Project Report
Study of malnutrition among under-6 children of Sheopur district with special focus on Saharia tribe
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis
Project Report
Study of malnutrition among under-6 children of Sheopur district with special focus on Saharia tribe
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis
Project Team
Under the Guidance of
Akhilesh Argal, Director, AIGGPA Madan Mohan Upadhyay, Principal Advisor, Centre for Social Sector Development, AIGGPA
Project Coordinator
Richa Sharma, Deputy Advisor, State Health Resource Centre (SHRC), Centre for Social Sector Development, AIGGPA
Consulant
Anil Mishra
Research Associate
Manisha Chouhan
Index S.No Particulars Page No Executive Summary 1 1 Introduction 4 1.1 Understanding Malnutrition 5 1.2 About Sheopur 7 1.3 Karahal Block 8 1.4 Introduction to Saharia tribe 8 2 Objectives and methodology 9 2.1 Objectives of the study 10 2.2 Key stakeholders involved 10 2.3 Interaction with Saharia community at 11 Institute 2.4 Methodology and sampling 12 2.5 Data collection 13 2.6 Limitations of the study 14 3 Data analysis 15 3.1 Socio-Economic Parameters 15 3.2 Hygiene related aspects 23 3.3 Food habits in the community 25 3.4 Family Planning related issues 28 3.5 Pregnancy and childcare related aspects 30 3.6 Action taken during common childhood 35 illnesses 3.7 Services of Anganwadi 39 3.8 Vaccination 41 3.9 Nutrition Rehabilitation Centre 43 3.10 Alcohol and consumption of tobacco 44 3.11 Observation during field visit 44 3.12 MNREGA in the district and Karahal 48 4 Findings against key objectives 50 5 Recommendations 57 References 68 Annexures 70
Abbreviations and Acronyms
ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist AWC Anganwadi Centre AWW Anganwadi Worker, Anganwari Karyakarta BPL Below Poverty Line CSR Corporate Social Responsibility ICDS Integrated Child Development Services IFA Iron Folic Acid MUAC Mid Upper Arm Circumference NFHS National Family Health Survey NRC Nutrition Rehabilitation Centre NRHM National Rural Health Mission POSHAN PM’s Overarching Scheme for Holistic Nourishment WASH Water, Sanitation and Hygiene WCD Women and Child Development
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Executive Summary
Childhood under nutrition is an important area of concern in India. Children with Severe Acute Malnutrition (SAM) have nine times higher risk of dying than well-nourished children.With appropriate nutritional and clinical management, many of such deaths can be prevented.Malnutrition among children is actually a manifestation of many other socio- economic and cultural factors. General poverty coupled with lack of assured employment round the year is the major issue which needs to be looked into. Generally there is a tendency among the planners and administrators to look into malnutrition as a health related issue and accordingly the interventions also focus on it. The main livelihood and poverty gets missed out. All this necessitate that the problem is dealt with in a more comprehensive and multi- disciplinary approach.
Sheopur is a predominantly tribal district with the Saharia being the major tribe residing mostly in Karahal block of the district. This study has been planned in order to understand the causal factors of malnutition in the area and thereby devising a context specific strategy to combat this problem. On account of various parameters of deprivation, Karahal block in Sheopur district was chosen as focal area for the study.
In order to develop an understanding of the issues faced by the Saharia community, men and women from the Saharia community in Sheopur district were invited to Bhopal and discussion was held on various aspects like climate in the region, livelihood opportunities, drinking water etc to get an overall view.After getting an understanding of the overall situation a detailed questionnaire was developed .The sample comprised of 200 families of Saharia community and 200 Non-Saharia .Four local female field investigators who were residents of the Sheopur district were involved in collection of data by means of the questionnaire. It was found that overall the children from the Saharia community had almost twice the incidence of malnutrition the Non-Saharia community.Illiteracy in the block is very high, 73 % of the Saharias and 65 % of the Non-Sahariia respondents were illiterate. 90% the Saharia community respondents worked as labourers while it was 48% for Non- Saharia.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Migration is a very significant aspect of the community in the area. It has an impact on the uptake of the health and other ICDS, nutrition, vaccination related facilities in the area. This breaks the continuity of the service delivery. Migration also reflects on the lack of livelihood related options available in the area. Overall 34% of the households migrated to neighbouring places for work. However among the Saharia households approximately 56% migrated for work while only 12% of those from Non-Saharia households migrated for work. Though women were adviced to consume additional food during pregnancy, it was found that additional food consumption was up to a maximum of 3-6 months.The most common illnesses reported for diarrhoea,fever and common-cold.
Saharia is notified as the Primitive Tribe Group (PTG) in Madhya Pradesh.It is strongly recommended that the government should have a higher allocation for PTG predominant blocks. It is also proposed that the quota of MNREGA allocation for 100 days may be increased to 150 -200 days in the year for the next 5 years in Sheopur district.The possibility of introducing a crash program for the next 4-5 years needs to be explored in order to address livelihood related problem and nutrition requirement in the region. Approximately 60 % of the area of Sheopur district is under forest cover. Collecting tendu patta is one of the commonly used forest based source of livelihood for the people in this area. Forests also provide a range of marketable products like Resins (gum), Bahera, Nagar motha, Edible gond, Satawar, Mahua etc. Many of the locally collected medicinal herbs fetch a good price in open markets but the tribal people end up selling these products to the intermediaries at abysmally lower prices. The support for marketing and value addition by creating processing facilities would enhance the income in the community.It is recommended that a special plan is drawn by the MFP cooperative federation, which has the resources, to identify all marketable Minor Forest Products and create Self Help Groups (SHGs) for them. Such SHGs should be empowered to scientifically harvest, process and sell at competitive prices to the larger markets outside Karahal. With effect from December 2017 onwards the Government has initiated a cash assistance scheme of Rs 1,000 per month to each of the families of special backward scheduled tribes (STs) as part of its efforts to eliminate malnutrition among the communities. The amount of Rs 1000 per month is being provided to special backward ST communities, including Saharia, Baiga and Bharia, to address the problem of malnutrition among them. The amount is being deposited in the bank account of the woman head of the family to be used for
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe buying nutritious food items. This initiative of the Government is likely benefit the community in addressing the problem of malnutrition among Saharia and other tribes also. The focus should be on expanding access to primary education in this region .There is a need for expansion of health care services in the affected area including reproductive and child care, pre and post-natal care, vaccination etc. Intensive health awareness in the target group of expectant mothers / adolescents needs to be launched in the campaign mode through women and child development department and health and family welfare department.
The district of Sheopur is identified under Phase –I of the Poshan Abhiyaan programme. It is the flagship programme of the Ministry of Women and Child Development (MWCD),which ensures convergence with various programmes.It lays emphasis on the first 1000 days of the child, which includes the nine months of pregnancy, six months of exclusive breastfeeding and the period from 6 months to 2 years to ensure focused interventions on addressing under nutrition. It is recommended that increased allocation of PDS be given to families having severely underweight children and for and SAM children discharged from Nutrition Rehabilitation Centres. Intensive monitoring is required at all levels including District Collector, CEO Zilla Panchayat, Saharia Vikas Pradhikaran, Chief Medical Officer, Block Medical Officer, Staff at Nutrition Rehabilitation Centre, Community Health Centre, Primary Health Centre, ANMs, ASHA Karyakarta, Anganwadi Karyakarta etc need work in co- ordination towards the aim of reducing malnutrition in the area. This will ensure that the problem of malnutrition is addressed properly in the region. Looking into the level of illiteracy in the regio and to address the specifics needs of the tribal community in local languages resource is available in the form of Vanya radio station to enhance community participation. It focuses on programs centred on tribal lifestyle, culture, society, traditions, folk resources etc. Radio station Vanya located in Sesaipura (Sheopur) provides a great window of opportunity as it makes programmes in Saharia dialect which is easily understood by the community. This communication medium may be used more agressively to communicate information on other aspects including hygeine, health, livelihood etc to the community.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Chapter 1
Introduction
Childhood under nutrition is an important public health and development challenge in India and such children have significantly higher risk of mortality besides increased risk of death and diseases, this also leads to growth retardation and impaired psychosocial and cognitive development. Children with Severe Acute Malnutrition (SAM) have nine times higher risk of dying than well-nourished children1. In India, the prevalence of SAM among children remains high despite overall economic growth1.
The National Family Health Survey-4 for India revealed that 7.5 percent of all children under-five years of age are severely wasted (weight-for-height) 2. With appropriate nutritional and clinical management, many of such deaths can be prevented. Strong evidence exists on synergy between under nutrition and child mortality due to common childhood illnesses including diarrhoea, acute respiratory infections, malaria and measles. From the perspective of health sector, the most important intervention is promotion of appropriate infant and young child feeding and nutrition practices and related maternal under nutrition. Malnutrition among children is actually a manifestation of many other socio-economic and cultural factors. General poverty coupled with lack of assured employment round the year is the major issue which needs to be looked into. Generally there is a tendency among the planners and administrators to look into malnutrition as a health related issue and accordingly the interventions also focus on it. The main livelihood and poverty gets missed out. All this necessitate that the problem is dealt with a more comprehensive multi-disciplinary approach. Globally approximately 52 million children under 5 years are wasted and 70 percent of them are in Asia3. Worldwide approximately 5 million children die every year due to causes linked directly or indirectly to undernutrition4. Household allocation of scarce family resources too affects child health. Children born with low birth weight are more likely to be exposed to the risk of experiencing malnutrition as they grow up, and are also likely to have high mortality risk5.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
1.1 Understanding malnutrition Malnutrition is a general term. It most often refers to under nutrition resulting from inadequate consumption, poor absorption or excessive loss of nutrients, but the term can also encompass over-nutrition, resulting from excessive intake of specific nutrients. An individual will experience malnutrition if the appropriate amount of, or quality of nutrients comprising for a healthy diet are not consumed for an extended period of time. Impact of under nutrition Children suffering from under nutrition begin their lives with a significant disadvantage. As mentioned above, child malnutrition significantly contributes to under-five mortality as undernourished children have increased susceptibility to infections and hence frequent episodes of illness and longer recovery period. Without treatment, children who are affected by moderate or severe acute malnutrition during the critical stage of life between conception and age 2, if not provided with timely and quality care, will find it difficult to achieve their full potential. Scientific evidence has shown that beyond the age of 2-3 years, many effects of chronic under nutrition are irreversible. This means that to break the intergenerational transmission of poverty and under nutrition, children at risk must be reached during their first two years of life1.
Anthropometry is a widely used, inexpensive and non-invasive measure of the general nutritional status of an individual or a population group. The three commonly used anthropometric indices are: Weight-For-Age (WFA). Length-For-Age or Height-For-Age (HFA). Weight-For-length or Weight-For-Height (WFH). Types of under nutrition The above three indices are used to identify three nutrition conditions: underweight, stunting and wasting, respectively. Each of the three nutrition indicators is expressed in standard deviation units (Z-scores) from the median of the reference population based on which under nutrition may be further classified as moderate or severe. Underweight: Underweight, based on weight for-age, is a composite measure of stunting and wasting and is recommended as the indicator to assess changes in the magnitude of
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe malnutrition over time. Stunting: Failure to achieve expected height/length as compared to healthy, well-nourished children of the same age is a sign of stunting. Stunting is an indicator of linear growth retardation that results from failure to receive adequate nutrition over a long period or recurrent infections. This in turn affects economic productivity at national level. A stunted child has a height-for-age Z-score that is at least two standard deviations (-2SD) below the median for the WHO Child Growth Standards. Wasting: Wasting represents a recent failure to receive adequate nutrition and may be affected by recent episodes of diarrhoea and other acute illnesses. Wasting indicates current or acute malnutrition resulting from failure to gain weight or actual weight loss. Causes include inadequate food intake, incorrect feeding practices, disease, and infection or, more frequently, a combination of these factors. Wasting in individual children and population groups can change rapidly and shows marked seasonal patterns associated with changes in food availability or disease prevalence to which it is very sensitive. A wasted child has a weight-for-height Z-score that is at least two standard deviations (-2SD) below the median for the WHO Child Growth Standards. Severe Acute Malnutrition (SAM): Severe acute malnutrition is defined by very low weight-for-height/length (Z- score below -3SD of the median WHO child growth standards), a mid-upper arm circumference <115 mm, or by the presence of nutritional oedema. Diagnostic criteria for SAM in children aged 6–60 months
Indicator Measure Cut-off Severe Weight-for-height < -3SD wasting Severe MuAC (Mid Upper < 115mm wasting Arm Circumference) Bilateral Clinical sign oedema ------SAM increases significantly the risk of death in children under five years of age. It can be an indirect cause of child death by increasing the case fatality rate in children suffering from common illnesses such as diarrhoea and pneumonia. Children who are severely wasted are 9 times more likely to die than well-nourished children1.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Mechanism of measurement of under nutrition According to the National Family Health Survey (NFHS-4, 2015-16) 55% of children in Sheopur District under are of five years were underweight (low weight for age ) while the same for Madhya Pradesh was 42.8% and 35.7 % at all India level. Further details on various parameters under NFHS 4 are at Annexure 1. The problem of malnutrition is more acute in the Sheopur district of Madhya Pradesh as compared to the National average and the overall status of the same in Madhya Pradesh and thus is the focus area for the study.
