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Assessment of growth monitoring activities conducted in anganwadi centers: A qualitative study in urban field practice area of a medical college in West Bengal


1 Department of Community Medicine, North Bengal Medical College, Darjeeling, West Bengal, India
2 Department of Community Medicine, IPGMER, Kolkata, West Bengal, India
3 CMOH Office of Bishnupur Health District, Bishnupur, West Bengal, India
4 Department of Community Medicine, Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
5 Deben Mahato Medical College, Purulia, West Bengal, India
6 Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India

Date of Submission13-Apr-2020
Date of Decision20-Jul-2020
Date of Acceptance11-Aug-2020

Correspondence Address:
Sumana Samanta,
Department of Community Medicine, Heritage Institute of Medical Sciences, NTS Hostel, Room No. 206, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_178_20

  Abstract 


Background: Growth monitoring under Integrated Child Development Services (ICDS) program is an essential strategy for the prevention and control of malnutrition. Objective: To assess growth monitoring activities done by Anganwadi workers (AWWs), the influencing factors related to it and perception of mothers about growth monitoring service. Materials and Methods: A cross-sectional study was conducted in all the Anganwadi canters of urban field practice area of Community Medicine Department of Bankura Sammilani Medical College. Qualitative data collection methods were employed which comprised of nonparticipant observation of growth monitoring activities, in depth interview (IDI) of AWWs, and focus group discussion (FGD) with mothers of enrolled children. While the checklists had been compiled in Microsoft Excel, transcripts of IDIs and FGDs were analyzed based on the thematic analysis. Results: Growth chart plotting, interpretation of growth curve, and discussion regarding child's growth had been carried out diligently, but preparation for weighing, putting child in the pants and actual weighing of the child were not properly done in all cases. AWWs mentioned logistic issues such as nonavailability of Taring scale and short supply of growth registers, perceived pressure of register maintenance, inadequate infrastructure, lack of periodic training, and supervision among the difficulties. Most of them were satisfied about community participation in growth monitoring process. Many mothers knew about weighing process, but the use of a growth chart had been reiterated by only a few. Conclusion: Logistic and infrastructural issues needed redressal while supportive supervision was essential to ensure the quality of the growth monitoring process. Mothers should also be made more involved in this key activity of ICDS.

Keywords: Anganwadi workers, growth monitoring, integrated child development services, qualitative method



How to cite this URL:
Biswas D, Basu SS, Lo S, Samanta S, Pramanik R, Sarkar GN. Assessment of growth monitoring activities conducted in anganwadi centers: A qualitative study in urban field practice area of a medical college in West Bengal. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=321285




  Introduction Top


Integrated child development services (ICDS) scheme in the pursuance of the National Policy for Children was launched on October 2, 1975–the 106th birth anniversary of Mahatma Gandhi–the Father of the Nation–India.[1] It provides a comprehensive package of services for the holistic development of children aged 0–6 years through a vast network of centres, known as “Anganwadi Center” (AWC).[2]

It is the foremost symbol of India's commitment to her children – India's response to the challenge of providing preschool education (PSE) on one hand and breaking the vicious cycle of malnutrition, morbidity, reduced learning capacity, and mortality, on the other hand.[3]

Growth monitoring is an operational strategy for the promotion of health, which enables mothers to visualize growth or the lack of it in their children by regular and sequential measurement of growth and to obtain specific, relevant and practical guidance to assure regular growth and health in their children.[4]

Growth monitoring strives to improve nutrition, reduce the risk of inadequate nutrition, educate caregivers, and produce early detection and referral for conditions manifested by growth disorders.[5]

Growth monitoring attempts to promote optimal growth through effective education to caregivers; detection of “early growth faltering,” “underweight,” and initiation of relevant action. Growth monitoring and supplementary feeding are directly associated with the obstruction and control of undernourishment in children.[6]

The program is executed through dedicated cader of female workers named anganwadi workers (AWWs), who are chosen from the local community and given 4 months training in health, nutrition, and child care. AWW is in charge of an AWC and is supervised by a supervisor called Mukhyasevika. AWW is also assisted by a helper who works with AWW and helps in executing routine activities at AWC.[7]

