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AM INFORMATION ’ EDUCATION - COMMUNICATION (IEC)
PROJECT FOR WORKING GIRLS (18-23 YEARS) ON
CULTURAL DIETARY PRACTICES TO INCREASE THE
IRON CONTENT OF THEIR EVERY-DAY-DIETS.
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TARA GOPALDAS
April 2000
Thrasher Research Fund
Salt Lake City, LT, U.S.A.
&
1 ara Consultancy Services
Bangalore, India.
C-H C' GU-tC
Title of the Project :
Funder
An Information-Education-Communication (IEC)
Project For Working Girls (18 - 23) Years On
Cultural Dietary Practices To Increase The Iron
Content Of Their Every-Day-Diets.
The conduct of this project was made possible through a
research grant received from Thrasher Research Fund, 50,
East North Temple, Salt Lake City, Utah 84150 - 6840
U.S.A.
Executor : Tara Consultancy Services, ' Saraswathi', 124/B, Varthur road,
Nagavarpalya, Bangalore 560 093, India,
Contract Number : 03001 -0.
Date of Commencement : 1st May 1998.
Date of Completion : 30th April, 2000.
Primary Contact :
1. Ms. Julia L. Busse, M.S. (Nutrition), Research
Manager, Thrasher Research Fund.
2. Ms. Michelle Inkley, Research Cycle Specialist,
Thrasher Research Fund.
Principal Investigator : Prof. Tara Gopaldas M.Sc. Indian Institute of
Project Director and
Science, Bangalore, India; Phd. Division of
Financial Controller
Nutritional Sciences University of Illinois, ChUrabana, U.S.A.
Project's Technical Teams :
Tara Consultancy Services
Consultants
Prof. Tara Gopaldas, Project Director
Dr. Arathi Singh, Project Coordinator
Ms. Usha Chettur, Research Asso.
Ms.Nandmi Ramkrishna, Research Asso.
Ms. Sharada, Research Asso.
Ms. Hemal Kunte, Secretarial
------Mr. V.K.Murthy, Driver and Pl
Dr. Prema Akki, IEC lecturer
Dr. B.S.P. Raj -Data Processor
Mr.D.Santosh -Graphics
Ms. Esther Mohan - Laboratory
Technician
Managers of the four Study L
Unit One : Ms. Iqbal Basith
Unit Two : Mr. Abdul Wahid
SOCHARA
Community Health
Library and Information Centre (CLIC)
Community Health Cell
85/2, 1st Main, Maruthi Nagar,
Madiwala, Bengaluru - 560 068.
Tel : 080-25531518
email: clic@sochara.org / chc@sochara.org
www.sochara.org
AN INFORMATION - EDUCATION COMMUNICATION (IEC) PROJECT
FOR WORKING GIRLS (18 - 23 YEARS)
ON
CULTURAL
DIETARY
PRACTICES
TO INCREASE THE
IRON CONTENT OF THEIR EVERY
DAY-DIETS
CONTENTS
PAGE
Acknowledgements :
Executive Summary :
(i) - (vi)
Chapter One : Introduction and Key Project Objective.
1-2
Chapter Two : Overall and Specific Objectives.
3-4
Chapter Three : Project Design and Methods
5-19
Chapter Four : Participatory Implementation.
20-29
Chapter Five : Development of the EEC.
30-33
Chapter Six : Results :
Section A : Socioeconomic Profile of the Working Girls
Section B : Dietary and Nutrient Intake (Before & After)
Section C : Knowledge, Attitude & Practice
(Before and After)
Section D : Nutritional Impact (Before and After)
52-60
61-75
Chapter Seven : Sustainability.
76-78
Chapter Eight: Discussion, Conclusions and Recommendations
79-85
References and Abbreviations :
86-92
34-41
42-51
ACKNOWLEDGEMENTS
It gives me great pleasure in thanking the Thrasher Research Fund (Food
Based Approaches), Utah, U.S.A, for giving us an adequate grant for the
successful completion of this research project. I thank in particular Dr. M.
Bnem, Ed. D., Associate Director, Thrasher Research Fund, Ms. Julia L.
Busse, Research Manager, Thrasher Research Fund and Ms. Michelle
Inkley, Research Cycle Specialist, Thrasher Research Fund.
All these
officers of Thrasher Research Fund gave us helpful guidance and timely
remittances! We are particularly appreciative of Thrasher Research Fund's
gesture of agreeing to the additional quantitative interventions namely : Iddli
m Unit One and Gooseberry juice in Unit Two in addition to the IEC The
Managements of these two units, that received the IEC were convinced that
the interventions would be useful in bringing about the required behaviour
change in their female workforce. We also greatly appreciate the additional
grant of USD 6000, which made it possible for us to complete two large
rounds of dietary intake surveys.
All my Colleagues, Consultants and Support Staff worked with zest and
enthusiasm, especially the Coordinator of the Project Dr. Arathi Singh. So
also did Usha, Nandini, Sharada, Hemal and Murthy.
We thank our contractual consultants namely, Dr. Prema Akki Dr. Raj, Mr.
San tosh and Ms. Esther Mohan for their special inputs.
Ms. Iqbal Basith, Director Unit One (fermented foods) is to be thanked in
particular for giving her 72 working women staff time to listen and
participate in the weekly IEC lectures and for all the cooperation extended
regarding the six-month-intervention. The Managers of the other three units
also cooperated with us, especially Mr. Wahid of Unit Two.
It is my only desire that the Government of India and all the State
Governments in my country will make it mandatory that the employers give
their employees both men and women: blanket deworming plus either a
fermented food snack; or a Vitamin C rich beverage; or medicinal iron
supplementation at the WORKPLACE.
April, 2000,
Prof. Tara Gopaldas
Director, Tara Consultancy Services,
Bangalore.
EXECUTIVE SUMMARY
An Information-Educarion-Communication (IEC) Project for Working
Girls (18-23 years) on Cultural Dietary Practices to Increase the Iron
Content of Their Everyday Diets.
1.
The Rationale and Focus : The Working Girl population (18-23
years) in most of India’s cities and towns is the phenomenon of this
millenium. Women are working as never before, mostly for economic
reasons.
Iron Deficiency Anemia (IDA) is highly prevalent in this
segment as most come from Low Income Group families. IDA has
been shown to have a clear effect on physical-work-capacity and
cognition.
Our recent study on female tea-pluckers has also re
confirmed its positive impact on productivity. Hence, this IEC study
was designed to increase the bio-availability of everyday-foodstuffs
by simple dietary changes. The emphasis was on cereals, which
are consumed in huge quantities.
Fermentation of cereal-pulse
batter is well accepted in South India, where the present study was
conducted (1998 — 2000). Fermentation of the cereal batters,
reduces the inhibitory action of phytate-iron, thus making the iron
more bio-available. Similarly, attempts were made through IEC
to increase the consumption of ascorbic-acid-rich gooseberry juice
or lime to increase the availability of dietary iron.
The target population was both the Employer and the Employee. The
emphasis was on doable and sustainable IEC at the Workplace and at
Home.
2.
Objectives : The overall objectives of this Efficacy trial was to
determine whether simple and culturally acceptable dietary changes in
the lunches at the Workplace and at Home could bring about
Knowledge, Attitude and Practice or Behavioural changes that would
increase the bioavailability of iron in their everyday diets.
The specific Impact Objectives in the 'Before’ and 'After’ surveys were :
•
Changes in Knowledge, Attitude and Practice (KAP) or Behaviour.
Dietary and Nutrient Intake especially of
foods.
• Hemoglobin status.
• Body Mass Index.
•
CO
bioavailable
iron-rich
3.
Participatory Implementation : The Stakeholders at the Workplace
in this study were the Employer; the Employee and us (Tara
Consultancy Services). The major gain in this study by adopting this
approach was the almost instantaneous Behaviour Change in the
Employer. The Employer agreed to underwrite the cost of the
dietary-food-interventions in Unit One and Two. The Employees
cooperated with us fully as they were getting two medical check ups; in
addition they were getting workplace lunches of fermented food (iddHs),
3 times a week in Unit One; or gooseberry juice 3 times a week in Unit
Two; and deworming + iron tablets in Unit Three.
We, the implementors and researchers of this study felt a sense of deep
gratitude in particular, to the Employer. This very positive gesture
from the Employer both deepened and widened the scope of the
original design of this study. It also strengthened it considerably.
4.
Project Design and Methods :
i.
Sample Selection : Consisted of 72, 80, 70 and 80 (total of 302)
Working Girls in Units One, Two, Three and Four. Each Unit
consisted of a small ancillary Unit or factory making parts for
electronic equipment, zippers, garments, or air-conditioners.
Details of the Study Design is given at Table 1.
ii.
Methods :
• A structured questionnaire was developed to collect data
relating to the Socio-economic status and the Profile of the
Working Girls;
• Dietary and Nutrient Intake (Before and After);
• Knowledge, Attitude and Practice (Before and After);
• General Health Status, Hemoglobin Status, Clinical
Assessment for Nutritional Status;
• Anthropometric Status.
Standard methods were used for all parameters above.
iii.
5.
Data Processing : The SPSS package was used.
Development of the IEC messages : Twenty one posters were
developed relating to IDA; fermented foods; dietary iron inhibitors (tea)
and enhancers (Vitamin C - rich foods); use <of' iron
'
woks; consumption
of GLVs; and how intestinal worms make the blood weak.
On popular request from the Employer and the Working Girls a few
more posters were developed on grooming; small family norm; and on
how to save money; and lectures on reproductive health were given by
the medical consultant and the Project Coordinator.
6.
Results :
Dietary and Nutrient Intake :
i.
• Average Intake of Food Stuffs in the Post-Survey did increase
significantly in the categories of cereals, pulses, leafy
vegetables, other vegetables (mostly tomatoes), seasonal fruit
(banana, mango, lime) and flesh foods, in Units One and Two
which received the IEC plus a concrete dietary-basedintervention at the Workplace.
•
ii.
At the Post-Survey, the mean intake of calories did go up
significantly in all four units; of protein in Units One, Two and
Three; of iron in Units One and Two; of calcium in Unit One;
of Vitamin A in Units One and Two; and of Vitamin C in
Units One and Two.
Health and Nutritional Status :
General Health :
•
•
iii.
Chronic Illness : Mostly related to reproductive health
namely leucorrhoea, scanty or irregular periods, which
improved significantly in Units One, Two and Three.
Intestinal Worms ; A very dramatic reduction was seen at
Post-Survey.
Hemoglobin Status :
•
The overall mean Hb g/dl at Pre and Post Surveys went up
significantly in Unit One, Two and Three. It did not in Unit
Four (Negative Control).
In Unit One the mean Pre Survey
Hb was 11.10 g/dl Vs 12.30 g/dl at Post Survey. In Unit Two
the mean Pre Survey Hb was 11.20 g/dl Vs 12.70 g/dl at Post
Survey. In Unit Three the mean Pre Survey Hb was 11.50 g/dl
Vs 13.00 g/dl at Post Survey. In Unit Four the mean Pre
Survey Hb was 10.90 g/dl Vs 10.90 g/dl at Post Survey.
The more severe the anemia greater was the Impact as a result
of the intervention.
• The interventions (please refer to Table 1) were very effective
as all the cases of Severe and Moderate Anemia were totally
eradicated in Units One, Two and Three at the Post Survey..
The percent prevalence of Normals rose to 67%, 79% and
87% respectively in Units One, Two and Three. It was the
same 20% at Pre and Post Survey in Unit Four.
• In the case of fermented foods a significant benefit and
increase in Hb values was seen, when the Employee (Mamed
Working Girl) was in control of her kitchen.
• The greatest mean increase in Hb levels of 1.50 g/dl was seen
in the Gooseberry Juice + I EC intervention; and the
deworming plus medicinal iron supplementation.
By
inference, it appears to indicate that the type of intervention
at the Workplace is of greater value than IEC delivered
with it; IEC in isolation; or the total lack of IEC.
• The BMI of Working Girls in all the four Units increased
significantly and was above 18.5, the accepted normal for a
female adult (> 18 years). We cannot explain why this
happened in Unit Four (Negative Control), except that the
mean age of the Working Girls in Unit Four was 20 years
versus 22 years in the other three Units.
•
iv.
Knowledge, Attitude and Practice :
•
•
•
•
•
Knowledge gains were impressive and went up to 87% correct
responses in the Post Survey.
Awareness among the Male members of the families of
Working Girls went up in all four Units.
The poster that received
maximum recall
was the one
exhorting the girls to eat fermented foods (37%); eat GLVs
(27%); and eat egg, meat and trotter soup (25%).
The Attitude to the Concrete Interventions such as the
fermented food at the Workplace was extremely positive with
75% saying they would make the iddlis even if the Management
stopped doing so. 25% said they could not, due to time
constraint, and no control over the kitchen’.
The Attitude to the Gooseberry Juice intervention was very
positive (100%), but the Working Girl said it was unaffordable.
Unfortunately the Employer also felt likewise.
7.
Conclusions/Recommendations :
i.
ii.
iii.
iv.
v.
*vi.
vi i.
vin.
ix.
First orient or educate the Employer rather than the Employee
with respect to the improvement of the health and iron-status of
the latter.
Expected behaviour change in enlightened
Employers is almost instantaneous.
A concrete intervention at the Workplace plus IEC would be
the best choice.
The Employees do appreciate the IEC and do implement the
dietary injunctions to the extent possible. However, their time
and economic constraints are the real limitations to total
behaviour change or sustainability.
Control of the kitchen is a paramount factor in the Employee,
where much greater consumption of fermented foods is
concerned.
In Urban India, aluminium cooking pots/vessels have come to
stay. Hence, iron woks will not be used.
Tea will be drunk 2 — 6 times a day at the Workplace. No
amount of IEC will change this. Perhaps approaching the big tea .
manufacturer to enrich or fortify their loose tea or cheap brands
with ascorbic acid (at the very least) may partially solve the
problem of widely prevalent IDA in the Working Girls.
The Employer of such small industrial units is generally a small
enterpreneur with small resources. This was the reason for non
continuance of the dietary-based interventions in Units One and
Two. But small cooperative efforts between Employer and
Employee will work. Iddli (fermented food) is an extremely ■
popular food eaten by all sections of South India.
A retired
Employee can be put in charge of making this popular dish
everyday and a small amount may be cut from the Employees’
salary’.
Although, the fermented food {iddli) did not increase the mean
Hb levels (1.20 Hb g/dl) as did the Gooseberry Juice or the
Medicinal Supplementation interventions (1.50 Hb g/dl), yet, it
was the food-based-fcfc&* intervention that was most
appreciated.
Enhancing the Hb levels of the Working Girls makes good
economic sense. Such a strategy brings about good labour
relations apart from the established rewards of greater
productivity, better reproductive health, better cognition and an
all round better working atmosphere.
i
Table 1 : Details of the various interventions :
INDICATOR
A & A Zippo-
UNIT 3
(Medical
Supplements)
Prestomac
UNIT 4
(Negative
Control)
MMS Exports
Zippers for the
garment Industry
Electronic components
for the T.V. Industry
Exporting readymade
garments
72
80
70
80
Intense at once a week
Less intense at once a
month
NO EC
NO EC
UNIT 1 (Iddili)
UNIT 2 (Goosebery
Juice)
Solid State Systems
Voltage Stabilizer for T.V.
Industry
4.
Name of the
Unit________
Type of
Business
engaged in
Sample size of
Working Girls
EC
5.
Intervention
Fermented, steamed
dumplings (iddlis)
With relish and lentil soup
thrice a week at 2 p.m.
when shifts changed
20 ml of Rebina
(goosebeny juice) to
deliver 40 mg Vit C,
thrice a week
400 mg albendazole
once + 60 mg
elemental iron as
ferrous sulphate,
(twice a week)
No Intervention
6.
T>pe of
Intervention
Lectures to
augment the
EC
Supervised
Supervised
Supervised
Nothing
Cleaving of phytic acid
from the Fe, making the
Fe much more bioavailable
Increasing the bio
availability of Fe with
a known enhancer
(15,16)
The above regimen
has been used by us
with a high rate of
success earlier (4,5)
No intervention
The Management
The Management
Rs. 156/- per worker
Or Rs. 11,232/- for the
entire intervention
Rs. 68/- per worker
or Rs. 5,460/- for the
entire intervention
1.
2.
3.
7.
8.
9.
Expected
benefit from
intervention
Who bore the
Cost?
10. How much
did it cost per
Beneficiary
for 6 months?
A lecture on Nutrition/
Health/ Reproductive
Health , twice a month
TCS
Rs. 4.30/- for the Fe +
Rs. 5/- for the
deworming once= Rs
9.30/- per worker
or Rs. 744/- for the
entire intervention
Nothing.
Note : Table 1, has been reproduced from Chapter Four on Project Design and Methods
Chapter One
INTRODUCTION AND KEY
PROJECT OBJECTIVE:
INTRODUCTION :
The Project attempts to answer the Salt Lake City Declaration on
Micronutrients (1995) which in essence said "Food-based systems offer
sustainable solutions to malnutrition .including the health problems caused
by micronutrient deficiencies, thus making material improvements to the
health, well-being and productivity of millions of people" (1).
Thrasher Research Fund in response to a request by Tara Consultancy
(TCS), Bangalore, India, was kind enough to send us the pertinent services
guidelines regarding
Food-based
Approaches to
Preventing
Micronutrient Malnutrition.
TCS submitted a proposal entitled "An
Information-Education-Communication (IEC) Project for Working Girls (18
- 23 years) on Cultural Dietary Practices to Increase the Iron Content of
Their Everyday Diets TCS was indeed honoured by being awarded the
above project in January, 1998.
A recent report on "A Data Base on Iron Deficiency Anemia (IDA) in India :
Prevalence, Causes, Consequences and Strategies for Prevention" (2) has
reported that the dietary intake of iron in the adult female (18 years plus) in
the state of Karnataka (location of the present project) was as high as 37.97
mg/day versus a RDA of 30 mg/day (3). Our two recent studies indicated a
lower dietary iron intake of 20 - 30 mg/day (4,5) . How then could the
available literature m the state of Karnataka (6) and our own data indicate an
extremely high prevalence (60% - 80%) of Iron Deficiency Anemia (IDA)?
