baseline
N
Dosing pattern
Supervisors
Known
Not known
Workers
Known
Not known
Benefits
Supervisors
Known
Not known
Workers
Known
Not known
Resurvey
%
N
%
15
88
18
2
12
1
95
5
98
82
18
163
99
1
1
47
53
18
1
95
5
78
161
98
22
3
2
21
8
9
93
26
Benefits = Intake of iron tablet improves hemoglobin level and physical work capacity, intake of Vitamin A
capsule improves vision and reduces frequency of illness, intake of iodized salt improves health and
prevents iodine deficiency
Known =Know a minimum of one benefit
Table 5.14
Nutrient intake of the sub sample of the female Pluckers
in the Baseline and Resurvey in the Study Estate
Baseline
Resurvey
| Calories (Kcal)
N
Mean
SD
89
1847
298
1950 ♦
250
%RDA
88
93
Protein (g)
Mean
SD
38
7
42 *
8
%RDA
76
84
Iron (mg)
Mean
SD
6.8
1.9
11.3 ♦
2.3
%RDA
94
38
Vitamin A (ug)
Mean
SD
129
65
165 *
38
%RDA
21
27
Calories 2100 kcal (Moderate worker)
Protein 50 gm
Iron
30 mg
Vitamin A 600 ug (Retinol beta carotene x 0.25)
>urce = ICMR 1993)
>A =
mparison between Baseline and Resurvey
significant at p < 0.05
5G
Table 5.15
Impact of the Micronutrient Intervention on clinical signs of Iron deficiency
in the Pluckers, Non-pluckers and Children in the Study Estate
Resurvey
Baseline
Prevalence
N
Plucker
No sign
Any sign
%
N
°/o
89
11
190
158
55
45
312
156
78
45
22
33
9 ♦♦♦
10
3 ***
141
128
52
48
242
112
81
42
30
21
2
Children
No sign
Any sign
29
55
35
65
55
14
Total
No sign
Any sign
360
341
51
49
609
73
Pale Conjuctive
Pale Nails
Non-plucker
No sign
Any sign
Pale Conjuctive
Pale Nails
Comparison between Baseline and Resurvey
*** Significant at p < 0.001
57
37
22
92
8
8 *♦*
1
80
20
89 ♦♦♦
11
Table 5.16
Impact of the Micronutrient Intervention on clinical signs of Vitamin A
deficiency in the Pluckers, Non-pluckers and Children in the Study Estate
Baseline
Prevalence
Plucker
No sign
Any sign
Night Blindness
Conj. Xerosis
Bitot's Spot
Non-plucker
No sign
Any sign
Resurvey
%
xN
281
81
67
19
3
9
8
2
29
6
208
61
77
23
N
%
335
14
96
4
8
8
2 ♦♦♦
3
| NS
255
9
2
97
3
o ♦♦♦
27
25
9
10
9
3
1 *♦*
3
2
< 1 ♦♦
Children
No sign
Any sign
79
94
6
67
2
97 NS
J
Total
No sign
Any sign
569
81
19
657
25
96 ♦**
Comparison between Baseline and Resurvey
*** Significant at p < 0.001, ** Significant at p
0.01, NS Not Significant
Night Blindness
Conj. Xerosis
Bitot's Spot
133
5^
4
Table 5.17
mpact of the Micronutrient Intervention on clinical signs of Iodine deficiency in
the Pluckers, Non-pluckers and Children in the Study Estate
Resurvey
Baseline
N
Prevalence
%
N
%
’lucker
Present
Not present
63
285
18
82
36
313
10
90
'Jon-plucker
Present
Not present
55
214
20
80
12
252
5 ♦ ♦♦
95
Children
Present
Not present
0
84
0
100
1
68
1 ♦ ♦♦
99
118
583
17
83
49
633
7 ♦**
Total
Present
Not present
93
jmparison between Baseline and Resurvey
* Significant at p < 0.001
Table 5.18
[mpact of the Micronutrient Intervention on Hemoglobin status of the Pluckers,
Non-pluckers and Children in the Study Estate
Hemog obin (g/dl)
Resurvey
Baseline
Subjects
N
Mean
SD
N
Mean
SD
Plucker
Female
Male
334
13
11.0
12.0
.9
.6
334
14
11.9 ***
13.5 ♦ ♦♦
1.1
1.3
Non-plucker
Female
Male
51
213
10.7
12.1
1.3
.9
51
209
11.6 ♦ ♦
14.0 ♦♦♦
1.8
1.2
Children
83
10.8
1.0
69
11.6
.9
.9
.9
385
223
11.9 ♦♦
1.2
1.2
Plucker & Non-plucker
11.0
385
Female
12.1
226
Male
omparison between Baseline and Resurvey
’♦ Significant at p < 0.001, ♦* Significant at p < 0.01
59
14.0 **♦
Table 5.19
Impact of the Micronutrient Intervention on Hemoglobin status of the Regular,
Irregular and ’’Stopped Taking” Pluckers and Non-pluckers in the Baseline and
Resurvey in the Study Estate
Resurvey HB (g/dl)
Baseline Hb (g/dl)
Subjects
Regular
Irregular
“Stopped
Taking”
Regular
Irregular
“Stopped
Taking”
174
8
11.0
1.4
174
12.0 *
1.0
135
11.8 *
1.1
8
11.3
1.3
9
13.6
.9
4
14.0
10
Plucker
Female
Male
N
Mean
11.1
135
10.9
SD
.8
1.0
N
4
Mean
9
11.6
SD
1.3
Non-plucker
N
.Female
Mean
Male
1
11.0
18
12.1
1.2
10.9
2.4
1
11.1
2.0
118
14.0
1.2
44
14.2
1.1
4
14.2
.5
9
11.4
1.3
SD
1.0
N
Mean
118
12.1
.9
44
12.2
.9
4
12.3
192
11.1
.8
145
10.9
.9
9
11.0
1.4
192
145
12.0 **
11.7 **
1.0
1.3
127
12.1
.9
48
4
127
12.2
12.3
14.0
.8
.6
1.2
48
14.2
1.1
N
Mean
SD
Male
1.3
10
10.8
.9
SD
Plucker and
Nonplucker
Female
1.2
.2
N
Mean
SD
18
11.1
.6
Regular Iron tablets taken twice a week
Irregular^ Iron tablets taken off & on /once a week
"Stopped Taking" = Stopped after taking for one to two months
Comparison within Baseline and Resurvey
