Community Based Maternal & Child Health Nutrition (MCHN) Project

Community Based Maternal & Child
Health Nutrition (MCHN) Project
Evaluation Report
Submitted to:
GoUP (Directorate of FW & Directorate of ICDS) and
Unicef, Lucknow
Ashish Gupta, MBA

Anamika Misra, PhD
ORG Centre for Social Research

(A Division of ACNielsen ORG-MARG Private Limited)
Lucknow
(2006)
Community Based Maternal & Child
Health Nutrition (MCHN) Project
Evaluation
Report
Submitted to:
GoUP (Directorate of FW & Directorate of ICDS) and
Unicef, Lucknow
ORG Centre for Social Research

(A Division of ACNielsen ORG-MARG Private
Limited)
Lucknow
Acknowledgement
We are extremely thankful to UNICEF for providing us an opportunity to Evaluate the

Community Based Maternal and Child Health Nutrition (MCHN) Project’ in four project
districts of Uttar Pradesh. We also thank Dr. L.B. Prasad, DG Family Welfare and ICDS
Directorate along its team for their valuable inputs and necessary support. The technical
inputs received from Dr. Sheila Vir, Project Officer (Nutrition), towards completion of
this assignment, are also appreciated.
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
1. Community based MCHN Project

-A Background……………………………...…………………I.01 – I.08
2. Evaluation Methodology
-An approach, data collection and analysis…………..….......II.01 – II.5
3. Accomplishing the processes

-An evaluation of the process objectives…………………..III.01 – II.19
4. Achieving the project objectives

-An evaluation of the project impact……...………………IV.01 – IV.43
5. The outcomes of the project

-MCHN concepts…….………………...…...……………...V.01 – V.013
ORG Centre for Social Research, Lucknow Executive Summary
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.
Key objectives of the Community based MCHN project included;

1. Reducing underweight in children <2years by 20%
2. Improving coverage of children with Vitamin A supplementation to 80%
3. Ensuring 60% women consume a minimum of 100 Iron-Folic-Acid (IFA) tablets
4. Ensuring 100% households use only iodised salt.
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
Community Based MCHN Project – An Evaluation I

Target Population " At Risk” Families:

The MCHN project focused on the most crucial period of life i.e. children below 2 years,
pregnant, lactating women and newly wed. Children below six years with clinical sign of sever
malnutrition were given special attention. Therefore families who had any one member in this
category were accorded priority and were recognised as "At Risk" of undernutrition.
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.
Community Based MCHN Project – An Evaluation II

Methodology and Sample Coverage:
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.
Community Based MCHN Project – An Evaluation III

A- Process Objectives (Qualitative Survey): Findings

• Malnutrition conceptual framework of UNICEF formed the basis for all the processes –
project planning, training, implementation as well as monitoring.
• 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.
• District-level, multi-sectoral orientation and planning workshops were more interestingly

conducted with full participation of various sectors and community-based exercises.
These workshops provided an insight into malnutrition and reinforced the concept of
multi-sectoral approach building consensus regarding the strategy, which lead to
formulation of comprehensive plan-of-action of the community based MCHN Project.
• District orientation workshops interestingly included community based activities with

special focus on issues to understand malnutrition problem of children through visits to
families for assessment, analysis and action. Following this exercise, other sectors such
as WES, PRI, Horticulture beside ICDS and Health could understand and appreciate
their role in reducing undernutrition. This led to not only a better understanding of
sectors but also resulted in higher level of involvement.
• 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
Community Based MCHN Project – An Evaluation IV

• 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.
B- Impact Objectives (Quantitative Survey): Findings
In accordance with the key Project objectives results have been presented as below:
i) Nutritional Status of below 2 years children:
• A considerable decline of 43% in the proportion of severely malnourished (IAP

classification method) children (baseline: 25%; endline: 14%). The proportion of
severely and moderate malnourished cases was slightly higher in case of female children
below 2 year of age, in comparison to their male counterparts
• 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.
Community Based MCHN Project – An Evaluation V

ii) Maternal & Newborn & Infant Care
iia) Consumption of IFA tablets:

• Overall, a high proportion (88%) of women contacted during study was found possessing
knowledge about consuming 100 IFA tablets during pregnancy.
• Compared to 6 percent during Baseline 61 percent in the endline confirmed receiving

90+ IFA tablets during their index pregnancy.
• 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.
iib) Maternal Care

• As against 80% of the mothers were aware about three ANC check ups to be done during
the pregnancy, only 12% of the mothers received all the three antenatal check-up during
their index pregnancy. Not much difference in the baseline and endline proportion was
observed in this regard.
• 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.
Community Based MCHN Project – An Evaluation VI

• 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.
iic) Newborn Care

• In high proportion of cases (87%) washing of hands with soap by person assisting
delivery was observed in the endline.
• 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.
iid) Infant & Young Child Feeding

• The practice of initiating breastfeeding within 1 hour of birth has increased by five times
in the endline (21.9%) than Baseline (4.6%)
• 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.
iie) Vitamin A supplementation (VAS):

• As per the vaccination card, slightly more than a fourth received one dose of VAS while
the proportion receiving all the three doses was 3 percent. One of the reasons for low
VAS coverage was poor service response from ANMs who got engaged in unexpected
priorities such as pulse polio drives. Also, the supply of VAS was not planned under the
Project and no special effort was made in this regard. VAS programme was totally
dependent on the governmental supplies and on going efforts administration of VAS.
• 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
Community Based MCHN Project – An Evaluation VII

services to address the problem of micronutrient malnutrition. The low coverage of

children with VAS in MCHN project 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 state-wide in 70 districts.
iii) Household level practices
iiia) Consumption of iodized salt:

• As far as awareness on benefit of consuming iodized salt is concerned, 12% responded
that it improves physical and mental health of newborn while one-third reported that it
prevents goitre.
• 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
iiib) Safe drinking water and Hygiene & Sanitation

• An increase in usage of ORS was reported. Use of ORS at the time of diarrohea was
known to more than one- fourth of the mothers contacted during endline study as
compared to that during baseline (16%).
• 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%.
Community Based MCHN Project – An Evaluation VIII

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.
• A system needs to be developed so that the State ownership of a Project is sustained

despite transfers of officials at State or district level. The ownership of project by ICDS &
Health at state and district level remained marginal. In MCHN the problem of Project
ownership was tackled, to a large extent, by involving Medical Colleges (SNRC/DNRC)
at the district. With their regular presence, they provided the necessary technical support
throughout the implementation of the Project.
• The strategy of involving Block-Trainer-cum-Monitor (BTM), who was the additional

staff, was very effective. Under the supervision of Medical Colleges BTM was the key
person helping Project implementation at grass-root-level.
• BPMs (Bal-Parivar-Mitra) meaning ‘friends of families’ were community based

volunteers selected and trained by the Project made regular contacts to target groups,
which helped increasing the correct knowledge and practices among them. They also
coordinated and supported ANMs and AWWs in their activities.
• 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.
Community Based MCHN Project – An Evaluation IX

• 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.
Community Based MCHN Project – An Evaluation X

Community Based MCHN Project
Overview of Nutrition Situation in U.P.

- A Background
1
Uttar Pradesh is the most populous state of the India Union and accounts for almost one
sixth of the country’s population. The state scenario with respect to the status of mother
and child calls for renewed efforts on the part of service providers on one hand and the
community on the other. As per SRS 2004, Uttar Pradesh has a high incidence of Infant
Mortality Rate (IMR) of 72 against the national average of 60. Further, according to
NFHS-II the state has high under-five mortality rate of 123, total fertility rate (TFR for
past three years) of 3.99, and a high prevalence of Protein-Energy Malnutrition (PEM) with
52 percent of children below three years of age being underweight and 55.5 percent are
stunted. Similar estimates at the national level are 47 and 46 percent, respectively. The
proportion of children who are severely undernourished is also very high – 22 percent
according to weight-for-age and 31 percent according to height-for-age category (using
International Standard Deviation Norms).
According to WHO estimations, malnutrition is directly or indirectly associated with over

half of all child deaths occurring in developing countries. U.P. has the highest number of
malnourished children in the country with 5 out of 10 children below three years of age
suffering from chronic under nutrition. Malnutrition in children usually sets at the age of 8-
11 months when adequate semi solid complementary foods are not given along with breast
milk. This period is the most vulnerable time for the transmission of faecal pathogens,
resulting in high incidence of diarrhoea and other preventable diseases. A malnourished
child is much more likely to die as a result of common childhood diseases than those who
are adequately nourished.
An analysis of causative factors associated with nutritional status of children of Uttar

Pradesh reveals an association of underweight children with the three essentials – health,
Evaluation of MCHN Project I-11

hygiene and sanitation – a Figure 1.1: Conceptual framework of MCHN strategy *
situation further complicated Outcome
Malnutrition
by a lack of awareness on
Immediate
maternal and childcare and Inadequate Dietary Intake Disease
determinants
nutrition. Poor food hygiene
combined with lack of ready Inadequate Inadequate Care Insufficient Health Underlying
Access to for Mothers services & Unhealthy determinants
access to water and Food and Children Environment
environmental sanitation, Inadequate Education

further contributes to Resources & Control Basic
Human, Economic & Organisational determinants
malnutrition and is therefore
considered important Political & Ideological Superstructure
Economic Structure * UNICEF
underlying causes of Conceptual
Potential Resources
framework
malnutrition.
Besides, children, malnutrition in form of Chronic Energy Deficiency is very high in

women in the reproductive age group. 30 percent of the women are reported to have Body
Mass Index (BMI) less than 18.5 (IASDS, 1998), and on an average 80 percent of pregnant
women are anaemic. Maternal malnutrition is often the major contributing cause of Low
birth weight (LBW). It is estimated that every third child in U.P is low birth weight.
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).

Community Based Maternal and Child Health Nutrition Project (referred as MCHN
project), was implemented with a view to deliver a community based model addressing the
poor nutritional status of women and children in the state of Uttar Pradesh. The project
has been conceptualized and developed in 1999 with the active participation of the
Directorate of Health and Family Welfare, Directorate of Women and Child development,
Departments of Social and Preventive medicine of state medical colleges and UNICEF.
For reducing the under-nutrition the MCHN project aimed at prevention of malnutrition
by addressing issues related to prevention of infections, intergeneration cycle of
malnutrition, poor birth weight and poor start in life.
The PROJECT STRETAGY:
Multi-sectoral (Health, ICDS, Rural

Development/ Panchayat Raj Figure 1.2: AREA OF PROJECT
Institution (PRI) participation, for Bichpuri & Fatehpur Sikri

(Agra)
addressing immediate and underlined
Harahua &
determinants of malnutrition, Chiraigaon
(Varanasi)
promoting community mobilization
and concentrating on selected “at
Babina & Bangara
risk” families who are reached through (Jhansi)
elected community volunteers

Jasra & Saidabad
(Community Health Nutrition (Allahabad)
Sanitation Mobilizers i.e. CHNSMs)

or Bal Parivar Mitra (BPMs). MCHN project is based on the principle of:
Addressing intergenerational cycle of growth failure.

Breaking nutrition and infection cycle
Converging of sectors of Health and Family Welfare, ICDS and Rural Development-
Water, Sanitation, Panchayat Raj Institutions.

PROJECT COVERAGE:
The project was to be implemented in Table 1.1: Population covered by the Project
four districts of U.P. - Jhansi, SNRC/
District Blocks No. of
Population DNRC
Allahabad, Agra, Varanasi. In each of villages
SN
Bichpuri 57 146625
four districts, two blocks were selected Agra
Medical
Fatehpur College,
95 154876
and high priority was given to blocks Sikri Agra
MLB
with ICDS project in operation. Babina 108 188473 Medical
Jhansi
College,
However, in block Saidabad Bangara 80 165637 Jhansi
Jasra 113 162540 MLN
(Allahabad) ICDS was not there Allaha- Medical
bad Saidabad 119 207000 College,
initially but it came in after sometime. Allahabad
Harahua 176 166466 IMS,
A total of 907 villages of 8 blocks of 4 Varanasi BHU,
Chiraigaon 159 139932 Varanasi
districts were covered under the
Total 907 1331549 -
project (Table 1.1 and Figure 1.2).
The community based Figure 1.3: Organograme of CB-MCHN Project

MCHN plan of action
Directorate of Family Welfare
(PoA) was developed in
1999. The roles of sectors
MCHN PROJECT
were defined along with
Social and Preventive State Based Institution (Medical Colleges)
Medicine (SPM)
Department of medical ICDS Block Trainers cum Monitor District CMO
(BTM)
colleges in the PoA. The
medical colleges focused Community Mobilisers
PRI WESS
(Community Demand and Behavioural Change)
on supporting planning,
and in coordination
Services- Infant/child/Maternal Care
implementation with MCH
department, Directorate of
Family Welfare. Directorate of Family Welfare was the nodal agency at state level.
Besides promoting holistic approach model for services (Figure 1.1), project also envisaged
the involvement of Community Health Nutrition and Sanitation Mobilisers (CHNSMs)

named as Bal Parivar Mitra (BPM). In each village of 1000 to 1500 population, 4 to 5
CHNSMs were identified using Cluster Community Participatory Approach. In order to
facilitate them in performing their major functions training was organized at sector level
for all the selected 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.
For effective multisectoral implementation, the process involved joint training of

representatives of the concerned departments as well as joint monitoring at district, block
sector level (refer organogram). Sensitization of all sectors (district to grass root level)
regarding their roles in addressing malnutrition was achieved by using the UNICEF’s

conceptual framework∗ of malnutrition (Figure 1.1) and using innovative participatory
training methodology. The emphasis of training was not merely on food and feeding but
role of various sectors (Health, Family Welfare, Agriculture, Water and Sanitation) in
preventing under nutrition was actively discussed. Investing in nutrition and addressing
malnutrition by all sectors was promoted as children’s right to good nutrition and health.
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.

