GPAF (IMP-006) Final Evaluation Report

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End Evaluation Report of Infant and Young Child Feeding Project,

Buniyaad in Bihar

Project implemented by Aga Khan Foundation

Report submitted by Intercooperation Social Development India (ICSD)

and Center for Socio-economic and Environmental Studies

mailto:[email protected]

http://www.intercooperation.org.in/

Endline Evaluation-Buniyaad Project Page 2

Contents

List of Tables ........................................................................................................................ 1

List of Figures ....................................................................................................................... 2

Abbreviations ........................................................................................................................ 3

Acknowledgements ............................................................................................................... 4

Executive Summary .............................................................................................................. 5

1.0 Background and Context of the Project Buniyaad ..................................................... 15

2.0 Project Buniyaad- Logic Theory and Results Framework ......................................... 16

3.0 Purpose and Objectives of the Endline evaluation .................................................... 20

4.0 Approach and Methodology ...................................................................................... 21

5.0 Findings - Quantitative Study .................................................................................... 25

6.0 Findings - Focus Group Discussions and Interviews ................................................. 67

7.0 Key Observations ..................................................................................................... 80

8.0 Recommendations.................................................................................................... 86

9.0 Limitations ................................................................................................................ 88

Annexures ........................................................................................................................... 89

Annexure 1: Terms of Reference ........................................................................................ 89

Annexure 2: FGD/KII Guidelines and Questionnaires.......................................................... 93


List of Tables

Table 1: Sample Size of the Endline Survey ......................................................................................................... 26 Table 2: Time of initiation of breastfeeding followed by mothers with newborns less than 7 days old .................. 28 Table 3: Knowledge about the advantages of early initiation of breastfeeding among women in the last trimester

of pregnancy: Endline survey ................................................................................................................ 29 Table 4: Advantages of colostrum feeding reported by women in the last trimester of their pregnancy: End line

Survey ................................................................................................................................................... 30 Table 5: Advantages of exclusive breastfeeding reported by mothers with newborns less than 7 days old and

mothers with a child 3-4 months of age ................................................................................................ 34 Table 6: Knowledge on age at which complementary foods can be started among mothers of children 3-4 months

of age .................................................................................................................................................... 39 Table 7: Age at which complementary food was introduced for children of 12-13 months of age ......................... 40 Table 8: Frequency of giving complementary food to children 12-13 months of age ............................................ 42 Table 9: Average of quantity (in ml) of solid/semi solid foodsgiven to children 12-13 months of age .................... 43 Table 10: Variety of Semi-solid food eaten by children 12-13 months of age in the last 24 hours ........................ 43 Table 11: Number of Food Groups from which children aged 12-13 months ate in the past 24 hours .................. 44 Table 12: Message related to IYCH heard or seen by women .............................................................................. 46 Table 13: Source of awareness about IYCF messages ........................................................................................ 47 Table 14: Proportion of women who attended at least one group meeting organised by PE/CC during the last 3

months: Women category-wise ............................................................................................................. 48 Table 15: Points discussed in the group meetings organised by PE/CC attended by respondents during the last 3

months: Women category-wise ............................................................................................................ 49 Table 16: Proportion of women whose homes were visited by PE/CC in the ........................................................ 50 last three months: Women category-wise ............................................................................................................. 50 Table 17: Points discussed during the home visits by PE/CC during the last three months: Women category-wise

.............................................................................................................................................................. 50 Table 18: Advantages of early initiation of breastfeeding mentioned by the service providers ............................. 52 Table 19: Knowledge of service providers about the advantages of exclusive breastfeeding ............................... 55 Table 20: Knowledge of Service Providers about the ideal timing (6 months) for introduction of complementary

food ....................................................................................................................................................... 56 Table 21: Knowledge of service providers about the frequency of complementary feeding in 24 hours for children

12-24 months of age ............................................................................................................................. 57 Table 22: Knowledge of service providers about the quantity of complementary feeding in 24 hours for children

12-24 months of age ............................................................................................................................. 58 Table 23: Perception of Service Providers about the variety of Foods to be given to the child for complementary

feeding .................................................................................................................................................. 59 Table 25: Average number of group meetings and home visits conducted by service providers in the past 3

months .................................................................................................................................................. 63 Table 26: Performance of facility based service providers on counselling postpartum mothers on IYCF issues in

past 3 months ........................................................................................................................................ 64 Table 27: Targets and Achievements of the Project.............................................................................................. 66 Table 28: Rating by pregnant women and mothers on IYCF indicators ................................................................ 71 Table 29: IYCF indicators and rating (on 0-10 point scale) by PEs and CCs ........................................................ 74 Table 30: Summary of the findings ........................................................................................................................ 79


List of Figures

Figure 1: Proportion of women in the last trimester of pregnancy who can cite ideal time for initiation of

breastfeeding (%) .................................................................................................................................. 26 Figure 2:Proportion of mothers with newborns less than 7 days old who report having breastfed their newborns

within one hour of birth (%).................................................................................................................... 27 Figure 3: Proportion of women in the last trimester of their pregnancy who knows that colostrum should be given

to the baby............................................................................................................................................. 30 Figure 4: Proportion of women in the last trimester of pregnancy who knows that nothing else has to be given

before breastfeeding for the first time .................................................................................................... 31 Figure 5: Proportion of mothers with newborns less than 7 days old who report have not given anything else to

drink/lick before breastfeeding for the first time ..................................................................................... 32 Figure 6: Proportion of mothers with newborns less than 7 days old who can cite at least 3 advantages of

exclusive breast-feeding ........................................................................................................................ 32 Figure 7: Proportion of mothers of children 3-4 months of age who can cite at least 3 advantages of exclusive

breast-feeding ....................................................................................................................................... 33 Figure 8: Proportion of mothers with newborns less than 7 days old who knows about the ideal duration (6

months) of exclusive breastfeeding ....................................................................................................... 35 Figure 9: Proportion of mothers with a child 3-4 months of age who knows about the ideal duration of exclusive

breastfeeding......................................................................................................................................... 36 Figure 10: Proportion of mothers with a child less than 7 days old who have started giving anything other than

breast milk ............................................................................................................................................. 36 Figure 11: Proportion of mothers with a child 3-4 months of age who have started giving anything other than

breast milk ............................................................................................................................................. 37 Figure 12: Proportion of mothers with a child 6-7 months of age who have exclusively breastfed their child for at

least six months ..................................................................................................................................... 38 Figure 13: Proportion of mothers with a child 6-7 months of age who have introduced complementary feeding for

their child ............................................................................................................................................... 40 Figure 14: Proportion of children 12-13 months of age receiving age appropriate feeding .................................. 45 Figure 15: Proportion of respondents who have heard or seen any message related to IYCF in the last three

months .................................................................................................................................................. 46 Figure 17: Knowledge of Service Providers about the ideal time of initiation of breast feeding ............................ 51 Figure 18: Proportion of Service Providers who are aware that nothing else should be given to the child to drink

or lick before breastfeeding the baby for the first time ........................................................................... 53 Figure 19: Proportion of Service Providers who are aware that colostrum should be given to the baby ............... 53 Figure 20: Proportion of Service Providers who knows the definition of exclusive breastfeeding ......................... 54 Figure 21: Proportion of Service Providers who knows the ideal duration (6 months) of exclusive breastfeeding 55 Figure 23: Proportion of service providers who have received training/orientation from AKF or AKF supported

agencies ................................................................................................................................................ 60 Figure 24: Proportion of service providers who knows the PE/CC working in their area ....................................... 60 Figure 25: Proportion of service providers who attended at least one group meeting and those who participated in

the home visits organised by PE/CC during the last three months ........................................................ 61 Figure 26: Average number of group meetings and average number of home visits organised by PE/CC in which

the service providers participated in the last three months .................................................................... 61 Figure 27: Proportion of service providers who have arranged at least one group meeting on IYCF in the past 3

months .................................................................................................................................................. 62 Figure 28: Proportion of service providers who have undertaken home visits in past 3 months for giving IYCF

related messages .................................................................................................................................. 62 Figure 29: Proportion of service providers who have conducted at least one type of counselling on optimal IYCF

practice .................................................................................................................................................. 65 Figure 30: Evaluation Wheel Tool on IYCF indicators by pregnant women and mothers ...................................... 71


Abbreviations

Abbreviations

AKF Aga Khan Foundation

AKRSPI Aga Khan Rural Support Programme India

ANMs Auxiliary Nurse and Midwives

ASHAs Accredited Social Health Activists

AWWs Anganwaadi Workers

BCC Behaviour Change Communication

BNPI Breastfeeding Promotion Network of India

CBR Crude Birth Rate

CCs Cluster Coordinators

CHARM Centre for Health and Resource Management

DMPU District Project Management Unit

FOGSI Federation of Obstetrics and Gynaecologists of India

GFF Government Frontline Functionaries

GoB Government of Bihar

IAP Indian Association of Paediatricians

ICDS Integrated Child Development Scheme

IMA Indian Medical Association

IMR Infant Mortality Rate

IYCF Infant and Young Child Feeding

NRHM National Rural Health Mission

PAC Project Advisory Committee

PEs Peer Educators

RMPs Registered Medical Practitioners

SPMU State Project Management Unit


Acknowledgements

Acknowledgements

We thank the teams at Aga Khan Foundation, both in New Delhi and SPMU Bihar under the

leadership of Mr. Abhishek Singh (Programme Manager) and all the implementing partners

for their whole hearted support in preparing this report. This might not have been possible

without the active support of Peer Educators and Cluster Coordinators. We also thank all

the pregnant women, mothers, grandmothers, local leaders, service providers and

government officials for their cooperation.

We also take this opportunity to thank Mr. Brajesh Kumar Das who coordinated the

evaluation, theCenter for Socio-economic and Environmental Studies for data analysis, Mr.

Yusuf Imam and Mr. JunaidHaider for field coordination, KRISHI- the local resource agency

and the ICSD team.

Joy Elamon Chief Executive Officer Intercooperation Social Development India


Executive Summary

Executive Summary

Nutrition of infant and young child has been a key consideration for public health

interventions, development planning and scientific research since the Alma Ata Declaration

on Health for All by 2000. The Innocenti Declaration on Protection, Promotion and Support

for Breastfeeding in 1990 was reinforced by the Global Strategy for Infant and Young

Feeding (IYCF) in 2002. It was a joint strategy issued by the World Health Organization

(WHO) and the United Nations Children’s Fund (UNICEF). As per the Global Strategy,

“Malnutrition has been responsible, directly or indirectly, for 60% of the 10.9 million deaths

annually among children under five. Well over two-thirds of these deaths, which are often

associated with inappropriate feeding practices, occur during the first year of

life……”.Strategies for achieving the target for Millennium Development Goal 4 (MDG 4)

emphasises Infant and Young Child feeding (IYCF).

Subsequently the Government of India developed the National Guidelines on Infant and

Young Child Feeding in the year 2004. Recognising the importance of IYCF, the Tenth Five

Year Plan included goals for early initiation of breastfeeding, excusive breastfeeding for the

first six months and complementary feeding beyond six months.

The state of Bihar in India, with a population of 100 million, has an infant mortality rate of 52

per 1000 births and under 5 mortality rate of 73 per 1000. 55% of children under two years

are underweight, compared to the national average of 40% (as per National Family Health

Survey III, 2005-06). The state has the highest Crude Birth Rate of 26.1 per 1000 births

(Annual Health Survey 2012-13). These indicate its status of development as well as health

and nutrition. There is also wide variation among the districts within the state.

It is in this context that the Aga Khan Foundation in collaboration with the State Government

of Bihar and supported by UKaid from the Department for International Development (DfID)

launched the Buniyaad project to bring about changes in knowledge, practices and

behaviour related to IYCF among mothers and care-givers of children from birth to 15

months of age.

Project Buniyaad – the Introduction

As the word Buniyaad implies, the project was designed to lay the ‘foundation’ for a healthy

child by “Reducing Infant Mortality in Bihar through Optimal Infant Feeding Practices in three

districts of Bihar” for three years (2012-2015).


Executive Summary

The project aimed at reducing neonatal and infant mortality through improved breastfeeding

and weaning practices among 400,000 mothers of children under two years among the

poorest and most marginalised communities in three districts of Bihar. It was spread across

selected 20 blocks of Muzaffarpur, Samastipurand Sitamarhi districts and implemented by

Aga Khan Foundation India along with its three other Implementing Partners (IPs)- Aga Khan

Rural Support Program, India (AKRSPI), Agragami India (AI) and Centre for Health and

Resource Management (CHARM).The project tried to demonstrate a strong Behaviour

Change Communication (BCC) model.It focused on “demand side” interventions through

BCC, thus enabling women to follow the recommended practices.

Organisation of the Project

BCC activities were rolled out through 500 project supported Peer Educators (PEs) and 132

PE supervisors called Cluster Coordinators (CCs) whose main job was to counsel mothers

and caregivers about recommended IYCF practices and help them overcome the barriers for

the same. It involved (i) interpersonal communication (PE-stakeholder direct interaction

through house visits, group meetings etc.), (ii) Mid media (engagement with community

through various meetings and event, community mobilization) and (iii) Mass media (radio,

street plays, puppet shows, wall paintings, print material etc.).While the primary stakeholders

were pregnant women and mothers, government frontline functionaries and policy

influencers were considered as secondary stakeholders.

End line Evaluation

Purpose of this endevaluation was to assess the achievement of the project over the period

2012-13 to 2014-15 and find out what has worked well as well as the challenges. It also

tried to assess the perceptions of beneficiaries regarding impact of project activities,

identified lessons learnt and suggest recommendations for future programming on nutrition

in general and IYCF in particular.

The study was divided into three parts: (i) Level of achievement of the project in relation to

the outcome and output indicators, (ii) Effectiveness of project planning and management

and relevance of the project design and (iii) Perceptions of beneficiaries regarding impact. It

involved a cross sectional survey. General methodology involved household survey with

respondents (among the pregnant and mothers of young infants as well as service

providers), focus group discussions, and key informant interviews with actors inside and

outside the project like the service providers, panchayat representatives, other government

officials etc. Multi stage cluster sampling was used for selection of respondents.


Executive Summary

Findings and Observations

Changes in knowledge, attitudes and practices that took place in the intervention

communities were assessed by comparing the results of the end line survey with that of the

baseline survey (conducted in 2012) and that of the two annual assessments conducted in

2013 and 2014. End line survey was conducted in the month of January 2015. Target

group women were asked questions about their knowledge, information, intention and

practice regarding IYCF behaviours. Findings have been reported in line with the three

important tenets of IYCF, namely (i) early Initiation of breastfeeding (including colostrum

feeding), (ii) exclusive breastfeeding and (iii) age appropriate complementary feeding. Apart

from understanding the knowledge, intention and practices of the women targeted by the

project, an assessment of knowledge and attitude of the service providers was also

undertaken.

Early initiation of Breastfeeding: Knowledge about appropriate time for initiating breast

feeding increased significantly during the project period. At the time of baseline study, only

about one-fourth of the women in the third trimester of pregnancy knew that breastfeeding

should be initiated within an hour of birth. The proportion crossed the target fixed for this

output indicator (70%) to reach 73 per cent in the end line study. In all the three districts,

more than 70 per cent of women in the third trimester of pregnancy knew the ideal time for

initiating breast feeding. There was not much difference between districts. Overall, two-

thirds of women who gave birth to a child in the seven days preceding the survey breastfed

their new born within one hour of birth. This is more than the target fixed for this outcome

indicator (60%).When asked about the advantages of feeding colostrum, more than three-

fourths of pregnant women who participated in the end line survey said that mother’s first

milk protects the baby from diseases and increases resistance to diseases. More than half

of them also were aware that the colostrum contains nutrients that are helpful for the health

of children and their growth.

Exclusive Breastfeeding: Nearly half of the mothers of children less than a week old

interviewed in the end line survey were able to cite at least three advantages of exclusive

breastfeeding. As high as 96 per cent of the mothers of new-borns less than 7 days old and

88 per cent of the mothers of children 3-4 months of age were aware that exclusive

breastfeeding should continue for six months. As per the end line survey, just one per cent of

mothers of new-borns and 3 per cent of mothers of children 3-4 months of age had given

any food other than breast milk. As noted earlier, while large majority of women were aware

that exclusive breastfeeding has to continue till the child attains the age of six months, but in

practice, only half of the mothers of children 6-7 months of age had exclusively breastfed the

child.


Executive Summary

Complementary Feeding: One of the outcome indicators of the project was the proportion

of mothers with a child 6-7 months of age who have introduced complementary feeding to

their child. The target fixed for this indicator to be achieved at the end of the project period

was 85 per cent. With 88 per cent of the mothers in this category having introduced

complementary feeding, the target was achieved. The corresponding proportion in the

baseline survey was 73 per cent. About one-third of the mothers of children 12-13 months of

age (31%) who responded in the end line survey started complementary feeding when the

child was six months old. Before the project intervention, 27 per cent of the children were

started complementary feeding before the age of six months. Whereas, by the end of the

project, the corresponding proportion was just 4 per cent. It was also found that the

proportion of mothers with delayed complementary feeding (after seven months) came down

from 36 per cent before the project intervention to just 10 per cent towards the end of the

project. Just 2 per cent of the mothers waited till the child attains the age of 10 months or

more at the end of the project period. The corresponding proportion in the baseline survey

was 12 per cent. It appears that the project interventions helped to arrest the early initiation

of complementary feeding i.e. before six months of age.

WHO recommends that infants of age 6-8 months should receive complementary foods 2-3

times a day in addition to breast milk. The frequency has to increase to 3-4 times daily for

children 12-13 months of age. Additional nutritious foods should be offered 1-2 times per

day. Overall, the average quantity of food given to a child increased from 349 ml during the

baseline survey to 455 ml in the end line survey. Proportion of children receiving age

appropriate complementary feeding increased from just 20 per cent in the baseline survey to

43 per cent in the end line survey.

Service Providers: One of the objectives of the project was to improve the knowledge and

performance of government health and nutrition functionaries with respect to infant and child

feeding practices (IYCF). Capacity building of service providers was through training

programmes, participation in group meetings and home visits, participation in monthly review

meetings, joint celebration of key events etc. Knowledge among service providers about

appropriate time for initiating breast feeding increased significantly during the project period.

This was the case with knowledge on exclusive breastfeeding as well as with

complementary feeding. PEs and CCs were also expected to ensure the participation of

government health and nutrition functionaries (such as ANM/ASHA/Anganwadi

worker/MAMTA) in PE led group meetings and home visits. This helped to improve their

knowledge regarding optimal IYCF practices as well as in enhancing their skills on inter-

personal and group counselling. It was hoped that such mentoring will help the Government


Executive Summary

frontline functionaries in dealing with and resolving IYCF issues during home visits and

group meetings conducted by them as mandated under their job responsibilities. This is

important to ensure sustainability of efforts beyond the project time-frame. Overall, two-

thirds of the service providers attended at least one group meeting organised by PE/CC

during the last three months. The proportion who participated in home visits was lower at 58

per cent. Community based workers such as Anganwadi workers and ASHAs participated

more in both group meetings and home visits, as compared to facility level health workers.

Feedback from FGDs and Interviews: It was also important to understand the

effectiveness of project planning and management, relevance of the project design and

perceptions of beneficiaries regarding impact. Qualitative study through FGDs and Key

Informant Interviews was conducted to capture information required for such an assessment.

Different categories of stakeholders were approached through specific guidelines or semi

structured questionnaire.

The Change: The project Buniyaad has been successful in covering 400,000 women

across 20 blocks in Bihar. As the household survey and the qualitative studies suggest,

there has been definite improvement in knowledge levels of pregnant women and

mothers of children below 24 months regarding IYCF practices. Apart from the knowledge,

there is remarkable change in behaviour too as they have been practicing the three tenets

of IYCF – early initiation of breast feeding, exclusive breastfeeding until six months and

complementary feeding beyond six months. The study clearly indicates that the

achievements of the project exceeded the target fixed for each of the outcome and output

indicators. The project’s success in bringing about behavioural change among the mothers

of infants and young children on optimal IYCF practices is evident. It is also evident that the

project was successful in building the capacity and knowledge of community based and

facility based health/nutrition functionaries. This, in turn, can lead to long-term sustainability

of the project benefits.

