WHY OUR CHILDREN ARE UNDERWEIGHT?Chinchohol Study

Presented by Dr Dhruv Mankad, Director, VACHAN, Nasik

CHINCHOHOL PHC PROFILE

Chinchohol PHC Profile

PHC Area Profile

Gram Panchayats 4

Villages 9

Habitations* 34

Population (Census 2001) 9656

% SC 3%

% ST 93%

HHs (est.) 2500

Anganwadis (ICDS, 2010) 32

Sub centres3+1(at PHC)

PHC Performance Profile

TotalInstitutional Deliveries

%

2008-09 47 16

2009-10 66 21

2010-11 133 37

Sources: Census 2001 Source: Chinchohol PHC reports 2009, 2010 and 2011

POPULATION PROFILE

About the study

Population Pyramid

NUTRITIONAL ASSESSMENTChildren of 0-60 months age group

(WHO Anthro)

There IS malnutrition

 Girls

(n=401)Boys

(n=426)Total

(n=827)

WASTING (WHZ)93

(23%)127

(30%)220

(27%)UNDERWT.(WAZ)

258 (64%)

309 (73%)

567 (69%)

STUNTING(HAZ)264

(66%)294

(69%) 558

(68%)

Malnutrition = WHZ, WAZ, HAZ (<-2 SD) (WHO Standards)

WASTING=> SAM/MAM

UNDERWEIGHT

STUNTING

Severity of malnutrition by prevalence ranges (%)

Indicator LowVery high

Chinchohol Survey

Wasting < 5>=15

%27% 220

Underwt.

<10>=30

%69% 567

Stunting <20>=40

%68% 558

Who are more malnourished?

When are they more malnourished?

0-24, 24-36 and 36-60 mths 0-24, 24-36 and 36-60 mths

SOCIO-ECONOMIC STATUS

Families and Communities

No of members

No of HH % HH

1 to 4 473 26%5 to 7 1109 61%8 to 10 199 11%10+ 31 2%  1812 100%

Communities

No of HHs

% HHs

SC 56 3%ST 1689 93%Others 67 4%Total 1812 100%

Land HoldingsLand Holding in the community Land Holding in the Scheduled Tribe

Who have irrigation facilities?

  Landowners

Irrigated %

SC 42 0 0%ST 1259 27 2%OTHERS

42 6 14%

TOTAL 1343 33 2%

Village Locations Total farmers

No. with Irrigation

%

Kas Kas 58 7 12%

Dolohol Kakadpana, Kakadpanapada

52 6 12%

Devdongra

Hedpapda, Kamathpada, Loharpada

30 6 20%

Chinchohol

Bardapada, Nilumbar

12 6 50%

Hatlondhi Hatlondhi 75 3 4%

Goldari Loharpada, Kathwadpada

16 3 19%

Bafanvihir Patachamal 12 2 17%

 Total   255 33 13%

How much are they educated?women and men

Women – agewise (%) Men-agewise (%)

How many families are aware and using govt. schemes?

  AWARE NOT AWARE USED NOT USED

Anganwadi for Nutr. Suppl.

91% 5% 70% 26%

NREGA/EGS 63% 34% 59% 37%

KHAVATI YOJANA

82% 15% 63% 33%

NGOs 10% 82% 6% 86%

IFA for Adolescent

Girls55% 41% 39% 57%

• Most families are aware of

and accessed Anganwadi

of WCD and Khavti Yojna

of TWD

• But, 34% are not aware

about any employment

guarantee scheme!

• EGS has not reached out

to 37% of the (mostly

landless) families

• 41% of families unaware

about adol. Girls

programme

• NGOs are also not very

visible

CHILD CHARACTERISTICS

Children of 0-60 age group

Composition of 0-60 months children

  No.SC 15ST 635Other 19 Total 669

Sex distribution in children 0-60 months age group

Place of Deliveries

At home 472 76%

Government hospital

144 23%

Private hospital/Jeep

4 0.6%

Total 620 100%

Birth weight• 81% have > 2 kg

birthweight• 53% > 2.5 kg• No major gender

difference

Profile of children 0-60 mths age

  No. %

Child clean 372 57

Child not clean

285 43

Total 657 100

FAMILY CHARACTERISTICSHouseholds where the children of 0-60 months age group are living

Land holdings

 

Families of 0-60 mths

children

Landless (<0.01 H)

169

Marginal (0.01-1.00 H)

232

Small (1.01-2.00 H)

157

Semi Medium + (>2.01 H)

63

Total  621

Types of housing

No.  

Kachcha 265 40%

Pucca (bricks)

404 60%

Total 669100%

Cleanliness of households

• 73% of Households have toilets

• Only 31% of HHs had clean kitchen (smokeless chullah, smoke outlet, waste water disposal system and glass tile or window)

Type of ration cards

Families having type

of ration cards

No. of familie

s

Other than Yellow Cards

242

Yellow Cards 384

  626

Families of 0-60 mths children migrating for work

 No. of

familiesMigrate for work

454

Do not migrate for work

202

Total 656

MOTHERS’ CHARACTERISTICSMothers of children of 0-6 months age group

Types of work mothers engaged in• Most mothers

engaged in household chores (non earning work)

• 44% engaged in productive (21% earning, 23% farm based)

• 13% engaged in more than one type of work – farming+labour

• 9% engaged in other types of work (petty shops etc.)