Liking community demand with the health and ICDS sectors with a view to ensure
timely services are provided.
Empower community with information on maternal and childcare 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.
IMPACT OBJECTIVES:
Key objective of the MCHN project were as follows:
Reducing protein-energy malnutrition in young children below 2 years by 20% of the

current level in a period of 2 years.
Improving coverage of children in the 9 months-3 years age group with doses of
vitamin A supplements to 80%.
Ensuring that 100% households use only iodized salt.
Ensuring 60% women consume a minimum of 100 IFA tablets.
EXPECTED OUTCPMES:
Reduction in moderate malnutrition in children <2yrs 20%

Reduction in severe malnutrition in children < 6yrs 50%
Ensuring availability of iodised salt in household 100%
Early registration of pregnant mothers with antenatal care services (Tetanus
immunization, iron and folic tablets, counseling on self care including diet) 80%
Coverage of pregnant mothers with minimum of 100 IFA tablets 60%
Registration of newborn children within 7 days and ensuring essential new-
born care to all 50%
Coverage of children less than 2 years with full immunization 80%
Coverage of children between 9 months to 3 years with 5 doses of Vitamin A 80%
Prevention and correct case management of episode of diarrhoea and ARI
cases of children below 2 years, including health education of mothers 80%
Percentage of mothers counseled on appropriate child care 80%
Mothers informed of exclusive breastfeeding for the first six months and
appropriate introduction of semi-solid food at about six months 80%
Ensuring newly married couples are aware of use and availability of birth
spacing devises and encouraged to delay first pregnancy to >20years of age 80%

PROJECT DURATION:
The project plan of Action was approved on 25th June 2000. The project commenced with
execution of baseline study between July to December 2000. The implementation of
project activities was undertaken during January 2001 to December 2004. A mid term
survey was conducted by all the four DNRCs to review the project progress and the
project continued up to December 2004.
STRUCTURE OF THE REPORT:

Chapter I, Preceded by Executive Summary, dealt with the project background. The
subsequent sections of the report would consist of 5 chapters. Chapter II contains the
detailed evaluation survey methodology. The evaluation of process objective has been
presented in Chapter-3, while the evaluation of impact objectives has been discussed in
Chapter-4. Chapter-5 presents the Discussion and Conclusion based on the study findings.

Evaluation Methodology
- An Approach, Data Collection & Analysis
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.
Methodology and Sample Coverage
A) Qualitative Survey (Process Documentation)
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. While in-depth discussions were done with the State, District and
Block project functionaries, semi-structured interviewed were undertaken with the village
level project functionaries/volunteers. Focus Group Discussions and In-depth interviews
were conducted on the target population of each of the projects.
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.
Evaluation of MCHN Project II-1

Table 2.1: Sample covered during qualitative phase
Village Level
Unicef State District Block
Projects level level level level Functionaries Target BPMs
officials officials officials officials Population
(ANM/AWW/VDO)
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’.
B) Quantitative Survey (Endline Impact Evaluation)

For quantitative surveys, both the blocks from each of the four MCHN districts viz. Agra
(blocks-Bitchpuri & Fatehpur Sikri), Allahabad (Jasra & Saidabad), Jhansi (Babina &
Bangara) and Varanasi (blocks Chiraigaon & Harhua) were covered. The quantitative
survey was carried out among the mothers of children currently aged 0-24 months, newly
married couples and Bal Parivar Mitras (BPMs). The MCHN project was withdrawn or got
completed in December 2004 but the fieldwork of quantitative evaluation study was
undertaken after a gap of around 4 to 5 months in the months of April to May 2005.
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.
Finalization of Tools of enquiry

The survey schedules were finalized in three steps. Draft schedules were developed
after reviewing baseline schedules and other secondary literature. The draft
schedules were discussed in a meeting organized for this purpose where all the
stakeholders shared their views and gave their joint suggestions. During this meeting
the sampling and research methodology was further refined. On the basis of this
meeting, all the schedules were revised and were then field-tested. Necessary
changes from field-testing were incorporated and the schedules were finalized after
suggestions from the Unicef.

Size for survey among the Mothers: 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:
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.

Procedure for Selection of Households: 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 each cluster, to select the required number of respondents
the field supervisor moved to the centre of the quadrant and selected a household
randomly. In the contacted household, it was verified whether the household had a child
who was aged 0-24 months of age. If the child and the mother were present there then the
household was selected and the structured household questionnaire was canvassed. If not,
the investigator moved to the immediate next household and a similar enquiry was made.
This process continued till the required sample size of 5 mothers in each quadrant was
achieved.
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.
Recruitment Of Field Staff: The concerned professionals of ORG-CSR in association with

the field executives looked after the recruitment of female investigators/ male investigators
and supervisors. The recruitment was made from the existing panel of trained and

experienced field supervisors and investigators. Candidates having prior survey experience,
especially in conducting large-scale surveys were recruited for the survey. The candidates
having at least a bachelor degree in any discipline were recruited as supervisors and
interviewers. Candidates having social science degree and prior survey experience were
given preference.
Table 2.2: Sample covered during quantitative phase

Total Sample Size
Sn Coverage (Area)
Mothers of <2 yrs child New Wed BPM
1. Agra 400 60 25
2 Allahabad 402 64 29
3 Jhansi 400 59 31
4 Varanasi 399 56 31
Total 1601 239 116
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.

BACKGROUND
Accomplishing The Processes
- An evaluation of the process objectives
3
Appraising the facts related to high incidence of malnutrition among children, MCHN project was
conceptualized to address the problem by adopting a multi-pronged approach involving
community participation and fostering multisectoral collaboration. UNICEF conceptual
framework formed the basis for all the processes – project planning, training, implementation and
monitoring.
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.
Evaluation of MCHN Project III- 1

This was followed by district-level, multi-
Box 3a: Plan-of-action – a prerequisite
sectoral orientation and planning workshops of
to effective implementation process
three days duration, which were organized at
Developing a blueprint for the project is lengthy
Agra, Varanasi, Allahabad, Jhansi and Lucknow
but a methodical process. It requires several
by the departments of Social and Preventive iterations and suggestions from all the sectors &
Medicines (SPM) of the respective Medical officials involved. Several planning workshops in
MCHN project were undertaken before the
Colleges. These workshops were more
overall design of the project was laid down.
interestingly conducted with full participation of
sectors and community-based exercises. The community based activities focused on the issues to
understand malnutrition problem of children through visits to families for assessment, analysis and
action. Following this exercise various other sectors such as WES, PRI, Horticulture beside ICDS
and Health could understand and appreciate their role in reducing undernutrition. This resulted in
various sectors appreciating the Unicef’s conceptual framework of malnutrition and recognizing
their roles in addressing malnutrition. This led to not only a better understanding of sectors but
also resulted in higher level of involvement. These workshops provided an insight into
malnutrition developing a strong conceptual framework and building consensus regarding the
strategy, which lead to formulation of comprehensive plan-of-action of the community based
MCHN Project.
Defining the Objectives
Use of UNICEF’s conceptual framework of

Box 3b: “Process objectives avoided
malnutrition helped in defining the project
deviations from planned execution…”
objectives. MCHN project clearly spelled out
both ‘Process Objectives’ and ‘Impact “…besides Impact objectives, defining the
process objectives not only helps in methodical
Objectives’ to achieve the pre-defined
implementation but also in measuring the
‘Expected Outcomes’. Key objectives on which process/stages of implementation”. – Dr. S.C.
project envisaged to make an impact were Mahapatra, DNRC (Varanasi)
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

clearly defined all the process objectives to achieve the project objectives, which helped in proper
implementation of the project.
Reaching the families most “At Risk” of undernutrition
Towards ensuring and reaching families the most ‘at

Box 3c: Families at Risk of undernourishment:
risk’ of undernutrition, MCHN project defined the
Pregnant women
population segment that need to be reached and Less than 2 year children (including
lactating mother)
counseled urgently for preventing under nutrition. Newly married women (within one year
and without any child)
These families were referred as ‘Risk families or
Severely malnourished children < 6 years
Khatare Wale Pariwar’ and included 4 groups (See
Box 3c). This resulted in reducing the number of families to be reached by Bal Parivar Mitra to
only 40-50-families/1000 population instead of 200 families. The identification of such families by
Bal Parivar Mitra was not difficult and they could be visited and counseled frequently.
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.

It also emerged that
Figure III.1: Project Organogram
barring few Panchayati
Project Directorate of Family
Raj functionaries others Convener
SNRC Departments Levels
remained superficially Agra/Lucknow
ICDS Health PRI
attached with the MCHN
DNRC (Medical District
College) Level
project. At the state level,
DPO CMO DPRO Block
the involvement of State BTM Level
Department of Family CDPO MOIC BDO

(Mukhya Sevika) (Health Supervisor) (ADO-P) Village
Welfare and ICDS was Level
not adequate. Following AWW ANM GPVA

project approval, the
nodal department did not BPM
play an active role. Not
only the coordination between the department and ICDS was week, but also, follow up regarding
implementation of envisaged project components was not viewed as a priority at the State level.
Moreover, the intensification of polio programme significantly reduced the interest of the nodal
department (MCH division of DGFW) in this programme. Support from the Directorate of ICDS
remained negligible since they viewed their responsibility was limited to ICDS-III projects being
implemented in 33 districts of the State. The support of ICDS to the project was seen mainly at the
district and block level.
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.

Identifying nodal person at Project Block level
A total of 907 villages (total
Box 3e: Supervision & capacity building by BTM
population being 1,331,549) were
Project appointed an additional staff at block level called
covered across 2 blocks in each of
Block-trainer-cum-monitor (BTM) who regularly trained and
the project district. Necessity of a kept a close watch on the activities of the community-
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.

Figure III.2: Cluster Community Approach
A village is not a homogenous unit. The village

population is divided into socio-cultural clusters
on the basis of religion, caste and creed. The
intra communication in clusters is better than
the inter cluster communication. In each cluster
there are normally 2-3 socially active persons
who are respected and their advice is sought.
These persons can act as influencers at the
cluster level and act as important agents for
behaviour change communication. This is the
underlying concept adopted by the MCHN
Project where primarily active women were
identified and trained as key change agents and are known as Bal Parivar Mitras (BPMs).
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.
Meticulously developed and pre tested common format

Schedules used in baseline:-
was used in all the project districts to get the status on Village Schedule,
Household Schedule and
different indicators and to ensure homogenous collection
Child Schedule.
of information. A sample of 4400 households was Newly married women

surveyed in each of the MCHN district. SNRC, Lucknow, acted as the nodal agency that
supervised the baseline survey for each of the project districts. Baseline findings were well
documented by respective DNRCs.
Agent of Change Accessible to Community– Bal Parivar Mitra (BPM)

MCHN Project was visualized Box 3g: BPM the ‘Change Agent’ of the community
as a demonstration project The community at large commonly knows some active women or
where the unique feature was a men, who have good knowledge on nitty-gritty of various
traditional practices. These are confident & vocal women or men
fairly simple idea – an agent of
who are looked upon with respect and are heard by everyone in
change always accessible to the
the village. They are approached for expert advice of various
‘at risk’ families of issues, as they are perceived wise and well informed as well as
undernutrition - a member of carrying some basic knowledge on issues. Their good interactions,
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.
Selection of BPMs was carried out Table 3.1: Profile of BPMs

right from the baseline survey No. of Male Female
District
BPMs
stage in the project areas. The No % No. %
investigators were asked to Jhansi 1139 23 2 1116 98
Allahabad 1192 108 8 1284 92
identify and record vocal persons
Varanasi 1354 6 1 1348 99
with high level of acceptability in
Agra 0831 0 - 831 100
the village. Both community as Total 4516 137 3.0 4579 97.0
well as village level functionaries of different departments especially ANM and AWWs were
involved in the identification of BPMs.

This approach helped the
Box 3h:
acceptance of the selected
Although methodical, the selection of BPMs was not that easy.
worker by the community and Mr. Davendra Singh, BTM of Bichpuri block in Agra told us in some
the existing functionaries. At villages the authoritative people tried their best to influence the
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
Community-based workers remain engaged and work till the

duration of project. Once the project is over their involvement
gradually declines in the absence of any motivation. The monetary
compensation for their work also ceases to exist as a motivator for
them. To provide for long lasting involvement of local resource
created in form of trained BPMs the project adopted a different
strategy. Uplifting the social image and recognition of BPMs was
adopted as prime motivators. The BPMs were given name plates
bearing their name and designation. The small ones were tucked
on their sarees while big square tin plates were put on their doors. A
low cost cloth bag bearing name & logo of projects was also given for carrying necessary materials
for fieldwork. To enhance their status, MCHN project designated them as BPMs. Uplifting their image
in their own community attempted their continuance even after the withdrawal of the project.