1.2 About Sheopur
Sheopur is situated on the western part of the state. It is surrounded by Rajasthan’s Sawai- Madhopur in the west, Kota in the south-west and Bara in the south whereas Shivpuri and Morena in the east and the north respectively. It extends from 250 15’ to 250 45’ north latitude and 760 22’ to 77022’ east longitude. Its geographical area is 6606 sq. km. The total forest area of Sheopur is 3949 sq. km which is 59.79% to the total area (6606 sq. km) of the district. Out of the 607 villages, only 180 villages are connected by road. The proportion of Scheduled Tribes to the total population of Sheopur is 23.5% while the proportion of Scheduled Caste population to the total population of Sheopur is 15.8 %. Majority of the population of Sheopur (84.4%) lives in rural areas6. Details about Sheopur district and its population etc are at Annexure 2.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
1.3 Karahal Block There are three blocks in Sheopur district namely: Vijaypur, Sheopur and Karahal. Karahal block in Sheopur is the focus for the purpose of this study. This block has the highest population of Scheduled Tribes (rural 63.08%) of the total population of the block. 21.53 % of population of Karahal block is cultivators while the percentage is (51.56 %) in Vijaypur block of the district. 62.63 % of the population in Karahal is engaged as agricultural laborers6.Detail of block wise status (within Sheopur district ) on various parameters as mentioned in district census handbook are available in Annexure 3.
1.4 The Saharia tribe
Madhya Pradesh is the tribal heartland of India. Among the 3 primitive tribal groups found in Madhya Pradesh Saharia tribe is the largest one with 75.76 % of the total PTGs population of Madhya Pradesh. (Source: Website of Tribal Welfare Dept. Govt of M.P.). The sporadically concentration of Saharia are not only limited by political boundary in Madhya Pradesh, but also their dispersals are located in Rajasthan, Andhra Pradesh, Orissa, Bihar and rarely in West Bengal. The early history of origination of Saharia is not exactly clear. Etymological point of view expresses that the word ‘Sahria’ is the combination of two independent words like “Sa’ (companion) and ‘Haria’ (tiger) which mean companion of tiger. Most of the Saharia are dependent on ecology which plays an important role in forming their economic structure (Mandal, 1998)7. The past economic history implies that they traditionally practiced shifting cultivation, hunting, gathering, pastoralism, etc. and sometimes also adopted nomadic life (Prabhu, 1983)8 but in present time, most of the Saharias have become daily wage earner instead of their traditional way of occupation (Singh, 1994)9. Most of them are landless and poverty stricken. Roti is considered as their staple food. But sometimes, due to unavailability of wheat, they consume roots, tubers, leaves, etc. too which are collected from the nearby forests. They are very much addicted to drink local wine. Their area usually faces shortage of water. Their poor food habits contribute to their malnutrition, especially among children and pregnant mothers, which lead to increased susceptibility to morbid conditions10.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Chapter 2
Objectives and Methodology Sheopur is a predominantly tribal district with the Saharia being the major tribe residing mostly in Karahal block of the district. Geographical isolation, unique cultural practices, low female literacy, poor health seeking behaviour has subjected this population to a wide spectrum of health problems in the form of both communicable and non communicable diseases. Amongst these health problems, malnutrition in young children is the most pressing one. The past few years have seen growing concern of government towards malnutrition in general and tribal areas in particular. Certain deaths of children were reported to have occurred due to malnutrition in the district. In order to understand the causal factors and thereby devising a context specific strategy to combat this problem, a study was assigned by the Health Department to this Institute on the issue of malnutrition among under 6 children in the district with a special focus on Saharia tribe. On account of various parameters of deprivation, Karahal block in Sheopur district was chosen as focal area for the study. In the past years several initiatives have been taken by the Central and the State Government to curb malnutrition in general which include: . Integrated Child Development Services (ICDS) Scheme- key measures include regular weight monitoring for early identification of growth faltering, nutritional supplementation in the form of take home ration for under 6 children and lactating mothers, meal provision, iron folic acid supplementation, Vitamin A supplementation, Nutrition counselling of mothers, early referral to Nutrition Rehabilitation centre (NRC) if severe acute malnutrition or medical complications arise. . Health Services- Antenatal, Intranatal and postnatal services, breastfeeding counselling and support, immunization services, early detection and referral if required for common childhood ailments including diarrhoea and acute respiratory infections. . Supplementation of Iron and Folic Acid to adolescent girls in schools to stall the intergenerational cycle of malnutrition. . Mid Day Meal scheme for school going children. . Potable water supply Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 9
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
. Assured Public distribution system. . Various other livelihood programs like MNREGA. However, it is a long process with requirement of consistent efforts and there is always a scope of learning and improving. This study aims to understand the determinants of malnutrition in Saharia tribe of Sheopur. 2.1 Objectives of the study 1. To understand the underlying causes of malnutrition among the children in the study area. It includes the following components. a. To assess the socio cultural and economic status, means of livelihood, status of family and food security situation in the study area. b. To assess coverage of basic child health services like immunization, supplementary nutrition, deworming, iron and folic acid supplementation, treatment of common ailments, use of ORS and Zinc during diarrhoea, treatment of Acute Respiratory Infections etc in children from Saharia and Non-Saharia families c. To assess the knowledge, attitude and practice of the family regarding the infant, the young child's nutrition and common childhood illnesses. d. To assess the uptake of key maternal health services like Antenatal, intra-natal and postnatal services and the ICDS centres in the study area. 2. To evaluate utilization of NRC services and relevance of its geo-physical location for serving the high burden areas.
2.2 Key Stakeholders involved Children from 0 to 6 yrs of age in Sheopur District Families in the area having children of the age group 0-6 years Health facilities in the district, including Nutrition Rehabilitation Centre ICDS centres in the district NRCs in the District District Administration and associated departments Rural Development Department, Govt of MP
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
2.3 Interaction with Individuals of Saharia community from Sheopur district at AIGGPA
In order to develop an understanding of the issues faced by the Saharia community, men and women from the Saharia community in Sheopur district were invited to the AIGGPA at Bhopal. The discussion was held on various aspects like climate in the region, livelihood opportunities, drinking water and nutrition and health related aspects to get an overall view of the problem of malnutrition which is affecting the life of the children. This pre-study discussion which was done in order to develop an understanding of the issues faced by them which could help to plan the study in a better way.
The following issues emerged from this discussion:- Livelihood related issues Majority of them worked as labourers with land ownership in the range of 1 to 4 Bigah. The main crops grown by them were Wheat, Mustard etc. They usually work as agricultural labour during the sowing and harvesting season which is for about 3 months in a year. Tendu Patta collection also provides them employment through forest department which carries out the plucking operations and pays them wages for that. They also collect various medicinal herbs that are sold in the local market. Migration is common in the region – during lean seasons they move out to neighbouring area in search of work as agricultural labourers. Some families have domesticated animals like Cows or Hen (usually 2-5 per family). The cows are not in good health and usually give milk only a few months of the year. They also rear Hen in the household and sell their chicks in the market. During summers the eggs get spoilt due to excess heat. It is a rocky terrain with chronic scarcity of water and tap water is not readily available. Hand pumps are the common source of drinking water which at times the water is not very clean. Nutrition and other aspects Majority of the community are illiterates. They suffer from various infections that result in diseases.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
They get wheat from ration shop and some families grow vegetables. They also eat eggs at times. Child care related aspects The average number of children per family in the community is 4 to 5. 108 ambulances services are available but the villages being in remote areas where road access is not very good so they face problems during the rainy season. At times, the marriage of girls in the Saharia community takes place before the age of 18 years.
2.4 Methodology and sampling
Karahal block having a population of 1,29,884 (as per 2011 census) was the focus of this study. This block was selected as it is among the worst affected area in context to Severe Acute Malnutrition (SAM). When it is not possible to study an entire population but the population is known, a smaller sample is taken using a purposive sampling technique. Slovin’s formula allows researchers to sample the population with a desired degree of accuracy. This was used to calculate the sample size. A confidence level of 95% was taken, Slovin's formula is: n = N / (1 + Ne2) Where: n = Number of samples, N = Total population e = Error tolerance The Slovin’s formula was calculated as follows: n = 129884/1+129884(0.05*0.05) =399 Using it, a sample of 400 children was taken from Karahal block. A child was eligible to be enrolled in the study if he/she is more than one year and less than six years of age at the time of collection of data. The study team did preferential selection of families having a SAM child who was admitted in the health facility/NRC in the last three years to assess the patient perspective of NRC functioning. Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 12
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
The study was designed as to enable the understanding of key factors that are specific to the study population and may be playing a contributory or causal role in the childhood malnutrition. The study intends to analyze the socio-cultural practices followed in the region in Saharia families with those who are Non-Saharia. In order to do that the study was initiated with a hypothetical consideration that there are probably, some factors; to which Saharia families and children are getting exposed which is making Saharia children more vulnerable to undernourishment. Keeping this hypothetical consideration in mind, a comparative element was introduced in the study to help the project team draw comparison. To eliminate bias in the village selection process, approach use was ‘Probability Proportionate to Size’ (PPS) sampling. A 30-cluster approach for section of villages was used. Within selected villages, to randomize household selection in a systematic manner, segmentation of each village in 4 parts was done and two Saharia families and two Non- Saharia families with children under more than one year of age but less than six years of age were selected from each segment, with preferential selection of family having a severely malnourished child (if not, then any malnourished child). The sample taken for the purpose of the study comprises of 200 families from the Saharia community and compares the same against 200 families of Non-Saharia families. Efforts were done to include 100 families each of Saharia –malnourished, Saharia –normal, Non –Saharia –malnourished and Non- Saharia –normal from the same area. Village selection was done based on secondary data received from the office of Collector, Sheopur. Primary data for socio-economic, cultural and food security aspects besides data about Knowledge, attitudes and practices (KAP) was collected through specially designed questionnaires. The KAP was administered to the mothers while general information was collected from any adult member of the household, preferably the head of the household. Details of village selection are available in Annexure 4.
2.5 Data Collection
For selection of households in the villages, the interviewers visited the Anganwadi and identified the households which have children between 1 and 6 years of age. A household that currently had a severely malnourished child in the stated age group in preceding 3 calendar years was preferentially selected. The process of identification of household of household for the purpose for the purpose of the study is given in Annexure 5.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Four local female field investigators who were residents of the Sheopur district were identified for the purpose. The information was gathered about the youngest child in the family in the age group 1 to 6 years called the index child for the purpose of the study. This was done to be able to understand the child feeding practices, age at which complementary feed was introduced to the child and certain other parameters like immunization etc. The youngest child was chosen as the index child for the purpose of the study because the parents are likely to recall information regarding care during pregnancy, immunization, services taken from the Anganwadi etc easily for the youngest child. During the collection of data from the village a total of 87 families of children suffering with malnutrition could be identified from the Saharia community and 42 families of children from the Non - Saharia community from the selected villages could be identified and included in the survey. The survey was conducted on 200 Saharia and 200 Non-Saharia families in the community.
2.6 Limitations of the study
The study is mainly based on primary data. There is a risk that because of the presence or influence of the interviewer in a face-to-face interaction, the interviewer might unknowingly bring out an untrue response to sensitive questions, e.g. the respondent may craft an answer to please the interviewer instead of answering truthfully or the interviewer might record a verbal response incorrectly because the statement is not interpreted correctly. Nevertheless, efforts were made to minimize the possibility of error as the field investigators, for the purpose of the study, were local from this area only.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Chapter 3
Data Analysis Overall the children from the Saharia community had almost twice the incidence of malnutrition than those who did not belong to the Saharia community. Thus the findings on certain important parameters were analyzed at overall level of for the population surveyed and also for the respective respondents of the Saharia and the Non-Saharia community. The findings of the study are based on the responses received on various parameters such as size of the family, number of children, livelihood related aspects, their understanding related to health aspects etc. The findings are as under: 3.1 Socio- Economic Parameters: Family type: Overall 84 % of the households covered under the study lived in a nuclear family and the 16 % belonged to a joint family. Among the respondents Saharia households, 86 % of the Saharia households lived in a nuclear family while approximately 82 % of the respondents from the Non-Saharia community lived in nuclear family. Level of literacy in the household: The Saharia community has a higher percentage of illiterate population than the Non-Saharia .Among the Saharia community, approximately 73 % of the respondents were illiterate while approximately 65 % of the Non – Saharia were illiterate. Overall 69 % of the respondents were illiterate.
