|Year : 2015 | Volume
| Issue : 1 | Page : 11-18
Impact of perceptions of key stakeholders in combating undernourishment among rural children in Delhi: A qualitative study
Sanjeev Davey1, Anuradha Davey2, Vivek Adhish3, Rajni Bagga4
1 Department of Community Medicine, Muzaffarnagar Medical College and Hospital, Muzaffarnagar, India
2 Department of Community Medicine, Subharti Medical College, Meerut, Uttar Pradesh, India
3 Department of Community Health Administration, National Institute of Health and Family Welfare (NIHFW), New Delhi, India
4 Department of Management Sciences, National Institute of Health and Family Welfare (NIHFW), New Delhi, India
|Date of Web Publication||4-Jun-2015|
Dr. Anuradha Davey
Department of Community Medicine, B-197, 3rd Floor, Prashant Vihar, Sector 14, Rohini, Delhi - 110 085
Source of Support: None, Conflict of Interest: None
Background: The role of community members in deciding nutritional status of their children reveal many complex issues in studies done in the past; in that one such issue is the mutual perceptions of the multilevel stakeholders toward each other, for their efforts usually taken by them for reducing undernourishment in rural areas of Delhi. Aim and Objective: To gain insight in the perceptions of Opinion leaders, Health, and Integrated Child Development Scheme (ICDS) functionaries toward each other in reducing under nutrition among rural children. Materials and Methods: The study was done in one Rural ICDS project in Delhi from January 1, 2015 to March 15, 2015. The prevalence of undernutrition in two AWCs was taken from previous studies in the past and thereafter the mutual perceptions of the community-level stakeholders, ICDS, and health care functionaries toward each other were studied by Qualitative research methods. The primary qualitative and quantitative data and secondary quantitative data both were finally triangulated to find out the reasons for existing scenario of undernutrition in Delhi. Results: The higher prevalence of undernutrition (58% from past studies) was supported by inadequate, ineffective and defective perceptions and uncoordinated efforts of PRIs, ICDS, and Health department reducing undernourishment in their area. Conclusion: To gain quality services from ICDS scheme and Primary health care system in rural area of Delhi; the need of the hour is the regular refresher and reorientation nutritional and health training programs for multilevel stakeholders in rural areas for tackling undernourished children in Delhi.
Keywords: Community-level stake holders, health department, ICDS scheme, PRIs, training, under nutrition
|How to cite this article:|
Davey S, Davey A, Adhish V, Bagga R. Impact of perceptions of key stakeholders in combating undernourishment among rural children in Delhi: A qualitative study. J Health Res Rev 2015;2:11-8
|How to cite this URL:|
Davey S, Davey A, Adhish V, Bagga R. Impact of perceptions of key stakeholders in combating undernourishment among rural children in Delhi: A qualitative study. J Health Res Rev [serial online] 2015 [cited 2019 Dec 11];2:11-8. Available from: http://www.jhrr.org/text.asp?2015/2/1/11/158123
| Introduction|| |
Children who are the future of India are its most vital national resource and Indian government who is also committed to overall development of children by means of providing many health and nutritional programs, such as Integrated Child Development Scheme (ICDS), which are directed toward augmenting health and nutritional status of under 6 years children. This is an indication that although the government of India efforts are ongoing but its real impact is not evident on children's nutritional status.  In fact, India's share in underweight category across the whole world is therefore around 40%. In India, approximately 46% of children below 3 years are undernourished in the form of 47% being underweight and around 16% wasted.  The prevalence of undernutrition varies also across states in India, with Madhya Pradesh recording the highest rate (55%) and Kerala among the lowest (27%). 