Knowledge and information regarding complementary feeding has increased as a result of

the interventions of PEs/CCs. Through demonstration using BCC tool kits, PEs/CCs were

able to improve the knowledge of mothers regarding optimal complementary foods to the

children. In fact, they were the only source of knowledge regarding this. PEs provided

support and motivation, but practice has other social and economic determinants and was

not always adhered to especially regarding quantity, quality and frequency. PEs were also

able to influence mothers in addressing gender discrimination in complementary feeding,

though not in its entirety. Mothers acknowledge the usefulness of PEs and they trust them.


Executive Summary

For certain problems which are related to health conditions of mother or child, they did prefer

to meet local health service providers.

Government field/ office based functionaries realize that there is a positive impact on IYCF

practices. Service seeking behaviour of mothers have changed and they are forthcoming

in seeking services like immunization, ante natal care, IFA (Iron and Folic Acid) tablets etc.

Immunization status and institutional deliveries have increased. There is increased

acceptance of their work and services by the communities.

Project strategy focused on demand side interventions. Study shows that these

interventions have contributed to the increase in demandwhich alsoled to improvement in

supply. This was due to the integration of local level service providers with the project. It

was definitely beyond the mandate of the project to address other determinants like income

levels and poverty which would also be factors which prevent appropriate IYCF practices.

However, the project interventions were able to influence social norms and culture, which

is a major achievement.

The project used various BCC tools which have proved to be useful and successful.

Considering the fact that the main activity was based on interpersonal communication, the

project has been human resource intensive. However, it also mobilised the existing

service providers and built their capacities too.

Project Design and Management

The project was clearly conceptualised with no ambiguities at any level. All the actors at

all levels were clear about their role, activities and overall concept. It had a thoroughly

defined strategy and operational plan. Responsibilities at each level were demarcated

and regularly followed up. Meticulous planning helped in the operationalization of the project

strategy.

It has been a human resource intensive project. Considering the number of stakeholders to

be covered through interpersonal communication, it required such a large human resource.

Highlight of the project management is the rigorous reporting and monitoring system

followed by feedback based action at all levels. These seem to have contributed in a major

way in achieving the project targets. In general, IPs played a key role in the overall

management of the project in the districts.


Executive Summary

Household visits and face to face communication by the PE, who had been selected from

the locality itself, was the key to behaviour change. Messages were very clear; and were

imparted regularly and repeatedly leading to reinforcement. Close follow up of individual

cases, especially at the time of child birth and after, too were useful. The project had focused

on the three tenets of IYCF and never got diverted. Various tools used, including the

demonstration kit, were appropriate to the theme, context and location. These were

pedagogically appropriate. PEs and CCs were trained to use these tools. Field studies

showed that these tools were used by the PEs for demonstration. Special mention needs to

be made about the Growth card of the child used as a tool for BCC which was much

appreciated by the stakeholders.

Unlike many such projects, the government related service providers were included as part

of the project design itself. Their capacity building was also taken up by the project. There

was every effort to integrate the routine activities of the service providers with the Buniyaad

activities. This was mutually reinforcing. Engagement with community leadership including

the PRI (rural local governments) and religious leaders was useful in addressing various

community/religious practices detrimental to the IYCF practices.

Targets vs. Achievements

Indicator Project

Baseline (%) Project

Target (%) Achievement

(%)

Outcome Indicators 1. Early Initiation of Breast feeding (Proportion of mothers with

newborns less than 7 days old who report having breastfed their newborns within one hour of birth) 17.4 60 65.2

2. Exclusive breast feeding (Proportion of mothers with a child 6-7 months of age who have exclusively breastfed their child for at least six months) 15.2 40 49.5

3. Complementary feeding (Proportion of mothers with a child 6-7 months of age who have introduced complementary feeding for their child) 73.4 85 87.7

4. Complementary feeding (Proportion of mothers with a child aged 12-13 months who are giving age appropriate complementary feeding for their child) 19.8 35 42.9

Output Indicators Proportion of women in the last trimester of pregnancy who can cite

ideal time for initiation of breastfeeding. 23.2 70 72.8

Proportion of mothers of children 3-4 months of age who can cite at least 3 advantages of exclusive breast-feeding 12.4 60 64.6

Proportion of community/facility based health / nutrition functionaries who have the correct knowledge regarding IYCF practices 37.3 60 71.3

Proportion of community/facility based health / nutrition functionaries who are conducting IYCF counselling sessions with mothers / care-givers 46.5 75 79.1


Executive Summary

Outcome/Output Indicators Target Observation based on qualitative data

Outcome: To increase the adoption of one or more recommended IYCF practices by 300,000+ mothers of children under two years of age, among the poorest and most marginalised populations in the three districts of Bihar

Outcome indicator 5:Perception of mothers regarding influence of the contacts by PEs/CCs in improving their knowledge and practice for providing optimal complementary foods to the children

Target: Improved mothers' knowledge and practice regarding complementary feeding

Knowledge and information regarding complementary feeding of child has increased due to the PEs/CCs.

Through demonstration using BCC tool kits, PEs/CCs were able to improve the knowledge of mothers regarding optimal complementary foods to the children. In fact, they were the only source of knowledge regarding this.

PEs provide support and motivation, but practice has other determinants and not always adhered to, especially regarding quantity, quality and frequency.

PEs were also able to influence mothers in addressing gender discrimination in complementary feeding, though not in its entirety.

Output 1: Pregnant women, mothers of children under two years of age and other care-givers in the family have the appropriate knowledge and develop requisite skills to follow the recommended IYCF practices, through the messages and assistance imparted by peer educators in selected blocks of three districts of Bihar

Output Indicator 1.3: Perception of mothers on the usefulness of PEs' visits for problem solving in improving the compliance towards optimal IYCF practices

Target: Mothers find PEs' visits useful in improving compliance towards IYCF practices

Mothers acknowledge the usefulness of PEs and they trust them.

They are able to share their problems with PEs

Regularity and effectiveness of PEs in problem solving is wanting.

PEs were able to influence mothers for early initiation, exclusive breast feeding and complementary feeding even when there were problems.

For certain problems which are related to health conditions of mother or child, they did prefer to meet local health service providers.

Output 2: Community based frontline workers (AWW/ASHA) and facility based health service providers (ANMs/MAMTA) have increased knowledge level and perform better in the context of IYUC counselling

Output Indicator 2.2: Perception of community/facility based health/nutrition functionaries with respect to impact of project intervention on their work (in the context of IYCF counselling)

Target: Government field functionaries feel positive impact of project intervention on their work

Govt. Field / office based functionaries realize that there is a positive impact on IYCF practices.

There is clear change in early initiation of breastfeeding.

Service seeking behavior of mothers have changed and they are forthcoming in seeking services like immunization, ante natal care, IFA tablets etc.

Immunization status and institutional deliveries have increased.

There is increased acceptance of their work and services by the communities.


Executive Summary

Recommendations

As immediate follow up, the following actions are suggested:

Learning should be shared with service providers, governments at state and national

levels, private sector and with other development actors.

These need to be compiled to develop policy briefs, which could be used by the

governments and for policy advocacy.

Knowledge levels of PEs, CCs and service providers need to be upgraded regularly

which may be ensured through the setting up of knowledge network for PEs, CCs

and service providers.

The project has developed a large data base which is great source of information on

IYCF and child health. Data base has information of around 400,000 mothers drawn

over a period of three years. Analysis of this data along with growth card based data

and various secondary data should be done to build evidences for IYCF practices

and their linkage with child health.

While upscaling or replicating Buniyaad,

It is would be useful to have a programme directly linking IYCF with overall child

health.

Other determinants of child health also need to be addressed while designing the

strategy.

Evidences should be generated on IYCF effectiveness on child health by

documentation and research on Buniyaad experiences.

Focus has been mainly on IYCF and mother’s health needs to be highlighted. BCC

should include tools to address this.

Policy briefs have to be developed on how to integrate service providers with similar

projects so that it becomes less HR intensive.

Problem solving requires improved strategy. Linkages with local and higher level

service providers and institutions are important since specific problems require

professional and governmental support.

Ensuring community ownership through active engagement with PRIs, religious

leaders, CBOs like women’s self-help groups etc. needs to be emphasised.

Role of men in bringing about behaviour change also should not be ignored

especially in the overall health status of the child and mother.

An institutionalisation strategy with an exit plan should be there while designing

similar projects so that sustainability is ensured. This should consider community


Executive Summary

ownership, linkage with local service providers and higher levels of health care

service providers.

It is also important to ensure active involvement of higher levels of service providers

and policy makers from the beginning of the project itself.

A system of mentoring of service providers could be initiated and set up within the

health care system as a follow up of the project Buniyaad.


1.0 Background and Context of the Project Buniyaad

Nutrition of infant and young child has been a major consideration for public health

interventions, development planning and scientific research since the Alma Ata Declaration

on Health for All by 2000. The Innocenti Declaration on Protection, Promotion and Support

for Breastfeeding in 1990 was reinforced by the Global Strategy for Infant and Young

Feeding (IYCF) in 2002. It was a joint strategy issued by the World Health Organization

(WHO) and the United Nations Children’s Fund (UNICEF). As per the Global Strategy,

“Malnutrition has been responsible, directly or indirectly, for 60% of the 10.9 million deaths

annually among children under five. Well over two-thirds of these deaths, which are often

associated with inappropriate feeding practices, occur during the first year of life……” .WHO

strategies for achieving Millennium Development Goal 4 (MDG 4) target of reducing by two-

thirds, between 1990 and 2015, the under-five mortality rate, also emphasises IYCF. The

Innocenti Declaration on infant and Young Child Feeding (IYCF) in 2005 gave the Call for

Action. During this period, countries across the globe expressed their national commitment

towards these declarations. Government of India too came up with the National Guidelines

on Infant and Young Child Feeding 2004. Recognising the importance of IYCF, the Tenth

Five year Plan for the first time included goals for early initiation of breastfeeding, excusive

breastfeeding for the first six months and complementary feeding at six months.

The state of Bihar in India, with a population of 100 million, has an infant mortality rate of 52

per 1000 births and under 5 mortality rate of 73 per 1000. 55% of children under two years

are underweight, compared to the national average of 40% (as per National Family Health

Survey III, 2005-06). The state has the highest Crude Birth Rate of 26.1 per 1000 births

(Annual Health Survey 2012-13). These indicate its status of development as well as health

and nutrition. There is also wide variation among the districts within the state.

It is in this context that the Aga Khan Foundation in collaboration with the Government of

Bihar and supported by UK Aid from the Department for International Development (DFID)

launched the Buniyaad project to bring about changes in knowledge, practices and

behaviour related to IYCF among mothers and care-givers of children from birth till the child

is 15 months of age.


2.0 ProjectBuniyaad- Logic Theory and Results Framework

The word Buniyaad, used in Hindi and Urdu, means ‘foundation’. As the name implies, the

project tried to lay the foundation for a healthy child by “Reducing Infant Mortality in Bihar

through Optimal Infant Feeding Practices in three districts of Bihar” for three years (2012-

2015).

Goal

Project goal was to impact MDG-4 by reducing neonatal and infant mortality in selected

blocks of three districts in Bihar. Improving infant and young child feeding practices among

the poorest and most marginalised populations in these districts would improve both

children’s and mothers’ nutrition and productivity, contributing to reduced hunger and poverty

(MDG-1).

Aims

Aims of the project were to reduce neonatal and infant mortality through improving healthy

breastfeeding and weaning practices among 400,000 mothers of children under two years

among the poorest and most marginalised communities in three districts of Bihar. It made

an attempt to mobilise a strong Behaviour Change Communication (BCC) model through

500 Peer Educators (PEs) to counsel mothers and caregivers on infant and child nutrition

and provide problem-solving to help overcome barriers they face.

Strategy

As part of the strategy the project focused on “demand side” interventions through BCC, thus

enabling women to follow the recommended practices. The assumption was that the tenets

of IYCF is independent of provision of health services (i.e. the “supply side). BCC activities

were rolled out through 500 project supported Peer Educators and 132 PE supervisors

called Cluster Coordinators (CCs) whose main job was to counsel mothers and caregivers

about recommended IYCF practices and help them overcome the barriers for the same. The

PEs counsel pregnant women and mothers largely through four home visits and five group

meetings at designated times as per the technical strategy of the project.

BCC model under the project included a wide range of interventions which could be broadly

categorised as:

Interpersonal communication or IPC (PE/CC-stakeholder direct interaction through

house visits, group meetings etc.);


GoB, NRHM

Level 4: Policy influencers

ANMs, Mamtas

Level 3: Facility based service providers

ASHA, AWW

Level 2:Community based service providers

Mothers in Third Trimester and with children up to 2 years of age

Level 1:Household Level

Mid media (engagement with community through various meetings and event,

community mobilization)

Mass media (radio, street plays, puppet shows, wall paintings, print material etc.)

Stakeholders and Approach

While the primary stakeholders were pregnant women and mothers, the government

frontline workers and policy influencers also were considered as secondary stakeholders so

as to build the capacity of the existing system to sustain the initiative and scale and/or

replicate them in other districts of the state. A classification of direct stakeholders addressed

by the project interventions is as follows:

A. Women i. Pregnant Women in the last trimester

ii. Mothers with a child less than 7 days of age

iii. Mothers with a child 3-4 months of age

iv. Mothers with a child 6-7 months of age

v. Mothers with a child 12-15 months of age

B. Health and nutrition workers (service providers)

i. Community based health and nutrition functionaries (i.e., ASHAs and AWWs)

ii. Facility based health functionaries (i.e., ANMs and Mamtas)

It can also be considered as a four level structure as a convergence model shown below:


Geographical Spread

The project was spread across selected 20 blocks of Muzaffarpur, Samastipur and Sitamarhi

districts of Bihar and implemented by Aga Khan Foundation India along with its other three

Implementing Partners (IPs) - Aga Khan Rural Support Program, India (AKRSPI), Agragami

India (AI) and Centre for Health and Resource Management (CHARM). These blocks had

high proportion of poor and marginalised populations such as the scheduled castes and

minorities (i.e. Muslims). Many of them are high risk blocks as notified by the Government of

Bihar, in terms of health indicators. Another reason for selecting them was their

geographical proximity to each other, which facilitates logistics, reduces travel time of

community workers and helps in better monitoring. While the project was intended to

directly reach to 400,000 women, it covered an overall population of over forty lakhs.

Agency Districts Intervention Blocks

AKRSP(I) Muzaffarpur Sakra, Bandra and Gaighat

Samastipur Samastipur, Tajpur and Kalyanpur

AKF (I) Muzzaffarpur Bochha, Kanti Kurhni& Marwan

Agargami India Samastipur Saraianjan, Patori, Morwa, Ujjaipur, Dalsinghsarai&Vidyapati Nagar

CHARM Sitamarhi Dumra, BajpatiPupri and Bathnaha

Project Structure

Technical Partner

Agragami India

Community Level : Peer Educator (125)

Cluster Level: Cluster Coordinator (33)

Agragami India

SamastipurProject Manager (1), Project Coordinator (2)

Admin Asst (1), MIS (1)



AKF India

MuzaffarpurProject Manager (1), Project Coordinator (2)




AKRSPI

SamastipurProject Manager (1), Project Coordinator (2)




CHARM

SItamarhiProject Manager (1), Project Coordinator (2)


Implementing Partners

Aga Khan Foundation India

State Office BiharProgramme Manager, Programme Officer (Health)

FInance Manager, M&E Manager

Coordination and Advocacy

Health Department State GovernmentProfessional Bodies viz IMA, IAP, FOGSI, BPNI

Development Partners in Bihar

Aga Khan Foundation, India

(Delhi)

Chief Finance Officer, Director Programms,

Senior Programme Officer (Health), Programme Officer (Health)

Aga Khan Foundation (UK)

Key Activities

Identification and capacity building of project field staff PEs and CCs

KAP baseline study for the project area

Development of technical strategy for BCC on the three tenets of IYCF

Implementation of technical strategy through Implementing Partners (IPs)


Celebration of Breastfeeding Week and National Nutrition Week

Healthy Baby Shows in villages

Supporting VHSND in project villages

Development of BCC materials for different target groups

Orientation of government frontline functionaries on IYCF practices


3.0 Purpose and Objectives of the Endline evaluation

Purpose of the endline evaluation was to assess the achievement of the project over the

period 2012-13 to 2014-15. It aimed at identifying what worked well, the challenges and any

changes in the project implementation strategy that may have occurred during the period.

Specific objectives of the study were to:

1. Obtain end measurements to assess the level of achievement of the project in relation

to the outcome and output indicators

2. Assess the effectiveness of project planning and management, and review the

relevance of the project design

3. Assess the perceptions of beneficiaries regarding impact of certain project activities as

laid down in the log frame

4. Triangulate the evaluation findings with the baseline and project MIS data

5. Identify lessons learnt and lay down recommendations for future programming on

nutrition in general and IYCF in particular


4.0 Approach and Methodology

General approach to the study has been participatory, covering all stakeholders and actors

involved. To begin with, the entire Buniyaad model with its various components and their

relation to each other were understood, including the relationship among inputs, activities,

outputs, outcomes, impacts, environment in which it was designed, changes in this

environment during the course of the project, interplay of various stakeholders and other

players as well as externalities including policy changes. This exercise (often termed results

chain), leading to questionnaire finalisation, was discussed with the concerned personnel in

the Aga Khan Foundation, India, prior to finalising the approach. At every stage, guidance

and directions from the AKF team were considered for a better understanding of the project,

but the study team maintained its autonomy and integrity to ensure realistic and scientific

assessment of the project.

Targets for outcome and output level indicators were set under the Monitoring and

Evaluation (M&E) framework of the project. These indicators were measured regularly

through baseline survey and internal project MIS based quantitative evaluations at the end of

first and second year. There was a midterm evaluation, which was primarily qualitative in

nature. Thus, the endline evaluation had to be designed with a mix of qualitative and

quantitative assessments. Since the project had a baseline survey, along with subsequent

annual evaluations at various stages, the endline evaluation had to be comparable with the

baseline data, and therefore in line with the methodology adopted in the baseline survey.

The study engaged with pregnant women and mothers of young infants, and government

frontline functionaries at community and facility levels (AWW, ASHA, Mamta and ANM), both

for quantitative and qualitative data collection. In addition, it also sought responses from a

sample of project supported peer educators and cluster coordinators.

The study was divided into three parts:

Level of achievement of the project in relation to the outcome and output indicators

Effectiveness of project planning and management and relevance of the project

design

Perceptions of beneficiaries regarding impact

Tools, including questionnaires, were developed to capture these different aspects. Lessons

learnt were identified and recommendations suggested for future interventions.


Sampling

As mentioned earlier, baseline study of the project was followed by regular project

monitoring. In order to aid in comparison with the monitoring data and the baseline and mid-

term studies done so far, it was decided that the sampling and tools would be same as that

being followed so far in monitoring. Any additional inputs required would be collected

separately through FGDs and other sources of evidence.

General methodology was to have household survey with respondents from among the

pregnant women and mothers of young infants, focus group discussions, and key informant

interviews with actors inside and outside the project like the peer educators, cluster

coordinators, implementing partners, service providers, panchayat representatives, other

government officials etc.

Sample Size

Considering the previous evaluations and studies, the respondents were classified as

follows:

A. Women i. Pregnant Women in the last trimester

ii. Mothers with a child less than 7 days of age

iii. Mothers with a child 3-4 months of age

iv. Mothers with a child 6-7 months of age

v. Mothers with a child 12-13 months of age

B. Government Health and nutrition workers (service providers)

i. Community based health and nutrition functionaries (i.e., ASHAs and AWWs)

ii. Facility based health functionaries (i.e., ANMs and Mamtas)

C. In addition, a third group was also added from among Project Field Staff (Peer Educators

and Cluster Coordinators).

Same sample size as had been followed in the internal project monitoring was finalised. On

this basis and based on the regular monitoring system, following sample sizes were

followed:

A. Women in Last trimester and Mothers with children less than 7 days, 3-4 months, 6-7

months and12-13 months

Sample Size: Assuming 50% knowledge levels (to maximise sample size), 95%

Confidence Level and a CI of +/-7%, a sample size arrived at was 196 women in

each group. An additional 5 per cent was included to account for any non-

response/incomplete response. The final sample size realised (after excluding

incomplete responses) is reported in Table 1.


On the basis of total number, random numbers were generated with the help of

RANDOM.ORG.

B. Health and Nutrition Workers

Sample size: Assuming 50% knowledge levels (to maximise sample size), 95%

Confidence level and CI of +/_ 7%, a sample size of 200 workers each across two

groups i.e. a total of 400.