Education level of mothers of 0-6 age children

• 43% with no education

• 41% 7th std. or above

• 16% up to 10th or above

• 2 mothers graduate (1 PG, too)

WHAT WORKS FOR THE 16%?

Attitude about Breastfeeding practices

17% mothers

consider less than

12 months

adequate for

breastfeeding

33% consider 12

months as

adequate

breastfeeding

50% consider

Breastfeeding

beyond 12 months

Knowledge about Weaning Period

• 49% do not know

correctly about

when to start

weaning (0-6 too

early, 12-36 late)

CAUSES OF MALNUTRITIONRegression Analysis using R Programme

Causes of Malnutrition –Key Findings

 Types of causes

Causes of Malnutrition Association

Basic Age (in months) negative

No utilisation of NREGA/EGS negative (marginally)

No migration for work positive

Having small land positive

Underlying No Toilet negative

Child not clean negative

Having Pucca house positive

Mother’s education no association

Weaning food to be given between 6 months and 12 months positive

Breast feeding for one year after birth positive (marginally)

Immediate Anganwadi Nutrition Supplement scheme used no association

Causes of Malnutrition: Variable

Coefficient (p-value)

Model 1: Sex of the child

Age in months -0.005 (0.017)

Sex – Male (female as ref.) -0.111 (0.192)

Model 2: Breast feeding after birth (in hours) 

Age in month -0.006 (0.016)

Immediately (ref.)  

Within half-an-hour -0.138 (0.306)

Between 0.5 and 1 hour -0.109 (0.363)

Between 1 and 2 hours -0.071 (0.606)

Between 2 and 6 hours -0.102 (0.616)

Univariate Regression Analysis•Age a significant variate as a cause of malnutrition•Sex is not an important cause, both male and female are equally malnourished

Causes of Malnutrition: Variable Coefficient (p-value)

Model 3: Duration of breast feeding (in months) 

Age in month -0.005 (0.017)

Less than one year (ref.)  

One year 0.168 (0.188)

Between 1 to 2 years -0.004 (0.977)

Two years 0.182 (0.158)

Between 2 to 5 years 0.042 (0.826)

Model 4: When weaning food should be given 

Age in months -0.005 (0.017)

Before 6 months of age (ref.)  

Between 6 and 12 months 0.188 (0.044)

Between 12 and 36 months 0.112 (0.434)

Univariate Regression Analysis•Attitude about breast feeding after birth is not significant cause•Attitude about duration of breast feeding of one/two year is significant one•Knowledge about weaning between 6-12 months a significant one

Causes of Malnutrition: Variable Coefficient

(p-value)

Model 5: Accessing Employment 

Age in months -0.005 (0.014)

No utilization of NREGA/EGS -0.137 (0.169)

Model 6: Utilizing Anganwadi supplements 

Age in months -0.005 (0.032)

No utilization of A'wadi supplementary food

-0.019 (0.889)

Univariate Regression Analysis•No utilization of any employment guarantee scheme a significant cause•No access to Anganwadi supplementary food also an important cause

Causes of Malnutrition:

VariablesModel 1

(N = 620)Model 2

(N = 579 )Model 3

(N = 510)

Individual characteristics

Age -0.006 (0.03) -0.006 (0.02) -0.007 (0.02)

Sex- male (female as ref.) -0.109 -0.139 -0.123

Home delivery -0.067 -0.069 -0.107

Basic Causes: Human, Economic and Societal

Type of family      

Nuclear (ref.)      

Joint     -0.014

Family land      

Landless (< 0.01 H) (ref)      

Marginal (0.01 – 1.00 H)     0.285 (0.03)

Small (1.01 – 2.00 H)    0.397

(0.006)

Semi-medium+ (> 2.00 H)    0.126

(0.518)Migration      

Yes (ref.)      

No     0.208 (0.06)

Employment      

Utilization of NREGA/EGS (ref)

     

No utilization of NREGA/EGS

   -0.196

(0.075)

Multivariate Regression Analysis•Child’s age a significant cause•Place of delivery is not important cause•Joint family an important cause•Even a small piece of land is better than no land causing malnutrition•Migrating to work an important cause•No access to any EGS a cause

Causes of Malnutrition:

VariablesModel 1 (N = 620)

Model 2 (N = 579 )

Model 3 (N = 510)

Mother's characteristics

Work      

Not working (ref)      

Farm   0.049 -0.083

Labour   -0.022 0.056

Other source   -0.028 -0.154

More than one   -0.107 -0.087

Education      

Illiterate (ref.)      

