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Evaluation Report
Submitted to:
GoUP (Directorate of FW & Directorate of ICDS) and
Unicef, Lucknow
Evaluation
Report
Submitted to:
GoUP (Directorate of FW & Directorate of ICDS) and
Unicef, Lucknow
We as well wish to express our sincere thanks to Dr. Santosh Jain Passi, Reader in
Nutrition, Institute of Home Economic (University of Delhi) for providing training to the
field investigators on technical aspects related to weighing of children and support in
analysis of data.
We take this opportunity to thank the MCHN Project Conveners of the four districts – Dr.
Deoki Nandan (Agra), Dr. Shradhha Dwivedi (Allahabad), Dr. S.B. Gupta & Dr. B.P.
Mathur (Jhansi), Dr. S.C. Mahapatra (Varanasi) – SNRC/DNRC of all the four project
districts for providing our field teams with all necessary inputs and cooperation.
Thanks are also due to ANMs, AWWs, Bal-Parivar-Mitra (BPM) and the community for
their cooperation extended during the course of the field work.
We hope the study findings will be useful in planning and executing similar interventions
in the future.
Study team
ORG Centre for Social Research,
Lucknow
September 2006
CONTENTS
Executive Summary
2. Evaluation Methodology
-An approach, data collection and analysis…………..….......II.01 – II.5
Executive Summary
Community Based Maternal and Child Health Nutrition Project (referred as MCHN project),
was implemented in response to the grave health and nutrition situation of women and children
in the state of Uttar Pradesh. MCHN project is based on the principle of:
Breaking nutrition and infection cycle
Addressing intergenerational cycle of growth failure.
The strategy emphasised on a multisectoral approach and involved the two major system i.e.
Health and Integrated Child Development Services (ICDS) as well as Panchayati Raj (PRI).
Department of Social and Preventive Medicine of the Medical colleges, located in the selected
four demonstration districts, played the nodal role in the MCHN project management.
In order to effectively implement the project activities, in turn, achieve the project objectives
following process objectives were designed and undertaken in the project.
Develop capacity of the state based medical colleges (Department of Social and
Preventive Medicine)
Strengthen the linkages of Health- ICDS-Panchayati Raj Institutions (PRI), WES
programme services at block/community/family level
Identify minimum 3 to 4 community health nutrition and sanitation mobilisers (CHNSMs)
per 1000 population and strength the community capacity
Influencing behavioural care practices (maternal-child health, nutrition, sanitation and
hygiene) at family level with the help of community based mobilisers (CHNSMs or Bal
Parivar Mitra)
Establish a community based intervention and monitoring system for improving maternal
and child health and nutrition.
Empower community with information on maternal and child care as well as create
community demand to utilize the existing services of Reproductive and child health
(RCH), ICDS, WESS towards prevention of malnutrition in women and young children
Frontline Volunteers/Workers:
A block level facilitator was appointed in each of the project block of the demonstration districts
and was referred as Block Trainer cum Monitor (BTMs). The MCHN project strategy focused on
reaching and establishing regular contact with the selected families 'at risk' of undernutrtion
through a Community Health Nutrition-Sanitation Mobilizers (CHNS), referred as Bal Parivar
Mitras (BPMs). The BPMs, elected project volunteers, worked with an average of 50- 60
households in a village with about 1000 population and one BPM was expected to work with 15-
20 “ at risk families" in the community cluster for improving care during pregnancy and early
childhood care i.e. feeding, hygiene, health and child care behavioural practices. Community
mobilizers were not given any honorarium or fees but were paid Rs.100/quarter on submission of
monitoring reports
Coverage:
The project was implemented in four districts of U.P.- Jhansi, Allahabad, Agra, Varanasi. In
each of four districts, two blocks per district (Agra-blocks-Bitchpuri & Fatehpur Sikri,
Allahabad-Jasra & Saidabad, Jhansi-Babina & Bangara and Varanasi- Chiraigaon & Harhua)
were selected and high priority was to be given to selection of blocks with ICDS project in
operation. In Saidabad block (Allahabad) initially ICDS was not there but it was established
later. A total of 907 villages of 8 blocks of 4 districts with a total population of 1,331,549 were
covered under the project.
Duration:
The project was conceptualized and developed in 1999. The project commenced with execution
of baseline study between July to December 2000 and the project activities was undertaken
during January 2001 to December 2004. Baseline was conducted by the Medical Colleges of the
respective districts in the project area before the commencement of the project activities i.e.
July-December 2000.Process documentation was done during December 2004 to January 2005
and Evaluation study was done during April -May 2005.
Endline Study:
The prime objective of the study was to assess the impact and effectiveness of the community-
based Maternal and Child Health Nutrition (MCHN) project. ORG Centre for Social Research
(A division of ACNielsen ORG-MARG) conducted the evaluation of MCHNs project during April
-May 2005, after a gap of more than 4 months of closing the project. The evaluation was
preceded by a qualitative study on community-based approaches used in Uttar Pradesh for
nutrition and childcare. The qualitative study undertaken, as a part of separate assignment for
studying community based activities in all the four MCHN districts was also undertaken by ORG
Centre for Social Research during December 2004 to January 2005.
a) Qualitative Survey (Process Documentation): In each the four MCHN districts i.e. Allahabad,
Agra, Jhansi and Varanasi, both the project blocks of were covered for the endline study. The
qualitative research techniques such as In-depth Interviews/discussions, Focus group
discussions, Desk Review were undertaken to review the processes of the community based
MCHN projects. In all, 75 In-depth Interviews with the State, District and Block project
functionaries, 81 semi-structured interviewed with the village level project
functionaries/volunteers/target population and 18 Focus Group discussions with mothers of at
risk families and seven case studies were done from the project area.
b) Quantitative Survey (Endline Impact Evaluation): For quantitative surveys as well, both the
blocks from each of the four MCHN districts were covered. The quantitative survey was carried
out among the mothers of children currently aged 0-24 months, newly married women and Bal
Parivar Mitras (BPMs).
Tools of Enquiry: Three separate schedules used– Mother of children aged 0-24 months, newly married
women and Bal Parivar Mitras (BPMs) - were designed, pre tested and finalized in consultation with
stakeholders.
Sample size: The required sample size for the survey among the mothers of children aged 0-24 months was
calculated based on the standard formula for one point sample estimation. In each block a multi-stage sampling
procedure was followed to select the respondents. At the first stage, villages were selected followed by the selection
of households and respondents. The number of households selected per village was fixed at 20. Thus, in all 10
villages in each block were selected following PPS sampling procedure using 2001 census. Thus, a total of 1600
households from 80 projects villages were covered for quantitative study.
The total sample of 400 households was equally divided between the two blocks in each district. Thus, in each block
a sample of 200 households were covered for the survey among mothers of below 2 years children.
Each selected village was divided into 4 quadrants and from each quadrant, 5 mothers of children currently aged 0-
24 months were selected for the interviews. In a selected household, if more than one child was there the mother of
the youngest child was contacted for the interview.
Sample size for survey among newly married females: By following the same procedure as
followed for the identification of mothers, 3 newly married females who got married during last
one year & without having children were selected for the interview in each village (The Project
defined newly married females as less than 2 years & without children). Thus, against budgeted
total sample of 240 newly married females (60 per district), 239 were contacted for the
interview.
Selection of Bal Parivar Mitras (BPMs): Around 1-2 BPMs were randomly selected for the
endline survey): from each selected village.
The salient findings emerged from qualitative as well quantitative survey has been presented in
the following sections.
• A strong conceptual framework helped in defining the project objectives. MCHN project
clearly spelled out both ‘Process Objectives’ and ‘Impact Objectives’ to achieve the pre-
defined ‘Expected Outcomes’. MCHN project clearly defined all the process objectives to
achieve the project objectives, which helped in proper implementation of the project
• A methodical planning process was adopted and a series of planning workshops and
meetings were organized to develop a plan of action for the project. As an outcome a
detailed plan-of-action outlining the detail implementation strategy, sectors involved and
roles/responsibilities of functionaries at different levels was prepared.
• Towards ensuring and reaching families the most ‘at risk’ of under nutrition, MCHN
project defined the population segment that need to be reached and counselled urgently
for preventing under nutrition. At risk family approach was a successful idea since the
actions concentrated on selected families within a village, which resulted in focussed
attention for maximum difference.
• Community Based Mobilsers (BPMs) were selected by AWWs and ANMs in consultation
with community members as well as leaders/Pradhan. These mobilizers were women
(97%) and about half of them were illiterate.
• Community based Mobilisers (BPMs) were trained using special 'case based' training
module to equip them with information and skills to dialogue with communities and
families. For influencing appropriate behavioural changes at family level and also for
creating demand for health and nutrition services. for influencing appropriate
behavioural changes at family level
• BPMs, which were not, paid any honorarium or fees, acted as link person, with frontline
workers of health, ICDS and block assistant development officers/PRIs.
• An innovative pictorial monitoring format was developed under the project. That was
utilised by BPMs for monitoring action at the family level as well as a tool for
counselling. This pictorial card was also used for training and retraining of BPMs.
Understanding of pictorial monitoring format and its usage was evaluated by scoring
system, to assess the competence of BPMs. Two third of the BPMs contacted were found
having correct knowledge.