The BPMs were not paid any honorarium but were paid fees of Rs. 100 per quarter for completing
the pictorial monitoring formats. There was continuous demand for some fees. Initially some
training honorarium, badges and bags kept this demand low, but as the project progressed BPMs
demanded regular remuneration on a monthly basis. However, the motivation from BTM, AWW
and ANM kept their involvement high. Apart from the motivation for gaining social recognition,
mentioned above, this voluntary work was also seen to have a possible ‘pay-off’ in terms of higher
visibility for Pradhan election, any govt. or social field jobs, etc. coming up in future.
Training & Capacity Building

Box 3j: Appropriate capacity building improves
Systematic training was planned from the performance of project functionaries
district to village functionary level. A Capacity building at all levels is important. It is the
state level training task force was responsibility of any large-scale project to seek to build
capacity through experts of the field. And, if the project
formed to look into the training
fails to do so, quality is jeopardized during the life of the
requirements for the MCHN Project. project, and it will become unsustainable once the external
Taking into consideration the strategy support (financial and technical) ends. Equally important is
the involvement of technical expertise matching with the
and role of the functionaries at
level at which capacity building is targeted. MCHN project
various level three training modules, achieved this through a structured and a systematic
titled “Mobilising for Change”, to training/capacity building.
train the trainers, programme managers & functionaries were developed:

District level : Module I – Training module for trainers
Block level : Module II – Training module for block/sector level programme
managers functionaries
Community level : Module III – Training module for community mobilisers (BPMs)
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

modules are very illustrative, simple and easy to follow. Inclusion of case studies in Module-III
made it a very interesting and effective methodology. An important aspect of the modules is the
focus on standardized 27 messages relating to different aspects of the maternal childcare and
nutrition. Training was planned for all levels of functionaries. BTMs or representatives of medical
colleges were expected to be present during various trainings. The training plan details are
presented in Figure III.3.
Figure III.3 : Plan of Training
State Directorate of Family Welfare
DG/Joint Directors MCH State/District Nutrition Resource Centre

State Nodal Officer (SNRCs/DNRCs)
Training of Trainers – (3 days)

Chief Medical Officer - Deputy Chief Medical Officers (Dy CMO)
(CMO) - Reps. from SPM department
- Medical Officer In charge (MOIC)
- Block Trainer cum Monitor (Project BTM)
- NGO Representative
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
Sectoral Level Joint * Training (3 days

or 2 days)
- BPMs
- Anganwadi worker (AWW)
- ANM
* (BTMs & DNRCs played nodal role)

District as well as Block level functionaries of all the
concerned departments participated in the training
sessions. Almost all the functionaries contacted during
the process of study, expressed their satisfaction with the
quality of training given and the Training module design
was well-accepted. A similar reaction was observed from
the ANMs and AWWs who expressed that despite of
being involved in the similar role since years, training was
indeed very informative and clear about their roles and responsibilities. ANM, Manorama Devi
of village Khalisipur, block Chiraigaon in Varanasi said that – “Group Discussions helped me
understand how to answer to the questions and refutations presented by the community-level functionaries and
beneficiaries”. Imparting training to BPMs was most critical component as they were the primary
person reaching the “at risk” families and the success of project laid. Considering low levels of
literacy among BPMs, a three-day extensive and easy to understand training was imparted. The
training aimed at imparting right knowledge along with sensitizing them on MCHN issues and
their involvement as a BPM. Group discussions using posters, charts and booklet was appreciated
by most of the BPMs in the understanding the issues. BPMs interviewed said that demonstration
method helped them registering various issues specially the right technique of holding the child
during the breastfeeding.
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.

In order to ensure smooth execution of the project
activities, nearly 5080 Gram Pradhans were also
sensitized with the project in the project districts.
Mr. Shiv Shankar Singh, Pradhan of Dubkiyan, is
an ardent supporter of the MCHN Project. He
said – “ This project is different from others due to the role
played by the BPM. The awareness levels have gone up”
He personally supervised the project in his village, and met BPMs regularly and even helped in
their record keeping.
Linking the Community and Services: Pivotal Role of BPMs

Each BPM was expected to reach out to 40- Table 3.2: Improvements due to BPMs – as mentioned by ANMs
and AWWs
50 families in her cluster, and of these about
Improvements Response
15-20 households, at a time are “at risk” Total Sample (16 ANMs and 14 AWWs) (n)=30
Awareness and health seeking behaviour of at 'risk families'
households. The BPM regularly visited these has improved
87%
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 3L:
Clearly Defined Roles: BPMs
Responsible for 50 household
(about 20-25 ‘at risk’ families
Identifying and updating the
target families
Counseling and motivating target
population
Refer case to ANM/PHC, AWW
Water testing using simple kits
Salt testing using salt testing kits
The BPMs also linked up with the ANMs’ fixed

Box 3M:
routine immunisation (RI) day. In 2004, these Water-testing
BPMs also participated in the biannual child health To demonstrate the community about
the dirty and unsafe water obtained
and nutrition activities launched in the State. The
from open-well and other unsafe
BPMs regularly participated in Pulse Polio drives sources, water testing was also planned
and carried out in the Project. However,
and family health awareness camps for due to inadequate supply of good
HIV/AIDS that were organized by the Health condition water-testing kits, this activity
could not be pursued for long.
Department. They also participated in salt-testing
and water-testing activities.
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)
- Chandra Prabha Devi (AWW)
“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)

When asked about the support received from
BPMs, both ANMs and AWWs expressed
that BPMs have been helping them a lot for
various activities. The AWW appreciated
work of BPMs the most, while ANM also
find them extremely helpful (Box 3a). A ‘fixed
month, fixed theme’ approach was used to
reinforce one or two specific themes related
to season. However, messages on initiation of
breastfeeding, exclusive breastfeeding, complementary, ANC check ups, age at marriage, use of
iodized salt was promoted throughout the year. The messages communicated by BPMs through
Interpersonal communication and wall writing were standardized.
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”.

Box 3P: Achieving the Innovative Convergence
“It was absolutely impossible for me to comprehend
the integration of ICDS and Health, at first. Although
both of them worked towards improving the overall
health of mother and child, yet there convergence
appeared a distant goal. But, I am surprised and
delighted that I was wrong. I congratulate Dr. Sheila
Vir from Unicef and everyone involved in the
successful implementation of the MCHN project” –
emphasizes Prof. S. C. Mahapatra, Prof and Head
Department of Social and Preventive Medicine,
Banaras Hindu University, Varanasi.
Monitoring of the Project

To ensure smooth and objective Box 3Q:
progress a joint multisectoral meeting Participatory monitoring brings success
Participatory monitoring refers to self- monitoring
was facilitated by the block project undertaken by community to assess their development
person i.e. BTM on a quarterly basis goals. Taking into account the literacy levels of the
BPMs, MCHN project developed and used a unique
with BPMs, AWWs, and ANMs to monitoring tool- ‘pictorial monitoring card’.
share their experiences. However, as far

as ‘Gram Panchayat Viaks Adhikari’ (GPVA) is concerned they did not often participate.
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

meeting with BPMs. There was provision of Rs. 100/- per quarterly session per BPM, following
submission of monitoring forms.
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.
Box 3R: Monitoring Formats

Format A: For BPMs, filled every month at village level used in the Project
Format B: Compilation of Format A on quarterly basis at sector level
Format C: Compilation of data at the block level once a quarter Planned but
Format D: Compilation of data at the district level once every quarter not used
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).

Figure III.4
Section 1: Information of the cluster Section 2: Pregnant women & Section 3: Care of newborn
and messages for newly weds key messages to be given to her
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
Evaluation of MCHN Project III-17

Competence of BPMs
BPM’s understanding of monitoring card and their overall knowledge on record keeping was
evaluated by the field researcher’s interviewing them. The BPMs were asked to explain and
demonstrate the use of pictorial monitoring card. On the basis of their responses to different
parameters their understanding of monitoring card was given scores. Two-third of the BPMs
scored well i.e. either excellent or good.
Box 3S: Competence of BPMs* –

Record keeping, knowledge on Monitoring Card
Score % BPMs
Excellent (90-100%) 38%
Good (60-90%) 29%
Average (40-59%) 28%
Poor (<40%) 5%
* Based on Field Researcher’s evaluation
BPM – a valuable human resource created locally

Having heard the community and
analysed the sources of positive Box 3T: BPM…the best byproduct of MCHN
change on various aspects of Dr. Amita Jain, Deputy Director (IEC), ICDS III, UP feels –
maternal-child care, covered in “BPM is best byproduct of the MCHN project. They
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.
Box 3U: Sociological Assessment Package (SAP) Study

DNRC, Varanasi, took initiative to computerize the system of tracking BPM’s
progress. Under the guidance of Prof. S. C. Mahapatra, a ‘Sociological
Assessment Package’ (SAP) was developed to assess BPM’s performance
both in quantitative and qualitative terms. It was well tested and results from
it were consistent with the actual findings.

Limitations
There was a gap of 5 months between the starting of the current evaluation study and withdrawal of the
MCHN project. This time gap would have, possibly, reduced the respondent’s recall on various issues covered
in the survey.
During survey ‘mothers of children less than 24 months’ and ‘women married in last two years’ were selected
for the interview. This resulted in including children born and women married during the time period of 5
months after the withdrawal of the project and starting of the current evaluation study.
Active involvement of Health department and directorate of ICDS at State reduced during project
implementation period with the frequent transfer of staff. Similar situation was also noted at district level.
Increased level of State authorities would have supplemented in implementation of the project
ICDS at block and community level were fully involved in the Project but with no active involvement of State
Directorate of ICDS, the commitment at the lower level was below the desired level.
The Project envisaged that the ANMs would play a central role to provide health services (immunization,
supplements, etc). But, their participation remained low due to Polio drive due to which outreach sessions were
not held regularly. Increased awareness, therefore, did create demand at community level, but service response
(immunization, supplements, etc) did not increase proportionately, instead it was very poor at places. Special
programme implementation plan for delivery of health services would have possibly resulted in better response.
Considering the large area being covered, it was felt that larger number of Block-Trainer-cum-Monitors
(BTMs) would have further enhanced the effectiveness of the monitoring.
Although money is not the only motivating factor, yet presence of some monetary incentive (Rs.100/- per
quarter i.e. Rs.400 per annum which is 40% of Anganwadi monthly honorarium incentive), such as one
linked to performance, encouraged BPMs. Monthly incentive of Rs. 50 per month could have resulted in better
incentive for BPMs
Pradhans were trained but involved in the implementation of the project. Increased involvement and
participation of various opinion leaders like teachers, pradhan and other elderly members of the community
were suggested by almost all BTMs.
BPMs were not competent in carrying out water testing. Conveners of medial colleges felt that water testing was
not found very effective because in many cases the colour of the water, even from the recommended sources (such
as hand pump), did not prove safe and free from contamination. Improvement in water testing methods and
ensuring continuous availability of proper salt testing kits is desirable.

Box 3V:
Visitors to the Project
In many ways, the MCHN project has been a torchbearer lighting up an otherwise dark path.
Its essence lies in the simple, but innovative ideas that govern its approach. The project,
therefore, has attracted global attention and has had its share of visitors from various
agencies and departments, who came to observe the implementation of this innovative
strategy. These visitors have ranged from Krishna Belbase, a nutrition specialist from UNICEF,
New York, to representatives from other donor agencies like USAID and CARE. Students and
faculty from Lady lrwin College of Home Science and Nutrition in Delhi also visited Agra. A
Swedish team visited the Sarojini Nagar block of Lucknow district and interacted with the
BPMs, ICDS functionaries and observed the community meeting under the MCHN Project.

Achieving The Project Outcomes
- An evaluation of the impact
4
The goal of reducing undernutrition` and improving micronutrition status of children below two
year was the prime expected outcome of the project. As discussed in the preceding section, a
multi-pronged approach was adopted to address this issue. Correct knowledge, influencing the
behaviour/practice related to various causative factors was imparted to the target groups. A
community based volunteer named ‘Bal-Parivar-Mitra’ was entrusted the responsibility of active
counseling on correct maternal & childcare practices for improving the nutritional status of
children. The evaluation findings have been compared against the baseline situation available from
the project implementation document. The impact analysis has been discussed under two sections.
• Section-A : Impact on behavioural practices & health services
• Section-B : Impact on nutritional status of children below two years children and severe
undernourishment amongst less than six years children;
To reiterate, the evaluation study was carried out after a gap of more than four months of
completion of MCHN project. This time lag is expected to have possibly reduced the effect on
recall of certain issues.
SECTION A: IMPACT ON BEHAVIOURAL PRACTICES & HEALTH SERVICES
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.
Evaluation of MCHN Project IV-19

3) Care during pregnancy: Delaying conception to over 18 years, ANC care
including consumption of IFA, taking one additional meal & at least two hours
of rest/day for gaining weight, usage of iodized salt by family
4) Care of newborn: birth registration, washing hands while assisting delivery
5) Health & nutrition services: ANC services as well as health services for child
i.e. immunization and vitamin A supplementation.
As the immediate determinants of

Figure IV.1 : Conceptual framework of MCHN strategy *
malnutrition in children being –
Malnutrition Outcome
‘Inadequate dietary intake’ and
‘Disease’, the MCHN project focused Immediate
Inadequate Dietary Intake Disease
determinants
on:
(i) Improving dietary / feeding Inadequate Inadequate Care Insufficient Health Underlying
Access to for Mothers services & Unhealthy determinants
practices Food and Children Environment
(ii) Ensuring provision of health & Inadequate Education

Basic
determinants
nutrition services to pregnant mothers Resources & Control
Human, Economic & Organisational
and young children
(iii) Delaying conception to above 18 * UNICEF
Political & Ideological Superstructure Conceptual
years to reduce possibility of low birth Economic Structure framework
Potential Resources
weight babies.
The impact of the following MCHN interventions has been analyzed against the expected project
outcomes.
I) Consumption of 100 IFA tablets

II) Taking one additional meal For pregnant
mothers
III) Taking 2 hours of additional rest
IV) Initiation breastfeeding within ½ to 1 hour of birth

V) Feeding of colostrum For newborn &
children upto 6
VI) Exclusive breastfeeding (not even water) upto months of age
first 6 months of birth

VII) Appropriate introduction of complementary feeding
VIII) Three doses of Vitamin-A to a child
IX) Complete immunization For children
X) Use of ORS during diarrhoea
XI) Continuing breastfeeding during diarrhoea
XII) Consumption of iodized salt Family level

XIII) Use of safe water and personal hygiene practices
For Currently Married Women

XIV) Right age of conception & newly weds
In accordance with the

A Brief Socio Demographic Profile
outcomes expected for
In majority of cases the head of household belonged to
each indicator under the ‘other backward castes’ (42%) and was Hindu (92%). 57% of
project, the study findings them lived in nuclear familiy while 43% in joint families. The
type of house was semi-pucca (37%), pucca (33%) and
are segregated into
kutcha (30%). Main source of light was Kerosene oil (62%)
subsections viz. Pregnant followed by electricity (37%). Almost all the women (93%)
Mothers, Newborn/ were, reportedly, housewives and majority of them were

illiterates. Mean age of women at the time of survey (May
Infant, Children below 24 2005) was 25.2 years. Age of mothers at time of marriage
months, Family Level, and and gauna, was 15.9 years and 16.8 years, respectively.
Newly Married Women. For key indicators, summary findings presented as graphs precede
the detail discussion.
A. Pregnant mothers
(I) ANC services:

As shown in Figure IV.2, Figure IV.2 : Practice – ANC services
an improvement is 75% Baseline %
63% 61%
observed across all the 45% 47% Endline %
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
Proceeding sections discuss each of the ANC services in detail.