Regular Vs Irregular; Regular Vs “Stopped Taking”; Irregular Vs “Stopped Taking”
** Significant at p < 0.01, * Significant at p < 0.05
Go
4
14.2
.5
Table 5.20
Impact of the Micronutrient Intervention on average Leaves Plucked
(kg/plucker/day) by the Good, Moderate and Poor Pluckers and their
Hemoglobin levels in the Study Estate
Pluckers
Good
N
During Intervention
Pre Intervention
Leaves Plucked
Hb
Leaves Plucked
113
107
166
Hb
♦ ♦♦
143
11.9 ***
1.13
Mean
28.1
11.1
29.3
SD
2.47
0.91
3.15
227
227
173
Mean
19.9
11.0
21.7 ♦♦♦
SD
3.01
0.96
2.49
137
12.1 **♦
1.18
Overall
N
340
308
339
284
Mean
22.6
11.0
25.4 ♦ ♦♦
12.0 ♦♦♦
0.94
4.74
1.16
Moderate + Poor
N
4.79
SD
________________________ —
Good plucker: More than 25 kg leaves plucked per day
Moderate plucker: 14 to 25 kg leaves plucked per day
Poor plucker: Less than 14 kg leaves plucked per day
Cpmparisons within Pre and During Intervention periods
Good Vs Moderate-rPoor, kg leaves plucked; Hb levels
Comparisons between Pre and During Intervention periods, kg leaves plucked; Hb levels
**• Significant at p < 0.001
G\
Table 5.21
Impact of the Micronutrient Intervention on Body Mass Index (BMI) of the
Pluckers and Non-pluckers in the Study Estate
Resurvey
Baseline
Nutritional Status
N
%
42
63
140
195
7
7
50
10
71
50
4
29
129
219
37
150
43
63
199
57
18.5
22
42
69 **
BMI < 18.5
30
58
37
17
31
45
107
51
BMK 18.5
97
120
55
103
49
Total
BMI >= 18.5
BMK 18.5
119
150
44
144
120
55 *
Plucker
Female
BMI >= 18.5
BMK 18.5
Male
BMI>= 18.5
BMK 18.5
N
%
122
212
37
58
Total
BMI>= 18.5
BMK 18.5
Non-plucker
Female
BMI >
Male
BMI >
18.5
Comparison between Baseline and Resurvey
** Significant at p < 0.01, * Significant at p < 0.05
56
45
Table 5.22
Impact of the Micronutrient Intervention on average Leaves plucked
(kg/plucker/day) by female pluckers in relation to their
Body Mass Index (BMI) in the Study Estate
BMI
Pre Intervention
During Intervention
113
123
25.9
4.59
>= 18.5
N
Mean
SD
23.0
4.80
< 18.5
N
227
Mean
22.5
SD
4.79
Comparison between Baseline and Resurvey
Relationship within intervention period not significant at p < 0.05
216
25.2
4.82
Table 5.23
Impact of the Micronutrient Intervention on common Health problems in Pluckers
and Non-pluckers as perceived by them in the Study Estate
Baseline
(N=617)
Health Problems
Present
Not present
General weakness
All aches/pains (Body, head, neck,
limbs, joint, shoulder)
Bronchitis, URI, cough &
congestion
Abdominal pain, giddiness,
gastritis
Obstetrical & gynaecological
problems(Female)_________________
Comparison between Baseline and Resurvey
*** Significant at p < 0.001
N
Resurvey
(N=613)
N
%
%
54 **♦
46
543
74
88
12
280
104
400
17
65
44
82
13 **♦
66
11
8
1 ♦♦♦
43
7
195
32 ***
81
13
20
2 ♦♦♦
G3
7
Table 5.24
Impact of the Micronutrient Intervention on the perceived improvement in health
by Regular, Irregular and "Stopped Taking" Pluckers and Non-pluckers
in the Study Estate
Regularity
Health
Regular
(N=345)
perception
N
%
Irregular
(N=218)
N
%
Feel better
248
72
80
37
3
Improoved
appetite
41
12
16
7
59
No change
94
27
128
___________ _________ _________________
Regular = Iron tablets taken twice a week
[regular = Iron tablets taken off & on /once a week
Stopped Taking" after taking for one to two months
“Stopped Taking”
(N=50)
N
%
Total
(N=613)
N
%
6
331
54
1
2
58
9
47
94
269
44
lelationship between Regularity and Health Perception significant at p < 0.05
Table 5.25
Impact of the Micronutrient Intervention on Attendance of female Pluckers in
relation to their hemoglobin status in the Study Estate
Attendance
<= 20 days
Hemoglobin
status (g/dl)
N
Attendance
> 20 days
%
N
%
< 10
10 to 11.9
8
57
6
43
58
52
53
48
12 and above
80
44
100
56
Comparisons within attendance
Relatioship not significant at p 0.05
64
Figure 5.1
Month by month comparison of Crop Yield
in the Pre and During Intervention(l) periods
in the Study and Control Estates(E)
Avg kg/hactare
300 ---------------------
n
H
L
200
1
I I
I j
■' ■' •]
\I
100
I
It'
II II
1
■ I
i
I I
I I I I mI
I
I
I
I I
r'J
l.'i
hI
I
I
0
u
r''.i
y
Aug Sep
N
1I
I
Oct
j
I
'1 I
Nov
Dec
I' i
Bn
h
fe
I
I ’
I:
B
B
B i
I I B b
1 lU B
i
Jan
Feb
Mar
Apr
Study E Pre I
Study E During I
j Control E Pre I
Control E During I
C5
IjI
Overall
Figure 5.2
Month by month average kg leaves plucked/day
per plucker in the Pre and During Intervention(l)
periods in the Study and Control Estates(E)
Kg/plucker/day
40-------------------------
I
I
x:;
30
1
k'
i
L J
I
1
w
rj It'
20
■ j p
!
