Presentation of Study Conducted by VACHAN on Causes of Malnutrition in District Planning and Development Committee and to Secretary, Governor of Maharashtra

1. WHY OUR CHILDREN
ARE UNDERWEIGHT?
Chinchohol Study
Presented by Dr Dhruv Mankad, Director, VACHAN, Nasik

2. CHINCHOHOL PHC
PROFILE

4. Chinchohol PHC Profile
PHC Area Profile PHC Performance Profile
Gram Panchayats 4
Total %
Institutional
Villages 9 Deliveries
Habitations* 34
Population (Census 2001) 9656 2008-09 47 16
% SC 3%
% ST 93% 2009-10 66 21
HHs (est.) 2500
Anganwadis (ICDS, 2010) 32
2010-11 133 37
3+1(at
Sub centres PHC)
Sources: Census 2001 Source: Chinchohol PHC reports 2009, 2010 and 2011

5. POPULATION PROFILE

6. About the Population Pyramid
study

7. NUTRITIONAL
ASSESSMENT
Children of 0-60 months age group
(WHO Anthro)

8. There IS malnutrition
Girls Boys Total
(n=401) (n=426) (n=827)
93 127 220
WASTING (WHZ) (23%) (30%) (27%)
UNDERWT. 258 309 567
(WAZ) (64%) (73%) (69%)
264 294 558
STUNTING(HAZ) (66%) (69%) (68%)
Malnutrition = WHZ, WAZ, HAZ (<-2 SD)
(WHO Standards)

9. WASTING=> SAM/MAM

10. UNDERWEIGHT

11. STUNTING

12. Severity of malnutrition by prevalence
ranges (%)
Very Chinchohol
Indicator Low
high Survey
>=15
Wasting < 5 27% 220
%
Underwt >=30
<10 69% 567
. %
>=40
Stunting <20 68% 558
%

13. Who are more malnourished?

14. When are they more
malnourished?
0-24, 24-36 and 36-60 mths 0-24, 24-36 and 36-60 mths

15. SOCIO-ECONOMIC
STATUS

16. Families and Communities
Communiti No of % HHs
es HHs
SC 56 3%
ST 1689 93%
Others 67 4%
Total 1812 100%
No of No of HH % HH
members
1 to 4 473 26%
5 to 7 1109 61%
8 to 10 199 11%
10+ 31 2%
1812 100%

17. Land Holdings
Land Holding in the community Land Holding in the Scheduled Tribe

18. Who have irrigation facilities?
Village Locations Total No. with %
farmers Irrigation
Kas Kas 58 7 12%
Dolohol Kakadpana, 52 6 12%
Kakadpanapad
a
Landowner Irrigated % Devdongr Hedpapda, 30 6 20%
s a Kamathpada,
SC 42 0 0% Loharpada
Chinchoh Bardapada, 12 6 50%
ST 1259 27 2% ol Nilumbar
OTHE 42 6 14% Hatlondhi Hatlondhi 75 3 4%
RS
Goldari Loharpada, 16 3 19%
TOTAL 1343 33 2% Kathwadpada
Bafanvihir Patachamal 12 2 17%
Total 255 33 13%

19. How much are they educated?
women and men
Women – agewise (%) Men-agewise (%)

20. How many
families are
aware and
using govt. AWARE NOT AWARE USED NOT USED
schemes? Anganwadi
for Nutr. 91% 5% 70% 26%
• Most families are aware of Suppl.
and accessed Anganwadi
of WCD and Khavti Yojna NREGA/EGS 63% 34% 59% 37%
of TWD
• But, 34% are not aware KHAVATI
82% 15% 63% 33%
about any employment YOJANA
guarantee scheme!
• EGS has not reached out NGOs 10% 82% 6% 86%
to 37% of the (mostly
landless) families IFA for
• 41% of families unaware Adolescent 55% 41% 39% 57%
Girls
about adol. Girls
programme
• NGOs are also not very
visible

21. CHILD
CHARACTERISTICS
Children of 0-60 age group

22. Composition
of 0-60
months
children
No.
SC 15
ST 635
Other 19
Total 669

23. Sex distribution in children
0-60 months age group

24. Place of Deliveries
At home 472 76%
Government
144 23%
hospital
Private
4 0.6%
hospital/Jeep
Total 620 100%

25. Birth weight
• 81% have > 2 kg
birthweight
• 53% > 2.5 kg
• No major gender
difference

26. Profile of children 0-60 mths age
No. %
Child clean 372 57
Child not
285 43
clean
Total 657 100

27. FAMILY
CHARACTERISTICS
Households where the children of 0-60 months age
group are living

28. Land holdings
Families
of 0-60
mths
children
Landless
169
(<0.01 H)
Marginal (0.01-
232
1.00 H)
Small (1.01-
157
2.00 H)
Semi Medium +
63
(>2.01 H)
Total 621

29. Types of
housing
No.
Kachcha 265 40%
Pucca
404 60%
(bricks)
100
Total 669
%

30. 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)

31. Type of ration
cards
Families
No. of
having type
familie
of ration
s
cards
Other than
242
Yellow Cards
Yellow Cards 384
626

32. Families of 0-
60 mths
children
migrating for
work
No. of
families
Migrate for
454
work
Do not
migrate for 202
work
Total 656

33. MOTHERS’
CHARACTERISTICS
Mothers of children of 0-6 months age group

34. 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.)

35. 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%?