The AWW in ICDS program assumes a pivotal role in AWC owing to her close and continuous contact with the community. By virtue of her position in the community, the AWW presents more chances to interact and educate the mothers. ICDS is applied to aid mothers to ensure useful health and nutrition care, prior detection, and timely treatment of disorders.[6]

Through discussion and counseling growth monitoring also increases the participation and capability of mothers in understanding and improving child care and feeding practices, for promoting child growth and development.[8],[9]

Review of literature could reveal that most of the study concentrated on the nutritional and health status of the beneficiaries of ICDS. Less focus has been given over to assess the growth monitoring activities among AWWs, who are actually the main resource person. With this background, the proposed study was conducted to assess quality of growth monitoring by AWWs, factors related to it, and perception of mothers of child beneficiaries about growth monitoring in AWCs.


  Materials and Methods Top


A descriptive, facility-based, cross-sectional study was conducted at AWCs in the urban field practice area of Department of Community Medicine of Bankura Sammilani Medical College, West Bengal from July 2017 to December 2017. There were four AWCs covering 300 preschool children of the urban field practice area. AWWs from AWCs and mothers of beneficiary children aged 6–36 months were the study participants.

Complete enumeration of all four AWCs was done from the territory of urban field practice area of community medicine department for nonparticipant observation of growth monitoring activities and in depth interview (IDI) of four AWWs. From each center, eight mothers of child beneficiaries who were present during the time of visit fulfilling the criteria were selected by systematic random sampling for focus group discussion (FGD).

After getting approval from the Institutional Ethics Committee (IEC) and permission from Development Project Officer ICDS and District Social Welfare Officer the study was started. Data collection was commenced by obtaining informed consent from the AWWs and the mothers of child beneficiaries who had participated in FGD.

Three FGDs were conducted. The average time of FGD was 90 min. The FGDs were conducted based on Qualitative Research Methods: A Data Collector's Field Guide.[1] The FGDs were audio-taped and transcribed verbatim along with field notes. Nonparticipant observation of growth monitoring activities done by AWWs was assessed by using a checklist based on ICDS Growth monitoring manual developed by National Institute of Public Cooperation and Child Development (NIPCCD)[8] which included accurate and safe weighing of child, plotting weight on the growth chart, interpretation of growth curve and action taken. Their skills in respect to growth monitoring were assessed by observing their performance by using the pretested structured checklist. IDI guide was used for interviewing the 4 AWWs regarding factors related to growth monitoring perceived by them. FGD guide was used for the mothers of the child beneficiaries (aged 6–36 months) to grasp their perception regarding growth monitoring in AWCs.

Data related to observation checklist were compiled in MS excel sheet. A score of either “1” or “0” was earmarked for the activity performed correctly or incorrectly respectively. Data regarding IDI and FGD transcripts were analysed using an approach based on thematic analysis. This process involved code generation from segment of information (transcripts), code reduction, theme generation. Then, these themes were refined as recurring themes were identified.


  Results Top


Assessment of growth monitoring

In Preparation for weighing “Placement of upper hook through the hole at the top of the scale,” “Room for the scale to hang freely,” and “Placement of the lower hook on the bottom of the scale” were most correctly done. “Placement the pants/infant sling on the lower hook” and “Adjusting the needle to zero (“0”) the screw at the top of the scale” were least correctly done by AWWs.

In Putting the child in the pants “Making it sure that the straps are in front of the Child's arms” and “Removal the pants from the hook” were the least correctly done activities. In this part none of the activities were done 100% correctly.

In Weighing of the child, “Making it sure that the child's feet are not touching the ground” and “Making it sure that the child is not holding on to anything, other than straps of the sling” were done accurately, whereas “Asking the mother to stand close by and talking to the child to prevent crying” was the least correctly done activity.