Aug
B
|j
k''
I: i
il
•I I
!I
r. • \
b '
I
rI I
I
’’ I
10
IJ
I
I
1I II I
I
il Uli
I
’I
0 J
Sxi
r
I
Sep
Bj
■'
R I
I
Nov
I
I Study E Pre I
- Control E Pre I
Dec
Jan
■ ■
I
■
III
IH II
'''1 V
i I■
| I
i
Oct
I
r
Feb
1I
1t
Mar
I
Apr
EZ3 Study E During I
Control E During I
i
Overall
Percent Pluckers who plucked more in the
During Vs Pre Intervention period
in the Study Estate
350
No. of Pluckers employed/month
300
94%
91%
81%
250
75%
74%
200
64%
54%
150
34%
100
34%
33%
50
\:^
0
^13....
Sep
Oct
Dec
Jan
J Who plucked more
** Significant at p < 0.01
L
Feb
Mar
Apr
I Total Pluckers
Overall
Figure 5.4
Month by month no. of pluckers employed
in the Pre and During Intervention periods
in the Study Estate
No. of pluckers
400 ---------------- —
flIt i
300 -
■J
■
■ A'l
j
i ■■
1'^;
I
| \w'
.■
1
f '''X!
I"1
l.?'l
H
B
R
I
I
I
■ '•
I
I
La\!
""t
■
■ ■
I bI
I'-'l
200 -
■I •
■
H ■■ 4i
I' \'l
I
B -
I '" '1
I B
H
:’"\W
I
■1
r
I
I
I
■'1
;\>\\\
Aug
■t
'W
Sep
Oct
'■
I
Nov
Pre Interventiom
Aug95 to Apr96
Dec
Jan
B3
■.;
-
■
hl ■ . BI ' 7
'
I■
■a'
B '
i i
IB ■ ••'
■
■
I
;
hl I1
■■ M
hl
■1
100 ■.
s 1 J I
I i I« It II
■;
II
w I
s. h'.' '> i
B1L
0
L'-'.w
■
■ ■-■
B ;
B
B
B -' -
II
B ■ ' 'A
B't
■■ ;
■
■I
■ i BB
14 B■ t
■1
y.W
■ -''V.
Feb
■ ■'.'1
| ■ C.'j
I H ■'•i
Mar
I -1
Bl
Apr
^11) During Intervention
Aug96 to Apr97
I
Figure 5.5
Month by month percent days absent by
pluckers in the Pre and During Intervention
periods in the Study Estate
% days absent
40----------------------
■
I
30 -
i
Ift ■’
II 'i
20
I';;
r
II
I
II
R
10 1
H
I
Ia
■1
0
■i
Aug
I1
I
■a
h I ■■ ;’
I.a'J
II "'AN
I
IJ
I
■s
I
IIM :
R
t'AAj
■
I
w
I
■
; \\\V
Oct
Nov
Dec
I
J
■ J
11 ■
:
1
'1
Sep
I
I1 II I I
I v'W
I-I -'N:
g
I11j
H i
■
I
I
■■
['•■'A I
I I
H11'
iI 1 Ml I ;
Jan
Feb
. V’j !
I>
Mar
Apr
I
Overall
Pre Intervention!
During Intervention
Aug95 to Apr96
Aug96 to Apr97
G9
’
Figure 5.6
Knowledge of the Supervisors(S) and Workers(W)
(sub sample) regarding the dosing pattern of the
Micronutrients & their benfits in the Study Estates
Percent
100 -
95
99
98
95
88 ifIS
80 -
p'
Pi
60
&•>
•■•••
■i
40 -
ft'a
BO
20 -
0 L
■
■
Bw
Bill
Bifel
■■
-NW
<
\'?'j
J
■\\\\\.
Dosing Pattern
Benefits
I Baseline S (N-17)
Resurvey S (N«19)
J Baseline W (N-119)
Resurvey W (N»164)
no
Figure 5.7
Impact of the Micronutrient Intervention as indicated
by reduction in Anemia in Female, Male Pluckers and
Non-pluckers and their children in the Baseline and
Resurvey in the Study Estate
% Anemic
100 -
100
98.4
86.7
80 -
60 -
| 52.2***
■
l
| 41.6 ‘
40 -
■
I II
20 r
i
i
0
■
J
i-.
B •a
| 21.5 —
bw;.