Graduate Post 12th 1% Graduate 9% 1%
8th 10%
5th 10%
illiterate 69%
Graph 1: Level of literacy among the households
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
74 73 %
72 69 % 70
68
66 65 %
64
62
60 Saharia Non- saharia Overall
Graph 2: illiterates among Saharia and Non-Saharias
Opinion of the community on how many children a couple should have: 52 % of the respondents were of the opinion that a couple should have three or more children.
One More than Four 1% four 11% 1%
Two Three 47% 40%
Graph 3: Opinion of the community on the number of children a couple should have
Actual number of children in the family: Out of the households covered in the survey, 17 % had one child only, 31 % had two children overall 52 % of the households had 3 or more showing the poor awareness about family planning in this region. When the same was analyzed at the community level, 60 % of the Saharia households had 3 or more children while 44 % of the Non-Saharia household surveyed had 3 or more children.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Five Six Seven 5% 3% 1% One 17%
Four 16%
Two 31% Three 27%
Graph 4: Actual number of children per couple at the community level
70 60% 60 52% 50 44% 40
30
20
10
0 Saharia Non- saharia Overall
Graph 5: Saharia and Non-Saharia families having 3 or more children
Occupation: Approximately 69 % of the respondents worked as labourers , 21 % in agriculture , almost 10% followed other occupation (collecting tendu patta ,selling milk, teacher , petty employment , shopkeeper , selling Gums and Medicinal Herbs and taking care of the cattle).When the same was analyzed among Saharia and Non-Saharias , huge majority (90%) of the respondents from the Saharia community worked as labourers while only 48 % among the Non- Saharia worked as labourers.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Other 10%
Agriculture 21%
Labourer 69%
Graph 6: Occupation at the community level
Saharia 90 % 90 Overall 69 % 80 70 Non- saharia 60 48 % 50 40 30 20 10 0 Saharia Non- saharia Overall
Graph 7: Saharias and Non-Saharias working as labourers
Caste classification: 63 % of the respondents in the study belonged to the scheduled tribe, 27 % to other backward classes, 8 % to scheduled caste and only 2 % of belonged to the general category.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
General Scheduled 2% Caste 8%
Other Backward Classes 27%
Scheduled Tribe 63%
Graph 8: Caste category at the community level
Migration: Migration is a significant social aspect of the region and it has an impact on the uptake of the health and other ICDS, nutrition, vaccination related facilities in the area. This breaks the continuity of the service delivery. Migration also reflects on the lack of livelihood related options available in the area. Overall 34 % of the household mentioned that they migrated to neighbouring places for work. However among the Saharia households approximately 56 % migrated for work while only 12 % of those from Non-Saharia households migrated for work.
60 56% 50 40 34% 30 20 12% 10 0 Saharia Non- saharia Overall
Graph 8: Percentage of Saharias and Non –Saharias who migrated for work Land Holding: Approximately 52% of the respondents had some land. Among Saharia only for 39% of the respondents had land holding while among the Non-Saharia 65 % of the respondents had land holding.
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 19
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
70 65% 60 52% 50 39% 40 30 20 10 0 Saharia Non- saharia Overall
Graph 9: Land holding among Saharia and Non-Saharia
Among those who had land, 75 % were marginal farmers, 19 % of them were small farmers only 3 % were medium farmers while another 3 % were large farmers. For the purpose of the study the following approximation was used: Land holding less than 2.5 acre were considered marginal farmers, holding in the range 2.5 to 5 acre were considered small farmers and land in the range 5 acre to 10 acre were considered medium farmers .Land holding greater than 10 acre were considered large farmers.
75% 80 70 60 50 40 30 19 % 20 3% 3% 10 0 Marginal Small Medium Large farmers farmers farmers farmers
Graph 10: Land holding at the community level
The major crops are grown during the Rabi and Kharif season. It was found that in some cases they grow one crop on certain portion of land and another crop on the remaining portion of land.
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 20
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Kharif season: Urad dal, rice, bajara and soyabean were the commonly grown crop during the kharif season. Rabi crop: Wheat was the major crop during rabi season with 67 % of the land owners growing wheat, 8 % grew chana, 1 % rice and 3 % mustard. There were some cases where they did not grow any crop on the land during the Rabi season. Domestic Animals: Almost 42 % of the respondents had domestic animals. In some cases more than one animal was domesticated by them. Among animals, cow and buffalo were the most common, followed by goat and hen.
34% 35
30
25
20 16%
15
10 5% 5 3%
0 Cow Buffalo Goat Hen
Graph 11: Domestic Animals
However amongst those who had cow ,majority belonged to the Non-Saharia commuinty. Only almost 10 % of the surveyed Saharia households had cow.
Annual family income: An effort was done to know the annual income of the household. Huge majority around 91 % of the respondents mentioned their annual family income was less than Rs 50,000
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 21
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
100 91% 90 80 70 60 50 40 30
20 7% 10 1% 1% 0 upto 50000 50001-1 lac > 1 lac >2 lacs
Graph 12: Annual family income per annum in rupees
BPL card: Almost 65% of the respondents had BPL card. 77% of the respondents from the Saharia community had BPL card while 52% of the respondents from the Non- Saharia community had BPL card.
90 80 Saharia, 77 % Overall, 65 % 70 Non -Saharia, 60 52 % 50 40 30 20 10 0 Saharia Non -Saharia Overall
Graph 13: BPL card holders among Saharia and Non-Saharia
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 22
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
3.2 Hygiene related aspects:
An effort was done to identify the commonly used source of drinking water in the community and the practice followed, if any, for the treatment of water before using it for drinking. They were asked about the practices they follow regarding washing their hands after defecation. They were also asked about their practice regarding cutting nails, brushing the teeth and frequency of brushing the teeth. Source of drinking water: The respondents were asked about the source of drinking water used by them. 48% of the mentioned that they used tube well water whereas 37% took water from the hand pump, 6% used water from uncovered well, and 3% of the respondents used water from covered well. Only 3% of the respondents have facility of piped drinking water.
48 % 50 37 % 40 30 20 3% 6 % 10 3 % 2% 0 Open Covered Hand Boring Water Piped well well Pump from Water pond Graph 14: Source of drinking water
About 10 % of the respondents mentioned that they found the water they used for drinking was visibly dirty. Treating drinking water before usage: 91 % of the respondents did not do anything extra to purify the water. Only 4% added chlorine tablets to the water, 4 % cleaned the water with a cloth, only 1 % of the respondents added alum powder (fitkari) to the water for cleaning the same.
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 23
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
100 91% 90 80 70 60 50 40 30 20 4% 4% 10 0 1% 0 Filtering Boiling Adding Adding Nothing the water fitkari chlorine to with cloth water
Graph 15: Treating drinking water before usage
Washing hands after defecation: Attempt was made to know if the community is aware of the importance of washing hands after defecation. 96% of the respondents mentioned that they are aware of the importance of washing hands post defecation. However, when asked about how they washed their hands post defecation, 46% of the respondents mentioned that they washed hands with soap and water, while 34% used water and ash, approximately 10% washed their hands with plain water and another 10% wash their hands with mud and water .
46% 50 34% 40 30 20 10% 10% 10 0 With plain With water With ash Soap and water and soil and water water
Graph 16: Practice of washing hands after defecation
Frequency of brushing of teeth: 96% of the respondents mentioned that they brush their teeth only once a day (on waking up in the morning).
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 24
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
96 % 100
80
60
40 3 % 20 1% 0 0 0 Once daily in Twice daily in Thrice daily One daily at Once in a morning morning and night while but not at night daily
Graph 17: Frequency of brushing teeth
Practice regarding cleaning the teeth: 89% of the respondents used brush and toothpaste, 10 % of the respondents used twigs of neem tree (Azadirachta Indica) while 1 % of the respondents cleaned their teeth with their fingers only.
89%
90 80 70 60 50 40
30 10 % 20 1% 10 0 With brush and With neem twigs Cleaning of teeth toothpaste with fingers
Graph 18: Practice regarding cleaning of teeth
3.3 Food habits in the community:
Daily food habits: Almost all the respondents reported consumption of rotis on a daily basis, while 72% of the respondents included dal in their daily diet. Only 30% of the respondents consumed vegetables on a regular basis while 17 % of them consumed rice and 9% of the respondents reported regular consumption of milk.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
100% 100 90 80 72% 70 60 50
40 30% 30 17% 20 9% 10 0 Rice Dal Roti Vegetables Milk
Graph 19: Daily food items consumed at the community level Food consumption pattern among the Saharia and Non –Saharia community: On comparison it was found that only 24 % of the Saharia households consumed vegetables on a regular basis while this percentage among the Non-Saharia was 37%. Only 11% of the households of Saharia community consume rice on regular basis while this percentage among the Non-Saharia was 23%. Approximately 35 % of the respondents mentioned that they consumed milk at least sometime. The consumption of milk was also found to be much lower among the Saharia families (11% in Saharia against 60 % in Non- Saharia).
40 37% 35 30% 30 24% 25 20 15 10 5 0 Saharia Non- saharia Overall
vegetables
Graph 20: Consumption of vegetables among Saharia and Non-Saharia
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 26
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
25 23%
20 17% 15 11% 10
5
0 Saharia Non- saharia Overall
rice
Graph 21: Consumption of rice among Saharia and Non-Saharia
70 60% 60 50 40 35% 30 20 11% 10 0 Saharia Non- saharia TOTAL
Graph 22: Milk consumed at least sometime among Saharia and Non-Saharia Consumption of milk, egg and meat in the family: Milk is a good source of calcium while eggs are a good source of protein. It is essential to identify the pattern of consumption of milk, eggs and meat in the family to get a fair idea of the overall nutrition position in the households. Consumption of milk was found to be very low among the Saharia community as compared to their Non-Saharia counterparts. Only 6% of the respondents consumed eggs. 17% of the respondents consumed hen’s meat while 7% of the respondents consumed the meat of goat.
Efforts were made to further analyze the daily food consumption patterns in terms of bowls per day out of the respondents who reported consumption of rice, dal and vegetables. While only about 30% of the respondents reporting consuming vegetables on a daily basis only 13% of the same consumed 3-4 bowl of vegetable per day. The quantity of food intake also depends on the size of the bowl. An effort was further done to analyze the size of the bowl of
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 27
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe in which food was consumed on a regular basis 42% of the respondents used small size bowl, 41% of the respondents used a medium size bowl while only 17% of the respondents used large size bowl on a regular basis. Roti consumption pattern per day among the families was as under: Average number of Rotis Number of respondents Approximate Percentage eaten per person per day 2-3 18 5 % 4-5 57 14% 6-7 64 16 % 8-9 147 37 % 10-12 114 28 % Total 400 100 %
Recommended Dietary Allowance: It is essential to have a balanced diet for overall well being of the individual. A balanced diet contains all essential (macro and micro) nutrients in optimum quantities and in appropriate proportions that meet the requirements. The recommended daily allowance of Balanced diet for Adults is available in the Dietary Guidelines for Indians- A Manual published by National Institute of Nutrition, Indian Council of Medical Research; Hyderabad (Enclosed as Annexure 6).It is evident from the details of dietary pattern in the community that dietary needs of the community are not being fulfilled. Also given the fact that overall consumption of vegetables is low and the consumption of milk, eggs and meat is meagre at the community level and and that tribal population is in general prone to chronic energy deficiency they are more likely to suffer with Protein Energy Malnutrition(PEM)11.
3.4 Family planning related aspects:
Family planning: To know the level of awareness, the respondent women were asked about the various methods of family planning. An unusual feature that was noticed here was the usage of water extracted after boiling black pepper (kali mirch) or black cumin (jeera) for the purpose of family planning. The respondents were also asked if they are using any method of family planning. Almost 75% of the respondents mentioned that they are not using any Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 28
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe method of family planning. Among the respondent women who resorted to family planning technique the commonly used techniques were operation and birth control pill. The usage of family planning methods was found to be even lower among the Saharia community at approximately 22%.
30 28% 25% 25 22% 20
15
10
5
0 Saharia Non- saharia Overall
Graph 23: Any method of family planning used among Saharia and Non-Saharia
Age at the time of marriage and child birth related responses: The respondents were asked about their opinion what should be the age of a girl at the time of marriage. 95 % of the respondents felt the ideal age of marriage for girls should be 18 years or above while the balance 5% felt that the girls should be married before the age of 18 years. Similar question was asked about boy’s age. 90 % of the respondents felt the ideal age of marriage for boys should be 21 years or above and only 10% felt that the boys should be married when they are in the age group 18-21 years. Approximately 20 % of the respondent women mentioned that they got married before attaining the age of 18 years.
50 41% 40 26 % 30 18% 20 13 % 10 2% 0 16 year 17 year 18 year 19- 21 Did not years respond
Graph 24: Girl’s age at the time of marriage
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 29
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Approximately 28 % of the respondent women from the Saharia community mentioned that they were less than 18 years of age before marriage.