Delhi despite being the capital of India, has also not been spared by undernourishment where four out of every 10 children in Delhi are undernourished (overall 36% of the children-undernourished) and the rate of undernourishment is higher among girls (38%) than boys (34%). , In Delhi, from April 2012, where around 64 children were reported to be severely malnourished and this figure rose to 216 children found severely malnourished till January 2014, indicating an issue of concern. , In Delhi, this concerning situation gets further complicated by nutritional ICDS scheme targeted at the 0-6 age group, reaching only up to 30% of the intended beneficiaries, indicating that Delhi has also been hit by coverage surveys conducted by AWWs significantly in the ICDS scheme. ,
The condition of states such as Delhi where around 94 ICDS projects, 10,560 AWWs were operational till 2011 covering 8,93,372 supplementary nutritional children (0-6 years) beneficiaries, the situation of undernourishment in children has therefore not yet reached to a satisfactory level. , Delhi is also one of the states where less than half of Enumeration Areas are covered by an AWW (35%) indicating a decline in the qualitative aspects of the (ICDS) programme in Delhi.  The CRY study (2014) had also recently found that only 30% of children under 6 years were covered by the ICDS. 
Furthermore, there also appears to be a gap in the knowledge of health and ICDS service providers regarding undernutrition in both the public and separate private health sector. The inability of health and ICDS service providers to manage undernutrition in under 5 years children is in part contributing to the high number of children who suffer from undernutrition in this age group.  This situation gets further complexed by differences in the perceptions of different health stakeholders in the understanding of comprehensive notion and action against undernourishment; so greater emphasis also needs to be placed on community capabilities, informal link with other social sectors based on trust, and local initiatives as found in a study done in Iran.  A study in Nigeria had also stressed on the involvement of traditional, religious leaders, and community leaders in the planning and implementation of health and nutritional activities in all communities. 
Therefore, due to the multifaceted aspect of child malnutrition, a comprehensive approach, taking social factors into account, has been frequently recommended in health literature to focus on areas such as factors of community-level involvement apart from familial and cultural factors. ,, So undernourishment in children can be better elucidated by studying perceptions of various stakeholders such as community-level leaders as well as ICDS and health care functionaries, which has not been explored till date in the literature by triangulating method to gain a better picture in this area. This was the reason for selecting this research area by the authors.
| Materials and methods|| |
To gain insight into the mutual perceptions and efforts of Opinion leaders, Health, and ICDS functionaries toward each other in reducing undernutrition among children younger than 6 years in rural area of Delhi, by applying qualitative research approach.
There are around five ICDS projects, which are running in the rural areas of Delhi. The study was carried out in the area of two AWCs of one rural ICDS project in the community development block of Delhi, which was selected randomly. The two Anganwadis (A) and (B) were also subsequently selected randomly to select community stakeholders from their area.
The study was carried out from January 1, 2015 to March 15, 2015.
Sample size and sample design: Study population
Out of five rural ICDS projects, one ICDS project was sampled simple randomly for study. From the sampled ICDS project-2 Anganwadi Centers were also sampled further by simple random selection technique. All the key stake holders of these two Anganwadi Centers from Community (Opinion Leaders), ICDS Functionaries, and Health Care Functionaries were subsequently In-depth Interviewed and FGDs were done to explore their perceptions.
Selection of ICDS and health care functionaries
Two AWWs posted at two AWCs, one ICDS Supervisor (Mukhya Sevika), and one CDPO who were supervising the AWWs, one ICDS program officer at district social welfare department, one RCH program officer at the district, 1 MO, 1 lady health visitor (LHV), 1 ANM posted at the health center linked to AWCs and two Opinion leaders of the village were included in the study.
Selection of the AWWs
The two AWWs working in the selected AWCs were included in the study.
Selection of the supervisor
The supervisor for the selected AWWs of the AWCs was included in the study.
Selection of the CDPO
CDPO of the selected ICDS project was included in the study.
Selection of the district ICDS program officer
ICDS program officer at the district of social welfare department was also included in the study.
Selection of the district RCH program officer
RCH program officer at the district was also included in the study.
Selection of the medical officer
Medical officer posted at the health center linked to AWC was selected for the study.
Selection of the LHV
The LHV posted at the health center was selected for the study.
Selection of the HW (female)
One ANM was involved in the study. 10 ANMs/HW(f) other than the ANM of AWC-A and B were involved in 1 FGD.
Selection of Opinion leaders of the community
Total two Opinion Leaders were taken (two each from two villages of one ICDS Block, randomly out of five Rural ICDS Blocks in Delhi) representative of community were chosen and opinion leader from each of 100 villages in Rural ICDS Block. He/she was interviewed in depth to obtain the information about prevention and management of malnutrition in children from family level to ICDS and health department level with their comparison with their knowledge, attitudes, and practices.
No Health Worker-Male [HW(M)] and no Health Assistant-Male [HA(M)] were posted at the Health center in the study, so they were excluded from the study.
Data collection tools and technique
Primary data was collected as per the objective of the study by the means of Interview schedules and check list after visiting the two AWCs.
To fulfill the objective of this study, the following tools and techniques were utilized:
- In Depth Interviews (For all Community level Stakeholders, ICDS, and Health Functionaries)
- Focus Group Discussions (AWWs and ANMs)
- Record study: Last 3 years (2012-2014).
As per the objectives of the study, the collected data was analyzed using appropriate qualitative statistical data analysis software ( Atlas More Details.ti 7.1).
| Results|| |
Sociodemographic profiles training status of ICDS and health care functionaries
Information related to sociodemographic profile and training status of the functionaries of the ICDS and health staff is as follows:
- Profiles of auxiliary nurse midwife (ANM) and Anganwadi worker (AWW)
All of them were in the age bracket of 39-50 years. For ANM distance of AWC from the residence was about 5 km and mode of conveyance was rickshaw but for AWW distance of the AWC from the home was less than 1 km [Table 1].
|Table 1: Distribution of AWWs and ANM as per their sociodemographic status and training received |
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The duration of induction training was 6 months for ANM and was 3 months for AWW [Table 1].
- Profiles of LHV and supervisor
Supervisor in the ICDS scheme was a graduate from home science, whereas LHV was matriculate in educational qualification. Both of them have experience as a supervisor or LHV for 14 years or above [Table 2].
Induction training received by supervisor was for 2 weeks and by LHV was for 6 months [Table 2].
|Table 2: Distribution of lady health visitor and supervisor (MS) according to their sociodemographic status and training received |
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Both CDPO and MO were above 40 years of age. CDPO was postgraduate in social work whereas medical officer was a postgraduate in gynecology and obstetrics. Both of them had received induction training for 2 weeks and refresher training for 2-3 times in the last 5 years [Table 3].
|Table 3: Distribution of MO and CDPO according to their sociodemographic status and training received |
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- District RCH officer and ICDS officer
Both the program officers were older than 45 years. ICDS program officer was male and had done postgraduation in social work. Both of them had received induction training for 2 weeks as well as reorientation training for 2 weeks [Table 4].
|Table 4: Distribution of district RCH officer and ICDS officer according to their sociodemographic status and training received |
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Opinion and practices of ICDS and health functionaries toward malnutrition
Functionaries under the ICDS scheme and department of health care were assessed for their opinion for malnutrition among children under the age of 6 years and practices followed by them for prevention and treatment of malnutrition in children and efforts taken by them for sensitization of family as well as community stakeholders.
• Perceptions of ICDS and health functionaries on causes of malnutrition:
- According to AWWs - "Malnutrition among children occur due to lack of good quality food given at home by mothers, wrong sociocultural beliefs on child feeding, frequent infections in child. Semi-solid foods given to the child is late"
- Both LHV and Supervisor-Mukhya Sevika mentioned that-"lack of proper child care, poverty, illiteracy, lack of good quality, and less quantity of foods given to the child at home are the main causes of malnutrition among children and frequent illness among children due to diarrhea, measles, fever was told by ANM as a cause of malnutrition of children"
- "Lack of protein in the food, poverty, illiteracy, and ignorance on the part of the mother for child care" were the main reason mentioned by CDPO, MO, and district program officer.
• Perceptions of ICDS and health functionaries on the effect of malnutrition:
- For the effects of malnutrition on the children AWWs mentioned that - "child loses weight and their immunity is depressed to fight against the infection"
- "Frequent illness among malnourished children" was also mentioned by ANM, LHV, supervisor, CDPO, and MO.
• Perceptions of ICDS and health functionaries on prevention of malnutrition:
- Anganwadi workers mentioned that - "Mothers are given nutrition and health education on the importance of child feeding hygienic practices, immunization, and regular weighing of their children at AWC. They give nutrition and health education to mothers of all grades of malnourished children as well as to mothers of normal children"
- For prevention of malnutrition, ANM recommends that "they do regular health check up of the children and give immunization, iron tab, and vitamin syrup to the children"
- According to the Supervisor (Mukhya-Sevika) for prevention of malnutrition, "they supervise the health education activities and growth monitoring activities conducted by AWWs"
- The supervision conducted by the CDPO for the preventive action for malnutrition among the children they said, "through monthly progress report, field visits, and monthly staff meetings with AWWS and their supervisors"
- According to medical officer, " they provide health education, importance of vaccination, hygienic practices to the mothers who are visiting the health centers for some reason."
• Perceptions of ICDS and health functionaries on treatment of malnutrition:
- For treatment of malnutrition, AWWs said that " they provide supplementary nutrition to mild to moderate grade and double diet to the severe grade of malnutrition, and children are regularly weighed for their growth monitoring"
- According to the supervisor, " severe malnourished children are referred to the health center and they monitor the activities of the AWWs for the growth monitoring"
- For the mothers for malnourished children ANM said that " they provide health education and IFA and vitamin tab for the children"
- According to the CDPO and district ICDS program officer, " child with grade 1 malnutrition nutrition and health education is given to the mother for better care at home. To grade 2 malnourished child, the AWWs give supplementary nutrition (300 calories and 10-12 g proteins) and to grade 3 and 4 malnourished child, double diet 500 calories and 25 g proteins/day are given and these children are referred to MO for proper health examination"
- The MO and district RCH program officer also said that " malnourished children need extra care at home as well as from health and ICDS functionaries."
• Perceptions of ICDS and health functionaries on follow up of malnourished children
- To follow the malnourished children, AWWs mentioned that " they do make a regular home visit and ask the mothers to bring their child to AWC regularly for growth monitoring"
- At ANM, a follow up of malnourished children is done " mainly through mahila mandal meeting and monthly home visit"
- Supervisor and LHV followed the malnourished children " mainly through the activities of the children"
- CDPO and District ICDS Program officer said that " they make a surprise home visit of the malnourished children but their channel to follow the malnourished children is through records and reports received from the AWCs"
- Medical officer and district program officer follow the malnourished children " mainly through monthly reports and staff meetings."
• Actions taken by ICDS and health functionaries on monitoring and supervision of management of malnutrition
CDPO and district ICDS officer perceptions
- "They give 10-15 visits to AWCs in a month"
- "In the visit they check whether AWWs has taken the weight of the children properly, distribute the food to malnourished children in proper amounts, and whether supervisors check all these activities"
- They assess the nutritional work of supervisors through record checking.
According to the supervisor (Mukhya-Sevika) perceptions
- " She gives 15-20 visits in a month to AWCs under her supervision"
- " She monitors the activities of growth monitoring conducted by AWWs and health messages given by her to the mothers."
Medical officer and district RCH program officer perceptions
" They monitor immunization and distribution of IFA tabs and Vit A syrup to malnourished children."
Lady health visitor perceptions
" She gives 5-10 visits in a month in the AWC, to check whether ANMs immunize the child properly and distribute the IFA tabs and Vitamin A to malnourished children in proper amounts, and provide nutrition and health education to mothers of normal and malnourished children."
Perceptions toward staff meetings
- " To discuss the problems in the supplementary nutrition distribution to registered beneficiaries and to collect the reports and record for normal and malnourished children in the area," staff meetings of AWWs are held at block levels with CDPO and Supervisors and also at the main point of the circle with the Supervisors
- Both the AWWs mentioned that - " their meetings with CDPO were held once in 3 months. Issues discussed in the staff meeting were registration of children and pregnant mothers from underprivileged cast for supplementary nutrition, amount of supplementary nutrition to be given daily, and growth monitoring activities"
- " Nutrition and health messages to be reached out to mothers through AWWs are also discussed. Home visits given to normal and malnourished children, pulse polio, growth monitoring of children, immunization, stock maintenance, and mahila mandal meetings" are the other issues that were discussed in the staff meeting with CDPO and Supervisors.
Perceptions of opinion leader of the community on causes, treatment, and prevention of malnutrition
•When opinion leader of the community was asked, what he understands by malnutrition, he said -
- "It is Kuposhan. It occurs due to less food given to a child at home by mothers or family members, it can also occur due to diseases like diarrhea, from which the child loses her weight
- "He feels that the main cause behind giving the less food is poverty"
- "He also said the exact cause of malnutrition is not known to majority of families, but only few people know that it occurs due to lack of proper food given to mother and children, so they take all precautions on child feeding"
- "He also said that if such children are not given proper care or treatment, may die"
•When opinion leader of the community was asked for the prevention and treatment of malnutrition they said that - "such children need proper care at home such as foods of good quality and in good quantity like milk, fruits, vegetables, egg, roti, dal-chawal, along with immunization from AWC and health center"
•The opinion leader of the community also said that - "food is not available to each children (0-6 years) due to limited budget of government for sending food to each and every child, the AWW registers only 100 children below 6 years and 20 mothers who are pregnant or lactating from SC/ST/OBC caste, which are below the poverty line families."
The opinion leader of the community perceptions -
- "Though AWW registers weak/malnourished children from SC/OBC caste, monitor their weighs, and distribute food for them
- "But despite all these activities of AWW some families do not utilize their services due to poor quality and tasteless food given to their children"
- In his view "these services of AWW are useful for the child to remain healthy."
Focus group discussion findings: AWWs and ANMs
From the focus group discussion (FGD) of AWWs and ANMs of Rural ICDS Block, it appeared that AWWs and ANMs had adequate knowledge on child health, causes, effects, treatment, and prevention of malnutrition in children. They realized the importance of food distribution, growth monitoring, breast feeding, weaning, and they have sufficient knowledge of their activities. AWWs and ANMs gave all nutrition and health education (NHE) messages on breast feeding, weaning, child hygiene, but their advices were not followed by family members and less understood by PRI members. Moreover, AWWs received no cooperation from health staff in giving nutrition and health education to community members, health examination, and immunization of children but they are regularly guided and supervised by their Supervisor (Mukhya- Sevika) and CDPO.
Data triangulation of key findings
The summary of validity of findings among Health, ICDS functionaries, and Opinion leaders regarding efforts taken by them after data triangulation is given in [Table 5].
| Discussion|| |
There has been no significant change in the prevalence of malnutrition even after the presence of ICDS functionaries and other health care providers in ICDS blocks from last 40 years; making the malnutrition a rife in India and the reasons for it are intriguing. Authors tried to explore reasons for this in study by knowing the perceptions of functionaries and community-level stakeholders and this study has revealed few interesting issues.
In our study, both AWWs had received induction as well as reorientation training; worked for more than 5 years, out of them majority of AWWs were intermediate passed, with a good nutritional knowledge and this finding was in consonance with study by Kapil et al. (1996)  and Gujral et al. (1991).  In our study, we found that the practical training of AWWs were inadequate, training activities were less realistic and there was too much emphasis on nutritional status with less emphasis on hands on training as found by other studies also by Kapil et al.,  Tandon and Kapil (1998),  and Kapil et al. (1996).  In our study, the reorientation training on malnutrition (PEM) was also lacking, which was also suggested in study of Saha et al. (2000). 
In our study; the supervisory and monitoring staff from ICDS and health department were however sufficiently qualified and experienced enough to tackle undernourishment in the ICDS Block, but their attitudes and practices were not up to the expected levels, which might be responsible for persistence of undernourishment in the area (prevalence 58% from past records) due to poor motivations percolating down the lane among AWWs as well as ANM in our study. In our study, it came out that both the AWWs (a key ICDS functionary) and ANM had adequate knowledge on child health, causes, effects, treatment, and prevention of malnutrition in children. AWWs and ANM realized the importance of supplementary nutrition or therapeutic nutrition, growth monitoring, breast feeding, and weaning.
AWWs gave all nutrition and health education messages on breast feeding, weaning, and child hygiene, but they felt that their advices were not followed by mothers. Supplementary nutrition was not distributed by AWWs on a focused target group. AWWs especially took care of severely malnourished children but focused less on mildly undernourished children. AWWs took all necessary steps to improve their health and nutrition by frequent home visits but they did not follow up the Grade 1 and 2 malnourished child. AWWs received no cooperation from health staff (ANM) in organizing nutrition and health education session, health examination, and immunization of children but they are regularly guided and supervised by Supervisors and CDPO. Radhakrishna and Ravi (2004)  had found that the mere existence of Anganwadi in village had no effect on malnutrition, only for severe malnutrition the ICDS scheme is of some help and this corroborates with our findings also.
In ANM's view, most of the mothers liked to go to a private doctor instead of government doctors and utilization of ANM's services were very selective. ANMs opined that mothers do not take preventive measures for child illnesses and malnutrition and do not follow their advices. It appeared in our study that children younger than six years were indirectly hammered by many issues such as lack of convergence at all levels of policy; poor involvement of community in planning and executing nutrition programs; and limited resource allocation as was also found in the study by Kapil et al.(1997).  In our study we also found that, there are several mismatches between the ICDS program's design and its actual implementation that prevent it from reaching its potential such as an increasing emphasis on the provision of supplementary feeding and preschool education to children of 4-6 years of age, at the expense of other program components that are crucial for combating persistent undernutrition as found in other studies also. 
It also came out from the key findings of qualitative issues in our study that from the opinion leaders had some knowledge regarding child health, child feeding, hygiene, care, health and nutritional facilities availability, and utility in the area, the causes, effects, treatment, and prevention of malnutrition in children, the main reason according to them for the malnutrition in the village was the poverty in majority of families, which restrict them to buy good food. They were also taking all possible steps for improvement of child health and nutrition and prevention and treatment of malnutrition in children of villages, although the contacts with community were very less. They were also of opinion that coordination between AWW and ANM was lacking for the follow up of malnourished children. Our study reveals that the community leaders should be trained on health and nutritional aspects of malnutrition as also advocated in studies across the globe. ,, In our study we also found that community partnerships were compromising their own success by the way the in which the community stakeholders involvement was done by ICDS and Health Care functionaries and this issue was also similar to study by Lasker (2003).  We finally found that two key perception factors such as perceptions regarding poor quality of foods distributed at AWCs as well as improper nutrition and health education in view of community members as imparted by ICDS and health department is impacting children's nutritional status in Rural ICDS block as similar to the findings of a study in Urban blocks of Delhi by Davey et al.(2008). 
Limitations of the study
Only two AWCs from a one Rural ICDS Block were selected to study the qualitative issues of perceptions and efforts of multilevel stakeholders and a very small sample size of functionaries selected may not give true generalization of the findings of this study to whole population.
| Conclusion|| |
Lack of coordination and weak efforts of ICDS and health staff, coupled with less knowledge of community-level members such as PRIs on causes, treatment, and prevention of malnutrition in their children might be responsible for poor situation of rising undernourishment in under six years children in rural area of Delhi, for which some kind of regular training programs can be conducted in community, therefore further studies also needs to be carried out on this area on priority basis.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]