(a) ANC Registration
Early registration of pregnancy Figure IV.3 : Awareness – Importance of ANC
registration
Endline %
immediately after confirmation of
89% 84% 77% 75%
pregnancy is important not only
52%
for proper delivery of services, also
necessary for timely identification
of complications, if any. ANM Agra Jhansi Allahabad Varanasi Total
n=400 n=402 n=400 n=399 N=1601
registers the pregnancy and then
extends various maternal care services to the pregnant woman. Three- fourth of mothers
were found aware on this issue across four MCHN districts (Figure IV.3).
Although, ANC registration is

Figure IV.4 : Practice – registering pregnancy
mainly dependent upon the supply
Baseline % Endline %
side and response from the ANM, 85.5 84.6
75.2 75.8
64.3 57.8
yet the community empowerment 55.3
44.5
through counseling/advice helped 28.4
19.0
achieving high levels of pregnancy

Agra Jhansi Allahabad Varanasi Total
registration, too. Increased levels
of awareness improved the overall attitude and the health-seeking behaviour (the demand
component)…evident from the increase in ANC registration from 45% in the baseline to
76% in the endline (Figure IV.4). This was despite the fact that outreach sessions were not
being held regularly but ANMs were available at subcentres and therefore mothers were
convinced to go to the local subcentres.
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.

About the place of pregnancy registration, one-third reported registering with ANM and
one-fourth at the PHC/CHC.
Source of information: Bal- Table 4.1: Sources of information on pregnancy registration
Parivar-Mitra emerged as the Agra Jhansi Allahabad Varanasi Total

Endline %
n=400 n=402 n=400 n=399 N=1601
most often source of
BPM 50.1 32.8 70.3 72.2 56.2
information on ANC
ANM 13.8 53.0 12.8 10.8 22.6
registration (Table 4.1). BPMs AWW 34.3 10.7 15.3 17.0 19.3
could influence the target Other 2.0 3.5 1.8 0.0 1.8
groups better because they were trained to methodically identify and counsel the pregnant
women during their visit in their allotted clusters. BPMs also contacted the ANMs when
ever it was felt necessary. BPMs were in fact the link between the service-providers and the
service-seekers.
As shown in Figure IV.6, the awareness

Figure IV.6 : Awareness – Importance of 3 ANC
regarding importance of 3 ANC check- check-ups
Endline %
ups during pregnancy was found quite 73%
88% 79% 81% 80%
well among the mothers. However, high

level of awareness did not get equally
translated into practice. As against four- Agra Jhansi Allahabad Varanasi Total
n=400 n=402 n=400 n=399 N=1601
fifth of the mothers were aware about
three ANC check ups to be done during the pregnancy, only 12% of the mothers received
all the three antenatal check-up during their index 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
consonance with the decrease

observed on above indicators due to poor availability of ANM particularly in these two
districts (Figure IV.7).
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.
An overwhelming proportion of Figure IV.8: Awareness – Receiving 2 doses of TT

mothers were found aware about Endline %
93% 97% 94% 96% 95%
taking two TT shots during
pregnancy. High levels of awareness
were reported across all the four Agra Jhansi Allahabad Varanasi Total
n=400 n=402 n=400 n=399 N=1601
MCHN districts.
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.
Almost two-third of the mothers

Figure IV.9: Practice – Receiving 2 doses of TT
(63%), reportedly, received two TT Baseline % Endline %
injections during their index
70.0 71.4 71.3 68.7
pregnancy, which however improved 63.0
55.1
from 47% of the baseline. Those who 41.8
47.3
37.7
did not received two shots of TT cited
25.9
distant location of health facilities from
their residences or no visit by ANMs
to give TT were the prominent reasons Agra Jhansi Allahabad Varanasi Total
mentioned.

Source of information: ANM Table 4.2 : Sources of information - 2 doses of TT
featured as main source of % Agra Jhansi Allahabad Varanasi Total

response n=334 n=349 n=267 n=338 N=1288
information regarding 2 doses
ANM 28.1 72.5 55.8 58.9 54.0
of TT in majority of the cases
BPM 30.3 13.5 38.2 28.8 27.0
(54%). The role of BPMs, AWW 35.0 7.2 3.4 10.1 14.4
however, emerged as one of the Other 6.6 6.9 2.6 2.4 4.7
main informants (Table 4.2).
(b) Intake of Iron and Folic Acid Supplementation (IFA):
As per the project Table 4.3 : Mother’s understanding regarding anaemia (%)
guidelines, BPMs first
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).

i) Supply of IFA tablets:
As far supply of IFA tables Table 4.4 : Receiving of IFA tablets (%)
in the study district, the Agra Jhansi Allahabad Varanasi Total

Endline
results showed a positive
% Received n=400 n=402 n=400 n=399 N=1601
trend. Compared to 54% any IFA tab
71.8 76.9 51.3 65.9 66.5
during the baseline, more >90 tablets 72.4 63.7 48.3 55.5 61.1
than two third received any Baseline
IFA tablets in the endline. % Received n=713 n=513 n=321 n=598 N=2145
any IFA tab
57.5 60.6 39.3 50.5 53.6
These mothers confirmed
>90 tablets 2.3 16.0 5.6 Data NA 5.7*
receiving IFA tablets during
their index pregnancy. It is interesting to note that there was a substantial increase in the
proportion receiving more than 90 IFA tablets (baseline: 6%; endline: 61%). This indicates
that MCHN project could alteast create proper awareness, in turn demand for the services.
Further, the consumption Table 4.5 : Consumption among those that received IFA tablets
pattern of IFA tablet also Agra Jhansi Allahabad Varanasi Total

Endline * Figures do not include Varanasi; N=1843
presents progressive trend.
% Consumed n=287 n=309 n=205 n=263 N=1064
The consumption of IFA any IFA tab 89.2 89.6 90.8 99.0 89.6
tablets amongst those >90 tablets 22.2 22.3 22.0 19.6 22.1
women, who received any Baseline
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.
ii) IFA consumption- side affects associated:

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 (Table 4.6). This problem of
compliance needs further counseling form the BPMs.
Table 4.6 : Reasons for not eating IFA tablets (% response)

n=287 n=309 n=205 n=263 N=1064
Feeling of vomit 22.3 35.6 21.0 22.4 25.9
Malaise/bad after taste 14.3 6.1 21.0 17.1 13.9
Very hot, feel giddy 17.1 12.0 9.3 8.0 11.8
Smells bad 4.9 6.8 7.3 13.7 8.1
Not aware of benefits 10.8 2.6 3.9 2.7 5.1
Others 2.7 3.8 4.0 2.7 3.3
Source of information: IFA Table 4.7 : Sources of information on IFA tablets (%)
tablets as a policy are to be Agra Jhansi Allahabad Varanasi Total
given by ANMs. However, the n=287 n=309 n=205 n=263 N=1064
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.
II) Taking Additional Diet During Pregnancy:

Besides increasing consumption of IFA tablets, the project focused on increasing
awareness on the importance gaining of 8-10 kgs weight during pregnancy. For this, the
intervention focused on following the practice of consuming one additional full meal and
taking atleast 2 hours of rest during the daytime. No activity regarding weighing of mothers
was included in the MCHN Project. The subsequent paragraphs deal with the awareness
and practice of mothers’ on these issues. However, no baseline data is available on this
issue for comparing endline results with baseline.

Awareness – gaining weight: Figure IV.11 : Awareness – gaining 8-10 kg weight
during pregnancy (Endline %)
As shown in the Figure IV.11,
100%
two-third of the mothers 75%
80% 70% 69% 66%
contacted during the 60% 50%
evaluation survey were aware 40%
20%
that at least 8-10 kgs weight
0%
should be gained during Agra Jhansi Allahabad Varanasi Total
pregnancy. Barring Agra, high n=400 n=402 n=400 n=399 N=1601
levels of awareness was observed across all MCHN districts.
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
in Allahabad and Varanasi, while it

was quite low in Agra and Jhansi. Since the baseline did not contain the information on the
awareness of mothers’ on the above two aspects, the endline results could not be
compared with the baseline.
In sharp contrast to high levels

Figure IV.13: Practice – Taking one additional diet
of awareness, practice was during pregnancy (Endline %)
found quite poor during the

endline. Overall, less than a 24%
20%
18%
fifth of mothers (as compared 14%
12%
to more than three fifth being
aware) confirmed taking one Agra Jhansi Allahabad Varanasi Total
additional meal every day

during their index pregnancy, This decline was mainly due to Varanasi and Allahabad
where the compliance, on this aspect, dropped down significantly (Figure IV.13). Findings
regarding reasons for not taking one additional meal per day during pregnancy revealed
that ‘Loss of appetite’ (48%) and ‘Feeling of heaviness and Indigestion’ (35%). These are
actually pregnancy related issues and were the main reasons cited by most of the women.
Besides, there were few mothers carrying a wrong notion that ‘additional eating may
compress the baby in the womb’ (16%), or their ‘family resisted eating of additional diet’
(3%) indicating the more efforts needed to counsel on this aspect (Table 4.8).
Table 4.8 : Reasons – For not taking one additional diet during pregnancy (Endline %)
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.
Overall, more than

Table 4.9 : Source of advice on additional diet during pregnancy
three fifth of the Endline %
n=400 n=402 n=400 n=399 N=1601
mothers attributed their
BPM 42.4 44.9 85.0 73.6 61.9
high levels of awareness
ANM 29.7 50.5 17.1 22.8 30.3
to BPM. They emerged AWW 17.6 5.1 4.3 6.7 8.1
as the main source of Others 17.0 6.1 2.1 0.5 6.1
advice on this aspect across all the four MCHN districts (Table 4.9).
III) Two Hours of Rest per Day During Pregnancy:

‘At least two hours of additional rest (during daytime) per day’ helps a pregnant woman
conserve sufficient energy, body fat and therefore facilitates in gaining adequate weight.
This was one of the practices focused under the project.

A high proportion (78%) of Figure IV.14 : Awareness – Taking at least two hours
of rest during pregnancy (Endline %)
mothers’ contacted during the
72% 85% 91% 78%
endline survey was aware of taking 64%
‘at least two hours of rest (during

daytime) per day’ during
pregnancy (Figure IV.14). n=400 n=402 n=400 n=399 N=1601
In line with the high levels Figure IV.15: Taking rest for 2 or more hours during
pregnancy (%)
of awareness, practice of
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,
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).