• The experience of the community based MCHN project and BSPM resulted in the
redesigning of ICDS to reach under threes through the Intensification of Child Health
and Nutrition (ICHN) activities. Thus, policy guidelines for the same was developed
using MCHN concepts. The ICHN also adopted the concept of “at risk’ families of
MCHN project for its Home visit activity to concentrate primarily on families “at risk” of
undernutrition. ICHN has been further absorbed in the “Mission Poshan” action plan of
Uttar Pradesh for reduction of protein energy malnutrition and micronutrient
malnutrition.
In accordance with the key Project objectives results have been presented as below:
i) Nutritional Status of below 2 years children:
• An increase in ‘mild & moderate’ cases (IAP method) is observed in the endline, in
comparison to baseline indicating shifting of severe malnourished cases into ‘mild &
moderate’ category of nutritional status.
• The proportion of children with normal nutritional status (IAP method) improved only
slightly from 25% in baseline to 28% in endline. The normal category children are
generally not perceived at risk of under nourishment hence increase in normal category
children is difficult to achieve in a period of 4 years – possibly additional time is required
to shift the mild cases to normal category.
• As per the NCHS (Standard Deviation - SD) method, the proportion of children falling
under –2SD category was 34% and – 3SD 32% in the endline. However, a comparison
with baseline could not do due to incomplete data/figures of baseline.
• As far the consumption of 90 or more tablets, it has increases from 9 percent in the
baseline to 22 percent in the endline.
• Overall, the consumption of IFA tablets amongst those women, who received any number
of IFA tablets, has increased more than twenty percent in the endline as compared to
baseline.
• In line with the findings of qualitative survey, fear of side effects arising from certain
misconceptions was also another reason for low consumption of IFA tablets. Feeling of
vomiting (26%), malaise or bad after taste in the mouth (14%) and very hot/feel giddy
(12%) were certain side effects, reportedly, associated by the mother with the
consumption of IFA tablets that led them to stop taking of these.
• 95% of mothers across all the four MCHN districts were found aware about taking two
TT shots during pregnancy. 63% of the mothers, reportedly, received two TT injections
during their index pregnancy, which however improved from 47% of the baseline.
• In sharp contrast to high levels of awareness, practice was found quite poor during the
endline. Overall, less than a fifth of mothers (as compared to more than three fifth being
aware) confirmed taking one additional meal every day during their index pregnancy
• ‘Loss of appetite’ (48%) and ‘Feeling of heaviness and Indigestion’ (35%), which are
actually pregnancy related issues, were the main reasons cited by most of the women.
• 78% of mothers’ contacted during the endline survey were aware of taking ‘at least two
hours of rest (during daytime) per day’ during pregnancy. In line with the same nearly
three-fourth of the mothers reportedly practiced this during their index pregnancy.
• A high proportion of mothers (87%) confirmed washing of hands, specifically with soap,
by the person assisting the delivery. Impact of the project intervention could not be
compared with the baseline due to non-availability data.
• Bathing of newborn after third day of birth was reported in 22% cases in the endline.
• Regarding birth registration, three-fourth mothers expressed their awareness while birth
registration was actually done in three-fifth cases. In majority cases (63%) birth
registration was done after 7 days of birth.
• 78% mothers confirmed having given something or the other (pre-lacteal feeds) to their
child before initiating the breastfeeding,
• Nearly 60% of the mothers were aware about the ‘importance of colostrums feeding.’ A
comparison with the baseline shows an overall improvement regarding the practice of
colostrum feeding in the endline (baseline: 28%; endline: 53%).
• With 78% mothers giving pre-lacteal feeds, the proportion without any pre-lacteal feed
was 22% of which the proportion of children that were breastfeed exclusively up to first 6
months was 10%. (or 2.1% of total 1580 children).
• The proportion of such cases where semi-solid food was introduced between 6 to 9
months substantially increased from 18% in the baseline to 63% in the endline.
• The awareness level of community on importance of VAS was not very encouraging as
barring few of the mothers, none could not respond on this issue.
• The Project revealed that it was critical to introduce a programme design in the state,
which would positively influence joint functioning of health and ICDS systems to provide
• Overall, the proportion of household using salt with iodine (either <15 ppm or =>15
ppm) increased from 31% of baseline to 67% in the endline.
• The proportion of households using salt with ‘0’ ppm reduced from 60 percent of
baseline to 33 percent in endline.
• Household where salt was found containing more than 15ppm iodine were 16% in the
endline, which also increased from 11% of baseline.
• Since the supply of iodized salt packets are incorrectly labelled or have less than 15 ppm
iodine, the issue is the authentic supply of iodized salt with appropriate (15 ppm) iodine
• 68.5% of families started using hand pumps as main source of drinking water as
compared to that during baseline (41.5%).
• The availability of latrine facility has improved only marginally from 7% of baseline to
10% in the endline. The usage of latrines facility (by those having it) increased from
(endline: 82%; baseline: 62 %,) mainly due to increase in awareness in the endline.
• A significant increase in the practice of washing hands with soap after defecating
(baseline: 35%, endline: 83%).
• Washing of hands before other activities such as before preparing any food (81%), before
eating (70%) was also high. The practice of washing vegetables/fruits before eating was
followed in 86%.
Source of Information:
• On almost all the issues – health, nutrition, water, hygiene & sanitation education as well
as nutritional health services, BPMs (Bal-Parivar-Mitra) emerged as the main source of
information, followed by ANM and AWW.
CONCLUSIONS:
• Sound planning of MCHN project was a positive attribute that helped methodical
execution of all the envisaged activities. Unicef’s conceptual framework, which explains
determinant of undernourishment, was used to develop strategies for tackling
undernourishment.
• Defining the target audience, as ‘Risk-families’ was an innovative approach that enables
easy management by ensuring identification of the population segments that was to be
reached and counselled urgently. This strategy inspired the ‘Home visit guidelines’ of
ICDS, in the GoUP plan of action. Some components of MCHN have gone in the strategy
of ICHN (Intensification of Child Health & Nutrition) activities also.
• Considering low levels of literacy among the target population, poor access to electronic
media and electricity supply in rural areas, ‘Inter-Personal Counselling (IPC)’ was
planned and undertaken as a technique to communicate with the community on MCHN
issues. Thus, Project as a strategy did not use any IEC tool mainly to demonstrate the
impact community-based-workers. IPC would have been possibly more effective if it was
complemented with community level education.
• Pictorial monitoring format was developed primarily for the use of illiterate BPMs in
undertaking all necessary activities. But, since it carried uniform messages and
pictorially illustrated all the activities using ‘life cycle approach’ it also substituted the
need for IEC material in the Project to a large extent. The idea is expected to extend to
others.
• The awareness level on majority of the issues was found relatively higher in Allahabad
and Varanasi in comparison to Agra and Jhansi. This difference is probably due to
variation in socio-economic conditions impacting the local customs and practices.
However, as far as practice is concerned no significant variation or trend was observed
across four MCHN districts.
• It emerged that community changed their behaviour more easily on certain aspects/issues
such as – a) 2 hours rest during daytime during pregnancy, b) registration of pregnancy,
c) ANC services, d) colostrums feeding, e) semi-solid between 6-9 months, f) use of ORS
during diarrhoea, g) consumption of iodised salt, h) hygiene & sanitation practices.
• On the other hand, relatively lesser change was observed on issues – a) taking one
additional diet during pregnancy, b) initiating breastfeeding within an hour of birth, c)
exclusive breastfeeding up to 6 months. These issues are closely linked with local customs
and traditional myths & misconceptions that involve lot of unlearning before new and
contradictory knowledge gets completely imbibed and a new behaviour emerges.
• No specific and separate strategy was planned or implemented for increasing vitamin A
administration. Immunization and administration of vitamin A, which is the responsibility
of Health system, could not show good results as the ANMs got diverted in other
unexpected emerging priorities such as polio campaign in year 2000. Further, supply of
vitamin A by Unicef was not envisaged in the Project.
• The positive shift in nutritional status can be primarily attributed to adoption of practices
pertaining to infant feeding (early initiation of breastfeeding & colostrums feeding),
usage of safe drinking water and other hygiene practices as well as special attention
given to children presenting clinical signs of protein energy malnutrition. Monitoring
growth, using weighing and plotting growth chart was not part of the MCHN project.
However, this could have, possibly, further enhanced the project outcome.
• However, nutritional status would have further improved if local customs and traditional
myths had not hurdled important feeding practices during pregnancy and infancy. In fact,
correct behaviours related to feeding are critical for improving nutritional status, and
hence such behaviours should possibly be addressed with efforts beyond interpersonal
counselling (IPC). Thus, it is recommended that for such issues besides IPC,
communication tools using strong emotional appeal than rational appeal should be
employed to sensitize the target groups. Dramas (Nukat-natkas), folk dances, folklores
with interesting storylines could be used to communicate the messages. Practices related
to infant feeding, safe drinking water and hygiene practices are easy to change through
IPC.
• Nodal nutrition officers, attached to Health and ICDS sectors, appear critical in
coordinating district level activities and follow nutritional status.
Early marriage combined with early conception contributes to CED in Women. As per
NFHS-II, the median age at the first birth among women in 20-49 years age group is 19.1
years. The relationship of adolescent pregnancy and low birth weight babies is well
established. These young mothers, often anaemic and malnourished have low birth babies.
Moreover, malnutrition in women combined with poor antenatal services results in high
incidence of maternal mortality. The coverage of Antenatal Care (ANC) services is
reported to be rather poor in U.P. with only 63% of women utilizing these services.
Coverage with iron supplement have also been found to be low i.e. less than 3 percent of
pregnant women receiving full doses of IFA supplement (IASDS, 1998).
Besides promoting holistic approach model for services (Figure 1.1), project also envisaged
the involvement of Community Health Nutrition and Sanitation Mobilisers (CHNSMs)
IMPLEMENTATION PROCESS:
The elected project volunteers, community mobilizers
Box 1A: “At Risk Families”
referred as (CHNSMs/ BPMs) work with 50- 60 Φ Newly Wed
Φ Pregnant/Lactating Mothers
households in the community cluster and focus on Φ Children <24 Months
identified 15- 20 “ at risk families" (Box 1A) for Φ Severely Malnourished
children
improving family feeding, Hygiene, health and child
care behavioural practices. Community mobilizers were not given any honorarium or fees
but were paid Rs.100/quarter for monitoring reports.
These volunteers were trained to reach the Figure 1.3: Pictorial Monitoring Card
identified at risk families and counseled on
appropriate behavioural change and also
create demand for health and nutrition
services. Provision of services at family level
by (BPMs) was linked person with the
frontline workers of health, ICDS, PRI and
other relevant sectors. Presented in Figure
1.3, an innovative pictorial format was used
by the BPMs for promoting appropriate
behavioural practices and monitoring action
at the family level.
PROCESS OBJECTIVES:
In order to effectively implement the project activities, in turn, achieve the project
objectives, below mentioned process objectives were designed and undertaken as a part of
project strategy.
Develop capacity of the state based medical colleges (Department of Social and
Preventive Medicine) in the prevention and management of malnutrition of women
and children
Strengthen the linkages of Health- ICDS-Panchayati Raj Institutions (PRI), WES
programme services at block/community/family level for addressing malnutrition
using multi-sectoral approach. Undertake joint training to bring their convergence at
district/block/sectoral and village level.
Identify minimum 3 to 4 community health nutrition and sanitation mobilisers
(CHNSMs) per 1000 population and strength the community capacity for
identification and prioritization of problems as well as utilization of available child
and maternal health and nutrition care services for prevention of malnutrition
Influencing behavioural care practices (maternal-child health, nutrition, sanitation and
hygiene) at family level with the help of community based mobilisers (CHNSMs)
(later referred as Bal Parivar Mitra) selected in the community with the help of ICDS
and Health functionaries.
Establish a community based intervention and monitoring system for improving
maternal and child health and nutrition.
∗
Based on Thailand model of Community Based Approaches developed by Dr. Krisid Tontisirin.
IMPACT OBJECTIVES:
EXPECTED OUTCPMES:
As a part of project strategy, evaluation was carried out to assess the impact and
2
effectiveness of the community-based Maternal and Child Health Nutrition (MCHN)
project. At behest of UNCIEF, ORG Centre for Social Research (A division of ACNielsen
ORG-MARG) conducted the evaluation of this project during April and May 2005 i.e. four
months after closing of the project in December 2004. The evaluation was preceded by a
qualitative study on community-based approaches used in Uttar Pradesh for Nutrition and
Childcare. The qualitative study was also undertaken by ORG Centre for Social Research
during December 2004 to January 2005 in all the four MCHN districts. The evaluation
report therefore includes the findings of qualitative as well as quantitative study. The
research methodology and sample coverage of both qualitative and quantitative phase i.e.
Process documentation and Impact study are described in the following sections.
Two blocks each from four MCHN districts i.e. Allahabad, Agra, Jhansi and Varanasi were
covered for this assignment. Table 2.1 presents the details of functionaries and target
population contacted for the study. The study was conducted from 9th December 2004 to
20th January 2005.
MCHN
2 3 12 30 25 66 28
Project
In addition, 18 Focus Group discussions and seven case studies were done from the
project area (refer detail reports). Since the project envisages the multisectoral approach,
perception of the functionaries of ICDS, Health and Family Welfare, PRI/DUDA, UPJN
at each level were sought. Beside, 3-4 community-based volunteers (referred as Bal Parivar
Mitras, BPMs) were interviewed at village level. The population group interviewed
comprised ‘Currently pregnant women’, ‘Mothers of children upto 24 months’.
Tools of Enquiry: Three separate schedules – Mother of children aged 0-24 months,
newly married couples and Bal Parivar Mitras (BPMs)- were designed for the study.
The Formula
n= Z2 1-∝/2 * P * (1- P)
d2
where:
n = required sample size
Z 1-∝ = Standard normal value at (1-a) % level of confidence i.e. the Z -
score corresponding to '∝' level of confidence, i.e., ± 1.96
p = Anticipated Proportion of the indicator
d = Standard Error
To ensure coverage of minimum required sample size for estimating different outcome
indicators of the project the value of ‘P’ was assumed as 50%. With the above assumption
the required sample size at 95 percent level of confidence with 5 percent of permissible
error in the estimates, was worked out as:
n = 1.962 * 0.5 * 0.5 / 0.052 = 384
Since the analysis was required district wise, the minimum required sample per district was
fixed at 400 households having 0-24 month old child. So in all 4 districts a total of 1600
households were selected for the interview.
The total sample of 400 households was equally divided between the two blocks in each
district. Thus, in each block a sample of 200 households were covered for the survey
among mothers of below 2 years children.
In each block a multi-stage sampling procedure was followed to select the respondents. At
the first stage, villages were selected followed by the selection of households and
respondents. The number of households selected per village was fixed at 20. Thus, in all 10
villages in each block were selected following PPS sampling procedure. Prior to the
selection of villages all the villages in a block were arranged in ascending order of their
population size (as per 2001 census). Thus, a total of 1600 households from 80 projects
villages were covered for quantitative study.
Selection of Respondents: In each selected household where the child aged 0-24 months
was identified, the mother of the selected child was contacted for the interviews. In a
selected household, if more than one child was there the mother of the youngest child was
contacted for the interview.
Sample size for survey among newly married women: In each village, 3 newly married
women who got married during last one year were selected for the interview. Thus, against
budgeted total sample of 240 newly married women (60 per district), 239 were contacted
for the interviews. The selection of household for interviews among newly married women
was made following the same procedure followed for selection of the households for
interviews among the mothers of children aged 0-24 months.
Selection of Bal Parivar Mitras (BPMs): In order to get the perspectives of Bal Parivar
Mitra about the programme, their role in the programme and their level of understanding
about the core issues covered under the MCHN project, from each selected village around
1-2 BPMs were randomly selected for the endline survey.
Briefing of Main Survey Teams: All the investigators and supervisors recruited for the
survey were given two-day intensive training by the professionals. The training of
investigators comprised both classrooms as well as field practice. An experienced
Nutritionist was involved in explaining the technical details and nitty-gritty of the
project. Instructions in quantitative data collection, field procedures and a detailed
discussion of each item in the interview schedule were done. Mock calls were also done
in the classroom before taking them to field for trial calls. Only those trainees
performing satisfactorily in the entire training process were retained for final survey.
Data Entry and Analysis: Data entry package namely, Integrated System for Survey
Analysis (ISSA) was used for data entry. A data entry programme with built-in consistency
and range checks was prepared to ensure data cleaning. One programmer monitored the
entire data entry and data cleaning operation. The required tables were generated using
SPSS (version 10.0). The results of the Household survey were compiled in the required
format and compared with the baseline to understand the impact of the project. However,
since the raw data of baseline was not available the statistical test of significance could not
be done to compare the baseline results with the endline results on different indicators.
PLANNING
Planning is the most crucial and deciding factor in the success of every mission. MCHN project
sets an example of better planning. A methodical planning process was adopted and a series of
planning workshops and meetings were organized to develop a plan of action for the project. As
an outcome a detailed plan-of-action outlining the detail implementation strategy, sectors involved
and roles/responsibilities of functionaries at different levels was prepared. MCHN project
proceeded in a methodological manner. Two State ‘Nutrition and Resource Centres’ (SNRCs) at
Lucknow and Agra and three ‘District Nutrition and Resource Centres’ (DNRCs) at Allahabad,
Varanasi and Jhansi were established by Government of Uttar Pradesh. The two SNRCs also
functioned as DNRCs.
First, a state-level workshop held at ‘Sarojni Naidu Medical College’, SNRC Agra on 23rd
December 1998. Participants included; key officials and representative from district and Medical
College, Health, ICDS of U.P., UNICEF. The workshop focused at recognizing the multisectoral
nature of malnutrition using conceptual framework of malnutrition (Figure 1.1), appreciating
various cause of malnutrition and the trans-generational cycle of growth failure. The workshop
followed up with a series of core group meetings towards formulation of the strategy and
operation plan to address malnutrition in children.
clearly spelled because it is against clear objectives and measurable outcomes that a project’s
impacts as well as success or failure can be monitored and evaluated. Besides, measurable broad
objectives defining the process objectives helps in taking appropriate action and evaluating the
project in terms of various processes that project was expected to undertake. MCHN project
Establishing Linkages
The Nodal agency for the project was ‘Directorate General of Family & Welfare (DGFW)’ at State
level. At district level, ICDS played a major role. Medical Colleges at district level and Unicef
provided technical and financial support to the project. A multifaceted approach at district level
brought together various sectors beside Health and ICDS i.e. PRI and UP Jal Nigam. Involvement
of grass root functionaries – ANM, AWW and ‘Gram Panchayat Vikas Adhikari (GPVA)’ was
considered very effectual, as they are the first source of services at community level.
Observation of processes and discussions with functionaries revealed that in practice the block
level involvement of health and ICDS was high while Jal Nigam remained almost negligible and
WES activities could not be undertaken as enthusiastically as envisaged. Involvement of District
level official was not very useful, as almost in all the MCHN districts, many of the officials who
undertook the orientation, had got transferred. Moreover, due to demise of Director General of
Family Welfare who was initially involved, the ownership of the nodal agency in the Project
declined at the State level. Further, the ANMs also got diverted to unexpected emerging priorities
like polio campaign in year 2000 due to which service response of health services also declined.
Although special effort was made to sensitize and involve Pradhans of ‘Panchayati Raj Institutions’
(PRI) yet their participation remained minimal in the Project.
Box 3d: Health Service response should match the demand created by the Project
The focus of the project was on Behavior Change communication (BCC) by ICDS and BPMs on
issues related to child development and maternal care. It was usually seen that the department
through which Projects makes entry, remains active throughout the implementation phase.
However, the other departments take a backseat and usually remain quite passive. The MCHN
project would have shown much better results if the service response from the health department
had matched the demand created at the community level. It emerged that many target groups
were aware on the MCHN issues and demand for relevant services was created. However,
community could not avail them due to inadequate service response due to other emerging
urgent priorities such as polio drives from the year 2000 (same period of project launch) giving low
priority to services by ANMs during the outreach sessions. Moreover, for effective involvement of
district and block ICDS officials, it is important that the Directorate of ICDS issues directives. This was
not done since ownership of the project was not there.
link person at each project block mobilisers. BTMs overall supervised the BPMs and were link
between the community and SNRC/DNRC and also
was well thought of during the coordinated with other sectors.
planning workshops for smooth
implementation of project. Each DNRC identified Block Trainer-cum-Monitor (BTM) who
worked under the supervision of respective DNRCs and coordinated with ICDS and Health
sectors from block to grass root level. The BTMs were involved in identifying the community-
based volunteers, provide support in training and during project implementation period provide in-
service training, necessary timely support and guidance to undertake their defined roles and closely
monitor their work. Also, BTMs were to coordinate with both grass-root level and block-level
functionaries of various departments– ICDS, Health, PRI etc. to ensure the effective delivery of
services at village level. BTMs were also responsible to ensure quarterly monitoring meetings that
were planned and executed with their support.
IMPLEMENTATION
Appropriate selection of an entry point proved to be success factor in project designing and
planning. The baseline survey, when first contact was made with the community, served as an
appropriate entry point to the project implementation process. Community was contacted through
qualitative techniques like PLA and FGD. Cluster mapping, including resource and beneficiary
mapping, at this stage helped in identifying clusters (for project implementation) and also the
BPMs (the grass-root voluntary community worker). The information gathered at this stage also
helped in developing background/material for the development, orientation and capacity building
of functionaries at various levels.
Baseline survey
Comprehensive evaluation of the Box 3f: Baseline and end line survey are must
impact of the project not only involves to systematically measure impact of Project
comparison with the defined objectives “Baseline survey is a methodical way of assessing the
but also a comparison with the baseline existing situation. But, information collected through
baseline is helpful in several ways. Firstly, it gives the
situation on all the outcomes laid down existing position of various issues covered in the project.
at the beginning of the project. Secondly, it throws light on strategy that could be
followed while addressing the issues in project. Thirdly, it
Adequate and methodical collection of
becomes an easy starting point. Fourthly, it provides an
baseline data, in all the MCHN districts, opportunity to interact with the community. And lastly, it
was done before the launch of MCHN helps in evaluating project when it has completed its
planned course”
project i.e. July-December 2000.
Similarly, methodical mid term evaluation was also envisaged and subsequently done.
the community who is ready to knowledge and love for the community have earned them the
wide acceptability.
provide voluntary services, a
friend and guide, who is respected, knowledgeable and wise. This agent of change, identified,
trained and nurtured by the project was called ‘Bal-Parivar-Mitra’ – meaning – friend of families
with children. Each block had an average of 560-570 BPMs. Thus, over 4500 community
mobilisers were involved in 8 blocks of 4 MCHN districts.
some places FGDs were fair selection of the BPMs. A Pradhan attempted to push the
names of the ladies from his family for the BPMs, which were not
directly conducted with the
in the list of ANM. But, when they were explained about the
villagers to identify potential
objective of MCHN and the exact roles and responsibilities of
BPMs, while in others ANMs BPMs and that it was an unpaid job, they withdrew silently. They
and AWWs were asked first to not only helped the BTMs to proceed in their way of selecting the
BPMs but also assisted them wherever required.
prepare a list of potential BPMs
in their area in some places and
then FGDs were undertaken by the BTMs with the suggested BPMs. Finally those having positive
attitude on influencing social issues pertaining to children and women and were vocal, dynamic
and respected were selected. Excepting Agra, other three DNRCs selected small proportion of
males as BPMs (Table 3.1). This was an effort to ensure the involvement of male members, also
because the MCHN issues such as intake of additional meal, at least two hours of rest per day by
pregnant women or family planning issues require adequate support from male members.
Box 3i: Social recognition is better motivator than monetary compensation in long run
These training modules were developed by an expert agency with technical and financial support of
UNICEF. A core group comprising of representatives from Health & ICDS departments,
SNRC/DNRCs and UNICEF, undertook a series of review and provided inputs in the finalization
of the training module. For the BPMs and prospective workers, module III was developed using a
case study format. The modules were prepared in both Hindi and English. Hindi modules were
developed for usage in the State and English versions were developed for wider dissemination. The
Sensitisation Training
of Pradhans
Block Level Training (2 days)
(2 trainings / block) - Medical Officer (MO)
- ½ day training - Lady Health Visitor (LHV)
- Asst. Development Officer (ADO)
- Block Development Officer (BDO)
- Child Development Project Officer (CDPO)
- District Programme Officer (DPO)
- Representative of Local NGOs
Box 3K:
During the discussion with the Shusheela Pandey, BPM in Allahabad district, showed the training
module, properly kept in her cupboard. On being asked to comment on usefulness of the
training module, she said – “This is a proof that I undertook the training…Its very easy to
understand with the help of photos and diagram shown in the booklet…I don’t read…my son
reads it for me…Yes many times he read it for me whenever I faced problems…I keep it very
safely”
Following completion of training, the community mobilisers were awarded a certificate, badge and
a bag. These items were not given together but at an interval of 3-4 months. This kept the
motivation levels high of the BPMs. Moreover, they not only felt empowered but their social image
got uplifted.
households and counseled them on the Support to ANM for immunization has improved 57%
Support to AWW in giving supplementary nutrition has
13%
appropriate practices and behaviour. improved
Awareness and usage of iodized salt has improved 13%
Targeting a fixed coverage and defining the Health conditions, overall, are improving 13%
target population, the strategy of frequent Due to multiple response total exceeds 100%.
dialogue on a one-to one level in convincing families and influencing practices related to maternal
and child health and nutrition to “at risk” household got a success. Even, this emerged very
strongly from the interviews with ANMs and AWWs, who recalled, unprobed, the most important
role of BPMs of interacting with ‘at risk’ families for various health services.
The MCHN activities were dovetailed to ongoing activities of other sectors. The BPMs worked in
coordination with ICDS functionaries and also linked with the ‘outreach’ sessions of ANMs. In
ICDS blocks, the weekly contact point with mothers was the ‘Take Home Ration’ (THR) day at
the AWW. The BPMs participated enthusiastically in village level events like Health Melas and
Mother and Child Day organised by ICDS.
Box 3N:
Sincere Working…an opinion
“BPM ls rks cgqr enn feyrh gS” (We receive lot of help from BPM)
- Maya Pandey (ANM)
“oSls rks lc lkFk gh dke djrh gSa ij BPM yksxksa ds lkFk ls lgkjk jgrk gS”- (Although we all work
together, but we get all of support from the BPM)
“BPM dks xkao esa fdldks D;k nsuk gS] T+;knk vPNh rjg ls irk jgrk gS”- (BPM is better aware
regarding what is to be given to whom in village)
- Susheela Devi (ANM)
The BPM also participated in activities of special groups at the village level, i.e. Mahila Swasthya
Samiti, Mahila Mandals, SHGs, Grameen Swasthya Kalyan Samitis and used these as opportunities to
converse with the community and counsel them for behaviour change. Social functions like
marriages, festivals and fairs were used as opportunities by BPMs to interact with the community.
Box 3O:
BPMs…the helping hand to ANMs
Senior professionals from both ICDS and Health said that BPMs were very useful. Dr. A. K. Jain,
Deputy CMO of Jhansi, was involved with MCHN project since October 2000. He affirms – “I feel
that our ANMs get more help from BPMs, in comparison to AWWs. ANMs involve them as their
team-member educating and training on various health services. Since ANM has a very huge
area to look after and many roles to play, she is not able to give a focused attention to maternal
and childcare. BPMs not only keep ANMs updated with families where health services are
required but also make the delivery of various health services easier and smoother”.
The quarterly monitoring meeting provided an opportunity to BPMs to share their experiences as
well as problems with others and learn from each other. Specific subject pertaining to the
scheduled fixed monthly theme was also discussed. The BTMs checked the monitoring formats
filled by the BPMs and encouraged them to improve their performance. This provided direct
motivation to those who performed well, and indirectly encouraged other to do well. This most
positive aspect of the project was the use of pictorial monitoring card and quarterly reports and
discussion with multisectoral representations that allowed everyone to get noticed. The pictorial
monitoring card was also used as training and counselling tools by BTMs during their monthly
Similarly, for monitoring at block level a Coordination Committee comprising the MOIC, CDPO,
BDO, PRIs officers, Jal Nigam and Education Department, BTM, representative of DNRC met
once in a quarter and shared the progress of the project. The block meeting was organized with the
help of medical colleges and was held regularly. To review the progress of the project at district
level an ‘Advisory Committee’ comprising representatives of Health, ICDS, PRIs, Education
Department and Project Coordinator from the DNRC was created. Though, this committee was
supposed to meet at every four months under the chairmanship of Chief Development Officer, it
could not happen as envisaged.
Four monitoring formats were planed but only Format-A was used. This monitoring card was
pictorial and developed using the ‘life- cycle- approach’, depicting messages through coloured
instructions. The BPMs easily recorded the information and was used as monitoring- cum-
counseling format. It was divided in 6 sections (Figure III.4).
Section 4: Care of children in Section 5: Messages for households- Section 6: Key messages (27)
the 6- 24 months age group water, sanitation, iodized salt communication uniformly
Score % BPMs
Excellent (90-100%) 38%
Good (60-90%) 29%
Average (40-59%) 28%
Poor (<40%) 5%
* Based on Field Researcher’s evaluation
MCHN project, the contribution of underwent extensive orientation and training equipping
them with the knowledge and skills at the local level. They
BPM stand out, significantly. The
are sensitized to the extent that they have been working
BPM were ordinary village-folk, not
without any remuneration. We should explore the possibility
necessarily always illiterate, backward of internalizing this concept in the ICDS system, U.P.”.
and poor but with a latent desire to do something for their community, waiting for an opportunity
that can skillfully utilize their potential. From their identification to selection and through
continuous training & regular interaction they were trained and converted into valuable human
resource, now available right at the grass-root level.
The community based MCHN Project aimed at prevention of malnutrition by focusing in the most
critical period i.e. below two years children, including pregnant mothers as well as newlyweds. The
primary focus was on the following family level practices:
1) Improving infant feeding practices: early initiation to breastfeeding, feeding of
colostrum, exclusive breastfeeding for the first six months with special
emphasis on no water for six months, appropriate complementary feeding.
2) Prevention of diarrhoea infection: following of hygiene practices; care of
diarrhoea cases (use of ORS & breastfeeding, feeding), use of appropriate
source of water for drinking.
The impact of the following MCHN interventions has been analyzed against the expected project
outcomes.
Newly Married Women. For key indicators, summary findings presented as graphs precede
the detail discussion.
A. Pregnant mothers
22%
aspects of ANC care in 10%
6%
the endline as compared
ANC regn. TT 2 doses Recd. >90 IFA Consumed >90
to the baseline. Tabs IFA Tabs
Figure IV.5 shows that Figure IV.5 : Month of pregnancy when registration
was done
among those who got
35.4% Endline %
their pregnancy
21.5% 20.5%
registered, nearly half of
9.3% 6.9%
them, reportedly, got 3.4% 1.1% 0.3%
1.5%
their pregnancy
1st 2nd 3rd 4th 5th 6th 7th 8th 9th
registered within first
trimester. Nearly same proportion got it done in the second trimester of their pregnancy.
A comparison of the endline and Figure IV.7 : Practice – Receiving of all the 3 ANC
check-ups during pregnancy
baseline shows that the proportion
of cases receiving all the three ANC Baseline % Endline %
check-ups is almost same. The
23.9
decrease observed in Varanasi and 13.5 13.9
9.4
13.2 11.5
9.3 8.6 8.5 8.5
Allahabad district in the endline is in
Agra Jhansi Allahabad Varanasi Total
consonance with the decrease
Qualitative Study also substantiate the findings as most of women, despite being aware, went for
one ANC check up until they had some visible health problems.
Further probing on other two indicators i.e. ‘place of ANC registration’ and ‘person
extending ANC services’ was also done. It shows that for ANC check-ups a higher
proportion of mothers in Allahabad and Varanasi, reportedly, went to government health
facility. Similarly, of all the ANC check-up, only 33% were done by the ANMs.
Similar to other findings, the high level of awareness was not proportionately
accompanied by the practice as is clear from the Figure IV.9 below.
mentioned.
As per the project Table 4.3 : Mother’s understanding regarding anaemia (%)
guidelines, BPMs first
Agra Jhansi Allahabad Varanasi Total
explained the pregnant n=400 n=402 n=400 n=399 N=1601
mothers about anaemia Causes physical
56.8 53.0 67.5 56.6 58.5
weakness
and then counseled the Anorexia 32.8 31.6 37.0 39.6 35.2
importance of taking Loss of appetite
9.5 5.4 4.8 7.1 6.7
& skin paleness
100 IFA tablets during
Do not Know 22.0 24.6 7.8 8.3 15.7
the pregnancy. This
resulted in increasing awareness amongst the mothers’ of less than two year children in the
community. Endline survey findings show that majority of women contacted appeared
having correct knowledge on anaemia and its symptoms.
Overall, a high proportion (88%) Figure IV.10 : Awareness – 100 IFA tablets should be
taken during pregnancy (% Endline)
of women contacted during study
83% 92% 87% 89% 88%
was found possessing knowledge
about consuming 100 IFA tablets
during pregnancy. A similar trend
was found across all the MCHN Agra Jhansi Allahabad Varanasi Total
n=400 n=402 n=400 n=399 N=1601
districts (Figure 1V.10).
Further, the consumption Table 4.5 : Consumption among those that received IFA tablets
number of IFA tablets, has % Consumed n=410 n=311 n=126 n=302 N=1149
any IFA tab 72.9 42.1 84.1 87.1 69.5
increased more than twenty
>90 tablets 1.6 15.2 9.4 15.6 9.5
percent in the endline as
compared to baseline. A significant increased in this regard was observed in case of Jhansi
district. As far the consumption of 90 or more tablets, it has increases from 9 percent in
the baseline to 22 percent in the endline. The significant change with regard to
consumption of 90 or more tablets was, specifically, found in Agra and Allahabad districts.
Source of information: IFA Table 4.7 : Sources of information on IFA tablets (%)
trained BPMs not only helped ANM 49.8 79.6 52.2 57.4 60.8
BPM 12.9 7.0 35.6 33.0 20.6
the districution of IFA tablets
AWW 31.4 8.1 8.3 7.2 14.2
but they also reinforced the Other 5.9 5.2 3.9 2.3 4.4
importance of IFA tablets
resulting in better compliance. The evaluation finding also indicate that ANMs, followed by
BPMs, emerged as the primary source of information on this (Table 4.7). However, the
importance of consuming IFA tablets needs frequent reinforcement to convince mothers
for better greater compliance in a regular manner during the pregnancy.
20%
that at least 8-10 kgs weight
0%
should be gained during Agra Jhansi Allahabad Varanasi Total
Taking one additional meal/day: Figure IV.12 : Awareness – Taking one additional diet
during pregnancy (Endline %)
Regarding taking one additional
77% 78%
meal everyday, three fifth of
61%
women expressed their awareness 50%
37%
on this aspect (Figure IV.12). It
was interesting to note that
knowledge was higher (reported Agra Jhansi Allahabad Varanasi Total
more than three-fourth mothers) n=400 n=402 n=400 n=399 N=1601
Table 4.8 : Reasons – For not taking one additional diet during pregnancy (Endline %)
Agra Jhansi Allahabad Varanasi Total
Reasons
n=183 n=177 n=182 n=165 n=707
Don't feel like eating at all 57.9 50.8 41.2 43.0 48.4
Indigestion, feeling of heaviness 36.1 42.4 25.8 37.0 35.2
Eating more compresses womb 9.9 6.8 32.9 14.5 16.1
Other (resistance from family, etc.) 1.6 1.7 1.6 6.1 2.7
The MCHN project followed the approach of addressing the entire family, through Bal-
Parivar-Mitra, to foster easy change in the knowledge levels and reducing barrier from the
family-members.
In line with the high levels Figure IV.15: Taking rest for 2 or more hours during
pregnancy (%)
of awareness, practice of
Baseline % Endline %
taking rest for two or more
78.3 79.4
hours (during daytime) per 70.0 72.1 73.1
64.8 69.6 70.9 69.7
61.2
day, was reported by almost
three-fourth mothers
(Figure IV.15). Some
Women (4%), however,
Agra Jhansi Allahabad Varanasi Total
could not take rest at all
during daytime, as they had
to involve in some earning activity due to poor economic conditions of the household. In
contrast to increasing diet during pregnancy, information on taking rest was easy to put
into practice, as it was in syncronisation with the existing knowledge and traditional
practice of the community. Some counseling from the BPMs reinforced their beliefs and
resulted in high compliances.
Source of information: Table 4.10 : Source of advice - Practice of taking 2 hrs rest diet
The prime role of BPMs Agra Jhansi Allahabad Varanasi Total
Endline %
in reinforcing the n=400 n=402 n=400 n=399 N=1601
BPM 60.7 52.7 86.3 76.7 70.3
awareness regarding the
ANM 17.2 41.7 9.4 16.5 20.5
importance of ‘taking
AWW 22.2 5.5 4.2 6.9 9.1
atleast 2 hours rest Others 15.9 7.9 3.2 1.4 6.6
(during daytime) per day’ emerged as they were mentioned as the main source of
advice/information by 70% mothers interviewed (Table 4.10).
Almost half of the mothers Table 4.12: Place of recording the birth of newborn (%)
was the most often mentioned n=400 n=402 n=400 n=399 N=1601
BPM 40.1 36.8 81.6 74.8 59.5
source of information on
AWW 40.0 16.2 5.8 14.0 19.0
‘registering of birth within 7 ANM 11.8 40.8 11.0 10.3 18.5
days after newborn’s birth’ Other 7.3 6.2 1.8 1.0 4.1
Almost three-fourth Table 4.14 : Awareness – minimum desirable birth wt. of newborn
of the mothers had Agra Jhansi Allahabad Varanasi Total
Endline %
n=400 n=402 n=400 n=399 N=1601
the correct knowledge
% Having correct
knowledge
63.0 84.6 76.5 65.7 72.5
regarding minimum
desirable birth weight of newborn. They said it should be at least 2.5 kgs.
Only 22% (347 Table 4.15: Birth weight of newborn – as recalled by mothers
Community was Table 4.16: Whether person-assisting delivery washed hands with soap
breastfed their child (Table 4.18). No (%) 2.5 0.2 1.7 0.8 1.3
Such mothers were Table 4.19 : Reasons for not breastfeeding the child (Endline%)
Remaining 99% (1580 mothers) Table 4.20 : Time of initiating breastfeeding (Endline %)
The mothers were further Table 4.22 : Giving any feed before initiating breastfeeding to
the newborn (Endline%)
probed regarding giving any
Agra Jhansi Varanasi Total
feed before initiating the Allahabad
n=390 n=401 n=393 n=396 N=1580
breastfeeding (pre-lacteal). As
No (%) 21.5 19.4 29.3 17.5 21.9
presented in Table 4.22, 78% Yes (%) 78.5 80.6 70.7 82.5 78.1
mothers confirmed having given some pre-lacteal to their child
b) Colostrum feeding:
Awareness: The awareness on
Figure IV.19 : Awareness – Importance of colostrum
‘importance of colostrum feeding (Endline %)
84%
feeding’ was found similar to 77%
The reason behind these two Figure IV.20 : Practice – Feeding the colostrum
phenomenon is strong Baseline %
Endline %
presence of local 67.4
63.4
cultural/traditional practices 52.9
48.2
linked with practice of 27.4 29.0 32.9 27.4 27.9
colostrum feeding (Refer Box
below). Awareness regarding *
Agra Jhansi Allahabad Varanasi Total
colostrum feeding is low in * Varanasi data of Baseline not available
In certain areas, there is a belief that both mother and newborn are untouchable (ashudh).
“Usually for the first three days, until the cord dries up, the period is called sutak in local
language. Until then the mother does not breastfeed the child” – ANM, Susheela,
Chiraigaon block, Varanasi
There is also a belief that it is ‘amrit’ and hence a part of it is offered to local deity. The
importance of colostrum for the infants needs to be emphasized.
80% 72%
66%
MCHN project. Both, awareness
60% 50%
and practice on exclusive 34%
40% 29%
breastfeeding was gauged in the 20%
semi-solid food was not Upto 6 months 42.6 51.2 50.0 59.2 50.4
Between 7 to 9 months 32.4 41.0 21.4 31.6 32.3
yet started shows that half
Above 9 months 25.0 7.7 28.6 9.3 17.5
of them were below 6
months of age (Table 4.26). However, around 18% did not introduce any semi-solid food
even at the age of 9 months.
All those who have started Table 4.27: Semi- solid given in last 24 hours (Endline %)
AWW & ANM need to play an active ANM 1.8 8.7 3.5 1.5 3.9
Other 3.3 5.0 1.0 0.0 2.3
role in influencing the target groups
about the feeding practices (Table 4.28).
supplementation (VAS) to a child to increase immunity and protect from severity and
death from common childhood diseases as well as to prevent them from night blindness.
The awareness level of community on importance of VAS was not very encouraging as
barring few majority of the mothers could not respond on the issues (Table 4.29).
As expected, response to the administration of the doses of VAS to index child was also
found low. During the study, the administration of dose of VAS was primarily recorded
with the help of vaccination card produced by the mothers during the study. In the
remaining cases where vaccination card was not available, mothers were asked to recall and
give the status whether Vitamin-A was given to the child or not. It is worthwhile to
mention that only one-fourth mothers contacted during the study could produce the card.
Since mothers’ could not recall the exact number of doses of VAS given to a child, the
information available through vaccination card was used to analyze the status of VAS.
As presented in Table Table 4.30: Status of vitamin A as per the vaccination card
4.23, slightly more Agra Jhansi Allahabad Varanasi Total
Endline %
n=102 n=113 n=77 n=107 N=399
than a fourth could get
Vitamin-A (1st dose) 25.5 18.6 35.1 29.0 26.3
one dose while three
Vitamin-A (2nd dose) 2.0 3.5 10.4 0.9 3.8
given only 3 percent of Vitamin-A (3rd dose) 1.0 3.5 7.8 0.0 2.8
the children (Table 4.30). Mothers without vaccination card recalled that VAS was given to
the child in 18% cases. However, they could not recall and specify the exact number doses
Under MCHN, no special supply of VAS was given nor any special effort was made to
motivate the service providers to visit villages and follow the dosage schedules.
It is worthwhile to mention here again that the Table 4.31: Immunization status
immunization status of child against six killer diseases Endline % Baseline %
n=1601 N=4574
was taken with the help of vaccination card as well as BCG 62.6 54.9
recall method. However, during the study only a DPT-I 54.8 51.4
fourth of mothers’ could provide the vaccination card. DPT-II 42.7 46.9
DPT-III 29.8 42.2
Thus, from rest of mothers’ status of immunization OPV-I 51.0 54.9
was taken on the basis of their recall. The combined OPV-II 39.2 46.1
OPV-III 27.1 41.3
status of immunization through vaccination card and
Measles 26.1 24.5
mother’s recall for each of the vaccines has presented
in Table 4.31. It shows that overall immunization coverage against six killer diseases has
marginally improved in the endline.
Reasons for not receiving any vaccination: “ANM’s didn’t visit”(40%), “Child wasn’t
well”(25%) and “did not get time” (15%) were the main reason cited by mothers’ for not
getting their child vaccinated. Indicating that service response was poor to meet the
demand in most of the cases.
As compared to baseline (16.1%), 28.7% mothers in the endline were aware of use of
ORS at the time of diarrohea. The improvement on this aspect was observed across four
MCHN districts. As far awareness about various benefits are concerned, more than half of
Place of ORS availability: Table 4.35: Place of ORS availability in the village
featured as the source of getting ORS availability. Half of the mothers mentioned ‘other
sources’ that included ANM, doctor, BPM, etc (Table 4.35).
fifth of the mother still Less than normal 65.3 49.0 60.8 59.9 58.7
carried a wrong notion that Normal 28.8 40.8 31.0 30.3 32.7
the child suffering from More than normal 6.0 10.2 8.3 9.8 8.6
diarroheal episodes should be given less than normal feed or breastfeeding. Only 9% of the
mothers had correct knowledge regarding giving additional feeds to a child who had
dirrahoea. Around a third said that the quantity of feed/breastfeeding should remain same.
Although not very enlightening, the awareness level has increased when compared the
same with baseline (Table 4.37).
Around 46% mothers opined Table 4.38: Awareness – Feeding, apart from breastfeeding
during pneumonia
that other food and liquids
Agra Jhansi Allahbad Varanasi Total
such as Khichdi, dal, and milk Endline %
n=400 n=402 n=400 n=399 n=1601
other than breast-milk should
Yes 61.5 69.7 31.8 19.8 45.7
not be restricted during
No 8.3 2.7 53.0 71.2 33.7
illness. One-third said that
Don't know 30.3 27.6 15.3 9.0 20.5
nothing other than breast-
milk should be given during pneumonia, while one-fifth expressed complete unawareness
on this aspect (Table 4.38).
This section deals with family level issues such as ‘consumption of iodized salt’, hygiene &
sanitation, etc. Questions related to these issues were commonly asked to 1600 mother’s
and to 239 newlyweds. Hence, the total sample of the findings presented under this section
works out to be 1840.