■I ?
h
Male
(N-385, 385)
(N-226, 223)
Baseline
_
Children
(N-84, 69)
Re survey
Anemia ■ Hb<12g/dl in Female and Children
Hb<13g/dl in Male (DeMaeyer 1989)
Comparisons between Baseline and Resurvey
*** Significant at p < 0.001
7/
.
fey: ■
JBBISIL
Female
■ •■'i
•M
J
Figures 5.8 to 5.10
Impact of the Micronutrient Intervention on
shift in the hemoglobin status distribution
curve in Pluckers, Non-pluckers and
children in the Study Estate
Figure 5.1 Female Pluckers
and Non-pluckers
~ Percent
200150100r
50l
9
-----
Figure 5.2
Male Pluckers
and Non-pluckers
;WHO Cut off
10
11
12
13
14
Hemoglobin (g/dl)
9
WHO cut Off
10
11 12 13 14
Hemoglobin (g/dl)
Baseline (N=23tt
Figure 5.3
Children
Percent
6050r
40302010-
°<8
>16
Baseline (N-386)— Resurvey (N-389)
Percent
100806040L
20-
°<8
15
9
15
16
>16
Resurvey (N-224)
WHO cut off
10
11
12
13
Hemoglobin (g/dl)
Baseline (N-84)-----
14
>14
Resurvey (N»69)
Figure 5.11
Relatioship between Hemoglobin status and
average kg leaves plucked/plucker/day (as
stated by them) in the Resurvey
in the Study Estate
kg leaves plucked/plucker/day
35------------------------------------------------------------------ -------------
32.2
30.5
30 -
27.9
25 -
20 -
15 -
10 -
5 -
0
< 10 (N-16)
10 to 11.9 (N-123)
Hemoglobin (g/dl)
Relationship not significant at 0.05
73
12 & above (N*209)
Figure 5.12
Perecnt shift in Good, Moderate and Poor pluckers
from Baseline to Resurvey in the Study Estate
% pluckers
80 -------------70
65.3
60 -
50.7
49
50
i
r
j
40
33.2 !
S!
i
30 -
. life i
20 -
10 0
I
■■
Good
1.5
i
Moderate
Baseline (N=340)
F
0.3
Poor
j Resurvey (N=339)
Good : > 25kg leaves plucked/day
Moderate : 14-25kg leaves plucked/day
Poor : < 14 kg leaves plucked per day
Shift significant at 0:05 p<O,<7o/
Figure 5.13
Relatioship between Hemoglobin status and
Attendance of female pluckers
in the Study Estate
% pluckers
70----------------
60 -
57
56
; ''Ml
52
| 48
50 -
■
II 43
—
40
20 r
10L
1
■
tel ■
■
I ■ '' '
30 -
v. tote
■'
0
< 10
' I’
I ;
Mi
■
t!
to
I
i®
I.
44
Mil
10 to 11.9
12 & above
Hemoglobin (g/dl)
Attendance <•20 days
(N-146)
S Attendance >21 days
(N-159)
Relationship not significant at 0.05
Chapter Six - Discussion
Hidden Hunger for iron, iodine and Vitamin-A :
The reduction or the removal of the “Hidden Hunger’ for iron, iodine and Vitamin-A
among the underprivileged populations of the developing world has engaged the
attention of public health professionals and Governments the world over (23).
There is proof from tea plantation-based studies in India (3); Indonesia (22); and Sri
Lanka (7) that physical work capacity and hemoglobin levels are significantly
related. However, the transfer of the findings of these classical studies of the late
seventies/ early eighties to the plantations has not had the spread effect it should
have.
The Importance of Demonstration Projects
This Demonstration cum Research Action Study was an attempt to partner and work
closely with a Tea Plantation in South India and to evaluate whether the health,
productivity and if possible the profitability of the Plantation mcreased as a result
of delivering all the three micronutrients of ‘iron, iodine and Vitamin-A’
together, to the entire work force and families of the Tea Plantation, using the
Plantation’s own infrastructure and on-going Management-Information-Systems.
Therefore, the success of this study is to be judged as much or more, by its
Participatory Plan of Action, its Development and its Implementation as by the
Impact achieved as a result of the Micronutrient Intervention.
Improved Health of the Plantation Workforce, especially the
Female Pluckers
fhe Tea Plantation Industry has some unique characteristics which can be
:apitalized upon in the delivery' of the micronutrient package (iron, iodine and
i/itaniin-A) to its Workforce. The Tea Pluckers are almost always women (24) and
tkilled pluckers are becoming a rare commodity. Forty to fifty percent of the field
iperational costs of tea-production can be accounted for by the “plucking of leaves
irocess”. Therefore, it makes good sense to devise and assess an intervention or
itrategy that is simple, acceptable and sustainable.
Was the Micronutrient Intervention simple, acceptable and
sustainable ?
Chickmagalur District is an endemic district for Iodine Deficiency Disorders (IDD).