B. Care of Newborn / Infants
(I) Birth registration of newborn:

This was emphasized in the
Figure IV.16: Awareness – Birth registration of newborn
MCHN project to ensure (Endline %)
proper follow-up is done with
89% 84% 77% 75%
respect to keeping the 52%
newborn warm and preventing

infection such as pneumonia, Agra Jhansi Allahabad Varanasi Total
n=400 n=402 n=400 n=399 N=1601
early initiation of breastfeeding
and colostrum feeding, etc. High level of awareness (75%) on birth registration was
reported by the mothers in the endline.
Actual registration of Table 4.11: Birth registration of newborn (Endline%)
birth was reported in Agra Jhansi Allahabad Varanasi Total

n=400 n=402 n=400 n=399 N=1601
59% mothers. Of
Registering birth 82.8 77.6 31.5 45.4 59.3
these, birth registration
within 7 days was, Duration of birth registration
reported by 37% n=331 n=312 n=126 n=181 N=950
st
On 1 day 31.7 21.8 7.1 6.1 20.3
mothers only,
2 to 7 days 10.6 21.5 20.6 14.9 16.3
indicating poor service After 7 days 57.8 56.6 72.3 79 63.3
response on this aspect, too (Table 4.11).
Almost half of the mothers Table 4.12: Place of recording the birth of newborn (%)
(49%) reported that they Agra Jhansi Allahabad Varanasi Total

Endline %
n=331 n=312 n=126 n=181 N=950
registered their newborn
With AWW 62.5 51.9 23.0 37.6 49.1
with AWW. 20% mothers
Discharge card 24.2 16.3 23.0 17.1 20.1
reported recording in At Panchayat 0.9 0.6 1.6 3.9 1.5
‘discharge card’. Other 12.4 31.1 52.4 41.4 29.4

Source of information: As Table 4.13 : Sources of information (Endline %)
presented in Table 4.13, BPM Agra Jhansi Allahabad Varanasi Total
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
mothers) among the Agra Jhansi Allahabad Varanasi Total

Endline %
n=400 n=402 n=400 n=399 N=1601
total mother could
% recalled the birth
recall the birth weight weight
27.5 23.4 15.3 20.6 21.7
of their child. Nearly Birth weight recalled by mothers

n=110 n=94 N=61 n=82 N=347
two-third said that
Less than 2500 gms 45.5 31.9 23.0 32.9 34.9
the weight of their
2500 gms or more 54.5 68.1 77.0 67.1 65.1
baby was 2.5 kgs or
more while a third recalled that the weight of the child less than 2.5 kgs (Table 4.15).
(II) Handling of the newborn:
Community was Table 4.16: Whether person-assisting delivery washed hands with soap
sensitized towards the Endline % Agra Jhansi Allahabad Varanasi Total

n=400 n=402 n=400 n=399 N=1601
importance of hygiene
Washing hands % 69.8 84.3 95.0 98.7 86.9
& sanitation at every
stage. Washing of hands with soap minimizes the chances of infection to mother and child
at the time of delivery. In the endline, a high proportion of mothers (87%) confirmed
washing of hands, specifically with soap, by the person assisting the delivery (Table 4.16).
The relatively higher proportion of mothers in Varanasi confirmed these practices as

compared to rest of the study districts. Impact of the project intervention could not be
compared with the baseline due to non-availability data.
It is envisaged under Table 4.17: Bathing of newborn (Endline %)

the project that the Agra Jhansi Allahabad Varanasi Total
bathing of newborn n=400 n=402 n=400 n=399 N=1601

rd
After the 3 day 4.0 11.4 30.5 41.4 21.8
should be done after 3
days of child’s birth. Only in 22% cases it was done after the 3rd day (Table 4.17).
However, in more than half of the cases (52%), newborn was bathed within 1st day of
birth. This practice is linked with some traditional perceptions and practices difficult to
influence to change. As emphasized earlier that lot of unlearning goes before new
behaviour/habit is formed, hence this issue would also require further reinforcement.
III) Infant & Young Child Feeding Practices:

As seen in Figure IV.17a, an Figure IV.17a: Practice – Breastfeeding / Semi-solid
food
improvement is observed in the
endline on various aspects related Baseline %
63%
53% Endline %
to breastfeeding / feeding semi-
22% 28%
solid food to children. Proceeding 18%
5% 2%
*
sections discuss each of the
Initiating BF Feeding Exclusive BF Sem i-solid
aspects related to feeding w ithin 1 hr of colostrum upto 6 betw een 6-9
birth m onths m onths
practices in detail. * Baseline data not available
a) Initiating breastfeeding within an hour of birth:

Awareness: MCHN project
Figure IV.17b : Awareness – Importance of initiating
envisages on early initiation of breastfeeding within one hour of birth
Endline % 67% 71%
breastfeeding to newborn,
49%
colostrums feeding and exclusive 29%
21%
breastfeeding (not even water) as
the best practice to ensure the
n=400 n=402 n=400 n=399 N=1601
better health & nutritional status

of infants’ upto 6 months. Initiation to breastfeeding within half an hour of birth was
emphasized so as to enable smooth suckling, which triggers and increases the production
of breast-milk. In all, nearly half of the mothers of children of less than 2 years were aware
about the importance of initiation of breastfeeding within half an hour of delivery.
Relatively more proportion of mothers in Varanasi and Allahabad were aware about this
practice, however, levels of awareness was observed significantly low in case of Jhansi and
Agra, which has pulled down the overall awareness (49%) on this aspect.
Practice: Of all the mothers

Table 4.18 : Ever breastfed the child (Endline%)
interviewed, a very small Agra Jhansi Varanasi Total
Allahabad
proportion, just 1.3% (21 n=400 n=402 n=400 n=399 N=1601
mothers), said that they never Yes (%) 97.5 99.8 98.3 99.2 98.7
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%)
further probed for

the reasons of never
n=10 n=1 n=7 n=3 N=21
breastfeeding their
Mother being sick 50.0 0.0 28.6 33.3 38.1
child. Mother’s
Breast problem 10.0 0.0 28.6 0.0 14.3
illness and breast
Inadequate milk secretion 20.0 0.0 0.0 0.0 9.5
problem emerged as Child do not take 0.0 0.0 28.6 0.0 9.5
the main reason Other 20.0 100.0 14.3 66.7 28.6
behind it (Table 419).
Remaining 99% (1580 mothers) Table 4.20 : Time of initiating breastfeeding (Endline %)
that breastfeed their child were Duration

Agra Jhansi Varanasi Total
Allahabad
further queried about the time
n=390 n=401 n=393 n=396 N=1580
of initiating the breastfeeding. Within 1 hr 22.1 15.2 31.8 18.4 21.9
As presented in Table 4.20 a 1 hr to 24 hrs 41.3 17.7 35.6 29.8 31.0
After 24 hrs 36.7 67.1 32.6 51.8 47.2
fifth initiated breastfeeding
within one hour of child’s birth. However, in 47% cases it was initiated after 24 hours of
child’s birth, suggesting the awareness on this issue could not be translated into practice

mainly because in rural areas of Uttar Pradesh certain local customs (see box below) are
observed soon after delivery, which in turn hinder the timely initiating of breastfeeding.
Local customs/myths related to initiating breastfeeding

“The birth of a baby, in rural areas, is a big family affair, attracting various traditions and
local customs. Usually the baby is first given to the paternal aunt called ‘Bua’ or ‘Fofee’
(the sister of father) who observes some customs. There is also the custom of placing the
child first in front of the family-deity in the house for blessings. At some places, local
astrologer-cum-priest is also present who forecasts the future of the newborn and calls for
immediate offerings if the horoscope is uncongenial. And, if the newborn happens to be a
baby boy, the family members and other visitors express their happiness by offering gifts.
All these activities are time consuming and recommended health practices, such as
initiating breastfeeding within one hour of birth, are immediately followed after birth are
delayed…” – Dr. S. B. Gupta, Prof. SPM department, Medical College (Jhansi)
However, when compared with the

Figure IV.21 : Practice – Initiating breastfeeding
baseline, a substantial improvement in within one hour of birth
practice was noticed. The practice of

Baseline % 21.9
initiating breastfeeding within 1 hour of
Endline %
birth has increased by five times in the
4.6
endline (Figure IV.21). Possibly the
Total (all 4 districts combined)
practices will change significantly once
the older family members and community at large becomes aware of the importance of
early initiation of breastfeeding. And, this can be achieved by using other IEC methods
along with inter-personal counseling done by the community mobilizers like BPMs of
MCHN project.
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

Regarding pre-lacteal Table 4.23: Feed given before initiating breastfeeding (Endline%)
given to the newborn, Agra Jhansi Allahabad Varanasi Total
animal milk (45%) or n=306 n=323 n=276 n=327 N=1232

Cow/Buffalo/Goat
water (41%) was 28.3 70.7 45.2 33.4 44.5
milk
mentioned by majority of Water 45.2 32.1 35.7 49.8 40.9

Tea 34.7 1.2 0.7 0.3 9.3
the mothers. Around
Honey 9.2 0.3 7.4 11.6 7.1
3%, reportedly, gave
Ghutti 10.5 0.0 1.4 0.6 3.1
ghutti to the child (Table Other 19.1 4.3 0.4 1.5 6.4
4.23). It was interesting to note that animal milk or water was the first feed and this is
contrary to the belief that homey / ghutti is the predominant first feed.
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%
awareness on ‘importance of 58%
initiating breastfeeding within 35% 38%
one hour of birth’. For both these

practices the awareness was
higher in Allahabad and n=400 n=402 n=400 n=399 N=1601
Varanasi, while it was low in

Jhansi and Agra (Figure IV.19). Both the practice of feeding colostrum and initiation of
breastfeeding within one hour of birth were equally influenced by observance of certain
local customs/traditions.
Practice: Figure IV.20 presents data Practice in rural Uttar Pradesh

on colostrum feeding practices. A As per the NFHS-2, colostrum is discarded in 76%
cases in rural areas of Uttar Pradesh. The custom of
comparison with the baseline shows discarding colostrum is widely practiced in the State
an overall improvement regarding in every group, but it is particularly common in
Central and Bundelkhand regions.
the practice of colostrum feeding in
the endline (baseline: 28%; endline: 53%).

District-wise there is lot of variation, but improvement is observed in the endline
regarding the practice of colostrum feeding. Two important features are observed
regarding the practice of colostrum feeding. Firstly, there is no consistent pattern
observed regarding colostrum feeding is observed across all the four MCHN districts.
And, secondly, no direct relationship is observed between the awareness and practice.
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 *
colostrum feeding is low in * Varanasi data of Baseline not available
Agra but the practice is quite

high. It implies that in Agra mothers feed colostrum despite being unaware of its
importance. On the other hand, a high level of awareness is observed in Varanasi, yet
the practice remains quite low. This pattern indicates that there is no link between
awareness and practice regarding colostrum feeding.
Local customs/myths related to colostrum

In few communities colostrum is considered ‘bad or stale milk’. “Being thick and yellow,
colostrum is usually considered harmful for the baby, hence the custom was complete
discarding by manually squeezing out four-six times a day. Now people are changing” –
BPM, Ranoo, Village Sangram Patti, Saidabad.
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.

This goes on to explain that local practices related to colostrum feeding continue to be
rather strong and these are influenced by change in the knowledge levels. It highlights
the need for further strategies not only for reinforcing the awareness regarding
colostrum feeding but also converting it into practice.
III) Exclusive breastfeeding

Exclusive breastfeeding upto first
Figure IV.21 : Awareness – Exclusive breastfeeding for
six months being an important first six months (Endline %)
issue was also covered in the 100%
80% 72%
66%
MCHN project. Both, awareness
60% 50%
and practice on exclusive 34%
40% 29%
breastfeeding was gauged in the 20%
survey. In coherence with 0%

awareness on other parameters, n=400 n=402 n=400 n=399 N=1601
awareness on exclusive
breastfeeding was, too, found low in Agra and Jhansi while it was on a higher side in
Varanasi and Allahabad. Overall, half of the women contacted during the survey were
aware about the exclusive breast-feeding to child till six month of age.
Local customs/myths hindering exclusive breastfeeding

Various local practices emerged were; “There is a custom of making ‘om’ with honey on
the tounge of the newborn”. At some places, “kheer (sweetened rice in thick milk) is feed
to the baby with silver spoon and silver bowl by the grand uncle and mother from the
maternal side (called Nana and Nanee in local language)”. “Holy water is regularly given
to the baby to prevent from any evil eye (buri-nazar)”. “…in rural areas, cow is worshiped
as mother (gaiy-mata) and cowmilk is considered better and compulsory”

Figure IV.22: Breastfeeding Practices
Whether ever Feed given

Whether anything was given Yes: 78%
breastfed the child Animal milk : 45% Water : 41% Honey : 7%
Yes: 98.7% before initiating breastfeeding Tea : 9% Ghutti : 3% Others : 6%
n=1580 n=1232
N=1601 Time of starting BF
n=1580
No: 22% Within 1/2 hours : 5.6% Within 4 hours to a day : 7.5%
No: 1.3% n=21 n=348 Within 1 hour : 7.4% Within 1 to 4 hours : 5.4%
nd th
Within 2 day to 4 day : 54.1%
Reasons Table 4.23a : Breastfeeding with pre-lacteal
Table 4.23 : Exclusive breastfeeding
Mother being sick : 38% Agra Jhansi Allahabad Varanasi Total
Breast problem : 14% Endline %
Endline % n=306 n=323 n=276 n=327 N=1232
Inadequate milk secretion : 10% n=84 n=78 n=117 n=69 N=348
Child do not take : 10% < 30 days 93.1 93.2 87.0 85.0 89.6
Others : 28% < 30 days 76.2 67.9 17.9 47.8 49.1
30 days 2.9 1.9 4.3 4.3 3.3
30 days 7.1 9.0 13.7 11.6 11.0
> 30 – 90 days 2.6 2.2 2.5 6.4 3.5
> 30 – 90 days 6.0 10.3 40.2 24.6 22.0
> 90 – 150 days 0.7 0.9 2.5 3.4 1.9
> 90 – 150 days 2.4 5.1 13.7 11.6 8.0
Table 4.24 : Exclusive breastfeeding 180 days4.24 : Breastfeeding
Table 0.7 1.9 3.6pre-lacteal
with 0.9 1.7
180 days 8.3 7.7 14. 4.3 10.0
Agra Jhansi Allahabad Varanasi Total Agra Jhansi Allahabad Varanasi Total
Endline % Endline %
n=390 n=401 n=393 n=396 N=1580 n=390 n=401 n=393 n=396 N=1580
Break-up 348 ‘Children who
< 30 days 16.4 13.2 5.3 8.3 10.8 < 30 days 73.1 75.1 61.1 70.2 69.9
were not given anything
30 days 1.5 1.7 4.1 2.0 2.3 30 days 2.3 1.5 3.1 3.5 2.6
before initiation of
> 30 – 90 days 1.3 2.0 12.0 4.3 4.9 > 30 – 90 days 2.1 1.7 1.8 5.3 2.7
breastfeeding’ as a > 90 – 150 days 0.5 1.0 4.1 2.0 1.9 > 90 – 150 days 0.5 0.7 1.8 2.8 1.5
180 days 1.8 1.5
Breast 4.3
Feeding 0.8 6 months
upto 2.1 : 2.1% + 1.3% =180
3.4%
days 0.5 1.5 2.5 0.8 1.3
Evaluation of MCHN project IV-21