30 28% 25 20% 20 15 13% 10 5 0 Saharia Non- saharia Overall
<18 years …
Graph 25: Age of the girl less than 18 years at time of marriage 3.5 Pregnancy and childcare related aspects:
Care during pregnancy: The respondents were asked whether they were aware of the need for taking care during pregnancy. Further the respondents were asked about the care /precautions actually taken by them during pregnancy. This was done in order to compare the awareness with the practice actually followed.
Knowledge of precautions/ care to be taken during pregnancy Care /precautions actually taken during pregnancy
94 94 93 94 100 92 88 88 83 86 90 78 70 80 64 64 70 55 53 60 50 42 40 30 20 10 0
Graph 26: Comparison of knowledge of precautions/care to be observed during pregnancy and the care actually taken during pregnancy
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 30
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
83% of respondents felt that they need to take adequate rest while only 64% of the respondent’s actually took adequate rest during pregnancy. While only 53% of respondents felt they should abstain from heavy work during pregnancy, actually only 42% of the women refrained from doing heavy work during pregnancy. The most commonly used service of the Anganwadi by the pregnant women and the lactating mothers was the service of food. A question was asked to the respondents if they consumed the take home ration themselves or shared the same with the family. 79% of the respondents mentioned that they ate the take home ration themselves and gave it to their children. 8% of the respondents shared the take home ration with the family and about 13% of the respondents did not respond to this question. Respondents were asked if they had an abortion during pregnancy, 3% of the respondents had an abortion during pregnancy.
Nutrition and care for the pregnant women and lactating mothers: It is essential that the maternal nutrition should also be balanced, fresh and preferably home-made and there should not be any unscientific restrictions. Optimal nutrition of adolescent girls, pre-pregnant women and pregnant mothers is critical to growth, foetal well-being and to prevent malnutrition in the postnatal period.
Information was gathered if there is a practice of giving additional nutrition for the pregnant women and lactating mothers in the family. Only 68 % of the women actually followed the advice of consuming additional / special diet during pregnancy or as lactating mothers.
72 72%
70 68% 68
66 65%
64
62
60 Saharia Non- saharia Overall
Graph 27: Additional / Special diet taken by women during pregnancy / by lactating mothers among the Saharia and Non-Saharia
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 31
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
65 % of the mothers belonging to the Saharia community took some additional/special diet during pregnancy or while they were breast feeding the baby. Among the women who consumed certain additional eatables during pregnancy and while they were feeding the baby with breast milk, 40% of the respondents consumed additional fruits, 34% took additional vegetables, and 14 % took additional milk while 12% increased the quantity of the daily food. However it was noticed that the additional food consumption was up to a maximum of 3-6 months only.
Milk, 14%
Fruits, 40% Poshak Aahar, 12%
Vegetables, 34%
Graph 28: Additional eatables consumed by pregnant women / lactating mothers
100100 100 89 87 81 82 82 73 80 69 66 66 60 48 40 34 34 40 28 27 19 18 13 20 10 12 8 11 3 0 0 0 0 100-250 250-500 1-2 kg 1-2 time 3-4 time 1-2 3-6 gm gm months months Qty /day times/day for how many months Fruits 40% Vegetables 34% Poshak Aahar 12% Milk 14%
Graph 29: Quantity and frequency of consumption of additional food by pregnant women/ lactating mothers (value in percentage)
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 32
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Infant feeding practices : Infant and young child feeding practices such as initiation of breast feeding, feeding of colostrums, duration of exclusive breast feeding upto the child reached the age of 6 months and particulars of complementary feeding in terms of age of initiation, the type of complementary food and frequency of feeding was assessed. In addition, information on socio-cultural aspects of infant and young child feeding practices by mothers was also collected. For the well being of the child it is essential to feed the colostrums. 92 % of the respondents said they fed the child with colostrums after birth while 8 % of the respondents started feeding the child after throwing the initial colostrum.
The respondents were asked if the children were given exclusive breast milk for the initial 6 months. 78% of the respondents gave exclusive breast milk to the babies while 21% of the respondents gave water also in addition to mother’s milk. Only one percent of the respondents gave other milk (mixed with water) in addition to mother’s milk.
Information was also gathered regarding the frequency of feeding the child to know if the child gets sufficient nutrition. 47 % of the respondents fed the child whenever the child cried for food, about 36 % of the respondents fed the child up to 4-5 times a day 7 % of the respondents fed the child with breast milk 2-3 times while only 10 % of the respondents fed the child every 2-3 hours during day and night also
47% 50 36% 40
30
20 10% 7% 10
0 When ever 2-3 times a 4-5 times a Every 2-3 the child day day hours during cried for milk day / night
Graph 30: Frequency of breastfeeding the index child
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 33
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Initiation of semi-solid food: As the child grows it is essential to introduce semi-solid food at the right age so that the growth of the child is not hampered. The general norm for the age for introduction of semi-solid food for the child is around 6 months of age. Information was gathered regarding their opinion on the right age of initiation of other semi-solid food
40% 40 35 30 23% 25 22% 20 15 12% 10 3 % 5 0 0 2-4 4-5 5-6 6-7 7-8 After 8 months months months months months months Age of the child in months
Graph 31: Opinion at community level on right age for introduction of complementary feed
Majority of the respondents introduced complementary feed to the child when the child was around 6-7 months of age.
60 51% 50
40
30 26% 20% 20
10 3%
0 5 months 6 months 7 months 8 months
Graph 32: Actual age of child when complementary feed was introduced
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 34
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
97 % of the respondents reported that they continued to give breast milk to the baby even after the introduction of complementary feed. The respondents were further asked till what age did they continued to give breast milk to the baby. 42% of the respondents continued to feed the baby with breast milk up to the age of 2 years, while 34% continued till the child was one and half years of age. 14% of the respondents continued to give breast milk up to the age of one year, while 1% of the respondents continued doing so up to the age of eight months.
45 42% 40 34% 35 30 25 20 14% 15 10% 10 5 1% 0 continued continued continued continued continued upto 8 upto 1 year upto 1 and upto2 to 3 upto 3 to 4 months half years years years
Graph 33: Age of the child till when feeding of breast milk was continued According to the Infant and Young Child Feeding Guidelines, 2016 published by the Indian Academy of Paediatrics, after the child reached six months of age introduction of optimal complementary feeding should be practiced preferably with energy dense, home-made food. Breastfeeding should be continued minimum for 2 years and beyond12. However, in almost 49 % of the cases feeding of breast milk to the child was not continued till the child reached two years of age. Thus it is essential to encourage the optimal feeding practices for the children at the community level.
3.6 Action taken during childhood illnesses
One of the parameter for health and overall well being is absence of disease. An effort was made to analyze the frequency of illness reported at the community level. The most commonly reported illness were: fever, diarrhoea and common cold. The highest number of
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 35
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe respondents (83%) mentioned that the child suffered from diarrhoea during the past one year, this was followed by fever (79 %) and common cold (45%). Efforts were also made to view further the frequency of occurrence of the illness. Majority of the children suffered with the above mentioned illnesses on an average 2-5 times in a year. The members from the Saharia community reported marginally higher incidence of illness as compared to Non-Saharia, 86 % of the respondents of the Saharia community mentioned that the children suffer from diarrhoea/ vomiting, while 42 % of respondents mentioned that their children suffer with common cold while 76 % of the respondents from the Saharia community that their children suffered with fever.
44 45 40 35 32 31 32 27 30 26 25 18 20 17 16 17 13 15 12 10 5 7 3 5 0 1-2 time 2-3 time 3-4 time 4-5 time 5-8 time times / 1 year
Fever 79% Diarrhoea 83% Common cold 45%
Graph 34: Common illness reported with annual frequency
An effort was further made to analyze the treatment/options exercised by respondents when the children fell ill. Multiple responses were taken from the respondents as it is possible that an individual may take more than one course of action during illness. 34% of the respondents mentioned that they normally do not take much attention of common illness like fever, diarrhoea and common cold the children get cured in some time. As high as 39% of the respondents mentioned that they opted for jhad-phoonk practices while 21% of the respondents used home remedies (gharelu nuska) for medication.
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 36
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
34% Do nothing
Take the child to private hospital 63%
56% Take the child to district hospital
Take the child to Sub -centre/ PHC/CHC 49%
ASHA/ ANM do not visit the village regularly so 34 have to take the patient out of village for …
Show the pateint to the only doctor available in 47 the village
Show the child to ANM 54
Jhad Phoonk 39
Use home remedies 21
0 10 20 30 40 50 60 70
Graph 35 : Action taken by the respondents during illness of the child
The children in the community frequently suffer with diarrhoea, information was collected on what practices are followed in the community when the children suffer from diarrhoea. Multiple responses were collected from the respondents. Approximately 84 % of the respondents gave ORS to the children. The major source of getting ORS was ASHA/ Anganwadi karyakarta. Almost 57% of the respondents gave the children a solution of water salt and sugar. Approximately 20% of the respondents used local herbs for the purpose of treatment of diarrhoea.
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 37
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
90 84%
80
70
60 57%
50 41% 42% 40 33% 30% 30 20% 20 8% 8% 8% 10
0
Graph 36: Action taken and feeding restrictions when child suffers with diarrhoea
86% 90 70% 80 65% 70 60 31% 50 40 27% 30 20 10 0
Graph 37: Source from which ORS was obtained Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 38
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
The respondents were also asked what action was taken when the child suffered with respiratory or other illnesses. Multiple course of action is taken in such circumstances. The responses were as under:
Action taken when child suffered with respiratory illness
Admitted the child in a health facility 6% Used the medicine available at home which … 12% Took the child to private hospital 44% Took the child to Govt hospital / centre 50% Adopted jhad-phoonk practices 41% Took the child to anganwadi 56% Took the child to Private doctor 64% Consulted the ASHA 66% Tried gharelu nuska, jadi-booti,kada etc 19% Took the child to ANM 61% Did nothing 1%
0 10 20 30 40 50 60 70
Graph 38: Action taken when child suffered with respiratory illness
Information was also gathered if they used any of the practices like witchcraft (jadu-tona) or other course of action taken when the child fell ill, since multiple course of action can be taken in such circumstance, multiple responses were taken from the respondents. 41% of the respondents went for jhad-phoonk, 28 % of the respondents showed the child to any baba/phakeer, 28 % took the child to any religious place while 17 % of the respondents used the practices of witchcraft. The respondents from Saharia community marginally higher inclination towards such practices.
3.7 Services of the Anganwadi
An effort was made to identify the awareness about the services of the Anganwadi centre. The respondents showed a very high degree of awareness towards the services provided by the Anganwadi. About 93 % of the respondents from Saharia community and 86 % of the
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 39
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe respondents from the Non-Saharia community sent their children to Anganwadi centres. The facility of nutritional food is one of the most significant facilities that is the first recall among the services provided by the anganwadi. The Take home ration (THR) is one of the mechanisms used in the anganwadi to ensure that nutritional food is available to the pregnant and lactating women. An effort was done to identify if the take home ration was actually consumed by the pregnant women and the children or did they share the same with the family. 79 % of the respondents said they consumed the take home ration themselves and shared the same with their children.
A feedback was taken from the respondents regarding the quality of service provided by the anganwadi. The overall response was favourable.
56% 60 50 40 34% 30 20 6% 10 5% 0 0 0
Graph 39: Feedback on services of the Anganwadi
Measurement of weight of the child on regular basis: The weight of index child was taken every month in 62 % of the cases while 26 % of the respondents mentioned that the growth of weight of the index child was monitored 8-10 times in a year. Overall 88% of the respondents mentioned that the weight of the child was regularly monitored by the Anganwadi.
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 40
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
70 62% 60 50 40 26% 30 20 8% 10 1% 1% 2% 0 Every 8-10 6-7 times 4-5 times 2-3 times Do not month times know
Graph 40: Frequency of measurement of weight of the child by the Anganwadi in a year An effort was done to identify the action taken when it is noticed that the child is not growing well. Since mutiple course of action is taken is such circumstances, responses under the same were mapped. The responses were as under .Though the respondents used options like consulting the ASHA/ Anganwadi karyakarta or the nurse, it seems a lot of time and effort is also wasted in the processes like: tie amulet (tabeez) to the child, visiting quack doctor etc.
Take the child to PHC/ CHC/ District 42% hospital
Take the child to ASHA/Anganwadi 72% karyakarta
Consult private doctor 61%
Consult ANM 68%
Tie amulet (tabeez) to the child 35%
Take the child to a quack 24%
Do puja for the proper growth of child 50%
Consult elders in the family 37%
0 20 40 60 80
Graph 41: Action taken at the community level if the child is not growing well/ is weak
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 41
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
3.8 Vaccination/ Immunization of children:
While 81 % of the respondents mentioned that they have got their children vaccinated 19% mentioned that they could not get the children vaccinated.