Multi–stage cluster sampling was used for selection of respondents.

Tools

There were six schedules of questionnaire for different categories mentioned above. As

mentioned earlier, due to the need of comparable outputs, the same questionnaires were

used as were being used for monitoring. Additionally, three more indicators were added in

the later stages of the project, for which FGDs were used to collect information.

Number of FGDs and Interviews conducted were as follows: FGDs

• Pregnant women and Mothers – 8

• CCs – 4

• PEs – 4

• IP team – 4

Key Informant Interviews

• Grandmothers – 8

• Husbands – 8

• CDPOs – 4

• Doctors / Health Managers – 4

• Panchayat elected representatives – 8

• Religious leaders – 4

• SPMU (AKF state team, Patna) – 2

Specific FGD guidelines were prepared for each of the groups. Similarly, semi structured

questionnaires were used to guide the interviews.

Analysis

Through a series of interactions among the core team, the data – both qualitative and

quantitative – were analysed. Triangulation was considered to validate qualitative data. This

was done through the comparison of household surveys vs. FGDs or other tools used.


Documentation like guidebooks, training modules, tool kits/demo, annual reports, other

written reports of events etc. were collected to support the primary data collected through

interviews and other methods. Thus the facts collected from different sources were used in a

converging manner to define the “facts” of the case. This was done to satisfy one basic

requirement of the qualitative studies - reliance on “multiple sources of evidence”.

Convergence of Multiple Sources of Evidences

Published & Unpublished Documents/reports

Household survey Focus Group Discussions

In-depth Interviews

Household survey Findings Conclusions

Focus Group Interview Findings Conclusions

Key informant interviews Findings Conclusions

FACT


5.0 Findings- Quantitative Study

Introduction

This section presents the findings of the quantitative survey conducted among different

categories of women as part of the end line evaluation. Respondents were asked questions

about their knowledge, information, intention and practice (as applicable according to the

stage of pregnancy or age of their child) regarding IYCF behaviours. Changes in

knowledge, attitude and practices that took place in the intervention communities were

assessed by comparing the results of the endline survey with that of the baseline survey

(conducted in 2012) and that of the two mid-year evaluations conducted in 2013 and 2014.

End line survey was conducted in the month of January 2015. Findings are being reported

in line with the three important tenets of IYCF, namely early Initiation of breastfeeding

(colostrum feeding), exclusive breastfeeding and age appropriate complementary feeding.

Apart from understanding the knowledge, intention and practices of the women targeted by

the project, an assessment of knowledge and attitude of the service providers was also

undertaken.

For baseline, mid-term and end line surveys, women belonging to the following five

categories women were interviewed:

1. Women in the last trimester of pregnancy

2. Mothers with a child less than 7 days of age

3. Mothers with a child 3-4 months of age



In addition to the women who have been targeted by the programme, the service providers

and project field staff viz. PEs and CCs were interviewed in all the three districts. Altogether

4023 women belonging to the above cited five different categories and 492 service providers

spread across the three project intervention districts were covered. Final sample size of the

end line survey according to the category of respondents is presented in Table 1.


Table 1: Sample Size of the Endline Survey

Category Muzaffarpur Samastipur Sitamarhi Total

Women in the last trimester of their pregnancy 309 289 200 798

Mothers with a child less than 7 days of age 315 284 198 797

Mothers with a child 3-4 months of age 307 291 199 797



Service providers 250 145 97 492

Early Initiation of Breast Feeding

Knowledge about appropriate time for initiating breast feeding has increased significantly

during the project period. During the baseline study, only about one-fourth of the women in

the third trimester of pregnancy knew that breastfeeding should be initiated within an hour of

birth. The proportion crossed the target fixed for this output indicator (70%) to reach 73 per

cent in the end line study (Figure 1). In all the three districts, more than 70 per cent of the

women in the third trimester of pregnancy knew the ideal time for initiating breast feeding.

There is not much difference between the districts.

Across the districts, not much progress was experienced in the first year of the project. In

the next two years, there has been significant improvement in the awareness among women

in their third trimester of pregnancy about the appropriate timing of initiating breast feeding.

Figure 1: Proportion of women in the last trimester of pregnancy who can cite ideal time for initiation of breastfeeding (%)


Understanding whether early breastfeeding was practiced by women who gave birth to a

child recently is important as knowledge may not always translate into practice. Women who

gave birth to a child in the seven days preceding the survey were asked about the actual

timing of the initiation of breastfeeding. The results are presented in Figure 2.

Figure 2: Proportion of mothers with newborns less than 7 days old who report having breastfed their newborns within one hour of birth (%)

Overall, two-thirds of women (65%) who gave birth to a child in the seven days preceding

the survey breastfed their newborn within one hour of birth. This is above the target fixed for

this outcome indicator (60%). Muzaffarpur fared better than the other two districts with about

three-fourths of the mothers started breast feeding within one hour of birth. As against this,

Samastipur district did not achieve the target level, with only 56 per cent of the mothers

actually initiating breastfeeding within one hour of birth. The gap between Muzaffarpur and

the other two districts widened during the project period.

A comparison with Figure 1 indicates that the gap between knowledge and actual practice is

not high. This was true about both baseline and end line surveys. Actual timing of the

initiation of breastfeeding by women who gave birth to a child in the seven days preceding

the end line survey is reported in Table 2.


Table 2: Time of initiation of breastfeeding followed by mothers with newborns less than 7 days old

Muzzafarpur Samastipur Sitamarhi Overall

Baseline Endline Baseline Endline Baseline Endline Baseline Endline

Immediately, within one hour of birth 19.3 75.2 16.3 56.3 16.7 62.1 17.4 65.2

Same day between 1 - 6 hours after birth 48.1 17.8 32.5 33.1 31.0 34.8 37.6 27.5

Same day (6-24 hours after birth) 18.9 5.1 21.9 4.9 10.4 1.0 17.9 4.0

1-3 days 10.3 1.6 16.6 5.3 27.7 1.5 16.5 2.9

After 3 days 2.9 0.0 9.2 0.4 15.6 0.0 8.6 0.1

Others 0.4 0.3 2.0 0.0 0.5 0.0 1.1 0.1

Never 0.2 0.0 1.5 0.0 1.0 0.5 0.9 0.1

Total 100 100.0 98.5 100.0 100.0 100.0 100.0 100.0

No. of women 524 315 590 284 384 198 1498 797

At the end of the project, majority of the mothers who have not breastfed the child within one

hour of birth, have done it on the same day (Table 2). Overall, just 3 per cent of the mothers

postponed the initial breastfeeding for the next day. As against this, before the project

intervention, one-fourth of the mothers initiated breastfeeding after one day. According to

end line survey, even in Samastipur and Sitamarhi districts where the proportion of

breastfeeding within one hour was lower, most of the mothers have breastfed their child on

the day of birth itself.

The discussion above indicates that there has been significant impact on the timing of

initiating breast feeding after birth among the targeted households in all the districts. While

73 per cent of the women in the last trimester of pregnancy had knowledge about the ideal

timing of initiating breastfeeding (Figure 1), the proportion of mothers with newborns less

than 7 days old who actually initiated breastfeeding within one hour of birth was 65 per cent

(Figure 2). Thus, there is a gap of 8 percentage points between knowledge and actual

practice at the aggregate level. Among the districts, Muzaffarpur fared slightly better than the

other two districts. A comparison of awareness on ideal timing of breastfeeding among

women in the last trimester of pregnancy in the baseline, midterm and end line assessments

indicated that there was not much progress in the first year of the project (Appendix Table

A1and Table A2). However, awareness about the ideal timing and actual practice of initial

breastfeeding within one hour of birth increased significantly in the subsequent years.


Women in the last trimester of their pregnancy were asked to enumerate the advantages of

early initiation of breastfeeding. Most frequently reported advantage was that the mothers’

milk is the best food for the newborn. Nearly two-thirds of the pregnant women were able to

recall this advantage. The other prominent advantage, according to the respondents, was

that it helps in maintaining the heat of the child’s body as the child is nearer to the mother’s

body at the time of breast feeding. A few other advantages were reported by about one-third

or lower proportion of respondents (Table 3).

Table 3: Knowledge about the advantages of early initiation of breastfeeding among women in

the last trimester of pregnancy: Endline survey

Advantage mentioned

DISTRICT

Overall Muzaffarpur Samastipur Sitamarhi

Mother's milk is the best food for the newborn 62 76 51 64

While breast-feeding infant remains nearer to the mother's body which helps in maintaining heat of the child's body 52 60 58 56 Breastfeeding immediately after birth helps in uterus shrinking and also helps to bring out placenta and stops heavy postpartum bleeding 37 27 45 36

The more the baby sucks mother's breast, the more milk is made in the mother's body for baby 21 23 22 22

Breastfeeding immediately after birth helps in decreasing problems related to breastfeeding 21 17 14 18 The earlier the baby is put to the breast, the more quickly it learns to breast feed 18 15 16 16 Baby is wide awake in the first hour after it is born. Its sucking reflex is strongest at this time 11 7 14 10

No. of women 309 289 200 798

Note: No baseline data was collected on this aspect

Pregnant women in the last trimester of their pregnancy were also asked about whether they

are aware that colostrum should be given to the baby. Almost all the women respondents in

the endline survey respondend in the affirmative (Figure 3). Not much difference existed

between districts. The projectachieved significant improvement with respect to this indicator.

It is to be noted that before the project intervention, only around one-third of the pregnant

women in the last trimester of their pregnancy recognised the importance of giving

colostrum.


Figure 3: Proportion of women in the last trimester of their pregnancy who knows that colostrum should be given to the baby

When asked about the advantages of feeding colostrum, more than three-fourths of the

pregnant women who participated in the end line survey said that mother’s first milk protects

the baby from diseases and increases resistance to diseases. More than half of them were

also aware that the colostrum contains nutrients that are helpful for the health of the children

and their growth. The proportions were much lower in the baseline survey.

Table 4: Advantages of colostrum feeding reported by women in the last trimester of their pregnancy: End line Survey

Advantages

DISTRICTS

Muzaffarpur Samastipur Sitamarhi Overall


Colostrum protects the baby

from diseases. It also

increases resistance to

disease. It work as the first

immunization of child 55.0 72.0 56.7 79.6 46.8 83.2 53.6 77.6

Colostrum contains all the

nutrients that are helpful in

child health and their growth 46.2 63.2 46.4 58.2 47.5 51.0 46.6 58.3

Others 53.4 7.4 37.1 4.3 71.6 1.5 52.4 4.8

No. of women 251 296 194 280 141 196 586 772


Traditional practices and ignorance of mothers and family members may lead to the practice

of giving substances such as honey, water, sugar etc. before initiating breastfeeding. Almost

all the pregnant women who responded in the end line survey were aware that no substance

(pre lacteals) should be given before the first breastfeeding. As against this, the proportion

was just 27 per cent during the baseline survey. The difference that existed between the

districts before the project intervention seems to have disappeared.

Figure 4: Proportion of women in the last trimester of pregnancy who knows that nothing else has to be given before breastfeeding for the first time

As noted earlier, most of the pregnant women in the last trimester of pregnancy who

responded in the end line survey have the knowledge that no substance should be given

before initiating breastfeeding. Figure 5 indicates that, by the end of the project, most of the

mothers with newborns less than 7 days old did not give anything to the child at the time of

birth. This implies that there is no gap between knowledge and practice.


Figure 5: Proportion of mothers with newborns less than 7 days old who report have not given anything else to drink/lick before breastfeeding for the first time

Knowledge about Exclusive Breastfeeding

Mothers of newborns less than 7 days old and those with a child 3-4 months old were asked

to enumerate the advantages of exclusive breastfeeding. Nearly half of the mothers of

children less than a week old interviewed in the end line survey were able to cite at least

three advantages of exclusive breastfeeding. As against this, less than one-fifth of the

respondents in this category were able to do so in the baseline survey.

Figure 6: Proportion of mothers with newborns less than 7 days old who can cite at least 3 advantages of exclusive breast-feeding


One of the output indicators of the project was the proportion of mothers of children 3-4

months of age who can cite at least three advantages of exclusive breast-feeding. It was

found that nearly two-thirds of the respondents in this category were able to cite three or

more reasons for exclusive breastfeeding. Target to be achieved by March 2015 was 60

per cent for the project as a whole. Overall the target was achieved. Only the achievement

of Samastipur district was below the target. However, the gap between the target and

achievement even in this district was small.

Figure 7: Proportion of mothers of children 3-4 months of age who can cite at least 3 advantages of exclusive breast-feeding

There has been significant increase in the awareness among women about different

advantages of exclusive breastfeeding. Advantage of exclusive breastfeeding reported

most frequently by mothers (Table 5) was that it helps the mental and physical development

of the child. More than three-fourths of the women who responded in the end line survey

were aware of this advantage. About half of the mothers said that mother’s milk was the

best and complete diet for first six months of a child. Other advantages such as the

protective effect of breast milk against common childhood diseases such as diarrhoea and

pneumonia were reported by less than one-fourth of the mothers. Overall, awareness about

the different advantages of exclusive breastfeeding was more among mothers with older

children i.e. children aged 3-4 months as compared to children less than a week old.


Table 5: Advantages of exclusive breastfeeding reported by mothers with newborns less than 7 days old and mothers with a child 3-4 months of age

DISTRICTS

Total Muzaffarpur Samastipur Sitamarhi


Mothers with newborns less than 7 days old

Mental and physical development of child 48.7 68.9 56.9 90.5 28.1 75.8 46.7 78.3

Mother's milk is the best and complete diet for first six months of a child 27.7 43.2 25.1 54.6 14.3 45.5 23.2 47.8

Prevents diarrhoea 13.5 27.9 15.9 19.7 10.4 21.2 13.7 23.3

Prevents pneumonia 7.6 22.5 6.1 20.1 9.1 19.7 7.4 21.0

Increases attachment with mother 13.0 21.3 14.6 18.7 12.2 27.8 13.4 22.0

Mother's milk also saves money by having it free 19.7 18.4 12.7 7.7 15.1 10.6 15.8 12.7

Mother's milk is available all the time also saves time 10.3 14.0 8.0 5.6 8.1 9.6 8.8 9.9

Other milk requires fuel in boiling of utensils and milk boiling whereas mother's milk saves fuel and time 6.7 2.9 2.2 2.1 3.6 4.5 4.1 3.0

Reduces the risk of the child falling ill frequently also saves the money spent on treatment 11.3 22.9 6.8 20.8 9.6 16.2 9.1 20.5

Due to breastfeeding generally period begins after 5 to 6 months which reduces the risk of blood loss 4.8 4.8 3.2 4.2 3.4 9.1 3.8 5.6

Reduces the risk of pregnancy and work as contraceptive 1.1 2.5 2.0 1.1 3.1 2.5 2.0 2.0

Protects the mother from breast cancer 2.7 7.3 2.0 5.6 2.6 9.6 2.4 7.3

No. of women 524 315 590 284 384 198 1498 797

Mothers with a child between 3-4 months of age

Mental and physical development of child 59.1 80.8 54.5 88.3 26.8 75.4 49.3 82.2

Mother's milk is the best and complete diet for first six months of a child 39.8 58.6 34.7 53.6 15.4 54.8 31.7 55.8

Prevents diarrhoea 20.3 45.0 14.0 32.3 9.6 31.7 15.2 37.0

Prevents pneumonia 8.6 42.0 6.9 30.2 9.9 36.7 8.3 36.4

Increases attachment with mother - 20.2 - 18.2 0.0 22.6 - 20.1

Mother's milk also saves money by having it free - 27.4 - 10.3 0.0 14.1 - 17.8

Mother's milk is available all the time also saves time

- 15.6 - 8.6 0.0 13.1 - 12.4

Other milk requires fuel in boiling of utensils and milk boiling whereas mother's milk saves fuel and time

- 7.8 - 2.1 0.0 4.5 - 4.9

Reduces the risk of the child falling ill frequently also saves the money spent on treatment

- 25.1 - 26.1 0.0 18.6 - 23.8

Due to breastfeeding generally period begins after 5 to 6 months which reduces the risk of blood loss

- 6.5 - 3.1 0.0 8.0 - 5.6

Reduces the risk of pregnancy and work as contraceptive

3.2 3.9 4.9 4.1 2.6 6.0 3.7 4.5

Protects the mother from breast cancer 7.7 10.1 4.5 6.9 3.6 7.0 5.5 8.2

No. of women 558 307 594 291 384 199 1536 797


Mothers with newborns less than 7 days old and those with children 3-4 months of age were

enquired about their knowledge on the ideal duration of exclusive breastfeeding. It was

found that large majority of women were aware of the ideal duration of exclusive

breastfeeding. As high as 96 per cent of the mothers of newborns less than 7 days old and

88 per cent of the mothers of children 3-4 months of age were aware that the exclusive

breastfeeding should continue for six months (Figure 8 and Figure 9). Sitamarhi district

which lagged behind the other two districts in the baseline survey came on top. However,

only marginal differences exist between districts.

Figure 8: Proportion of mothers with newborns less than 7 days old who knows about the ideal duration (6 months) of exclusive breastfeeding


Figure 9: Proportion of mothers with a child 3-4 months of age who knows about the ideal duration of exclusive breastfeeding

Practice of Exclusive Breastfeeding

Mothers are expected to practice exclusive breastfeeding till the child is six months of age.

Mothers of children less than a week old and those aged 3-4 months were asked whether

they had given any food other than breast milk. If any food was being given, it implied that

the mothers are not following exclusive breastfeeding. In the end line survey, just one per

cent of the mothers of the newborns and 3 per cent of the mothers of children 3-4 months of

age had given any food other than breast milk (Figure 10 and Figure 11).

Figure 10: Proportion of mothers with a child less than 7 days old who have started giving anything other than breast milk


Figure 11: Proportion of mothers with a child 3-4 months of age who have started giving anything other than breast milk

As noted earlier, large majority of women were aware that exclusive breastfeeding has to

continue till the child attains the age of six months. But, in practice, only half of the mothers

of children 6-7 months of age had exclusively breastfed the child for six months. Proportion

of mothers of children 6-7 months of age who have exclusively breastfed the child at least for

six months is an outcome indicator of the project. Target fixed for this indicator was to

achieve 40 per cent. While the project has been successful in achieving the target, the huge

gap between knowledge and practice needs to be taken into account. High level of

knowledge among women about the ideal duration of exclusive breastfeeding has not

translated into practicing exclusive breastfeeding. There exist significant differences

between districts in the practice of exclusive breastfeeding.Samastipur district fared better

than the other two districts on this aspect. Sitamarhi district just crossed the target with 40

per cent of the women practicing exclusive breastfeeding. In Muzaffarpur, the proportion

was 48 per cent. It may be noted that the differences between the districts in the

performance on this aspect widened during the project period.


Figure 12: Proportion of mothers with a child 6-7 months of age who have exclusively breastfed their child for at least six months

Complementary Feeding

Introduction of Complementary Feeding

According to WHO guidelines, when breast milk is no longer enough to meet the nutritional

needs of the infant, complementary foods should be added to the diet of the child. This

transition from exclusive breastfeeding to complementary feeding should be initiated when

the child completes 6 months of age.

Mothers of children 3-4 months of age were asked about the ideal time for introduction of the

complementary food. Just 10 per cent of the mothers with a child of age 3-4 months who

responded in the end line survey gave a figure other than 6 months or 7 months. Some of

the mothers could not give the exact age of the child at which the complementary food

should be introduced but gave qualitative responses such as “when the child is ready”,

“when the child is hungry even after breast milk”, “when the child starts teething” or “when

the child grabs food”. The corresponding proportion in the baseline survey was just 33 per

cent. There is not much difference between districts on this aspect. (Table 6).


