Forty-five percent of the global deaths in children younger than five years have been attributed to nutritional disorders. Over two-thirds of these malnutrition cases occur during the first year of life owing to inappropriate feeding practices. Inappropriate feeding practices, poor dietary diversity, limited feeding frequency and low energy intake are important risk factors for malnutrition and related morbidities. Promoting appropriate early childhood nutrition is the single most effective child survival intervention.
Optimal Infant and Young Child Feeding (IYCF) practices imply that every child gets the best possible head start in life. The IYCF practices of exclusive breastfeeding for the first six months and continued breastfeeding for two years or beyond together with adequate and appropriate complementary feeding (CF) after six months not only substantially reduce malnutrition and morbidity but also reduce under-five deaths by 19% and improve quality of life outcomes in children.
The state level survey data for Gujarat, India, show underweight and stunting in under-five children at 44.6% and 51.7% respectively, reflecting the failure to receive adequate nutrition over a longer period of time. The IYCF indicators in the state are still at suboptimal level, with only 48.3% practicing initiation of breastfeeding within one hour of birth, 41.4% practicing exclusive breastfeeding till six months and 47.8% children receiving appropriate complementary feeding. Similarly, the most recent nutrition survey shows inadequate consumption of essential food groups by 1-3 year old children in rural Gujarat and protein and energy inadequacy in the diet at 57.8%.
The Integrated Child Development Services (ICDS) is the flagship programme of India to address childhood malnutrition in the country. The ICDS programme provides services through community-based workers, referred to as Anganwadi workers (AWWs). The services are provided from a centre called the Anganwadi centre (AWC), a courtyard play centre, which is located within the village itself. One AWW is appointed for 1,000 people and provides a package of the following six services under the ICDS Project: supplementary nutrition, immunisation, health check-up, referral services, pre-school nonformal education, and nutrition and health education.
The ICDS programme in Gujarat was launched in 1975 and presently covers 5.2 million beneficiaries (children under 6 years, pregnant and lactating women, and adolescent girls) through 49,338 operational AWCs with AWWs serving as the first point of contact on nutrition needs of children below 6 years of age. To successfully execute implementation of ICDS services, the government has developed comprehensive training programmes that include induction, job and refresher trainings for AWWs, delivered from the district level Anganwadi Workers Training Centres (AWTCs). Facilitating behaviour change among caregivers through increased awareness, skill building and effective counselling is seen as an important pathway to address the problem of inappropriate IYCF practices.
The present study was conducted to assess knowledge of AWWs on IYCF practices as well as their counselling skills in promoting these among beneficiaries. The AWWs were selected through a multistage cluster sampling technique. Four districts, viz Dahod, Jamnagar, Patan and Surat were randomly selected from four of the six divisions in the state. In the second and third stage, ICDS sectors and AWC respectively were selected from each district, based on probability proportional to size and randomisation. Out of 96 AWWs selected, 80 participated in the study.
Each AWW interacted with two mothers separately in a non-time-bound manner during which their competencies on (1) weighing the child, (2) plotting and interpreting the growth monitoring chart, (3) understanding current feeding practices of children and (4) ability to provide appropriate counselling on IYCF practices were assessed.
Profile of Anganwadi Workers (AWWs)
The data on education qualification shows that close to 37% of AWWs had completed 10th grade while 31% completed grade 12. Years of experience in the AWW position ranged from 1-31 years, 13.7% had 1-5 years of experience while more than half of AWWs had worked for more than 15 years as AWWs. The proportion of AWWs who had received a six-day induction training was small (6.25%); but more than three-fourths (76.2%) had received a 26-day job orientation training and 65% had received a five-day refresher training in the past two years.
Knowledge on breastfeeding practices
(a) Early initiation of breastfeeding: In the simulation exercise, AWWs were asked to advise a mother who had newly delivered, about breastfeeding. Some 95% of AWWs advised immediate initiation of breastfeeding or within one hour of child birth. The remaining 5% advised the mother to wait for the secretion of milk to start before initiating breastfeeding.
