Impact of Enhanced NutritionImpact of Enhanced Nutrition Program on Child Growth and g

Diet in India

Rasmi Avula1,Edward A. Frongillo1, Mandana Arabi2 Rasmi Avula ,Edward A. Frongillo , Mandana ArabiSheel Sharma3, Werner Schultink2

October 9, 2009October 9, 2009

1University of South Carolina; 2UNICEF; 3Banasthali University

F d d b UNICEFFunded by: UNICEF

C nt t

Prevalence

Context

Prevalence 60 million children underweight46% stuntedInter-state variation

India’s Policy ResponseIntegrated Child Development Services (ICDS)

Anganwadi Centers

Gragnolati, M., Shekar, M., Gupta, M., Bredenkamp, C., & Lee, Y. (2005). India’s undernourished children: A call for reform and action. Health Nutrition & Population Discussion Paper.

S ppl t l N triti Pr rSupplemental Nutrition ProgramChildren receive food in ready-to-eat Children receive food in ready to eat form, hot-meal cooked at the AWC, or as a take-home rationFood centrally procured from public or private vendors at the national or state level

Pr blProblemsIrregularities in the food supplyIrregularities in the food supplyLeakage to non-targeted individualsLack of awareness among the mothers Lack of awareness among the mothers about the food or eligibility of their childrenFailure of the AWW to contact the mother when food is available

Obj tiObjectiveAssess the effect of an enhancedssess t e e ect o a e a cedsupplemental nutrition program on growthand dietary outcomes among 6-36 monthsy gchildren

P E h tProgram Enhancement

Usual Program GroupUsual Program GroupCentrally procured Baby Mix

E h d N i i Enhanced Nutrition Program Group

Locally prepared Baby Mix Locally prepared Baby Mix Anuka (Multiple Micronutrient Supplement)M it iMonitoring

Q antitative St d MethodsQuantitative Study Methods

Study Designy gQuasi-experimental pre-post test design

Sample30 villages (N = 1190)

15 villages from one block in the enhanced program 15 villages from another block in the usual program

MeasuresHeight and Weight (6-36 months children)24-hour Dietary Recall (6-18 months children)

An l

Multi-level Linear Regression

Analyses

Multi level Linear Regressionchange over time between the groupsaccounted for village-level variation

Growth OutcomesHAZ, WAZ, and WHZ HAZ, WAZ, and WHZ control variables - age, initial Z score

Di t O tDietary OutcomesEnergy, Protein, and Iron control variables - age, initial nutrient intake, and gbreastfeeding status

Qualitative Study MethodsQualitative Study Methods

Site VisitSite Visit

Interviews with key personnelInterviews with key personnelProject Officer at UNICEFChild Development Project Officer (ICDS)Child Development Project Officer (ICDS)Anganwadi WorkersMothers

R lt G th O tResults – Growth Outcome

Change in Height-Age-Z Score

0 8*p<0.05

0.6

0.7

0.8

ed-U

sual

**

0.3

0.4

0.5

ce: E

nhan

ce(S

D)

0

0.1

0.2

Diffe

renc

6-8 9-11 12-18 19-25 26-31 32-36

Age in Months

Results Growth OutcomeResults - Growth Outcome

Change in Weight-Age-Z Score

3*p<0.05

2

2.5

ced-

Usua

l

*

1

1.5

nce:

Enh

an(S

D)

**

0

0.5

6-8 9-11 12-18 19-25 26-31 32-36

Diffe

ren

6-8 9-11 12-18 19-25 26-31 32-36

Age in Months

R lt G th O tResults - Growth Outcome

Ch i W i ht H i ht Z SChange in Weight-Height-Z Score

3*p<0.05

*

2

2.5

ced-

Usua

l

0 5

1

1.5

ce: E

nhan

c(S

D)

*

-0 5

0

0.5

6-8 9-11 12-18 19-25 26-31 32-36Diffe

ren

0.5

Age in Months

R lt Di t O tResults - Dietary Outcome

Ch i E I t kChange in Energy Intake

160

al

* <0 05

100

120

140

nced

-Usu

ad)

* *p<0.05

40

60

80

ence

: Enh

a(k

cal/ d BOYS

GIRLS

0

20

40

6 8 9 11 12 18

Diff

ere

6-8 9-11 12-18Age in Months

Q lit ti St d R lt

Decentralization of Baby Mix

Qualitative Study Results

Decentralization of Baby MixCentral procurement vs. local preparationQuality of the productQ y pAcceptability

TrainingCounseling skillsDemonstration of administration of the supplement with the Baby Mix

Q lit ti St d R ltQualitative Study Results

Child Dev Project

Monitoring

Dept. DirectorChild Dev. Project Officers

Lady Supervisors Anganwadi Workers

MonitoringRecord MaintenanceIncreased visitsIncreased visitsAdequate Staff

C l iConclusionsProgram enhancement benefited children

Plausibility of benefit is supported by y pp yqualitative study results

Observed outcomes can be attributed to: local preparation of Baby Mixtraining and monitoringuse of micronutrient supplement

AcknowledgementsAcknowledgements

Dr Laxmi Bhawani CDN Project Officer UNICEF JaipurDr. Laxmi Bhawani - CDN Project Officer, UNICEF, Jaipur.UNICEF Staff, JaipurTonk and Malpura Block ICDS Personnel Banasthali University Technical Team Members, RajasthanMothers in Tonk and Malpura Block villages Ashok Patni – Data entry assistantyPink City - NGO, JaipurSanskriti – NGO, Jaipur