Table 6: Knowledge on age at which complementary foods can be started among mothers of children 3-4 months of age

Age

DISTRICT



Numeric Response 1 month 0.2 0.0 0.3 0.0 0.0 0.0 0.2 0.0

2 months 0.2 0.0 0.8 0.0 0.0 0.0 0.4 0.0

3 months 0.0 0.0 0.8 0.0 0.8 0.0 0.5 0.0

4 months 1.6 0.3 1.7 0.0 1.3 0.0 1.6 0.1

5 months 2.0 0.0 1.7 0.0 1.6 0.0 1.8 0.0

6 months 26.2 31.6 21.0 38.5 13.3 38.2 21.0 35.8

7 months 18.5 55.7 11.4 55.7 6.8 46.2 12.8 53.3

8 months 6.8 1.6 5.4 1.7 4.4 1.0 5.7 1.5

9 months 4.3 1.3 4.7 1.0 4.4 2.0 4.5 1.4

10 months 1.6 0.0 0.7 0.0 1.6 0.0 1.2 0.0

11 months 0.0 0.0 0.2 0.0 0.5 0.0 0.2 0.0

12 months 8.4 0.3 7.9 0.3 8.3 0.0 8.2 0.3

More than 1 year 1.8 0.0 0.8 0.3 5.7 3.0 2.4 0.9

Sub-Total 71.5 90.9 57.6 97.6 48.7 90.5 60.4 93.2

Non-numeric responses/Non-response 28.5 9.1 42.4 2.4 51.3 9.5 39.6 6.8

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

No. of women 558 307 594 291 384 199 1536 797

To assess whether exclusive breastfeeding has been put into practice in the project areas,

mothers of children aged 6-7 months and 12-13 months were asked whether they had

initiated complementary feeding (defined as giving food other than breast milk). One of the

outcome indicators of the project was the proportion of mothers with a child 6-7 months of

age who have introduced complementary feeding for their child. Target fixed for this

indicator at the end of the project period was 85 per cent. With 88 per cent of the mothers in

this category having introduced complementary feeding, the target has been achieved.

Corresponding proportion in the baseline survey was 73 per cent. Performance of

Muzaffarpur district was better than the other two districts on this aspect.


Figure 13: Proportion of mothers with a child 6-7 months of age who have introduced complementary feeding for their child

Table 7: Age at which complementary food was introduced for children of 12-13 months of age

Age in months

DISTRICT



1 3.8 0.3 7.2 2.1 8.0 1.5 6.1 1.3

2 5.0 0.0 7.9 0.4 3.5 0.0 5.8 0.1

3 3.8 0.0 9.4 0.4 5.9 1.0 6.5 0.4

4 2.8 0.3 4.8 0.7 5.3 0.5 4.2 0.5

5 3.4 1.3 4.2 2.1 4.1 2.0 3.9 1.8

6 18.6 30.4 15.5 26.6 11.8 36.5 15.7 30.6

7 14.3 51.1 13.7 54.3 8.6 44.7 12.6 50.6

8 10.5 6.1 10.0 5.7 13.6 1.5 11.0 4.8

9 10.7 3.2 5.7 3.2 14.5 3.6 9.6 3.3

10 6.1 0.6 4.8 1.1 7.4 2.0 5.9 1.1

11 3.4 0.3 1.8 0.4 2.1 0.5 2.4 0.4

12 5.7 0.0 2.2 0.0 2.4 0.5 3.5 0.1

Don't remember 12.1 6.4 12.7 3.2 13.0 5.6 12.8 5.1

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

No. of women 505 313 542 282 339 197 1390 792


It is important to ensure that initiation of complementary feeding should be timely, meaning

that all infants should start receiving food in addition to breast milk from six months

onwards.Mothers of children 12-13 months of age were asked about the actual age of the

child when the complementary feeding was started.

About one-third of the mothers of children 12-13 months of age (31%) who responded in the

end line survey started complementary feeding when the child was six months old. The

proportion varied between 27 per cent in Samastipur to 37 per cent in Sitamarhi.

Corresponding proportion in the baseline survey was 16 per cent. Half of the mothers

started giving complementary food to their child in the seventh month. A comparison of

figures in Table 6 and Table 7 indicates that there is not much gap between knowledge and

practice. Table 6 and table 7 also reveals the confusion existing among mothers (and

perhaps the service providers) whether the complementary feeding have to start on

completion of six months or during the sixth month.

Before the project intervention, 27 per cent of the children started receiving complementary

feeding before the age of six months. By the end of the project, the corresponding

proportion was just 4 per cent. It was also found that the proportion of mothers starting

complementary feeding after seven months came down from 36 per cent before the project

intervention to just 10 per cent towards the end of the project. Just 2 per cent of the mothers

waited till the child attained the age of 10 months or more to start complementary feeding at

the end of the project period. Corresponding proportion in the baseline survey was 12 per

cent. It appears that the project interventions have helped to arrest the early initiation of

complementary feeding i.e. before six months of age.

Three dimensions of complementary feeding are quantity, quality and frequency. It is also

important to ensure that complementary feeding should be adequate, meaning that it should

be given in amounts, frequency and using a variety of foods to cover the nutritional needs of

the growing child while maintaining breastfeeding.

Mothers of children 6-7 months of age and 12-13 months of age were asked about the

frequency of complementary feeding for their child. WHO recommends that infants of age 6-

8 months should receive complementary foods 2-3 times a day in addition to breast milk.

This frequency has to increase to 3-4 times daily for children 12-13 months of age.

Additional nutritious foods should be offered 1-2 times per day for the children. Since the

baseline data on frequency of complementary feeding is ambiguous about whether the

frequency mentioned by the respondents includes foods or only “full meals”. Therefore, the


baseline study took the minimum frequency of three times for children 3-4 months of age

and 4 for 12-13 months of age. Baseline survey also did not seek the actual number of

meals. Instead, the responses were grouped as “1-2 times”, 3-4 times”, “5 times” and “more

than 5 times”. Therefore, the information on frequency of complementary feeding in the end

line survey is not comparable to that of baseline survey. Findings of the end line survey and

the first midterm survey are presented along with that of the two mid-term evaluations in

Table 8.

Table 8: Frequency of giving complementary food to children 12-13 months of age

Frequency

DISTRICT


Year1 Endline Year 1 Endline Year 1 Endline Year 1 Endline

1 2.5 0.6 4.3 2.5 1.3 1.5 3.0 1.5

2 23.4 9.3 31.4 10.6 13.8 5.1 24.3 8.7

3 13.3 31.6 29.0 27.7 23.8 29.4 23.2 29.7

4 13.3 28.4 9.8 28.0 17.5 35.5 12.9 30.1

5 6.3 10.9 1.6 13.8 10.6 12.2 5.4 12.2

6 8.2 6.4 0.8 9.6 5.6 7.1 4.2 7.7

7 5.7 3.5 1.2 2.1 0.0 2.5 2.1 2.8

8 2.5 0.6 0.8 2.1 0.6 0.5 1.2 1.1

9 1.3 0.0 0.0 0.4 0.0 0.0 0.3 0.1

10 0.0 0.3 0.4 0.7 0.0 0.0 0.2 0.4

Don't know/ No response 23.4 8.3 20.8 2.5 26.9 6.1 23.2 5.7

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

No. of women 158 313 255 282 160 197 573 792

At the end of the project, 60 per cent of children 12-13 months of age were receiving

complementary food 3-4 times daily. Corresponding proportion in the first mid-year survey,

held in 2013, was 36 per cent. About one-tenth of the children were still getting food less

than three times daily. A few of the children were also receiving food six or more times.

District-level analysis shows that the proportion varied between 65 per cent in Sitamarhi to

56 per cent in Samastipur. Quantity of food received by the children on the previous day

was also assessed. Results are presented in Table 9.


Table 9: Average of qty. (in ml) of solid/semi solid foods given to children 12-13 months of age

District Year

Children 12-13 months

Mean Quantity(ml) No. of women

Muzaffarpur

Baseline 287 376

Year 1 369 122

Year 2 309 211

Endline 477 300

Samastipur

Baseline 350 454

Year 1 441 194

Year 2 330 263

Endline 462 273

Sitamarhi

Baseline 463 199

Year 1 437 113

Year 2 343 140

Endline 407 176

Overall

Baseline 349 1029

Year 1 420 429

Year 2 326 614

Endline 455 749

Overall, the average quantity of food given to the child increased from 349 ml during the

baseline survey to 455 ml in the endline survey. At the district level, Muzaffarpur and

Sitamarhi experienced an increase over the baseline survey while Samastipur registered a

decline.

Mothers with a child 12-13 months of age were asked about the variety of foods they were

offering the child. Table 10 presents the details of the responses.

Table 10: Variety of Semi-solid food eaten by children 12-13 months of age in the last 24 hours

Food item

DISTRICT



Cereals (Rice, Roti etc.) 95.5 98.6 95.4 94.5 94.1 95.7 95.1 96.4

Roots and tubers 23.9 36.8 18.5 29.6 36.3 35.9 24.8 33.9

Green leafy vegetables 18.0 27.5 18.3 20.8 28.6 33.7 20.7 26.6

Yellow and orange Fruits 6.1 17.9 10.3 13.1 15.6 17.4 10.1 16.0

Sugar 23.3 35.4 16.3 48.2 27.1 35.9 21.5 40.2

Oil, Ghee 16.6 24.1 9.7 51.5 22.4 21.2 15.3 33.4

Other fruits and vegetables 12.8 13.4 6.6 20.4 19.8 19.0 12.1 17.4

Dairy Products 25.1 46.7 18.3 53.6 26.8 51.1 22.9 50.3

Pulses and Sprouted grains 51.4 73.2 30.6 66.1 20.4 73.4 35.7 70.6

Meat, fish, poultry etc. 5.9 10.0 2.8 15.0 20.9 18.5 8.3 13.9

Eggs 5.5 14.1 2.8 14.2 14.7 15.2 6.7 14.4

No. of women 506 291 545 274 339 184 1390 749


Cereals followed by pulses/sprouted grains were food items most frequently used, reported

both in the baseline and end line surveys. Half of the mothers who participated in the end

line survey gave dairy products to children in the past 24 hours. One-third of the children

received roots and tubers and one-fourth received green leafy vegetables at the end of the

project period. While most of the children were being given cereals even before the project

interventions, consumption of other food items such as pulses increased significantly by the

end of the project period.

Table 11: No. of Food Groups from which children aged 12-13 months ate in the past 24 hours

No. of categories

DISTRICT

Overall Muzaffarpur Samastipur Sitamarhi Baseline Endline Baseline Endline Baseline Endline Baseline Endline

One 17.4 1.6 27.9 2.5 26.8 3.6 23.8 2.4

Two 29.4 12.1 33.8 10.6 21.2 10.2 29.1 11.1

Three 24.5 32.3 20.0 18.8 12.4 23.9 19.8 25.4

Four 13.2 22.4 7.2 23.8 12.1 21.3 10.6 22.6

Five 7.3 12.8 4.0 15.2 5.6 12.7 5.6 13.6

More than 5 6.1 16.9 3.9 24.5 17.7 24.4 8.1 21.5

No response 2.0 1.9 3.3 4.6 4.1 4.1 3.0 3.4

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

No. of women 506 313 545 282 339 197 1390 792

Table 11 indicates that the proportion of children 12-13 months of age who were given three

or more categories of food increased from 44 per cent before the project intervention to as

high as 86 per cent by the end of the project. There existed only marginal differences

between the districts.

Age Appropriate Complementary Feeding

The project had adopted a simple definition of “age appropriate complementary feeding” for

monitoring. This definition applied only to the children in the 12-13 months age group and is

based on PAHO guidelines of complementary feeding. Children in the age group 12-13

months were considered to be receiving appropriate complementary feeding if:

1. The child had started receiving foods other than breast milk

2. The child had received complementary food at least 3 times in the previous 24 hours

3. The child had received at least 375 ml of complementary food in the past 24 hours

Based on this definition, the proportion of children 12-13 months of age receiving age

appropriate complementary feeding was worked out (Figure 14).


Figure 14: Proportion of children 12-13 months of age receiving age appropriate feeding

Figure 14 indicates that overall the proportion of children receiving age appropriate

complementary feeding increased from just 20 per cent in the baseline survey to 43 per cent

in the end line survey. Target fixed for this outcome indicator was 35 per cent. Proportion

was the highest for Samastipur district and lowest for Sitamarhi district. It may be noted that

Sitamarhi district had the highest proportion of children receiving appropriate complementary

feeding at the time of initiation of the project. All the three districts could achieve the target.

Information on IYCF

This section presents the findings related to assessment of project’s key activities for

improving the knowledge of pregnant women and mothers regarding optimal IYCF

practices. Same set of questions were asked to all categories of respondents viz., pregnant

women in the last trimester of pregnancy, mothers of infants less than 7 days old, mothers of

children 3-4 months, 6-7 months and 12-13 months of age. As the section deals with the

effect of project interventions, only end line results are presented in this section as there is

no baseline data on these aspects.

Pregnant women and mothers with children of different age groups were enquired whether

they have heard or seen any message related to IYCF in the three months preceding the

end line survey. The results are presented in Figure 15.


Figure 15: Proportion of respondents who have heard or seen any message related to IYCF in last 3 months

Figure 15 indicates that a large majority of women have heard or seen messages related to

IYCF in the last three months. The proportion was the highest in Sitamarhi district and

lowest in Muzaffarpur.

When asked about these messages, the most noticed message was related to exclusive

breastfeeding, followed by the importance of complementary feeding along with mother’s

milk after six months. Early initiation of breastfeeding was also mentioned by half of the

women (Table 12).

Table 12: Message related to IYCH heard or seen by women

Message heard or seen

District Overall Muzaffarpur Samastipur Sitamarhi

Early initiation of breast feeding 51.2 46.8 54.4 50.4

Exclusive breast feeding 62.9 61.5 61.6 62.1

Introduction of Complementary feeding with mother's milk after 6 months of child 55.0 60.2 54.8 56.9

Breast feeding 27.3 36.5 21.6 29.2

Others 1.5 1.9 0.3 1.3

No. of women 1437 1343 950 3730

The sources of awareness of IYCF were also enquired. The results are presented in Table 13.

91.2

92.7

95.0

92.7

0.0 20.0 40.0 60.0 80.0 100.0

Muzaffarpur

Samastipur

Sitamarhi

Overall


Table 13: Source of awareness about IYCF messages

Source District


From PE / CC 97.4 96.9 98.5 97.5

Health worker 22.3 33.4 17.9 25.2

Radio 13.3 8.8 1.5 8.7

Poster/hoarding/wall painting 7.2 6.3 4.5 6.2

TV 8.7 4.8 3.6 6.0

Community Meetings 2.8 4.3 3.3 3.5

Pamphlet / Handbill 3.4 1.0 0.9 1.9

Newspaper/Magazine 1.2 1.2 1.4 1.2

From Friend/relative 1.6 1.1 0.6 1.2

Exhibition/Mela 1.3 0.0 0.3 0.6

From Work Place 1.1 0.6 0.0 0.6

Husband 0.4 0.2 0.4 0.3

School/teacher 0.3 0.2 0.1 0.2

Adult education programme 0.1 0.0 0.2 0.1

Religious leader 0.0 0.0 0.3 0.1

No. of women 1437 1343 950 3730

Most of the women said that they heard the messages about IYCF from the project

functionaries such as PEs and CCs. One-fourth of them reported that they heard it from

health worker. The reach of radio and outdoor communication methods such as

poster/hoarding/wall painting seemed to be low.

The project had adopted group meetings as a strategy to reach out to the target group.

Participation of pregnant women and mothers of infants and young children were expected

to improve their knowledge about healthy child feeding practices.


Group meetings of pregnant women in the third trimester of pregnancy and mothers of

children in the 6th month, 7th month, 9th month and 15th month were planned in the project.

Therefore, among the groups of respondents, mothers of children of age 3-4 months were

unlikely to attend any group meetings in the last three months. Table 14 presents the

proportion of women who attended at least one group meeting in the last three months.

Table 14 indicates that, overall, two-thirds or more of the women in the target groups have

attended group meetings during the last three months. Highest proportion was in Sitamarhi

district indicating that the group meetings were organised more effectively in the district

compared to the other two districts.

Table 14: Proportion of women who attended at least one group meeting organised by

PE/CC during the last 3 months: Women category-wise

Category of Respondents

District


Pregnant Women 84.5 82.4 90 85.1

Mothers with < 7 days old 66.7 61.3 71.2 65.9

Mothers with child 6-7 months 61.7 84 85.2 75.6

Mothers with child 12-13 months 68.3 67.4 79 70.6


Behavioural change communication (BCC) activities were undertaken through grass root

level workers- PEs and CCs. They were responsible for providing information about

recommended IYCF practices and were expected to help the women overcome the barriers

to adopt the same. The pre-structured group meetings were expected to discuss various

issues related to IYCF. Table 15 presents the details of the points that were discussed in

these group meetings.

Table 15: Points discussed in the group meetings organised by PE/CC attended by respondents during the last 3 months: Women category-wise

Points discussed Pregnant women

Women with child:

Less than 7 days

old

6-7 months

old

12-13 months

old

New born care 73.5 78.3 40.2 32.9

Early initiation of breast feeding 74.8 76.2 20.5 17.5

Exclusive breast feeding 64.5 69.1 46.3 31.0

Introduction of complementary feeding with mother's milk after 6 months of child 0.0 16.8 67.9 63.7

Cleaning and washing hands 0.0 51.0 61.4 62.8

Child's weight and its relationship with child growth 0.0 17.7 34.4 36.3

Preparation of complementary food types of food groups 0.0 3.2 28.7 32.9

About contraceptives 0.0 3.0 24.1 31.1

Quantity and frequency of complementary feeding in 24 hours 0.0 1.9 16.0 23.0

Diarrhoea management 0.0 5.9 11.2 17.1

Problems during breast feeding 0.0 7.8 12.2 10.9

Feeding during illness 0.0 3.2 10.1 16.8

No. of women 679 525 614 578

About three-fourths of the pregnant women in the last trimester of pregnancy and mothers of

newborns less than seven days old reported that aspects related to new born care and the

importance of early initiation of breast feeding were discussed in the group meetings they

had attended in the last three months. Compared to this, a lesser proportion of women in

these two categories reported that the meetings discussed the need for practicing exclusive

breastfeeding. This is reasonable as the focus at the stages mentioned were on new born

care and early initiation. About two-thirds of the mothers of children who have completed six

months of age recalled that the meetings discussed the introduction of complementary

feeding after 6 months. Table 15 also indicates that the meetings discussed aspects beyond


the IYCF practices. Such aspects include the importance of ‘cleaning and washing hands’,

‘child's weight and its relationship with child growth’, ‘use of contraceptives’ etc.

Another major activity undertaken to improve the knowledge of pregnant women and

mothers regarding optimal IYCF practices was the home visits by PE/CC. As per the project

design, home visits were planned soon after child birth (up to 2 months of age). Table 16

presents the proportion of mothers with child less than 7 days old and those with child 3-4

months old whose homes were visited by PE/CC in the last three months.

Table 16: Proportion of women whose homes were visited by PE/CC in the last three months: Women category-wise

Category of Respondents

District


Mothers with < 7 days old 60.6 73.6 75.8 69.0

Mothers with child 3-4 months 80.8 89.3 83.4 84.6

Table 16 indicates that large majority of the mothers of child 3-4 months old reported PE/CC

visited their homes in the last three months. More than two-thirds of the mothers of newborn

less than 7 days old also reported that their homes were visited by PE/CC. Since the data is

about the visits during the three months prior to the survey, this implies that the houses of

majority of the mothers are visited soon after birth. Samastipur and Sitamarhi districts were

better than Muzzafarpur district in this respect.

The respondents were also asked about the points that were discussed during the home

visits by PE/CC. The responses are compiled in Table 17.

Table 17: Points discussed during home visits by PE/CC in last 3months: Category-wise

Points discussed

Mothers with a child:

Less than 7 days old 3-4 months old

New born care 76.9 64.7

Early initiation of breast feeding 64.0 46.1

Exclusive breast feeding 65.6 66.5

Cleaning and washing hands 48.4 57.0

Child's weight and its relationship with child growth 31.1 41.1

Introduction of complementary feeding with mother's milk after 6 months of child 17.5 30.7

About contraceptives 4.2 21.4

Problems during breast feeding 11.1 13.5

Feeding during illness 4.2 8.8

Diarrhoea management 4.7 7.6

No. of women 550 674


As in the case of group meetings, new born care related aspects received the highest

attention in home visits by PE/CC. This was followed by topics such as “exclusive breast

feeding”, “importance of cleaning and washing hands” and the need for early initiation of

breast feeding.

Service Providers

One of the objectives of the project was to improve the knowledge and performance of

government health and nutrition functionaries with respect to infant and child feeding

practices (IYCF). While project based Peer Educators (PEs) and Cluster Coordinators (CC)

were primarily responsible for carrying out BCC activities, the project aimed at improving the

capacity of facility based service providers(FBSP) such as ANM and Mamta and community

based service providers (CBSP) such as Anganwadi worker/AWW and ASHA. This was

important to ensure the sustainability of the project interventions. Capacity building of

service providers was through training programmes, participation in group meetings and

home visits, participation in monthly review meetings, joint celebration of key events etc. PEs

and CCs were responsible for mentoring the service providers for this role. In this section,

the findings of the survey among the service providersare presented. A total of 492 service

providers (300 FBSPs and 179 CBSPs) were interviewed as part of the endline study.