(b) Pre-lacteal and colostrum feeding: In a situation where a family holds the opinion that something ‘sweet’ should be given to the new-born, all AWWs reported that they would strongly advise mothers against giving pre-lacteal feeds. Similarly, all AWWs concurred that the mother should feed colostrum to the baby and not discard it. Further asked to explain the benefits of colostrum, all AWWs highlighted immunity and the protection it provides against infections. However, very few could highlight the nutritional properties of colostrum.
(c) Attachment for breastfeeding: Correct breastfeeding technique is important for ensuring successful breastfeeding, as incorrect technique may cause breast engorgement leading to painful breasts. The AWWs were evaluated for their ability to identify the correct attachment for breastfeeding by showing different pictures. About 91% of AWWs identified correct attachment to the breast during feeding. Regarding specific awareness about signs of correct attachment, about 56% of AWWs stated visibility of areola above the top lip and widely open mouth during suckling whereas about 29% and 21% of AWWs mentioned correct position of lower lip and chin respectively. None was able to explain all four signs of correct attachment.
(d) Identification of signs for milk insufficiency: One of the common reasons for early termination of breastfeeding is that caregivers believe that they are not producing enough milk and therefore AWWs were asked to identify the signs of insufficient milk supply. About 40% of the AWWs proposed they would consider poor weight gain as one of the signs for judging breast milk insufficiency whereas only 8% highlighted a small amount of concentrated urine (less than 6 times per day) passed by the baby as an indication of not getting highlighted both the signs (ie weight loss and concentrated urine).
(e) Exclusive breastfeeding (EBF): To judge knowledge of the AWWs with respect to feeding additional food to an infant less than 6 months, about 96% of the AWWs reported that giving cow’s milk as an additional feed to a three month old infant was an incorrect practice. To further assess their understanding of the benefits of EBF, 65% AWWs reported it reduced infections, 36% believed it provided all required nutrients, 31% reported that it helped to gain weight and 30% stated that it was enough to satisfy the hunger of the child.
(f) Expressing and storing breast milk: To sustain exclusive breast feeding, especially in the case of a working mother, AWWs should have knowledge and skills to teach the method of expressing breast milk. About half of the AWWs (51%) were aware of the procedure for expressing and storing breast milk for later feeding and advised the mother to do the same.
(g) Continuation of breastfeeding: When asked, through a given situation, to advise a mother regarding continuation of breastfeeding after the mother had introduced complementary foods to the 6 months child, about 95% of AWWs shared that breastfeeding should be continued along with other feeds while 5% believed that it should be substituted with additional feed.
Knowledge on complementary feeding
(a) Age of introduction of complementary foods and implications of delay: About 94% of AWWs felt that six months was the right age to start feeding complementary foods to the infant while 6% were in favour of starting complementary feeding prior to six months. Regarding implications for delayed complementary feeding, about 71% of AWWs referred to inadequate weight gain, 63% stated compromised growth and development in children while 25% referred to increased risk of infections.
(b) Consistency (thickness) of complementary food: To assess knowledge on correct consistency/thickness of food for infants, pictures of food with different consistencies were shown to AWWs and they were asked to select the correct pictures and provide reasons. Only about 19% of AWWs could identify the correct consistency for the food while the rest (81%) selected pictures with a thin consistency. When asked to provide reasons for selecting the incorrect picture, AWWs indicated that such food was easy to swallow and digest, did not require chewing and that it was better to start with liquid and then move on to semi solid and solid food.
(c) Energy and nutrient density of complementary foods: Given a certain situation, AWWs were asked about additional ingredients to be added in Khichdi (A semi-solid, gruel-like preparation with rice, legumes, salt and turmeric, commonly consumed in the state) to make it energy and nutrient dense. Addition of oil, ghee, butter, etc., to make khichdi energy dense was advised by 71% of AWWs, while 65% of AWWs suggested addition of green leafy and other vegetables to make the food nutrient dense.