36. 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

37. Knowledge
about
Weaning
Period
• 49% do not know
correctly about
when to start
weaning (0-6 too
early, 12-36 late)

38. CAUSES OF
MALNUTRITION
Regression Analysis using R Programme

40. Causes of Malnutrition –Key
Findings
Types of
Causes of Malnutrition Association
causes
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

41. Causes of
Coefficient (p-
Malnutrition: Variable
value)
Univariate Regression Model 1: Sex of the child
Analysis
•Age a significant variate
Age in months -0.005 (0.017)
as a cause of Sex – Male (female as ref.) -0.111 (0.192)
malnutrition
•Sex is not an important Model 2: Breast feeding after birth (in hours)
cause, both male and
female are equally Age in month -0.006 (0.016)
malnourished 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)

42. Causes of
Malnutrition: Variable Coefficient (p-value)
Univariate Regression Model 3: Duration of breast feeding (in months)
Analysis
•Attitude about breast Age in month -0.005 (0.017)
feeding after birth is not Less than one year (ref.)
significant cause
One year 0.168 (0.188)
•Attitude about duration
of breast feeding of Between 1 to 2 years -0.004 (0.977)
one/two year is Two years 0.182 (0.158)
significant one Between 2 to 5 years 0.042 (0.826)
•Knowledge about
Model 4: When weaning food should be given
weaning between 6-12
months a significant one 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)

43. Causes of
Malnutrition: Variable
Coefficient
(p-value)
Univariate Regression Model 5: Accessing Employment
Analysis
•No utilization of any Age in months -0.005 (0.014)
employment guarantee
scheme a significant No utilization of NREGA/EGS -0.137 (0.169)
cause
•No access to
Model 6: Utilizing Anganwadi supplements
Anganwadi
supplementary food also
an important cause Age in months -0.005 (0.032)
No utilization of A'wadi
-0.019 (0.889)
supplementary food

44. Model 1 Model 2 Model 3
Variables
(N = 620) (N = 579 ) (N = 510)
Individual characteristics
Age -0.006 (0.03) -0.006 (0.02) -0.007 (0.02)
Causes of Sex- male (female as ref.) -0.109 -0.139 -0.123
Malnutrition: Home delivery -0.067 -0.069 -0.107
Basic Causes: Human, Economic and Societal
Multivariate
Regression Analysis Type of family
•Child’s age a significant Nuclear (ref.)
cause Joint -0.014
Family land
•Place of delivery is not
important cause Landless (< 0.01 H) (ref)
•Joint family an
important cause Marginal (0.01 – 1.00 H) 0.285 (0.03)
•Even a small piece of 0.397
Small (1.01 – 2.00 H)
land is better than no (0.006)
land causing Semi-medium+ (> 2.00 H)
0.126
malnutrition (0.518)
•Migrating to work an Migration
important cause Yes (ref.)
•No access to any EGS No 0.208 (0.06)
a cause Employment
Utilization of NREGA/EGS
(ref)
No utilization of -0.196
NREGA/EGS (0.075)

45. Model 1 Model 2 Model 3
Variables
(N = 620) (N = 579 ) (N = 510)
Mother's characteristics
Causes of Work
Malnutrition: Not working (ref)
Farm 0.049 -0.083
Multivariate Regression
Analysis Labour -0.022 0.056
•Non earning mother an Other source -0.028 -0.154
important cause of More than one -0.107 -0.087
malnourished child
Education
•Mother’s education not
important cause Illiterate (ref.)
•Knowledge about Education up to
Weaning period 0.014 0.121
primary school (4th)
important cause
Education up to
-0.041 -0.033
secondary school (7th)
Education above
0.113 0.145
secondary
Weaning
When weaning food
0.229
should be given (6 to
(0.023)
12 mths)

46. Model 1 (N Model 2 (N = Model 3 (N
Variables
= 620) 579 ) = 510)
Underlying Causes: Food Security, Environment, MCH and
Causes of Health Care Services
Malnutrition: Ration card
‘Yellow’ ration card
Multivariate Regression (ref)
Analysis
•Yellow ration card
Other than ‘yellow’
-0.015
ration card
holding is important
cause House type
•Kaccha household also Kaccha (ref)
an important factor Pucca 0.082
•No cleanliness has a
Toilet
significant effect
Yes (ref.)
No -0.029
Clean kitchen
Yes (ref.)
No 0.048
Cleanliness of child
Yes (ref.)
No -0.209 (0.07)

47. 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)

48. RECOMMENDED ACTION
PLANS
Short Term and
Long Term Action Plans

49. Short Term Action Plan
Family Centered, Simultaneous implementation
Approach
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
1. 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.

50. Short Term Action Plan
3. 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

51. 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

52. Short Term Action Plan
5. 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

53. 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

54. 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

55. Spider Map for Long Term Action Plan
HEALTH CARE SERVICES
FOR MOTHERS AND SUPPLEMENTARY FOOD
CHILDREN FOR CHILDREN
ENHANCED FOOD
SECURITY FOR FAMILIES
HEALTH CARE SERVICES
HAVING VULNERABLE
FOR ADOLESCENT GIRLS
CHILDREN AND ADULTS
IMPROVED
NUTRITION
EDCUATION INCL. LIFE IMPROVED NUTRITIONAL
SKILL EDUCATION STATUS AS A GOAL OF
POVERTY ALLEVIATION
ADOLESCENT GIRLS
PROGRAMMES
VOCATIONAL TRAINING/ NUTRITION DEFICIT AS A
EMPLOYMENT ORIENTED BASIS OF POVERTY LINE
EDUCATION TO BOYS AND WAGES
AND GIRLS