Knowledge regarding optimal IYCF practices

Early Initiation of Breastfeeding:

Knowledge among the service providers about appropriate time for initiating breast feeding

has increased significantly during the project period.

Figure 17: Knowledge of Service Providers about the ideal time of initiation of breast feeding


Figure 17 indicates that almost all the service providers are aware that breast feeding has to

be initiated within an hour of birth of the child. The level of awareness is almost the same for

facility based and community based service providers. Service providers were also enquired

about their understanding about the advantages of early initiation of breast feeding. The

responses are compiled in Table 20.

Table 18: Advantages of early initiation of breastfeeding mentioned by the service providers

Advantage

FBSP CBSP Overall

Baseline Endline Baseline Endline Baseline Endline

While breast-feeding infant remains nearer to the mother's body which helps in maintaining heat of the child's body

39.0 64.9 26.1 77.7 33.2 69.5

Breastfeeding immediately after birth helps in uterus shrinking and also helps to bring out placenta and stops heavy postpartum bleeding

26.8 64.9 20.1 66.5 23.8 65.4

Breastfeeding immediately after birth helps in decreasing problems related to breastfeeding

15.2 28.8 17.2 32.4 16.1 30.1

The earlier the baby is put to the breast, the more quickly it learns to breast feed.*

-- 22.0 -- 27.9 -- 24.2

Baby is wide awake in the first hour after it is born. Its sucking reflex is strongest at this time*

-- 13.7 -- 18.4 -- 15.4

The more the baby sucks mother's breast, the more milk is made in the mother's body for baby*

-- 29.4 -- 43.0 -- 34.3

Mother's milk is the best food for the newborn*

-- 60.1 -- 63.7 -- 61.4

No. of service providers 164 313 134 179 298 492

* These responses are not mentioned in the baseline survey Awareness about the advantages of early initiation of breastfeeding has increased among

the service providers during the project period. About two-thirds of the service providers

interviewed in the endline survey said that early initiation of breastfeeding helps to keep the

baby’s body warm and reduces the incidence of postpartum haemorrhage. The fact that

mothers’ milk is the best food for the newborn was recalled by a slightly lesser proportion of

service providers (61%). Recall of the advantages of early initiation of breastfeeding was

marginally higher among community based service providers than facility based providers.


Figure 18: Proportion of Service Providers who are aware that nothing else should be given to the child to drink or lick before breastfeeding the baby for the first time

At the end of the project, almost all the service providers were aware that nothing else

should be given to the child to drink or lick before initiating breastfeeding (Figure 18). Most

of them were also aware that colostrum must be given to the baby (Figure 19).

Figure 19: Proportion of Service Providers who are aware that colostrum should be given to the baby


Exclusive Breastfeeding

Knowledge of the service providers is important in promoting exclusive breastfeeding

practices among women. There has been considerable improvement in the understanding

among service providers about the correct meaning of exclusive breastfeeding during the

project period. At the time of baseline survey, two-thirds of the service providers were aware

that exclusive breastfeeding refers to giving the child nothing other than breast-milk, not

even water. The corresponding proportion has increased to 92 per cent in the end line

survey (Figure 20). It was also found that the awareness is slightly lower among community

based service providers than facility based service providers.

Figure 20: Proportion of Service Providers who knows the definition of exclusive breastfeeding

Proportion of service providers who knew that exclusive breastfeeding should continue for

six months increased from 73 per cent in the baseline survey to 97 per cent in the end line

survey (Figure 21). There is only marginal difference between community based and facility

based service providers.


Figure 21: Proportion of Service Providers who knows the ideal duration (6 months) of exclusive breastfeeding

Service providers were asked about the advantages of exclusive breastfeeding. The

responses are compiled in Table 19.

Table 19: Knowledge of service providers about the advantages of exclusive breastfeeding

Advantage

FBSP CBSP Overall


Mental and physical development of child 62.4 86.6 55.3 91.6 58.8 88.4

Mother's milk is the best and complete diet for first six months of a child 40.7 58.1 39.3 63.1 40.0 60.0

Prevents diarrhoea 33.5 41.5 31.6 44.1 32.5 42.5

Prevents pneumonia 26.3 31.9 18.0 30.2 22.0 31.3

Increases attachment with mother* -- 30.7 -- 26.8 -- 29.3

Mother's milk also saves money by having free* -- 15.7 -- 20.7 -- 17.5

Mother's milk is available all the time also saves time* -- 14.7 -- 16.8 -- 15.4

Other milk requires fuel in boiling of utensils and milk boiling whereas mother's milk saves fuel and time* -- 7.3 -- 12.3 -- 9.1

Reduces the risk of the child falling ill frequently also saves the money spent on treatment* -- 24.3 -- 35.2 -- 28.3

Due to breastfeeding generally period begins after 5 to 6 months which reduces the risk of blood loss* -- 21.4 -- 16.8 -- 19.7

Reduces the risk of pregnancy and work as contraceptive 17.5 16.0 11.2 19.6 14.3 17.3

Protects the mother from breast cancer 15.5 17.9 9.7 17.3 12.5 17.7


* These responses are not mentioned in baseline survey

76.8

69.9

73.3

82.3

79.4

80.5

97.4

96.4

96.7

97.1

95.5

96.5

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

FBSP

CBSP

Overall

Per cent

Endline Year 2 Year 1 Baseline


The most frequently recalled advantage was that exclusive breastfeeding helps in the mental

development of the child. This was followed by the knowledge that mother's milk is the best

and complete diet for first six months of a child. Other advantages recalled by a significant

number of service providers include its protective effect against diarrhoea and pneumonia

and that it helps to increase the bonding of the child to the mother. Overall, the awareness

about different advantages of exclusive breastfeeding among the service providers at the

end of the project period was much higher than it was before the project interventions.

Table 20 presents the understanding of the service providers about the ideal timing for

introducing complementary food.

Table 20: Knowledge of Service Providers about the ideal timing (6 months) for introduction of complementary food

Timing

FBSP CBSP Overall


Less than 6 months 6.2 0.6 1.5 0.6 3.8 0.6

6 months 61.3 78.9 52.9 81.0 57.0 79.7

7 months 21.6 18.8 26.7 15.6 24.3 17.7

More than 7 months 8.2 0.3 7.3 1.1 7.8 0.6

No response/qualitative response 2.6 1.3 11.7 1.7 7.3 1.4

Total 100.0 100.0 100.0 100.0 100.0 100.0


Four-fifths of the service providers knew about the correct time for introduction of

complementary food i.e. after six months. Corresponding proportion in the baseline survey

was 57 per cent. Most other respondents in the end line survey gave the response as ‘7

months’. As pointed out in the report of the baseline survey, this has to be interpreted with

caution. There is widely prevalent practice of reporting the age in ‘running months’ than

completed months. Thus a child who has completed six months is now into her seventh

(running) month. Thus, it is possible that some of the respondents who gave the response as

‘7 months’ may be referring to six completed months. In any case, the proportion of

respondents who gave the response ‘6 months’ is much higher in the end line survey than in

the baseline survey.

Proportion of community/facility based health / nutrition functionaries who have the ‘correct

knowledge’ regarding IYCF practices is an output indicator of the project. Optimal IYCF

practices include timing of early initiation of breastfeeding, exclusive breastfeeding and

timely initiation of complementary feeding. “Correct knowledge” of the service provider has

been defined in the project context as knowledge related to:

i. timing of initiation of breastfeeding (i.e. within 1 hour of delivery)


ii. definition of exclusive breastfeeding (i.e. only breast-milk given to the child, not even

water)

iii. duration of exclusive breastfeeding (i.e. 6 months), AND

iv. age for introduction of complementary foods (i.e. 6 months)

Figure 22: Proportion of service providers who have the correct knowledge regarding IYCF practices

Service providers were asked how often a child should be given complementary food in 24

hours. Since the project has fixed norms only for 12-13 months old, responses for the age

group 12-24 months are compiled in Table 21.

Table 21: Knowledge of service providers about the frequency of complementary feeding in 24 hours for children 12-24 months of age

Frequency Baseline Endline

No response 11.0 4.3

1-2 times 1.8 0.2

3-4 times 19.0 36.6

5 times 15.8 28.7

More than 5 times 52.5 30.3

Total 100.0 100.0

During the baseline survey, half of the service providers gave the response ‘more than 5

times’. This may be ‘over feeding’ the child and therefore may reduce the dependence of

the child on breast milk. At the end of the project, only 30 per cent suggested that the child

should be given complementary food more than 5 times. The proportion suggesting ‘3-4

times’ and ‘5 times’ has gone up in the end line survey compared to the baseline survey.


Perception of service providers about the desired quantity of complementary food that

should be offered to the child was also enquired both in the baseline survey and the end line

survey. Service providers were asked to express the desired quantity as number of cups (of

150ml) and number of spoons (of 10ml) which was then converted into millilitres. Since

there is some possibility of error in the calculation of the quantity in such a way, therefore

400 ml (instead of 375 ml) was considered, as suggested for 12-24 months old.

Table 22: Knowledge of service providers about the quantity of complementary feeding in 24

hours for children 12-24 months of age

Quantity Baseline Endline

No response 9.5 4.9

1-200 ml 2.8 1.6

201-400 ml 8.3 5.9

401-600 ml 29.3 43.1

601-800 ml 14.8 23.0

801-1000 ml 14.3 12.4

1001-1200 ml 10.3 5.5

1201-1400 ml 2.5 0.8

1401-1600 ml 3.8 1.4

1601-1800 ml 2.3 0.2

1801-2000 ml 1.5 0.6

Above 2000 ml 1.3 1.6

Total 100.0 100.0

No. of service providers 400 492

In the baseline survey, quantity of complementary food suggested by about one-fifth (21%)

of the service providers was less than 400 ml. This proportion was reduced by half. As

against 29 per cent in the baseline survey, 43 per cent suggested 401-600 ml in the end line

survey.

A wide variety of foods was suggested by the service providers (Table 23). The proportion

reporting all the varieties was higher in the end line survey than in the baseline survey

indicating the increasing knowledge among service providers about the importance of giving

different varieties of food to children.


Table 23: Perception of Service Providers about the variety of Foods to be given to the child

for complementary feeding

Food Group

Age of the child

6-9 months 9-12 months 12-24 months


Cereals (Rice, Roti etc.)6-9 months child 81.8 86.8 86 85.2 87.3 84.1

Roots and tubers 11.3 26.6 17.0 42.1 24.5 47.0

Green leafy vegetables 19.8 22.8 27.8 39.2 39.0 51.8

Yellow and orange Fruits 16.0 18.7 27.5 32.5 28.5 36.8

Sugar 15.5 35.4 22.5 35.8 26.5 39.4

Oilseeds, Ghee 12.0 35.6 18.0 36.6 25.5 41.1

Other fruits and vegetables 8.5 14.2 19 29.1 39.5 40.4

Dairy Products 25.8 41.5 40.5 45.9 48.8 47.2

Pulses and Sprouted grains 57.5 73.8 51.5 65 63.5 68.7

Meat, fish, poultry etc. 3.5 10.0 9.3 25.2 43.3 63.8

Eggs 2.5 9.35 7.8 37.4 34.3 57.3

Support Received by the Service Providers from the Project

A major task of the PEs and CCs was mentoring and supporting the service providers like

ASHAs, ANMs, AWWs and Mamtas. Service providers were given training/orientation on

IYCF practices by the project team. Figure 23 presents the proportion of Community/Facility

based Health/Nutrition functionaries who have received any training from Buniyaad project.


Figure 23: Proportion of service providers who have received training/orientation from AKF or AKF supported agencies

Only 10 per cent of the service providers did not attend any training/orientation programme

related to IYCF organised by the PEs/CCs of the project. There exists only marginal

difference between facility based and community based service providers in this regard. The

end line survey also revealed that large majority (95%) of the service providers knew about

the PEs and CCs working in their area (Figure 24).

Figure 24: Proportion of service providers who knows the PE/CC working in their area

PEs and CCs were also expected to ensure the participation of government health and

nutrition functionaries (such as ANM/ASHA/Anganwadi worker/MAMTA) in PE led group

meetings and home visits. This would help to improve their knowledge regarding optimal

IYCF practices as well as inter-personal and group counselling skills. It was hoped that such

mentoring will help the government frontline functionaries in dealing with and resolving IYCF

89.1

91.1

89.8

0.0 20.0 40.0 60.0 80.0 100.0

FBSP

CBSP

Overall

94.6

94.4

94.5

0 20 40 60 80 100

FBSP

CBSP

Overall


issues during home visits and group meetings conducted by them as a part of their job

responsibility. This was important to ensure sustainability of efforts beyond the project time-

frame. Figures 25 and 26 present the details about participation of the service providers in

group meetings and home visits organised by PE/CC.

Figure 25: Proportion of service providers who attended at least one group meeting and those who participated in the home visits organised by PE/CC during the last three months

Overall, two-thirds of the service providers attended at least one group meeting organised by

PE/CC during the last three months. The proportion who participated in the home visits was

lower at 58 per cent. Community based workers such as Anganwadi workers and ASHAs

participated more in both group meetings and home visits as compared to the facility level

workers.

Figure 26: Average number of group meetings and average number of home visits organised by PE/CC in which the service providers participated in the last three months

64.7

68.7

66.2

52.7

65.9

57.6

0 20 40 60 80 100

FBSP

CBSP

Overall

Participation in Home visits Participation in Group meetings

5.0

5.0

5.0

8.4

8.0

8.2

0 2 4 6 8 10

FBSP

CBSP

Overall

No. of times gone for home vists No. of Group meetings


On an average, a service provider attended five group meetings and eight home visits

organised by PE/CC in the last three months, with no significant difference between facility

based and community based service providers.

Performance of Service Providers

As noted earlier, service providers such as ANMs, Anganwadi workers, ASHAs and the

Mamtas are the people who are expected to be responsible for sustaining the impact of the

project beyond the project timeframe.

Figure 27: Proportion of service providers who have arranged at least one group meeting on IYCF in the past 3 months

Figure 28: Proportion of service providers who have undertaken home visits in past 3 months for giving IYCF related messages


It was found that the service providers were getting more involved in organising group

meetings and home visits, as a part of their own job responsibility, to promote optimal IYCF

practices (Figure 27 and Figure 28). Nearly two-thirds of the service providers have been

organising group meetings and home visits for this purpose. Before the project intervention,

only about one-third of the service providers were doing so. It was also found that

community based service providers such as Anganwadi worker and ASHA were more

successful in organising these activities aimed at promoting optimal IYCF practices than

facility based workers such as ANMs and Mamtas. Table 25 provides the details about the

average number of .group meetings and home visits organised by the service providers in

the past three months.

Table 25: Average number of group meetings and home visits conducted by service providers in the past 3 months

FBS CBS Total

BL EL BL EL BL EL

No. of group meetings on IYCF in past 3 months 12.3 7.1 3.5 8.7 7.0 7.7

Average no. of members present in a group meeting 20.8 26.6 19.3 20.1 19.9 23.9

Average no. of home visits undertaken in past 3 months for giving IYCF related messages 22.4 34.4 24.2 42.8 23.6 38.2

Note: The “average” here refers to the arithmetic mean. The denominator takes into account only those health workers who said that they conduct group meetings or undertake home visits (as the case may be).

On an average, about eight group meetings were organised by a service provider. While the

number of meetings organised by community based service providers registered an increase

from the baseline figures, it declined in the case of facility based workers. However, the

attendance of women in the group meeting showed an increase in both cases. The project

appears to have influenced more in increasing the frequency of home visits than in

organising group meeting. The number of home visits organised by the facility based and

community based service increased significantly.

Another important platform for counselling women on optimal IYCF practices was the health

facility where delivery takes place. Counselling could be on early initiation of breastfeeding

and on exclusive breastfeeding. Obviously, such an option is available only to the facility

based service providers such as ANM and Mamta and not for Anganwadi worker and ASHA.


Table 26: Performance of facility based service providers on counselling postpartum mothers on IYCF issues in past 3 months

Indicator Baseline Endline

Proportion of service providers who are posted in health facility where delivery takes place 26.8 16.6

Proportion of service providers who attended a delivery in the health facility where they are posted 21.6 18.2

Proportion of service providers who counselled at least one mother in the last 3 months on initiation of breastfeeding 21.6 17.6

Proportion of service providers who counselled at least one mother in the last 3 months on exclusive breastfeeding 16.5 16.9

Proportion of service providers who had attended a delivery who counselled at least one mother in the last 3 months on initiation of breastfeeding 100.0 96.5

Proportion of service providers who attended a delivery who counselled at least one mother in the last 3 months on exclusive breastfeeding 76.2 93.0

No. of facility based service providers 194 313

Table 26 indicates that the proportion of health workers posted in a health facility where

delivery has taken place in the last three months has actually declined over the project

period. Consequently the proportion of service providers who attended delivery and who

counselled a postpartum mother also witnessed a decline. But almost all the health workers

who attended a delivery in the last three months counselled the postpartum mother on early

initiation of breastfeeding.

Proportion of community/facility based health / nutrition functionaries who have conducted

IYCF counselling sessions with mothers/care-givers was an output indicator of the project.

As noted earlier, ‘counselling sessions’ in the context of the project refer to a) group

meetings conducted to discuss IYCF issues b) home visits undertaken to discuss IYCF

issues c) counselling on initiation of breastfeeding provided to a postpartum mother at a

health facility, OR d) counselling on exclusive breastfeeding provided to a postpartum

mother at a health facility. We have noted that the proportion of service providers who

attended group meetings and home visits have gone up from the baseline stage. Proportion

of health/nutrition functionaries who counselled postpartum women also increased. Figure

29 presents the proportion of service providers who conducted at least one type of

counselling session on optimal IYCF practices.


Figure 29: Proportion of service providers who have conducted at least one type of counselling on optimal IYCF practice

Overall participation of service providers in the counselling sessions on IYCF has increased

significantly from the project initiation stage. At the end of the project period, four-fifths of the

service providers had conducted at least one type of counselling session.

Summing Up

End line study indicates that the project has effected behavioural change among the target

groups viz., pregnant women and lactating mothers. There has also been changes in the

way the community based and facility based service providers (ANMs, ASHAs, Anganwadi

workers and Mamtas) perform their role in promoting optimal IYCF practices. Before

concluding this discussion, we present the achievements of the project on status of the

outcome and output indicators of the project against the targets proposed to be

accomplished at the end of the project period (Table 27).


Table 27: Targets and Achievements of the Project

Indicator Project

Baseline (%) Project

Target (%) Achievement

(%)

Outcome Indicators Early Initiation of Breast feeding (Proportion of mothers

with newborns less than 7 days old who report having breastfed their newborns within one hour of birth) 17.4 60 65.2

Exclusive breast feeding (Proportion of mothers with a child 6-7 months of age who have exclusively breastfed their child for at least six months) 15.2 40 49.5

Complementary feeding (Proportion of mothers with a child 6-7 months of age who have introduced complementary feeding for their child) 73.4 85 87.7

Complementary feeding (Proportion of mothers with a child aged 12-13 months who are giving age appropriate complementary feeding for their child) 19.8 35 42.9

Output Indicators Proportion of women in the last trimester of pregnancy

who can cite ideal time for initiation of breastfeeding. 23.2 70 72.8

Proportion of mothers of children 3-4 months of age who can cite at least 3 advantages of exclusive breast-feeding 12.4 60 64.6

Proportion of community/facility based health / nutrition functionaries who have the correct knowledge regarding IYCF practices 37.3 60 71.3

Proportion of community/facility based health / nutrition functionaries who are conducting IYCF counselling sessions with mothers / care-givers 46.5 75 79.1

Table 27 clearly indicates that the achievements of the project exceeded the target fixed for

each of the outcome and output indicators. Project’s success in making behavioural change

among the mothers of infants and young children on optimal IYCF practices is evident. It is

also evident that the project was successful in building capacity and knowledge of the

community based and facility based health/nutrition functionaries. This, in turn, can lead to

long-term sustainability of the project benefits.