The study findings Table 4.39: Awareness – Benefits of eating iodized salt
revealed that Agra Jhansi Allahabad Varanasi Total
Endline %
around 12% were n=460 n=461 n=464 n=455 N=1,840
Salt Testing Kit (STK) was Agra Jhansi Allahabad Varanasi Total
As presented in Figure IV.27, Figure IV.27: Households using salt =>15 ppm
the proportion of household
23.1 Baseline %
using salt with iodine (either 20.5 Endline %
17.5
<15 ppm or =>15 ppm) 15.6
11.8 11.5 10.6
increased from 31% to 67%. 9.5 8.3
However, household consuming 3.2
salt with over 15ppm iodine
Agra Jhansi Allahabad Varanasi Total
were 16%, which also increased
from 11% of baseline. However, the overall increase in consumption of iodized salt
indicates that possibly there is limitation or fault in supply of iodized salt packets after salt
packets are incorrectly labeled as iodized salt but have less than 15 ppm iodine. The issue
is, therefore, of authentic supply of iodized salt with appropriate (15 ppm) iodine despite
increased demand for iodized salt from community.
started using handpumps as main source of drinking water as compared to that during
baseline. Similarly, respondents using Taps as main source marginally increased compared
to baseline. A shift from unsafe source to safe source of drinking water could be
contributed to the counseling as well as water testing done by BPMs under MCHN project.
Testing of water was also envisaged in the Project mainly to demonstrate that the quality of
water taken from other than tap or handpump was “not clean” and unsafe for drinking or
cooking. This highlighted the importance of consuming drinking water from safe sources
such as handpump and tap. However, due to inadequate supply of good quality ‘water
testing kits’, this activity could not be pursued for long in all the areas under the MCHN
project. Also, PRI and WES did not respond well for installation of handpumps.
Use of Sanitary latrines: Table 4.44: Awareness – benefits of using latrine facility
Observing proper Agra Jhansi Allahabad Varanasi Total
Endline %
sanitation prevents from n=460 n=461 n=464 n=455 N=1,840
infection, which in turn Defecating in
open is avoided
78 59.6 59.1 61.2 64.6
helps in preventing
Saves time 6.7 10.4 11.7 11.4 10.1
malnutrition. Although, Prevent spreading
13.9 16.1 29.3 22.9 20.5
of infection
three-fourth of the
Convenient during
2.6 0.4 2.6 1.8 1.8
mothers’ mentioned illness
Don’t know 19.8 34.1 22.8 23.7 25.1
some or the other benefit
of using sanitary latrines, only two-fifth said that it prevents from spreading the infection
(Table 4.44).
In all the cases where availability of Figure IV.30 : Practice of using latrine facility
latrine facility was available further Baseline %
probing regarding the practice was 100.0 Endline %
88.7 90.2
undertaken. As compared to 82.4
75.0 77.6
65.0
baseline of 62% the utilization of 57.6 62.4
42.5
latrines by community increased to
82% in the endline due to possibly
being counseled and convinced of
Agra Jhansi Allahabad Varanasi Total
the advantages of using latrine
facility (Figure IV.30).
Personal hygiene: Being Table 4.46 : Awareness – activities requiring hand washing
an important aspect of Agra Jhansi Allahabad Varanasi Total
Endline %
n=460 n=461 n=464 n=455 N=1,840
personal hygiene, washing
Before food
81.5 83.9 78.9 81.3 81.4
of hands was seen as most preparations
After defecation 70.0 65.7 82.1 81.3 74.8
important ‘before
Before eating 73.3 66.6 67.5 72.5 69.9
preparing food’ (81%), After cleaning
child defecation
49.3 32.3 51.7 53.2 46.6
after defecation (75%) and
before eating (70%) by the mothers. Results imply that washing hand after cleaning child
defecation needs a focus as only 47 percent of the mothers contacted during the study
As shown in Figure IV.31, comparison of endline results with that of baseline findings show a significant in
As shown in Figure IV.31, Figure IV.31: Washing hands with soap after defecation
eating. The other activities Other activities 11.1 9.8 11.0 10.1 10.5
Cleaning
before hands are vegetables/ fruits
86.1 84.4 85.3 87.0 85.7
Across the four MCHN districts, a total of 239 women, married in last one year, were
contacted during the endline survey. The issue related to the correct age of conception and
family planning was also ascertained to mothers of children less than 2 years. The
responses of both the target groups have been discussed in proceeding paragraphs.
Table 4.49: Awareness – Perceived Correct age at various occasions (Average age)
Total Total
Particulars Agra Jhansi Allahabad Varanasi
Newlyweds Mothers
n=60 n=59 n=64 n=56 N=239 N=1601
Correct age of marriage for boys 21.1 20.9 19.7 20.3 20.5 20.5
Correct age of marriage for girls 18.6 18.1 17.9 17.7 18.1 18.4
st
Correct age for 1 conception 20.7 19.2 20.2 21.2 20.4 19.5
Minimum spacing between two
2.9 2.8 3.4 3.3 3.1 3.2
successive children (Avg.)
Total Total
Agra Jhansi Allahabad Varanasi
Newlyweds
Mothers
n=60 n=59 n=64 n=56 N=239 N=1601
Awareness :
Condom 60.0 50.8 68.8 91.1 67.4 64.0
Copper-T 36.7 32.2 50 48.2 41.8 43.5
Oral Pills 76.7 64.4 68.8 58.9 67.4 72.7
Others 5.0 5.1 7.8 1.8 5.0 6.2
Do not know 18.3 32.2 15.6 3.6 17.6 16.6
Practice :
Condom 5.0 5.1 4.7 0.0 3.8 8.5
Copper-T 0.0 0.0 3.1 0.0 0.8 1.7
Oral Pills 1.7 0.0 6.3 0.0 2.1 6.1
None 95 94.9 92.2 100 95.4 79.5
Source of information:
Bal Parivar Mitra of Table 4.52: Source of information
Total Total
MCHN could be Agra Jhansi Allahabad Varanasi
Newlyweds Mothers
Endline%
attributed for the N=400 n=402 n=400 n=399 N=239 N=1601
children in the endline (Figure IV.32). A similar trend was observed across all the four
MCHN districts.
The proportion of children with normal nutritional status (IAP method) slightly improved
from 25% in baseline to 28% in endline. In fact district-wise analysis indicates that increase
in normal cases was highest in Allahabad followed by Agra while in Varanasi it is almost
same. The baseline data of Jhansi was not available in the format required for working out
the nutritional status and therefore could not be compared. The district-wise data of
nutritional status has been presented in Table 4.53.
Table 4.53: Nutritional status of children below 2 years of age (IAP Classification)
Agra Jhansi Allahabad Varanasi Total
Endline %
n=403 n=440 n=416 n=416 n=1675
Normal 39.21 25.91 20.67 24.76 27.52
The nutritional status Table 4.54: Nutritional status – below 2 years children (SD Method)
analyzed through SD Agra Jhansi Allahabad Varanasi Total
% Endline
method shows that the n=403 n=440 n=416 n=416 n=1,675
proportion of - 2SD 30.1 35.4 37.6 32.1 33.9
the endline, is 66%, while with the IAP method it is 72.5%. However, since baseline data
was not available in the SD classification, no comparison could be done between baseline
and endline (Table 4.54).
Table 4.55: Nutritional status of children below 2 years of age (Gender-wise) - Endline
Gender-wise analysis: Gender- Table 4.56: Gender-wise severely malnourished children below
six years of age (IAP method)
wise analysis shows that the Agra Jhansi Allahabad Varanasi Total
Endline %
proportion of severely n=638 n=687 n=646 n=666 N=2637
six years of age is slightly Female 10.9% 9.1% 17.5% 23.8% 15.9%
higher in case of female children (16%), in comparison to their male counterparts (12%).
However, gender-wise variation emerged substantially higher in Varanasi, where the
proportion of severely malnourished female children was 24% when compared to severely
malnourished male children, which were 16% (Table 4.56). This indicates that more efforts
are needed to improve the nutritional status of female children by reinforcing the
counseling of parents on importance of giving attention on feeding and care of girl child.
The MCHN project did not include the component of regular weighing and Growth
Monitoring & Promotion (GMP) of children below 2 years. Low availability of scales and
skills was the reason for exclusion of the component from the project in the planning stage
Further, 17% of the mothers whose child was identified as undernourished (Table 4.58),
confirmed that the child was referred for proper care and medical advice. The referral was
mainly done by BPM (89%). The place of referral was Government hospital (26%) or
private clinic/NGO/trust (56%) in majority of cases.
Table 4.58 : Referral of child, Person who referred and Place of referral (Endline %)
Agra Jhansi Allahabad Varanasi Total
Whether referred
n=67 n=39 n=10 n=45 N=161
Yes % 17.9 2.6 20.0 26.7 16.8
Person who referred
BPMs 91.7 0.0 100.0 91.7 88.9
AWW 0.0 0.0 0.0 8.3 3.7
ANM 0.0 100.0 0.0 0.0 3.7
Others 8.3 0.0 0.0 0.0 3.7
Place of referral
Govt. hospital 0.0 100.0 100.0 33.3 25.9
PHC/Community center 16.7 0.0 0.0 8.3 11.1
NGO / Trust / Pvt. clinic 75.0 0.0 0.0 50.0 55.6
Others 8.3 0.0 0.0 8.3 7.4
In brief, it can be concluded that the efforts made under MCHN project has shown as
positive results as far the achievement of outcome objectives are concerned. However,
continuous and rigorous efforts would be required for reducing the incidences of
malnourishment.
a) Process indicators
b) Impact indicators
Broadly, covering each indicator, results have been critically discussed, also citing the
reference wherever they have been adopted by or inspired any other programme.