Our own data in the present project indicated a prevalence of EDA of 70%
to 80%.
And in our previous Tea Plantation Worker Project in
Chickmagalur district of the state of Karnataka indicated that IDA
prevalence among the even relatively well paid women pluckers was about
60%, 1998 (4).
This was an enigma and a research challenge to be
addressed.
- -
WORKING GIRLS AND WOMEN - A PHENOMENON OF THE
MILLENIUM IN INDIA :
Industrially burgeoning Bangalore, in Karnataka; a state in South-West India
has increased its already large population of working girls several fold
Girls/young women in the age group of 18 - 23 years are preferred in the
ancillary or feeder units for the export garment industry, packaging of
i
medicines, assembly of electronic gadgets, air coolers etc.
Theneducational qualification is middle to high school level. These girls belong
to the non-organized sector which is far larger than the organized sector.
Information-Education-Communication (IEC) is essential for both the
Employer and the Employee. These girls come from Low Income Group
Homes (LIG) where the total family income is less than Rs. 5,000/- (about
USD 120) per month. They live in "urbanized villages" which are villages
that were in the outskirts of Bangalore, now engulfed by the fast growing
city.
Yet they have no basic amenities like piped water (quantity and
quality), tarred roads, electricity, garbage disposal or even a reasonably good
public transport system. These young women put in long hours of work ( 8
a.m. to 5 p.m.) with only a half hour lunch break.
More often than not these girls leave home in a hurry with a morning cup of
tea/coffee to sustain them till lunch. This is a forgotten population of extra
bread-winners for the LIG family. These girls will be future mothers if not
married already. It is they who are in urgent need of timely IEC on how to
improve their own iron status.
More so as traditional recipes and
ingredients have been forgotten or scorned in the race to be modem.
The aim to Reduce Iron Deficiency Anemia among pregnant women to
25% by 2000 AD by the Government of India as a National Nutrition Goal
would find a good start if it began with the working girl (7).
KEY AIM OF THE PROJECT :
The Key hypothesis in this "efficacy trial" specifically, was to assess
whether individuals can be convinced to alter their dietary practices relating
to the bioavailability of dietary iron. If so, within a very short time period, a
significant difference in hemoglobin levels can be achieved.
The
relationship between dietary practices to enhance the bioavailability in
the typical food stuffs consumed by the study population - is the
essential focus of this proposal.
2-
Chapter
Two
OBJECTIVES:
OVERALL
AND
SPECIFIC
Overall Objective :
The Overall objectives of this Efficacy trial on Information-EducationCommunication for both Employer and Employee,, was to determine
whether simple and culturally acceptable dietary changes at the Workplace
and at Home (for the Employees) could bring about knowledge, attitudinal
and practice or behavioural changes that would increase the bioavailability
of iron in their every-day-diets.
Plan of Action Objectives :
• To first orient the Employers of the 4 Study Units as to the objectives of
the present study and to obtain their full cooperation in the
implementation of the same.
• To then orient the Employees of the 4 Study Units as to the objectives of
the present study and to seek their full cooperation in the implementation
of the same.
• To develop the EEC content and a mutually agreed upon Plan of
Implementation for this EEC study.
• To develop packages’ for the IEC interventions, namely, simple
workplace lunches that would reinforce the audio-visual IEC content.
• To document the acceptability, cost-effectiveness and sustainability of
the said strategies.
Socioeconomic and Impact Objectives :
I.
Socioeconomic Objectives :
• To document the Socioeconomic profile of the Working Girl (18-23
years) employed in the small ancillary units of peri-urban Bangalore.
IL
Dietary and Nutrient Intake :
• To assess the increases, if any, in the dietary and nutrient intake of the
Working Girls, Before and After the specific Interventions.
• To examine, in particular, the consumption of bioavailable-iron-rich
foods Before and After the specific Intervention
3
III.
Knowledge, Attitude and Practice :
• Knowledge, Attitude and Practice (Behaviour) regarding the 'packages’
of IEC + Workplace lunches, Before and After the specific
Interventions.
IV.
General Health, Hemoglobin Status and Nutritional Status :
• To determine whether some chronic illness and common illnesses
improved as a result of the interventions.
• To determine in particular, if intestinal helminthic infections decreased as
a result of the interventions.
• To assess, m particular, the ’Before’ and ’After’ Hb status of the
Working Girls as a result of the specific interventions.
• To assess the clinical and nutritional status, particularly with respect to
EDA Before’ and After’, as a result of the specific interventions.
• To assess the BMI of the Working Girls, ’Before’ and ’After’, as a
result of the specific Interventions
Chapter Three: PROJECT DESIGNAND METHODS:
PROJECT DESIGN :
Rationale : • As stated earlier, the major aim of this IEC study was to
attempt to increase the bio-availability of iron in every-day diets of the
Working Girls.
Maximum weightage was given to increasing the
consumption of fermented cereal foods.
It is well established that the
inhibitory effect of phytate iron is reduced in such fermented foods, making
the dietary iron more available (8-14). This effort was greatly augmented by
the Employer (also our target for IEC), agreeing to supply the iddh to the
Employee population at the Workplace (Unit One).
The EEC study also attempted to change dietary behaviour through
promoting the greater use of iron enhancers such as Vitamin C (15-16). In
this instance also the Employer (Unit Two) readily agreed to supply
Gooseberry Juice to the Employee population at the Workplace.
Our research and project design was consequently strengthened by the
Employers realising very early (at the time of signing agreement letters in
October/November, 98), that the 'good health’ of the Working Girls would
translate into better productivity. The Project Design included a Positive
Control group, where deworming and medicinal iron supplementation were
given (Unit Three). Our own work in two earlier studies among schoolers
in Gujarat; (5) and Plantation Workers in Karnataka (4), had shown
consistent and positive results of deworming plus medicinal iron
supplementation, significantly improving Hb levels, in spite of nutritionally
poor diets and high prevalence of soil-transmitted helminthic infections (5).
The Project Design also included a Negative Control group, which did not
receive any IEC or dietary based/any other intervention (Unit Four).
Please refer to Table Ifor details of the various interventions.
METHODS :
1. Sample selection :
Selecting the Study Ancillary Units : This activity took up much more
time than we estimated. Project staff visited atleast ten large factories
and several small - sector - Ancillary or Feeder Units, employing working
girls in peri-urban Bangalore before we could finally select four units that
S’
exclusively employed about 70 to 80 working girls/women each and who
were comparable in some major characteristics such as socio - economic
level, place of residence, salaries paid, working hours, social benefits and
so on. We finally selected and entered into written agreements with Four
Units as under:
• Solid State Systems Pvt. Ltd., made voltage stabilizers for the TV
industry and employed 72 women workers predominantly in the age
group of 18 - 23 years. This was our Unit No. One.
• A and A Zipper Pvt. Ltd. made zippers for the garment industry and
employed 80 girls. This was our Unit No. Two.
• Prestomac Pvt. Ltd., which made electronic components for the TV
industry and employed 70 girls. This was Unit No. Three.
• MMS Export Pvt. Ltd., which made ready-made-garments for export. It
employed 80 girls. This was our Unit No. Four.
Our total sample in the four units was 302. We obtained full cooperation
from the Owners/Managers of each of our Study Units. The Aims,
Objectives and Scope of work/collaboration were fully explained to the
Owners/Managers. Signed Agreements were entered into. Meetings were
held with the workers, all of whom agreed to the medical examination and
the Hb estimations. Signed Agreements for the various tests were obtained
from the Management. The Owners/Managers of the Small Ancillary Units
knew each and every worker well. They wanted their workforce to be in a
better state of health for work efficiency and humanitarian reasons. They
were appreciative of the fact that TCS was trying to improve the health of
their women workforce.
We on our part found it much more convenient to give our different
intervention treatments to comparable but different units. TCS staff and our
Consultant in Graphics visited a number of homes of the Working Girls best to worst - to get a pre - Baseline feel of living conditions.
2. Visiting Homes and Making Inventories of Food Shopping, Cooking
and Eating Habits :
The Project Coordinator and the Research Associates visited 30
representative homes out of the total sample of 302 women workers (about
10%). This is the summarized information collected regarding
food
shopping, cooking and eating habits. In addition several other areas
of relevance to health and nutritional status such as Water, Sanitation, Type
of Dwelling and Space Constraints were observed.
Food Shopping Habits : All the homes visited were 'Ration Card Holders’
which entitled them to buy rice, sugar and kerosene at subsidized rates
through the Public Distribution Shops (PDS). What was interesting to note
was that the majority of the households only availed of the kerosene ration
for cooking their food. The reason stated was that the Ration Shops were
far away. Further, there was not much difference in the price of rice or
wheat in the open market. Depending on the size of the family about 60
Kgs of rice, 10 Kgs of wheat and 10 Kgs of ragi (Eleusine coracana) were
purchased every month. Meager quantities of sugar, oil, pulses (all very
expensive) were purchased.
Very spicy food was eaten - hence large
quantities of red chillies, tamarind and other condiments were bought.
Generally one Kg of meat and a few eggs were bought once a week; half a
Kg of seasonal vegetables especially tomatoes every day; as well as 250 to
500 ml of milk every day. Iodized salt was bought by almost all. It was
gratifying to note that greens were consumed in lentil curry at least twice a
. week. Beetroot and tomatoes were favorites as they were tasty. Also being
red in colour were perceived to heighten the red colour of their blood! Fruit
consumption was limited to bananas, jackfruit and seasonal mangoes.
Guavas (rich in ascorbic acid) were believed to give sore throat! Lime was
bought for lime rice (once a week) and by some of the working girls for lime
juice (in summer).
Cooking and Eating Habits :
• Life styles have changed dramatically. All male and female family
members from the age of 16 + years were earning for economic reasons
and to enjoy a better level of food and clothing. Hence, where the
worker was unmarried, the mother or some other relative did the cooking
and controlled the kitchen.
• Several family members (5 to 10 members) lived in tiny 2 - room row
houses. Five to Ten houses shared a common toilet. Although, family
members rose very early to fetch water and do the various daily chores,
we found that time management by the working girl regarding eating
breakfast or even carrying a full packed lunch was extremely constrained.
• All homes had moved away from brass, copper or iron vessels. All
homes had aluminium pressure cookers.
Cooking was done in
aluminium vessels. We hardly saw an iron wok or vessel any more.
Food was served on stainless steel plates (status symbol).
• Cooking was done on kerosene pump stoves. Most homes possessed
small electrical grinders. Hardly any had a refrigerator. All food was
consumed on that very day.
7
• The packed lunch of choice and convenience was rice and lentil curry ( 3
to 4 times a week); fermented and steamed dumplings (iddli) once a
week; and lime rice or curd rice two times a week. No beverage was
carried to work as tea was served several times at the workplace.
• Although fermented and steamed dumplings or fermented and fried
pancakes were great favourites, the person doing the cooking found it
labourious to soak the rice and lentil, grind, steam or fry the fermented
batter more than once a week. Fermented food lunches were the Monday
treat. They were eaten with spicy coconut chutney and/or lentil curry.
Special food including meat was prepared on Sundays. Entertaining of
guests was done on this day. Hardly anyone, especially the working
girl, spent money on eating out.
• Perhaps this is why they longed for ice-cream, pastries, chocolates and
snack food (made by the roadside vendors). All their earnings were
handed over to the head of the household. A small amount was given
back as pocket money for personal needs and necessities. Even a new
set of clothes was bought by the head of the household once a year for
Diwali (festival of lights). All walked a few kilometers to work and
back. The head of the household was expected to take care of all the
needs of his family including food, shelter, clothing and saving-up for the
girl’s marriage expenses.
• We did not see the dire poverty or raw hunger of rural or slum India in
this population group. Generally 3 to 5 adult members pulled in a
collective income of Rs. 3000/- - Rs. 5000/- per month (middle class
incomes). If the girls did not eat breakfast before they left for work or
regularly it was due to poor time management of household chores and
getting ready for work.
Water/Space/Sanitation :
Hardly any of the houses had piped water, their own private toilet or clean
surroundings. Water had to be fetched in bucketfuls (at a nominal cost)
from a common tap or borewell and stored at home. In the kitchen, very few
had water filters. If they did, the candle was rarely replaced. The most
pronounced negatives were the extreme congestion of living space (17), no
privacy and no separate kitchen. The street lanes were dirty and slushy
with cattle, stray dogs and hens making the living environment even worse.
Almost all family members complained of worm infections, chronic
diarrhoea (amoebiasis) and repeatedly asked for prescriptions for treatment.
Water for bathing was boiled outside with firewood with cowdung cakes. A
few who had a patch of green did grow greens, chillies, coriander and
vegetables for home consumption.
8
3. Development of the IEC content and Pretesting it:
Since our graphics artist visited almost all the homes with the coordinator,
he got a feel of what he was expected to develop. A list of 21 messages was
developed by the Project Director/Coordinator (please refer to Chapter Five
for details). Each message was made into a large colourful poster with
simple captions in the local language.' Each of these were tested over a one
month period, one a day per poster, at another Ancillary Unit that was
similar to the Four Units where our IEC study was to be conducted. All the
messages were understood and appreciated. The working girls in particular
were concerned about their looks and grooming (not necessarily health).
They showed a lot of interest in the posters on how to rid oneself and family
members of intestinal infections. Almost all the working girls at this Unit
where we did the pre-testing and at our 4 Study Units had more than a
primary school education in the local language - Kanada.
4. Developing and Standardizing Methods of Data Collection :
November, 1999 was devoted to developing a comprehensive Baseline
Questionnaire. The Research Associates administered the questions in the
local language - Kanada. The questionnaire comprised four sections.
Section A covered Socio-economic data. Section B covered Medical
Assessment which included Medical History; Nutritional and Clinical
Assessment. Section C covered KAP (Knowledge, Awareness and Practice).
Section D covered information on the family's monthly to daily purchases of
non-perishables to perishable food items. It also covered information on
usual or special daily dietary patterns, packed lunches, consumption of
fermented foods and ascorbic acid-rich-foods. The questionnaire was pre
tested for ease of comprehension, in a similar but different small factory
employing working girls. Slight modifications as required, were made and
this tool was finalized. All three Research Associates were jointly trained by
the Director and the Coordinator in the use of the questionnaire.
5. Standardization and Use of other Methods :
• The four quantitative measures were : hemoglobin value (g/dl); Height
(upto 0.1 cm); Weight (upto 0.5 Kg); and Dietary and Nutrient Intake.
• Well known and standard methods were used for all measures or
indicators. (18).
9
A Plus Diagnostic' was our contractor for the Hemoglobin estimation.
This was done by the Standard Direct Cynmethamaglobin method. (19,
20).
A digital colorimeter was carried to the factory sites.
The
Hemoglobin estimations were done within a week of the conduct of the
Dietary and Nutrient Intake estimations on the subset of 180 girls. The
WHO cut offs used were : severe anemia (< 7 g/dl), moderate anemia ( 7
- 9.9 g/dl), mild anemia (10 -11.9 g/dl); and normal 12 or above 12 g/dl
(19).
• The team coordinated well.
The concerned Research Associate
administered Section A, C and D. Dr. Arathi Singh, the Coordinator
took full responsibility for Section B (Medical etc).
After this, the
subject's Height and Weight was taken by the Research Associates. The
subject then proceeded with her questionnaire to the Lab Technician (Ms.
Esther Mohan) who did the Hemoglobin estimations and filled in the
value in the questionnaire. The subject (all had primary schooling or
more) was shown her Hemoglobin value on the digital colorimeter. This
method elicited good participation from the subjects which was done at
Pre and Post Survey. This was a powerful IEC instrument in itself. The
entire interview took 30 - 40 minutes per subject. The Managements
were very cooperative and sent working girl by working girl.
•
Details of procedures used :
• Body Weight : The subject was weighed with normal clothing to the
nearest 0.5 Kg using a Krup's weighing scale. The Scale was adjusted to
zero each time the subject was weighed.
• Body Height : Height was measured to the nearest 0.1 cm with the help
of a non-stretchable measuring tape affixed on a smooth surface wall.
Body Mass Index (BMI) : Waterlow's classification was employed for
nutritional categorization of the subjects based on their BMI. A cut-off
point of equal to or above 18.5 indicated normal nutritional status. A
BMI of less than 18.5 was taken as indicative of under-nourished status.
BMI was calculated using the formula. Weight (Kg) / Height2 (m) (21).
Clinical examination :
All Subjects were examined for eye signs of Vitamin A deficiency using the
"Field Guide to the detection and control of Xerophthalmia" (22). The
ocular signs of Vitamin A deficiency were classified as follows :
XN
XIA
XIB
Night Blindness
Conjunctival Xerosis
Bitot's spot
Corneal Xerosis
fa
Presence of Anemia : An anemia recognition card (cards were obtained
from the Voluntary Health Association of India) was used to determine the
prevalence of anemia, especially of pale conjunctiva.
Iodine Deficiency Disorder (IDD) : The subjects were clinically examined
for the presence of clinical/sub clinical manifestation of iodine deficiency.
Hemoglobin estimation
The direct cyanmethomoglobin procedure as
described by Oser (1976) was used for hemoglobin estimations (19, 20).
6. Dietary and Nutrient Intake Survey :
This was done by the 24 hour recall method. Atleast 2 home visits were
made for each subject. The raw food commodities were weighed on the
first visit.
The cooked food and that consumed by the working girl
(inclusive of her packed lunch) was assessed the next day.
The 180
randomly selected families were very helpful and cooperative. However, the
organization and conduct of this measure, proved to be the most exhausting
activity in this Project. The Nutritive Value of raw foods was calculated
using the Indian Council of Medical Research (ICMR, 1989) (23) data.
The Recommended Daily Allowance of Nutrients was calculated following
ICMR, 1992 (3).
The concerned Research Associate held a few informal Participatory
Research Assessments at the Workplace in Unit One, to get to know whether
more of the fermented food iddlis was being made and consumed at home.
If not what were the real constraints? The Supervisors (also an employee)
gave useful feed-back in Units One and Two.
7. 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.
Tabulation and Statistical Analysis : SPSS was used for tabulation and
statistical analysis. SPSS commands were written to apply statistical tests
namely t-test, and Chi square test. Finally, when the complete data set was
ready. Tables were, produced and Statistical Analyses carried out. All tests
were considered significant at p < 0.05.