6.0 Findings - Focus Group Discussions and Interviews

Introduction

Reliance on multiple sources of information is one of the key requisites of any such

evaluations. While the household survey of pregnant women and mothers and the survey of

service providers used the quantitative study tools, the findings were validated through

qualitative studies. It was also important to understand the effectiveness of project planning

and management, relevance of the project design and perceptions of beneficiaries regarding

impact. Outcome indicator like the ‘perception of mothers regarding influence of the

contacts by PEs/CCs in improving their knowledge and practice for providing optimal

complementary foods to the children’ and output indicators like the ‘perception of mothers on

the usefulness of PEs' visits for problem solving in improving the compliance towards

optimal IYCF practices’ and ‘perception of community/facility based health/nutrition

functionaries with respect to impact of project intervention on their work (in the context of

IYCF counselling)’ were also to be assessed. Qualitative study through FGDs and Key

Informant Interviews tried to capture information required for such an assessment. Different

categories of stakeholders were approached through specific guidelines or semi structured

questionnaire for each of them.

Pregnant Women and Mothers

Knowledge about the project: Every pregnant woman and mother within the target groups

in the villages visited were aware about the project Buniyaad. It is not that all of them

mentioned the name Buniyaad, name of the implementing partner or Aga Khan Foundation.

In fact, most of them relate it with the visit of PEs and the messages on child care and

feeding. FGDs in general pointed towards their understanding that the project was there to

help their children become healthy and free from diseases. In a few cases, they could not

differentiate between the project and activities of the service providers. As one of them

commented:

‘Whenever the Anganwadi worker, ASHA or ANM visits the hamlet or household, the ‘sister’

(PE) is there with them. She is there during immunisation and also in the meeting at the

centre (referring to VHSND – Village Health, Sanitation and Nutrition Day)’.

Knowledge and understanding on IYCF: Three basic tenets of IYCF are early initiation of

breastfeeding, exclusive breastfeeding until six months and complementary feeding after six

months. Everyone in focus groups seemed to be aware about these tenets and their


importance in the health of children. Level of knowledge and understanding on each of the

tenet varied. All of them were aware of the need for early initiation. They knew that

colostrum feeding within one hour is very important. Knowledge on exact benefits varied

among the group members, but overall understanding that the colostrum feeding is important

for the health of the child and it provides immunity to the child was consistent across the

groups.

Many such messages on various aspects of IYCF through different media and agencies are

imparted to the communities. However, why did they accept this message on early initiation

of breastfeeding? The following comment in one of the FGDs (repeated in different words in

all the FGDs) is worth noting:

‘PE came before the child birth and explained a little bit. At that time, I just heard, not really

listened or cared too much about it. But she came just before the child birth, she was there

with me during the delivery and immediately after that’.

It clearly points to the importance of interpersonal communication and repeated visits to

reinforce the knowledge so that behaviour is also impacted. This seemed to be followed up

by members of the community by sharing among relatives and neighbours, leading to a

snowball effect.

They were forthcoming to give anecdotal evidences too, which seems to have been a

motivation for behaviour change among others. As one of them puts it:

‘My eldest child (now 4 years) had been regularly taken to the doctor for some illness or the

other. He was always ‘patla’ (lean) and was not even taking food properly due to illnesses.

This time things are different. Only very rarely she gets ill, that too only ‘running nose’

because of the weather’.

They feel that the household and the community also understand the importance of early

initiation of breastfeeding. As one of the FGDs pointed out:

‘Men folk do not know anything about such things. Usually it is the mother or mother-in-law

or any elderly woman in the family or neighbourhood who advices or guides us. They also

know about early initiation. But there are certain religious practices or norms which force to

delay initiation of breastfeeding. However, religious leaders and community elders have

started understanding and they are now supportive’.


Knowledge about exclusive breastfeeding was there but a few of them still had

apprehensions. They are worried about the health of the child in situations like ‘limited or no

breast milk’, injuries or sores over the breast and nipple, ‘child cries because s/he is hungry’

etc. During such times, the pressure from other household members also mounts which

they find difficult to ignore. However, the constant efforts from PEs helped these women

overcome the pressure and make meaningful choices. In one of the FGDs the following

comment came up:

‘We used to look at baby’s stomach and always felt that the breast milk will not be sufficient

to fill that stomach. Initially it was hard to believe or accept that the size of the ‘real’ stomach

was as small as was shown by the PE’.

In case of complementary feeding, level of knowledge and understanding seemed to

decrease. Of course all of them were aware about the need for complementary feeding after

six months. The issue was with the knowledge about frequency, quantity and quality of

complementary feeding. They acknowledged the various demonstration sessions held by

the PE with the kit. It had spoons and vessels of appropriate size to demonstrate the

quantity.

‘It is not always possible to measure and give. We want to give our children good food, but

what we give is what we have’.

Another tool which they found very useful was the growth card. It gave them an idea of the

growth of the child and gave an indication ‘if something is wrong’ with the child.

They were aware that the quality of food was not always about the price of the items. Many

low-cost food items are available locally. However, in the cases of a few mothers, various

household chores and even wage labourthey had to undertake prevented them from

planning for appropriate food.

The group was also appreciative about the information and knowledge shared by PEs on

immunization. Family planning including spacing did not seem to be a key message

imparted through the project. Rather, they mainly attributed such messages to the ASHAs

and ANMs.


Peer educator visits and group meetings: As mentioned earlier, all the groups

acknowledged the regular home visits of the PEs.However, the number of such visits

reported varied from three to even eight in certain cases. In one of the FGDs they even

mentioned that the PE holds even five meetings in a month. These did not match the

proposed schedule of visits in the project activity plan. On further enquiry, it was clear that

the focus group members could not differentiate between a formal house visit as part of the

project, visit to the neighborhood houses, visit along with Anaganwadi worker/ASHA and

group meetings. Since PE belongs to the area, it was also difficult for the households to

remember and differentiate her visits to their hamlet and households. It also had the recall

period bias. The focus groups were unanimous that the PEs visited them just before and

after the baby was born, weighed them from time to time and ensured post-natal care.

Role of PEs and CCs: In general the focus groups were clear about the roles of PEs and

CCs. They were to give information on child health and feeding, keep a regular check on the

infant's growth, convince those households which either neglect or face difficulties in

following optimal IYCF practices, and guide mothers who find difficulty in feeding the child

with the help of various tools and techniques. PEs and CCs were also meant to work with

service providers, assist during immunization sessions and organize community meetings.

Problem solving: Mothers face problems at various stages of feeding. In the early initiation

of breastfeeding, the problems such as ‘lack of milk, baby is not sucking properly, baby is

weak’ etc. came to the fore. Appropriate advice and guidance by the PEs have been

acknowledged by the mothers who participated in the focus groups. During exclusive

breastfeeding, apart from these, injuries and sores on the breast and nipples, illnesses of the

child, ‘weak child’, ‘child is hungry as it cries’ etc. were the usual problems. While the

guidance by the PEs and in certain cases CCs were acknowledged, the mothers felt that

they had to go to the doctor too. This was especially the case with problems of the breast,

weak child and illnesses of the child. Earlier, the local doctors (later identified that many of

them were untrained ‘quacks’ who were practicing medicine in villages) used to suggest and

promote baby food but now they do it less. Even if they suggested, rarely the mothers

bought baby food as they had clearly understood that such foods were not good. All the

participants in the focus groups said that they did not buy baby foods.


Gender concerns: The groups confirmed that the communities have preferential treatment

for boys, though the trend has been decreasing. Discrimination extended to the feeding

practices as well; however, the project interventions through interpersonal communication at

the household level helped in reducing it to some extent. Differential treatment was worse

in cases where there was more than one girl child for the parents.

FGDs with the pregnant women and mothers also tried to see their rating of the importance

of IYCF indicators on a scale of 1-10, 1 being the least important and 10 the most. One

such set of ratings is given below. The group felt that colostrum feeding and complementary

feeding were the most important aspects to be considered, closely followed by the need for

exclusive breast feeding until 6 months.

Table 28: Rating by pregnant women and mothers on IYCF indicators

This was also done through an evaluation wheel tool of Participatory Rural Appraisal (PRA).

Figure 30: Evaluation Wheel Tool on IYCF indicators by pregnant women and mothers

Indicator Rating

Colostrum feeding or feeding the child within 1 hr of the birth 9

Exclusive Breast Feeding till 6 months 8

Complementary Feeding along with mother's milk after 6 months 9

Cleanliness 5

Assurance of good health and proper care of infant during illness

like diarrhoea.

1

Non-discrimination between a girl child and a boy child on the basis

of feeding practices

6

Other aspects related to health, vaccination, family planning etc. 6


Peer Educators and Cluster Coordinators

There were 500 Peer educators and 132 Cluster coordinators who were the key interface of

the project with the stakeholders. Moreover, interpersonal communication which was a

major element of behavior change communication, took place through them under the

project. FGDs were conducted separately for PEs and CCs. Since the main points

discussed and the responses received were similar, the findings are reported together.

Knowledge on IYCF: Both the PEs and CCs were well versed with all the key tenets of

IYCF. All of them brimmed with confidence while explaining these in the focus groups. They

were clear about various aspects of IYCF like Kangaroo care, colostrum feeding, early

initiation, exclusive breastfeeding and complementary feeding. Knowledge about routine

immunization and general understanding about nutrition were evident among them. They

were also able to mention the various problems mothers face in practicing IYCF, including

the social, cultural, economic and gender issues.

Role in promoting IYCF practices: Both the PEs and CCs were clear about their roles.

They had to provide up-to-date knowledge on IYCF, motivate the mothers to practice them,

and create awareness about pre- natal care and post- natal care and care of the child.

Ensuring early initiation of breastfeeding, exclusive breast-feeding and complementary

feeding were their priorities. This was done through house visits and group meetings. Prior

to this, they prepared a list of pregnant mothers and categorize or group them.

Promoting IYCF practices: PEs paid regular home visits on 7th, 15th, 30th, and 60th day of

the new born. All of them were meticulous in visiting the mother and child right after the birth

of the child. They were even posted at the health centers where delivery takes place to

ensure early initiation of breastfeeding and explain to the mothers and care givers the

importance of colostrum feeding. Apart from this, they organisedfivegroup meetings of the

pregnant women and mothers at different stages. During these visits and meetings,

importance of vaccinations was also discussed. In addition, organizing ‘Baby shows’

seemed to have also contributed to the adoption of IYCF practices by mothers. Generally

there had not been much resistance from the households for approaching them as the PEs

were from the neighborhood. By the end of the project, all households knew about the

project and the messages given.


Addressing problems: As mentioned earlier, addressing problems faced by mothers in

IYCF practices was anothercrucial role played by the PEs and CCs. According to the

PE/CCs, it was not just lack of awareness or knowledge that prevented mothers from

practicing IYCF, there also were other‘genuine’ issues related to health of the mother and

child, issues related to perception of mothers about child nutrition, lack of confidence in

practicing what they learnt, pressure from the family members, inability to change the

behavior were also issues, etc. These were addressed through repeated visits and

motivation. Demonstration using the kit provided has also been very helpful. In the case of

health related problems, guidance and reassurance along with promotion of IFA tablets and

other nutritious supplements proved to be useful. They provided special home visits to those

mothers who underwent some kind of problem while practicing breast-feeding. In cases of

difficulty, the visit of CCs were also organized. However, it was difficult for the project staff

to be sure if the mothers practiced exactly as they had demonstrated once they leave the

house. This was especially a concern in case of complementary feeding and to some extent

in exclusive feeding. Early initiation seemed to be practiced better by the mothers.

Family planning and IYCF practices: PEs and CCs were also mandated to provide

information and messages on family planning. Their role was to make mothers aware of the

various family planning measures and encourage them to have a gap of at least 3 years

between two children. This was to be explained in the context of IYCF. Though they

mentioned that the message on family planning was provided, it was also clarified that they

did not follow up to see whether it was practiced. They felt that the ASHAs and ANMs were

already doing this.

Promotion of hand washing: Discussion on proper techniques of washing hands before

eating and after toilet were held during house visits and group meetings. PEs demonstrated

the appropriate way of hand washing. They encouraged women to prefer soap for hand

washing. They emphasized and encouraged the mothers to wash their hands and clean

their breast before feeding the child. While everyone agreed on each of the points

mentioned, the practice did not pick up at the scale on which the three main tenets of IYCF

were practiced. It is also a fact that the follow up by the PEs and CCs was more towards the

main three tenets of IYCF than other practices mentioned above.


Tools for BCC: PEs were provided with a set of tools for BCC. This included Flip book

which contains pictorial representation on how to carry proper breast feeding practices, a

doll to give a live demo to the mother, routine immunization chart, which also included

various vaccines, a weighing machine and MCH Card or growth card. According to the PEs

and CCs, this set of tools were very useful to make the mothers understand better. They felt

that this kit of tools was one of the key factors that contributed to the success of the project.

Trainings: CCs and PEs were appreciative of the various trainings they had undergone. It

built a good understanding among them about the project and provided insights on how to

win the confidence of mothers and other caregivers, and convince them. CCs were also

trained on reporting and monitoring. They mentioned being interested in getting further

trainings but many of the PEs were apprehensive of what they would do with all the

knowledge and experiences gained once the project is over.

Gender concerns: PEs and CCs also reported on the gender differences in IYCF practices.

A situation cited is as follows:

‘Family where there were 2-3 kids out of which two were girls. The fourth was a girl child.

She was not given proper care as the family believed that even government does not assure

any kind of cash benefits in such cases’.

Though the discrimination was not found on a massive scale especially in IYCF practices

since the beginning of project intervention, still gender discrimination persists in a few

households.

Table 29: IYCF indicators and rating (on 0-10 point scale) by PEs and CCs

Indicator Rating

Colostrum feeding or feeding the child within 1 hr of the birth 7

Exclusive Breast Feeding till 6 months 6

Complementary Feeding along with mother's milk after 6 months 5

Cleanliness 3

Assurance of good health and proper care of infant during illness

like diarrhoea.

2

Discrimination between a girl child and a boy child on the basis of

feeding practices

0

Other aspects related to health, vaccination, family planning etc. 6


Above self-rating on the importance of IYCF indicators (Table 29) was done using evaluation

wheel tool of Participatory Rural Appraisal (PRA). It again showed that the PEs and CCs

considered colostrum feeding, exclusive breast feeding until 6 months and complementary

feeding after 6 months as the most important practices to be adopted.

Service Providers

Health and nutrition workers (service providers) are classified as Community based health

and nutrition functionaries (i.e. ASHAs and AWWs) and Facility based health functionaries

(i.e. ANMs and Mamtas). Key Informant Interviews were carried out with them to

corroborate the findings of the quantitative survey conducted with this cadre and to

understand their perception with respect to impact of project intervention on their work (in the

context of IYCF counselling).

Knowledge about the project: They were found to be well aware about the project

Buniyaad, including its objectives and various activities. They knew the implementing

partners and the Aga Khan Foundation. They also were very well aware about the various

PEs and CCs working in their area.

Knowledge about IYCF: Service providers were found to have a good understanding on

IYCF and its three main tenets. They had fair knowledge about the nutritional benefits of

colostrum feeding. While they had some knowledge about quality, quantity and frequency of

feeding, but when enquired,

they could not provide

specific details about quantity

and quality. As one of them

puts it:

‘Though we have been given

training on these by our own

department, it was not so in

depth as it is in Buniyaad.

Moreover, we are tied with

many activities and many

messages. So we cannot

focus on any specific message like IYCF. In fact we learnt a lot through Buniyaad’.


Role of PEs and CCs: As per the service providers, CCs and PEs played an important role

in approaching people. Since they were very focused on IYCF it was easier for them to

regularly contact people and influence. CC co-operated in counseling and motivated the

mothers and care givers when they were not convinced by the ASHA and AWW. CC came

on VHSND and helped in filling the registers and counseling sessions. They also

acknowledged that PEs and CCs gave information on matters they did not know. They had

been very helpful in monitoring many of the issues the service providers had to carry out.

Activities of the PEs and CCs have been useful to them as their own achievements in terms

of various targets could be made possible. For instance, as a result, both immunization

status as well as institutional deliveries improved in their areas.

Problem solving by PEs and CCs: Service providers felt that various problems related to

IYCF cannot be addressed by them because of multiplicity of tasks, larger area and

population to be covered and distance. However, PEs and CCs were able to address

individual cases much better and service providers pitched in when there was real need.

They knew that in such problem cases, special visits to these special mothers were made by

PE where they helped the mothers by telling and teaching them about how to feed the weak

babies. Regular visits to those special mothers and child and monitoring the growth of child

improved the situation. However, PEs and CCs themselves felt that ‘unless and until the

beneficiaries consult a doctor, they don't get relief as such by the suggestion given by PE’.

In certain cases, PEs called the service providers to instill confidence in mothers.

Impacts: Service providers mentioned that changes were clearly visible in the field.

Awareness levels had gone up among the mothers regarding IYCF as well as various other

aspects of mother and child care. They also felt that the mothers started seeking services of

service providers more than they used to do earlier. This was especially true of ante natal

care, IFA tablets, immunisation etc. Their own records showed that the various targets on

these aspects have been achieved well than prior to the project. Their own activities

improved in terms of quality as they now possessed in depth knowledge, and PEs helped

them to reach the households. One of the ANMs mentioned:

‘Earlier when we went to households it was difficult to motivate them. But now they know

many things and also there is demand from their side to know more and get facilities from us

like IFA tablets and immunisation. So, we also feel motivated to go to the households’.

This statement seems to be very important to understand how the project Buniyaad’s

approach to focus on demand side has contributed to the improvement in supply side.


Doctors and Health Managers

Key informant interviews (KIIs) were done with at least one doctor or NRHM Health Manager

in each of the IP areas. They had good knowledge about the project Buniyaad,

implementing partner and Aga Khan Foundation, and were also aware about the objective of

the project, which was to increase and strengthen Infant and Young Child Feeding (IYCF)

practices. With regard to the role of the project, one of the managers mentioned thus:

"Is pariyojna ne aag main ghee kakaamkiyahai" (the work done by this project is like putting

ghee into fire!)

All of them felt that the level of awareness on IYCF has increased in the community as well

as among service providers. Functioning of ASHAs and MAMTA has also been

strengthened and improved during the process. It was acknowledged that considering

service providers as secondary stakeholders in the project helped the government system to

improve. In fact, when the project was launched there were apprehensions among the local

service providers like ASHAs whether the PE and CC would replace them. But with time,

they all worked together in coordination towards a common goal. One of the managers was

also impressed with the monitoring system of Buniyaad and as a result he too introduced the

same in their HMIS.

Doctors and managers mentioned that the PEs and CCs played an active role in introducing

IYCF practices. They delivered key massages of IYCF within the target community and

supported in counseling mothers for early initiation of breast-feeding. PEs and CCs also

played a critical role in monitoring the work of ASHAs and MAMTA. They also supported in

VHSND. Doctors and managers also shared their apprehensions that having made

significant improvements in IYCF practices if the project is withdrawn at this stage there are

chances of target community going back to the earlier stage of behavior with respect to

IYCF.

Community Leaders

There are elected members of the Panchayats (local government) and also local opinion

leaders in the villages. Interviews with a few of them revealed that they were aware about

the project and its objectives. Many of them had watched the healthy baby show and also

attended a few meetings organized by the project. They felt that there was better awareness

about IYCF in the community. One of them said that a meeting on breast feeding was

organized in the Panchayat and PRI members discussed this issue in their own meeting.

However, they felt that by themselves it was not possible to carry forward the initiative and

required further support. They felt that it would have been better if there were such regular

meetings with PRIs.


Religious leaders and priests too have a major role in many of the social norms. Interviews

with a few of them revealed that they were aware about the project. Their support seemed

to be useful in the success of the project. The system of Ajaanafter birth could have delayed

early initiation of breastfeeding, but the religious leaders (having become aware about IYCF)

have been forthcoming to have the Ajaanas early as possible so that early initiation was not

affected. One of the religious leaders even said:

‘I do preach the community during sermon about breastfeeding but not sure people are

practicing as these are related to female members who would not be attending my sermon’.

Grand mothers

It was understood from the field studies that grandmothers played a major role in deciding

the feeding practice of infants and young children. Thus, key informant interviews were held

with a few of them. They did know about the project and had knowledge about various

tenets of IYCF.

Men

Study team felt that the husbands and other male members of the community need to be

interviewed to understand their knowledge and attitude regarding the project and IYCF.