Practice of exclusive
Figure IV.23 : Practice – Exclusive breastfeeding for
breastfeeding was probed further first six months (Endline %)
among the caregivers of 348 Endline %

children to whom nothing was 4%
2% 2% 1% 2%
given before initiation of Agra Jhansi Allahabad Varanasi Total
breastfeeding (Refer Figure

IV.22 above). Of these only 35 children were exclusively breastfeed upto 6 months,
which works out to be 2.1% of the total 1580 children. Contrary to the findings on
awareness, only 3 percent of the mothers practiced exclusive breastfeeding (not even
water) for their index child (Figure IV.23). As emerged from the qualitative findings of
the survey, various local customs accompanied by misconceptions hindered this
practice (refer above).
IV) Age when semi-solid food was initiated

Introduction of semi -solid Table 4.25: Semi- solid given in last 24 hours (Endline %)
food after completion of Agra Jhansi Allahabad Varanasi Total
Endline %
first 6 months was also n=400 n=402 n=400 n=399 N=1,601
emphasized in the Project Less than 6 months 10.6 19.3 10.1 3.5 10.8
6 to 9 months 54.9 61.5 69.5 64.3 62.6
because after first six
10 months & Above 14.5 7.3 12.1 16.4 12.6
months only mother’s milk Not yet started 20.1 11.9 8.3 15.8 14.0
is not adequate to fulfill the Baseline %
n=232 n=139 n=197 n=4,384 N=4,952
physiological needs of the
Less than 6 months 3.9 10.8 5.6 4.8 5.0
child. Timely initiation and 6 to 9 months 95.7 76.3 68.0 10.0 18.2
adequate quantity of 10 months & Above 0.4 13.0 26.4 85.2 76.9
complementary food improve the nutritional status of the child. Ideally semi-solid food
should be introduced after 6 months to a child. Table 4.25 shows improvement in this
practice in the endline. 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. Simultaneously there was a substantial decrease in late introduction of semi-solid
food. Introduction of semi-solid was found relatively higher in Allahabad.
Evaluation of MCHN Project IV- 22

Age-wise analysis of 14% Table 4.26: Age-wise break-up of those who have ‘not yet started’
giving any semi-soild food (Endline %)
children (189 children)
Agra Janshi Allahbad Varanasi Total
where introduction of n=68 n=39 n=28 n=54 N=189
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 %)
giving semi-solid food given Agra Jhansi Allahabad Varanasi Total

Endline (%)
n=332 n=363 n=372 n=345 N=1412
were further queried about the
Mashed roti 63.1 60.6 52.1 55.6 57.8
type of semi-solid food given khichree 24.8 22.9 14.8 19.9 20.6
in the last 24 hours. In Dal/ Pulses 45.4 70.0 80.5 78.9 68.7
Cereals 44.1 69.0 79.7 77.8 67.6
majority of the cases cooked
Vegetables 23.9 46.2 29.3 14.0 28.2
pulses, cereals and mashed roti
Fish/egg 0.3 1.2 2.1 3.8 1.9
in milk was given to the child. Other 38.6 29.1 25.4 22.8 29.0
Similar to other issues, BPMs Table 4.28 : Sources of information/advice on feeding

practices to Infants
emerged as the main source of
Endline Agra Jhansi Allahabad Varanasi Total
information (91%) on various % n=400 n=402 n=400 n=399 N=1601
aspects related to feeding of Child BPM 89.3 83.6 93.3 96.0 90.5
across MCHN districts. However, AWW 5.8 2.7 2.3 2.5 3.3
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).

C. Children below 24 months
I) Vitamin A Supplementation (VAS)

Vitamin A deficiency is
Table 4.29: Awareness regarding the importance of Vitamin-A
one of the most Agra Jhansi Allahabad Varanasi Total
Endline %
n=400 n=402 n=400 n=399 N=1601
common nutritional
Prevents from
deficiencies in the world. 5.5 4.5 7.5 5.8 5.8
night blindness
MCHN project included Good for eyes 0.0 0.2 0.3 0.3 0.2
a component regarding Improves immunity 0.0 0.0 0.0 0.0 0.0
administering vitamin A Don't know 94.1 95.3 91.5 94.0 93.8
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

of VAS given to their child. Further, since no baseline information on administration of
VAS to child is available, the comparison between endline and baseline surveys could not
be done.
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.
Poor Health service response

MCHN project created awareness and depended on Health System for health services
such as ANC check up, TT Vaccination, Child Immunisation, vitamin A supplementation etc.
Being dependent on health attendant, the engagement of ANMs in polio drives and not
holding the Routine Immunization (RI) sessions, became the main reason behind the low
results on vitamin A coverage. The supply of vitamin A was not planned under the Project.
Moreover, the use of only vaccination card to estimate the VAS administration has its own
limitations.
II) Routine Immunization Status
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.
Status of complete immunization: Being more reliable, the status of complete

immunization (BCG, Measles, 3 doses each of DPT and OPV) was worked as per the
vaccination card. Overall, 33 percent children were found fully vaccinated (Table 4.32).
Impact of MCHN could not be adjudged, as similar data during baseline was not analysed.

Table 4.32: Complete immunization as per the vaccination card (% cases)
n=102 n=113 n=77 n=107 N=399
Complete Immunization (BCG, Measles,
3 doses each of DPT and OPV)
31.37 27.43 33.77 39.25 32.83
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.
Source of information: Table 4.33: Sources of information on immunization & Vitamin-A

As presented in Table 4.33, Endline%
n=400 n=402 n=400 n=399 N=1601
BPM and ANM were the BPM 24.6 19.9 31.3 40.1 28.9
most often mentioned source of ANM 19.0 53.5 15.5 21.3 27.4
information on this issue of AWW 37.8 10.0 6.0 13.0 16.7

Other 18.8 16.7 47.3 25.6 27.0
MCHN project.
III) Use of ORS during Diarrhoea

Considering the serious impacts of
Figure IV.24: Awareness – use of ORS
diarrohea on the health, in turn,
Baseline % 44.4
nutritional status of child, the
Endline %
training focused on prevention and 28.4 28.7
26.0 25.6
management of diarrhoea. The 18.9 19.0
14.2 16.1
Project emphasized on increasing 10.6
frequency of feeding and giving

ORS to a child during diarrhoea
(Figure IV.24).
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

the mothers were not aware of them. Few benefits known to them included, prevention
from dehydration (27%) and replenishment of lost fluids (18%) (Table 4.34).
Table 4.34: Awareness regarding the benefits of using ORS

Agra Jhansi Allahbad Varanasi Total
Endline % n=400 n=402 n=400 n=399 n=1601
Prevents dehydration 30.8 27.1 21.8 28.1 26.9
Replenishes for the water loss 12.0 19.4 16.5 23.1 17.7
Don't know 56.8 53.0 60.3 47.7 54.4
Availability of ORS packets: Figure IV.25: Aavailability of ORS packets

The supply of ORS was made
% Baseline
available under MCHN project, % Endline 42.4
36.5
as a result availability of ORS 32.8 33.9
has significantly improved from 23.8

21.7
the baseline. As shown in the
9.74 11.3
(Figure IV.25) proportion of 8.4
mother reported availability of

ORS packets has gone up from Agra Jhansi Allahabad Varanasi Total
11% of baseline to 34% of

endline. Similar trend was observed across the three MCHN districts. Since Jhansi did
not have any baseline information, the necessary comparision could not be done.
Place of ORS availability: Table 4.35: Place of ORS availability in the village
BPMs counseled regarding Agra Jhansi Allahbad Varanasi Total

Endline %
n=146 n=132 n=95 n=169 n=542
the place of getting ORS
At AWC 41.8 32.6 23.2 15.4 28.0
packets. When asked about At Sub
center/TBA
14.4 27.2 17.9 26.7 21.9
the source of supply, AWC
Other (ANM,
43.8 40.2 58.9 58.0 50.0
and sub-centre / TBA doctor, BPM, etc)
featured as the source of getting ORS availability. Half of the mothers mentioned ‘other
sources’ that included ANM, doctor, BPM, etc (Table 4.35).

Prevention of diarrhoea – awareness: Majority of the
Prevention of diarrhoea?
mothers (62%) were not aware about the ways to Drinking safe/clean water
prevent diarrhoea. Slightly more than one-third (37%) Eating hygienic food
Using clean bottle feed
opined that safe drinking water should be used to avoid Hygienic living conditions
diarrhoea (Table 4.36).
Table 4.36: Awareness regarding prevention of diarrhoea (% responses)

Endline %
n=400 N=402 n=400 n=399 n=1601
Safe drinking water 13.0 8.5 62.3 64.7 37.0
Use of Sanitary latrine 0.3 0.0 0.3 0.0 0.1
Washing of hands with soap 0.8 0.0 1.0 0.3 0.4
Child Breastfeeding 0.0 1.5 0.0 0.0 0.4
DPT vaccination 0.0 0.2 0.0 0.3 0.1
Don't know 86.0 89.8 36.5 34.8 61.8
Awareness- feeding during diarrhoea:

Continued feeding is Table 4.37 : Awareness – Quantity of feed/breatfeeding to be
given during diarrohea (Endline %)
crucial factor for
Jhansi Allahbad Varanasi Total
improving the prognosis Quantity of Agra
Breastfed
of diarrohea. Nearly three n=400 n=402 n=400 n=399 N=1601
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).

Breastfeeding during pneumonia:
Figure IV.26: Awareness- Breastfeding during
Continuing breastfeeding during pneumonia
% Baseline % Endline
pneumonia is recommended
84.3
because daily nutrient and weight
68.0 69.9
loss may be considerable that could 53.9 51.8 54.2 58.3
in turn lead to malnutrition. 40.1 43.4
Around 58% of mothers said that

breastfeeding should be continued
during pneumonia. The proportion Agra Jhansi Allahabad Varanasi Total
of such cases has slightly gone up
in the endline from the baseline (Figure IV.26).
Around 46% mothers opined Table 4.38: Awareness – Feeding, apart from breastfeeding
during pneumonia
that other food and liquids
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).

D. Family level practices
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.
I) Consumption of iodized salt

Iodine is an important micronutrient. A lack of iodine in the diet can lead to Iodine
Deficiency Disorder (IDD) which usually cause miscarriages, brain disorders, cretinism,
low IQ & poor school performance and retarded psychomotor development. Iodine
deficiency is the single most important and preventable cause of mental retardation
worldwide. This message was communicated and explained in entire project area of
MCHN district along with salt testing of individual household by each BPM. In order to
see the impact of the effort, the awareness and practice related to consumption of iodized
salt was ascertained among the mothers of children less than 2 years and newly married
females during the study.
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
aware that it Improves physical &

11.1 20.2 12.1 6.6 12.5
mental health of newborn
improves physical Prevent goiter 34.8 24.3 42.4 30.5 33.0
and mental health Good for pregnant women 7.6 3.3 1.5 0.4 3.2
of newborn. One- Do not Know 48.3 56.6 42.2 58.2 51.3
third of
respondents were aware about the prevention of goiter as the benefit of consuming iodized
salt. Across four MCHN districts, correct knowledge about the issue was found better in
Jhansi and Allahabad as compared other districts (Table 4.39).

Consumption- salt testing: Table 4.40: Results of salt testing done at Household level
Salt Testing Kit (STK) was Agra Jhansi Allahabad Varanasi Total
used as a tool under the Endline%

n=420 n=447 n=420 n=445 N=1732
MCHN project to 0ppm 36.9 40.7 26.0 27.4 32.8
promote awareness on <15ppm 40.0 51.0 53.6 61.1 51.6
importance of consuming =>15 ppm 23.1 8.3 20.5 11.5 15.6

Baseline%
iodized salt at the n=4,526 n=4,400 n=4,400 n=4,384 N=17,710
household level. Salt tests 0ppm 53.45 69.67 56.70 96.76 69.03
<15ppm 28.99 20.84 31.52 0.00 20.42
through STK visually
=>15 ppm 17.48 9.48 11.77 3.24 10.55
demonstrated the presence
of different levels of iodine content in samples of salt taken form the household. It helped
in sensitizing the importance of consuming of iodized salt. A comparison of salt testing
results at baseline and endline confirm increased use of iodized salt in the project area. As
it is evident from Table 4.40, the proportion of households using salt with ‘0’ ppm was
reduced by half (69% to 35%) in the endline. There was an increase in household using salt
with iodine <15ppm salt in the endline indicating a shift from ‘0ppm’ to <15ppm.
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
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.

Iodized salt – Consumption & Awareness
During the survey it emerged that although the mothers said that they are aware that
consumption of iodized salt is good for health but many of them could not specify the exact
benefits. The type of responses obtained were: “…iodized salt should be eaten. I can’t say
why it should be eaten…perhaps it is good for heath”. Around half of them could mention
the benefits and thus these women, reportedly, insisted for iodized salt while purchasing. They
confidently said that only iodized salt is consumed in the household but iodine-testing
conducted during the survey revealed the presence of iodine (=>15ppm) in salt from 16%
households only. In households were dhela salt (bargara or big crystal salt) was used, the
practice of washing (to make it clean) it before use was reported in around 45% cases. These
facts highlight the need for continuing the efforts for increasing the awareness on benefits of
eating iodized salt and discouraging use of dhela salt (bargara salt), which is often washed
There is enough evidence

Table 4.41: Source of information on consumption of iodized salt
regarding positive change in
behaviour related to Endline %
n=428 n=435 n=439 n=415 N=1717
consumption of iodized salt BPM 63.6 76.2 94.8 73.4 82.5
in the families targeted by AWW 1.9 1.6 1.4 1.9 1.7
MCHN project. The high ANM 0.2 2.5 1.8 0.2 1.2
levels of awareness could TV/Radio 44.2 25.3 8.2 10.6 22.1
easily translate into practice. There was no custom or tradition prevalent in the community,
which contrdicts messages on promotion of consumption of iodized salt, or hindered the
practices. The role of BPM in achieving this objective, again, emerged to the forefront
across four MCHN districts.
II) Hygiene & Sanitation

Presented in Figure Figure IV.28a: Practice – Hygiene & Sanitation
IV.28a, a substantial Baseline % Endline %
improvement is 75% 82% 83% 86%

62%
46% 35%
observed in the
endline on various Source of Using latrine Washing hands Washing
drinking w ater facility w ith soap after vegetables/fruits
issues related to (Handpum p & defecation before use
Tap)
hygiene & sanitation.
Proceeding paragraphs discuss each of the issues in detail.