In Plotting weight on the growth chart and Interpretation of growth curve, all activities were done 100% correctly, but in Discussion the child's growth with the mothers was not correctly done as per the ICDS growth monitoring manual developed by NIPCCD [Table 1].
Table 1: Distribution of different growth monitoring activities conducted by Anganwadi workers (n=32)

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Factors related to growth monitoring perceived by anganwadi workers

Regularity of weighing

Weighing was done on a monthly basis and children usually come on the due date for it.

Problems related to weighing and plotting

While weighing, AWWs did not face any major problem. Sometimes, it became very difficult to measure weight when some children cried vociferously. One of the AWW stated that the line division in the growth chart was very narrow. With increasing age, it was becoming very difficult to plot on the chart correctly.

Issues related to logistics

Majority of AWWs felt that the supply of growth charts was not sufficient. They faced the difficulty when new children were enlisted, and at that moment, they had to erase the previous recorded plot. There was no supply of Taring scale. Hence, they had to use bathroom weighing scale. Difficulty in measuring small fraction of weight had been pointed out by many of them.

Issues related to training, retraining, and supportive supervision

They had got only one training (job training) almost 8 years ago. One of them said that frequent training was necessary to find out their mistakes and for filling up the gaps. The present acting supervisor had got many centers under her supervision. Hence, the visits were inadequate.

“If there is no one to point out my faults how can I rectify those?”

-Stated by one AWW.

Community participation

Community participation was good as per most of the AWWs but one AWW told different story that due to lack of awareness some people did not participate.

“I learn from the people coming to my centre.”

“Interested people don't need IEC activity, it is for them who are not!”

-Told by one AWW.

Issues related to day-to-day activities as perceived by anganwadi workers

Some portion of the mothers had the lack of awareness regarding growth monitoring and that was due to low attendance in mothers meeting. There was conflict about timing and supplementary nutrition in one center which run in a primary school. All AWWs mentioned that due to the pressure of maintenance of various types of registers the quality of services was being hampered.

“CDPO told me whatever the situation is all the registers must be kept updated.”

-Stated by one AWW.

Due to inadequate ventilation, darkness, dampness, peeling of plasters from celling and floor, parents did not want to send their children to the centre which had its own building and was also used as a store room for broken furniture by municipality. AWWs were doing growth monitoring once or twice in a month. Hence, there was a rush of children, and it became hard to manage in measuring weight and plotting simultaneously. However, another AWW used Community Growth Chart for plotting at the time of weighing.

“The problems related to growth monitoring is not due to lack of time, it is due to lack of concern among us!”

-Mentioned by one AWW.

Perception of mothers about growth monitoring in anganwadi centres

Perception of mothers about anganwadi centre

All mothers had a positive perception about the center. They had more interest on supplementary nutrition and PSE; however, they were aware of growth monitoring. They thought that regular growth monitoring ensured nutritional status, early detection, and timely treatment of any disorder. All mothers agreed that AWC made the school going habit among their children.

Idea about growth monitoring and revised integrated child development services growth chart

“Khichri school” is a popular name for its supplementary nutrition but not so much for growth monitoring. A substantial portion of mothers had knowledge about the use of growth chart, importance of color categorization, and their children's nutritional status according to the colour zones. A few mothers had an idea about the growth curve.

“My child was in yellow zone and after following the instruction given by AWW my child is now in green zone.”

-Worded by one of the participant mothers.

Suggestions/recommendations about anganwadi centre

Mothers had suggested for the construction of independent buildings for the centers. Renovation of the building and maintenance of cleanliness had been proposed by them.


  Discussion Top


Observation of growth monitoring revealed that hanging the scale correctly, adjusting the scale to zero, placing the child in pants proper and safe way and reading the accurate weight were not appropriately done in all cases. These had concordance with the study done by Barua and Baruah and Gurukartick et al.[10],[11]

However, growth chart plotting and interpretation of growth curve carried out diligently. This could be because of that AWWs were more concern about documentation than the actual process of weighing. The similar picture has been seen in the study conducted in Guwahati and in a study done in Puducherry.[10],[11] However, in contrast to this study, plotting on growth chart was poor in the studies conducted in Rajasthan and Jammu and Kashmir.[12],[13]