100 91% 81% 80 70%
60
40
20
0 Saharia Non- saharia Overall
Graph 42: Vaccination /Immunization among Saharia and Non-Saharia Overall 81 % of the respondents mentioned that they got their children immunized however only 70 % of the respondents from the Saharia community got their children vaccinated. Effort was done to look at the vaccination card to verify the actual status of vaccination. The vaccination card was available with only in 37 % of the cases. It was found that there was lack of continuity in the schedule of vaccination and the vaccination was not completed properly in majority of the cases. Therefore even in cases where it has been reported that vaccination has taken place, there is a problem that complete vaccination as per schedule has not been adhered to. The common reasons for being unable to get the children vaccinated were migration to other places for work, they had gone to the field for work as agricultural labourer, the mother of the child had gone to maternal home and in certain cases the AWW/ANM would not come to the village on time as the village was in remote location.
42 40% 40 38 37% 36 34% 34 32 30 Saharia Non- saharia Overall
Graph 43: Vaccination card available among Saharia and Non- Saharia
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 42
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
ANM / Anganwari karyakarta does not come on Migration/ time 14% went out of the village 51%
We go to field for majdoori 35%
Graph 44: Reason why vaccination was incomplete
Anaemia: When the respondents were asked if they got the medicine to control anaemia among adolescent girls and pregnant women, almost 90 % of the respondents mentioned that they received such medicine.
Iron and Folic Acid (IFA) Prophylaxis (Action taken to prevent anaemia): Iron and Folic acid is given to children via the Anganwadi centre. About 93 % of the respondents from Saharia community and 86 % of the respondents from the Non-Saharia community sent their children to Anganwadi centres. Majority of the respondents who sent the children to Anganwadi were aware about the iron and folic acid (IFA) being provided to the children at the Anganwadi centre.
Deworming: Almost 77 % of the respondents mentioned that deworming medicines were given to the children
3.9 Nutrition Rehabilitation Centre (NRC):
About 15 % of the respondents reported to have availed the facility of Nutrition Rehabilitation Centre. Almost all of the respondents who availed the services of NRC responded stating that the NRC was overall clean, the nurse and staff took good care of them, and they also received formula feed for the child and good meals for the attendant. Majority of the respondents who availed the services of NRC mentioned that the services of NRC were
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 43
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe good. The respondents were also asked if they received the money on account of loss in wages from the NRC. Majority (86 %) of those respondents who were admitted in the NRC received the money on account of loss of wages during admission to NRC. Though the nutrition rehabilitation centre provides an effective mechanism to ensure that the mother and the child are taken care of and the weight and other parameters of the child are regularly monitored, there is still a risk of relapse after being discharged from the NRC 13.
3.10 Alcoholism and consumption of tobacco: About 71 % of total households surveyed spent at least some portion of the expenditure on alcohol or tobacco. The problem of alcohol and consumption of tobacco was found to be very high among the Saharia community with approximately 83 % of the Saharia respondents spending at least some amount regularly on a monthly basis on alcohol/tobacco products while approximately 59 % of the households from Non-Saharia community reported spending at least some amount on amount regularly on a monthly basis on alcohol/tobacco products.
100 83% 80 71% 59% 60 40 20 0 Saharia Non- saharia Overall
Graph 45: Alcoholism and Consumption of tobacco among Saharia and Non-Saharia
3.11 Observations during the field visit: During the course of visit to Karahal block it was observed that some of the hand-pumps and taps were broken also the overall cleanliness in the villages was not very good with children were found playing in unclean surroundings, there was lack of connectivity and water logging in certain places and animal excreta.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Discussion was held with D.P.O Mahila Evam Bal Vikas to know in detail about the initiatives taken in the district to monitor the problem of malnutrition in the district. Duties have been assigned to various staff members of the government departments to visit respective anganwadi and report about the facility and functioning of the Anganwadi along with suggestions for improvement. The same was found to be in practice. Monitoring of the malnutrition related issue was done by including this issue in Time-Limit (T/L) meeting.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Occupation and other issues: The major season of earning is at the time of sowing of seeds and also at the time of reaping the produce. They also go to the forest to collect tendu patta and gum .The problem of alcoholism was also reported by the community. Certain issues are found regarding quality of water available in the community. The problem of eating pan- masala was found among men and women also .The eldest sibling was found to be available taking care while the mother would go to the forest for collecting firewood, tendu patta, herbs etc.
Visit to Anganwadi: Visit was undertaken to Anganwadi. Immunization was done on 3rd Tuesday of every month. Initially a meal of sattu was given to the children. Anganwadi registers were maintained and the children were checked to verify their weight and the mid upper arm circumference was measured to identify the cases suffering with severe and acute malnutrition. (SAM). The meal of puri and kheer was provided. The take home ration was also distributed. The anganwadi had sufficient supply of Take home ration and ORS.
Anganwadi at Karahal block, Sheopur
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Community Health Centre and Nutrition Rehabilitation Centre at Karahal: Visit was also undertaken Community Health Centre and Nutrition Rehabilitation Centre at Karahal. At the time of the visit about 35 patients were admitted in the NRC which had a capacity of 20 beds. Arrangement for beds was made from the neighbouring chatrawaas. The weight of the child is taken at the time of admission and growth graph is maintained. The child is put to the prescribed diet. The facility also provided food for the mothers (including daliya, dal, roti, rice and vegetables) two times a day. During discussion with the members of the community it was understood that they go for migration during harvesting during the months of February to April every year. This leads to depletion in their nutrition status. The Anganwadi and the NRC have to work harder towards improving their nutrition status.
Nutrition Rehabilitation Centre – Karahal Block, Sheopur
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Food being served at Nutrition Rehabilitation Centre Karahal block, Sheopur During discussion with a mother admitted at the NRC it was known that she had gone a neighbouring village for wheat harvesting for two months. They also go to the jungle to collect local gums. There are two varieties of gums that they collect form the forest. The gum (rubber) is collected as a sap from the trees. It is sold for Rs 200 per Kg approximately. It was informed that the women have made a self help group for the same. They also collect another type of Gum (edible) from the forest which they sell for Rs 150-200 per kg. The detail of items commonly gathered from the forest and sold are as under:
Commonly available Forest Rate at which it is sold Product Gum resins (rubber) Rs 200 per kg Gum resins(edible) Rs 150-200 per kg Kamarkas Rs 300 per Kg Amla Rs 50-60 per kg
3.12 MNREGA in the district: An effort was done to analyze the impact of MNREGA in the state and district. The data for the same was downloaded from the MNREGA website regarding the district wise households to whom work was provided during the financial year 2016-17. Employment was provided via MNREGA to approximately 28 lakh house-holds via MNREGA during the financial year 2016-17. Sheopur district ranks at number 36 among all the 51 districts of Madhya Pradesh in terms of employment provided to the households. The Karahal block has the highest (63.08 %) of the population of Scheduled Tribes (rural) Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 48
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe population among the total population of the block, thus an analysis was done of the livelihood provided under MNREGA for each of the block in Sheopur district.
Out of 35,238 households to which employment was provided via MNREGA in year 2016-17 for the Sheopur district, approximately 18 % of households of Karahal block got employment under MNREGA.
On analysis of block wise households who demanded for work month wise under MNREGA and comparing the same with the work under MNREGA given to them month wise during financial year 2016-17, 81% of those who demanded work from Vijaypur Block were given work under MNREGA, however only 63% of those who demanded work from Karahal Block were given work under MNREGA (Details are available in Annexure 7).
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Chapter 4 Findings against objectives of the study
The overall objective of the study was to understand the underlying causes of malnutrition among the children in the study area.
It was found that the children from a Saharia household were almost twice more prone to the problem of malnutrition than their Non-Saharia counterparts. This vulnerability is due to their poor economic conditions.
The findings against each of the objective are as under: Objective 1(a): To assess the socio cultural and economic status, means of livelihood, status of family and food security situation in the study area. On analysis of the main occupation among people residing in the district it was found that only 21.53% of population of the Karahal block is cultivators while the percentage of workers involved in cultivation is as high as 51.56% in the Vijaypur block of the Sheopur district. The majority of the population of the Karahal block 62.63 % is engaged as agricultural labourers. There is a very high percentage of ST population in the area and the level of literacy is also very low. Almost 73% of the respondents from the Saharia community were illiterate and almost 65 % of the respondents from the Non- Saharia community were illiterates. Approximately 84 % of the respondents live in nuclear family. Though overall 69% of the respondents worked as labourers, when the same was analyzed at the community level, huge majority (90%) the respondents from the Saharia community worked as labourers while 48% among the Non- Saharia worked as labourers. Approximately 52% of the respondents had some land. But among Saharia community only 39% of the respondents had some land while among the Non-Saharia community approximately 65 % of the respondents had land. However approximately 75% of those who had land were marginal farmers .Huge majority around 91% of the respondents mentioned their annual family income was less than Rs 50,000. Migration is a very significant aspect of the community in the area. It has an impact on the uptake of the health and other ICDS, nutrition, vaccination related facilities in the area. This breaks the continuity of the service delivery. Migration also reflects on the lack of livelihood Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 50
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe related options available in the area. Overall 34% of the household migrated to neighbouring places for work. However among the Saharia households approximately 56% migrated for work while only 12% of those from Non-Saharia households migrated for work. Almost 65% of the respondents had BPL card. On analysis between the Saharia and Non- Saharia community it was found that 77% of the respondents from the Saharia community had BPL card while 52 % of the respondents from the Non- Saharia community held BPL card. Approximately 56 % of the respondents from the Saharia community had three or more children. Daily food consumption at the community level: Almost all the respondents reported consumption of Rotis on a daily basis, while 72% of the respondents included Dal in their daily diet. Only 30% of the respondents consumed vegetables on a regular basis while only 17 % of them consumed Rice and 9% of the respondents reported regular consumption of milk. Approximately 35 % of the respondents mentioned that they consumed milk at least sometime. Consumption of milk, egg and meat in the family: Milk is a good source of calcium while eggs are a good source of protein. It is essential to identify the pattern of consumption of milk, eggs and meat in the family to get a fair idea of the overall nutrition position in the households. Consumption of milk was found to be very low among the Saharia community as compared to their Non-Saharia counterparts. Only 6% of the respondents consumed eggs. 17% of the respondents consumed hen’s meat while 7% of the respondents consumed the meat of goat. Food consumption pattern among the Saharia and Non –Saharia community: When comparison was done among the Saharia and Non-Saharia households, it was found that only 24 % of the Saharia households consumed vegetables on a regular basis while this percentage among the Non-Saharia was 37%. Only 11% of the households of Saharia community consume Rice on regular basis while this percentage among the Non-Saharia was 23%. The consumption of milk was also found to be much lower among the Saharia families (11% in Saharia against 60 % in Non- Saharia). Objective 1(b) : To assess coverage of basic child health services like immunization, supplementary nutrition, deworming, iron and folic acid supplementation, treatment of common ailments, use of ORS and Zinc during diarrhoea, treatment of Acute Respiratory Infections etc in children from Saharia and Non-Saharia families
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
A comparative picture of the healthcare structure in Sheopur is given below: Name of Number of Number of Sanctioned ANM ASHA Nutrition Block Community Primary post at sanctioned sanctioned Rehabilitation Health Health PHC/ for the for the Centre Centre Centre actually block / block posted actually posted Vijaypur 1 3 27/12 31/24 246 NRC , Vijaypur Karahal 1 1 7/4 26/19 130 NRC. Karahal Sheopur 1 6 39/24 33/29 240 NRC , District Hospital , Sheopur Immunization: Information was gathered whether the children were vaccinated for common illnesses. While 81 % of the respondents mentioned that they have got their children vaccinated while 19 % mentioned that they could not get the children vaccinated. However only 70 % of the households among the Saharia community got their children vaccinated. The common reasons for being unable to get the children vaccinated were: . palayan or migration . they had gone to the field for work as agricultural labourer . the mother of the child had gone to maternal home . In certain cases the AWW / ANM would not come to the village on time as the village was in remote location. Effort was done to look at the vaccination card to verify the actual status of vaccination. The vaccination card was available with only in 37 % of the cases. It was found that there was lack of continuity in the schedule of vaccination and the vaccination was not completed properly in majority of the cases. Therefore even in cases where it has been reported that vaccination has taken place but there is a problem that complete vaccination as per schedule has not been adhered to. Supplementary nutrition: 68 % of the women actually followed the advice of consuming additional food during pregnancy and while they were feeding the baby with breast milk during pregnancy .Among the 68% of the women who consumed certain additional eatables 40% of the respondents consumed additional fruits, 34 % took additional vegetables, and 14% took additional milk while 12% increased the quantity of the daily food. However it was noticed that the additional food consumption was up to a maximum of 3-6 months and not during the entire period of pregnancy to be continued while feeding the child as well.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Majority of the respondents introduced complementary feed to the child when the child was around 6-7 months of age. Deworming: Almost 77 % of the respondents mentioned that deworming medicines were given to the children Anaemia: When the respondents were asked if they got the medicine to control anaemia among adolescent girls and pregnant women, almost 90 % of the respondents mentioned that they received such medicine. Iron and Folic Acid (IFA) Prophylaxis (Action taken to prevent anaemia): Iron and Folic acid is given to children via the Anganwadi centre. About 93 % of the respondents from Saharia community and 86 % of the respondents from the Non-Saharia community sent their children to Anganwadi centres. Majority of the respondents who sent the children to Anganwadi were aware about the iron and folic acid (IFA) being provided to the children at the Anganwadi centre. Frequency of illness among children: One of the parameter for health and overall well being is absence of disease. An effort was made to analyze the frequency of illness reported at the community level. The most commonly reported illness were: fever, diarrhoea and common cold. The highest number of respondents (83%) mentioned that the child suffered from diarrhoea during the past one year, this was followed by fever (79 %) and common cold (45%). Efforts were also made to view further the frequency of occurrence of the illness. Majority of the children suffered with the above mentioned illnesses on an average 2-5 times in a year. The members from the Saharia community reported marginally higher incidence of illness as compared to Non-Saharia 86 % of the respondents of the Saharia community mentioned that the children suffer from diarrhoea/ vomiting, while 42 % of respondents mentioned that their children suffer with sardi/ khansi and 76 % of the respondents from the Saharia community that their children suffered with fever. Action taken when child fell ill: An effort was further made to analyze the treatment / options were exercised by respondents when the children fell ill .Multiple responses were taken from the respondents as it is possible that an individual may take more than one course of action during illness. 34% of the respondents mention that they normally do not take much attention of common illness like fever, diarrhoea, and common cold and they children get cured in some time. As high as 39% of the respondents mentioned that they opted for jhaad- phoonk practices while 21% of the respondents used home remedies for medication.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Action taken when child suffered with diarrhoea: The children in the community frequently suffer with diarrhoea, information was collected on what practices are followed in the community when the children suffer from diarrhoea. Multiple responses were collected from the respondents. Approximately 84 % of the respondents gave ORS to the children. The major source of getting ORS was ASHA/ AWW .Almost 57 % of the respondents gave the children a solution of water salt and sugar. Approximately 8 % of respondents mentioned that they gave small quantity of opium to the child suffering from diarrhoea while approximately 20 % of the respondents used jadi-booti for the purpose of treatment of diarrhoea. Action taken when child suffered with respiratory infections: The respondents were also asked what action was taken when the child suffered with respiratory or other illnesses. Multiple course of action is taken in such circumstances. Approximately 50 % respondents took the child to Public Health Centre or Community Health Centre while 44 % showed the child private facility. Objective 1(c): To assess the knowledge, attitude and practice of the family regarding the infant, the young child's nutrition and common childhood illnesses.
