EVALUATION OF SELECTED NUTRITION AND HEALTH PROGRAMMES IN TELANGANA STATE
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Date
2018
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PROFESSOR JAYASHANKAR TELANGANA STATE AGRICULTURAL UNIVERSITY
Abstract
The present study entitled “Evaluation of selected nutrition and health
programmes in Telangana State” was undertaken to evaluate and enhance the
functioning of Weekly Iron Folic Acid Supplementation, Anganwadi Centres and
Nutrition Rehabilitation Centres.
Under National Health Mission, 12 Nutrition Rehabilitation Centres (NRCs) had
become functional in Telangana State for treatment and nutritional rehabilitation of
children suffering from Severe Acute Malnutrition (SAM) along with medical
complications. In congruence with the GOI guidelines, each NRC had one medical
officer, one nutritionist-cum-counsellor, a staff nurse, and one cook-cum-attendant for
the functioning of NRC
Among the twelve medical officers, half of the medical officers were trained in
the facility-based care of Severe Acute Malnutrition (SAM) children and rest was not
trained.
Nine (75%) nutritionist-cum-counselors were specialized in nutrition, two (17%)
were from chemistry background and one from nursing. All the twelve nurses working
in the NRCs were qualified from the General Nursing Midwifery (GNM). The medical
social worker (MSW) position was vacant in the all 12 NRC units.
All the Nutritionist - cum - counselors were trained in facility-based care of
SAM children. Among the 12 NRCs, 4(33%) cook-cum-attender were given training
related to preparation of therapeutic diet and preparation of food with locally available
food materials. While the rest of 67% were untrained.
Highest percentage of SAM children admitted to NRC were majorly below 3 yrs
old indicating that infants and preprimary children were the most vulnerable group,
susceptible for severe acute malnutrition. The incidence of SAM was found to be more
or less equal among all castes, lowest being in minority groups.
Less admission in NRC from tribal and urban areas could be due to low
incidence of SAM or ignorance or non-willingness of people in these areas. The factors
like mother’s age at primigravida, mother’s educational status, nutritional and health
status during pregnancy and lactation period could be the possible reasons for the higher
incidence of poor nutritional conditions of mothers (primi and second gravida).
Too early pregnancies as in women between 18-22 yrs or too late pregnancies as
in 33-37 yrs, which was obvious from the age of children admitted in NRCs (< 5yrs)
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could be the other reasons for entry of children into SAM condition or at risk of
nutritional and health problems.
Low or no literacy of mothers as majority of the study group along with much
higher percent of fathers being illiterate or semiliterate might have been one of the
causes of severe acute malnutrition among children, also due to ignorance and improper
child rearing practices.
The parents of SAM children were majorly low wage earners and this factor
could be attributed to the possibility of malnutrition of children and lack of affordability
of treatment of illness and infections associated with malnutrition.
The most common complications among SAM children were severe weakness
with anorexia associated with fever and dehydration and convulsions in some cases.
Hypothermia, hypo glycemic, unconsciousness, severe anaemia caused complications.
Feeding the child on therapeutic formulas and treatment of the complications formed the
immediate action in NRCs to save the child from mortality.
The underlying causes of malnutrition among SAM children were inadequate
food intake, low socio-economic status and illiteracy. Malnutrition because of low
socioeconomic status, poor sanitation and illiteracy explained about the condition of
their admitted child..
As the SAM children undergo treatment in NRC and were given nutritious
therapeutic diet at regular intervals, there was a shift from severe acute
malnourishment stage to moderate and mild degree of malnourishment and it was a
slow and steady process.
The admitted children had all 4 services of nutritional screening, assessment of
feeding problems, feeding of modified diets and diet counseling sessions for mothers. It
was observed that all the emergency essential medicines were available at NRCs. The
children were treated for individualized health conditions, and the medicines were given
to the children. The supply of medicines to the NRC seem to suffice the requirement
and NRC had added advantage of other treatment facilities from the district hospitals.
Nutrition counseling was given by the nutritionist-cum-counsellor to almost
92% of the mothers /caretakers, while 8% were counselled by cook-cum-attender. Food
demonstrations help the mothers to make special therapeutic and nutritious foods for
improving the condition of malnourished children. Combinations of cereal, pulse,
vegetable, oil along with milk and milk products can be demonstrated using proper
cooking methods. Nutritional counselling to the mothers is very important to make them
understand the causes of malnutrition, growth pattern in children, importance of
nutritious food and nutritional requirements of their children.
Visual aids are important for nutrition education and the materials used for imparting
nutrition knowledge by the NRC.
As the follow up period increased from 15 days to 30 days and further to 90 days, the
percent follow up cases visiting NRC has declined. Community mobilization through
the key personnel plays a major role to comply with follow up visits to NRC.
Marginalized population should be reached through volunteers, ASHA workers,
Anganwadi teachers and other community health workers, to bring awareness on
existence and services of facility-based management of SAM children at the Nutrition
Rehabilitation Centre. These personnel should also monitor the follow up visits of the
discharged children to the NRC and help clients to comply with all three follow up
visits.
xviii
The NRC units in every district had attached bathrooms and a separate hand
wash area. In all 12 NRCs hand washing facilities in the ward were well utilized, staff
consistently washed hands thoroughly with soap. Nails of staff were clean and washing
hands before handling food was practiced by staff in all 12 NRCs. The staff had
provision for hand wash and they maintained cleanliness and hygiene during the
preparation, handling and distribution of food.
