9654.pdf
Media
- extracted text
-
SUMMARY REPORT
OF THE
USAID ASSISTED ICDS IMPACT EVALUATION PROJECT IN
PANCHMAHALS (GUJARAT) AND CHANDRAPUR (MAHARASHTRA)
1984-1990
I
//to
c
BY
SUNDER GUJRAL
TARA GOPALDAS
Department of Foods and Nutrition
Faculty of Home Science
Maharaja Sayajirao University
Baroda
1991
1
USAID Assisted ICDS Impact Evaluation
CREDITS
Field Data Collection
I
Baroda Team
(Department of Foods and Nutrition, Faculty of Home Science and
Faculty of Medicine, M. S. University, Baroda)
ii)
II
Nagpur Team
(Department of Home Science and Indira Gandhi Medical College,
Nagpur University, Nagpur)
Data Processing and Report Preparation
Baroda Team
III Assistance/Advice in Survey Design
Dr Mary Ann Anderson,
Deputy Chief Health Service Division, Office of Health
Services Division, AID Washington, USA
1
r
USAID Assisted ICDS Impact Evaluation
HIGHLIGHTS OF THE FINDINGS
Marked improvement In the coverage of the target mother and
child population for ICDS service* was observed over the five year
period, but the coverage did not reach pre-set project targets.
Inspite of this, the Impact of the ICDS services In concert, resulted in
a substantial improvement In the survival, and health and nutritional
status of children and pregnant women.
Infant mortality was reduced by 35% In Panchmahals and by 33%
in Chandrapur and toddler mortality by 9% in Panchmahals and by
27% in Chandrapur. Furthermore, severe malnutrition in children 0-36
months of oge was reduced by 25% in Panchmahals and by 53% in
Chandrapur, The prevalence of moderate plus severe malnutrition
was reduced by 13% In Panchmahals and by 32% in Chandrapur. In
children 37-72 months of age, the decline in severe malnutrition was
36% in Panchmahals and 68% in Chandrapur. The decline In severe
plus moderate malnutrition was 9% and 29% In Panchmahals and
Chandrapur respectively. Major declines were also observed In
Vitamin A deficiency in children and iron deficiency in anemia in
pregnant women. These achievements are consistent with those
anticipated per the USAID Assisted ICDS Project goal in Chandrapur,
but fell short In Panchmahals with the exception of the decline In
infant mortality, due in part to severe drought which affected that
district
Since most of the pre-set goals of the USAID-ICDS model were
met, it needs to be supported and extended to other ICDS blocks In
the country. Greater efforts need to be made to assure near universal
coverage of priority g
vices in the ICDS programme in order to obtain the maximum benefit
from the inputs Invested.
L
2
USAID Assisted ICDS Impact Evaluation
The Integrated Child Development Serv;ces (ICDS) scheme initiated in 1975 by the
Government of India (GOI) in 33 blocks operates today in about 1952 blocks in different states
of the country. The ICDS is a multi-sectoral program which delivers a comprehensive package
of services to children and their mothers population through village based centres called
Anganwadis (AWs). One AW center caters to a population of about 700 and 1000 in tribal and
rural areas respectively.
The United States Agency for International Development (USAID) as an independent
bilateral donor organisation assisted the Government of India to introduce innovative inputs into
the ongoing ICDS program in two assigned districts namely, Panchmahals of Gujarat state and
Chandrapur of Maharashtra state in order to enhance the impact of ICDS on the nutritional status
and survival of children. The Foods & Nutrition department of M S University, Baroda was
commissioned to evaluate the success/impact of the USAID-assisted ICDS model over a six
year period (1984-1990) against pre-set project goals.
The features of the USAID Assistance designed to enhance the existing ICDS Scheme were;
Priority attention to regularly reaching most pregnant and nursing women and malnourished
children under three years of age with supplementary nutrition, health services and nutrition and
health education.
Enhanced nutrition and health education using social marketing approaches.
Better trained workers with essential skills primarily through Mobile-ln-Service Training.
Improved supervision through reducing the supervision to Anganwadi Worker ratio by half
(Panchmahals only).
Improved management information system, monitoring and evaluation.
Establishment of food processing plants to improve the quality of foods distributed for
supplementary nutrition.
The goal/sub-goal of the USAID project were:
1.
An average decline of 25% in the 0-11 months Infant mortality rate and of 33% in the 12-36
months toddler mortality rate in communities within six years after an AW is established.
2.
An average reduction of 50% in the prevalence of severe malnutrition in children 0-36 months
of age and of 35%
in severe plus moderate grades of malnutrition in communities within
4 years after an AW is established
Objectives of the Impact Evaluation Survey
1.
To estimate the coverage of malnourished children 6-36 months and pregnant and nursing
women by supplementary feeding and health check-ups.
2.
To estimate the coverage of children 12 to 72 months of age with Vitamin A prophylaxis.
3
3.
USAID Assisted ICDS Impact Evaluation
To establish the coverage of pregnant women with two doses of tetanus toxoid, 3 months
supply of iron and folic acid and delivery by a trained person (dai, female health worker etc.)
4.
To determine the coverage of mothers of malnourished children and pregnant and lactating
women with Nutrition Health Education (NHED)
5.
To determine the changes in nutritional status and child mortality status every two years in
Panchmahals and Chandrapur.
6.
To measure changes in nutrition knowledge and behaviour.
7.
To determine the extent of prevention of malnutrition in younger children enrolled for
supplementary feeding and/or whose mothers who received NHED.
8.
To verify the data collected by Management Information Systems.
The impact evaluation was conducted over a 6-year-period from 1984-1990. The data were
collected from 3-7 randomly selected AWs in each of the 19 blocks (all 11 blocks in Panchmahals
and all 8 blocks in Chandrapur). In all, 93 AWs (51 AWs in Panchmahals and 42 in Chandrapur)
were sampled. The entire population was surveyed within an AW area. Details of the surveys
conducted are outlined below.
Year
Survey Title
Survey code
1984- 85
Baseline
B
1985- 87
First Follow-up
F1
1987-88
Second Follow-up
F2
1989-90
Third Follow-up
(Final Survey)
F3
Survey was not conducted in the year 1988-89 because of the delay in implementation of
USAID inputs by the said state governments.
For the sake of brevity, the above survey codes will be used through the report.
The final round of the survey was conducted in 1989-90, which had been preceded by three
years of unprecedented drought for many states in India. The intensity of the droughts effect
was more stark in Gujarat state as severe drought conditions prevailed for three consecutive
years from 1985 through 1987. Maharashtra suffered from mild drought only in 1987. The
impact of the programme must therefore, be viewed keeping in mind the aftermath of the drought
on the socio-economic, nutritional and health status of the ICDS communities.
Data were collected on coverage for various services offered under ICDS viz. immunization,
health check-ups, nutrition supplementation, iron/folic acid tablets distribution, Vitamin A
4
USAID Assisted ICDS Impact Evaluation
prophylaxis and nutrition health education. The impact of these services was evaluated by
measunng the nutritional and health status of women and children.
By design data were collected on ICDS beneficiaries viz. children 0-72 months of age
pregnant women and nursing mothers upto 6 months postpartum. The data were collected by
medical/non-medical investigators from M S University of Baroda in Panchmahals and by similar
type of investigators in Nagpur University and Indira Gandhi Medical College in Chandrapur.
The investigators underwent 3 days intensive training before they were sent to the field.
Data cleaning, processing and analysis were done on an IBM Compatible PC/XT at the
Department of Foods and Nutrition., Faculty of Home Science, M S University of Baroda. Details
of the sampling procedure and other methodological aspects of the evaluation are found in the
final report (1991) of USAID Assisted ICDS Impact Evaluation Project.
The present summary report contains the major findings of the final survey (F3) as compared
to the findings of the baseline survey (B) after a period of five years. The findings of the F3 will
be discussed according to the service components of the ICDS under the following heads.
1.
Coverage of women and children under health and nutrition services viz. Immunization
health check-ups, Vitamin A and anemia prophylaxis, antenatal and postnatal health
services for pregnant and lactating women, supplementary nutrition for children, pregnant
and lactating women and nutrition health education for mothers.
2.
Impact of nutritional and health services on nutritional and health status of women and
children viz. infant and toddler mortality, nutritional and health status of children, pregnant
and lactating women and nutrition and health knowledge of mothers.