Source of drinking water: Use of Figure IV.28: Practice – Sources of drinking
water
handpump and tap increased from 46% to 68.5
53.0
75%. The dependency on well for drinking Baseline % 41.58
water reportedly declined from 53% in Endline % 24.8
baseline to 25% in endline (Figure IV.28). A 4.5 6.0
substantially higher proportion of families Tap Handpum p Well
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.
Handling drinking water: Table 4.42: Handing drinking water (% response)

To prevent the Jhansi Allahabad Varanasi Total
Agra
contamination of drinking n=460 n=461 n=464 n=455 N=1,840
water, it is necessary to Covering the vessel containing drinking water (Endline %)
Keep close 94.3 88.3 79.7 68.6 82.8
store the drinking water
Keep open 5.7 11.7 20.3 31.4 17.2
covered. Field observations Retrieving drinking water from vessel (Endline %)
suggest that the vessel Tilt the vessel 21.3 39.0 34.1 36.3 32.7
Using ladle 17.2 31.3 17.5 6.8 18.2
containing drinking water
By dipping other
small vessel
56.3 29.5 48.3 56.5 47.6
was kept covered in 83% of
Other 5.2 0.4 0.2 0.4 1.6
the families contacted Using ladle to pour out water (Baseline %)
during the study. Use of a n=4,526 n=4,400 n=4,400 n=4,384 N=17,710
Using ladle 19.1 36.2 19.2 0.0 19.5
ladle (known as ‘ghanti’ or
‘dandi-wali-lutiay’ in local language) was advised for drawing the water out during the project.
Use of ladle was found marginally better in endline. This is possibly due to the fact that the
predominant practice of drawing water tilting the water vessel has instead increased.

BPMs, once again, emerged
Table 4.43: Source of information on drinking water
as the main source of
information for the practice Endline %
n=460 n=461 n=464 n=455 N=1,840
related to correct source to be BPM 77.4 69.8 95.1 95.8 84.5
used for drinking water as AWW 4.3 1.7 0.6 1.1 2.0
well as storage and handling ANM 0.9 1.3 0.4 0.2 0.7
of drinking water. TV/radio TV/Radio 21.3 19.5 6.5 9.7 14.2
also contributed a little in this

regard (Table 4.43).
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).
Availability and Practice of Figure IV.29: Availability of latrine facility

using latrine facility: As Baseline %
13.3
presented in Figure 1V.29 the Endline %
10.8 10.3
9.6
availability of latrine facility has 7.8
8.9
6.6 7.1
improved only marginally from 7% 5.8
of baseline to 10% in the endline. 3.0
Also, quite a number of them were

not aware of the fact that sanitary

latrines are constructed by getting financial assistance from Government where a small
contribution is needed from community.
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
the advantages of using latrine
facility (Figure IV.30).
Source of information: The Table 4.45 : Source of information on sanitary latrine
high level of awareness and Agra Jhansi Allahabad Varanasi Total

%Endline
n=460 n=461 n=464 n=455 N=1,840
practice observed regarding
BPM 65.1 69.6 75.0 78.9 72.0
the use of latrine can be
AWW 2.6 5.0 8.2 8.8 6.1
attributed to BPM as they ANM 0.0 2.2 0.2 0.7 0.8
were the most often TV/Radio 37.2 29.7 22.0 18.2 26.8
mentioned (72%) source of
information on this issue (Table 4.45).
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

perceived washing of hands after cleaning child excreta (Table 4.46). Even, the qualitative
survey findings also substantiate these results.
Hygiene & Sanitation – Awareness & Practice

During the FGDs held in MCHN villages, majority of the women participants informed that not
only they, but the other family members as well started washing their hands before cooking
and eating and after defecation. They cited, “now we know, the importance of hygiene,
cleanliness for good health. The BPMs have been telling us a lot about cleanliness”.
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
comparison of endline results

with that of baseline findings 88.4 89.5
79.1 83.1
75.5
show a significant increase in the
42.8 42.8
practice of washing hands with 28.6 34.8
25.1
soap after defecating (baseline:

A gra J ha ns i A lla ha ba d V a ra na s i T o tal
35%, endline: 83%).
Respondents were asked Table 4.47 : Washing hands / raw eatables
to mention other Agra Jhansi Allahabad Varanasi Total

Endline %
n=460 n=461 n=464 n=455 N=1,840
activities, after which
Before food
81.5 83.9 78.9 81.3 81.4
hands is washed by them. preparations
After defecation 70.0 65.7 82.1 81.3 74.8
A high proportion (81%)
Before eating 73.3 66.6 67.5 72.5 69.9
washed hands before
Before interacting
45.9 38.4 53.7 69.0 51.7
preparing any food while with children
After cleaning
70% washed hands before 49.3 32.3 51.7 53.2 46.6
child 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
reportedly washed have

been mentioned in Table 4.47. The practice of washing vegetables/fruits before eating was
followed in 86%. N o baseline data on this aspect available for comparison with endline.

The observed levels of awareness
Table 4.48 : Sources of information
and practice on various aspects of Agra Jhansi Allahabad Varanasi Total
%Endline n=460 n=461 n=464 n=455 N=1,840
hygiene and sanitation can again
BPM 82.2 84.2 103.7 109.7 95.0
be attributed to the BPMs as they
AWW 8.7 11.9 10.3 12.5 10.9
featured as main source of ANM 8.3 10.6 8.4 6.8 8.5
information in majority of the TV/Radio 27.4 20.6 5.4 7.7 15.3
cases (95%). Refer Table 4.48.
E. Newly married women / Mothers

Among the other factors, the age of conception is also linked with overall health and
nutritional status of the newborn. Appreciating the importance of correct age of
conception as an underlying determinant of malnutrition, newlywed women were also
targeted under the MCHN project to sensitize them on this issue. However, during the
contact with newlywed females, an opportunity to inform them about other issues was also
felt besides providing them information on issues related to family planning. Some basic
information on maternal & childcare was also given to them in an attempt to increase their
overall health seeking behaviour.
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.
I) Correct age of marriage, conception and birth spacing

Awareness: With regard to correct age of marriage for boys and girls; age of first
conception and minimum spacing between two successive children, majority of the newly
married females and mothers interviewed were having correct knowledge. Average age for
these events, as cited by them, worked out was; 21 years for boys’ marriage, 18 years for
girls’ marriage, 20 years for first conception, while the average time gap between two
successive children was 3 years. The awareness regarding the average time gap between two

successive births was, reportedly, 3.1 years. The knowledge on this aspect was almost same
across the four MCHN districts.
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.)
II) Birth spacing methods:

Awareness & Practice: More than two third of the newly married females were found
aware about oral pills and condoms whereas more than two fifth knew Copper-T as
method for spacing birth. Contrary to high levels of awareness, low levels of practice was
observed regarding use of any spacing method.
Table 4.50: Birth spacing methods (Endline %)
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

III) Husband’s support regarding family planning issues:
As presented in Table 4.51, a low proportion of newlywed females (23%) reported
receiving husband’s support on family planning issues. The proportion of such cases
was relatively better in case of mothers.
Table 4.51: Receiving husband’s support on family planning issues (% response)

Total Total
Agra Jhansi Allahabad Varanasi
Newlyweds Mothers
n=60 n=59 n=64 n=56 N=239 N=1601
% Reporting yes 43.3 18.6 20.3 8.9 23.0 39.8
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
levels of awareness BPM 90.1 100.0 98.5 101.8 97.5 86.1

ANM 1.7 0.0 0.0 0.0 0.4 6.1
on correct age of AWW 6.7 0.0 0.0 0.0 1.7 4.0
marriage, first
conception and time gap between two successive children along with information on
family planning related issues (Table 4.52).

SECTION B : OUTCOME - NUTRITIONAL STATUS OF CHILDREN
a) Nutritional Status of below 2 years children:
In order to measure the impact of the

Figure IV.32: Nutritional status of children below
efforts that were put in under MCHN 2 years
Project, Nutritional status of 1675

Baseline %
children less than two years, across the Endline %
four MCHN district, was assessed. The 32.7
27.5 27.5 25.9 24.5
24.6 23.3
results when compared with the baseline 14.0
show a significant decline in the
proportion of severely malnourished Normal Mild Moderate Severe
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)
Endline %
n=403 n=440 n=416 n=416 n=1675
Normal 39.21 25.91 20.67 24.76 27.52
Malnourished-mild (GRADE-I) 30.77 33.64 34.13 31.97 32.66
Malnourished-moderate (GRADE-II) 18.36 28.41 34.38 21.88 25.85

Malnourished-severe (GRADE -III & IV) 11.66 12.05 10.82 21.39 13.97
Baseline %
n=1542 n=1007 n=1496 n=4,045
Normal 32.62 12.81 24.33 24.62
Baseline
Malnourished-mild (GRADE-I) 26.26 data 18.27 23.73 23.34
incomplete
Malnourished-moderate (GRADE-II) 26.39 33.96 24.33 27.52
Malnourished-severe (GRADE -III & IV) 14.72 34.96 27.61 24.52

The above trend in nutritional status of baseline and endline suggest that decline in severe
malnourishment is more easy to achieve compared to shifting from moderate/mild to
normal level. Improvement in semi-solid feeding practices and moreover special attention
to ‘at risk’ children who are visibly severely undernourished could have contributed to this
reduction of 43%. It may be noted that MCHN project gave a special focus to children
who were severely undernourished and presented with clinical features.
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
malnourished children, in - 3 SD 24.5 31.9 34.9 36.7 32.1
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).
Gender-wise analysis: Gender-wise analysis of nutritional status of children less than 2

years shows a marginal difference between male and female children in the endline (Table
4.55). Overall, the proportion of severely and moderate malnourished cases was slightly
higher in case of female children, in comparison to their male counterparts.
Table 4.55: Nutritional status of children below 2 years of age (Gender-wise) - Endline

Endline % Male Female Male Female Male Female Male Female Male Female
n=229 n=174 n=238 n=202 n=214 n=202 n=222 n=194 N=903 N=772
Normal 38.4 40.2 28.6 22.8 22.4 18.8 24.8 24.7 28.7 26.2
Mild 32.3 28.7 33.6 33.7 37.4 30.7 35.1 28.4 34.6 30.4
Moderate 18.8 17.8 25.6 31.7 31.3 37.6 23.0 20.6 24.6 27.3
Severe 10.5 13.2 12.2 11.9 8.9 12.9 17.1 26.3 12.2 16.1

b) Severely malnourished children under 6 years of age:
In addition to focusing on Figure IV.33 : Severely malnourished children under
6 years of age
nutritional status of below two
39.1
years children, the project also Baseline %
Endline %
addressed the problem of severe
22.5
malnourishment amongst below 19.6 19.7
15.6
six years children. Thus, in order 12.5 12.5 13.7
10.0 9.5
to assess the status of severe
malnourishment, 2637 children Agra Jhansi Allahabad Varanasi Total
up to 6 years of age were covered
across four MCHN districts during the study. Finding shows that overall 14 percent
children were found severely malnourished in the endline as compared to 23 percent in the
baseline. In Varanasi, unlike for ‘below 2 years children’, there was a significant decline in
severely malnourished cases for ‘below 6 years children’ (baseline: 39%; endline: 20%).
However, the overall decline severely malnourished cases are similar to that observed in
case of less than 2 years children (Figure IV.33).
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
malnourished children below Male 9.4% 9.8% 13.9% 15.9% 12.2%
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

by the Directorate of Family Welfare, GoUP. However, training the ANMs, AWWs &
BPMs focused on identification severely underweight children by clinical signs. Feeding,
counseling and severe cases of underweight were identified based on observations of
clinical symptoms. In all, 10 percent of the mothers mentioned that the health
functionaries or health volunteer had identified one or more number of children in their
household as severely malnourished.
Table 4.57: Presence of malnourished child (observed on bases of clinical symptoms) in
household (% response)

Whether the household had a
malnourished child
n=400 n=402 n=400 n=399 N=1601
Yes % 16.8 9.7 2.5 11.3 10.1
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 %)
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.