(d) Knowledge about iron and vitamin A rich foods: Assessment of the knowledge of AWWs regarding three locally available iron and vitamin rich foods showed that about 89 % of AWWs identified at least one iron-rich local food while 24% could name three such local foods. Similarly, for vitamin A-rich local food, 71 % of AWWs identified at least one such food while only 16% were aware about three such foods. About 30% and 11% of AWWs could not recommend any locally available vitamin A and iron-rich food respectively.
(e) Portion size and feeding frequency: When asked to choose portion size and number of feeds for a 15 month old child, 86% and 96% of AWWs responded correctly with appropriate quantity and frequency of food to be fed daily to the child respectively.
(f) Preparing a meal plan for a year old infant: In a situation where AWWs were asked to prepare a one day meal plan for a 1-year old child, the analysis showed a meal primarily comprised of cereal, pulses and milk and/or milk based products, reflecting the common diet of rural households in Gujarat. All AWWs recommended meals containing cereal grains. Inclusion of pulses and fats/oils were recommended by 95% and milk/milk products were recommended by 88%. Inclusion of Balbhog (a Ready to Eat micronutrient fortified take home ration provided under ICDS scheme) and green leafy vegetables were recommended by 66% and 26% of AWWs respectively. Poultry and meat products, as well as fruits were included in the meal plan by 38% and 50% of AWWs respectively.
Growth monitoring and IYCF counselling skills
In the ICDS programme, when a caregiver visits the AWC with the child, it is expected that the AWW would weigh the child, plot the growth chart to assess the growth status, identify reasons for growth faltering and finally counsel the caregiver on child care and feeding practices. During the two simulations, skills of AWWs were evaluated on the above steps.
(a) Weight measurement: Before measuring the weight of the child, about 78% and 71% of AWWs ensured minimal clothing or undressed the child during simulation 1 and simulation 2 respectively. The practice of checking zero-setting on the weighing scales seemed low as only 40% and 32% of AWWs checked zero setting before taking the weight during simulation 1 and 2 respectively. Many AWWs continued to weigh the child with a positive error of as much as one kilogram. While weighing the infants on suspended balances (Salter type) during simulation 1, only 60% of AWWs could position the infant correctly.
(b) Plotting and interpreting the growth monitoring chart: Growth charts used in Gujarat are colour coded as per the gender of the child; pink for girls and blue for boys. About 25% of the AWWs overlooked this and used an incorrect growth chart for the exercise. During simulation 1, about 65% of AWWs could correctly plot the child’s weight against his age while this was done by 75% during simulation 2. The growth of the child was correctly inferred and explained to mothers by 80% and 78% of AWWs during simulation 1 and 2 respectively.
(c) Understanding feeding practices of children: After plotting the growth monitoring chart, it is important for AWWs to identify causes of growth faltering. This requires that they should have skills for asking the right questions while taking a feeding history of the children. During simulation 1, 30% of AWWs asked caregivers the status and frequency of breastfeeding, about 18% of AWWs probed on the duration of breastfeeding and 33% took the history of feeding of other foods, 25% enquired about positioning and attachment during breastfeeding, 2% asked questions regarding symptoms of sufficiency/insufficiency of breast milk while 24% sought information about the morbidity history of the child. During simulation 2, with a mother of 12-18 month child, 19% of AWWs asked about feeding frequency, 9.5% probed about portion size, and 7% enquired about consistency of food being fed to the child. A history of Balbhog feeding was taken by 17% of AWWs and about 12% asked about its consistency. About 8% of AWWs asked mothers about any iron and vitamin A rich foods being given to the child.