II
Table 1 : Details of the various interventions :
INDICATOR
1.
A & A Zipper
UNIT 3
(Medical
Supplements)
Prestomac
UNIT 4
(Negative
Control)
MMS Exports
Zippers for the
garment Industry’
Electronic components
for the T.V. Industry
Exporting readymade
garments
72
80
70
80
Intense at once a week
Less intense at once a
month
NO EC
NO EC
UNIT 1 (Iddili)
UNIT 2 (Goosebery
Juice)
Solid State Systems
Voltage Stabilizer for T.V.
Industry’
4.
Name of the
Umt________
Type of
Business
engaged m
Sample size of
Working Girls
EC
5.
Intervention
Fermented, steamed
dumplings (iddlis)
With relish and lentil soup
thrice a week at 2 p.m.
when shifts changed
20 ml of Rebina
(gooseberry juice) to
deliver 40 mg Vit C,
thrice a week
400 mg albendazole
once + 60 mg
elemental iron as
ferrous sulphate,
(twice a week)
No Intervention
6.
Type of
Intervention
Lectures to
augment the
EC
Supervised
Supervised
Supervised
Nothing
Cleaving of phytic acid
from the Fe, making the
Fe much more bioavailable
Increasing the bio
availability of Fe with
a known enhancer
(15,16)
The above regimen
has been used by us
with a high rate of
success earlier (4,5)
No intervention
The Management
The Management
Rs. 156/- per worker
Or Rs. 11,232/- for the
entire intervention
Rs. 68/- per worker
or Rs. 5,460/- for the
entire intervention
2.
3.
7.
8.
9.
Expected
benefit from
intervention
Who bore the
Cost?_______
10. How much
did it cost per
Beneficiary
for 6 months?
A lecture on Nutrition/
Health/ Reproductive
Health , twice a month
TCS
Rs. 4.30/- for the Fe +
Rs. 5/- for the
dewonning once= Rs
9.30/- per worker
or Rs. 744/- for the
entire intervention
Nothing.
Note : Table 1, has been reproduced from Chapter Four on Project Design and Methods.
12-
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13
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Dry measure of food cooked per
day for a family of 3 adults and
one child. Total family income
Rs. 1,800/-.
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The cooked ration of food for
the day
Water stored in
the kitchen in a
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Cowdung cakes drying on the wail is
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Some grow their own vegetables at
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Pre Survey Height and Weight
record, Hemoglobin estimation
and Medical examination.
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Condiments'dried and
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±9
Chapter Four- PARTICIPATARY IMPLEMENTATION :
INTRODUCTION :
We have devoted a chapter to Participatory Implementation as we feel that
apart from cost-effectiveness and the four 'A's of Availability, Accessibility,
Adequacy and Affordability probably - Participatory Implementation
stands on top of the pyramid (4, 5). We have therefore, described in some
detail as to how the Employer or Management, the Employee or the
Working Girl and TCS participated in this research project, in each of the
three units where specific IEC and supportive interventions were conducted.
UNIT ONE (The Intense Level of IEC + Iddli or Fermented Food) :
What did the Employer do? :
On being convinced by TCS that the health and. productivity of the
Employees would improve, the Employer :
• Made available a spacious hall with table and chairs for TCS to conduct
its various tasks.
• Delegated a middle-level staff (Ms. Yamuna) to be our primary contact.
• Gave the Working Girls time to listen to the IEC sessions.
• More than anything financially supported the girls being given 2 iddlis,
with coconut relish and lentil soup per worker three times a week at Rs.
156 (USD 3.60) per worker for the entire intervention for the 72 Working
Girls. Or Rs. 11,232/- (USD 261) for the entire intervention; or Rs. 2/(4-5 US cents) per worker per serving. The same serving would have
cost double in and around Unit One.
• The two Directors demonstrated their total support to our ActionResearch endevour by financing the project; and by attending some of
the IEC sessions.
• They made unannounced visits on the "Iddli" distribution days.
What did the Employees do? :
• The Employees readily gave their consent to the Hb and medical
examination.
They felt they were definitely the gamers, as private
doctors and medical tests were unaffordable.
• Hardly any of them absented themselves on the 'Employer-Financed'
Iddli days! The 12 to 15 odd men workers were included for the free
iddlis, as they felt excluded and marginalised. The iddlis were served at
2.00 p.m. when the shift went off, and the other came in. The timing
was greatly appreciated as the Working Girls on the first shift clocked in
at 6.00 a.m. Consequently, many missed their meager morning snack.
This was also one of the reasons why the girls could not bring an iddli
lunch. A quick packed lunch was rice, cooked with a small packet of
bought curd. However, our EEC on steeping rice overnight and mixing it
with curd (please see later) was considered infradig.
• As stated earlier the IEC sessions by Dr. Prema Akki and Dr. Arathi
Singh were greatly appreciated. The poster of the week was later put up
on the General Notice Board so that the Employer and the Men
Employees could also benefit.
• The Women Employees readily opened up their tiffin-dabbas (lunch
boxes) on request by Usha Chettur, the Research Associate. These were
random checks at about 12 (72/6=12) girls on any working day. After a
month- or so of the intervention, we did notice that the young marrieds
who had control over their kitchens or those who were severely or
moderately anemic did increase their home level iddli consumption.
What did TCS do? :
• Took full responsibility of co-ordmation between Employer, Employee,
developing the IEC content, delivering the lectures, and hiring a
contractor to deliver the iddlis for the Employer.
• TCS met Ms. Iqbal Basith the Employer. Explained the aims and key
objectives of the' project and obtained the signed concurrence to
continued collaboration and participation.
• TCS developed 21 key IEC messages for the posters and for the lectures
(Please see the separate booklet on EEC messages attached).
• TCS developed a cyclic menu of what we felt would be simple and
doable iron-bioavailable lunches. The girls did not agree that all our
suggestions were simple or doable!
• Took full responsibility for all aspects of Research.
• In fact, in most action-research projects the outcomes depend heavily on
the planning, organizational and managerial skills of the researchers.
Even when an intervention is very simple, the institution or target
population does not appear to have the confidence to continue.
UNIT TWO (The Less Intense Level of IEC + Gooseberry Juice
intervention) :
What did the Employer do? :
• In spite of Unit Two not being so financially stable as Unit One, the
Employer Mr.Wahid, summed it up by saying "It is good for the health
of my girls. I will collaborate and cooperate".
• Made available the canteen for the various tasks and activities of TCS.
• Delegated Ms. David to be our prime contact.
• Gave the Working Girls time to listen to the monthly IEC sessions.
• More than anything, financially supported the girls being given
Gooseberry juice, (Please refer Table One, Chapter Four for details).
This intervention cost Mr. Wahid Rs. 5,460/- (USD 127) or Rs. 68/(USD 1.60) per girl for the whole intervention of six months; or a mere
33 paise (less than one US cent) per serving to deliver 40 mg of Vitamin
C.
•
What did the Employees do? :
• The Employees readily gave their consent to the Hb and medical
examination.
They felt they were definitely the gainers, as private
doctors and medical tests were unaffordable.
• Hardly anyone missed out on the refreshing drink 3 times a week for 30
weeks (about seven month till the Post-Survey) was conducted.
• However, they did not stop drinking tea 2 - 4 times a day.
• Practically all the Working Girls attended the monthly IEC sessions. We
noted in both the units - Unit One (Jddlf) as well as Unit Two
(Gooseberry Juice), that whatever intervention was done had to be done
during the working hours.
The Working Girls got very restive and
anxious if requested to stay back.
What did TCS do? :
• TCS appealed to Smithkline Beecham (SB), Bangalore, to kindly deliver
100 bottles of Rebina’ (Gooseberry concentrate) free. SB delivered 20
bottles free to TCS. TCS in turn handed over these bottles and made
arrangements for the monthly requirements for this intervention.
• Apart from this all that we have stated for Unit One, applied here also.
I
UNIT THREE (Deworming + Medicinal Iron Supplementation ) :
What did the Employer do? :
• At Unit Three, it is we (TCS), who underwrote the cost of the
intervention. However, Mr. Suhas Tiwari was extremely cooperative.
He permitted the Employees free interaction with TCS. He gave them
time off for the Baseline and Endline surveys
• However, he was unwilling to continue with the intervention.
His
argument was that the girls were paid enough to spend about Rs. 20/year
on keeping themselves worm + IDA free. Further it was statutory that all
Employers had to pay for the Employees’ State Insurance (ESI) of their
Employees.
What did the Employees do? :
• As reported in the case of Units One and Two, all the Employees
appreciated being given the deworming tablet (400 mg albendazole)
more than the bi-weekly iron tablets (60 mg elemental iron in the form
ferrous/sulphate). Dr. Arathi Singh herself undertook the responsibility
of dosing the subjects. Since, no IEC was given, neither the Employer
nor the Employee had to do much.
• Many of the Employees, after the intervention bought the expensive
deworming tablet at Rs. 5/- single dose tablet for both themselves and
their family members. Strangely enough they did not purchase the iron
tablets although we explained that one bottle of 1000 tablets, at Rs. 33/per bottle, would last 10 Working Girls for a whole year. We suggested
to Mr. Tiwari that he could stock both the deworming and iron tablets in
his factory. He was not amenable to this suggestion. He said “you
doctors are here now, what shall I do later on?”
MTiat did TCS do? :
• The same as has been reported previously. Since we knew from where
to get the deworming and medicinal iron supplementation at wholesale
rates - we passed on this information to the Employer and Employees.
• We were able to obtain low-cost iron tablets at Rs. 33/- for 1000 tablets
or just a few paise per tablet per dosing.
2-S
UNIT FOUR (Negative Control) :
What did the Employer do? :
He was good enough to agree to giving each girl half hour to an hour off for
the Baseline and Endline data collection.
What did the Employees do? :
They cooperated as they were getting two medical examinations free.
What did TCS do? :
Same as reported for Units One, Two and Three.
siSf-'A
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IEC : girls find the
poster "Your Key to
Good health" most
intriguing.
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IEC; lecturing the girls
on the importance of
using iron vessels for
cooking.
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IEC : recording by 24
hour recall methoo
fermented or other
iron rich food eater
the previous day.
Unit One: intervention
with fermented food
- iddlis
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Unit Two: intervention
with Gooseberry juice
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were more or less stagnant
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The Gooseberry Intervention :
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3
Chapter Five - DEVELOPMENT OF THEIECMESSAGES:
I.
RATIONALE :
• A scrutiny of the most recent Nutrition Profile of Karnataka (6) indicated
that as much as 450 to 600g of cereals were consumed per day by women
(> 18 years) V/s an RDA of 440 g. The most commonly eaten cereals
were rice and to a lesser extent ragi (Elusine Coraccmci). Hence, a
specific and key hypothesis was that a reduction in the phytate level in
cereals by well known and well accepted household level fermentation
methods will make much more of the non-available cereal-iron;
available.
In summary, our Information-Education-Communication
(EEC) Strategy strongly promoted the consumption of iddlis, dosais,
appam (all made from fermented rice - lentil batter) at Home and at the
Workplace (12, 13, 14).
• Our EEC strategy also promoted the much greater use of Lime Juice rich
m Vitamin C, an Iron Enhancer in the popular Lime Rice or in the
commonly drunk lentil soup.
Gooseberry juice and lime juice as
beverages at the Workplace rather than tea.
• The use of iron woks or traditional sauce pans and griddles were
promoted (24-28). Our innovation was an EEC poster on dropping in an
iron key into the lentil soup as it cooked and fishing it out before serving.
• Use of jaggery, seasonal fruits (bananas, citrus, papaya, guavas, orange)
and vegetables such as tomatoes, GLVs, beetroot were promoted (29-32).
• However, in order to develop the IEC, on visiting some 10% of randomly
selected though representative homes of the Working Girls of Units One,
Two, Three and Four, pointed to the need of adding on messages. These
were as under :
• Eat as much of trotter soup, meat, chicken and eggs on Sundays.
(Non vegetarian foods are cooked only on Sundays.)
• Wear slippers when you use the out-side toilet (Intestinal worm
infections were rampant in the slums) (33, 34, 35).
• Don't buy food from the street Vendor. Drink only boiled water
(messages relating to very poor environmental hygiene) (36).
• The Working Girls wanted to know about grooming; small family
norm (how?); and how to save money? So the lectures on these
were interwoven.
The Management requested that some general lectures be given on
Reproductive Morbidity and Mortality; Prevention of Unwanted Pregnancy;
Safe Motherhood; Child Survival; and Sexually Transmitted Diseases.
30
II.
THE MESSAGES :
1. Relating to Prevalence of IDA :
• You have iron in your blood. If there is little iron in your blood you
will feel weak and tired. This malaise is called Anemia. 8 out of 10
of you are anemic. 2 out of 10 of you are healthy.
2. Relating to Fermented Foods and Dietary Injunctions :
• Your health is in your hands. If you are healthy there will be no need
to go to the hospital. EAT FERMENTED FOODS.
• Drink tea not more than twice a day. Use jaggary instead of sugar.
Jaggary is full of iron. It will strengthen your blood.
• Eat more fruit, lime juice.
• Eat groundnut and jaggary toffees instead of cakes and ice creams.
• Every morning instead of just tea eat a breakfast of one egg and two
slices of bread or two chappties and one glass of milk.
• Eat meat once a week. Eat an egg a day.
• Eat plenty of greens and vegetables. This will strengthen your blood.
3. Relating to the use of iron enhancement:
• Use lime to sour your soups or sambars.
4. Relating to the use of iron cooking vessels :
• Put your iron key into the lentil soup being cooked. The iron from the
key will enter the soup. From the soup into your blood and hence
you will be strong.
• Cook your vegetables in an iron wok.
5. Relating to worms, vendors, innoculations :
• Wear your rubber slippers when you go to the toilet or if you have to
walk through slush and mud.
• Eat home cooked food. Do not buy and eat food sold on the roadside.
Drink boiled water.
l/^ f >•
LL
S \
• jf
T ( •
^30 2>
31
f-JuT
* G /e t
• To prevent worm infection in you and your family, do the following :
Sun dry the seeds of papaya fruit. Give each person 6-8 seeds to
chew and swallow. It will rid you of worms.
• Ask for your typhoid vaccination at the hospital.
6. Relating to good grooming :
• De-louse your heads every week. Brush your teeth twice daily. Oil
and braid your hair everyday. Apply turmeric to your face as it serves
as an antiseptic and keeps away pimples.
7. Relating to IDA, small family norm :
• It is important to have strong blood even when you are married.
• Marry after you are 21. Two children are enough.
• If your blood is full of iron before you marry, your children will be
strong.
8. Relating to monthly saving practice :
• Save at least Rs. 50/- per month at the Post Office Savings Account.
9. Relating to our final injunction :
• If you have followed our advice, then 6 months later when we check
your blood again you will find your blood has become stronger and
contains more iron.
(Please refer to the separate booklet on IEC posters).
III. DELIVERY OF THE IEC AT THE WORKPLACE (UNITS ONE
AND TWO) :
Each poster was put up for a whole week on a big Notice Board at the
entrance of Unit One. The points made in the poster were reinforced by the
expert in the bi-monthly lectures. The concerned Research Associate stayed
on to answer questions and clear the doubts.
The poster of the week caught the eye of all Employees (male and female).
the Employer and the
The same poster was then shifted to Unit Two, for the next week. Lectmes
were'given in the same way, but only once a month, as is the case in most
government - run - IEC programmes.
I
I
I
The lecturers, namely Dr. Prema Akki and Dr. Arathi Singh again and again
stressed the facts that :
• All the messages could very well be implemented by all the Working
Girls.
• Prevention was better than cure.
I
I
I
I
33,
The poster of the week caught the eye of all - the Employer and the
Employees (male and female).
The same poster was then shifted to Unit Two, for the next week. Lectures
were' given in the same way, but only once a month, as is the case in most
government - run - IEC programmes.
The lecturers, namely Dr. Prema Akki and Dr. Arathi Singh again and again
stressed the facts that :
• All the messages could very well be implemented by all the Working
Girls.
• Prevention was better than cure.
32>
Chapter Six - RESUL TS:
SECTION A : SOCIO ECONOMIC PROFILE OF THE WORKING
GIRLS :
As stated in Chapter One namely. Introduction and Key Project Objectives,
the Working Girl/Woman is the phenomenon of this millenium in India,
especially so in her mega cities. Bangalore is the capital of Karnataka in
South West India. This project was conducted in the outskirts of this
enormously expanding city.
This section is organised into five sub sections as under :
1.
2.
3.
4.
5.
1.
Socio economic profile of the Working Girls or Employees.
Household Data of the Working Girls.
Contribution of the Working Girls to Household’s Monthly Income.
Kitchen Gadgets and Vessels owned by the Working Girls family.
Other Valuable Assets owned by the Working Girl’s family.
Socio economic profile of the Working Girls : As can be seen from
Table 1, the average age of these girls/young women in our study
range from 20 years to 23 years. In each of our four study units, most
of the Working Girls or Employees had a primary level to even junior
college level of education in the local language of Kanada. Hence,
overall they were in a very good position to comprehend the EC and
the lectures given by the two women doctors.
Approximately half were married - usually at 18 to 20 years of age,
except for Unit Four (Negative Control) where all were unmarried at a
mean age of 20.
Overall the majority had lived in the Urban Villages’ all their lives.
Almost all had a job experience in their respective units of three years
or more.
2.
Household Data of the Working Girls : Table 2 indicates that
approximately half came from nuclear families; while the rest came
from joint families.
Generally, three adult members earned in a household.
The
composition of the households indicated that adult earning members
predominated (>75% ). This again differs from the present rural
pattern of households having young children (37). The rural and urban
poor are entitled to ration cards under the Public Distribution System.
Units One and Four had a large number of ration card holders (>
75%); while in Units Two and Three only about 40% held ration
cards. In any case, the ration cards were only used for the purchase
of kerosene. The market rates for coarse rice, poor quality wheat,
sugar and edible oil were only slightly higher.
3.
Contribution of the Working Girls to Household’s Monthly
Income : The average monthly pooled earnings of a family ranged
from about Rs. 3,000/- to Rs. 6,500/- with a mean of about Rs.3,700/-.
The average monthly contribution of the Working Girl had a range
from 20% to 40% of the pooled income. The overall average was
about 30%. In our Participatory Research Assessment, these girls
were told by the male head of the household, that they had to earn for
their marriage expenses and dowry. Since most of the unmarried
Working Girls had already crossed 18 years of age, they willingly
handed over their monthly income except for a niggerdly amount
handed back to them for their personal expenses and pocket money
(Table 3).
4.
Kitchen Gadgets and Vessels owned by the Working Girls family :
From Table 4, it can be seen that hardly any family except for 15% in
Unit 4, owned a refrigerator.
The reason given was that all the
cooked food was consumed on that day itself. Vegetables, milk,
meat/chicken were bought and consumed on that very day.
Aluminium Pressure Cookers which were cheap, fuel efficient and
easy to clean were used in almost all the households of all the four
units (overall > 80%). A brass water filter, big brass vessels and
every-day-cookware (alumimum) and a set of stainless steel vessels
are usually given to the girl as part of her trousseu. Hence, these
were owned by most of the households in all the four units (> 75%).
The big brass vessels were pawned and came in handy when the
family required money. Cooking gas was a rare luxury. Except for
Unit Four, in the other three units, only about 13% had cooking gas.
Most used fuel wood or kerosene.
A small mixie grinder was found in about 50% of the households in
Units One and Two; while its ownership was much higher in Units
Three and Four. A mixie or grinder is an essential requirement for
making the iddlis (fermented food). Raw rice and black gram
{phaseolus mungo roxb) 2 : 1 ,which is soaked in water overnight, is
finely ground and then the dumplings are steamed in a pressure
cooker. However, practically every street had large commercial
electrically operated grinders which charged a very nominal amount
for grinding. Hence, whether a family had a mixie or not was not a
great constraint to making iddlis if they so desired to make them.
5.
Other Valuable Assets owned by the Working Girl’s family : As
we had pointed out earlier these households had their own aspirations
and 'wish list’.
A bicycle was owned by about 50% of the
households and was usually the sole property of the man of the house.
Two wheelers which were much more expensive were owned by only
14% of the households. Radio, a good source of information from
the outside world was owned by only 35%.
Overall by way of
contrast, the audio-visual television was owned by 78%. The TV we
found was an extremely potent influencer. A branded iodized salt
(Captain Cook), frequently advertised on TV was used in almost all
the households. Other items considered of value such as tape-recorder
were owned overall by 45%; table fans by 72%; and a steel cupboard
by 63% (Table 5).
3G
SECTION - A
Table 1 .-Socio-economic Profile of the Working Giris :
UNIT 1
(Iddili or the
fermented
food)
UNIT 2
(Goosebery
Juice)
UNIT 3
(Medicinal
Supple)
UNIT 4
(Negative
Control)
Population Size N
72
80
70
80
Average Age
23
21
22
20
11(8)
15(11)
74(53)
8(6)
30(24)
62(50)
17(12)
23(16)
60(42)
0(0)
0(0)
100(80)
Married
54(39)
Unmarried
46(33)
48(38)
52(42)
64(45)
36(25)
0(0)
100(80)
Urban or rural background
in %
Urban
Rural
100(72)
0(0)
100(80)
0(0)
83(58)
17(12)
66(53)
34(27)
Years of experience in %
<1 year
1-3 years
>3 years
0(0)
56(40)
44(32)
0(0)
89(71)
11(9)
0(0)
91(64)
9(6)
0(0)
88(70)
12(10)
Characteristics or Indicator
Education in %
Illiterate
Upto Primary
Primary and/or College
Marital Status in %
Note : n is in brackets.
2>7
Table 2 : Household data of the Working Girls :
Characteristics or Indicator
Population Size N
Families in %
Nuclear
Joint
Average number of earning
Members
UNIT 1
(Iddili or the
fermented
food)
UNIT 2
(Goosebery
Juice)'
UNIT 3
(Medicinal
Supple)
UNIT 4
(Negative
Control)
72
80
70
80
53(38)
47(34)
50(40)
50(40)
36(25)
64(45)
51(41)
49(39)
2.7
3.0
2.9
2.9
73.5(53)
Percentage of :
Adult (>18 years)
Children (<18 years)
26.5(19)
76.7(61)
23.3(19)
77.6(54)
22.4(16)
84.8(68)
15.2(12)
Urban or rural background
in %
Urban
Rural
100(72)
0(0)
100(80)
0(0)
83(58)
17(12)
66(53)
Ration Card holders in %
Yes
No
74(53)
49(39)
51(41)
41(29)
59(41)
83(66)
26(19)
Note : n is in brackets.
32
17(14)
17(14)
Table 3 : Contribution of the Working Girls to the Household^ Monthly Income :
UNIT 1
(Iddili or the
fermented
food)
UNIT 2
(Goosebery
Juice)
UNIT 3
(Medicinal
Supple)
UNIT 4
(Negative
Control)
Population Size N
72
80
70
80
Average monthly household
Salary in INR
3739
3275
3061
4920
Average monthly salary of
Working Girl in INR
850
577
951
1048
27
20
44
23
Characteristics or Indicator
Average contribution of
monthly household income
in %
Table 4 : Kitchen Gadgets and Vessels owned by the Working Girl’s family :
UNIT 1
(Iddili or the
fermented
food)
UNIT 2
(Goosebery
Juice)
UNIT 3
(Medicinal
Supple)
UNIT 4
(Negative
Control)
Population Size N
72
80
70
80
Refrigerator in %
Yes
No
1(D
99(71)
1(1)
99(79)
3(2)
97(68)
15(12)
85(68)
Pressure Cooker in %
Yes
No
90(65)
10(7)
68(54)
32(26)
74(52)
81(65)
19(15)
Water filter in %
Yes
No
28(20)
72(52)
18(14)
82(66)
21(15)
79(55)
40(32)
60(48)
Big Brass Vessels in %
Yes
No
83(60)
17(12)
74(59)
26(21)
81(57)
19(13)
68(54)
32(26)
7(5)
93(65)
34(27)
66(53)
77(54)
Items
26(18)
Cooking Gas in %
Yes
No
19(14)
14(11)
81(58)
86(69)
Mixie in %
Yes
No
53(38)
47(34)
46(37)
54(43)
23(16)
73(58)
27(22)
Others in %
Yes
No
1(1)
99(71)
0(0)
100(80)
0(0)
100(80)
5(4)
95(76)
Note : n is in brackets.
Table 5 : Other Valuable Assets owned by the Working Girl's family :
Items
Unit 1
(iddli or the
fermented
food)
Unit 2
(Gooseberry
Juice)
Unit3
(Medicinal
Supple)
Unit 4
(Negative
Control)
72
80
70
80
53(38)
47(34)
39(31)
61(49)
43(30)
57(40)
59(47)
41(33)
Two wheeler in %
Yes
No
26(19)
74(53)
3(2)
97(78)
9(6)
91(64)
18(14)
82(66)
Radio in %
Yes
No
43(31)
57(41)
35(25)
65(55)
20(14)
80(56)
40(32)
60(48)
Television in %
Yes
No
71(51)
29(21)
78(65)
22(15)
90(63)
10(7)
73(58)
27(22)
Tape Recorder in %
Yes
No
26(19)
74(53)
44(32)
56(48)
46(32)
54(38)
63(50)
37(30)
Table Fan in %
Yes
No
67(48)
33(24)
66(53)
34(27)
76(53)
24(17)
80(64)
20(16)
Steel cupboard in %
Yes
No
39(28)
61(44)
70(56)
30(24)
73(51)
27(19)
68(54)
32(26)
Population Size N
Bicycle in %
Yes
No
Note : n is in brackets.
SECTION B :DIETARY AND NUTRIENT INTAKE (BEFORE AND
AFTER):
1.
Average Daily Intake of Food Stuffs by the Working Girls (Before
and After :
1.
Cereals and Millets : Rice followed by ragi (Elusine Coracana)
were the cereals consumed in great quantities. Wheat, as wheat flour
was consumed in far less quantities.
The Nutrition Profile of
Karnataka (6), indicates that adolescent (16 years plus) and young
women were consuming on an average 605 g Vs an RDA of 440 g for
cereals. The bulk of the common man’s and woman’s diet in this
southern state came from cereals. The mean Pre-Survey intake
among the 180 girl subjects in our study was 519 g. As indicated
earlier our subject households did not buy their rice from the Public
Distribution System or ration shops. Generally rice ranging from Rs.
15/- to Rs. 20/- per Kg (or USD 50 cents) was bought. Ragi (Elusine
Coracana) was about half this price. In the four Units this rose to a
mean intake of 635 g at Post-Survey or a mean increase of 101 •
Kcal/subject. The mean calorie increase in Unit One, Two, Three
and Four were 163 Kcal; 192 Kcal; 32 Kcal and 17 Kcal respectively.
In Unit One (fermented food), the calorie increase was mostly
contributed by the iddlis. In Unit Two, the Working Girls in our
PRAs said they felt so hungry that they bought some roasted
groundnuts from the roadside hawker.
ii.
Pulses or Lentils : The mean intake of pulses among our subjects at
the Pre-Survey was 28 g Vs a RDA of 45 g. The Nutrition profile for
Karnataka indicated a higher mean intake of 39 g for similar age
group. Pulses are very expensive and at current prices are about Rs.
40/- (USD 1 per Kg). Generally to make iddh (fermented food) two
measures of raw rice to one measure of split black gram (Phaseolus
mungo roxb) is used in middle to upper middle class homes.
However, we noted that only half to one - fifth the amount of black
gram was used due to its high cost. The lentil soup which was an
everyday item also contained minimal quantities of red gram (Cajanus
cajari). To compensate huge quantities of red chilli powder and
quite large quantities of tamarind pulp (to sour the soup) were used
Significant increase in pulse consumption at the Post-Survey was
noted (only in Unit One).
Leafy vegetables
The Pre-Survey revealed an extremely poor
consumption of green and leafy vegetables (GLVs). The mean intake
iii.
was 12 g Vs the RDA of 100 g. The Nutrition Profile of Karnataka
confirms this (value of 16 g). Greens are called “sappu” and are
bought in small quantities (250 g/day for the whole family) as a filler
for the lentil soup. It is also believed to relieve constipation. In the
Post-Survey, the intake of GLVs went up significantly in Units One
and Two where the EEC was given. The mean intake of GLVs at
Post-Survey rose to 19 g Vs 11 g at Pre-Survey in Unit One.
In our PRAs, it emerged that GLVs are not a favourite, as a lot of time
is spent in rinsing the greens in water and chopping it up fine.
Usually, the GLVs also have tiny worms/insects or poochis (local
term) or sometimes come with a fine dusting of insecticides or DDT
powder. Hence, GLVs are never given to young children.
The
seasonal GLVs were drumstick leaves, knol-knol, agathi, corriander
and cabbage.
J
iv.
Other Vegetables : Tomatoes were the favourites. In India tomatoes
are considered a vegetable and not a fruit. They had to be used in the
daily cooking, no matter what the price. Depending on the size of the
household, usually 3 to 4 adults and 3 children (6-8 members), 100g
to 250 g were bought everyday. It was also used to give body and
taste to the lentil soup.
Depending on the season and available
finances, other vegetables bought were beetroot, cauliflower, carrots,
yellow pumpkin, onions, ridge gourd, ash gourd, brinjal, cluster
beans, field beans, ladies fingers etc.
The mean intake was about 22 g at the Pre-Survey Vs 25 g at Post
Survey Vs a RDA of 40g per day.
The IEC appears to have been successful in propelling families in
Unit One and Two to consume more of the above vegetables.
V.
Roots/Tubers : Potatoes head the list of tubers. However, a separate
vegetable dish is not eaten everyday except in the homes of the better
off. The mean intake was 33 g at the Pre-Survey Vs 34 g at Post
Survey Vs the RDA of 50 g. No significant increase was observed in
any of the four Units at Post-Survey.
vi.
Oils/Fats : Extremely low intake of oils/fats was seen. This is in
confirmity with the observations of the Nutrition Profile of Karnataka
(6). The mean intake at Pre-Survey was a mere 6 g Vs 7 g at Post
Survey Vs the RDA of 25 g.
43
Oil is again a very expensive item for the common man at Rs. 55/- to
Rs. 70/- per litre (about USD 1.25 to 1.75).
It was saved for
seasoning the condiments used in the lentil soup or the occasional
vegetable dish. Most of the oil/fat (hydrogenated) was used up on
Sunday when a special non-vegetarian fare was served.
vii.
Milk : Milk intake was extremely low with a mean intake of 30ml
per day. This however, is one and a half times what is reported in the
Nutrition Profile for women (>18 years) in the rural, slum or lowincome-group areas, Karnataka (6). The intake of milk did not show
any significant increase. It was 30 ml at the Pre-Survey Vs 31 ml at
Post-Survey Vs the RDA of 150 ml.
Tea was the beverage of choice where a dash of milk was used to
whiten it. Milk in the form of curd (used for the weekly curd-rice)
was a great favourite. Whatever was available was given as milky
tea or coffee to the young ones or schoolers.
Milk packets are readily available at Rs. 12/- per litre (about 35 US
cents) - yet not affordable in the homes with pooled incomes of Rs.
3,000/- to Rs. 5,000/- p.m.). It is indeed a sad testimony that India
which is the biggest milk producer in the world today, cannot reach
out to this not so poor’ population segment. This is one everyday
commodity that can be fortified with all the fat soluble vitamins.
Our PRAs brought out the argument from the side of the Working
Girls as under :
•
•
•
•
vm.
Tea is available to us at the Workplace.
Milk is only for children.
Milk is good but too costly.
Milk is the food of the rich and our Gods.
Sugar/Jaggery : Although jaggery (for Hb enhancement), instead
of sugar, formed an important lesson of our TEC, hardly anyone
switched from sugar to jaggery.
The mean intake of sugar was 24 g at the Pre-Survey Vs 26 g at Post
Survey Vs the RDA 20 g. The intake levels remained more or less
static.
ix.
Fruit : This category of food stuffs is again economically beyond the
means of the households of the Working Girls. The mean intake of
fruit at Pre-Survey was 22 g Vs 27 g at Post-Survey Vs the RDA of
100 g.
Apparently the IEC did have a positive impact as there was a
significant rise from 27 g to 38 g of fruit in Unit One and from 20 g to
28 g in Unit Two.
In Unit Two (Gooseberry Juice intervention) the increase in fruit/fruit
juice was almost entirely due to the Employer giving the Employee,
gooseberry juice 3 times a week. The consumption of lime as lime
rice, lime-pickle and very occassionally lime juice did go up
somewhat.
x.
Flesh Foods : Generally, one or even two Kg of meat at Rs. 100/- a
Kg was purchased for the Sunday lunch. Theorotically, this would
have nearly met the RDA of 30 g for a 6 member household.
Unfortunately, the intra-household distribution was such, that the male
members and male guests got the lion’s share. The Working Girl
hardly got her fair share. In short, any food stuff that was of high
biological value was expensive. Whatever was bought, bar milk, was
consumed mostly by the male members of the household.
The mean intake of flesh food and eggs was 20 g at Pre-Survey Vs 16
g at Post-Survey Vs the RDA of 30 g. It is indeed ironic and sad that
these households were prepared to spend on an average Rs. 500/- a
month for the Sunday - lunch - meat, but could not be persuaded to
spend it on more milk, more fruit or more fats/oil.
2.
Average Daily Nutrient Intake by the Working Girls (Before and
After:
i)
Calories : The mean calorie intake at the Baseline Survey was 2620
Kcal Vs the RDA of 2225 Kcal for a Moderate Woman Worker. Or
nearly 400 Kcal more/day for a woman worker in this category.
Since, hardly anyone of our Working Girls were obese, it would
appear that they leaned in their work load (home load, running home
some 4-5 Kms to work and back and; the work load at the workplace),
in between the Moderate’ and Heavy Worker’ category, namely
2925 Kcal RDA for women (3). The mean and significant calorie
increase from Pre to Post Survey in Unit One was 163 Kcal,
contributed mostly from the iddh lunch at the Workplace.
Two the increase was 192 Kcal.
In Unit
In sum, the EC plus the food based intervention in Units One and
Two do appear to have influenced food-energy intake to some extent.
ii)
Protein : The mean protein intake at Baseline was about 70 g Vs the
RDA of 50 g. The Protein sources were predominantly cereals and
pulses of biological value. There were significant increases in protein
intake at Post and Endline Survey of 6 g in Unit One; 7 g in Unit Two
and 5 g in Unit Three.
iii)
Iron : This study was primarily focused on an IEC strategy based on
removal of dietary inhibitors of iron in Unit One and; the addition of a
dietary iron enhancer in Unit Two. The mean dietary iron availability
at Baseline was 27 mg Vs the RD A of 30 mg. However, very little of
it appears to have been available. (In Units Three and Four there
were small but non-significant increases of 1 g of dietary iron at Post
Survey).
There does appear to have been some impact of our IEC messages on
greater consumption of vegetables, fruits and meat. However, by
inference in Unit One, the much greater and/or frequent consumption
of iddlis at the workplace and at home, does appear to have been the
main reason for the significant increase in the mean Hb values of the
Working Girls in Unit One. In Unit Two (Gooseberry Juice
intervention), the major reason for enhancement of Hb values in this
group at Post-Survey appears to have been due to the regular but
intermittent consumption of the gooseberry juice again at workplace.
Vitamin C-rich gooseberry is known to be a powerful enhancer of Hb
values (15, 16). The Indian gooseberry is possibly one of the richest
sources of Vitamin C (63 mg/lOOg edible portion) in India.
iv)
Calcium : The mean intake of calcium was 534 mg at the Baseline
Vs the RDA of 400 mg. In Unit One, there was significant increase in
dietary intake of calcium from 511 mg at Baseline to 539 mg at
Endline Survey.
This did not happen in the other three units.
Calcium in known to be an inhibitor of iron bioavailability (37 ).
v)
Vitamin A
India is known to be one of the most Vitamin A
deficient countries in the world (38 ). Our dietary and nutrient intake
data for this not-so-economically-poor’ group also shows this to be
46
true. The mean intake of Vitamin A or its precurssor p-carotene, was
only 267 mcg Vs the RDA of 600 mcg.
It is heartening to note that the intake of Vitamin A did go up
significantly in Units One and Two, namely the Units where the
Employer and the Employees received IEC and a specific dietarybased-intervention to enhance the Hb status of the Working Girls.
The increase came mostly from a higher consumption of tomatoes, a
rich source of P-carotene (590 mcg per 100 g). Our latest edition of
the Nutritive Value of Indian Foods, 1993 (39), also lists ripe tomato
as a good source of folic acid (30 mcg per 100 g edible portion by the
HPLC method); and of Vitamin C (27 mg/100 g edible portion).
vi)
Vitamin C : The mean intake of Vitamin C was 29 mg at Pre-Survey
Vs the RDA of 40 mg.
It went up significantly in Unit One from 24 mg at Pre-Survey to 31
mg at Post-Survey. This reflects a Practice or Behaviour change,
perhaps due to a combination of the intense level of EEC plus the
actual food-based intervention.
The greatest and significant enhancement of Vitamin C was seen in
Unit Two, which was contributed almost totally by the gooseberry
juice at the workplace.
CONCLUSIONS :
Dietary Intake :
• The Dietary Intake Survey supported the claims that the appetite had
improved’ (Please refer Section C & D). It was also supported by
significantly higher intake of food stuffs, especially so in Units One and
Two.
Nutrient Intake :
• The IEC plus the fermented food (iddlis) aided in enhancing Hb levels of
the Working Girls.
• The Gooseberry Juice intervention was the most successful in enhancing
the Hb levels of the Working Girls.
• Enlightened Managements should offer such simple and cost-effective
lunches at the workplace.
Table 1 : Average Daily Intake of Food Stuffs by the Working Girls :
FOOD
STUFFS
RDA
(g)
UNIT 1
UNIT 2
(Goosebery
Juice)
N = 45
N
45
UNIT 3
(Medi.
Supp)
UNIT 4
(Neg.
Control)
N = 45
N = 45
Before
Alter
Before
.After
Before
.After
Before
.After
Cereals
440
491 ±39
670±21
483±41
667±19
513±9
593±3
589±30
Pulses
45
28±8
35±4
21±2
21±9
29±9
30±2
34±8
609+21
XS
34±7
Leafy Vegs.
100
11±9
19±4
16±3
20±8
10±4
8±3
10±2
io±i
Other Vegs.
40
21±3
29±9
19±3
22±4
22±2
24±1
24±2
Roots/Tubers
50
31±1
29±9
3O±2
XS
31±2
3O±3
40±2
Oils/Fats
2‘:
6±1
5±1
7±2
6±1
150
33±4
7±4
XS
27±1
7±3
Milk
3O±3
Sugar/
Jaggery
Fruit
20
21±4
33±3
XS
6±2
XS
35±1
XS
2O±3
XS
21±4
3O±9
:
XS
30±4
31±3
25±3
30±l
27±9
38±4
20±l
28±5
30
15±1
Flesh Foods/
Eggs________
♦
Note : p < 0.1
p< 0 01 = **
p < 0 001 = ♦ * ♦
NS = Not significant
19±3
10±l
U±3
NS
100
4g
27±3
XS
2O±3
XS
19±3
XS
12±2
20±l
13±3
XS
22±3
XS
19±2
25±5
XS
42±1 1
XS
8±4 I
j
XS
31±1
XS
31±8
XS
23±
5 XS
19±3
XS
i
I
1
I
I
Table 2 : Average Daily Nutrient Intake by the Working Girls
NUTRI
ENTS PER
DAY
RDA
(8)
I
Calories
(Kcal)
N = 45
Protein (g)
(for the
moderate
worker
category)
50
Iron (mg)
30
Calcium
(mg)
400
Vitamin A
(mcg)
UNIT 1
(Iddili)
600
UNIT 2
(Goosebery
Juice)
UNIT 3
(Medi.
Supp)
UNIT 4
(Neg.
Control)
N = 45
N = 45
N = 45
Before
After
Before |
After
Before
After { Before ] .After
2546±
258
2709±
201
2507±
211
2699*
204
2609±
198
2641±
179
65±4
72±9
68±3
74±8
70±2
J 75±5
29±2
32±3
29±1
3 lr2
25±3
5U±35
239±3l
Vitamin C
40
24±4
(mg)
_____
Note : p < 0.1 = *
p<0.01 =**
p < 0 001 = ***
NS = Not significant
539±41
502±25
501±34
NS
295±19
205±23
3l±3
29±9
49^4
28±4
'
' NS
i 26x2
I 24x4
j NS |
521±31 | 513±
33
NS
24I±1I
263 5± :
249 |
213
I _____
__
| 74±4 | 73±8 I
L_ *
3OO±52
2618*
|
I
6O5±39
NS
NS
6U±
44
NS
I
219*
11
NS
! 29*3
I
NS
I
• 25x6 i
381x8
373*
24
NS
34x5
■ 35±7
I
NS
i
I
Post Dietary Intake Survey
=^=5 That’s what most of us eat
most days!
;t k
£■-
1
'r
We love tomatoes' Have to
have some in our lentil soup
everyday
^7/
Rice and lentil curry -die usual
workplace lunch
i
fe- O-J
A ’T
rjg
tw re
I
*Mbw
Rxx?
-XI-/
l&M V'b.^ a
SOtlR
•.-■
■?
...
_
-'T
.
■I
^Tv-Ul^l
1/
n
Wi
ibr'1
F^;
P
■
inn
/C*
BBSH
Dietary record of food cooked per day for a
family of 6 adults and 4 children. Total
family income is Rs. 6,000/-.
f-
•«.
'VxS
l
* .Is-
■
^\O°
SECTION C : KNOWLEDGE, ATTITUDE, PRACTICE (BEFORE
AND AFTER) :
To recapitulate the IEC interventions were as follows :
• In Unit One, it was a poster session with a simple lecture by either of the
lady doctors once a week, on how one s blood could be made strong
through simple dietary changes.
This intense level of IEC was
buttressed by the Employer giving the Employee the fermented food
iddlis 3 times a week at the workplace.
• In Unit Two, the same poster sessions were repeated once a month. The
EEC was buttressed by the Employer giving the Employee gooseberry
juice three times a week at the workplace.
• In Unit Three, our Positive Control, deworming + medicinal iron
supplementation was given. No EEC was given.
• In Unit Four, our Negative Control, no intervention was done.
The ’Before’ and After’ KAP evaluation was done in all the four units.
Spontaneous as well as aided recall techniques were used. This section is
organized into three sub sections as under .
1 Knowledge responses Before and After.
2. Attitude responses Before and After.
3. Practice responses Before and After.
1. Knowledge responses Before and After :
From Table 1, it can be noted from the Before’ situation that, the
spontaneous recall responses and the general knowledge of anemia or IDA
was extremely poor ranging from 9% in Unit Three to 23% in Unit Four.
Highly significant increases of correct responses of > 87% were noted in
Units One Two and Three in the After’ situation. This was seen even m
Umt Four (Negative Control) a jump from 23% to 35%. The major reasons
quoted for anemia were : Weak blood and deficiency in the diet. Although
21 messages - not all dietary - were beamed at our target working girls, the
one that made the greatest impression were food - related. Even m the
specific intervention groups of fermented food (Unit One) and the
Gooseberry Juice intervention (Unit Two), all four groups were firmly
convinced that meat (trotter soup) was a good dietary way to make one s
blood strong'
Aided recall of “Eat fermented foods” and “fruits and
vegetables” also were high on the list. Although drinking more milk’ was
not any in of our IEC messages, the spontaneous responses m the After
situation was significantly higher V/s. the 'Before’. Milk is considered the
food of the Gods and the affluent. Perhaps this could be a reason for this
unexpected response.
From our section on Impact, it will be noticed that Knowledge does not
necessarily translate into Practice or Behaviour Change. The Hb levels of
the girls in Unit Four (Negative Control) did not show a change, although
their Knowledge levels did. Fermented foods did obtain high After’ scores
we expected. As a result of much higher consumption of the fermented food
(iddlis) at the workplace and a somewhat higher consumption of the
same at home, the mean Hb levels of the Working Girls did go up
significantly.
The all-important-male-heads also benefited by being more aware of the
causes and consequences of anemia (Table 2).
At the end of the 6 months intervention each Working Girl was given the
booklet containing all the visuals and copy of the 21 messages. She was
given 5 minutes to go through the booklet. She was told she should pick the
poster or lesson that impressed her the most. In an aided-recall situation,
we see that fermented foods topped the list (Table 3).
In both Units One and Two, we noted that the poster asking the girls to eat
more fermented foods (iddlis, dosais) or cooked rice steeped in water
overnight with their favorite lime pickle and tomato chutney was the most
popular scoring 38% in Unit One; and 36% in Unit Two. In Unit One, the
other toppers were Eat eggs, meat, and trotter soup’ (30%) and Eat a lot of
GLVs and Vegetables (27%).
In Unit Two the posters that had made a deep impression were Put the Iron
Key into the lentil soup as it cooks’ (13%); Save some money every
month’ (17%); 'Eat eggs, meat and trotter soup’ (15%).
2. Attitude responses Before and After :
Attitude in Unit One was assessed at Post - Intervention.
It can be seen from Table 4, that the attitude to the iddli (fermented food)
was extremely positive. All the Working Girls were highly appreciative of
the Employer being so magnanimous as to serve them their favorite packed
lunch’ of iddhs three times a week.
This had not happened before.
Generally the packed lunch for Mondays were iddhs'. Many claimed that
they did increase the number of times and quantity of iddlis brought from
home or eaten at home. This also coincided with what we observed in a
few homes on our home visits.
About three-quarters claimed that they
would continue to eat iddlis 4 times a week even if the intervention stopped.
The remaining fourth frankly stated that they did not have time to make
iddlis 4 times a week, should the intervention stop. All requested the
Employer to please continue with the intervention. The various reasons
stated for continuing with making - the iddlis even if the Employer
discontinued with it were : improved health; strong blood; better appetite,
and irregular periods (some confided to us that their white discharge or
leucorrhoea) had stopped. The iddli intervention was considered above all
as a food intervention. However, we were disappointed to note that when we
did a random check of some homes in end October, that most had
discontinued with their good intentions and had gone back to the 'Monday iddli ’ pattern. However, the Working Girls claimed that they ate 4 - 6 iddlis
at their Monday packed lunch. The Employer did not continue the
intervention.
Our Impact Evaluation confirmed that the mean Hb of this group had gone
up by 1.20 Hb g/dl.
In Unit Two the Gooseberry Juice intervention was greatly appreciated
(Table 5). Our Impact Evaluation revealed that it was as good as the
medicinal supplementation in enhancing the Hb levels of the Working Girls.
In contrast to Unit One, the Working Girls stated quite candidly that they
could not afford to buy a bottle of Gooseberry juice (brand name Rebina),
marketed by SB for Rs. 68/- per bottle, even though it would last them for
two months.
They requested the Management to continue with the
intervention.
The positive reasons stated were : extremely refreshing; made their blood
strong; improved their appetite; and that their periods had become regular
and prevalence/incidence of leucorrhoea had decreased.
3. Practice responses Before and After :
Table 6 shows that apart from extremely good Knowledge gams and
Attitudinal changes, the most favoured practice was to seek the help of a
doctor; and/or take the medicinal iron supplementation!
SECTION - C : KNOWLEDGE - ATTITUDE - PRACTICE (KAP)
Table 1 . Knowledge Regarding Anemia in the Working Girls before and after the
Interventions :
UNIT 1
EEC+
(Iddili)
INDICATOR
N = 72
UNIT 2
EEC+
(Goosebery
Jui)
N = 80
UNITS
(Medi.
Supp)
UNIT 4 (Neg
Control)
N = 70
___ N = 80
Before
After
87(61)
23(18)
35(28)
11(8)
66(46)
H(9)
30 (24)
71(57)
19(13)
66(46)
12(1)
26 (21)
61(49)
18(14)
70 (49)
5(7)
89 (71)
53(92)
11(9)
66 (53)
14(10)
19(13)
11(9)
36(29)
Before
Before
.After
Before
After
10(7)
99(71)
14(11)
94(75)
9(6)
15(11)
57(41)
21(17)
64 (51)
Deficiency in
diet
KU)
65 (47)
18(14)
Can’t say
83(60)
6(4)
15(H)
22(16)
After
Knowledge :
% having heard
of anemia
«««
«*«
% stating
correctly:
weak blood
«•«
% stating which
food makes
blood strong
Fruits
«**
• ««
Vegetables
32 (23)
54(39)
26 (21)
Meat
58(46)
37 (26)
75(54)
53 (37)
16(13)
39 (31)
«»«
«««
47(33)
86 (60)
13(10)
39(31)
18(14)
43 (34)
13(10)
38 (30)
»*»
17(12)
•«*
•««
«« «
28 (22)
65(52)
13(10)
33(26)
11(8)
14(10)
8(6)
NS
10(8)
NIL
NIL
Milk
*»»
10(7)
Others
47 (34)
***
8(6)
15(11)
Notes : 1. Sample size is given in brackets.
2. The ’ Students' t-test was applied for each statement Before and After.
P<0.05 *
P<0.01**
P< 0.001***
.
■
Sometimes % responses add up to more than 100% for each statement Before and After.
^5
Table 2 : Awareness about Iron Deficiency .Anemia .Among the Male Members in the
Households of the Working Girls :
INDICATOR
UNIT 1
CEC+
(Iddili)
I
N = 72
I Before
f
.After
UNIT 2
IEC+
(Goosebery
Jui)
N--80
__ N = 70
___ N = 80
Before
After
Before
.After
Before
UNIT 3
(Medi.
Supp)
UNIT 4 (Neg.
Control)
.After
% stating
»» »
»« »
YES
17
(12)
33
(24)
9
(7)
23
(18)
9
(6)
14
(10)
29
(23)
34
(27)
NO
83
(60)
67
(48)
91
(73)
78
(62)
91
(64)
86
(60)
71
(57)
| 66
(53)
Notes : The Chi-Square Test was applied
<0.05 *
<0.01 **
< 0.001 ***
SC
Table 3 : Which IEC poster Impressed you the most? Aided recall answers by the
Working Girls who received the Iddli or the Gooseberry Juice Intervention :
Caption of Poster
Iddlis (Unit One)
N=72
Gooseberry Juice
(Unit 2)
N=«0
1. Eat Foods rich in Fermented Foods
38%
36%
4
2%
Eat full breakfast
5. Deworm yourself with papaya seeds
8.
If you follow our advice your blood will be
stronger with more iron.
9.
Put the Iron Key into lentil soup being
Cooked
4%
4%
13%
12. Save some money every month
2%
17%
13. Use lime in your lentil soup
4%
4%
14. Don't eat food sold bv Hawkers
2%
15. Eat egg. meat and trotter soup
30%
21. Eat a lot of GLVs and Vegetables
27%
TOTAL
109%
15%
115%
Notes : 1. Eat foods rich in Iron (fermented; lime; gooseberry) 2. Better Grooming. 3. Drink less tea. 4. Eat a
full breakfast. 5. Deworm yourself with papaya seeds. 6. Eat jaggery groundnut toffee. 7. Should have strong
blood even if you are married. 8. If you follow our advice your blood will be stronger with more Iron. 9. Put the
Iron Key into lentil soup being cooked. 10. Wear slippers when you go to the toilet or walk is slush and mud.
11. Cook vegetables in an iron work. 12. Save some money every month. 13. Use lime in your lentil soup. 14.
Don't eat food sold by hawkers. 15. Eat egg, meat and trotter soup. 16. Eat Gooseberries. Guavas, Papaya,
Bananas, Mangoes and Apples. 17. Eight out of 10 of you are anemic. 18. Take Typhoid vaccination. 19.
Strong blood results in strong baby. 20. Marry’ aftet 21, have only 2 kids. 21. Eat a lot of GLVs and Vegetables
S'/
ATTITUDE
Table 4 : Attitude at Post - Survey to the Iddli Intervention and reasons for the same
among the Working Girls :
INDICATOR
(N)
(%)
1. Total number receiving iddlis thrice a week at
the work place
(72)
100%
2. Number stating that they will continue making
the iddlis at home even if the intervention stops
(53)
74%
3. Number stating that they will not be able to do
so.
(19)
26%
4. Number requesting the Management to continue
the intervention
(72)
100%
(72)
(72)
(72)
(36)
(36)
100%
100%
100%
50%
50%
(19)
26%
5. Major Positive Reasons for continuation :
i.
ii.
iii.
iv.
v.
Greatly influenced by the IEC programme
Will improve my health.
Will make my blood strong
My appetite has improved
My periods have become more regular
6. Major Negative Reasons for not being able to
Continue :
i.
No time to make iddlis 4 times a week
58
ATTITUDE
Table 5 : Attitude at Post - Survey to the Gooseberry Juice Intervention and reasons
for the same among the Working Girls :
INDICATOR
(N)
(%)
1. Total number receiving the Gooseberry juice
thrice a week at the work place
(80)
100%
2. Number stating that they cannot afford it.
(80)
100%
3. Number requesting the Management to continue
the intervention
(80)
100%
(80)
(80)
(80)
(32)
100%
100%
100%
40%
4. Major Positive Reasons for continuation
i.
ii.
iii.
iv.
Very refreshing
Good for blood and health.
Improves appetite
My periods have become more regular
^7
PRACTICE
Table 6 : Practice regarding Control of .Anemia in the Working Girls Before and .Alter the
Interventions :
N = 72
i
i—
| Before
.Alter
Before
| Aller
UNIT 4 (Neg.
Control)
UNIT 3
(Medi.