Except for the two husbands whose children were within the project age group, others do not

know much about the project or IYCF. A couple of them commented that ‘those who

received spoon and bowl from her (PE) only could recognize her’. They were not able to

differentiate between service providers and PEs. ‘We do not know whether she comes here

or not as she contacts only women’. One of the fathers mentioned that ‘situation has

improved, children are not frequently falling sick and their body growth is also ‘proper’.

Immunization sessions have also become regular. Situation may reverse when project

closes as they do not have faith on AWW and ASHA.’

They also suggested that the project should also discuss about diarrhea because most of

the mothers stop feeding their children during diarrhea.PE should approach men too and

educate them.


The following Table 30 summarises the findings which is compared with the relevant

outcome and output indicators.

Table 30: Summary of the findings

Outcome/Output Indicators Target Observation based on qualitative data




Knowledge and information regarding complementary feeding of child has increased due to the PEs/CCs.

Through demonstration using BCC tool kits, PEs/CCs were able to improve the knowledge of mothers regarding optimal complementary foods to the children. In fact, they were the only source of knowledge regarding this.

PEs provide support and motivation, but practice has other determinants and not always adhered to, especially regarding quantity, quality and frequency.

PEs were also able to influence mothers in addressing gender discrimination in complementary feeding, though not in its entirety.

Output 1: Pregnant women, mothers of children under two years of age and other care-givers in the family have the appropriate knowledge and develop requisite skills to follow the recommended IYCF practices, through the messages and assistance imparted by peer educators in selected blocks of three districts of Bihar



Mothers acknowledge the usefulness of PEs and they trust them.

They are able to share their problems with PEs

Regularity and effectiveness of PEs in problem solving is wanting.

PEs were able to influence mothers for early initiation, exclusive breast feeding and complementary feeding even when there were problems.

For certain problems which are related to health conditions of mother or child, they did prefer to meet local health service providers.




Govt. Field / office based functionaries realize that there is a positive impact on IYCF practices.

There is clear change in early initiation of breastfeeding.

Service seeking behavior of mothers have changed and they are forthcoming in seeking services like immunization, ante natal care, IFA tablets etc.

Immunization status and institutional deliveries have increased.

There is increased acceptance of their work and services by the communities.


7.0 Key Observations

Beyond the Numbers and Targets

Before moving to understand and learn from the findings of the field studies, it would be

useful to recap the background and context in which the project Buniyaad was launched.

The project had chosen 20 blocks in the three districts of Muzaffarpur, Samastipur and

Sitamarhi in Bihar. These are areas which are comparatively less developed than many

other districts in India in terms of human development. Literacy and education levels are low

and poverty level high.

Despite being a large project in terms of area and coverage, it had to be set up from the

beginning and was never an off shoot of an existing project or activities. And launch to

closure had to be completed within three years. This is an issue as many questions would

have been raised by the communities, especially because people have different perceptions

about NGOs in various parts of the country. There was nothing tangible to offer like any

facilities, infrastructure or the like. Government programmes do have components on

maternal and child health including nutrition and IYCF. So, what was the value addition the

project would bring in? How does one explain to the people and the government

functionaries? The latter at the field level would have been apprehensive as the thematic

and geographical areas are within their domain and the project intervention with its own

human resources at the field level could be treated as ‘threat’ to the frontline service

providers.

The project was designed as a behaviour change communication initiative to bring changes

in the behaviour of the target population. While it is possible to build awareness and impart

knowledge, changing the behaviour within a short span of three years had been a challenge.

Moreover, it was a large initiative covering 50 lakhs population and directly approaching four

lakhs women in the villages. As interpersonal communication was the key tool used which

required to address each of the beneficiaries on one-to-one basis, monitoring and ensuring

compliance would have also been a major challenge. Apart from this another issue was that

there were five cohorts, the constituents of which were ever changing. It is also important to

note that changes in behaviour related to feeding and nutrition as well as improving the

health status of a population is dependent on other various determinants. Many of them are

externalities for the project.


Targets achieved vis-à-vis log frame indicators

As mentioned elsewhere in the report, the project Buniyaad has been successful in covering

400,000 women across 20 blocks in Bihar. As the household survey and the qualitative

studies suggest, there has been definite improvement in knowledge levels of pregnant and

mothers of children below 24 months regarding IYCF practices. Apart from the knowledge,

there is remarkable change in behaviour too as they have been practicing the three tenets of

IYCF– early initiation of breast feeding, exclusive breastfeeding until 6 months and

complementary feeding after six months. While the study has not gone into the changes in

health status of children, there are anecdotal evidences to suggest these changes as well as

acknowledgement from the community regarding the overall influence of the project

intervention, especially IYCF, on child’s health. Table 27 indicates that the achievements of

the project exceeded the targets fixed for each of the outcome and output indicators. The

project’s success in making a behavioural change among the mothers of infants and young

children on optimal IYCF practices is evident. It is also evident that the project was

successful in building the capacity and knowledge of the community based and facility based

health/nutrition functionaries. This, in turn, can lead to long-term sustainability of the project

benefits.

Knowledge and information regarding complementary feeding of child increased due to the

PEs/CCs. Through demonstration using BCC tool kits, PEs/CCs were able to improve the

knowledge of mothers regarding optimal complementary foods to the children. In fact, they

were the only source of knowledge regarding this. PEs provided support and motivation, but

practice has other determinants and not always adhered to especially regarding quantity,

quality and frequency of complementary feeding. PEs were also able to influence mothers in

addressing gender discrimination in complementary feeding, but not in its entirety.

Mothers acknowledge the usefulness of PEs and they trust them. They are able to share

their problems with PEs. Regularity and effectiveness of PEs in problem solving is wanting.

PEs were able to influence mothers for early initiation, exclusive breast feeding and

complementary feeding even when there were problems. For certain problems which are

related to health conditions of mother or child, they did prefer to meet local health service

providers.

Government field / office based functionaries realize that there is a positive impact on IYCF

practices. They feel that there is clear change in early initiation of breastfeeding. Service

seeking behaviour of mothers have changed and they are forthcoming in seeking services

like immunization, ante natal care, IFA tablets etc. Immunization status and institutional


deliveries have increased. There is increased acceptance of their work and services by the

communities.

The bottom line drawn from the project Buniyaadis that behaviour change communication

works and that communities can be mobilised forIYCF practices with success.

Strategy vs Achievement

Strategy of the project was to have demand side interventions. However the study shows

that these interventions have contributed to the increase in demand as well as improvement

in supply. Thus it had contributed to supply side responses too.

One of the interventions was on addressing the problems that mothers face in IYCF

practices. While this has contributed in ensuring IYCF practices by mothers, PEs alone

could not address all such problems. Issues of gender discrimination in child feeding was

also addressed and there is increased awareness about the issue among the mothers. It

was definitely beyond the mandate of the project to address other determinants like income

levels and poverty which would also be factors which prevent appropriate IYCF practices.

However, the project interventions were able to influence social norms and culture, which is

a major achievement.

The project used various BCC tools which have proved to be useful and successful.

Considering the fact that the main activity was based on interpersonal communication, the

project has been human resource intensive. However, it had also mobilised the existing

service providers and built their capacities too.

Project Structure

The project, as reported, is human resource intensive but considering the number of

stakeholders to be covered through interpersonal communication required such a large

human resource. Highlight of the project management was the rigorous reporting and

monitoring system followed by feedback based action at all levels. There have been case

specific corrective measures. These seem to have contributed in a major way in achieving

the targets. However, the new indicators were introduced in the last year which seemed to

have missed the attention of the Implementing partners. In general, IPs played a major role

in the overall management of the project in the districts.


Beyond the Indicators

The project activities were planned and rolled out across all districts in the same manner.

This in a way contributed to the time bound execution of the project and monitored to

achieve the results. However this had also prevented the possibility of any innovative

approaches and activities at the local level.

In each of the parameters there were inter district differences. These differences were

generally not statistically significant. A closer look at each of the parameters show that there

is no uniform trend in these differences. Thus, a district which would have been better in

one of the parameters would be lower in another. FGDs with IP team, CCs and PEs clarify

that these achievements change over time depending upon the cohorts and added initiative

taken by the respective IPs based on feedback on previous quarter report.

Buniyaad project had established a strong linkage with the service providers at the local

level and even upto the block and district. Local service providers – both community based

and facility based – were integrated into the project activities.

At the state and national level, the policy influencing activities were initiated towards the later

stages of the project. Evidences from the yearly reports and field reports were useful for

this. The final workshop on Best Practices in Infant and Young Child Feeding organised in

March 2015 brought together the experiences and learnings from other similar projects also.

This was expected to influence the government policies on IYCF and child health.

Can behaviour change of a community happen within 2-3 years is the question raised.

Buniyaad project seems to be an evidence. In fact, it also shows that if changes cannot be

brought about within this period, it would be even difficult to achieve it through a longer term

intervention.

Sustainability of such a resource intensive initiative is always be an issue to be addressed.

Of course, it would be difficult to take this initiative forward by the community themselves or

by the government agencies. But the experience from the field shows that the messages on

IYCF provided to the community have a snowballing effect.


What Worked

As we conclude that the project Buniyaad had been successful in promoting IYCF by

bringing about behaviour change, it is validated by the findings of the study and indicator

based achievements. In the following paragraphs, we highlight a few reasons for this

achievement.

Project design: The project seems to have been clearly conceptualised with no ambiguities

at any level. All the actors at all levels were clear about it. It had a thoroughly defined

strategy and operational plan. Responsibilities at each level were demarcated and followed

up. Meticulous planning helped in the operationalization of the project strategy.

Interpersonal communication: Household visits and face to face communication by the PE

from the locality was the key to behaviour change. Messages were very clear. These were

imparted regularly and repeatedly leading to reinforcement. Close follow up of individual

cases especially at the time of child birth and after, along with special problem-solving visits,

too were useful.

Focus: The project had focused on the three tenets of IYCF and never got diverted.

Monitoring: As mentioned elsewhere in the report, the monitoring framework and system

was well designed and managed with rigorousness. Regular reporting was followed up with

feedback and corrective measures on a quarterly basis at all levels.

Implementing partners: IPs played a major role. Each of them provided staff solely

dedicated to the project. In every quarter, achievements were scrutinised and corrective

measures were taken on a case to case and location basis.

Communication tools: BCC is heavily dependent on appropriate communication tools. The

various tools used, including the demonstration kit, were appropriate to the theme, context

and location. These were pedagogically appropriate. PEs and CCs were trained to use

these and they used them too.

Growth card: Special mention needs to be made about the Growth card of the child used as

a tool for BCC.

Service providers: Unlike many such projects, the government service providers were

included as part of the project design itself. Their capacity building on IYCF was also taken


up by the project. There was every effort to integrate the routine activities of the service

provider with the Buniyaad activities. This was mutually reinforcing.

Community: Engagement with community leadership including the PRI and religious leaders

was useful in addressing various community/religious practices detrimental to the IYCF

practices.

What could have been done

As in any similar initiative, there would be gaps and areas to be improved. A few of them are

narrated below:

Health status of children: Considering that the focus on IYCF was to improve the status of

health of children, the project activities could have worked on other determinants of health as

well (of course without deviating from the focus on IYCF). Importantly, its monitoring system

could have included outcome indicators pertaining to that. These would have been sources

of evidences for IYCF practices and behavioural change communication.

Data management: As part of its reporting and monitoring system, software based data base

was established and followed up with regular updation on a quarterly basis. This large data

base could have been used for understanding many other aspects of child care and health.

Public service providers: The project had close linkage with lower levels of service providers.

This did not seem to be the case with higher levels of public service providers for policy

influencing. Plans for integrating the project activities and approach with the public health

system would have been useful for ensuring sustainability. While there were attempts to

converge with the activities of initiatives like VHSND, these were not done as a systemic

change.

Community: Ownership of the initiative by the community through active and regular

engagement with PRIs, local CBOs and the like would have been useful for ensuring

sustainability. This is also applicable in the case of engagement with men.

Capacity building of PEs/CCs: The project had built the capacities of PEs and CCs on IYCF

and BCC tools. Considering the number and experience of them drawn from the local

communities, it would have been useful to train them on other aspects of health so that they

emerge as local health resource persons.

Exit/graduation plan: Considering that the project has been only for three years, an exit or

graduation plan would have been appropriate.


8.0 Recommendations

Though the project Buniyaad is coming to an end, there are certain activities which should

be taken up as an immediate follow up and a few which are to be considered if the

experiences and learnings are to be used for up scaling or replicating in any other area.

Immediate Follow Up

Sharing of Learnings: Within three years of intervention, the project Buniyaad has

developed a large pool of experiences and learnings on IYCF, child care and behaviour

change communication. It’s monitoring system, software package and communication tools

have also been very useful. These may be shared with service providers, governments at

state and national levels, private sector and with other development actors.

Policy Support: Learnings and experiences need to be compiled to develop policy briefs,

which could be used by the governments and for policy advocacy.

Knowledge Network: PEs, CCs and service providers in the project areas have been

capacitated through the project and their knowledge levels need to be upgraded regularly so

that the efforts put in so far are not wasted. This may be done through the formation of a

knowledge network for PEs, CCs and service providers.

Database: The project has developed a large data base which is great source of information

on IYCF and child health. The data base has information of around 400,000 mothers drawn

over a period of three years. Analysis of this data along with growth card based data and

the various secondary data should be done to build evidences for IYCF practices and their

linkage with child health.

For Upscaling or replication

Revised Strategy: In case of up scaling or relocation, it is would be useful to have a

programme directly linking IYCF with overall child health. Other determinants of child health

also need to be addressed while designing the strategy. Major focus should be IYCF and

with BCC approach.


Impact of IYCF: In project Buniyaad, there were anecdotal evidences which were used to

emphasise the impact of IYCF on child health. However, in a future intervention, evidences

should be generated on IYCF effectiveness on child health. Documentation and research on

Buniyaad experiences itself could be used as evidence.

Mother’s Health: Focus has been mainly on IYCF and mother’s health needs to be

highlighted. BCC should include tools to address this.

Human Resources: Not always does one get an opportunity for large scale human

resources for such initiatives. So, plans have to be made on how to integrate service

providers with the project so that it becomes less HR intensive. Based on the experiences

from Buniyaad, policy briefs may be prepared on this.

Problem Solving: This requires improved strategy. Linkage with local and higher level

service providers and institutions is important. Specific problems require professional

support.

Community ownership: Ensuring community ownership through active engagement with

PRIs, religious leaders, CBOs like women’s Self-help Groups etc. need to be emphasised.

Role of men in bringing about behaviour change also should not be ignored especially in the

overall health status of the child and mother.

Institutionalisation: An institutionalisation strategy with an exit plan should be there while

designing the project so that sustainability is ensured. This should consider community

ownership, linkage with local service providers and higher levels of health care service

providers. Ensure active involvement of higher levels of service providers and policy makers

from the beginning of the project itself.

Local Service Providers: A system of mentoring of service providers could be initiated and

set up within the health care system as a follow up of the project Buniyaad.


9.0 Limitations

The endline evaluation did try capture all key elements of project Buniyaad. However, there

are also certain limitations to this exercise:

• Shortage of time for detailed training of field investigators, cross checking and

analysis, especially for causal factors

• There could be respondent bias as group meetings were organised with the help of

local IP support as the interview teams were new to the locations which are rural and

remotely placed.

• Possibility of recall bias as questions are, in a way, leading questions.

• Evidence on ‘practice’ cannot be validated within a short time and by survey and

FGDs. It requires close and longer term observation.

Endline evaluations usually face the problem of lack of support and availability of personnel

with complete knowledge and information regarding the project as the project staff are on the

verge of leaving the project. Their motivation also gets affected as it is the project closure

stage. However, in the end line evaluation of project Buniyaad, the project personnel at all

levels – SPMU, IP, PEs and CCs actively supported the evaluation team in providing

information and facilitating the activities.


Annexures

Annexure 1: Terms of Reference

Aga Khan Foundation

Health Program

Terms of Reference for Project End Evaluation for Infant and Young Child Feeding Project,

Buniyaad in Bihar

Introduction and Background Aga Khan Foundation, India (AKF, India) in collaboration with three other Non-government partners

is implementing a UKAid supported Buniyaad project in three districts of Bihar with the goal to

reduce infant and neonatal mortality by ensuring uptake of optimal Infant and Young Child Feeding

(IYCF) practices. Buniyaad is a three year project (April 2012 to March 2015). As IYCF is

independent of provision of health services (i.e. the “supply side), the project is focusing on “demand

side” interventions by developing a Behaviour Change Communication (BCC) model that will enable

women to follow the recommended practices.

Coverage and Target Group

The project is being implemented in selected 20 blocks of Muzzafarpur, Samastipur and Sitamarhi

district. These blocks have been chosen as the demographic details suggested that they include a

larger proportion of the poor and marginalised populations compared to other blocks in the districts.

The overall population covered in the selected blocks of all three districts is over fifty lakhs. The

target of the project is pregnant women and mothers of children under two years of age. The project

will reach out to 400,000 women with BCC messages on the three tenets of IYCF (early initiation of

breast feeding and exclusive breastfeeding and complementary feeding) in its lifetime.

Implementation Structure

The BCC activities are being rolled out through 500 project supported Peer Educators (PEs) and 132

PE supervisors called the Cluster Coordinators (CCs) whose main job is to counsel mothers and

caregivers about recommended IYCF practices and help them overcome the barriers to the same. The

PEs counsel the pregnant women and mothers largely through pre-structured group meetings and

home visits at designated times based on the gestational age (duration of pregnancy) and the age of

the child. The project also considered that the PEs and CCs might have to undertake additional home

visits to help those women who are facing problems in following recommended practices even after

the information shared and discussions at the group meeting

The target for outcome and output level indicators of the project is set and approved from the donor

for the project. Status of indicators as measured in the baseline survey and after completion of first

year, second year and midterm evaluations is attached in the dossier. These indicators are regularly

(quarterly) captured through the project’s Management Information System (MIS). The project team

conducted a baseline survey between September and October 2012 and Mid Term Evaluation between

December 2013 and March 2014.

Project End Evaluation AKF, India is soliciting proposals for conducting Project End evaluation comprising of data

collection, analysis, conclusion, recommendations and writing of report for project Buniyaad in Bihar.

Objectives of the Project End Evaluations

The Purpose of the Evaluation is to assess the achievement of the project over the period 2012-13 to

2014-15 in relation to expected outcomes, highlighting what has worked well together with capturing

significant challenges. The Evaluation shall also identify any changes in the project implementation

strategy that may have occurred and establish whether the assumptions made at the project inception


stage still hold true. It will also be the key source for capturing and validating project’s strategy and

outputs. The specific objectives include:

1. Obtain end-line measurements to assess the level of achievement of the project in relation to

the outcome and output indicators (in comparison to the baseline)

2. Assess the effectiveness of project planning and management and review the relevance of

project design.

3. Assess the perceptions of beneficiaries regarding impact of certain project activities as laid

down in the log frame (as Qualitative Indicators).

4. Triangulate the evaluation findings with the baseline as well as project MIS data.

5. Identify lessons learnt and lay down recommendations for future programming on nutrition in

general and IYCF in particular.

A detailed description of method of sample selection, evaluation instruments, field work, data quality

management and assurance and analysis should be presented. The description of the method should

include the rationale for the same.

Credentials of Bidders

Awards will be made to one firm with capability to perform both qualitative and quantitative aspects

of the proposed assignments. Bidders must meet the following:

1. Firms must have substantive experience in conducting evaluation research of behaviour

change communication interventions to improve healthy nutrition practices in India.

Evaluation research should focus on outcomes and impact.

2. Firms must have experience in conducting literature reviews.

3. Firms must be able to demonstrate that they have either staff or have access to qualified

consultants that can complement in house capabilities.

4. Firms must be capable of responding promptly to potential tasks and develop needed task-

related proposals in timely manner.

5. An earlier similar evaluations in the assigned state would be an added advantage.

Evaluation Design

Agency’s Role

End-line evaluation will be primarily conducted by the agency in support of a team at AKF India

(based at Delhi Office and Bihar). The main responsibility of the agency will be to prepare tool,

undertake data collection, analysis and report writing, providing comparative background etc. and

other tasks those are part of the research design and evaluation framework. AKF India team will

provide inputs at tools to the selected agency for administering the data collection process as per the

suggested sampling design. All specifics about location will be provided to the agency, along with the

on field support for identifying communities and connecting to facilitate data collection.