68 % of the women actually followed the advice of consuming additional food during pregnancy and while they were feeding the baby with breast milk during pregnancy .Among the 68% of the women who consumed certain additional eatables, 40% of the respondents consumed additional fruits, 34 % took additional vegetables, and 14% took additional milk while 12% increased the quantity of the daily food. However it was noticed that the additional food consumption was up to a maximum of 3-6 months and not during the entire period of pregnancy to be continued while feeding the child as well. The respondents were asked whether they were aware of the need for taking care during pregnancy .Further the respondents were asked about the care /precautions actually taken by them during pregnancy. This was done in order to compare the awareness with the practice actually followed. 83% of respondents felt that they need to take adequate rest while only 64% of the respondent’s actually took adequate rest during pregnancy. While only 53% of respondents felt they should abstain from heavy work during pregnancy, actually only 42% of the women refrained from doing heavy work during pregnancy. 92 % of the respondents said they gave initial colostrum to the children. 78% of the respondents gave exclusive breast milk to the babies up to the age of 6 months while 21% of
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe the respondents gave water also in addition to mother’s milk. Only one percent of the respondents gave milk (mixed with water) from outside in addition to mother’s milk. 47% of the respondents fed the child whenever the child cried for food, about 43 % of the respondents fed the child up to 4-5 times a day while only 10 % of the respondents fed the child every 2-3 hours during day and night also. Majority of the respondents mentioned that the child was 6 to 7 months of age when complementary food was introduced. Information was also gathered if they used any of the practices like witchcraft or other course of action taken when the child fell ill, since multiple course of action can be taken in such circumstance, multiple responses were taken from the respondents. 41% of the respondents went for jhad-phoonk, 28 % of the respondents showed the child to any baba/phakeer, 28 % took the child to religious places while 17 % of the respondents used the practices of witchcraft.The respondents from Saharia community have marginally higher inclination towards such practices. Objective 1(d): To assess the uptake of key maternal health services like antenatal, intra-natal and postnatal services and the ICDS centres in the study area. The respondents showed a very high degree of awareness towards the services provided by the Anganwadi. The facility of nutritional food is one of the most significant facility that is in the first recall among the services provided by the Anganwadi. The take home ration (THR) is one of the mechanisms used in the Anganwadi to ensure that nutritional food is available to the pregnant and lactating women. An effort was done to identify if the take home ration was actually consumed by the pregnant women and the children or did they share the same with the family. 79 % of the respondents said they consumed the Take home ration themselves and shared the same with the children. A feedback was taken from the respondents regarding the quality of service provided by the Anganwadi. The overall response was favourable with 56 % of the respondents saying that the services of Anganwadi were good and another 34 % mentioned that the services provided by the Anganwadi were average.
Objective 2: To evaluate utilization of NRC services and relevance of its geo-physical location for serving the high burden areas. About 15 % of the respondents reported to have availed the facility of Nutrition Rehabilitation Centre. Almost all of the respondents who availed the services of NRC responded stating that the NRC was overall clean, the nurse and staff took good care of them, they also received formula feed for the child and good meals for the attendant. Majority of
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe the respondents who availed the services of NRC mentioned that the services of NRC were good. The respondents were also asked if they received the money on account of loss in wages from the NRC. Majority (86 %) of those respondents who were admitted in the NRC received the money on account of loss of wages during admission to NRC. The Nutrition Rehabilitation Centre at Karahal block is located adjoining the Community Health Centre at the Karahal block. Visit was also undertaken Community Health Centre and Nutrition Rehabilitation Centre at Karahal. At the time of the visit about 35 patients were admitted in the NRC which had a capacity of 20 beds. Arrangement for beds was made from the neighbouring chatrawaas. The weight of the child is taken at the time of admission and weight growth graph is maintained. The child is put to the prescribed diet. The facility also provided food for the mothers including daliya, dal, roti, rice and vegetables two times a day. The Nutrition Rehabilitation Centre, Karahal is located adjoining the Community Health Centre which is beneficial that the services and advice of the doctors at Community Health Centre can also be used for the benefit of the children. Thus the location of the NRC seems appropriate. The overall bed occupancy of the NRC was 81 % in the year 2016-17 and 91.4 % during the year 2017-18. Majority of the patients who were referred to the NRC were sent by the Anganwadi workers. The NRC staff should council the mothers for the planning procedures which is lacking.
Test for significance: The test for significance of factors affecting malnutrition in the children of the community was done using chi-square test using p value at 95 % of accuracy and degree of freedom = 1, cross-tabulation of data was done and the values were determined using statistical formulas. The following factors were found to have significant impact on malnutrition among children: households living Below the Poverty line, Occupation as labourers and migration. Mothers who took some additional food during pregnancy and while feeding the child with breast milk were able to prevent malnutrition among their children to a great extent.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Chapter 5 Recommendations Based on the primary information from questionnaire, analysis of the data received from different agencies and interactions at field level, the following are the recommendations to address malnutrition among children in Sheopur district. These are stated under four broad categories to emphasise inter sectoral co ordination among departments: 1. EXPANDING LIVELIHOOD OPPORTUNITIES 2. BETTER EDUCATION 3. IMPROVED ACCESS TO HEALTH CARE 4. EXTENSION EFFORTS AT COMMUNITY LEVEL
1. EXPANDING LIVELIHOOD OPPORTUNITIES :
(1.1)Creating better employment opportunities for the vulnerable tribal population: It was found that the children from a Saharia household were almost twice more prone to the problem of malnutrition than their Non-Saharia counterparts. This vulnerability is due to their poor economic conditions. There is a need for better targeting of employment programs. The following table gives a comparative picture:-
Class Illiterate Land holding Working as Migration labourers Saharia 73 % 39 % 90 % 56 % Non- Saharia 65% 65 % 48% 12 % The above table clearly brings out the vulnerability of the community on social and economic parameters. Saharia is notified as the Primitive Tribe Group (PTG) in Madhya Pradesh. This being the scenario, it is strongly recommended that the government should have a higher allocation for PTG predominant blocks. Three tribes of Madhya Pradesh Baiga, Bhariya and Saharia have been declared specific backward tribes by the Government of India. Their total population is very small when seen as a ratio of the total population in the state. This sub group within the larger ST population is facing the most severe challenge of livelihood and malnutrition. In the study it’s seen that very clearly that the in Poor wage employment opportunities for Saharias is affecting them in all aspects of their life. Thus the following interventions can help in different programmes:
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
(1.1) MNREGA: The government implements a series of rural development activities to generate employment for the rural poor and alleviate poverty. MNREGA, which ensures 100 days of employment to all poor adult population in the country, is a significant step in this regard. There is a need to continue the focus on the same. However, it was found that within the district the ST dominated Karahal performed poor on availability of funds for MNREGA. Sheopur district ranks at number 36 among all the 51 districts of Madhya Pradesh in terms of employment provided to the households. The Karahal block has the highest (63.08 %) of the population of Scheduled Tribes (rural) population .Out of 35,238 households to which employment was provided via MNREGA in year 2016-17 for the Sheopur district, approximately 18 % of households of Karahal block got employment under MNREGA. In the non ST dominated Vijaypur 81 % of the households who demanded work under MNREGA got work under MNREGA, while in Karahal block 62% of household who demanded work under MNREGA got work under MNREGA. Unemployment being higher in Karahal makes them more vulnerable to migration. The migration in the Karahal block was found to be generally for duration of about 2-3 months in a year. It is proposed that the quota of MNREGA allocation for 100 days may be increased to 150 -200 days in the year for the next 5 years in Sheopur district. There are instances when the MNREGA allocation of days has been increased in certain duration to take care of the immediate distress like drought. Saharia and other PTGs being a special class needs preferential allocation so that they could sustain themselves and not take recourse to migration. It is proposed that the special package under MNREGA should remain at least for 5 years when it can be reviewed again. Thus increased focus on MNREGA will also help to address the problem of migration to a great extent. (1.2) Expanding Employment opportunities in rural areas: - The Panchayat and Rural Development Department Govt of Madhya Pradesh is doing a series of activities for the benefit of the people living in the area like creation of self-help groups, promotion of livelihood related activities like animal husbandry, making washing powder, Agarbattis soap, Sanitary napkins, stitching, making of Dona – Pattal etc .Such activities need to be strengthened. There are also schemes that provide loan for livelihood generation. These schemes are carried out by multiple departments targeting different interest groups .These activities need to done regularly and monitoring of the same is required. (1.3) National Rural Livelihoods Mission (NRLM): NRLM promotes and supports collectives towards sustainable livelihoods of the poor (CSLP) around key livelihoods. These
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe collectives offer their members access to livelihoods knowledge, skills, technology, market intelligence, risk management products and credit support through their SHGs and federations. Support of NRLM may be taken in enhancing livelihood opportunities in the region.
(1.4) Comprehensive package involving all stakeholders departments for Primitive Tribe Groups: The possibility of introducing a crash program for the next 4-5 years needs to be explored in order to address livelihood related problem and nutrition requirement in the region. Several instances where found where the respondents were aware that it is advised that certain precautions and care like additional nutritious food to be taken by the pregnant women , avoid heavy physical labour etc should be taken during pregnancy, however they were unable to do so in practice. A lot of it has to do with the lack of employment opportunity in the area. If they are able to get enough food and nutrition such problems are likely to be minimized. A holistic convergent plan is required, that will include government departments like the Tribal Welfare Department, Department of Women and Child development, Department of Health and Family Welfare, Department of Agriculture and Horticulture, Public Health Engineering Department, Forest department and Panchayat and Rural Development department. Saharias are the largest group of Primitive Tribe Groups in Madhya Pradesh .This being a small proportion of the total population, it will not be much of a burden on funds, this package will not put a big additional burden on them as only the gaps need to be addressed. With effect from December 2017 onwards the Government has initiated a cash assistance scheme of Rs 1,000 per month to each of the families of special backward scheduled tribes (STs) as part of its efforts to eliminate malnutrition among the communities. The amount of Rs 1000 per month is being provided to special backward ST communities, including Saharia, Baiga and Bharia, to address the problem of malnutrition among them. The amount is being deposited in the bank account of the woman head of the family to be used for buying nutritious food items. This initiative of the Government is likely benefit the community in addressing the problem of malnutrition among the Saharia and other tribes also.
(1.5) Identifying and expanding the MFP (Minor Forest Produce) activities in PTGs areas: Approximately 60 % of the area of Sheopur district is under forest cover. Thus it is essential to take the benefit of forest economy to the fullest in a comprehensive manner.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Collecting Tendu Patta is one of the commonly used forest based source of livelihood for the people in this area. This is a seasonal operation done in the months of May and June for only 45 to 50 days in a year. Enhanced efforts are required to be done in co-ordination with the Minor Forest Produce Development Corporation working in the state.