Most Low Income Groups(LIGs) manifest high prevalence of Iron Deficiency
Anemia(IDA) and Vitamin-A Deficiency (VAD) as well A recent Karnataka
Nutrition Profile of women, adolescent girls and children confirmed that the hidden
hunger for iron, iodine and Vitamin-A was indeed widely prevalent in Chickmagalur
District (9) where our Study Estate was located. Our previous experience in
advising the Government of Gujarat (GOG) Western India, had shown that it was
possible for the GOG to successfully procure and distribute the above
micronutrients along with albendazole (anthelmentic) for nearly three million
schoolers in every district of Gujarat on an continuing basis (10). Hence, we knew
that it would be not be difficult to devise a similar and much needed Intervention for
the Plantation Workforce. An uninterrupted supply line is essential for any
intervention. Fortunately, ferrous sulphate and iodized salt were in abundant
supply - though Vitamin-A was not. Double fortified salt (iron + iodine) was our
first choice - but a Madras-based supplier was not able to even meet our small order
of about 1000 x 1kg packets of double fortified salt every six months. In Gujarat,
the cost of albendazole + iron + Vitamin-A came to just Rs. 10.50/ school child per
year (10). In this intervention, the cost of the three micronutrients was just about
Rs. 12/ person/ year. Provided there is a well established conduit to deliver the
micronutrients, such as the Plantation Hospital for the medicinal supplements; and
the Plantation Ration Shop to stock the iodized salt, supplementation or
fortification is by far the most easily managed, cheap and accountable of
nutrition interventions (25). The whole purpose of this Demonstration cum
Research Action Project was to jointly design and implement an intervention that
was fully acceptable to the Plantation Management and Workforce. It has been the
experience of many well-intentioned national and international projects, that not
sufficient importance is given to the community, its leaders, or the local
implementing researchers in operational project design. Very often the project ends
with the exit of its research team ! (26) In this project, maximum emphasis was to
evolve a strategy/ intervention that this Study Plantation now, and other surrounding
ones in the near future - could and would adopt willingly. The CEO of the Study
Plantation and his Management on the Plantation have continued with the micro
nutrient intervention, even after we the research team (TCS) has exited in April,
1997. We believe that this was possible due to : (i) The simplicity of the
intervention; (ii) Its high acceptability with the Management and Workforce and
'1'7
(iii) its sustainability as it was cost-effective, and the micronutrient inputs were
easily available in the market.
Did the Health of the Workforce Improve ?
Very significant micronutnent-specific-improvement in the health of the Workforce
(Pluckers and non-Pluckers) and their dependents was observed. The clinical signs
of iron, iodme and Vitamin-A deficiency declined. At the Baseline Survey, the
Workforce as a whole either had no IDA or suffered from mild IDA. The mean
Hb level of the Woman Pluckers was 11 g/ dl and this went up by a gram due to the
intervention. In the men workers the mean Hb level was 12g/ dl which went to
14g/ dl. Hence, the Intervention did improve the iron status of the Workforce.
Referral to big hospitals for nutrition and the micronutnent-related health problems
lid decrease significantly. Above all, the majority of the Workforce stated that they
felt better’, ‘ate more’and ‘felt less tired’. Perception is almost as potent as the
eal thing. The intervention created a resovoir of good will and a feeling of being
:ared for. The improved health of the Workforce permeated to the Management as
veil. The Research Team (TCS) heard many Workers state this was the first-time
ill of them and their families were being given a Health check-up in the Plantation
fospital, even when they were well.
Did the Productivity of the Pluckers Improve ?
Tie second objective was to see whether the Intervention mcreased labour
iroductivity as measured by increases in Average Tea Plucked ? The answer is a
'ery definite ‘yes’. Two types of controls were employed. The first was the Prentervention period of August 1995 to April 1996 (9 months) which served as an
ntemal Control to the Experimental Intervention Penod of 9 months (August 1996
d April 1997) m the Study Estate. We also had an External Control m a carefully
latched nearby Estate which has been referred to m the body of the report as our
/ontrol Estate. The Study and Control Estates matched beautifully on the Key
haracteristic of Average Crop Yield (kg/ Hectare). Our results showed that the
average Tea Plucked (kg/ worker/ day) was significantly higher than m the Internal
'ontrol of the Pre-Intervention Period. It was also significantly higher in the
itervention period as compared to the External Control Estate over the same
itervention period of August 1996 to April 1997.
he significant increase was supported by the fact that the mean Hb levels of the
'omen Pluckers had also gone up from 11g/ dl (Baseline) to 11 9g/ dl at Resurvey,
he overall health and well being of the Pluckers had improved. Their Body Mass
Index (BMI) had unproved; their dietary and nutrient intake had unproved; they had
fewer micro-nutrient related health problems; the attendance of pluckers who had
Hb levels of more than 12g/ dl had better monthly attendance (more than 21 days);
they plucked nearly 30kg leaves/ day versus significantly less by those pluckers
whose Hb levels were between 10g - 11g/ dl (at Resurvey); they had less h^lth
problems that those with lower Hb levels.
There were some major differences in the design and implementation of our study
and those done by other investigators on Plantations. Rahamutullah’s Indian Study
was done some 20 years prior to ours and was conducted in Kerala, South India.
The subjects of her study were very anemic (Hb of 6.2g/ dl by the Sahli’s method,
which is not accepted now) The Pluckers had an Average Plucking Rate of 17kg/
worker/ day. The major objective of her double-blind study was to evaluate the
impact of iron, on Hb status and increased work performance and monthly
attendance. Iron supplementation was 65mg elemental iron given continuously at
the worksite for 100 days. The conclusions of this 6-months-study were that . Mean
Hb levels rose from 6.2g to 8.5g/ dl; Average Plucking Rates rose from 17kg to
22kg/ worker/ day; the monthly attendance rose from 19 days to 22 days. The
author sums up that human relations between workers improved, absenteeism due to
fatigue decreased and potentially good pluckers plucked even more. Pluckers with
low Hb levels were not necessarily poor pluckers. Also exceedingly high plucking
rates were achieved by the erratic plucker - perhaps driven by other considerations
(3).
An Indian study in 1987 on IDA and Farm women, clearly indicated that iron
supplementation conserved energy and work output was significantly increased after
supplementation (27). A recent study in Chma, in 1994 on the functional
consequences of iron supplementation in iron-deficient female cotton mill workers,
also corroborated the Indian study by concluding that iron supplementation enabled
these women to do the same work at a lower energy cost (28).
A study in Bombay on the effect of ferrous fumarate on the iron status and physical
work capacity(PWC) of women concluded that even middle class Maharashtnan
women suffering from mild to moderate iron deficiency anemia showed significant
benefits in PWC and increased Hb levels(29).
Edgerton etal in a Sri Lankan study on IDA and its effect on worker productive' and
activity patterns among female tea pluckers also established the significant
relationship between iron supplementation and work capacity. The impact
evaluation was done after two months (entire duration of the study). The
-1A
mvestigators reported frat work productivity was unproved in subjects even with
moderate won-deficiency (Hb levels of 11g/ dl).
Subjects with lower Hb
concentrations initially expenenced the greatest increase in productivity(7).
Husaim and co-workers in an evaluation of nutritional anemia intervention among
anemic female workers on a tea-plantation in Indonesia, compared the impact of
iron-fortified salt (1.5mg Fe/ g salt) or iron supplemented group (60mg elemental Fe/
worker/ day) for four months. Both groups were dewormed as well. The Control
group received a plaacebo. They reported that there was a significant relationship
between iron supplementation, enhanced Hb status, and enhanced average tea
plucked. Direct non supplementation brought up Hb levels much faster than did non
fortified salt (22). The relationship between Hb concentration and PWC has been
established on agricultural labour in Gautemala(30); in the Philippines (31); in
Africa ( 32); and m Indonesia (22).
All these studies were exploratory in nature with the basic objective of examining
the relationship between hemoglobin status and Physical Work Capacity (PWC).
They were usually controlled, double-blind and of short duration (generally 2-4
months). The sample size of subjects was generally small. Hence, they cannot be
compared with our study.
Our study was designed to be Demonstration cum
Research Action. Our study had the longest reported intervention period of nine
months, which took in the seasonality in crop yield. We delivered a triple
micronutrient package of iron + iodme + Vitamin-A. What we did in this study was
to move forward and attempt to empower a Tea Plantation to implement and
manage their own micronutrient program for their workforce.
We cuncurrently evaluated the impact of the “iron + iodine + Vitamin A”
micronutrient intervention on the health of the entire workforce and their families ;
the worker productivity of the Female Tea Pluckers; and the Profitability to the
Plantation Management.
Did Profitability Increase ?
Our third objective was an attempt to improve profitability. This was a bit over
iptimistic and ambitious on our part. However, we can say with certainty frat the
:ost of the ‘three-in-one micronutrient’ intervention was extremely cheap at
Rs.61.50/-(about USD 1.50) per worker + family per annum. The annual cost per
ndividual (assuming frat there were five individuals/ family) was just Rs. 12 (or 30
JS cents). Basta etal had quoted a figure of USD 50 cents for supplementation
vith 1 OOmg elemental iron per day for 60 days/ man year in the seventies (4).
SO
We do not know if there were other managerial considerations, but our data show
that 104 less pluckers were employed to pluck more tea leaves m the During
Intervention Period Vs the corresponding Pre-Penod (even though the crop-yield
was the same). This translates to a substantial saving in wages of a little more that
Rs. one lakh. The total cost of the micronutrients for this intervention was
Rs.43,050. Hence, if nothing else, the Management more than recovered the money
and time spent in implementing and managing this Intervention.
Other Considerations :
The Influence of Crop Yield, Seasons :
The influence of rainfall and season is of paramount and significant importance in
the average tea plucked/ worker/ day. Since, our Intervention ran for a duration of
nine-months, we were able to assess this for ourselves. We now regret we did not
continue our observations for a whole year. A review of the literature shows that
even Rahamutullah’s impact study was of 6 months duration though data of tea
plucked is available for a year. We are surprised that Rahamutallah did not notice
from her own data, that the average tea plucked from March to September was
noticebly higher than the other months of the year(3). This was followed by the
study of Husaini etal, whose intervention lasted four months. All the other studies
were just of 2 months duration. The effect of season and crop yield appears to have
been discounted (4,7). Although the Sri Lankan impact study of Edgerton etal was
only of two months duration in the drought months, they have also presented data of
average tea plucked for a whole year. It is very apparent from their data presented
that the average tea plucked in all the four divisions of the Estate were relatively
high in the months of February to August. The ‘plucking rate’ went down sharply
from June to September and started limping back in October, November and
December. The answer is simple. The monsoons and rainfall influence the crop
yield which in turn influence average tea plucked. We feel that the most accurate
comparisons should be made on matched data of Pluckers, month by month for
a Pre and During situation over one full year. The month by month crop yield will
also have to be compared and controlled for. In spite of this if the intervention (such
as ours) had a significant impact, one can conclude with a strong degree of
confidence that it was a true and not chance effect.
The Effect of a Multinutrient Package Vs a Single Micronutrient:
Multinutrient interventions ride very comfortably and cost-effectively on on-gomgprograms (10). Studies are available which clearly show the positive effect of
SI
Vitamm-A on iron status (33,34,35). Whenever and where ever possible it would
make good sense to deliver a ‘three-in-one-package’ of iron, iodine and Vitamin-A
at the very least.
The Inclusion of Anthelmentics with the Micronutrient Package :
Again there is abundant evidence that mass-deworming of entire Plantation
populations would not only control intestinal helminthic infections, but would bring
about much better utilization of the micronutrients (10,36,37,38). We are happy to
say that this is being done on the Study Plantation from April 1997.
Weekly versus Bi-weekly supplementation with Iron :
This study has shown that two times a week iron supplementation or once a week
iron supplementation worked just as well. Again there is ample evidence that
weekly iron supplementation is as effective as daily supplementation (11,12,13). A
strategy that advocates by-weekly or weekly iron supplementation, particularly in
institutions such as schools, colleges or even sectors such as industry or agriculture
is sure to be much more acceptable to any target population.
Importance of Empowering the Target Population to be responsible
for their own Micronutrient Health
Finally one has to empower an underprivileged community to take care of itself.
One cannot be policing regular intake. This study showed that by and large the
Workforce were responsible about self-dosing, especially so with regard to their
children.
Chapter Seven - Recommendations
The following recommendations are based on the findings of this Demonstration
cum Research-Action project, which conclusively demonstrated that the
micronutrient (iron, iodine and Vitamin-A) health of the Plantation Workforce
and the Labour Productivity (of the pluckers) had improved significantly.
They are as under :
i. Encourage partnerships between the Management of Plantations, academia/
researchers , and the pharmaceutical/ food processing industry to design and
deliver simple, cost-effective and sustainable micronutrient interventions of iron,
iodine and Vitamin-A for the Workforce on Plantations.
ii. Build confidence and capacity among the Management/ staff of Plantations to
manage micronutrient interventions on their own.
iii. Demonstrate how combined multinutrient interventions can be easily integrated
into the ongoing health programmes or activities on the Plantation.
iv. Encourage and enthuse the Management, Medical and Health staff to strongly
support Preventive Health Programs.
v. Encourage Plantation Ration shops to only procure and store reputed brands of
iodized salt and to sell it at subsidized rates. Fortification of common foods is
the cheapest and simplest way of ensuring that the three micronutrients, namely,
iron, iodine and Vitamin-A are consumed by the entire Workforce and their
families. In the future, the Plantation Management should seriously think of
procuring double fortified salt (iron + iodine) and selling it to their Workforce
at subsidized rates.Cooking oil, likewise can be fortified with Vitamin A, D
and E.
vi. Convince Apex bodies such as the United Planters of South India to make it
mandatory to include Micronutrient Interventions into the Comprehensive
Labour Welfare Schemes (CLAWS).
vii. Convince the Managers that the improvement of the health and well being of
their Workforce through Micronutrient Interventions, will result not only in better
33
worker |productivity but also m
Management and Workforce.
more cordial relations between the
™P'“a"0"
IX. In the spirit of each one teach one we reouest
S9
'•o replicate the Study Estate’s
j c .
1. A Restive Brew : The Economic Times, September 8, 1997.
2. Kalita MC: Influence of type of Plantation on the nutritional status of male and
female tea-plantation workers of Assam : A Doctoral Thesis, University
Department of Foods and Nutrition, M.S.University, Baroda, 1991.
3. Rahamathullah V: Anemia and productivity among tea-plantation workers in
South India : Proc Nutr Soc India, 28, 16-24, 1983.
4. Basta SS, Soekiraman MS, Karyadi D and Scrimshaw NS : Iron deficiency
anemia and the productivity of adult males in Indonesia, Am J clin Nutr, 32, 916925, 1979.
5. Gardner GW, Edgerton VR, Senewiratne B, Barnard RJ and Ohira Y : Physical
work capacity and metabolic stress in subject with iron deficiency anemia:
Am.J.Clin.Nutr, 30, 910-917, 1977.
6. Edgerton VR, Ohira Y, Heltiarachchi acheni J, Seniwiratne B, Gardner GW and
Barnard RJ : Elevation of hemoglobin and work tolerance in iron deficient
subjects: J Nutr Sc Vitamins, 127, 77-86, 1981.
7. Edgerton VR, Gardner GW, Ohira Y, Ganawardena KA and Senewirathne B:
Iron Deficiency Anemia, its effect on worker productivity patterns. Bnt Med J,
2, 1546-1549, 1979.
8. Kalita MC : Personal Communication.
9. Nutrition Profile of Karnataka : Prepared by the centre for Youth and
Development, Bangalore, 1996.
10. Tara Gopaldas and Sunder Gujral : The Pre-Post Impact Evaluation of the
Improved Mid-Day-Meal Programme, Gujarat (1994-Continuing) : Tara
Consultancy Services, Baroda, 1996.
ll.Schultink W, Gross R, Gliwitzki M, Kary adi D and Matulessi P : Effect of daily
Vs twice weekly iron supplementation in Indonesian pre school children with
low iron status : Am J Clin Nutr, 61, 111-5, 1995.
12.Liu-X-N, Kang J, Zhao L, Viteri FE: Intemittent iron supplementation is efficient
and safe in controlling iron-deficiency and anemia in preschool children. Food
Nutr Bull, 16, 139-46, 1995.
13.Viteri FE, Liu X-N, Martin A, Tolomei K. : True absorbtion and retention of
supplemental iron is more efficient when adminstered every-three-days rather
than daily to iron-normal and iron-deficient rats : J Nutr, 125, 82-91, 1995.
14.Gopalan C, Ram Shastri BV and Balasubramaniyan SC Nutritive Value of Indian
Foods. National Institute of Nutrition. ICMR. Hyderabad. 1989.
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dietary allowances for Indians. A report of the expert group of the Indian
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Monograph. Series No. 53. WHO Geneva. 1966.
17.Waterlow JC : Classification and definition of protem calorie malnutrition : Br
Med J. 3, 566-569, 1972.
18. Sommer A. A field guide to Vitamin A deficiency and its consequences, its
detection and control. WHO. 1995.