Research Methodology and Sampling Design

The basis of the evaluation is the project log-frame across the project area and is attached as annexure

1. To have a high quality and statistically relevant data, it is expected that the agency has a well

defined data collection, date entry and storage and analysis team. The agency is required to propose a

robust and relevant methodology considering that this is an end-line evaluation of key performance

indicators.

It is envisaged that most of the indicators will be assessed through quantitative methods and

techniques, however for the process evaluation, the agency need to apply qualitative techniques which

be better to assess some of the interventions and they may please suggest engagement of expert, tools

etc in the proposal, including framework of analysis for both type of data.


Sample Size and Sampling Technique

The end-line evaluation will be used to compare the data with the baseline in the future in order to

assess the program coverage and progress against key performance indicators. The agency should

prepare a robust methodology and sampling keeping in mind the comparison of data. The agency

based on discussion with AKF should determine the sample size. The intervention on IYCF is being

carried out in three districts of Samastipur, Muzaffarpur and Sitamarhi with focus on 20 blocks with

more than 50% scheduled castes and minority population. A representative sample for quantitative

data collection should be suggested by the Agency. Site selection should be done in a consultative

process with AKF from among the three districts of Samastipur, Muzaffarpur and Sitamarhi.

Evaluation Instruments

Agency will develop quantitative and qualitative study instruments in English and Hindi and present

two copies of the finalized tools to the project management for approval, before any training of

enumerators commences. The agency will carry out a pre-test of the tools. AKF will participate in the

pre testing of the instruments and provide feedback. The agency will be responsible for printing

sufficient copies of instruments for purposes of training and data collection.

Fieldwork

Agency will be responsible for identifying and training of interviewers (preferably females who hold

graduation in Social work/sciences (preferably) with experience in conducting Health Surveys) and

Supervisors fluent in Hindi/local dialect (preferably graduation/Post graduation in Social

Work/Sciences). Training should include in-classroom and field based exercises. The agency will

prepare a training plan and share it with AKF. A representative from AKF will remain present during

training to oversee the quality of the training. The agency will also be required to submit a broad

schedule of the data collection exercise.

Data Management & Quality Assurance As part of the proposal, the Agency should outline a detailed data quality assurance plan for each

level of data management (data collection, data entry and analysis, and interpretation). The team at

AKF will also carry out back-check on random basis to ensure the quality. In case of minor

discrepancy, the agency will take appropriate corrective measures. In case of any gross discrepancy,

the agency will repeat the survey in the particular area. The agency will prepare the complete work-

plan and will also be responsible to outline the assurance plan for interview completeness and data

consistency and submit the copy before commencement of actual field work.

Analysis and Report writing

The agency will develop a detailed analysis plan and share it with the AKF team who will approve the

final plan. On the basis of the analysis plan the Agency will analyze data and present top line findings.

The agency will also be required to prepare an outline of the report and share it with AKF, for

approval. Based on the approved outline of the report the agency will be required to prepare the final

report of the evaluation which will include findings and recommendations. The agency will be

expected to make a presentation to the AKF team on the key evaluation findings and

recommendations before finalization of the report. A draft report then will be provided to AKF.

Following review and feedback further analysis and revisions will be completed by the agency. The

final report will be submitted to AKF no later than ten working days after receiving consolidated

feedback. The agency will provide hard and soft copies of the final report.

Deliverables

Two sets of each of the following, hard and electronic copies will need to be submitted as per the

work plan. All deliverables will be considered final only when approved by AKF. Please provide

clear timelines for each of the deliverables enlisted below:


1. Evaluation proposal: A finalized evaluation proposal with detailed methodology,

sample selection, data collection tools leading to achievement of objectives outlined

above.

2. A consultative meeting with AKF India team to have common understanding about

the processes and expected outcomes of the assessment.

3. Progress brief: While there is no formal progress report required during the

implementation of the assignment, the Agency shall be expected to regularly bi-

weekly share with the AKF the key emerging issues and trends to avoid surprises or

misconceptions by either party.

4. Training plan :The agency will prepare a training plan and share it with AKF.

5. Data collection plan: The agency will submit a broad schedule of the data

collection.

6. Analysis Plan and Report Outline: The detail analysis plan and report structure

should be shared with AKF beforehand.

7. Submission of raw data and transcription as soon as the data collection is over.

8. Draft Report: This shall be prepared and submitted towards the end of the

assignment. The draft report shall require feedback in form of comments, questions

and inputs from the AKF. In addition, the Agency may also be required to present

the Draft Report to a wider AKF audience for validation.

9. Final Report: This shall be submitted on, or before the expiry of the assignment

contract. Any valid extension may be mutually agreed upon between the Agency and

the AKF, provided it carries no extra cost to the latter. The following will also be

expected from the Agency :

A PowerPoint presentation capturing background, Methodology, results/findings of the

study, along with the recommendations.

A master copy of the final report (with all Annexes) suitable for reproduction, and two

copies, in full color and bound, as well as soft copies.

Electronic version of all data-sets and questionnaires used during the review shall be a

property of the AKF, and shall be the responsibility of the agency to carefully deliver them to

AKF.

Scope of Agency’s Work

Thus in order to fulfill the tasks outlined above the Agency will:

Review the secondary data in the project area related to IYCF and familiarize with local

context and similar programmes undertaken by government and other agencies. Also review

existing documents related to the project on formative research and baseline study.

Develop detailed evaluation methodology including sampling

Develop data collection tools

Recruit interviewers (preferably female) and supervisors able to communicate in Hindi/ Local

dialect.

Plan and manage all logistic aspects of the survey.

Provide sufficient copies of the protocols in English and Hindi (based on the sample size) for

the training and data collection phases.

Develop a plan for identification of eligible respondents prior to data collection.

Develop a data quality assurance plan.


Annexure 2: FGD/KII Guidelines and Questionnaires

END TERM EVALUATION: FGD/SEMI STRUCTURED PERSONAL INTERVIEW WITH BENS/SERVICE PROVIDERS/KEY INFORMANTS

Project Name: Reducing Infant Mortality in Bihar through Optimal Infant Feeding Practices Following are the key indicators for which the qualitative data is to be collected through FGDs and Individual semi structured interviews (adapted from the updated LFA of the project)

Outcome/Output Indicators Target Data Collection Methods to capture qualitative

data




Focused Group Discussion FGD) : 1 FGD (mixed group: Mothers with a child 6-7 months of age and mothers with a child 12-13 months of age) to be conducted in each of the project districts with an objective to assess the understanding of the mothers pertaining to the importance/benefits of complementary feeding

Output 1: Pregnant women, mothers of children under two years of age and other care-givers in the family have the appropriate knowledge and develop requisite skills to follow the recommended IYCF practices, through the messages and assistance imparted by peer educators in selected blocks of



Focused Group Discussion: 1 FGD to be organized in a mixed group in each districts to understand the role of Peer Educators/Cluster Coordinators in imparting the technical inputs pertaining to IYCF practices; also efforts to be put to assess the frequency of the visit of Peer Educators/cluster Coordinators as part of Home Visit and IPC


Outcome/Output Indicators Target Data Collection Methods to capture qualitative

data

three districts of Bihar




Focused Group Discussion/ Semi-Structured Personal Interview to be organized to assess their knowledge level pertaining to the IYCF practices, role of Buniyaad Project Staff in improving key critical behavior amongst the beneficiaries and need to improve further

I. Key Points for Conducting Focus Group Discussion (FGD) /Semi Structured

Interview with Beneficiaries

Objective: To assess the knowledge level of the bens on IYCF practices especially

complementary feeding and to gauge the perception of the beneficiaries on the role of Peer

Educators and Cluster Coordinators in improving the IYCF practices in the project areas of

Buniyaad Project

Suggestive Questions to guide the discussion:

A. Knowledge of Beneficiaries on IYCF Practices

1. What is your understanding on IYCF especially Complementary Feeding

a. Early Initiation of Breast Feeding (Colostrum Feeding)

b. Exclusive Breastfeeding

c. Complementary Feeding (quantity, quality and frequency):

i. when it should be started

ii. probing needs to be done to assess their knowledge about quantity,

quality and frequency aspect of complementary feeding;

iii. gender lens should also be used to assess the element of

discrimination pertaining to initiation of complementary feeding for girl

and boy children

iv. Is the mother able to monitor the growth of her child

d. Continued Breastfeeding up to 2 years along with Complementary Feeding


2. Has Peer Educator or Cluster Coordinator have visited your home, if yes, when and

how many times

a. in the third trimester of your pregnancy

b. at the time of the birth of your child

c. when your child is 3-4 months old

d. when your child completed 6 months

e. when your child is more than 6 months old

3. Has the Peer Educator met any of your family members during home visits; what

was the intention of the home visit; has the peer educator motivated any of the

family members about the importance of IYCF practices; were the visits useful for

you and your child

4. Have you ever attended any group meeting organized by Peer Educator or Cluster

Coordinators;

a. how many times;

b. what were the major agenda of the meetings;

c. were the meetings useful for you and others

d. Timing of three meetings

5. Have you ever faced any problem in practicing breastfeeding/complementary

feeding to her child, if yes, what and who has helped you to overcome such problem

6. Do the mothers have enough breast milk to feed the child?

7. What is the kind of food mothers take during the first few months of breast feeding?

8. What are the hygienic practices followed by women before / after/ during breast

feeding? –like cleaning, bath, changing clothes..etc

9. What is the gap between children?

B. Knowledge on Buniyaad Project

1. Do you know anything about Buniyaad Project

2. How did you come to know about it?

3. What was the initial reaction of yourself and the community?

4. How did it change?


5. Are you familiar with the position and role of Peer Educator and Cluster Coordinators

in your areas

6. Have they supported/motivated/counselled you about IYCF practices

7. Was the methodology useful?

8. How better they could have done this?

9. Was there any difference of opinion with PEs?

10. Were you comfortable with the status of PEs?

11. If you/ community have accepted the suggestions by the PEs – why did you accept,

what was the reason?

12. In your opinion, why did this project succeed (or not succeed)?

II. Key Points for Conducting Focus Group Discussion (FGD)/Semi Structured

Interview with Service Providers (AWW/ASHA/ANM/)

Objective: To assess the knowledge level of the service providers on IYCF practices and to

assess the role of Cluster Coordinators and Peer Educators in improving the key critical

behaviours amongst the beneficiaries in the project areas of Buniyaad Project

Suggestive Questions to guide the discussion:

Before initiating the FGD/Semi Structured Personal Interview, the moderator and team

members will ask the service providers about the facilities where they are working-in and

about their nature of work pertaining to health & Nutrition activities (like VHND, Home Visits,

Immunization, due list preparation for Routine Immunization, Growth Monitoring, Mahila

Mandal Meeting, Ensuring ANC, Referral Services, Nutrition & Health Education etc). Once

the tempo is set, the moderator & team members will further extend the dialogue with the

service providers using some of the following questions:

A. Knowledge of Service Providers on IYCF Practices

1. What is your understanding on IYCF

a. Early Initiation of Breast Feeding (Colostrum Feeding) -

i. why it is important and how it is useful for the growth of the child

(probing is required);

ii. Probing to know whether pre lacteals (honey, water, cow's milk etc)

are being given to the children just after birth

b. Exclusive Breastfeeding -periodicity of exclusive breastfeeding and its

importance (probing is required)



i. when it should be started, probing needs to be done to assess their

knowledge about quantity, quality and frequency aspect of

complementary feeding;

ii. gender lens should also be used to assess the element of

discrimination pertaining to initiation of complementary feeding for girl

and boy children

iii. Periodicity of Growth Monitoring

d. Continued Breastfeeding up to 2 years

2. What is your key role in promoting the IYCF practices

3. How do your address the problem of the mother, if arises, in breastfeeding practices

4. How do you promote that the mothers must practice IYCF practices for their child

5. Is there any relationship between Family Planning with IYCF practices

6. Importance of hand washing practices

7. Importance of home visits to promote IYCF: need to understand about their

knowledge which are the important contact times to promote IYCF; whom to be

contacted other than mother

8. Importance of convergence in promoting IYCF

B. Capacity Building of Service Providers on IYCF

1. Have you undergone any training programme on IYCF and what are the major

components of the training programme

2. How many times have you undergone training programme on IYCF

3. Who has conducted the training programme

a. Government

b. Buniyaad Project

c. Other Agency

4. What sort of skills have they imparted other than technical components of IYCF

a. IPC

b. Use of BCC materials


c. Home Visits

5. Have the organizers equipped you with some materials/tools like BCC materials,

Growth Chart, Home Visit Tools etc

6. Messages and methods of communications found to be most effective

7. Your opinion on these tools and materials and suggestions on improvement

8. Constraints that the project staff faced and how they overcame it?

9. Any difference between communities in relation to the impact

C. Knowledge on Buniyaad Project

1. What do you know about Buniyaad Project; what are the major components of the

project

2. Role of Peer Educator and Cluster Coordinators in your areas

3. How do you work jointly with Peer Educator and Cluster Coordinator along with other

grass root level government functionaries

D. Conclusion

a. Suggestions of the project staff for future interventions

b. Perceptions on the sustainability of the program benefits

c. What is the greatest misperception and how far it has been addressed?

d. What is the change which happened in the community with this project?

e. Usefulness of the Monitoring system and its process

f. Reporting system

g. Usefulness of the midterm correction, if any

h. You are already working on health of mother and child and why did this project impress

you (or not)? What was the difference this project offered?

III. FGDs with CCs

A. Getting introduced to the Buniyaad project

1. How did you come to know about Buniyaad project?

2. What were the initial impression about the project?

3. When the key messages were explained to you, having known the situation in

your own villages, how did you think you would be able to achieve the results?

4. What were your experiences during the project – with PEs, households,

community and your own family

5. Why did the strategies work / not work?


B. Knowledge of CCs on IYCF Practices (this would be a quick round to get a general

impression)




importance



2. What was your key role in this project

3. How did you address the problem of the mother, if arises, in breastfeeding practices

4. In your opinion, why did this effort by you worked?

5. How did you address the questions raised by PEs?

B. Capacity Building

1. What were the key trainings you have undergone as part of the project?

2. What was the regularity of these training programmes?


a. Government

b. Buniyaad Project

c. Other Agency


a. IPC


c. Home Visits






9. How was the reporting system?

10. How were you monitored?

D. Conclusion

1. Suggestions of the CCs for future interventions

2. Perceptions on the sustainability of the program benefits


3. What is the greatest misperception and how far it has been addressed?

4. What is the change which happened in the community with this project?

5. Usefulness of the Monitoring system and its process

6. Usefulness of the Reporting system

7. Usefulness of the midterm correction, if any

8. Why did this project impress you (or not)? What was the difference this project vis a

vis other projects you might have worked with or seen?

IV. FGDs with PEs

A. Getting introduced to the Buniyaad project

1. How did you come to know about Buniyaad project?

2. What were the initial impression about the project?

3. When are the key messages were explained to you, having known the situation in

your own villages, how did you think you would be able to achieve the results?

4. What were your experiences during the project – with CCs, households,

community and your own family

5. Why did the strategies work / not work?

B. Knowledge of PEs on IYCF Practices (this would be a quick round to get a

general impression)




importance



2. What was your key role in promoting the IYCF practices

3. How did you address the problem of the mother, if arises, in breastfeeding practices

4. How did you address the questions raised by mothers, relatives and community?

B. Capacity Building, reporting and monitoring

1. What were the key trainings you have undergone as part of the project?

2. What was the regularity of these training programmes?


a. Government

b. Buniyaad Project

c. Other Agency



a. IPC


c. Home Visits






9. How did you overcome the barriers from the community, families and mothers?

10. How was the reporting system?

11. How were you monitored?

D. Conclusion

1. Suggestions of the PEs for future interventions

2. Perceptions on the sustainability of the program benefits

3. What is the greatest misperception and how far it has been addressed?

4. What is the change which happened in the community with this project?

5. Usefulness of the Monitoring system and its process

6. Usefulness of the Reporting system

7. Usefulness of the midterm correction, if any

8. Why did this project impress you (or not)? What was the difference this project vis a

vis other projects you might have worked with or seen?

V. FGDs with IP team

1. A brief introduction about the project in your area

2. What was your perception about the success of this project when it was

started?

3. What were the enabling factors you had foreseen and later experienced?

4. What were the hindering factors you had foreseen and later experienced?

How did you overcome them?

5. What was the perception of the community at large about this project?

6. What is the present perception of the community?

7. Why has this change happened (if happened)?

8. What were the key strategies and approaches you have used?

9. Was it in any way different from the overall project strategy and approach or

is there any innovation from your side?

10. There are four IPs and how are you different in implementing this project?


11. What was your engagement with the government and other agencies related

to this thematic area?

12. What is your opinion about the reporting and monitoring system of this

project?

13. Is the concept of the project being adopted or adapted by your organization in

any of your other interventions?

14. What is the difference of Buniyaad project with other projects which you have

managed?

15. What are your key experiences and learnings from this project in terms of the

content and as well as process?

16. What is your opinion about the staff strength – IP team, CCs and PEs?

17. How did you ensure the quality of staff in field?

18. Your opinion about the trainings, materials and tools used in this project?

19. What are your key suggestions for any similar future interventions?

VI. Key Informant Interviews with Grandmothers – 8

1. How did you come to know about the project?

2. What was your initial understanding about the project?

3. What was your initial reaction to the project?

4. What were the key messages the PE has given?

5. How did you react to these messages?

6. How were these messages different from your own knowledge and practices?

7. Has this initiative changed your perception about breast feeding, nutrition and

child care in general?


9. What was the reaction of your neighbours and relatives?

10. What was the reaction of the menfolk in your household?

11. Have you ever talked/discussed about the key messages of this initiative to

others in the community?

12. Do you see any perceptible change in the health of children and mothers over

this period of 2-3 years?

VII. Key Informant Interviews with Husbands – 8

1. How did you come to know about the project?

2. What was your initial understanding about the project?

3. What was your initial reaction to the project?

4. What was the initial reaction of elders and other community members?


5. What were the key messages the PE has given to your wife and family?

6. Have you seen any wall writings, leaflets etc on these?

7. How did you react to these messages?

8. Did anyone from the project talk to you about these messages?

9. How were these messages different from your own knowledge?

10. Has this initiative changed your perception about breast feeding, nutrition and

child care in general?


12. What was the reaction of your neighbours and friends?

13. Have you ever talked/discussed about the key messages of this initiative to

others in the community?

14. Do you see any perceptible change in the health of children and mothers over

this period of 2-3 years?

VIII. Key Informant Interviews with Doctors – 4

1. Were you engaged with this project in any way during the last few years?

2. As a practicing doctor, do you find any perceptible change in the attitude and

behavior of the mothers regarding IYCF?

3. How much can you attribute these changes to the project?

4. If there is any impact due to the project, why did this impact happen – is it the

process, content, tools or communication strategy which made the difference?

5. How as the project’s engagement with the activities you and your institution

conducting in the same or similar thematic area?

6. How beneficial were these?

7. Now that the project is coming to a close, how do you think the messages will be

taken forward in the community?

8. What roles did the concerned departments play in this project?

9. What are the potential roles of departments in such projects in future?

10. How has this project impacted on the functioning of concerned departments?

11. Has there been any changes in the policy or programme due to this project?

IX. Key Informant Interviews with Panchayat ERs – 8

1. How did you come to know about this project?

2. What was your initial perception about this project?

3. Did anyone in the project approach you or explain to you?

4. What was your initial reaction?

5. What are the key messages of this project?


6. In your opinion, has the attitude and behavior on IYCF changed in your

community?

7. Why did this happen?

8. What were the roles you played in this process of change?

9. Has it made any other contribution to the community in any behaviours other than

IYCF related?

10. What are the possibilities of community taking this kind of initiative forward?

11. What will happen if the project is closed?

12. What could be the roles Panchayats and community leaders can play?

X. Key Informant Interviews with Religious leaders – 4

1. How did you come to know about this project?

2. What was your initial perception about this project?

3. Did anyone in the project approach you or explain to you?

4. What was your initial reaction?

5. What are the key messages of this project?

6. How was it different from the views you had?

7. How difficult it was for you to accept these changes?

8. In your opinion, has the attitude and behavior on IYCF changed in your

community?

9. Why did this happen?

10. Has it made any other contribution to the community in any behaviours other than

IYCF related?

11. What are the possibilities of community taking this kind of initiative forward?

12. What will happen if the project is closed?

13. What were the roles you played in this process of change?

14. What could be your in such endeavors?