In the present study, child's growth was discussed to the mothers appropriately in most of the cases. However, only few were found to explain the mothers about the direction of the curves in Guwahati and a study done by Udani and Patel.[10],[14]

The present study revealed that the skills of the AWWs in respect of growth monitoring of the children were found to be compromised. However, Chattopadhyay conducted a study among AWWs in Hooghly district, West Bengal, shows that the knowledge and skills of AWWs in respect to different components of their sphere of activity varied.[15]

As per the current study, children usually came on due date for weighing, but in the study by Bhardwaj et al., majority of the parents were uninterested in sending their children for weighing sessions had been found.[6] In this study, majority of AWWs told that the supply of growth charts was not sufficient which was a contrasting picture with a study in Rajasthan where all the AWWs answered positively about the growth chart supply.[6]

The present study revealed AWWs faced difficulty while conducting growth monitoring due to lack of retraining. Similarity has been seen in the study conducted by Gurukartick et al.[11] However, in contrast to these regular monthly training and retraining of AWWs had been found in the study done by Bhardwaj et al.[6]

In the current study, community participation showed a mixed response. The same picture has been observed in Western Rajasthan.[6] AWWs perceived that due to the pressure of maintenance of various types of registers, the quality of services was being hampered. The similar statement was found among AWWs in Rajasthan.[6]

Mothers had some ideas about the activities done under AWCs. The same result had been seen in the study gone by Sivanesan et al. where a larger proportion of mothers were aware of growth monitoring, supplementary nutrition and PSE.[16] All mothers agreed with the fact that AWC made the habituation of school going to their children in this study. Contrasting result was found in the study done by Biswas et al.[17]

Growth monitoring undertaken by AWWs is an important component of ICDS. To improve the nutrition, assessment of nutritional status and its monitoring are the important aspects which can easily be done with the help of weighing, plotting on the growth chart and taking necessary actions regularly. Therefore, it is paramount for these workers to possess the correct practices in their routine activities.

Limitation

The present study was conducted in a limited area of Bankura municipality, so this result was not representative of the whole population. More such studies with larger sample size from various areas may be suggested. There might be Hawthorne effect as well.


  Conclusion Top


Quality of growth monitoring of children was found to be suboptimum in the study area. Despite having long experience, AWWs failed to follow accurate process of weighing. The frequency of in-service trainings needs to be increased for updating their skill domain. Awareness of the people about growth monitoring to be strengthen. Logistic and infrastructural issues need redressal while supportive supervision is to be strengthen for ensuring the quality of the growth monitoring services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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3.
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7.
Chudasama RK, Kadri AM, Joshi N, Bhola C, Zalavadiya D, Vala M. Evaluation of supplementary nutrition activities under Integrated Child Development Services (ICDS) at anganwadi centres of different districts of Gujarat. Online J Health Allied Sci 2013;12:1.  Back to cited text no. 7
    
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10.
Barua K, Baruah R. Application of growth monitoring charts by health care providers in Village Health and Nutrition Day (VHND) setting in rural Kamrup. Indian J Community Health 2014;26:322-26.  Back to cited text no. 10
    
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Gurukartick J, Ghorpade AG, Thamizharasi A, Dongre AR. Status of growth monitoring in anganwadi centres of a primary health centre, Thirubhuvanai, Puducherry. Online J Health Allied Sci 2013;12:2.  Back to cited text no. 11
    
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Sachdev HP. Textbook on nutrition in children. In: Mathai ST, editor. Growth Monitoring and Promotion – Is it Essential in Maternal and Child Health Programmes? New Delhi: B.I. Publications; 2004. p. 444-60.  Back to cited text no. 13
    
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Udani RH, Patel RB. Impact of knowledge of anganwadi workers on slum community. Indian J Paediatrics 1983;50:157-9.  Back to cited text no. 14
    
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16.
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17.
Biswas AB, Das DK, Roy RN, Saha I, Shrivastava P, Mitra K. Awareness and perception of mothers about functioning and different services of ICDS in two districts of West Bengal. Indian J Public Health 2010;54:33-5.  Back to cited text no. 17
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