3.
Nutrition and health knowledge of AWW and her performance at the AW.
Sample size
The population covered was 28,815 and 29,163 in Panchmahals and 29,466 and 29,780 in
Chandrapur at B and F3 respectively (Table 1). The proportion of 0-72 months children, pregnant
and lactating women was consistent with expected demographic norms.
Demographic and socioeconomic characteristics of the population
The economic status of the population improved in both districts over the five year period
that elapsed between B to F3 (Table 2) attributable to the rise in wages and the relief works
provided by GOI during the drought. Consequently, there was an increase in the population
above the poverty line. The per capita monthly income of the families when corrected for inflation
over the five year period exhibited no increase in family income in Panchmahals and of only 28%
in Chandrapur. A shift in the major occupation of agriculture to non-agnculture was observed in
Panchmahals indicating that farmers were reverting to the relief works, possibly due to their
apprehension that the drought may strike again and their subsistance livelihood from agriculture
may at anytime be jeopardized. The literacy status of mothers remained almost unchanged from
B to F3 in Panchmahals whereas in Chandrapur it showed a slight improvement. A smaller
5
USAID Assiated ICDS Impact Evaluation
proportion of mothers worked outside at F3 as compared to B in Panchmahals where as there
was no significant change in Chandrapur.
Coverage of children and women for nutrition and health services
Immunization
A significantly more children upto 12 months (Figure 1a) were immunized at F3 than at B in
both the districts by mother’s recall as well as by AWW’s records (Figure 1b). However,
recorded data show that 2 to 3 times more children were immunized as against recall data.
Similar observations were made in children 11-23 months of age (Figure 1c and 1d). The
maximum coverage was for BCG vaccine. The immunization coverage by health records was
comparable with that reported by Tandon (1990) and as expected, was higher than the coverage
in the non-ICDS blocks (Figure 1e). The Universal Immunization Programme (UIP) which was
introduced in 1985/86 in Panchmahals district and 1986/87 in Chandrapur district is largely
responsible for this improvement However, the coverage for immunization remained below the
target of 100% , especially in Panchmahals.
Motivation of parents to get their children immunized and educating mothers regard
ing the danger of the six fatal vaccine-preventable diseases Is needed to improve the
coverage, and to meet the target of 100% for immunization. In addition, the polio
Immunization schedule needs to be reworked as it has been reported that the unprotected
newborn period leaves more children susceptible to pollomelitus during the first three
months of life.
Health check-ups
Health functionaries like the Auxiliary nurse midwife (ANM) are expected to give health
check-ups to children 0-72 months of age at least once a month. A significantly higher proportion
of all children as well as those who were malnourished received 1 to 3 or more health check-ups
in the past three months at F3 as compared to that at B in both districts (Figure 2). This could
be attributed to the notable improvement in ANM visits to the Anganwadi (Only in Chandrapur)
in the past three months from B to F3 (Figure 3). However no differences were observed between
the percentage of younger (0-36 months) and older (37-72 months) children who received health
check-ups. Also equal proportion of malnourished and all children received health check- ups.
These data indicate that younger/malnourished children did not receive health check-ups on
priority basis as expected. The significant improvement in coverage of children for immunization
discussed earlier may also be attributed to the increased health check-ups and notable
improvement (Figure 3) in ANM visits to the AW (only in Chandrapur) in the past three months
from B to F3.
Health functionaries specifically of Panchmahals need to be motivated to make more
frequent visits to Anganwadls and priority be given In providing health check-ups to
younger/malnourished children.
6
USAID Assisted ICDS Impact Evaluation
Vitamin A prophylaxis
The National Vitamin A Prophylaxis programme provides oral mega-doses of vitamin A
semi-annually to children 12-72 months of age. A significant improvement from B to F3 in the
proportion of children who received mega-doses of vitamin A by both recall and AWW and health
centre records has been observed from B to F3 (Figure 4). The change in the distribution
guidelines introduced by the Ministry of Human Resource Development between B and F3 which
allows AWWs to distribute vitamin A might have contributed to the improvements observed in
coverage for vitamin A However, only 23% of children in Panchmahals and 41 % in Chandrapur
had received one or two doses of vitamin A at F3.
Perhaps, proper orientation to the staff concerned, preparation of the community for
utilizing the programme effectively, Improving nutrition knowledge of mothers and
ensuring that Vitamin A supplies meet the requirements, may help In Improving the
coverage and consequently the Vitamin A status of children.
Participation in supplementary nutrition by children and
pregnant/lactating women
Supplementary nutrition is provided by USAID through CARE under the label of PL 480 Title
II to malnourished children, pregnant and lactating women (upto 6 months postpartem) at the
AW under the ICDS programme. One of the objectives of the US AID-assisted ICDS project was
to attain at least 85% participation in supplementary feeding by malnourished children under
three years of age and the pregnant and lactating women.
Children: A definite age gradient (Figures 5a and 5b) was evident in the participation of
children in supplementary nutrition at the AW with maximum participation of the ‘above threes’
in both the districts (66% in Panchmahals and 86% in Chandrapur).
Supplementary nutrition at the AW is provided to 6-72 months old children and pregnant/lac
tating mother for 25 days in a month and 300 days in a year for the most part on-site. On an
average children received supplementary nutrition for over 21-22 days at B and 18-19 days at
F3 in Panchmahals (Figure 5c) and 19-20 days at B to 20-22 days at F3 in Chandrapur (Figure
5c) by mothers’ recall. The attendance (days) for supplementary nutrition between ‘under* or
'above threes’ did not vary. The recorded data (Figure 5d) were comparable with the recall data
for attendance (days)in supplementary nutrition. These data show that the children are not
attending the AW for the supplementary nutrition for the number of days they ought to attend in
a month. Also equal proportion of malnourished and normal children of 6-36 months of age
participated in supplementary nutrition in both districts. The participation by malnourished
children 6-36 months fell short of 40% in Panchmahals and 20% in Chandrapur in meeting the
project target of 85% (Figure 6).
There is a need for food at the AW to be prioritized first for the ‘below threes’ rather
than to the ‘above threes’. Also, mothers need to be motivated to bring or send their
7
USAID Assisted ICDS Impact Evaluation
children to the AW for supplementary nutrition. Further, It is desirable that the food when
cooked is of low viscosity but high nutrient density.
It appears that if children participate In supplementary nutrition then they become
available to receive other health services. In the present study a significantly higher
percentage of children who participated In supplementary nutrition received health
services than those who did not (Table 3a). Also literacy status of mothers appears to
affect delivery of nutrition and health services. More children of literate than Illiterate
mothers participated In supplementary nutrition and received Vitamin A, Immunization
and health check-ups (Table 3b) in Panchmahals where literacy rates were very low. In
contrast, in Chandrapur where literacy rates are much higher this effect was only seen
on immunization.
Pregnant/Lactating women : Although participation of pregnant and lactating women in
supplementary nutrition improved from B to F3, neither in Panchmahals nor in Chandrapur the
participation reached the target of 85% (Figure 7). The gap between the target and the actual
participation in supplementary nutrition was larger in Panchmahals than in Chandrapur. The
findings thus suggest that the coverage of priority groups with supplementary nutrition was much
higher Chandrapur than in Panchmahals.
The average participation of pregnant women in supplementary nutrition was for not more
than 3-4 months as against a possible 6-9 months. As per the revised guidelines of the GOI,
pregnant women are eligible for the nutritional supplement from the time they know they are
pregnant. Therefore, theoretically they could have participated in ICDS services throughout their
entire pregnancy period.
The average participation of lactating women in supplementary nutrition during their preg
nancy and lactation period, was not more than seven to eight months.
Pregnant and lactating women need to be motivated to come to the AW for nutritional
supplement s or alternatively a lake home’ food supplement needs to be Introduced.
Home visits by AWW
In addition to four hours of work at the AW, the AWW is expected to make ‘home visits’
during which she counsels mothers, weighs children, provides health care to malnourished
children and encourages increased participation at AW. Malnourished children under three
years of age are considered a priority group for home visits as both counselling and Growth
Monitoring (GM) are of great importance in this group. In Panchmahals the percentage of
malnourished younger (0-36 months) and older (37-72 months) children visited at home by
Anganwadi workers atieast once in the past three months increased from 2% to 33% and 6% to
29% respectively from B to F3. In Chandrapur the increase in the percentage of malnourished
children who received home visits was from 29% to 49% in 0-36 months old and 29% to 46% in
above threes. It was encouraging to note that larger percentage of younger (0-36 months) than
older children received home visits at F3. Also in Chandrapur, larger proportion of malnourished
than normal children were visited at home (Figure 8). This could in part, be the reflection of
8
USAID Assisted ICDS Impact Evaluation
increased supervision and support that the AWs received from Mukhya Sevikas (MS) (Figure
9). The percentage of children visited at home by AWWs at least once in the past three months,
increased from 3% to 35% (0-36 months) and 6% to 30% (36 months) in Panchmahals and 31 %
to 46% (0-36 months) and 29% to 43% ( 36 months) in Chandrapur (Figure 9).
Antenatal and postnatal health services for pregnant women
The antenatal and postnatal health care provided to women includes immunization against
tetanus (two doses of tetanus toxoid during the second and third trimester at an interval of one
month), health check-ups by ANM/LHV/Doctor and a daily supplement of 60 mg elemental iron
and 0.5 mg of folic acid for 100 days during second and third trimester of pregnancy under the
National Anemia Prophylaxis Programme.
Tetanus Toxoid (TT)
The percentage of lactating women during pregnancy immunized with tetanus toxoid was
significantly higher at F3 as compared to at B (Table 4a) in both districts by recall as well as
AWW and health records.
Antenatal Health check-ups
The ANM/LHV/Doctor is expected to provide pregnant women with make a minimum of 4
antenatal check-ups per the ICDS guidelines. A small but significant increase was observed in
both Panchmahals and Chandrapur districts in the percentage of women who received antenatal
check-ups from B to F3 (Table 4a). Since a larger percentage of health-check-up-receivers’
had received TT and Fe/FA tablets in both districts (Table 4b), it suggests that efforts to improve
the frequency of health check-ups would automatically improve the delivery of other antenatal
health services.
Thus, stress should be laid on early and regular antenatal check-ups to detect high
risk pregnancy for appropriate care and provision of referral services at the AW.
Postnatal Health check-ups
Postnatal health check-ups (Table 4a) both within 10 days and 6 weeks after delivery
significantly improved over the five-years-period. However, this component of health services
needs to be strengthened as less than of 20% women had received health check-ups within 10
days or 6 weeks after child birth at F3.
Referrals to PHC by AWW
The actual number of children, pregnant and lactating women who were referred to the PHC
or hospital in the past month remained less than 2 in both districts (Table 5).
1
9
Impact of ICDS services on
USAID Assisted ICDS Impact Evaluation
nutritional and health status of women and
children
Infant (IMR) and toddler (TMR) mortality
In Panchmahals, IMR decreased by 9% and TMR (12-36 months) by 35% from B to F3
rr^hiP 61 Likewise in Chandrapur, the decrease' in IMR and TMR was 27% and 38%
(Tab1® 6)- Ljh®*1S
|Mr ln Chandrapur and of TMR In both Chandrapur and
P SPrhmahals met the USAID -aaalated ICDS target of 25% decline In IMR and 33% decline
i^TMR (within six years of an AW being established). The decline In IMR and TMR was
attributed to improved coverage of mothers and children for nutrition and health services.
Morbidity status of children
The prevalence of various morbidities (measles, pneumonia, polio, worms and diarrhea) in
children did not appreciably decline in Panchmahals; rather it showed an upward trend (Tab e7b
morbidities.
Th. decline in
nwibidilies in Chand.epu, was ellnMed »
and due to beiier coverage <« immunisaton. health check-ups and incased ANM visits to AWs
and possibly due to increased coverage with Vitamin A prophylaxis.
It is suggested that mass deworming be inciuded in the ICDS. AWs may make better
use of the simple generic drugs and first aid kits to combat common maladies. In addition
mothers could be educated about the adverse effects of worm InfestaUon on the growth
of their children and the Importance of diarrhea preventing measures such as observing
□ersonal hvglene maintaining environmental sanitation and providing clean food and
water to thei children. These measures may further help In curtailing the prevalence o
various morbidities.
Nutritional and health status of children
Prevalence of Vitamin A deficiency
Ocular sions of Vitamin A deficiency in children reduced significantly in both districts (Figure
of children with mega-doses of Vitamin A. This hypothesis is supported by the fact that of me
Vitamin A deficient children while 20% had received one dose and 16% had received two dose ,
64% were those who had not received Vitamin A (Figure 11b).
10
USAID Assisted ICDS Impact Evaluation
However, the risk factors for nutritional blindness appear to be:
a)
poor nutrition knowledge among mothers;
b) maternal illiteracy;
c) practice of feeding children less than 3 times a day (Table 8a); and
d) prevalence of malnutrition, measles and anemia (Table 8b).
These findings suggest that In addition to the Improvement In coverage for Vitamin
A prophylaxis, efforts to Improve nutrition and health knowledge of mothers and nutri
tional status of children would further help In reducing the prevalence of Vitamin A
deficiency.
Nutritional anthropometry
In Panchmahals as well as in Chandrapur the proportion of children 0-36 months of age
(Figure 12a) and 37-72 months of age (Figure 12b) who were severely malnourished (IAP
classification, normal : > 80%, First: 71-80%, Second : 61-70%, Third : 51-60%, and Fourth :
<51% and NCHS median wt/age) significantly decreased and that of mildly malnourished
increased at F3 as compared to at B. Chandrapur met the project goal of 50% reduction in the
prevalence of severe malnutrition in children 0-36 months and nearly met the goal in moderate
plus severely malnourished children (within 4 years after an AW is established). The reason for
less impact in Panchmahals may have been drought. The decline in malnutrition however was
higher in above threes than below threes in both districts. This could be the reflection of higher
participation in supplementary nutntion of above threes versus below threes.
Waterlow’s (1972) classification of 0-36 months children into normal, wasted, stunted and
wasted + stunted categories using a combination of two indicators viz. weight for height and
height for age showed an increase in the prevalence of stunting from 28% to 35% and a decrease
in that of wasting from 17% to 15% in Panchmahals from B to F3 (Figure 13a). Similar findings
were observed in Chandrapur but the increase in the prevalence of stunting was of a smaller
magnitude (35% to 41% Vs 28% to 35%) and the decrease in that of wasting was of a higher
(11% to 6% Vs 17% to 15%) magnitude as compared to those observed in Panchmahals. The
decrease from B to F3 in the prevalence of wasting + stunting was from 10% to 7% in
Panchmahals and from 11 % to 5% in Chandrapur children. The relatively better nutritional status
of Chandrapur versus Panchmahals children may be attributed to their relatively higher coverage
for nutrition and health services.
Similar analysis for 37 to 72 months old children (Table 13b) revealed that the prevalence
of stunting increased from 40% to 42% while that of wasting decreased from 12% to 10% in
Panchmahals from B to F3 . In Chandrapur, on the other hand, a smaller proportion of children
were stunted at F3 than at B (51% Vs 56%). The decrease in the prevalence of wasting plus
stunting was from 10% to 8% in Panchmahals and from 11 % to 6% in Chandrapur children. The
proportion of children in normal category increased from 38% to 41% in Panchmahals and from
26% to 37% in Chandrapur. These differences in anthropomatry remained even after adjusting
for family income, sex, age, birth order, birth interval, maternal literacy and maternal employement status. The scarcity of food for a prolonged period of time in the drought conditions that
I
11
USAID Assisted ICDS Impact Evaluation
had prevailed for more than three years from 1986-88 specifically in Gujarat appear to have
affected linear growth in children. These findings suggest that increased partapation in sup
plementary nutrition and the receipt of other health services perhaps helped children to at least
maintain their weights.
Table 9a shows a higher proportion of children 0-36 months, who had received health
check-ups were in a normal category by wt/age and Wage criteria only in Panchmahals. Such
effects of health check-ups were not observed in Chadrapur children. Also equal proportion of
children were morbid in the past year who received or did not receive health check-ups. Perhaps
health check-ups were provided to only morbid children.
The data were also analyzed to evaluate the impact of nutrition and health services on the
nutritional status of the children. Table 9b shows that a higher percentage of children who
received either health or health plus nutrition services were nutritionally superior as assessed
by percent of NCHS median Wtfage, to those who received none of the services.
Mothers knowledge of basic nutrition and health measures strongly influences their child
care practices which, in turn, affect the nutritional status of their children, and a positive
relationship has been reported between socioeconomic status and the ability of mothers to
provide adequate food and primary care to their children. Therefore, an analysis of covariance
was used to determine the effect of mothers nutritional knowledge on nutritional status of their
children. Table 10 shows that in both districts the nutrition knowledge score of mothers
categorized into 0 to 4 and above (maximum score of 9) significantly associated witfi the
nutritional status of children although income and literacy status of mothers were significant
intervening variables.
The above finding# demonstrate that the Improvement In nutritional status of the
Chandrapur children was better than that of Panchmahal’s children. This was attributed
to the better coverage of health and nutrition services in Chandrapur as compared to
those In Panchmahals. Also, nutrition knowledge of mothers was found to be positively
related to nutritional status of their children. It Is suggested that nutrition and health
knowledge of mothers be Improved by strengthening the NHED component of the ICDS.
Nutritional and health status of pregnant and lactating women
Prevalence of anemia in pregnant women
The increased coverage for iron/folic acid tablets distribution and increase in number of
tablets received were reflected in a better hemoglobin (Hb) profile of pregnant women at F3 as
compared to that at B in Panchmahals (Figure 14). At F3 56% of pregnant women had an Hb
level above llg/dl as compared to less than 3% at B. In Chandrapur, the Hb level of 29%
pregnant women was above 11 g/dl at F3 (Figure 14); Ohemoglobin data were not available
for B.
12
USAID Assisted ICDS Impact EvaJuation
Risk status by anthropometry in pregnancy
,i!k ■,a,“,p0'
“b ™
proportion of women at risk by height criteria, declined by 13% in Panchmahals and 26/»
Chandrapur (Rgure 15). But by the criteria of weight, a significantly higher proportion of women
upto 20th week of gestation were at risk at F3 than at B in Panchmahals. In Chandrapur on the
other hand, a significantly smaller proportion of women upto 20th weeks of gestation were at
risk at F3 than at B. Beyond 20th weeks of gestation, no significant differences were observed
in the proportion of risk at women between F3 and B in both the districts.
The nutritional status of the women had notlmproved appreciably from B to F3. Efforts
should be made by the AWW to motivate pregnant women so that they attend the AW
a longer duration In their pregnancy period, which In turn, will help to Improver meir
nutrlttonal status. Measures should also be Introduced to Improve the nutritional status
of women prior to pregnancy, espedaly during adolescence.
Delivery assistance received by lactating women
to 40%) and Chandrapur (49% to 56%) districts.
AWWs’ characteristics and performance
NHED sessions held by the AWW and mother's attendance
One of the ICDS services is to provide nutrition and health knowledge to mothers through
monthly sessions held by AWW. In Panchmahals, sessions were held once in two months an
in Chandrapur, once a month at F3 (Figure 17). However, in both the districts iota
mothers attended the nutrition health education sessions. Also, a lower percentage of mother
attended the sessions when the sessions were held once a month than once in two months.
Thus the findings suggest that less frequently held sessions tend to attract more mothers.
Nutrition and health knowledge of AWWs and mothers
Nutrition knowledge of AWWs and mothers of 0-72 months old children was evaluated on
a set of 7 and 9 nutrition knowiedge questions respectively. A score of one was given to each
valid response. The nutrition knowledge score being an aggregate of all responses. F 9ure
shows that the AWW had adequate nutrition knowledge in both the districts attnbutable to the
Mobile-ln-Service Training and nutrition and health education conducted by framing sessions by
13
USAID Assisted ICDS Impact Evaluation
CP Trust and CHETNA respectively from 1987 to 1989. Although the nutrition knowledge of
AWWs was sound, it did not percolate to the mothers.
These findings Indicate that the knowledge of AWW Is not being transferred to the
mothers. It may be that mothers do not attend NHED sessions by choice or they do not
have time to attend the sesslone as they may have to forego the entire day’s work which
means losing earnings of that day. It may also be that the AWWs lack counselling skills
which aid In Imparting knowledge. Efforts must be made to improve counselling skills of
AWW’s through NHED component of ICDS scheme. Also, mothers need to be motivated
to receive the counselling.
AWWs and mothers’ knowledge of Oral Rehydration Therapy (ORT) in diarrhea
management
All the AWWs but fewer than 30% of the mothers were aware of ORT at F3 (Table 11). The
knowledge of AWWs to correctly prepare ORS improved significantly from B to F3 but, no
appreciable changes were observed in the ability of mothers to prepare ORS. Fewer than 40%
mothers could prepare ORS correctly.
Growth Chart knowledge of AWWs and mothers
One of the activities of the AWW is to monitor the growth of children 0-72 months of age by
monthly weighing. The AWW also maintains Growth Charts (GO) for each child at her AW.
Although nearly 100% of AWWs were knowledgeable about growth charts, this did not benefit
mothers as only 3% of mothers in Panchmahals and 2% in Chandrapur could correctly interpret
2 of the 3 charts shown to them (Figure 19).
Perhaps AWWs need specific training to increase their counselling skills. Also,
mothers need to be motivated and prepared to receive the counselling. It should be
stressed that training to mothers in preparation of ORS needs to be continually re-inforced
and one-time training Is Insufficient
Growth Monitoring by AWW
A significant improvement in the Growth Monitoring (GM) or weighing activity of the AWW
was observed from B to F3 (Figure 20). This was revealed by the significant increase in the
proportion of children with an up-to-date, accurately plotted GO (accuracy was determined by
comparing the children’s most recent weight recorded on Growth Charts with those taken by the
investigators) in both the districts. Also, the proportion of children whose GC were maintained
(both accurately and inaccurately) increased from 10% to 46% in Panchmahals and 2% to 63%
in Chandrapur.
Although the growth monitoring activity by AWW was being performed more efficiently at F3
than at B, the knowledge of mothers regarding it remained poor, thereby, limiting its beneficial
impact on the nutritional status of the children.
14
USAID Assisted ICDS Impact Evaluation
Illiteracy among rural and tribal mothers appears to be one of the greatest obstacles
for growth monitoring to be used as an educational tool to counsel mothers regarding
the present nutritional status of the child and steps required for Its improvement It may
also be that the functionaries are not adequately trained to act as facilitators who can
Involve themselves In problem-solving dialogue and not Just be the purveyor of mes
sages.
Determinants of AWWs’ performance
AWWs performance was evaluated in terms of the coverage of children for nutrition and
health services in relation to her education level, knowledge of nutrition and guidance received
by her from ANM. It appears that three factors viz. the nutrition and health knowledge of the
AWW, the ANM’s regular visits to the AW and the educational level of the AWW alone or in
combination determined the AWWs performance in terms of coverage of the target child
population for various nutrition and health services. The coverage was two-to-four fold higher if
the AWW had an adequate nutrition knowledge or was receiving regular guidance from frie ANM
(Table 12). The performance of the AWW further improved if along with adequate nutrition and
health knowledge, her education level was above high school. The coverage of the child
population for various nutrition and health services increased from two to twenty four fold if all
these three factors were satisfied.
It Is suggested that the AWW must receive regular guidance from the Mukhya Sevlka
(MS)/ANM. She should have adequate nutrition and health knowledge and her education
level should be of high school or above.
The AWW, ANM, Village Health Guide VHG, MS, Child Development Program Officer
(CDPO) and District Program Officer DPO should work in concert in order to provide multiple
services of health, nutrition and education at the AW. Refresher courses for all these
functionaries are therefore, essential to improve their work efficiency. In Panchmahals because
of the lower AWW to MS ratio (10.4:1), the AWWs received more supervisory assistance than
the AWWs in Chandrapur where the ratio stood at 18.0:1 as of March 1990. There seems to be
a considerable need for further improvements in the training programme. There should be
uniformity in methodologies of training and the material used during training. The AWWs should
be provided with the same materials to be used at the AWs as was used during their training
programme. Refreshers, orientation courses and in-service training especially in the areas
where AWWs, with their minimal educational qualification, feel less confident, will surely improve
the efficacy of services delivered at the AW.
Data presented in this summary and in the detailed final report can be used to verify the
monthly progress report data from the CDPO, presented in the ICDS Management Information
Systems.
USAID Assisted ICDS Impact Evaluation
15
Table 1
I
Demographic break-up of the population
Panchmahals
N
%
N
%
F3
B
F3
B
Characteristics
Chandrapur
%
29780
29466
29163
N
%
N
Total population
28815
Children 0-72 months
5045
17.5
4923
16.9
4343
14.7
4301
14.4
Pregnant women
294
1.0
380
1.3
352
1.2
321
1.1
Lactating women
567
2.0
515
1.8
490
1.7
413
1.4
Demographic norms :
Children 0-72 months : 17% of total population
Pregnant and Lactating women : 2% of total population
Table 2
Socioeconomic characteristics of the population
Chandrapur
Panchmahals
Characteristics
B
F3
B
F3
Per-capita average monthly
income (Rs)
62
88
(61)
65
120
(83)
Above poverty line (%)
28
42
30
68
Agriculture
59
35
39
37
Non-agricultural
14
22
25
18
Other
27
43
37
Literate mother (%)
7
26
Mothers work outside (%)
53
8
32’
45
30*
69
68
Occupation
() Adjusted to baseline year 1984 = 100
Povery line :
B - Rs. 65/- per capita per month (Source Health statistics, Gujarat 1984)
F3 -Rs. 68/- per capita per month (Source VII five year plan document
Volume II, page 55, 1985-90)
Chi-square (B Vs F3)
*P <0.001, "p < 0.0001
USAID Assisted ICDS Impact Evaluation
16
Figure la
Immunization coverage of children Recall
(0-12 months)
Follow-up3
■ Baseline
Chandrapur
Panchmahals
100T
%
80--
70 ♦
C
o
60--
1
V
e
r
e
d
40-■
36 ♦
31 •
33 ♦
22
20-0
19
13
11 ♦
3
1
0
Polio
BCG
0
-----
+
4--------
DPT
51
■
Measles
3 doses 3 doses
DPT
Polio
BCG
Measles
3 doses 3 doses
♦ P < 0.0001
Figure 1b
Immunization coverage of children-Record
(0-12 months)
■ Baseline
100T
%
80-
C
o
60-■
Chandrapur
Panchmahals
83 ♦
61 ♦
■
52 ♦
V
e
r
e
d
Follow-up3
38 *
40--
42
20-■
9
0
DPT
Polio
3 doses 3 doses
0
4----Measles
BCG
I
DPT
54 ♦
■
9
5
i ----0
Polio
3 doses 3 doses
♦ P < 0.0001
44
BCG
Measles
USAID Assisted ICDS Impact Evaluation
17
*
Figure 1c
Immunization coverage of children—Recall
(12—23 months)
■ Baseline
BO-
C
o
60-
Chandrapur
Panchmahals
100T
%
Follow-up3
85 ♦
61 t
61
56 •
50 ♦
V
e
r
e
d
40-■
29
21 •
20--
2B
19 ♦ ■
6
3
22
1B
0 YMKA |
-------
0
DPT
Polio
3 doses 3 doses
BCG
4
DPT
Polio
3 doses 3 doses
♦ P < 0.0001
Measles
Measles
BCG
Figure Id
Immunization coverage of children—Record
(12—23 months)
■ Baseline
Follow-up3
Chandrapur
Panchmahals
100T
%
C
o
v
e
r
e
d
91 ♦
86
■
BO-
69 ♦
65 •
67 ♦
63 ♦
60--
1
53
40 7
15
13
20-■
5
0
DPT
Polio
3 doses 3 doses
0
4---Measles
BCG
14
DPT
Polio
3 doses 3 doses
♦ P < 0.0001
14
0 ®4
4-------
BCG
Measles
USAID Assisted ICDS Impact Evaluation
18
Figure 1e
Immunization coverage of children—Record
(0—72 months) .
10D-r
■ Non-ICDS—
Tandon
1990
■ ICDSTandon
1990
ICDS—
Chandrapur
■ ICDS—
Panchmahals
Panchmahals
91
90
86
86
80
80-6
%
C
o
v
e
r
e
6
6<
5J
52
|4'
I
4!
tI
41
d
2
B
1
2i
Polio
3 doses
51
42
I
J
I
440
24
I
19
0 0
DPT
3 doses
I
BCG
+
DPT
3 doses
Polio
3 doses
BCG
Children 0-36 months
Children 0-72 months
Tandon (1990) : Evaluation and Research 1975—1988.
Central Technical Committee. All India Medical Sciences
Ansari Nagar, New Delhi
USAID Assisted IGUS impact tvaiuaiion
19
1
Figure 2
Health check-ups received in past 3 months
by children (0-72 months)
E] Follow-up3
■ Baseline
80--
Chandrapur
Panchmahals
100T
0-36 months
37—72 months
0—36 months
37-72 months
60-%
37 ♦
40-■
20-- 14
0
36 ♦
34 ♦
38 ♦
37 ♦
35 ♦
36 ♦
19
15
+
+
All
Mai
All
Mai
a
All
. Mai
All
Mai
a
children children children children
children Children children children
Malnourished : <-70% NCHS median
weight for age
♦ P < 0.0001
Figure 3
ANM visits at Anganwadi in past three months
■ Baseline
12t
M
e
a
n
10--
v
i
6-
s
4
34 ♦
Follow-up3
Chandrapur
Panchmahals
8--
t
1
s
0
♦ P < 0.0001
1
20
USAID Assisted ICDS Impact Evaluation
Figure 4
Vitamin A received by children (12—72 months)
in past one year
■ Baseline
□ Follow-up3
100-r
Panchmahala
Chandrapur
Panchmahala
Chandrapur
80--
75 e
%
R
e
c
e
v
e
r
s
60--
40--
23 ♦
20--
8
0
Record
Recall
♦ P < 0.0001
USAID Assisted ICDS Impact Evaluation
21
Figure 5a
Participation in Supplementary nutrition
by children (6—72 months)
Follow—up3
■ Baseline
100T
scr
ee
eo
60--
58
48
%
4O-28
33
20-■
+
0
6-12
13-24
+
6-36
37-72
25-36
All children
Pan chm dials
Figure 5b
Participation in Supplementary nutrition
by children (6-72 months)
■ Baseline
100-r
□ Follow—up3
91
— 86
76
80-
80
76 76
65
59
56 H
60-
65
%
40-•
25
20--H
+
0
6-12
13-24
25-36
+
6-36
37-72
Chandrapur
All children
)*
)>
S'
USAID Assisted (CDS Impact Evaluation
22
Figure 5c
Attendance of children (6-72 months) for
supplementary nutrition during past one month-recall
■ Baseline
25T
Follow-up3
Pggchmahals
Chan^apiur
21
M
e
a
n
D
a
y
s
20-
18
18
19
18
20
20
22
20
15--
10-5--
0+
o
6-36
37-72
All children
6-36
37-72
All children
Figure 5d
Attendance of.children (6—72 months) for
supplementary nutrition during past one month—record
■ Baseline
25t
M
e
a
n
D
a
y
s
Follow—up3
Panchmahals
21
21
21
20--H
22
17
17
17
6-36
37-72
All children
Chandrapur
19
19
6-36
37-72
22
19
15-10--
5 -
+
All children
1
23
USAID Assisted ICDS Impact Evaluation
Figure 6
Agewise coverage (
of children (6—36_ months)
for supplementary nutrition at Follow—up3
□ Malnourished
100-r
□ Normal
Panchmahals
Chandrapur
Target
80--
69 «
67 ♦
65 «
60
%
c
51
o
V
e
r
e
d
46 ♦
45 ♦
59
■
46 ♦
39
■
34
28
i
2
a
»__
+
+
Sev-Mal Mod-Mal
Normal
+ Sev-Mal Mod-Mal------»__ 1
Normal
Severely malnourished children : < 60% NCHS median weight for age
Moderately malnourished children : 60-70% NCHS median weight for age
Normal children : > 70% NCHS median median weight for age
24
USAID Assisted ICDS Impact Evaluation
Table 3a
Difference in coverage for health services of 6-72 months old children by
participation in supplementary nutrition at Follow-up 3
Panchmahals
Chandrapur
6-36 months
37-72 months
6-36 months
37-72 months
Not
supp
Supp
Not
supp
Supp
Not
supp
Supp
Not
supp
Supp
%
%
%
%
%
%
%
%
DPT 3 doses
13
26
10
26
56
49
67
Polio 3 doses
11
24
9
22
52
64*
56
44
57
BCG
37
60
37
60
80
61
80
Measles
16
36
14
31
55
37
58
Vit A 2 doses
8
17
5
16
11
6
21
Check-ups
25
49
18
44
37
85*
64*
19*
40
16
32
GC accurate
13
40
6
30
43
57*
14
34
ORS pack received
4
19
3
19
29
43*
23
39
Services received
Chi-square (Supp Vs not supp)
*P<0.05
Table 3b
Difference in coverage of 0-72 months old children for nutrition and health services
by literacy status of mothers at Follow-up 3
Panchmahals
Services
Chandrapur
Illiterate
Literate
Illiterate
Literate
%
%
%
%
Supplementary nutrition
53
63*
73
63
Vit A prophylaxis
22
47**
39
38
Immunization
34
64**
76
90
Health check-ups received
36
54**
34
36
Chi-square (Illiterate Vs Literate)
*P < 0.05, ~P < 0.0001
USAiD Assisted ICDS Impact Evaluation
25
Figure 7
Participation in Supplementary nutrition
by Pregnant and Lactating women
■ Baseline
E3 Follow-up3
100-r
Target
85
80--
Chandrapur
Panchmahals
60--
%
40-33
25
20--
23
18
0
Pregnant
+ Lactating
Pregnant
Lactating
26
USAID Assisted ICDS Impact Evaluation
Figure 8
Home visits paid to Malnourished/Normal children
(0—72 months) by AWW in past three months
Malnourished
□ Normal
Panchmahals
60~ <= 36
mos
Chandrapur
> 36 mos
< = 36 mos
> 36 mos
Target
49
50--
45 ♦♦
46 **
42
I
%
33 ♦♦
V
35 ♦♦
r
■I
I
■I
I
32
32 ♦♦
29
s
29
t
e
d
40
I
29
I I
20--
6
6
3
(■- + + + + + + + + +
4
a
B
F3
B
F3
B
F3
Malnourished : <— 70% NCHS median Wt/age
♦♦ P < 0.001
• P < 0.01
B
i
F3
USAID Assisted ICDS Impact Evaluation
27
Figure 9
MS visits at Anganwadi in past one year
■ Baseline
100T
Follow—up3
Panchmahals
BO-
Chandrapur
74 ♦
61 ♦
X >= 10 60-Visits
36
40-20--
2
+
0-1----- 1
♦ P < 0.0001
Table 4a
Table 4b
Health Services received in pregnancy by
lactating women's recall and records
Iron folic acid and tetanus toxoid
received by pregnant women (third
trimester) in relation to antenatal
health check-ups at Follow-up3
Health Services
Panch
mahals
B
F3
Chandrapur
B
F3
Tetanus toxoid received (%)
Two doses
Recall
7
28
44 56
Record
2
10
11
58
Check-ups by
ANM\LHV\Doctor (%)
23*
Postnatally (10 days)
4
13*
47 51
11 17*
Postnatally (6 days)
4
13*
9
Chi-square (B Vs F3)
*P < 0.05, **P < 0.0001
Iron folic
acid tablets
%
20
79
21
79’
No (n=70)
53
51
Yes (n=51)
84*
77*
Panchmahals
No (n=115)
Yes (n=38)
15
Antenatally
Tetanus
toxoid
%
Health check-ups
15*
Chandrapur
Chi-square
‘P < 0.01, "P < 0.0001
USAID Assisted ICDS Impact Evaluation
28
Table 5
Referrals to PHC by AWW in past one month
Panchmahals
Chandrapur
Referrals (Mean)
B
F3
B
F3
Child
0.2
1.0
0.7
1.1
Pregnant/Lactating women
0.2
0.2
1.0
0.9
Table 6
Infant (0-12 months) and toddler (12-36 months) mortality rate
Panchmahals
Mortality rate in past one
year
Chandrapur
B
F3
Decline
B to F3 %
B
F3
Decline
B to F3 %
Infant mortality rate
Deaths/1000 live births
69
63
-9
82
60
-27
Toddler mortality rate
Deaths/1000 toddlers
17
11
-35
16
10
-38
I MR - Goal met in Chandrapur
TMR - Goal met in both the districts
Table 7
Morbidity among 0-72 months old children in past one year
Panchmahals
Chandrapur
B
F3
B
F3
%
%
%
%
Measles
17.0
15.5
21.8
14.9*
Pneumonia
6.5
13.5**
12.1
8.8*
Polio
0.5
0.4
0.5
0.2*
Worms
12.0
16.4**
19.8
12.8*
Severe diarrhea
37.7
38.2
54.1
36.4*
Morbidity
Chi-square (B Vs F3)
*P < 0.05, "P < 0.001
USAID Assisted ICDS Impac' Evaluation
29
Figure 10
Prevalence of pallor signs
in children (0-72 months)
■ Baseline
50 T
Follow-up3
Panchmahals
Chandrapur
%
P
r
e
v
a
I
e
n
c
e
40
40-33
30--
26 «
20--
10--
5 ♦
+
0-I----- 1
♦ P < 0.0001
Figure 11 a
Figure 11b
Vitamin A deficiency
signs present
Proportion of Vitamin A
deficient children in
relation to Vitamin A
doses received
■ Baseline
□ Follow-up3
2i
%
1
7I
X
Panchmabale
D
e
f
Chondropur
12
1
64
6I
0
f
c
c
n
t
e
n
t
1 ♦
'///////////z.
♦ P < 0.0001
2I
20
16
1
None
One tfaee Two doooi
Data of Panchmahale and
Chandarpir were pooled to avoid
skewness
USAID Assisted ICDS Impact Evaluation
30
Table 8a
Risk factors of nutritional blindness3 : Maternal factors at Follow-up 3
Prevalence of Vitamin A deficiency
Factors
N
%
23
265
4*
59
229
4
8
71
217
8*
Nutrition knowledge scoreb
> 3 (n=570)
<= 3 (n=4051)
7
Frequency of feeding children
> 3 times/day (n=1648)
<= 3 times/day (n=2973)
Literacy status
Literate (n=882)
Illiterate (n=3739)
Chi-square
6
><0.05, *><0.0001
adata of Panchmahals and Chandrapur were pooled to avoid skewness.
bMaximum score=9
Table 8b
Risk factors of nutritional blindness3 : Child factors at Follow-up 3
Prevalence of Vitamin A deficiency
Factors
Nutritional status
> 60% NCHS median wt/age (n=7028)
<= 60% NCHS median wt/age (n=573)
N
%
518
26
7*
100
435
172
363
229
317
9*
5
Morbidity status
Measles
Yes (n=1149)
Diarrhea
No (n=6444)
Yes (n=2843)
No (n=4750)
Anemia
Yes (n=1165)
No (n=6501)
chi-square
><0.05, **P< 0.0001
adata of Panchmahals and Chandrapur were pooled to avoid skewness.
7
6*
8
20*1
5
31
USAID Assisted ICDS Impact Evaluation
Figure 12a
Nutritional Status by weight for age index
IAP classification of 0—
— 36 months old childi
children
■ Baseline
□ Follow—up3
Panchmahals
50t
40--
Chandrapur
36
34
30-2526
30 31
29® 30 28
%
33
2i
20--
14
13
H7
104-
3 2
0
Normal
Fir>t
Second
Third
Fourth
+
+
Normal
First
Malnutrition decline
Severe 36%
Severe+moderate 13%
Second
Third
Focrth
Malnutrition decline
Severe 56%
Severe+moderate 28%
Figure 12b
Nutritional Status by’ weight for age index
IAP classification of
.. 37
_.'-72 months old children
■ Baseline
50t
O Follow—up3
Panchmtfials
Chanckapur
42
40-■
36
33
32
30 •
%
Covered
19
20 ’■16
12
10-
■8
2 1
Normal First Second Third
Fourth
+
Malnutrition decline
Severe 25%
Severed- Moderate 13%
2 1
+
Normal First Second Third Fourth
Malnutrition decline
Severe 53%
Severed Moderate 32%
a c/?/
) J
S(
5
09654
* 1\
>
USAID Ass.sted ICDS Impact Evaluation
32
Figure 13a
Nutritional status by combined weight for height and
height for age indices-Waterlow. classification of
0—36 months old children
Follow-up3
■ Baseline
60t
Chandrapur
Panchmahals
50--
45 45
41
40-%
35
35
28
30--
20-10--
04-
11
10
+
W+S
Wasted Stunted
Normal
5
■ 6
w+s
Wasted
Stunted
Normal
Figure 13b
Nutritional status by combined weight for height and
height for age indices-Waterlow of classification of
37-72 months old children
■ Baseline
□ Follow—up3
Chandrapur
Panchmahals
■O-r
56
51
90- -
40
40- -
42
41
38^
26
X Covered so- ■
20- ■
10-
o
10
12
8
11
10
■ 6
------------- J.
W+S Wasted Stunted Normal
W+S Wasted Stunted Normal
Wasted+Stunted : < 80% weight for height and < 90% for age NCHS median
Wasted : < 80% weight for height and >- 90% height for age NCHS median
Stunted : < 80% weight for heic^t and > 90% heidit for age NCHS median
Normal : >-80% wel^t for hei^it and >- 90% height for age NCHS mediar
33
USAID Assisted I CDS Impact Evaluation
Table 9a
Nutrition and health status of 0-36 months old children
by health check-ups at Follow-up 3
Panchmahals
Nutrition and health
status
Health
check-ups
Chandrapur
No health
check-ups
Health
check-ups
No health
check-ups
N
%
N
%
N
%
N
%
Malnourishedii
278
466
535
739
42
58
264
457
37
63
408
834
33
Normal
37
63*
46
608
666
643
631
48
52
51
49
404
317
381
340
56
44
53
47
663
579
660
582
53
Weight for age
67
Height for age
Malnourished'.2
Normal
Morbidity present3
339
405
384
360
54
52
47
53
48
47
Morbidity absent
1 Malnourished : < = 70% NCHS median weight for age
2Malnourished
I
: < = 90% NCHS median weight for age
3Morbid : Having one or more morbidities in past one year- Pneumonia, Measles, Diarrhea, Polio,
Worms infestation.
The analysis was done only for those children whose data on health check-up, anthropometry and mor
bidity were available.
‘P <0.05
Table 9b
Effect of various services on nutritional status as assured by percent of
NCHS median weight for age of 0-72 months old children at Follo-up3
Panchmahals
Mean weight as percent at median
Services received
Health services : Immunization
+ Check-ups + Vitamin A
Health + Nutritional services :
Immunization + Check-ups +
Vitamin A + Supplementary
Nutrition
Chandrapur
Unadjusted
Adjusted®
Unadjusted
Adjusted®
73.9
74.3
74.6
74.6
76.9
71.4
79.6
70.9
73.4
72.5
73.7
None
T‘Adjusted for family income and maternal literacy
Kruskal-Wai listest
Chandrapur: Services
* P < 0.05
71.9
USAID Assisted ICDS Impact Evaluation
34
Table 10
Association between mothers nutrition knowledge and then children’s nutritional
status as assessed by percent as NCHS median weight for age at Follow-up3
Panchmahals
Nutrition
knowledge score
Chandrapur
Mean weight as percent at median
Unadjusted
Adjusted®
Unadjusted
Adjusted®
1
72.7
73.8
70.6
72.9**
75.7
2
76.2
75.0
76.2*
3
76.8
78.9**
77.1
77.8*
______ ^4
78.0
81.2**
78.0
79.4*
Adjusted for family income and maternal literacy
Kmskal-Wallistest
*P < 0.01, “ P < 0.0001
Figure 14
Mean Fe/FA tablets
received by pregnant
women
Percent prevalence of
anemia Ac coverage for
Fe/FA of pregnant women
■ BoMlIrw
Panchmaholi
P
r
a
v
a
I
n
c
e
Ponchmohalo
80-
80 ■
60-
M
e 60a
n 40-
46*
44^
4020-
48 *
37 ♦
33
25
29
28*
Chandrapur
lOOr
97
100r
%
Chandrapur
□ Follow—up3
20-
8
Fe/FA
0
----
Hb < Fe/FA+ Hb <
llg/dl
11g/dl
• P < 0.01
•• P < 0.0001
+
• P < 0.001
USAID Assisted ICD$ Impact Evaluation
35
Figure 15
Risk status of pregnant women
Follow--up3
■ Baseline
100T
Chandrapur
Panchmahals
B0--
74
M 68
59
60--
52
48 ♦
%
46 *
47
40-■
20
”
24
20-- 15
+
+
0
< 145 cm
<40 k
at <weeks
< 14 cm
>20 weeks
<40 k'
at <■ .
weeks
-So
mo
>20 weekf
Figure 16
Delivery assistance received by lactating women
■ Baseline
Follow-up3
Chandrapur
100-rpanchmahals
81
80- •
60 *
60-■
51
% Lactating
women
56 *
40 ♦
40-■
20-■
0
19
+
+
Untrained+other Trained+doctor
Untrained+other Trained+doctor
♦ P < 0.05
USAID Assisted ICDS Impact Evaluation
36
Figure 17
Number of NHED,.sessions held by AWW
ana mother s attendance
Mother’s attendance
Sessions held by AWW
■ Baseline
l&r
100r
9080-
13.6 ♦♦
12--
70-
10--
No of
sessions
held
E3 Follow-up3
%
60'
Mothers 50attended 43.
B-5.9 ♦
6--
30-
20-
2.3
1.1
2
+
10-
0-
Panchmahals
Chandrapur
♦ P < 0.001
♦♦ P < 0.0001
10 **
1 M
Panchmahals
9 *♦
4
Chandrapur
** P < 0.0001
Figure 18
Nutrition and health knowledge of
mothers and AWWs at Follow-up3
St
Panchmahals
Chandrapur
6--
Mean
NHE 4 score
2-
0
AWWs
(Max Score-7)
Mathen
(Max score-9)
AWWs
(Max score-7)
Mothers
(Max Score-9)
USAID Assisted ICDS Impact Evaluation
37
Table 11
AWW’s and mother’s knowledge of Oral Rehydration Therapy (ORT) in diarrhea
management
Chandrapur
Panchmahals
Awareness of ORT
Mother
AWW
Mother
AWW__
Knowledge
J
F3
B
F3
B
F3
B
F3
%
%
%
%
%
%
%
100
100
4
%
15**
95
4
28'
0
65
38
33
34
100
76*
48
37*
ORS correct preparation
Chi-square (B Vs F3)
*P <0.001, "P <0.0001
Figure 19
Growth chart knowledge of AWWs and
mothers of children (0—72 months)
■ Baseline
Follow—up3
Chandrapur
Panchmahals
100 ♦
98 »
100T
80-■
60-■
57
% AWWs/
mothers
42
40-
200.7
3 ♦
0
AWWs
Mothers
AWWs
♦ P < 0.001
0.4
2 ♦
Mothers
USAID Assisted ICDS Impact Evaluation
38
Figure 20
Growth monitoring of children by AWW
Follow-up3
■ Baseline
100T
Chandrapur
Panchmahals
BO63 •
60-■
46 *
% Children
39 *
40-•
22 ♦
20--
10
3
+
0
GC acarate
GC maintained
2
0.4
GC acctrate
GC maintained
GC — Growth Chart
♦ P < 0.0001
Table 12
Relative coverage of child population for nutrition and health services by
determinants of AWW's performance at Follow-up 3
Determinants
Nutrition and health services
Health check-ups in past 3 montsh
Participation in supplementary nutrition
Vitamin A prophylaxis
Educa
ANM visit
Nutrition
tion level
in past 3
(>high knowledge® months
school)
(>4 score) (>1 visit)
(2)
(3)
0)
1.2
1.3
1.6
0.9
1.9
1.8
0.9
2.0
0.9
1.7
0.2
2.0
4.0
(1)+(2)
2.0
(1)+(2)+(3)
8.3
1.7
2.0
2.2
5.6
2.1
4.5
4.6
Growth chart maintenance
1.5
1.1
23.6
Immunization______________________
|h sschool), nutrition
Relative coverage was calculated
c J. J. L ‘ for
\ education level (<=hiqh school vs > high
vs > 1 visit), Immunization : BCG> + DPT 3 doses + Polio
knowledge (<=4 vs > 4 score). ANM visit (<=1
(<
3 doses and booster dose + Measles
amaximum 7 scores
39
USAID Assisted ICDS Impact Evaluation
THE TEAM ON THE USAID ASSISTED ICDS IMPACT EVALUATION PROJECT
GUJARAT
Honorary Director
Honorary Project Coordinator
Honorary Consultant
Stalistician/Programmer
Statistician
Investigator
Investigator
Investigator
Tara Gopaldas
Sunder Gujral
D N Shah
Rita Abbi
Narendra Lele
Rajni Mujoo
Dhruti Shah
Anju Bandhu
MAHARASHTRA
Asha Patwardhan
S W Kulkami
S M Morey
Honorary Director
Honorary Consultant
Statistician
ACKNOWLEDGEMENTS
We express our deep gratitude to the concerned officials at the department of Women and
Child Development, Ministry of Human Resource Development, for entrusting us with the
responsibility to conduct the Evaluation Survey and for the support extended to us at all stages
of the project.
We are grateful to the US Agency for International Development for providing the funds to
conduct this evaluation survey.
Thanks are also due to the governments of Gujarat and Maharashtra states for their support
and help in innumerable ways which expedited our work.
We express our profound gratitude and warm appreciation to Dr Mary Ann Anderson, Deputy
Chief Health Services Division, office of health AID Washington, who assisted us in all phases
of the study with never failing enthusiasm. We are particularly grateful for her review and
valuable comments on the summary reports.
Sincere thanks are extended to Samaresh Sengupta, Project Management Specialist,
USAID, who provided us with ever ready help for smooth running of the project.
Our special thanks to Dr Robert Timmons and Mr Kris Oswalt of CSF, Ann Arbor, Michigan,
USA for training and assisting the Baroda team in microcomputer applications in database
management and statistical analysis.
Sincere thanks to Mr K K Bansal of Information Systems and consultant CSF for preparing
software and for assisting in computerization of the data.
USAID Assisted ICDS Impact Evaluation
40
Papers Published/presented using the project data:
Mothers’ Nutrition Knowledge and Child Nutritional Status in India. Rita Abbi, Parul Christian,
Sunder Gujral and Tara Gopaldas.
1.
Food And Nutrition Bulletin 1988; 10(3):51 -54.
The Role of Maternal Education and Nutrition Knowledge in Determining Child Nutritional
Status. Parul Christian, Rita Abbi, Sunder Gujral and Tara Gopaldas.
2.
Food And Nutrition Bulletin 1988; 10(4):35-40.
Relationship Between Maternal and Infant Nutritional Status. Parul Christian, Sunder Gujral,
3.
Rita Abbi and Tara Gopaldas.
Journal of Tropical Pediatrics 1989; 35:71-76.
4.
Agreement between Hemoglobin Estimation and Anemia Recognition Card in Assessment
of Anemia in Pregnant Women. Sunder Gujral, Rita Abbi, Mary Ann Anderson, Parul
Christian and Tara Gopaldas.
European Journal of Clinical Nutrition 1989; 43/7:473-475.
5.
Socioeconomic Determinants of Child Nutritional Status in Rural and Tribal India. Parul
Christian, Rita Abbi, Sunder Gujral and Tara Gopaldas.
Ecology of Food And Nutrition 1989:17.
6.
At Risk Status of Pregnant Women of Panchmahals (Gujarat) and Chandrapur
(Maharashtra). Parul Christian, Rita Abbi, Sunder Gujral and Tara Gopaldas.
Arogya, A Journal of Health and Sciences 1989:XV:85-91.
7.
Agreement between Arm Circumference, Weight for Age and Weight for Height Measures
of Malnutrition in Children. Mary Ann Anderson, Tara Gopaldas, Rita Abbi and Sunder Gujral.
Indian Pediatrics 1990; 27:247-54.
8.
Does Growth Monitoring work as it Ought to in Countries of low literacy?. Tara Gopaldas,
Parul Christian, Rita Abbi and Sunder Gujral.
Journal of Tropical Pediatrics 1990; 36:322-327.
9.
• i on Nutrition and Health Status of their Children. Rita Abbi,
Impact of Maternal Work Status
Parul Christian, Sunder Gujral and Tara Gopaldas.
Food and Nutrition Bulletin
<•
10. Analysis of the Nutritional and Health Consequences of Drought in Indian Children. Parul
Christian, Rita Abbi, Sunder Gujral and Tara Gopaldas.
Ecology of Food and Nutrition (In press).
USAID Assisted ICDS Impact Evaluation
41
11. Child Diarrhoea: Oral Rehydration Therapy and Rural Mother. Tara Gopaldas, Sunder
Gujral, Rajni Mujoo and Rita Abbi.
Journal of Nutrition International (In press).
12. Maternal Age/Parity and Child loss in Rural and Tribal Women in Panchmahals district of
Gujarat. Sunder Gujral, Rita Abbi, Rajni Mujoo and Tara Gopaldas.
Journal of Home Science Association of India
SLOCxd
.
Papers Under Review
13. Prevalence of Xerophthalmia and Efficacy of Vitamin A Prophylaxis in Preventing Xeroph
thalmia Coexisting with Malnutrition in Rural Children. Tara Gopaldas, Sunder Gujral and
Rita Abbi.
Indian Pediatrics.
14. Determinants of Anganwadi Workers’ Performance Sunder Gujral, Rita Abbi, Rajni Mujoo
and Tara Gopaldas.
Journal of Tropical Pediatrics.
Papers Presented
15. Degree of Agreement between Weight for Age and Arm Circumference Measurements in
Identifying Malnourished Children.
XIX Annual Meeting of NSI On November 29, 1986 at Hyderabad India.
16. Nutrition Knowledge of Mother and the Nutritional Status of Children.
Annual Meeting of NSI, November 6-7 1987, Baroda.
17. At risk status of Pregnant women of Panchmahals (Gujarat)
Annual Meeting of NSI, November 6-7 1987, Baroda.
18. Agreement between Hemoglobin Determination (HB) and Pallor signs in Assessment on
Nutritional Anemia.
Fifth Asian Congress of Nutrition 26-29 October, 1987, Osaka, Japan.
19. Effect of Literacy Status and Nutrition Knowledge of Rural and Tribal Mothers on the
Nutritional status of their children.
Fifth Asian Congress of Nutrition 26-29 October, 1987, Osaka, Japan.
20. Socioeconomic Determinants of Weight of Preschoolers.
World Congress on Clinical Nutrition held at New Delhi 27th February to 1st March 1988.
21. Interaction effects of Vitamin A Prophylaxis and child Nut(ition/Morbidity Status on
prevalence of vitamin A deficiency in Rural India.
The XIV International Congress of Nutrition 20-25 August, 1989 Seoul, Korea.
42
USAID Assisted ICDS Impact Evaluation
22. Vitamin A, Morbidity and Malnutrition.
The XIV International Congress of Nutrition 20-25 August 1989 Seoul, Korea.
23. Does Growth Monitoring work as it ought to in Countries of low literacy?
XXVII National Conference of Indian Academy of Pediatrics, May 31 to June 3, 1990
Bangalore.
24. Prevalence of Xerophthalmia and efficacy of Vitamin A Prophylaxis in preventing Xeroph
thalmia coexisting with Malnutrition in Rural Indian Children.
XXVII National Conference of Indian Academy of Pediatrics, May 31 to June 3, 1990
Bangalore.
25. Determinants of Anganwadi Workers’ Performance.
XXIII Annual Meeting of NSI From December 1-3, 1990 Hyderabad.
26. The Role of Socioeconomic Factors in Determining the Utilization and Impact of the vitamin
A Prophylaxis Program in the Integrated Child Development Services (ICDS) Scheme
setting.
XIV International Vitamin A consultant group(IVAG) meeting in June 1991.
27. Risk Factors for Nutritional Blindness.
Sixth Asian Congress of Nutrition. 16-19th September 1991, Kualalumpur, Malaysia.
Doctoral Dissertations
28. The relationship between maternal nutrition and child growth in rural India. Mary Ann
Anderson. Tufts University, April 1989, Medford, MA., USA.
Position: 794 (6 views)