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iodization. WHO/NUT/ 1994.
20.Oser BL : Hawk’s Physiological Chemistry : Tata Me Graw Hill Publishing Co.
Ltd, New Delhi, 1976.
2EWorld Health Organization. WHO Technical Report series No 405. Nutritional
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among anemic female workers on a tea plantation : Proceedmgs on Iron
Deficiency and Work Performance. International Nutritional Anemia
Consultative Group Meeting, USA, : 1981.
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in developing countries. Washington D C. 1994.
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Association of Southern India (UPASI): 1994.
25.Micronutrient Fortification of Foods.
Current practices, research and
opportunities : Lotiffi etal : The Micronutrient Initiative and the International
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26.Tara Gopaldas : Problems and Prospects in Upscaling Nutrition Research Action
Projects or Pilots to Programmes : The Sixth Srikantia Memorial Lecture,
National Institute of Nutrition, Hyderabad, 1994.
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24,253 -259,1987.
28.Li R, Chen X, Van H, Deurenberg P, Garby L, Hautvaust J : Functional
consequences of iron supplementation in iron-deficient female cotton mill
workers in Beijing, Chma : Am.J. Clin Nutr, 59, 908-13, 1994.
29.Tumbi Z, Dodd NM : Effect of ferrous fumarate on the iron status and physical
work capacity of women : Nutrition Research, 10, 1375-1384, 1990.
30. Cifuentes E and FE Viteri Physical fitness, iron deficiency and anemia in
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31. Popkin, B.M etal. Cited from Reference No. 7.
Department of Public Works, Phillipines, 1975.
A report submitted to the
32. Davies CTM, JP Van Haaren : Effect of treatment on physiological responses to
exercise in East African Industrial Workers with Iron Deficiency Anemia Brit J
Industr Med, 30, 335-340, 1973.
33. Mejia LA, Hodges RE, Arroyave G, Viteri F, Torun B : Vitamin A deficiency
and anemia in Central Americal Children : Am J Clm Nutr, 30, 1175-84, 1977.
34. Bloem MW, Wedel M, Agtmaal EJ, Speek AJ, Saowakontha S, Schreurs WTLP
Vitamin A intervention Short-term effects of a single, oral, massive dose on
iron metabolism : Amer J Clin Nutr, 51, 76-9, 1990.
^7
k /
0
35. Northrop Clewes CA, Paracha PI, Me Loone UJ, Thumham D . Effect of
improved Vitamin A status on response to iron supplementation in Pakistani
infants : Am J Clin Nutr, 64, 694-9, 1996.
36.Atukorala TMS, de Silva LDR, Dechering WHJC, Dassenaike TSC, Perera RS.
Evaluation of effectiveness of iron-folate supplementation and anthelmintic
therapy against anemia in pregnancy-a study in the plantation sector of Sri
Lanka. Am J Clin Nutr, 60, 286-292, 1994.
37.Stolfus RJ, Chwaya HM, Tielsch JM, Schulze KJ, Albonico M, Savioli L :
Epidemiology of iron deficiency anemia in Zanzibari school children : the
importance of hookworms : Am J Clin Nutr, 65, 153-159, 1997.
38. Bundy DAP, Kan SP, Ross R: Age related prevalence, intensity and frequency of
distribution of gastrointestinal helminthic infections in urban slum children from
Kuala Lumpur, Malaysia : Trans R Soc Trop Med Hyg : 82, 289-294, 1988.
I
A bout Zara Consultancy Services (ZCS)
TCS is a technical NGO in public health nutrition. It was established in end 199?
by Professor Tara Gopaldas, former Dean Faculty of Home Science
M.S.Umvers’ty, Baroda; and the Chan of the Universrty department of Foods and
Nutrition in the Faculty. TCS has vast research and administrative experience m
Programme-Dnven-Research in the areas of Food, Nutrition and Health It has
expenence m Research Design, Policy and Programme Planning, Implementation,
Training Monitoring and Evaluation. It has the capability to do Operation^
Research m any area of Human Resource Development, Social Market Research
Participatory Research Assessment, and Cost-Effectiveness analvses are high oh its
agenda.
'
TCS has executed seven research projects or consultations since end 1992.
They
are:
1. A Workshop for Key Influencers on ‘irThe
— imperative need to integrate
The funder
2. A Demonstration cum Research Action project on “A multinutrient package for
70rtes for better heaith. productivity and profitaMitv” W961998. The fader was USAID-OMM-ILSI for global research projects
"
0 ?Sign ,f” “ ^-“u-Survey for the National Assessment and
Acctedttation Council (NAAC) of India on “What are the perceptions of quality
m higher education by the stake holders, namely, the students, parenB and
employers?” 1997. The funder was NAAC.
I
4
n-TC?1116
fOr c™ ^olopmeot (PCD), Orford
ty’
’ TCS conducted The pre-post impact evaluation of the
™proved Mid-Day-Meals-Programme, Gujarat” 1993-1996. The funder was the
_ Rockfeller Foundation for Health Sciences, USA - through PCD
6 HonT^A31/1’0* OnuWeaning Technol°gy for the Govenunent of India. 1994.
igga) 31^ V1SCr °n
Gujnrat to the Government of Gujarat (1992- I
7 th^'nuX'^10^ 3nd
G°Veniment Rajasthan on “The improvement of
±e nutnnon component for the ‘Below Threes’ in foe Intesrated Child
evelopment Services (ICDS) programme”. 1992-1993.
.M.
.2'
’’
k-J
Q
MAILING ADDRESS:
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NAGAVARAPALYA
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