Supp)
UNIT 2
EC+
(Goosebery j
Jui)
|___N = 80 - I
UNIT 1
EEC-r
(Iddili)
INDICATOR
N = 70
| Before
| .After
N = 80
|
| Before • j .After
1
II
i
% saying
Go to Doctor
96
(69)
79
(57)
59
(47) -
94
(75)
50
(35)
(57)
68
(54)
43
5
(34)
(4)
50
(35)
29
(20)
38
(30)
81
I
Do nothing
iI
(3)
3
(2)
i
l Take iron tablets
I as prescribed
I
; ...
i 4
(16)
98
(78)
eaa
44
(32)
74
(53)
36
(29)
63
(50)
36
! (25)
I
57
(40)
43
68
(34)
(54)
1
Notes : 1. Sample size is given in brackets
2. The Student T-Test was applied for each statement Before and .After
P < 0.05
P<0.01
P< 0.001
♦
£o
SECTION D: IMPACT (BEFORE AND AFTER) :
This section is organized into four sub sections as under :
1. General Health Status.
2. Hemoglobin Status.
3. Clinical Assessment for Nutritional Status.
4. Anthropometric Status.
1. General Health Status : (Table 1)
Chronic conditions or illness : Gastritis and/or severe acidity was very
often mentioned. Perhaps due to the extremely spicy and chilli hot food
consumed. The other illness quite often mentioned by the Working Girls
were leucorrhea and low backache. The few who worked in the soldering
section were particularly anemic. They also complained about acute acidity
due to the acid fumes they were exposed to. Such health problems showed
significant improvement on counselling by Dr. Arathi Singh (Table 1).
General illness : The general illnesses were intestinal helminthic infections,
which showed significant improvement in Units One, Two and Three. A
special poster and lecture dwelt on this subject in Units One and Two. In
Unit Three, where deworming and medicinal supplementation were given,
there was a highly significant reduction from 74% Before to 3 /o in the
'After’ situation. Since, worms were a very socially unacceptable condition
in adults, many acted on our advice and purchased dewormmg tablets in
Units One and Two. Upper Respiratory Tract infections were also
mentioned A significant reduction in this condition from 12% to 1% was
noted in Unit Two. Perhaps due to the effect of ascorbic acid m the
Gooseberry Juice served three times a week. As also higher intake of lime
and tomatoes (precursor of Beta Carotene). Other conditions mentioned
were constipation. Perhaps due to many having to share a smgle toilet, lack
’ ’ ’ that
1 GLVs were consumed
of time and short water supply. Many admitted
in the lentil soup to aid digestion and prevent constipation, The toilets at
at home
the Workplace were a luxury compared to what was available
l..
(Table 1)
2. Hemoglobin Status (Tables 2, 3, 4 and 5):
I) The Hb status was significantly improved in Unit One, Two and
Three. In Unit Four (Negative Control) the values remained more or
less the same : (Table 2)
• In Unit One or the IEC + fermented food intervention, there was a
significant mean increase of 1.20 Hb g/dl, from 11.10 Hb g/dl to 12.30
Hb g/dl. The greatest benefit as viewed by the Working Girl was that it
was basically a food with properties of making weak blood strong’.
• In Unit Two, IEC + Gooseberry Juice intervention, there was a
significant mean increase of 1.50 Hb g/dl from 11.20 Hb g/dl to 12.7 Hb
g/dl. The Working Girls viewed this intervention as a most refreshing
drink’ that also had the ability to make their blood strong.
• In Unit Three, deworming + medicinal iron supplementation, there was a
significant mean increase of 1.50 Hb g/dl, from 10.42 Hb g/dl to 12.43
Hb g/dl. This intervention was most successful in eradicating worms
and for'making the blood strong’. No IEC was given. However, when
it came to practice - it was the doctor and the medicinal iron
supplementation that scored.
• In Unit Four, Negative Control, there was no increase in Hb. It may be
recalled that there were significant knowledge gains regarding the causes
and consequences of IDA in spite of no intervention being given. The
questions asked in the Pre or Baseline Survey had made the Working
Girls in Unit Four curious enough to seek information on IDA.
This begs the question, should it be a concrete intervention alone (40)?
Or should it be IEC + a concrete intervention? (4, 5 and 40) ? Or Should
it be IEC alone (41)? As one can see there are studies to support or
disclaim each of the above questions.
II) Percentage Prevalence of the Different Grades of Anemia in the
Working Girls Before and After the Interventions : (Table 3)
Percentage prevalence of severe anemia (< 7 Hb g/dl) was totally
eliminated in all the four groups.
This was noted even in Unit 4
(Negative Control). On some probing in Unit 4, at the Endline Survey, it
emerged that the girls had sought medical intervention and had been
prescribed Matrae" or tablets by the lady doctor. Moderate anemia ( 7
to 9.9 Hb g/dl) had also been virtually eliminated in Units One, Two and
Three. Whereas, it had increased from 23% to 30% (significant at p <
0.05) in Unit Four.
Mild Anemia (10 to 11.9 Hb g/dl) had also
significantly reduced in Units One, Two and Three.
case in the Normals category (Hb > 12 g/dl).
The same was the
At Baseline, the overall prevalence figure for Normals in Units One,
Two and Three was 35%; at Endline it rose to an impressive 76%. The
largest group of Normals were found in Unit Three (87%). In the case
of Unit Four (Negative Control) a stagnant figure of 20% was noted.
III)Interrelationship Between the Intense Level of IEC + the Supervised
Iddli Intervention and the Severity of Anemia in the Working Girls
Before and After the Interventions : (Table 4)
• An analysis of the mean number of iddlis eaten at home and at the
Workplace was undertaken and is exhibited in Table 4. It was
interesting to note that the mean total number of iddlis eaten over six
months did not vary very much from the severely anemic (< 7 Hb
g/dl) to the normal (> 12 Hb g/dl). The range was 224 to 283.
However, what was very interesting was the effect of the above
intervention on the severely anemic (< 7 Hb g/dl) where the increase
was 5.0 g/dl; in the moderately anemic (7 to 9.9 Hb g/dl), it was 2.4
Hb g/dl; and in case of mildly anemic (10 to 11.9 Hb g/dl) it was 1.3
Hb g/dl; and in those who had normal Hb values (> 12 Hb g/dl) a
decrease of 0.60 Hb g/dl was noted. Overall the increase in the Hb of
the Working Girl Group was 1.20 Hb g/dl (11.10 to 12.30 Hb g/dl).
• Further analysis of the above intervention on the unmarried Working
Girls who generally did not have access to their kitchen and the
married Working Girls who did, strengthened our hypothesis that
'control of the kitchen’ was an important factor if the IEC
component was to be followed at home. The mean increase in the Hb
level in the 33 unmarried Working Girls was 0.9 Hb g/dl Vs 1.60
Hb g/dl in the married Working Girls (n=39). The difference in the
Hb values of the unmarrieds Vs the marrieds was found to be highly
significant.
Since, the psycho - social and cultural values are
unlikely to change in the near future, the above important finding also
strengthens the fact that the Employers need to be persuaded to
provide such iron-rich lunch packages at the Workplace to their
Working Girls.
e3
IV)Interrelationship Between the Less Intense Level of IEC + the
Supervised Gooseberry Juice Intervention and the Severity of
Anemia in the Working Girls Before and After the Interventions :
(Table 5)
• An analysis was conducted as described, for the iddli intervention.
Each Working Girl in Unit Two received 3120 ml of Gooseberry
Juice, at 40 ml per girl, three times a week for 26 weeks (6 months).
There was also some increase in the consumption of lime pickle,
occassionally of lime juice, and lime rice. Lime was usually not
used to sour the lentil soup, although this constituted one of the IEC
lessons. The post dietary intake survey among Working Giris in
Unit Two showed a mean increase of 8 g in the consumption of fruit
— not necessarily lime. The huge increase in Vitamin C or ascorbic
acid came almost entirely from the Gooseberry Juice at the
Workplace. There was a highly significant increase of 1.50 Hb g/dl.
The same trend of more severe the anemia — better the response was
noticed here also. In the two cases of severe anemia, the mean
enhancement was 4.30 g Hb g/dl.
In the next category of
moderately anemic, the mean enhancement was also 3.50 Hb g/dl.
In the mildly anemic category, the mean increase in Hb values was
1.20 Hb g/dl. And in the Normal category, the mean increase was a
mere 0.30 g/dl. The Gooseberry Juice was as good as deworming +
medicinal iron supplementation, where overall the mean increase in
both Units Two and Three was 1.50 Hb g/dl.
• An analysis of the increase in Hb values in the married (n=3 8) and
unmarried (n=42) group was undertaken. In the mameds, it was
1.50 Hb g/dl Vs 1.48 Hb g/dl in the unmarrieds. There was no
significant difference between the values.
3. Clinical Assessment for Nutritional Status : (Table 6)
I)
For Iron Deficiency Anemia (IDA) :
There was a significant reduction in the clinical indicators of IDA,
such as pale nails, conjunctiva, or chronic menstrual bleeding among
Working Girls in all the four Units. The more subjective indicators
of tiredness, listlessness, breathlessness and body aches also
significantly reduced in the first three Units. Lack of appetite’ was a
frequent complaint among the Working Girls in all the four Units.
Appetite improved, not only by clinical assessment, but as judged by
food and nutrient intake (please see section B of this chapter for more
data on Food and Nutrient Intake). We are surprised at the reduction
in clinical signs of IDA, except that many after the Baseline survey
did go to private doctors.
II)
III)
'
For Vitamin A Deficiency (VAD):
Clinical signs of Vitamin A deficiency, namely Night blindness,
(XIV) and/or conjunctival xerosis (XIA), where present, significant y
reduced, especially so in Unit Two (Gooseberry Juice intervention).
URI and ARI:
Upper Respiratory Infection (URI) was a problem in Unit Two at the
Baseline survey.
It was significantly reduced at Endlme survey.
Acute Respiratory Infection (ARI) was a problem in Unit Three at
Baseline survey and was significantly reduced at Endlme survey. We
can say that IEC had definite impact where worm eradication was
concerned in Units One and Two. In Unit Three, where deworming
tablets were personally given by Dr. Arathi Singh, a tremendous
reduction from 73% to 3% was seen. A significant reduction from
69% to 59% was also seen in Unit Four, which we cannot explain,
except that perhaps medical help was saught.
IV ) Vitamin C Deficiency :
It significantly reduced in the three units where food - based + IEC or
deworming + medicinal iron supplementation was done.
4. Anthropometric Status : (Tables 7, 8 and 9)
I)
ID
- . from Table 7, it can be seen, that there was a mean and
Weight
statiTticaily significant weight gam in all the Workmg. Girk m ail the
four Units. The mean weight gain was 3.4 Kg, 2.4 Kg, 2.7 Kg and
1 4Kg respectively.
This was possibly due to a combination ot
growth spurt, better appetite, and a higher intake of daily food,
especially in Unit One (fermented food) where m addition to their
packed lunch, there was a bonus of the iddh lunch from the
Employer. The free iddh lunch was about 200 Kcal. However the
majority of the Working Girls were below the Indian Standard of 5
Ke HCMR 1998). Many of the thin and skinny Workmg Girls asked
usrepeatedly for “get-fat-quick” recipies. Most of the South Indian
female stars are buxom. The local TV was a big influence (Table 7).
Height : There were non-significant height increase in all the four
Units. The mean height of the Working Girls just about cleared the
Indian Standard of 150 cm (ICMR, 1999), (Table 8).
Q5
Ill)
Body Mass Index : From Table 9, it is seen that the mean BM1
(Body Mass Index Wt/Ht2), was above the accepted value of 18.5 as
being the cut off for Normal female adults in Units One, Two and
Three. In Unit Four, all the girls were young ( mean age of 20 years)
and unmarried. In Unit One, Two and Three the mean age was 22
years. Generally, a woman puts on weight after having a child or two.
Even in Unit Four, the mean BMI of 19.7 (Post-intervention) was
above the cut off of 18.5 (Table 9).
Further, the Working Girls in this study were in between the Moderate
and Heavy Work category.
Conclusion :
This again indicates that food-based interventions to improve the iron
status of the Working Girls either through the reduction of inhibitors
(phytic acid in the iddlis) or through enhancers, namely, ascorbic acid rich - foods augumented by focussed EC, does significantly increase the
hemoglobin values of the target population (Working Girls) in a
relatively short period of time (six months) and at an extremely
affordable cost.
SECTION - D
Table 1 : General health of the Working Girls :
Characteristic or
Indicator
UNIT 1
(Iddli or
fermented
food)
UNIT 2
(Goosebery
Jui)
UNIT 3
(Medi. Supp)
UNIT 4
(Neg.
Control)
72
80
70
80
Population Size N
Intervention
Before
After
Before
After
Before
After
Before
After
Chronic Illness in %
Yes
No
32(23)
68(49)
28(20)’
72(52)
45(36)
55(44)
22(18)’
78(62)
59(41)
41(29)
50(35)’
50(35)
70(56)
30(24)
68(54)
NS
32(26)
General :
Worms (%)
43(31)
24(17)’
36(29)
19(15)’
74(52)
3(2)-
51(41)
81(65)
NS
URI (%)
10(7)
7(5)
12(8)
1(1)*
Nil
Nil
5(4)
8(6)
NS
No Illness (%)
43(31)
69(49)
61(49)
80(64)
26(18)
97(68)
41(33)
14(11)
Note : n is in brackets; Based on Chi-square test of significance
p < 0.05 = *
p< 0.001 = **
NS = not significant.
^7
Table 2 : Absolute Hemoglobin values in the four groups Before and After the
Interventions :
Degree of IDA
UNIT 1
(Iddili)
N = 72
UNIT 2
(Goosebery
Jui)
N = 80 ‘
UNIT 3
(Medi. Supp)
UNIT 4 (Neg
Control)
N = 70
__ N = 80
After
Before
After
Before
12.7
1
1.1
11.5
10.9
1.3
13.0
1
1.3
After
NS
10.9
1.4
1.5
6.0±0.0
7.510.0
6.4±0.0
8.910.0
(2)
(2)
(2)
(3)
NO
CASES
NO
CASES
9.40±
0.70
NS
9.701
1.20
(18)
(18)
10.80±
0.90
NS
11.0010.
60
Before
After
Before
Overall Mean
Hb
11.10
11J
2.1
12.30
1
1.0
Severe Anemia
<7 g/dl
5.70
10.7
6.9±0.1
(1)
(1)
(2)
11.21
0.5
(2)
8.9±
0.70
11.30±
0.90
8.80±
0.90
12.30
11.20
(21)
(21)
(17)
(17)
11.0±
0.60
12.301
12.40
10.80
10.90±
0.60
11.20±
0.50
0.50
12.401
0.50
(29)
(29)
(36)
(36)
(37)
(37)
(44)
(44)
13.8O±
0.90
13.20±
0.60
13.20±
0.90
13.50
±0.90
12.50±
0.30
14.001
.030
12.70±
0.70
12.801
0.50
(21)
(21)
(25)
(25)
(31)
(31)
(16)
(16)
±
±
1.9
•«*
±
Mild Anemia
10g to 11.9g/dl
Normal
12 or more
g/dl
±
•• •
•••
±
•••
•••
Moderate
Anemia
7g to 9.9 g/dl
•* *
NS
NS
Note : p < 0.05 = ♦
p<0.01 = ♦ ♦
p< 0.001 =
The Student’s t’ test was applied.
NS = Non Significant.
Unit One : Each subject was given 2 iddlis (fermented food) per day/3 times a week x 180
days.
Unit Two : Each subject was given 40 ml Gooseberry Juice 3 times a week x 180 days.
Unit Three : Each subject was give deworming once + 60 mg Ferrous Sulphate once a week
x 180 days.
Unit Four : No intervention at all.
eg
Table 3 : Percentage Prevalence of the Different Grades of Anemia Before and After
the Interventions :
Degree of IDA
UNIT 1
(Iddili)
N = 72
Severe Anemia
<7 g/dl
Moderate
Anemia
7g to 9.9 g/dl
UNIT 2
(Goosebery
Jui)
N = 80
UNIT 3
(Medi. Supp)
N = 70
UNIT 4 (Neg.
Control)
__ N
80
Before
After
Before
After
Before
After
Before
After
1
(1)
0
3
(2)
0
(0)
3
(2)
0
(0)
3
(2)
0
(0)
1
(1)
21
(17)
1
(1)
0
(0)
3
(2)
23
(18)
30
(24)
55
(44)
NS
50
(40)
20
(16)
NS
20
(16)
♦
29
(21)
♦♦♦
Mild Anemia
10g to 11 9g/dl
40
(29)
Normal
12 or more
g/dl
30
(21)
32
(23)
♦♦♦
45
(36)
25
(20)
53
(37)
31
(25)
74
(59)
44
(31)
♦♦♦
67
(48)
Note : p < 0.05 = *
p<0.01 = **
p< 0.001 =
NS = Non Significant.
10
(7)
♦♦♦
87
(61)
Table 4 : Inter relationship between lEC + Supervised Iddli Intervention and Seventy
of Anemia in the Pre and Post Intervention periods:
INC/DEC
POST
PRE
DEGREE OF IDA
In
Hb level
(N=72)
(N=72)
Mean no. of idlis eaten
per worker over 6
months
121
121+156=277
11.10±2.10
g/dl
12.30±1.00
g/dl
204
204+156
=360
5.7 g/dl
10 7 g/dl
114
156+114=270
Mean Hb of the group
(N = 21)____________
Mean no of Iddlis eaten
over 6 months by the
mildly anemic
(10 to 11.9 g/dl)
8.90±0.70
g/dl
11 30±0.90g/dl
127
156+127=283
Mean Hb of the group
(N = 29)
11 00+0.60
g/dl
12.30±0 60
g/dl
114
156+114=270
13.80±0.90
g/dl
13.20±0.60*
g/dl
Overall mean Hb
(g/dl) (N=72)
Mean no. of Iddlis eaten
over 6 months by
severely anemic
(< 7 g/dl)
Mean Hb of the group
(N=l)
Mean no of Iddlis eaten
over 6 months by the
moderately anemic (7
to 9.9 g/dl)
Mean no of Iddlis
eaten over 6 months by
the Normal
(12 or more g/dl)
Mean Hb of the group
(N = 21)
________
*»*
♦ ♦♦
+ 1.20
g/dl
+ 5.00
g/dl
+ 2.50
g/dl
+ 1.69 g/dl
*♦*
ro
- 0.60 g/dl
Table 5 : Interrelationship between LEO + Supervised Gooseberry Juice Intervention
and Severity of Anemia in the Pre and Post Intervention periods :_________
DEGREE OF IDA
PRE
POST
INC/DEC
(N=80)
(N=80)
In Hb level
Overall quantity of the
3120 ml
Gooseberry juice
consumed over 6 mths
Overall Mean Hb
(g/dl) (N=80)
11.20 g/dl
12.70 g/dl
Gooseberry juice
consumed by the
severely anemic
(< 7 g/dl)
Mean Hb of the group
(N = 2)____________
Gooseberry juice
consumed by the
moderately anemic
(7 to 9.9 g/dl)
+ 1.50 g/dl
3120 ml
6.90 g/dl
11.20 g/dl
+ 4.30 g/dl
3120 ml
Mean Hb of the group
(N=17)_________ __
Gooseberry juice
consumed by the mildly
anemic
(10 to 11.9 g/dl)
8.80 g/dl
Mean Hb of the group
(N = 36)
Gooseberry juice
consumed by the
Normal
(12 or more
g/dl)_______________
Mean Hb of the group.
(N = 25)
11.20 g/dl
12.30 g/dl
+ 3.5g/dl
3120 ml
12.40 g/dl
+ 1.2. g/dl
3120 ml
13.50 (g/dl)
13 .20 (g/dl)
TZ
+ 0.30 g/dl
Table 6 : Clinical Assessment of the Micronutrient Status of the Working Girls :
Characteristic or Indicator
UNIT 1 (Iddli
or fermented
food)
UNIT 2
(Goosebery Jui)
UNIT 3 (Medi.
Supp)
UNIT 4 (Neg.
Control)
72
80
70
80
Population Size N
Intervention
Before
After
Before
After
Before
After
Before
.Aft er
IDA - Tiredness
63(45)
28(20)
43(34)
15(12)
73(51)
24(17)
61(49)
56(45)
NS
Listlessness
50(36)
4(3)***
31(25)
5(4)’
23(16)
7(5)*
34(27)
Breathlessness
28(20)
3(2)
24(19)
KD*’
40(28)
3(2)**
9(7)
Body aches
31(22)
19(14)*
46(37)
8(6)**
43(30)
23(16)*
30(24)
32(25)
NS
8(6)
NS
30(24)
NS
Lack of Appetite
44(32)
17(12)**
60(48)
13(10)
54(38)
40(28)*
51(41)
29(23)*
Pale Nails
68(49)
3(2)***
48(38)
4(3)**
79(55)
11(8)
50(40)
35(28)*
Leucorrhoea
42(30)
22(16)**
4X36)
19(15)*
76(53)
1(1)
80(64)
58(46)*
IDA
64(46)
21(15)**
30(24)
12(10)
71(50)
13(9)**
40(32)
39(31)
NS
VAD - Night Blindness
KD
KD
15(11)
2(1)*
20(14)
1(1)*
5(4)
5(4)
NS
Conjuctival Xerosis
13(9)
7(5)*
18(14)
3(2r
7(5)
7(5)
21(17)
URI
1(D
KD
30(24)
4(3)*
3(2)
2(1) NS
3(2)
29(23)
NS
7(6)
NS
1(1)
4(3) NS
4(3)
4(3)
29(20)
1(1)**
Nil
Nil
49(35)
14(10)
30(24)
10(8)*
73(51)
3(2)*••
69(55)
59(47)*
Yes
17(15)
6(4)*
11(10)
3(2)*
17(12)
KD*
14(12)
No
83(57)
94(68)
89(70)
95(76)
83(58)
99(69)
86(68)
15(13)
NS
85(67)
ARI
Worms
«««
Vitamin C Deficiency
Bleeding gums (%)
___
Note : n is in brackets. Based on Chi-square test of significance
p<0.05 = ♦
p<0.01 = *♦
p< 0.001 = **♦
NS = not significant.
Table 7 : Anthropometric Status of the Working Girls (Mean Weight and SD)
Characteris
tic or
Indicator
UNIT I (Iddlior
fermented food)
UNIT 2 (Gooscbcry Jui)
UNI T 3 (Modi Supp)
UNIT 4 (Neg Control)
Population
72
80
70
80
Size N
Intervention
Aller
Before
After
Be foie
After
Before
After
Before
In Kgs
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SB
18-23
years
44.3
8.7
47.7*
7.9
44 4
9.5
46.8*
9.6
45.7
7.9
48.4*
7.1
42.7
6.7
44*
6.4
__________ L___l________
Note : Based on Student t test (difierence of means for smal samples and large samples)
p < 0.05 = *
**
p<0.01
NS = not significant.
Table 8: Anthropometric Status of the Working Girls (Mean I Iciglit and SD)
Characteris
tic or
Indicator
UNIT 1 (Iddli or
fennented food)
UNI 1' 2 (Gooscbcry Jui)
UNIT 3 (Mcdi. Supp)
UNIT 4 (Neg Control)
Population
Size N
72
80
70
80
Intervention
Befoie
In Cnis
Mean
18-23
years
153.1
pTo os35?
SB
6.2
After
Mean
153
Belbi e
SB
6.1
After
Before
After
Before
Mean
SB
Mean
SB
Mean
SB
Mean
SB
Mean
SB
Mean
SB
149 9
5.9
150
5.7
1518
5.0
152.4*
4.9
I 51.8
6.4
152.8
6.4
S'Uden' 'tCSI <‘lin'elence of ",ea"s ro1 s™ll “"'Pies and large samples)
p < 0.01 = **
NS = not significant
Aftet
fable 9: Percentage Distribution of Body Mass Index of the Working Girls
Characteris
tic or
Indicator
UNI T 1 (Iddli or
fermented food)
UNI f 2 (Gooscbcry Jui)
UNI T 3 (Mcdi. Supp)
UNIT 4 (Neg. Control)
Population
'll
80
70
80
Size N
Inlcrvcnlion
Before
Bvfoi e
ARer
Aller
Before
A lief
Before
.Aller
In Cms
Mean
SI)
Mean
SI)
Mean
SI)
Mean
SI)
Mean
SI)
Mean
SO
Mean
SI)
Mean
SO
18-23
years
19.5
-1.3
2U.5t
39
20.1
-1.2
21.7
-1.1
20.3
3.2
21.0*
3.1
1 8.6
3.1
19.7
3.2
in
Note Based on Student t test (difference o 'means for small samples and large samples)
p < 0.05 = *
p<0.01 = **
NS = not significant
Chapter Seven — SUSTAINABILITY:
Sustainability of any intervention or action-research-study is the most
difficult question to answer. The three important Stake Holders in this study
were : The Employer; the Working Girl or Employee and the last but not
the least - the person who cooks at home and controls the kitchen. I have
consequently discussed Sustainability ftom each Stake Holder s perspective.
A. Sustainability from the Employer’s perspective :
i
Unit One (intense IEC + the fermented food) : The Employer
straight away recognized the potential of enhanced Hb levels m their
Working Girls translating into better productivity at the Workplace. They
further saw the opportunity cost of each Working Girl getting full medical
checkups twice in that year (1999) at the Workplace. The IEC given every
week by committed and expert doctors was also considered as plus points.
Hence, we could say that there was an almost instantaneous and positive
behaviour change even before the commencement of the study. Although
it cost the Employer of a small enterprise Rs. 11,232/- (260 USD) for the
iddli or fermented food intervention - we were delighted to see they did not
grudge this expenditure. Further, the Employer cooperated with us in all
respects from start to finish. We found that the Owner/Employer of these
small units to be far more approachable, willing to listen and willing to
implement than the Management of the large State or Central Govemmen
undertakings. However, on the flip side was the fact that they have not
continued with the fermented food intervention after we exited.
Conclusion : Any Public Health intervention, be it food-based + IEC or
IEC alone can if at all succeed and be sustainable at the Workplace. Cost
effectiveness, cultural acceptability of the food-based intervention,
frequency of consumption of the said food, ease of distribution and its
accountability are all factors to be considered for its potential sustainability
in a scaled-up situation.
B. Sustainability from the Employee’s perspective :
The response to the IEC plus the fermented food, was overwhelmingly
positive from the Employee’s side as well. Those who were m control of
the kitchen did make and consume more of the fermented food. They also
acted on the other IEC messages. Over 75% said they would continue to
make and eat the iddlis, whether or not the Employer gave it to them free of
charge.
76
One could sense smouldering anger in the Working Girls (Employees), that
they got very few welfare benefits from the Employer. All that the
Employer had to do as per law was to pay their accident and health
insurance as the Employees’ State Insurance (ESI).
It was the first time
they had got two free medical check ups in a year, the EEC and the free
iddlis. Could not the Employer and TCS continue to do what we (TCS)
had started? We tried to reason with them that they could also form a
cooperative and pay the outside food contractor. This advise was met with
a sullen silence.
Conclusion : In our considered opinion the Working Girls may slip mto
their old routine of iddlis or fermented food on Mondays. They certainly
were eating many more iddlis on Monday i.e. once a week. Whether this
will result in enhanced Hb levels could form the basis of another research
study.
C. Sustainability from the Stake-holder’s (who does the cooking)
perspective :
If the Stake-holder is in charge of the Kitchen, sustainability may be
ensured. Otherwise not.
ii.
Unit Two (IEC+Gooseberry juice intervention) : This food based
intervention was definitely the best as far as procurement, distribution, cost
and efficacy were concerned.
Unfortunately, neither the Employer nor the Employee was prepared to
continue once we exited.
Conclusion : The Gooseberry juice intervention is worth persuing at the
Workplace, if the costs could be shared by the Employer and the
Employee.
Hi.
Unit Three (deworming + medicinal iron supplementation) : If
the Employer desires to improve the health of his/her workforce, this is
probably the simplest and most effective non-food-based intervention to
support at the Workplace. We have had consistent and sustainable success
with the above (4, 5).
TT
Conclusion :
Finally, it may be noted by inference, that it did not make much difference in
KAP whether IEC was given at the intense level (once a week), or the less
intense level (once a month).
Hence, a concrete intervention at the
Workplace such as the fermented food or the gooseberry juice may be
more efficacious or effective in enhancing Hb levels of the Working ■
Girls - with or without IEC.
^8
Chapter Eight - DISCUSSION,
RECOMMENDA TIONS:
CONCLVSINONS AND
INTRODUCTION :
We start this chapter by re-stating the key hypothesis of this Efficacy Trial.
It was, namely, to assess whether individuals could be convinced enough to
alter their dietary practices relating to the bio-availability of dietary iron. If
so, within a very short period, a significant difference in the Hb levels could
be achieved. In short, dietary practices to enhance the bio-availability in
the typical food stuffs consumed by the study population was the
essential focus of this specific dietary intervention cum IEC study.
Fermented Cereal and Pulse Foods : The strategy was to reduce the
phytic acid levels in food stuffs that are eaten in large quantities
regularly. Phytic acid or phytate, an inhibitor in cereals and pulses greatly
reduces the bio-availability of iron.
Ascorbic acid-rich Gooseberry Juice : Ascorbic acid is a well known
enhancer of dietary iron and makes it much more bio-available. However,
consumption of fruits in general and citrus fruits in particular, at the
household level is minimal. This strategy was included as it was likely to be
affordable by the Employer at the Workplace. The cost of delivering 40
mg of Ascorbic acid via gooseberry juice per worker per day was
approximately the cost of one cup of tea. Tea is supplied by the Employer,
adlib, in all offices and workplaces.
We shall pose a series of questions relating to the above and shall defend the
same, primarily from the Results of this study, as well as other recent or
appropriate ones.
Q. 1 Which are the food stuffs consumed in quantity, day-in and dayout?
In this study as well as others done in South India, it is very definitely
huge quantities of rice, a much lesser quantity of ragi (elusine
coracana), and a small quantity of wheat. The major reason for
doing so is the cheap cost of the staples versus that of pulses, fats/oils.
flesh foods, fruits and vegetables (2, 6).
Q. 2 Wfeat is the bio-availability of iron in a typical Indian meal?
The bio-availability of iron in a typical Indian meal is extremely low.
Narasinga Rao conducted a number of invitro studies which revealed
77
the following picture, which may be relevant to our study. A meal of
Ragiballs, Potato and Tea has a bio-availability of only 0.9. Rice,
Dal, Potato and Milk raised the bio-availability of iron to 4.5 % (42).
Such studies, unfortunately are not available to our knowledge for a
meal including Indian fermented foods, such as iddli, dosai, appam. or
dhokla. It would appear that our present IEC study is the first to
demonstrate invivo, that the mean Hb status of the Working Girls
did go up by 1.20 g/dl, when an average of 20 - 30 iddlis were
consumed per subject, per week. It would be interesting to
further study whether intermittant or once a week consumption
of iddlis would raise Hb levels?
Q. 3 How then did you propose to make the staple cereals bioavailable?
It is well known that cereals have a high content of phytic acid, a
significant inhibitor of dietary iron. We, therefore, considered a
culturally accepted, habitually practiced and a traditional food
processing procedure, namely, auto-fermentation of cereal and
pulses. Fermented foods such as iddli, dosai and appam are eaten
practically every day as a breakfast food or as a tiffin' (snack food) at
tea time, in the affluent South Indian households. Our dietary and
nutrient intake surveys revealed that the poor households made iddlis
once or at the most twice a week, but in large quantities. Hence,
we decided to capitalize on this established food practice in this
region of India.
Gibson etal in their recent work in Malawi, Africa, have described
several dietary interventions to prevent zinc deficiency, one being
fermentation as being the simplest and most effective at the household
level. (12: 13). Several other studies, mostly conducted in Africa
have shown the effectiveness of reducing the phytic acid content of
maize, sorghum, other millets or dry pulse grains by the simple
process of just soaking the cereals in water for a few hours to
overnight (8, 14).
Fermentation : Iddli, a fermented food, which is a day-in and day-out
breakfast food, is a very simple procedure for most South Indians.
Generally, one measure of raw rice (Rs. 10/- to Rs. 20/- per Kg), one
measure of parboiled rice (Rs. 10/- to Rs. 20/- per Kg), one measure
of black gram dal {Phaseolus mungo roxb.} at Rs. 40/- per Kg are the
main ingredients for iddli. The rice and blackgram dal are washed
and soaked separately in water with about two inches of water
so
standing over the raw ingredients for about 6-8 hours. The rice is
ground coarse. The lentil is ground fine. Both are mixed well. Salt
and cooking soda is added to taste. The batter is allowed to ferment
overnight (10 - 12 hours). This results in the souring of the batter and
in the lowering of the pH. The batter is poured into greased moulds
and steamed either in a pressure cooker or iddli steamer for 8 - 10
minutes. The steamed dumplings are served with spicy lentil soup
and coconut chutney. 2 Kgs of rice grain plus 1 Kg of blackgram dal
(raw ingredients) would yield about 60 to 70 iddlis.
The Low Income families use much less of the expensive lentil but
add much more cooking soda. It would be useful to conduct invitro
and invivo studies on the bioavailability of iron from different recipies
of iddli. The most practical, cost-effective and sustainable recipe
could then be promoted to the Employers as their contributory lunch
to their Employees at the Workplace.
Since, the Working Girls claim to eat anywhere from 2-8 iddlis per
time, an equivalent of 100 g raw rice plus pulse (for 2 iddlisy, to 400 g
of raw rice plus pulse ( for 8 iddlis') would be consumed per iddli meal
(43). At the Baseline Survey, iddlis were the packed Monday lunch
for most of our Working Girls. At Post Survey, iddlis were still a
Monday treat, but the quantity consumed was far greater. We were
astonished at the quantity of cooked cereal food the Working Girl
could consume at a meal at home. Generally less of cooked rice was
eaten at the Workplace.
Steeping cooked rice in water overnight : An even simpler method
to increase the bio-availability of iron for cereals would be to soak the
cooked rice in water overnight. The next morning, drain off the
water, add curd (yogurt), and carry it to work as a packed lunch’. As
stated earlier, this was considered to be something that the very poor’
did. Our IEC poster on this did not find favour. It was considered
infradig. The Working Girls further told us that all the cooked food
was consumed on that very day itself. So where was there any
leftover cooked rice? Our advice that more rice could be cooked for
steeping later on, was not received well.
Gibson and coworkers have recommended soaking of maize, the
staple cereal of Malawi, Africa, as being the most practical method of
reducing the level of phytic acid (12, 13). Svanberg and coworkers
list the advantages of soaking and fermentation of non-tannin and
8/
high-tannin cereals which certainly support our IEC attempt to
popularize the 'curd-steeped rice lunch’ for Working Girls in South
India (44).
Q. 4 How does fermentation induce phytase hydrolysis of phytic acid
(myo-inositol hexaphospate in cereals and pulses)?
Most plant-based foods contain some phytase enzymes. However,
this enzyme that hydrolyses the phytic acid finally to inorganic
orthophosphate and myo-inositol, is in a dormant state in dry grains
and pulses. Phytase is activated in the moist state. It has been
reported that phytate reductions may be as high as 98% for a variety
of fermented products based on cassava, cocoyam, maize, sorghum,
rice, soyabeans, cowpeas and lima beans consumed in West Africa,
depending on the conditions of perparation, storage and cooking (10).
Gibson and Ferguson list the other advantages of fermentation as : (i)
it reduces amount of fuel energy required for cooking the fermented
products; (ii) It improves the safety of the final food product as it
inhibits the growth of diarrhoeal pathogens; and (iii) Antimicrobial
substances may also be produced during fermentation (12).
Commercial phytase enzymes can be prepared from Aspergillus
oxyzae or A. niger which are stable over a fairly wide pH range (3.5
- 7.8), and temperature range.
However, they are extremely
expensive at the present time (45).
Q. 5 What about iron bio-availability enhancers like ascorbic-acid-rich
foods?
The present study found that an enhancer like gooseberry juice is
excellent in increasing the mean Hb levels of our target Working Girl
subjects.
Other recent studies have shown that guava fruit was
successful in raising the Hb levels of college girls in a short time (15).
In fact, in this present study, it proved to be superior to the fermented
food as the mean Hb increase was 1.20 g/dl Vs 1.50 g/dl in the
gooseberry juice group. All dietary sources of Vitamin C are very
expensive and quite beyond the economic reach of our subjects. If
Industry, in this case Smithkline Beecham, Bangalore; the Employer
(Mr. Wahid of Unit Two) and the Working Girls could have shared
the cost of the gooseberry juice, it would have been an extremely
feasible and sustainable strategy.
..
This is a good strategy as it would counteract the inhibitory effect of
the tannins and polyphenols in the cups of tea imbibed at the
Workplace. Alternatively, if the big Tea Houses namely, Tata Tea
and/or Brooke Bond could be persuaded to invest in R & D that would
lead to the enrichment or fortification of loose tea with Vitamin C.
This would be a fine gesture on their part (46).
Q. 6 How do enhancers such as ascorbic acid (Vitamin C) improve the
bio-availability of iron?
Enhancers such as ascorbic acid form soluble or chelated complexes
with iron and prevents the iron from percipitating or polymerizing.
Ascorbic acid also reduces ferric iron to ferrous iron at pH values
greater than pH3 as found the duodenum and small intestine.
Apparently ascorbic acid is dose related and can act even in the
presence of inhibitors (47). Although the consumption of lime and
lime juice did increase at the household level, it is a matter of
conjecture whether the dose level of ascorbic acid would have been
sufficient to have resulted in a mean increase of 1.50 Hb g/dl per
worker, in the Working Girl population.
Q. 7 How successful was this IEC study in propogating the use of iron
woks for cooking?
Recent reports have indicated that Ethiopian children were fed food
cooked in iron pots, had significant increase of 1.7 Hb g/dl (over 12
months intervention period) versus those fed food from aluminium
pots (increase of 0.4 Hb g/dl). Similar results have been reported by
other investigators (24). In our study there was outright rejection to
the idea of replacing aluminium cooking vessels with those of iron.
Food cooked fast in aluminium vessels, they were easy to clean and
easy to maintain. Pressure cookers were made of aluminium. 75% of
the Working Girls in Unit Two were intrigued by our IEC poster
advising them to put the Iron Key into the lentil soup as it cooked and
had tried to do so a few times at their homes. However, the men in
the household objected strongly stating that the food tasted strange’
and bad’. Although this was not true, the few who were enterprising
and courageous enough to try, had to stop.
Q. 8 Can IEC, as a free standing intervention have brought about a
positive and sustainable impact in the Hb status of the Working
Girls?
A study by Kanani and Agarwal (41), indicates a positive impact in
Hb status among school girls in the age group of 8 - 13 years. The
investigators state that over a one year’s intervention the mean
increase in the Experimental Group was 0.80 Hb g/dl Vs -0.27 Hb
g/dl in the Control Group.
In Unit One, (our present study), the Working Girls received IEC
once a week plus the supervised fermented food intervention. In Unit
Two, the Working Girls received the supervised gooseberry juice
intervention plus EC once a month. Yet, in the later group, there
mean Hb increase was 1.50 g/dl over a 6 months intervention. In
Unit Three the Working Girls received supervised deworming plus
medicinal iron supplementation and no IEC. Yet, their mean Hb
increase was 1.50 g/dl over a 6 months intervention.. In Unit Four,
our Negative Control, the Working Girls neither received EC or a
concrete intervention. The Pre-Post Hb levels were more or less
stagnant, in spite of their Post knowledge levels regarding IDA being
high. The interpretation from the result of our study is :
• First target and orient the IEC at the Employer. Behavioural
change will be instant or not at all.
• Concrete dietary or medicinal intervention at the Workplace, if
given free of cost, appears to give the best results as far as
reduction in IDA is concerned.
• The Working Girl, especially if she is unmarried, has very real
constraints of money, time and NO control over her kitchen.
• Both the Employer and Employee need Organizational and
Managerial help to implement and sustain such a programme.
CONCULSIONS/RECOMENDATIONS :
1.
ii.
ui.
First orient or educate the Employer rather than the Employee with
respect to the improvement of the health and iron-status of the latter.
Expected behaviour change was almost instantaneous in the
Employer.
A concrete intervention at the Workplace plus IEC would be the
best choice.
The Employees do appreciate the IEC and do implement the
dietary injunctions to the extent possible. However, their time and
economic constraints are the real limitations to total behaviour
change or sustainability.
iv.
Control of the kitchen is a paramount factor in the Employee, where
much greater consumption of fermented foods is concerned.
v.
In Urban India, aluminium cooking pots/vessels have come to stay.
Hence, iron woks will not be used.
vi.
Tea will be drunk 2-6 times a day at the Workplace. No amount of
EEC will change this. Perhaps approaching the big tea manufacturer
to enrich or fortify their loose tea or cheap brands with ascorbic acid
(at the very least) may partially solve the problem of widely prevalent
EDA in the Working Girls.
vii.
The Employer of such small industrial units is generally a small
enterpreneur with small resources. This was the reason for non
continuance of the dietary-based interventions in Units One and Two.
But small cooperative efforts between Employer and Employee will
work. Iddli (fermented food) is an extremely popular food eaten by
all sections of South India. A retired Employee can be put in charge
of making this popular dish everyday and a small amount may be cut
from the Employee’s salary.
viii.
Although, the fermented food (iddli) did not increase the mean Hb
levels (1.20 Hb g/dl) to the extent that the Gooseberry Juice or the
Medicinal Supplementation interventions (1.50 Hb g/dl) did, yet, it
was the food-based -iddh intervention that was most appreciated.
ix.
Enhancing the Hb levels of the Working Girls makes good economic
sense. Such a strategy brings about good labour relations apart from
the established rewards of greater productivity, better reproductive
health, better cognition and an all round better working atmosphere.
x.
The Working Girl and or Working Woman is the phenomenon of this
millennium in India. Large population - based surveys are required
on the 'total health’ of this girl/woman. This should also include her
occupational health; her psyco-social or emotional health; her
nutritional health; and her reproductive health.
QS
REFERENCES
1.
Combs G. F., Jr., Welch R. M., Duxbury J. M., Uphoff N. T.
and Nesheim M.C. :
Food Based Approaches to Preventing Micronutrient Malnutrition
Workshop : an International Research Agenda, published by CIIFAD,
Cornell University, 1 - 68,1998.
2.
Subadra Seshadri :
A Data Base on Iron Deficiency Anemia (IDA) in India : Prevalence,
Causes, Consequences and Strategies for Prevention. Dept, of Foods
and Nutrition and the WHO Collaborating Center- for Nutrition
Research, M.S. University, Baroda, India, 1996.
3.
Indian Council of Medical Research :
Nutrient requirements and recommended dietary allowances for
Indians. A report of expert group of the Indian Council of Medical
Research.
Printed by National Institute of Nutrition, Hyderabad,
1992.
4.
Tara Gopaldas and Sunder Gujral:
A Multinutrient Package for Tea Plantation Workers for Better
Health, Productivity and Profitability, Tara Consultancy Services,
Bangalore, India, 1998.
5.
Tara Gopaldas and Sunder Gujral:
The Pre-Post Impact Evaluation of the Improved Mid-Day-Meal
Programme, Gujhrat (1994 - continuing) : Tara Consultancy Services,
Baroda, 1996.
6.
Chandrasbekhar T. C. :
Nutrition Profile of Karnataka.
Dept, of Women and Child
Development of Karnataka and UNICEF, Hyderabad, 1996.
7.
Kumar Ashok :
The National Consultation on Control of Nutritional Anemia,
Government of India, Ministry of Health and Family Welfare, Delhi,
India, 1998.
8.
Chavan J.K., Kadam S.S. :
Nutritional improvement of cereals by fermentation. Crit. Rev Food
Sci Nutr 28:349-400, 1989.
8G
9.
Svanberg U., Sandberg A. S ,:
Improved iron availability in weaning foods through the use of
germination and fermentation. In : Alnwick D. Moses S, Schmidt
OG., eds., Improving young child feeding in eastern and southern
Africa.
Household - level' food technologies, Nairobi, Kenya :
International Development Research Center, 366-73, 1988.
10.
Marfo E. K., Simpson B. K., Idowu J. S., Oke O. L :
Effect of local food processing on phytate levels in cassava, cocoyam,
yam, maize, sorghum, rice, cowpea and soyabean. J Agric Food Chem
38:1580-5,1990.
11.
Chang R., Schwimmer S., Burr H. K. :
Phytate : removal from whole dry beans by enzymatic hydrolysis and
diffusion. J Food Sci 42:1098-101, 1977.
12.
Roselind S. Gibson and Ferguson Ealine L. :
Nutrition intervention strategies to combat zinc deficiency in
developing countries
Nutrition Research Reviews 11, 115-131,
1998.
13.
Roselind S. Gibson and Fiona Yeudall, Nancy Drost, Beatirce
Mtitimuni and Tim Cullinan :
Dietary interventions to prevent zinc deficiency : Am J Clin Nutr 68
(suppl), 484 S - 7S, 1998.
14.
Lorri W :
Potential for Developing New Home-Based Food Processing and
Preparation Techniques to Improve Micronutrient Nutrition. Abstract
of paper presented at the Food-Based Approaches for Preventing
Micronutrient Malnutrition.
Published by by CIIFAD, Cornell
University, 1996.
15.
Subadra Sheshadri and Budhwarkar S. :
Effect of guava fruit (Psidium guajava) consumption with the meals
on Hb levels in young anemic women : Dept, of Food and Nutrition,
M.S.University, Baroda, 1998.
16.
Subadra Sheshadri, Shah A and Bhade S. :
Hematologic response of preschool children to ascorbic acid
supplementation : J Human Nutr Appl Nutr 39 A : 151-154, 1985.
87
17.
Ramalingaswamy V., Jonsson U, Rohde J. :
The South Asian Enigma : In : The Progress of Nations. UNICEF,
New York, pages 11-17,1996.
18.
Tara Gopaldas and Subadra Sheshadri :
Nutrition : Monitoring and Evaluation. Oxford University Press,
1987.
19.
World Health Organization
WHO Technical Report Series No. 405. Nutritional Anemias. Report
of a WHO Scientific Group, 1968.
20.
Oser BL. :
Hawks Physiological Chemistry.
Ltd., New Delhi, 1976.
Tata Me Graw Hill Publishing Co.
21.
Waterlow JC :
Classification and definition of protein calorie malnutrition. Br Med.
J 3, 566-569, 1972.
22.
Sommer A :
A field guide to Vitamin A deficiency and its consequences, its
detection and control. WHO 1995.
23.
Gopalan C., Ram Shastri B. V. and Balasubramaniyan S. C.
Nutritive Value of Indian Foods. National Institute of Nutrition.
ICMR, Hyderabad, 1989.
24.
Adish A. A., Esrey S. A., Gyorkos T. W., Jean - Baptiste J.,
Rajhani A. :
Effect of Consumption of Food Cooked in Iron Pots on Iron Status
and Growth of Young Children : A Randomized Trial. The Lancet,
353, 712-716, 1999.
25.
Martinez FE, Vannucchi H. :
Bioavailability of iron added to the diet by cooking food in an iron
pot. Nutr Revs. 6 : 421-28; 1986.
26.
Burroughs A.L., Chan J.J. :
Iron Content of some Mexican-American foods : effect of cooking in
iron, glass or aluminium utensils. J. Am Diet Assoc 60 : 123-26,
1972.
SP
27.
Britun H. C., Nossaman C. E. :
Iron Content of food in iron utensils. J. Am Diet Assoc 86 : 897-901,
1986.
28.
Cheng J.Y., Britun H.C. :
Iron in food : effect of continued use of iron cookware J Food Sci 56 :
584-85, 1991.
29.
de Pee S., West C. E., Permaesih D., Muhilal and Hautvast,
J.G.A.J., :
Orange Fruit is More Effective Than Are Dark-green Leafy
Vegetables in Increasing Serum Concentrations of Retinol and 0carotene in Schoolchildren in Indonesia. Am J. Clin Nutr; 68 : 105867, 1998.
30.
West C. E., Poortvliet E. J. :
The Carotenoid content of foods with special reference to developing
countries. Washington D.C. : USAID, VITAL, 1993.
31.
C. Gopalan :
Micronutrient Malnutrition in SAARC - The Need For A Food-based
Approach, NFI Bulletin, 13, No. 3, 1998.
32.
de Pee et al :
Lack of Improvement in Vitamin A Status with increased
consumption of dark green leafy vegetables. Lancet 346 : 75-81,
1995.
33.
Tara Gopaldas, R. Raghavan and S. Kanani :
Nutritional impact of antiparasitic drugs, prophylactic Vitamin A and
iron folic acid in under privileged school girls in India. Nutr Res 3:
831-844, 1983.
34.
Tara Gopaldas, K. Sharma and I. Pant :
Parasitic infestation and hemoglobin levels, Arogya J Health Sc XII :
83-85, 1986.
35.
Stoltzfus R. J., Albonico M., Chwaya H. M., Tielsch J. M., Schulze
K. J. and Savioli L. :
Effects of the Zanzibar school-based deworming program on iron
status of children. Am J. Clin. Nutr. 68 : 179-186, 1998.
36.
Susan E., Burger and Steven A. Esrey :
Water and Sanitation : Health and Nutrition Benefits to Children.
Chapter 9, pp. 153-175 in P. Pinstrup-Andersen et al in Child Growth
and Nutrition in Developing Countries : Priorities for Action, Cornell
University Press, 1995.
37.
Fairweather - Tait:
Bioavailability of iron. In Nestel P., ed.. Iron interventions for child
survival : proceedings of the 17-18 May, 1995 Conference, London.
Opportunities for Micronutrient Interventions, Washington, D.C.,
U.S.A.., Proceedings, S. J. 1995.
38.
Vijayaraghavan K. :
Vitamin A deficiency. Chapter 22, pp 287-297. In Textbook of
Human Nutrition edited by Bamji M.S., Prahalad Rao N., Vinodini
Reddy, Published by Oxford University Press and IBH, 1996.
39.
Gopalan C. etai:
Nutritive Value of Indian Foods, National Institute of Nutrition :
Revised and Updated by B.S.Narasinga Rao, Y.G.Deosthale, and K.C.
Pant, 1993.
40.
Tara Gopaldas etal :
The Impact of Single and Combined Health and Nutrition Inputs on
the Nutritional Status of the Child. Project Poshak, Vol. 1, Chapter
Four, pgs 222 - 228, 1975.
41. . Kanani S. and Agarwal V. :
Reducing Anemia and Improving Growth in Early Adolescence Nutrition Education Alone Can Make a Difference. Paper presented
at the 16th International Congress of Nutrition, Montreal, Canada,
1997.
42.
Narasinga Rao B. S., Vijaysarathy C. and Prabhavati T. C. :
Iron absorbtion from habitual diets of Indians, studied by the extrinsic
tag technique. Ind J. Med Res 77, 648 - 657, 1983.
43.
Swaminathan M. :
Principles of Nutrition and Dietetics. Pg 490.
Bangalore Printing and Publishing Co. Ltd., 1997.
?o
Published by the
44.
Svanberg V. :
Dietary Interventions to Prevent Iron Defeciency in Preschool
Children. In Nestel P., editor of “Iron Intervention for Child
Survival”, 1995.
45.
Sandberg A. S., Rossander Hulthen, Turk M. :
Dietary Aspergillus niger phytase increases iron absorption in
humans. J Nutr 126:476-80, 1996.
46.
Preventing micronutrient malnutrition : A guide to food-based
approaches. FAO and ILSI Press, Washington D.C., 1997.
47.
Desrosiers T, Clydesdale F. :
Effectiveness of organic chelators in solubilizing calcium and zinc in
fortified cereals under simulated gastrointestinal pH conditions. J
Food Proc. Preserv 13:307-19, 1989.
^1
ABBREVIATIONS
ARI : Acute Respiratory Tract Infections.
BMI : Body Mass Index.
Dosai/Appam : Fermented Foods from Cereal - pulse fermented batters.
ESI : Employees’ State Insurance.
GLVs : Green Leafy Vegetables.
Hb : Hemoglobin.
ICMR : Indian Council of Medical Research.
IDA : Iron Deficiency Anemia.
IDD : Iron Deficiency Disorder.
Iddli : Fermented pancakes made out of cereal - pulse fermented batter.
IEC : Information - Education - Communication.
KAP : Knowledge - Attitude - Practice.
LIG : Low Income Group.
PDS : Public Distribution System.
PRA : Participatory Research Assessment.
RDA : Recommended Daily Allowance.
SPSS : Statistical Package for Social Sciences.
TCS : Tara Consultancy Services, Bangalore, India.
TRF : Thrasher Research Fund, Utah, U.S.A.
URI : Upper Respiratory Tract Infections.
USD : United States Dollar.
VAD : Vitamin A Deficiency.
WHO : World Health Organisation.
92-
MAJOR ASSIGNMENTS OF TCS ( 1993 - 2000 Continuing)
1.
Consultancy for Micronutrient Initiative, Ottawa, Canada, 2000-2001.
2.
An “DEC Project for Working Girls (18-23 years) on Cultural Dietary
Practices to Increase the Iron Content of Their Everyday Diets” - for
Thrasher Research Fund, Utah, U.S.A., 1998 - 2000.
3.
Consultancy for CARE - India for “Addressing Nutritional Gaps in
Children Under Two in Rural India”, 1998.
4.
“A Multinutrient Package for Tea Plantation Workers for Better Health,
Productivity and Profitability” for OMNI — ILSI, 1996 — 1998.
5.
Consultancy for the National Assessment and Accreditation Council of
India on “What are the Perceptions of Quality in Higher Education by the
Stake Holders, Namely, the Students, Parents and Employers?”, 19961998.
6.
A Technical Workshop for Smithkline Beecham on “Imperative Need to
Integrate Deworming and Micronutrient Supplementation into the
National Mid-Day-Meals Programmes (MDMP)”, 1996.
7.
Global Partner for Partnership for Child Development, Oxford University,
U.K. Executed a series of 4 research projects from 1993 to 1996.
8.
Consultancy for the Department of Women and Child, Ministry of Human
Resource Development, Govt, of India, 1994.
9.
Consultancy for UNICEF, Delhi and the Department of Women and
Child, Rajasthan (1992 - 1993).
EM
Mailing Address : Tara Consultancy Services, Saraswathi’,
124/B, Varthur road, Nagavarpalya, Bangalore 560093, India.
Ph : 91-80-5242999 Fax : 91-80-5288098
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