Forests provide a range of marketable products like resins (gum), bahera, nagar motha, edible gond, satawar, mahua etc. Many of the locally collected medicinal herbs fetch a good price in open markets but the tribal people end up selling these products to the intermediaries at abysmally lower prices. The support for marketing and value addition by creating processing facilities would enhance the income in the community. This is an activity which is fully privatized for a long time. This is also resulting in rapid depletion of these medicinal products. It is recommended that a special plan is drawn by the MFP cooperative federation, which has the resources, to identify all marketable Minor Forest Products and create Self Help Groups (SHGs) for them. Such SHGs should be empowered to scientifically harvest, process and sell at competitive prices to the larger markets outside Karahal.
(1.6)Enhanced focus on agriculture: The study has revealed the average land holding of the farmers is about one hectare. The farmers belonging to the Saharia Community have a land holding of less than one hectare on an average. The Karahal block receives less rainfall. Only 12.79 % of the land in the Karahal block is cultivable as a percentage of total area. Thus enhanced efforts are required to improve the availability of water and increase the cultivable area. The land holding status of the focus group needs to be kept in mind while planning a strategy for agriculture development. The benefits of beneficiaries’ oriented schemes aimed at enhanced productivity need to be taken up. The department needs to plan a special 3 to 5 years intensive multipronged attack on different fronts i.e. Seeds, Land management, irrigation, pumps and other water lifting devices, Watershed management, market development, expanding storage ,farm mechanisation practices etc. Saharias being a special focus group the State government i.e., the Agriculture Department should pay special attention to them and other similar marginalized farmers. The land in Karahal being of not too good quality, the agriculture production enhancement strategy will have to include Horticulture, Forestry and Agro-Farm Forestry in its mix of practices.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
(1.7) Horticulture Crops: There is an urgent need to explore possibility of introduction of nutritional horticultural crops suitable for the region. According to the report of department of horticulture, Government of Madhya Pradesh guava, ber, custard-apple (sitaphal) could be considered a crop under rain fed conditions in the region. Certain other crops recommended to be grown in the region are seasonal vegetables, coriander, chillies and garlic etc. 2. BETTER EDUCATION
(2.1) Expanding access to Primary education in PTGs areas: It was found that illiteracy in the sample was quite high. Almost 73 % of the respondents from the Saharia community were illiterate and almost 65 % of the respondents from the Non- Saharia community were illiterates. In spite of presence of schools in the region the overall education situation in the area is not very encouraging Block wise Primary Middle Higher High Total Population number of School School Secondary School schools School Sheopur 235584 326 108 11 18 463 Block Vijaypur 215041 308 100 11 11 429 Block Karahal 129884 240 75 9 13 337 Block Source: Education Portal, Government of Madhya Pradesh A. Number of girls enrolled in school in the entire district of Sheopur is lesser than the number of boys registered for education (Source: Education Portal, Government of Madhya Pradesh, year 2017-18). B. As illiteracy is the root cause of so many other social issues like poor health / awareness, poor awareness on safe motherhood, livelihood and related matters. The stark gap should be plugged in next few years. This will give confidence to general population and empower them on social issues. C. An effort for adult education in a drive mode is also needed in the district with special focus on the Saharia population owing to poor literacy in the region.
3. IMPROVED ACCESS TO HEALTH CARE (3.1) Enhanced focus on Health and greater convergence with the Women and Child Development Department: There is a need for expansion of health care services in the
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 61
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe affected area including health care activities including reproductive and child care, pre and post-natal care, vaccination etc. to deal with women and health related issues.
The tribal community face certain challenges in terms of exclusion which when added to the problem of poverty aggravate the problem and adds to further vulnerability. The health service seeking behaviour is improving while they still suffer with the problem of dealing with quacks, witchcraft etc even when the child suffers with common illness such as fever or diarrhoea or respiratory track illnesses. A lot of precious time is wasted in such circumstances.
A comparative picture of the healthcare structure in Sheopur is given below: Name of Number of Number Sanctioned ANM ASHA Nutrition Block Community of post at sanctioned sanctioned Rehabilitation Health Primary PHC/ for the for the Centre Centre Health actually block / block Centre posted actually posted Vijaypur 1 3 27/12 31/24 246 NRC , Vijaypur Karahal 1 1 7/4 26/19 130 NRC. Karahal Sheopur 1 6 39/24 33/29 240 NRC , District Hospital , Sheopur
It was found that the children born in Saharia families are much higher risk of being malnourished than among those born in Non – Saharia households, this coupled with their early marriage makes them vulnerable to anaemia and other childhood illnesses. Therefore, it is recommended that: a. Intensive health awareness in the target group of expectant mothers / adolescents needs to be launched in the campaign mode through women and child development department and health and family welfare department. b. Filling up infrastructure gaps – this would mean posting of doctors/ other support staff at the facilities. c. Creating new CHC/PHC as per the projected needs. The gaps mentioned above need to be addressed and bridged by new sanctions, better access would improve the access to health care for the child and the mothers. Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 62
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
The consumption of additional food by the mother during pregnancy / by lactating mothers was found to have positive impact in lowering the incidence of malnourishment thus it is desired that the pregnant women/ lactating mothers be encouraged to take additional diet and consume the take-home-ration. Looking into the disease pattern and the frequency at which the children in the community suffer from common illness like diarrhoea, fever and respiratory infections in the region, there is an immense need for advocacy and reiteration of optimal practices of health and nutrition especially infant and young child feeding practices. Also there is an urgent need to enhance the staff and capacity of the PHC and CHC in the region. The level of literacy was found to be very poor in the affected area; almost 73 % of the Saharia respondents were illiterate while 65% of the Non-Saharia respondents were illiterate. Therefore any IEC literature will not be of much use. There is an urgent need to make use of mobile vehicle with loudspeakers having announcement regarding health facility and hygiene, since the personal hygiene was not found to be very good during the course of the visits undertaken to the area. It is essential that the audio-visual IEC is in local language and local actors as used for the same. Radio station Vanya located in Sesaipura (Sheopur) provides a great window of opportunity as it makes programmes in Saharia dialect which is easily understood by the community. Health related messages could be propagated using his medium.
The Karahal block is one among the 89 tribal blocks identified in Madhya Pradesh. Iron and Iodised double fortified salt distribution has been initiated in the 89 tribal blocks of Madhya Pradesh. Increased emphasis should be given on the same as it is likely to tackle the issue of iron and iodine deficiency in the region. (3.2) Vaccination: It was observed that in most of the cases the vaccination was incomplete i.e. vaccination was started however the schedule of vaccination was not adhered to. An increased effort is required to address this issue in the region. The schedule of vaccination should be regularly monitored and adhered to. (3.3) Family Planning: Family Planning initiatives do not seem to be very effective in the region with almost 75 % of the respondents mentioning that they did not use any method of family planning .The Saharia community reported even lower inclination towards family planning with only 22 % of the respondents from the Saharia community adopting methods of family planning. At the community level also when the respondents were asked about their
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 63
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe opinion about how many children a couple should have almost 52 % were of the opinion that a couple should have 3 or more children. In such circumstances it is essential that the AWW, ASHA , ANM and other functionaries working the region should do more efforts to inform and encourage the community to adopt family planning practices. (3.4) Child feeding practices : According to the Infant and Young Child Feeding Guidelines, 2016 published by the Indian Academy of Paediatrics, after the child reached six months of age introduction of optimal complementary feeding should be practiced preferably with energy dense, home-made food. Breastfeeding should be continued minimum for 2 years and beyond. However, in almost 49 % of the cases feeding of breast milk to the child was not continued till the child reached two years of age. Thus it is essential to encourage the optimal feeding practices for the children at the community level.
(3.5) Opportunity under Poshan Abhiyaan: The National Nutrition Mission (NNM) was set up in December 2017 with a three year budget of Rs.9046.17 Crore commencing from 2017-18. All the States and districts will be covered in a phased manner under the mission. The district of Sheopur is among the 315 districts identified under Phase –I of the programme. Total 37 districts of Madhya Pradesh fall under phase-I of the programme. Poshan Abhiyaan the flagship programme of the Ministry of Women and Child Development (MWCD), Government of India, ensures convergence with various programmes i.e., Anganwadi Services, Pradhan Mantri Matru Vandana Yojana (PMMVY), Scheme for Adolescent Girls (SAG) of MWCD Janani Suraksha Yojana (JSY), National Health Mission (NHM), Swachh - Bharat Mission, Public Distribution System (PDS), Department Food & Public Distribution, Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS) and Ministry of Drinking Water & Sanitation. The Poshan Abhiyaan focuses to lay emphasis on the first 1000 days of the child, which includes the nine months of pregnancy, six months of exclusive breastfeeding and the period from 6 months to 2 years to ensure focused interventions on addressing under nutrition. Besides increasing the birth weight, it will help reduce both Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR). Additional one year of sustained intervention (till the age of 3 years) would ensure that the gains of the first 1000 days are consolidated. Attention is also given on children in the age group of 3-6 years for their overall development through the platform of the Anganwadi Services. The challenges in the region call for greater convergence in the region among the
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe department of Health and Family Welfare and Women and Child Development department, Government of Madhya Pradesh.
(3.6) Opportunity in Ujwalla scheme: During the course of the field visits, it was observed that the women would go to forest or walk long distances to get firewood. The women also face a risk of being attacked or assaulted while they go to the forest alone to collect firewood. The Ujwalla scheme offers a window of opportunity where by the women would not be required to go to the forest to collect firewood. This would mean that the women stays at home relatively longer and contributes to the well-being of the child. The respondents also mentioned one of the reasons for not getting the children vaccinated was they had to go to the jungle to get fire wood. This will also improve the vaccination and overall status of the children.
4. EXTENSION EFFORTS AT COMMUNITY LEVEL
(4.1)Public Distribution System: The Public Distribution System contributes significantly in the provision of food security. Public Distribution System in the country enables the supply of food grains to the poor at a subsidized price. The importance of public distribution system cannot be emphasized enough in an area facing risk of malnutrition. In such circumstances it becomes increasingly important that we continue to focus on the effective implementation of the public distribution system. In such circumstances it is recommended that increased allocation of PDS be given to families having severely underweight children and for and SAM children discharged from Nutrition Rehabilitation Centres.
(4.2) Involvement at all levels in the monitoring of efforts to reduce malnutrition: Intensive monitoring is required at all levels including District Collector, CEO Zilla Panchayat, Saharia Vikas Pradhikaran, Chief Medical Officer, Block Medical Officer, Staff at Nutrition Rehabilitation Centre, Community Health Centre, Primary Health Centre, ANMs, ASHA Karyakarta, Anganwadi Karyakarta etc need work in co-ordination towards the aim of reducing malnutrition in the area. Intensive monitoring would be required to ensure that the problem of malnutrition is addressed properly in the region. During the course of field visit to the region it was informed that duties have been assigned to various staff members of the government departments to visit respective anganwadi and
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe report about the facility and functioning of the anganwadi along with suggestions for improvement. Also, monitoring of the malnutrition related issue was being done by including this issue in Time-Limit (T/L) meeting. Though it is heartening to know that that progress on the front of malnutrition is being regularly monitored, there is a felt need for inclusion of standard monthly monitorable indicators of malnutrition and its corollaries in the T/L meeting to make the monitoring mechanism more effective.
(4.3) Campaign against substance abuse: The study showed that problem of substance abuse, consumption of alcohol and tobacco was found among the Saharia community as well as Non- Saharias: Problem of consumption of alcohol and tobacco Saharia 83 % Non- Saharia 59 %
The problem is more acute among the Saharia community. It is another drain on the limited income apart for making them vulnerable to diseases and poor health. A campaign needs to be taken to address this issue. The campaign needs to be supplemented with appropriate educational and de-addition interventions also. Adult education program should be planned in the region where special focus should be given to educate the community about good health practices and the ill effects of alcohol and tobacco there is an urgent need to focus on de- addiction and counselling of the household’s resident in the region about the ill- effects of alcohol and usage of tobacco. Local youth who understand the local issues better could be counselled and involved in the process.
(4.4) Greater use of Vanya radio station: To address the specifics needs of the tribal community in local languages resource is available in the form of Vanya radio station to enhance community participation. It focuses on programs centred on tribal lifestyle, culture, society, traditions, folk resources etc.Radio station Vanya located in Sesaipura (Sheopur) provides a great window of opportunity as it makes programmes in Saharia dialect which is easily understood by the community. This communication medium may be used more aggressively to communicate information on other aspects including hygiene, livelihood etc to the community.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
(4.5) strengthening of infrastructure of roads in the region: The network of roads in the region is poor with several villages not being connected by proper roads. As mentioned in the District Census Handbook on Madhya Pradesh – Sheopur Census of India 2011 only 180 out of the 607 villages in the district were connected by road. Thus it very essential to strengthen roads and transport facilities in the region. With greater access and road connectivity the residents of the region will have greater access to health and other services.