Education up to primary school (4th)

  0.014 0.121

Education up to secondary school (7th)

  -0.041 -0.033

Education above secondary

  0.113 0.145

Weaning      

When weaning food should be given (6 to 12 mths)

   0.229

(0.023)

Multivariate Regression Analysis•Non earning mother an important cause of malnourished child•Mother’s education not important cause•Knowledge about Weaning period important cause

Causes of Malnutrition:

VariablesModel 1 (N

= 620)Model 2 (N =

579 )Model 3 (N

= 510)

Underlying Causes: Food Security, Environment, MCH and Health Care Services

Ration card      

‘Yellow’ ration card (ref)

     

Other than ‘yellow’ ration card

    -0.015

House type      

Kaccha (ref)      

Pucca     0.082

Toilet      

Yes (ref.)      

No     -0.029

Clean kitchen      

Yes (ref.)      

No     0.048

Cleanliness of child      

Yes (ref.)      

No     -0.209 (0.07)

Multivariate Regression Analysis•Yellow ration card holding is important cause•Kaccha household also an important factor•No cleanliness has a significant effect

Most important causes

Basic Causes:•Age

Underlying Causes:•Small land holding•No utilisation of NREGA/EGS leading to low

purchase power•When weaning food should be given (between 6

to 12 months)

RECOMMENDED ACTION PLANSShort Term and

Long Term Action Plans

Short Term Action Plan

1. Rebuild confidence and role of Anganwadi Workers• Build up capacity of Anganwadi Workers: • Behaviour Change Communication through home visit• Make IEC material for BCC for child growth and development

2. Improve supplementary food for all AW children:• Introduce a variety of food – ground nut. Gud; egg etc.• Train AW helpers to cook such variety using local resources by

nutritionists/dieticians • Design a set of time table for day-to-day activities other than

supplementary feeding• Quality checking of any standard, FDA approved healthy food

(RUTF/RTF/THF), if it is introduced.

Family Centered, Simultaneous implementation Approach

Short Term Action Plan3. Ensure core intervention services for the vulnerable

population • Train newly wedded couples in responsible parenthood with focus on delay

parenthood, spacing – by ASHA • Train adolescent girls in life cycle and earning skills through vocational

training by NGOs• Train women for pregnancy and natal planning including for spacing and

breast feeding – by Dais, AWW helper• Continue supplementary feeding for pregnant women and breast feeding

mothers• Encourage a special services including temporary day care for 0-2 year old

children by trained dais, elderly or experienced women. • Ensure the families having underweight children have food security

through effective PDS and gainful employment to all able bodied members through employment guarantee schemes through Gram Sevaks

Short Term Action Plan

4. Involve media and NGOs in positive actions and its impact:

• Media and NGOs be involved in designing, planning, implementing and monitoring

• Training Workshop for the media persons about causes of malnutrition

• Involve NGOs in implementing innovative approaches and in monitoring the existing programmes

• Involve home science college/s for innovative approaches and in monitoring the existing programmes particularly for recipes for nutritious supplementary food using local resources

Short Term Action Plan5. Involve the community in positive actions and their

monitoring:• Involve VHSCs in community based monitoring of the

Anganwadis• Involve NGOs in reviving community based Child

Development Centers for MAMs

6. Enhance health care services for women and children:• Use of referral transportation for risk detection during ANC • Ensure frequent antenatal and postnatal care to eligible

women and newborn babies by mobile vans• Ensure availability of the guaranteed services at the sub

center, 24X7 PHCs and rural hospital including availability of an obstetrician and a pediatrician OR on a mobile van

Short Term Action Plan

7. Involve all the other related department, agencies to overcome other causes

• Workshop for other departments from block, district level and Nashik Municipal Corporation etc.

• Co-ordinate various services • Involve NGOs for alternative livelihood system to

discourage migration of parents of 0-6 age children • Ensure food security, women and child health care

under urban health services and at urban anganwadi through NGOs

What is to be done?

•Further studies • Tracking Children discharged from CDC• Tracking Children with migrated families• Analyzing Causes of Death of Children 0-5 using a new format (direct, indirect cause of death)

• Breast feeding practices among women ‘at home’ in rural background

IMPROVED NUTRITION

HEALTH CARE SERVICES FOR MOTHERS AND CHILDREN

SUPPLEMENTARY FOOD FOR CHILDREN

HEALTH CARE SERVICES FOR ADOLESCENT GIRLS

ENHANCED FOOD SECURITY FOR FAMILIES HAVING VULNERABLE CHILDREN AND ADULTS

EDCUATION INCL. LIFE SKILL EDUCATION ADOLESCENT GIRLS

IMPROVED NUTRITIONAL STATUS AS A GOAL OF POVERTY ALLEVIATION PROGRAMMES

VOCATIONAL TRAINING/ EMPLOYMENT ORIENTED EDUCATION TO BOYS AND GIRLS

NUTRITION DEFICIT AS A BASIS OF POVERTY LINE AND WAGES

Spider Map for Long Term Action Plan