‘Unicef’s Conceptual Framework’ was used as the basis to convince various sectors
of their role and to increase their involvement. Taking into consideration the multi-
sectoral approach for addressing undernourishment the MCHN involved various
sectors such as ICDS, Health, Panchayati Raj Institutions (PRI), UP Jal Nigam in the
planning stage at district level and block level. However, only two sectors i.e. ICDS
and Health, at the block level, played an active role. Special efforts were made to
sensitize the ‘Pradhans’ (the village elected representatives under PRI), but even they
remained superficially attached with the project.
At the State level, the ‘Department of Family Welfare (DGFW)’ – the nodal
department was initially actively involved in the finalization of plan. However, with
the change of Director General (due to demise of earlier DG), the interest decreased
and there was very little interest and follow up with the district officials by Health
department regarding MCHN Project. Hence, child nutrition was not viewed by
DGFW as a priority and the project did not get the desired support from the State
activities. The interest of shifted to Polio and their role also decreased.
ICDS Directorate interest was evident from 2001 with the establishment of
Programme unit under ICDS-III. The involvement of ICDS facilitated the
implementation of activities related to health & nutrition and education. However,
no additional staff was provided for these new activities. This declined the
anticipated involvement of ICDS Directorate in the MCHN project.
The evaluation reveals that the Bal-Parivar-Mitra (BPM) played a very critical role in
reaching the “at risk” families and community at large positively impacting both
The methodical selection of BPMs in the Project presents a successful approach for
selecting community-based workers. During the baseline, community was contacted
through qualitative techniques like PLA and FGD. ‘Cluster Community Approach’,
which involves cluster mapping (including resource and beneficiary mapping), was
done to identify clusters for Project implementation. From each such cluster, vocal
females having level of acceptability in the village were identified with the help of
ANMs and AWWs under the supervision of Medical Colleges. From the list of
potential BPMs, finally those having positive attitude on MCHN issues and were
respected, vocal and dynamic were selected in consultation with the Pradhan. BPMs
were motivated and sensitized through initial training and continuous on-job
training. They were volunteer workers who were not paid anything. However, there
was provision of Rs. 100/- per quarterly session per BPM i.e. Rs. 400/- year,
following submission of monitoring forms.
An additional staff at the block level – Block-trainer-cum monitor (BTM) was very
useful. Medical Colleges worked mainly through BTMs. Involvement of BTM was a
successful way of establishing link between community and the concerned
departments. BTMs coordinated for training, meetings and they also undertook
quarterly monitoring meetings with the BPMs.
Training in MCHN project was done in a very effective manner by the Medical
Colleges. It was done in a uniform manner and with no cascading. While all the
functionaries involved in the project were sensitized with the issue, an extensive
training was undertaken for the BPMs. The interesting feature of the training was the
involvement of technical experts – the medical colleges (SNRC/DNRCs). As a
result, even complicated technical aspects could easily be explained and imbibed by
the illiterate BPMs, which is evident from their high level of awareness on various
MCHN issues. BTMs played an important role during these training programmes.
The training was supported by three training modules, which were developed after
incorporating inputs from the experts and officials from the concerned departments.
These training modules not only provide technical knowledge, lucidly, but also
sensitized the reader by using ‘Case-study approach’. The logical flow of the content
supported rationale and case studies further enhanced the utility of these training
modules as valuable documents for future references. The third training module,
utilized for the trainers of community mobilizers in MCHN project, has been
adopted by the GoUP for facilitating AWWs to conduct Health & Nutritional
Education day.
An effective tool – ‘pictorial monitoring card’ – was developed mainly for the
purpose of monitoring of at risk families by BPMs. Adopting the flow of ‘life cycle
approach’, all the MCHN issues were pictorially presented, which made its use
extremely simple and easy. It aided illiterate BPMs in undertaking their assigned work
in the field without missing any activity. Being illustratively rich and carrying uniform
messages, it also substituted the need for IEC tool to a large extent. The idea is
expected to extend to others.
Testing of water was also envisaged in the Project mainly to demonstrate that the
quality of water taken from other than tap or handpump was “not clean” and unsafe
for drinking or cooking. This facilitated to highlight the importance of consuming
drinking water from safe sources such as handpump and tap. However, due to
inadequate supply of good quality ‘water testing kits’, this activity could not be
pursued for long in all the areas under the MCHN project.
Salt testing was also envisaged in the Project with the objective of demonstrating and
educating the community about the quality of salt consumed by them. It was
successfully carried out using salt testing kits in all the four MCHN districts. The
community was sensitized and there was increase in demand for iodized salt but
Overall, almost all the ‘Process Indicators’ (strategies) laid down in the MCHN
Project were successfully achieved. Certain activities like ‘growth monitoring’ was not
planned and therefore not reflected. At the time of planning, the planning team
considered that growth monitoring would consume too much of time and effort of
the functionaries leaving little interest in pursuing rigorous counseling and other
innovative activities developed under the Project. Name to the Project in local
language would have given an easy identification to the Project in the community
and the planning team could have considered this. But, it was outweighed by the
positive impact of not having a name to the Project. It is usually seen that a Project
with any such name is wrongly identified as separate programme whose strategies are
meant to sustain only the Project through its life cycle. Its innovative strategies,
which are in fact in consonance with the relevant department’s overall objectives,
loose a chance of being incorporated in the system.
IMPACT INDICATORS:
The MCHN strategies helped creating a positive impact on ‘Key Impact Indicators’.
As a strategy, the Project first increased awareness and then extended necessary
support to help community change behaviour and influence practices. Although all
programmes/projects attempt to increase the awareness and influence behaviour of
the community, but the uniqueness of MCHN project was the involvement of
community based workers (BPMs) with the objective of making regular contact with
“at risk” families creating a permanent resource that can sustain the Project efforts
for a longer period of time.
The project was successful in imparting the correct knowledge in the community
because a high level of awareness is observed across all the impact indicators and for
majority of these indicators BPMs emerged as the main source of awareness. This
further improved behaviour on selected practices such as:
However, for certain indicators there were two major factors that adversely affected
easy adoption of the correct practice despite of increase in levels of awareness –
a) Presence of contradictory local customs
b) Poor service response; unavailability of necessary supplies
For instance, ‘Taking additional diet per day during pregnancy’, ‘Early initiation of
breastfeeding’, ‘Exclusive breastfeeding upto 6 months’ could not show change in
behaviour in proportion to high increase in awareness mainly due to observance of
certain local customs or due to misconceptions & traditional myths.
For indicators where practice is closely linked with observance of local customs or
are influenced by traditional myths/misconception, only Interpersonal Counseling
(IPC) would not be very effective to bring about the desired levels of change in
practice. It increases the levels of awareness but still lacks in generating enough
motivation to adopt a new practice. On these issues, lot of unlearning goes before
new and contradictory knowledge gets completely imbibed and a new behaviour
emerges. Therefore, communication tools using emotional appeal strongly than
rational appeal should be employed to sensitize the target groups. Dramas (Nukat-
natkas), folk dances, folklores with interesting storylines could be used to
communicate the messages.
NUTRITIONAL STATUS:
Overall, there was a sharp decline in children with severe undernutrition (baseline:
24.5%; endline: 14.0%). A similar trend was observed across all the four MCHN
districts. Reduction in proportion of severely undernourished children could be
attributed to special focus on severe undernourishment as a ‘risk group’. Moreover,
since severe undernourishment is clinically easily observable it gets quick community
attention in comparison to mild and moderate undernourishment, which is not easily
detectable through observations of the caregivers. Moreover, lack of appreciation of
impact of mild/moderate undernourishment results in low interest of community in
taking action. Hence, the proportion of children with moderate nutritional status
remained at about 26-28% in the baseline and endline surveys. The children
classified mildly undernourished increased from 23% to 32.7%. There was a small
These changes in nutritional status can be attributed to a positive shift noted in the
adoption of practices pertaining primarily to infant, safe drinking water, hygiene
practices and sanitation as well as special attention given to children presenting
clinical signs of protein energy malnutrition. However, nutritional status would have
further improved if local customs and traditional myths had not hurdled important
feeding practices. In fact, correct behaviours related to feeding are relatively more
critical to improving nutritional status, and hence such behaviours should be
attended with double efforts, although a complete change would still take a lot of
time and effort.
The Project revealed that it was critical to introduce a programme design in the state,
which would positively influence joint functioning of health and ICDS systems to
provide services to address the problem of micronutrient malnutrition. The low
coverage of children with vitamin A supplement in MCHN project – 26% for 1st
dose and only 2.8% for the 3rd dose resulted in defining roles of ICDS & Health and
in the formulation of biannual strategy under the Biannual Child Health & Nutrition
Month (referred as Bal Swasthya Poshan Mah or BSPM), which is currently part of
RCH-II and is being implemented statewide in 70 districts.
The experience of the community based MCHN project and BSPM resulted in the
redesigning of ICDS to reach under threes through the Intensification of Child
Health and Nutrition (ICHN) activities. Thus, policy guidelines for the same was
developed using MCHN concepts. The ICHN also adopted the concept of “at risk’
families of MCHN project for its Home visit activity to concentrate primarily on
families “at risk” of undernutrition. ICHN has been further absorbed in the
“Mission Poshan” action plan of Uttar Pradesh for reduction of protein energy
malnutrition and micronutrient malnutrition.