(d) Providing appropriate counselling on IYCF: During simulation 1, it was expected that AWWs would counsel caregivers by giving appropriate advice on breastfeeding. During this counselling session, about 35% of AWWs advised mothers on exclusive breastfeeding. About 39% of AWWs counselled mothers on frequency and duration of breastfeeding. Few AWWs gave advice about feeding practices during a child’s illness, and equally few advised caregivers about the need for regular growth monitoring. During simulation 2, advice on frequency, quality and consistency of food was either cursorily mentioned or overlooked during the counselling session. About 19% of AWWs provided advice on food frequency, 10% on portion size and 7% on food consistency. No AWW promoted diet diversity in their discussion with caregivers. About 19 % of AWWs advised caregivers about giving iron- or vitamin A- rich foods to children, though the majority of the foods recommended were expensive. Nearly 26% of AWWs encouraged caregivers to feed the child with balbhog and some also gave a demonstration for making balbhog using the balbhog packet, water and spoon and yet, points related to both the consistency and the frequency of feeding balbhog were missed by all. Around 25% of AWWs were found to have counselled caregivers on responsive feeding, rendering advice on feeding the child slowly and with care. Many AWWs also recommended continued AWC visits for weight and growth monitoring.
The results of the study showed that a relatively large proportion of AWWs was aware of a number of key principles of correct IYCF practices. However, there were still some serious gaps in their knowledge and understanding: very few AWWs knew the nutritional properties of colostrum, none were able to enlist all the four signs of correct attachment of child to breast, a few recalled correct signs to identify milk insufficiency, only one-third knew the specific benefits of exclusive breastfeeding, a majority had wrong knowledge about the correct consistency of complementary food, more than three-fourths were not able to name at least three local foods rich in iron or vitamin A, and about the same proportion did not mention adding green leafy vegetables when they were asked about a meal plan for an infant.
Similarly a majority of the AWWs lacked specific skills essential for proper growth monitoring and counselling, like zero-setting of weighing scales, seeking the correct age of the child, asking the right set of questions while taking a feeding history of children, and giving appropriate and a complete set of messages while providing counselling. As observed elsewhere, AWWs considered weight recording as an “end in itself” as majority of them overlooked the step to discuss and identify causes for growth faltering with caregivers.
The duration and quality of interaction between AWWs and caregivers while counselling caregivers are of great importance. AWWs generally did not make an effort to build rapport with caregivers, necessary for caregivers to open up and share information about their child. Only a few AWWs showed active listening skills, following up on verbal and nonverbal cues. The brief interactions with caregivers were unidirectional and were not customized to or reflecting the specific needs of the child. Messages were general, incomplete, “standard directives” like ‘feed child more’ and not backed by specific details like ‘what’ ‘why’, ‘when’ and ‘how’ about these practices and hence were not conducive to convincing caregivers and fostering positive compliance or change.
In other words, even though AWWs demonstrated a reasonable level of theoretical knowledge related to IYCF practices, their level of knowledge and skills regarding the finer details on IYCF were found wanting. Perhaps even more importantly, a majority of AWWs were not able to correctly apply their knowledge in practice and to correlate caregivers’ practices with the nutritional status of their children, to effectively elicit caregivers’ IYCF related knowledge and behaviour and to use that for efficient counselling and, finally, to correctly identify and help overcome barriers to nutritional improvement.
Implications/policy relevance of findings
The findings of this study imply that the training given to AWWs needs a paradigm shift from being a knowledge focused one to being one that strengthens AWWs’ ability to analyse IYCF practices, identify problems, infer appropriate action and subsequently render personalised counselling to caregivers. Building rapport and emphatic engagement with caregivers, effective communication and associated skills should become central to the training. Studies have emphasised the need for “repeated practical reorientation training” and for reinforcing the importance of following certain minimum rules like correctly recording age, regular recording and plotting of weights and using correct interpretation of growth curves for counselling and follow up. This study points to a need for developing systems that would enable and induce AWWs to carry out necessary activities associated with IYCF, and provide responsive nutrition and health education, backed up by strengthening of outcome based supervision.
* Public Health Foundation of India, New Delhi. Excerpts from the original article, “Capacity of frontline ICDS functionaries to support caregivers on infant and young child feeding (IYCF) practices in Gujarat, India”, published in the “Asia Pacific Journal of Clinical Nutrition”, Volume 23,S1(Supplement 2014), supported by the First Affiliated Hospital of Zhengzhou University, the International Union of Nutrition Sciences, and the Asia Pacific Clinical Nutrition Society