Maintaining personal hygiene of children and mothers is very essential to
prevent growth of microbes, contamination and subsequent spread of infections. More
precautions have to be taken by NRCs to maintain bed hygiene, personal hygiene and
sanitation of the place of stay of the malnourished children whose resistance to
infections /immunity levels are already too low. Floor dust, food leftovers and
packaging materials often dumped in dustbins attract insects and rodents, which were
cleaned on a regular basis in the NRCs. Overall, general maintenance of the wards was
clean and tidy.
Immediate washing of food plates/ dishes prevent flies in the vicinity and
washing dishes with hot water removes grease and makes them thoroughly clean. In
general, mothers were given instructions on personal hygiene. They were explained
about the importance of washing hands and maintaining personal hygiene. Most of the
mothers/caretakers were satisfied with the cleanliness and services provided in NRCs.
As per the ward procedures, the children were screened by the medical officer
for any medical complications before they were admitted into the NRC and treated
accordingly. Necessary antibiotics were given and noted on the daily care chart in all
NRCs. Supplementation of folic acid, vitamin A and multi vitamin tablets was done
daily and recorded in all 12 NRCs.
The surroundings of NRCs were welcoming and cheerful only in 9 centres.
Mothers/caregivers were offered sufficient space to sit and sleep, and they were taught
and encouraged to be involved in child care, staff were consistently courteous to
mothers in all the centres. During recovery, the children were stimulated, encouraged to
move and play also child friendly environment was provided. Walls were brightly
painted and decorated in all 12 NRCs.
None of the NRCs could achieve the expected weight gain among admitted
children, which might be due to the short duration of stay in NRC and the infections and
health complications associated with malnourishment of children. Moreover, acute
malnutrition and associated complications do not facilitate easy weight gain especially
in short duration rehabilitation as in NRCs.
There was a significant weight gain during the nutrition rehabilitation period in
NRC, the expected weight gain of 15% above the admission weight could not be
achieved. The targeted 15% weight gain is possible only by increase in the duration of
stay in NRC for 20 to 25 days. Increase in the quantity of food supplementation to
achieve 15% weight gain might not be possible because the malnourished child’s
capacity to eat food is limited due to lack of appetite and associated infections and
diarrhea. As the age increased, there seem to be a constant gain in weight among NRC
admitted children in a linear approach.
The inception of WIFS in selected schools started in a periodical phase, but by
2013 officially all schools and AWCs were introduced with WIFS. But several schools
and AWCs did not have any data on inception or implementation of WIFS programmes.
Data on non-school going children in Khammam, Karimnagar and Ranga Reddy
districts could not be obtained as there were no signs of implementation of WIFS in
these areas.
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In any caste group, percent of school going children was higher than non-school
going children. Children from BC community were found to be highest percent of
school going children followed by SCs, STs, OCs and minority. Among the NSG
children BCs formed the highest percent followed by SCs, STs, OCs and minorities in
the decreasing order. No data on caste was available from 40% of NSG group.
The responses on consumption of IFA tablets could be based on previous
supplementation and not at the time of survey. In many schools it was found that only
once the supply of IFA tablets was mentioned by the school authorities.
By annual dose of albendazole for deworming has been given in these schools
and the compliance of supply and consumption of albendazole was better than IFA
tablets. Least consumption of albendazole was seen among the children in Hyderabad.
Children from Karimnagar and Hyderabad do not seem to be knowledgeable
about purpose and importance of deworming and their consumption also was less
compared to other districts. The major discomforts noticed with the intake of IFA tablet
among few students were stomach pain and vomiting.
The districts of Nizamabad, Karimnagar, Hyderabad and RangaReddy had no
supply of compliance cards to the children and across the state these compliance cards
were filled only by 6% of the school children.
The responses on consumption of IFA tablets and compliance from the NSG
children was nil or very poor from Khammam, Karimnagar, RangaReddy and
Hyderabad. Though consumption of IFA and albendazole tablets was seen in less
percentage of children, they were positive about the health benefits of the
supplementation and expressed no discomfort with IFA tablets. There was no supply of
compliance cards, children were not discouraged of consumption of supplementation
and around 43% NSG children were exposed to nutrition education through sample
balanced diet sheets and charts on iron and vitamin C rich foods. More responses have
come from the districts of Adilabad, Nizamabad, Mahabubnagar and Warangal.
In both schools and anganwadi centres the supply of IFA tablets for the purpose
of adolescent children was irregular, no follow up from Health department, no registers
and records maintained, the recommended updated class report (Format 2), updated
monthly report (Format 3) of schools and compliance cards for adolescence were not
found/supplied and educational charts on iron, vitamin C and balanced diet went
underground without use. Since there was no consistency in the supplies of IFA tablets,
tablets being expired, no supply or guidance in maintaining registers, records and
formats and overall failure of the monitoring system, the programme of Weekly Iron
and Folic acid Supplementation (WIFS) requires revamp and revival in all the districts
of Telangana state.
Since the children are in a phase of rapid growth, gain in weight and height are
natural but highly influenced by the food intake both in terms of quantity and quality.
Supplementary nutrition in AWCs not only provided quality food but also developed
positive attitude, knowledge and improved acceptance to a great extent.
The results of weight and height gain among children below 6 years after
education intervention and observed feeding showed that not much improvement has
occurred except for weight gain in 12-35months in Warangal. The results suggest the
need for evaluating and monitoring the feeding practices at home and educating mother
to give proper breakfast, inclusion of milk, balanced meal and diet plans in future. Mere
monitoring of AWCs is not sufficient to bring improvement in child’s growth and
development. Improvement with attitudinal change in health and nutrition habits of the
mothers and children shall positively and constructively improve their nutritional status.
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D 10,354