The Outcomes of the Project…
- MCHN Concepts
5
The strategies adopted in MCHN project and the
Success on
impact of these strategies in improving the ‘Process Indicators’ (Strategies)
by which improvement on each
nutritional status has been critically examined in ‘Key Indicator’ is achieved
the preceding sections of this report. To reiterate, Leads to
the goal of the MCHN project was not only to
Improvement on
improve the nutritional status of the target Key ‘Impact Indicators’ which
influences Nutritional Status of children
children, but more importantly, to put forth the
Leads to
successful strategies and processes that helped
Improvement on
achieving this prime objective. The project Nutritional Status
hypothesized and envisaged that improvement on

key independent factors – improved nutritional status of mothers (right age of conception,
ANC care that includes IFA consumption, taking additional rest of 2 hours), improving
infant and young child feeding (initiation to breastfeeding, colostrum feeding, better
hygiene practices) hygiene and safe water usage practices as well as sanitation practices, etc.
would together contribute in improving the gross outcome that is the overall nutritional
status. These contributory factors were defined as ‘Key Impact Indicators’ in the Project.
However, the Project also demonstrated the process/road-map of achieving results on
each of these impact indicators and in turn improving the nutritional status. Hence, the
innovative strategies/processes, defined as ‘Process Indicators’ by the Project, also need to
be discussed separately. Thus, the discussion in this chapter has been classified under two
headings:
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.
Evaluation of MCHN Project V-1

PROCESS INDICATORS:
Several ‘Planning-Workshops’ were executed for finalizing the ‘Plan-of-action’ for

the MCHN project. The Project clearly spelt out both ‘Process Objectives’ and
‘Impact Objectives’ to achieve the pre-defined ‘Expected outcomes’. Clearly defining
the objectives was strength of the Project as it helped the smooth implementation
without deviations and also monitoring the progress of Project at different intervals.
‘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.
Capacity building of Medical colleges was done by establishing them as State

Nutrition and Resource Centres (SNRC) / District Nutrition Resource Centres
(DNRCs) to coordinate the activities of project in the MCHN districts. This was a
very effective strategy for ensuring quality of training, monitoring and overall
implementation. They were constantly available with technical expertise and
knowledge of the local area. They also networked with other district level
departments for meetings or for other requirements. The MCHN project highlighted
their presence as a resource at the district level. Hence, they are now involved by
other agencies for coordinating similar kind of projects. However, since the fund
flow was also done through Medical colleges, their active participation adversely
affected active ownership by the nodal departments, which in turn decreased the
participation of the other sectors involved in the Project.

To tackle the problems related to unsafe drinking water, efforts were made to
establish linkages with ‘Water and Sanitation (WES)’ of UP Jal Nigam. But,
unfortunately WES did not view it as “their programme” and did not play any
significant role in the MCHN project. The awareness created at the community level
resulted in demand for safe drinking water but Assistant Development Officer
(ADO) in charge at block level did not respond to their demands. Probably,
increased stake of Water and Sanitation department at the State level in the Project
could have inculcated the sense involvement & ownership.
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.
Moreover, emerging priorities such as polio programme in year 2000 significantly

reduced the interest of Health department and nodal department (FW) at the State
level in the MCHN Project. This was naturally not envisaged in the planning stage
and the ANMs responsibility was fully diverted to polio programme, resulting in
poor response to the high demand created by the Project at the community level.
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

awareness and practice. BPMs were community-based workers who were extenders
of the frontline workers – ANM/AWW. They made frequent contacts with target
groups regarding MCHN issues and activities.
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.
Defining the target audience, as ‘Risk-families’ was an innovative approach that

enabled easy identification of the population segments that was to be reached and
counseled urgently. Further, the number of such families was also fixed at around
40-50 per community-based volunteers (BPMs). The approach ensured that no
households were left uncovered and that there was no overlap of area between the
BPMs. Hence, regular interaction with all the families/households became very easy
for the BPMs.

This strategy inspired the ‘Home visit guidelines’ of ICDS, in the GoUP plan of
action, where MCHN’s ‘at Risk-family’ approach has been used to identify the target
groups. Some components of MCHN have gone in the strategy of ICHN
(Intensification of Child Health & Nutrition) activities, also.
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.
The Project demonstrated the successful way of incorporating the component of

regular monitoring. It was done – a) Through ‘Quarterly monitoring meetings’ by
BTMs, and b) by use of ‘pictorial monitoring card’. The Quarterly monitoring
meetings provided an opportunity for all the BPMs to come together and share their
common concerns, discuss and explore for the possible solutions. It not only

ensured smooth monitoring of the project but also imparted on-job skills building
the capacity at the community level.
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.
As a communication strategy, ‘Inter-Personal Counseling (IPC)’ was planned and

undertaken as a technique to communicate with the community on MCHN issues.
This was done because low levels of literacy among the target audience does not
allow the use of high involving communication tools such as hoardings, wall-
writings, posters, banners, etc. The use of TV commercials and radio spots
dependent on the availability of electronic media and electricity in the poor rural
areas. Thus, Project as a strategy did not use any IEC tool mainly to demonstrate the
impact of community-based-workers.
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

supply was not adequate. The problem of spurious supply of iodized salt needs to be
controlled to further increase the consumption of iodized salt.
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:

Taking at least 2 hours of rest per day (baseline: 70%; endline: 73%),
Consumption of 90+ IFA tablets (baseline: 10%; endline: 22%),
Consumption of iodized salt (baseline: 31%; endline: 67%),
Colostrum feeding (baseline: 28%; endline: 53%),
Safe source (tap/handpump) of drinking water (baseline: 46%; endline: 75%),
Using sanitary latrines (baseline: 62%; endline: 82%),
Washing of hands after defecation (baseline: 35%; endline: 83%)
On all these indicators, there wasn’t anything to unlearn and hence increased levels of
awareness got easily translated in increased levels of practice, too.
Remarkable increase in practices related to correct hygiene practices (positive trends

were also observed in case of washing hands prior to feeding or cooking as well as
after defecation) and use of safe water sources possibly contributed to significant
reduction in diarrhoea and infection and played an important role in improving the
nutritional status of children as well as in breaking the infection and malnutrition
cycle.
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.
On the other hand, due to unexpected involvement of ANMs in polio campaigns

practice on indicators that dependent on services received from the ANM was
adversely impacted, such as ‘Immunization’ and administration of ‘vitamin A
supplementation’. Regarding ANC services (ANC registration, 3 ANC checks-ups, 2
doses of TT), although there was an improvement in practice, but the levels of
practice would have been higher had ANMs not got diverted in polio campaigns.

The findings also show that crucial practice of exclusive breastfeeding of infants
upto 6 months is particularly difficult to adopt by families since 50%
mothers/caregivers interviewed were aware of the importance of exclusive
breastfeeding infants upto 6 months but only about 2% translated the knowledge
into practice. Introduction of water (41%) and animal milk (46%) within a month of
birth and prelacteal feed of homey, etc. continues to be followed by mothers since
such practices are deeply grained in the culture and are not easily changed.
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

increase (of 3 percentage points) in children falling in normal category in the endline
survey which is in line with the fact that shift to normal category from mild category
takes relatively more time in comparison to shift from moderate to mild or from
severe to mild category of malnourishment.
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.

As envisaged, the nutritional status of target children (upto 24 months of children)
improved due to improvement in practice on various key indicators on which
nutritional status is dependent. Appropriate processes and innovative strategies of
MCHN Project helped achieving this to some extent in a short span of four years of
Project life. In fact, period of four years is short period to achieve substantial
improvement in nutritional status. However, the primary aim of the MCHN Project
was to demonstrate the process/model of achieving positive results on nutritional
status using community based approaches; and also to draw useful lessons for future
references.
Long term impacts of the Project:

Community based MCHN Project not only created enough resources in terms of trained
manpower (BTMs/BPMs) at the grass-root level but also demonstrated the role
importance of Medical Colleges in form of SNRC/DNRC created by the MCHN project.
The SNRC/DNRC can provide technical support to training/capacity building and
coordination of projects like MCHN at the district level. MCHN Project also presented
successful strategies/approaches that have resulted in redesigning ICDS to reach
undernourished.

Strengths, Weakness, Opportunities and Constraints/Threats (SWOC/T) Analysis
MCHN STRATEGY
Strengths Weakness
Developing capacity of medical colleges Involvement of Family Welfare Directorate
by establishing them as SNRC/DNRC. was in the planning only, which gradually
Regular coordination through technical came down with the change of DG.
body like SNRC/DNRC ensured quality The ICDS Directorate did not coordinate
implementation. at state level except while developing
Well-defined strategy and Plan-of-Action training modules & during process
defining roles of functionaries and documentation.
outlining the structure for recording, Response to health services was negligible
monitoring and evaluation. as ANMs got engaged in other emerging
Technical and other support form priorities like pulse-polio drives.
UNICEF. Outreach sessions by ANMs were not
Collection of baseline information and adequately held and project was not able to
plan for endline information. increase this as no funds were allocated for
Appointment of very qualified personnel it. Special strategies were needed.
exclusively acting as ‘Block-trainer-cum Use of local name for the project would
monitor’- (BTMs) to regularly monitor the have helped in better identification of the
activities of community-based worker project in the community.
called ‘Bal-Parivar-Mitra’ (BPMs) and Although mothers are well informed and
coordinate with block level functionaries. adequately sensitized, they could not put
Methodical selection (social-mapping) of their knowledge into practice. This was
BPMs. mainly due to observance of certain local
Elaborate and structured training/ customs or presence of misconceptions/
orientation to functionaries. myths. Also, service response from ANM
Active involvement of BPMs for inter- was poor.
personal counseling (IPC). Male participation and involvement should
Presence of ANM and AWW from Govt. also be ensured.
departments at the grass-root level. Absence of teacher’s involvement, who are
Use of pictorial monitoring card by BPMs very important opinion leaders in the rural
for collecting information. community.
Pictorial card was mainly used for Water and Sanitation Services of UP Jal

monitoring as well as training however it Nigam could not play any significant role.
also served as effective IEC and Lack of IEC support; no aid (such as flip
reinforcing tools chats/modules) to inter personal
Case studies based training module were counseling (IPC).
Informative tools. No monthly incentive was paid to BPMs.
Close and regular monitoring through Monthly incentive of Rs. 50 per month
quarterly review meetings by BTMs. could have resulted in better incentive for
Social recognition, as a motivator, given to BPMs.
the BPMs. They were paid quarterly
honorarium of Rs. 100/- on submission of
properly filled monitoring formats.
Traveling allowance to attend the quarterly
meeting was assumed by the BPMs as
monetary compensation for their
involvement in the project.
Additional financial support was worked
out and provided by the UNICEF.
Opportunities Constraints/Threats
Greater scope for programme design Weak ownership of the nodal agency at
improvements: lessons learnt from the the state level.
experience of MCHN in 4 districts can be Frequent transfer of key officials
incorporated in the next phase. involved in the Project.
Presence of Medical Colleges (as SNRCs / Hurdles posed by Pradhans and other
DNRCs) is very useful as they not only influential people in some villages.
have technical expertise but are also Contradictory messages spread by the
experienced in the area/issue. local medical parishioners on certain
Support from the Government. issues.
Availability of experienced and qualified Overloaded AWWs and ANMs.
grass-root level workers such as ANM Bureaucratic government structure
from Health Dept. and AWW from ICDS. causes unnecessary delays.
Availability of willing, trained and
experienced community-based workers for
the present project (if restarted) or for
other similar projects.


Community Based Maternal & Child Health Nutrition (MCHN) Project

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Community Based Maternal & Child Health Nutrition (MCHN) Project

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Community Based Maternal & Child

Health Nutrition (MCHN) Project

Ashish Gupta, MBA

ORG Centre for Social Research

ORG Centre for Social Research

We are extremely thankful to UNICEF for providing us an opportunity to Evaluate the

1. Community based MCHN Project

3. Accomplishing the processes

4. Achieving the project objectives

5. The outcomes of the project

Key objectives of the Community based MCHN project included;

Community Based MCHN Project – An Evaluation I

Target Population " At Risk” Families:

Community Based MCHN Project – An Evaluation II

Methodology and Sample Coverage:

Community Based MCHN Project – An Evaluation III

A- Process Objectives (Qualitative Survey): Findings

• District-level, multi-sectoral orientation and planning workshops were more interestingly

• District orientation workshops interestingly included community based activities with

Community Based MCHN Project – An Evaluation IV

B- Impact Objectives (Quantitative Survey): Findings

• A considerable decline of 43% in the proportion of severely malnourished (IAP

Community Based MCHN Project – An Evaluation V

ii) Maternal & Newborn & Infant Care

iia) Consumption of IFA tablets:

• Compared to 6 percent during Baseline 61 percent in the endline confirmed receiving

iib) Maternal Care

Community Based MCHN Project – An Evaluation VI

iic) Newborn Care

iid) Infant & Young Child Feeding

iie) Vitamin A supplementation (VAS):

Community Based MCHN Project – An Evaluation VII

services to address the problem of micronutrient malnutrition. The low coverage of

iii) Household level practices

iiia) Consumption of iodized salt:

iiib) Safe drinking water and Hygiene & Sanitation

Community Based MCHN Project – An Evaluation VIII

• A system needs to be developed so that the State ownership of a Project is sustained

• The strategy of involving Block-Trainer-cum-Monitor (BTM), who was the additional

• BPMs (Bal-Parivar-Mitra) meaning ‘friends of families’ were community based

Community Based MCHN Project – An Evaluation IX

Community Based MCHN Project – An Evaluation X

Overview of Nutrition Situation in U.P.

According to WHO estimations, malnutrition is directly or indirectly associated with over

An analysis of causative factors associated with nutritional status of children of Uttar

Evaluation of MCHN Project I-11

environmental sanitation, Inadequate Education

Besides, children, malnutrition in form of Chronic Energy Deficiency is very high in

Evaluation of MCHN Project I-12

The PROJECT STRETAGY:

Multi-sectoral (Health, ICDS, Rural

Institution (PRI) participation, for Bichpuri & Fatehpur Sikri

elected community volunteers

Sanitation Mobilizers i.e. CHNSMs)

Addressing intergenerational cycle of growth failure.

Evaluation of MCHN Project I-13

The community based Figure 1.3: Organograme of CB-MCHN Project

Evaluation of MCHN Project I-14

For effective multisectoral implementation, the process involved joint training of

Evaluation of MCHN Project I-15

Evaluation of MCHN Project I-16

Key objective of the MCHN project were as follows: