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SUMMARY REPORT
OF THE
USAID ASSISTED ICDS IMPACT EVALUATION PROJECT IN
PANCHMAHALS (GUJARAT) AND CHANDRAPUR (MAHARASHTRA)
1984-1990
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BY

SUNDER GUJRAL
TARA GOPALDAS

Department of Foods and Nutrition
Faculty of Home Science
Maharaja Sayajirao University
Baroda
1991

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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

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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.

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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.

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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

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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

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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.

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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

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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

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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).

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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).

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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

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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.

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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.

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