(4.6) Banking and Thrift facility: The overall availability of banking and credit facilities in the region was not very encouraging. Not many commercial / co-operative banks are active in the region. The presence of Agricultural Credit Societies and banks in Karahal block is even lower when compared with the other blocks in the district. Thus it is essential that more Regional Rural Banks and other institutions become active in the region to support income generation activities in the region. Name of Block Number of villages Banks Agricultural Credit Societies Vijaypur 162 8 14 Sheopur 235 13 33 Karahal 119 2 5 Source: District Census Handbook on Madhya Pradesh – Sheopur
(4.7) Role of NGOs in community development: During the study it was found that Tata Trust is in touch with the district administration through their NGO Transforming Rural India and is planning to work in areas of Livelihood, Literacy, Drinking water and forest produce. This needs to be followed up vigorously by the local administration. There is a great scope of work from the Corporates who may be willing to work in the region under the domain of Corporate Social Responsibility. This opportunity need to be explored further by the district administration for the overall benefit of the people.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
References:
1. Operational guidelines on facility based management of children with severe acute malnutrition by ministry of health and family welfare, Government of India, 2011 2. Dinachandra Singh K, Alagarajan M, Ladusingh L (2015) What Explains Child Malnutrition of Indigenous People of Northeast India? PLoS ONE 10(6): e0130567 3. United Nations Children’s Fund, World Health Organization, The World Bank. UNICEF-WHO- World Bank Joint Child Malnutrition Estimates. 2017 (UNICEF, New York; WHO, Geneva; The World Bank, Washington, DC). 4. Gross R, Webb P. Wasting time for wasted children: severe child undernutrition must be resolved in non-emergency settings. The Lancet. 2006;367:1209–11. 5. Mishra V, Retherford RD. Does biofuel smoke contribute to anaemia and stunting in early childhood? International Journal of Epidemiology. 2007;36(1):117–29. pmid:17085456 6. Shaw JCL. Malnutrition in very low birth-weight, pre-term infants. Proceedings of the Nutrition Society. 1974;33:103. pmid:4477386 7. Kimberly D, Ernst MD, Paula G, Radmacher MS, Salisa T, Rafail RD, et al. Postnatal Malnutrition of Extremely Low Birth-Weight Infants With Catch-Up Growth Postdischarge. Journal of Perinatology. 2003;23:477–482. pmid:13679935 8. Lemons JA, Bauer CR, Oh W, Korones SB, Papile LA, Stoll BJ, et al. Very Low Birth Weight Outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1995 Through December 1996. Pediatrics. 2001;107(1):1–8. pmid:11134427 9. Hack M, Klein NK, Taylor HG. Long-term developmental outcomes of low birth weight infants. Future Child. 1995;5(1):176–96. pmid:7543353 10. District Census Handbook on Madhya Pradesh – Sheopur Census of India 2011 Series -24 part XII-A 11. Sankhikiya Sanchhep of MP-2012 12. Jila Sankhikiya Pustika-2011 13. RanRanjan Kumar Biswas and A.K. Kapoor- A Study on Mortality Among Saharia – A Primitive Tribe of Madhya Pradesh- Anthropologist, 5(4): 283-290 (2003) 14. ManDal, Debabrata: Social and economic sensario of a primitive tribe in Madhya Pradesh: 236- 243. In: Tribal Culture and Identity. Chaturbhuj Sahu (Ed.). Sarup & Sons Publication, New Delhi (1998). 15. Prabhu, Pradip: Social forestry: An adivasi viewpoint: 134143. In: Towards A New Forest Policy: People’s Right and Environmental Needs. Walter Fernandes and Sharad Kulkarni (Eds.). Indian Social Institute, New Delhi (1983). 16. Singh, K.S. : The Scheduled Tribes, Volume – III. Oxford University Press, Delhi (1994). 17. Sethi GR, Sachdev HPS, Puri RK. Women’s health and fetal outcome. Indian Pediatr. 1991; 28:1379-92. 18. Narayanan I, Prakash K, Bala S, Verma RK, Gujral VV. Partial supplementation with expressed breast-milk for prevention of infection in low-birth-weight infants. Lancet. 1980;2:561-3. 19. Shaw JCL. Malnutrition in very low birth-weight, pre-term infants. Proceedings of the Nutrition Society. 1974;33:103. pmid:4477386 20. Sanghvi U, Thankappan KR, Sarma PS, Sali N. Assessing potential risk factors for child malnutrition in rural Kerala, India. Journal of Tropical Pediatrics. 2001;47(6):350–5. pmid:11827303 21. Bhutia D T. Protein energy malnutrition in India: the plight of our under five children. Journal of Family Medicine and Primary Care. 2014;3(1):63–7. pmid:24791240 22. Meshram II, Arlappa N, Balakrishna N, Mallikharjuna RK, Laxmaiah A, Brahmam GN. Trends in the prevalence of undernutrition, nutrient and food intake and predictors of undernutrition among under five year tribal children in India. Asia Pacific Journal of Clinical Nutrition. 2012;21(4):568–76. pmid:23017315
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Websites:
1. http://nhm.gov.in/images/pdf/programmes/child- health/guidelines/operational_guidelines_on_fbmc_with_sam.pdf 2. http://www.who.int/tb/advisory_bodies/impact_measurement_taskforce/meetings/prevalence_sur vey/psws_probability_prop_size_bierrenbach.pdf 3. http://www.mpwcd.nic.in/web/wcd/sc-ic-icds 4. http://www.crida.in/CP-2012/statewiseplans/madhya%20pradesh/MP18-Sheopur-26.6.2012.pdf 5. http://www.mp.gov.in/web/guest/gridregion- Proposed horticulture crop for Sheopur 6. http://www.indianpediatrics.net/aug2016/703.pdf Infant and Young Child Feeding Guidelines, 2016 recommendations by Infant and Young Child Feeding (IYCF) chapter of Indian Academy of Pediatrics 7. http://mnregaweb2.nic.in/netnrega/state_html/pmsr.aspx?lflag=local&state_code=17&state_name =MADHYA+PRADESH&fin_year=2016-2017&page=S&Digest=cUGUCP5k5v60KPElvKN1gw 8. http://www.who.int/mediacentre/factsheets/fs292/en/ 9. http://www.educationportal.mp.gov.in/Public/Schools/ssrs/State_Schools.aspx?MP=1 10. http://www.icds-wcd.nic.in/nnm/NNM-Web-Contents/RIGHT-MENU/NNM-States- Districts/NNM-Districts-315-Phase-I.pdf).Total 11. http://www.icds-wcd.nic.in/nnm/NNM-Web-Contents/LEFT-MENU/ILA/ILA-Guidelines- English.pdf
Footnotes :
1. Operational guidelines on facility based management of children with severe acute malnutrition by ministry of health and family welfare, Government of India, 2011 2. National Family Health Survey 4 (NFHS 4 )of India 3. United Nations Children’s Fund, World Health Organization, The World Bank. UNICEF-WHO- World Bank Joint Child Malnutrition Estimates. 2017 4. Gross R, Webb P. Wasting time for wasted children: severe child under nutrition must be resolved in non-emergency settings. The Lancet. 2006;367:1209–11. 5. Lemons JA, Bauer CR, Oh W, Korones SB, Papile LA, Stoll BJ, et al. Very Low Birth Weight Outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1995 Through December 1996. Pediatrics. 2001;107(1):1–8. pmid:11134427 6. District Census Handbook on Madhya Pradesh – Sheopur Census of India 2011 Series -24 part XII- A 7. ManDal, Debabrata: Social and economic sensario of a primitive tribe in Madhya Pradesh: 236-243. In: Tribal Culture and Identity. Chaturbhuj Sahu (Ed.). Sarup & Sons Publication, New Delhi (1998). 8. Prabhu, Pradip: Social forestry: An adivasi viewpoint: 134143. In: Towards A New Forest Policy: People’s Right and Environmental Needs. Walter Fernandes and Sharad Kulkarni (Eds.). Indian Social Institute, New Delhi (1983). 9. Singh, K.S. : The Scheduled Tribes, Volume – III. Oxford University Press, Delhi (1994). 10. Ranjan Kumar Biswas and A.K. Kapoor- A Study on Mortality Among Saharia – A Primitive Tribe of Madhya Pradesh- Anthropologist, 5(4): 283-290 (2003) 11. Dietary Guidelines for Indians- A Manual published by National Institute of Nutrition , Indian Council of Medical Research , Hyderabad http://www.ninindia.org/DietaryGuidelinesforNINwebsite.pdf 12. Infant and Young child feeding guidelines 2016,Indian Pediatirics pg 703 Volume 53 August 15,2016 https://www.indianpediatrics.net/aug2016/703.pdf 13. Taneja G, Dixit S, Khatri A K, Yesikar V, Raghunath D, Chourasiya S. A study to evaluate the effect of nutritional intervention measures on admitted children in selected nutrition rehabilitation centers of Indore and Ujjain divisions of the state of Madhya Pradesh (India). Indian J Community Med 2012;37:107-15
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Annexure 1
National Family Health Survey (NFHS-4, 2015-16) malnutrition in India, MP and Sheopur Particulars India Madhya Pradesh Sheopur Percentage of children under age 35.7 42.8 55 of five years who are underweight (low weight for age). Percentage of children under five 38.4 42 52.1 who are stunted (height for age). Percentage of children under five 21 25.8 28.1 years of age who are wasted (weight for height) Percentage of these children who 7.5 9.2 9 are severely wasted(weight for height) Source: National Family Health Survey 4, 2015-16
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Annexure 2
District Map of Madhya Pradesh
About Sheopur
Climate: The climate here is characterized by a hot summer and general dryness except during the monsoon and well distributed rainfall in the monsoon season. The winter season from December to February is followed by summer season from March to mid June. The period from mid-June to September constitutes the south-west monsoon season. The succeeding period lasting till the end of November is the post monsoon or retreating monsoon season. About 83 to 87 percent of the annual rainfall in the district is received during the south-west monsoon months, (June to September). The spatial variation of rainfall in the district is not much, July being the rainiest month of the district. After February temperature increase rapidly till May, which is the hottest month of the year. The mean daily temperature in May is 40 degree centigrade. Forest: Forest have vital role in the economy of the district. The total forest area of Sheopur is 3949 sq. km which is 59.79% to the total area (6606 sq. km) of the district. The
Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 71
Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe district has 3006 sq. km of reserved forest. There is vast stock of forest products like Tendu leaf, Timber wood, Mahua, Harra, Lac, Gum and other herbal and medicinal products. The forest of Sheopur district can be regarded as dry tropical forests. Agriculture and Animal Husbandry: The principal Kharif crops traditionally grown in the district are Jowar, Bajra, Soyabean and Tuar. To some extent Rice is also grown. Main Rabi crops are Wheat, Barley, Gram, Mustard and Groundnut all of which gained much importance. Major part of rural population is depending on agriculture and animal husbandry. Irrigation: Canals originating from the dam built on Chambal river in Kota district of Rajasthan are the main source of irrigation in the south-west part of the district. The total area irrigated by canal is 65,672 hectares and tube wells is 2,299 hectares. The economy of the district is dominated by agriculture. The decadal growth rate is a vital part of Census operations. This gives an overview of the percentage of total population growth in a particular decade. The decadal population growth rate for Sheopur is higher than the population growth rate in Madhya Pradesh. CENSUS FINDINGS OF SHEOPUR-POPULATION AND ITS DISTRIBUTION
Census Year
Sr. No. Particulars 2001 2011
1 2 3 4
1 Area (in sq. KM.) 6606 6606
2 Number of Tehsils 3 5
3 Number of CD Blocks 3 3
4 Number of Villages 607 582
5 Total Households 96898 146043
Household size 5.8 4.7
6 Total Population 5,59,495 6,87,861
7 Decadal Population Growth (Madhya Pradesh) in % 24.26 20.23
8 Decadal Population Growth (Sheopur) in % 29.7 22.9
9 Proportion of Rural population to total population 84.2 84.4
10 Proportion of Urban population to total population 15.8 15.6
11 Sex Ratio 895 901
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
12 Work Participation Rate 41 40.3
13 Literacy Rate 46.4 57.4
Age-group wise proportion to total population
0-14 years 43.1 37.6
14 15-59 years 51.2 56
60+years 5.5 6.3
Age not stated 0.2 0.1
15 Scheduled Castes Population 90420 108391
Proportion of Scheduled Castes to total population 16.2 15.8
16 Scheduled Tribes Population 120482 161448
Proportion of Scheduled Tribes to total population 21.5 23.5
Source: District Census Handbook for Sheopur Year 2011
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Annexure 3
Block wise detail of Sheopur District There are three blocks in Sheopur district namely: Vijaypur, Sheopur and Karahal. The Karahal block has the highest population of Scheduled Tribes (rural 63.08%) of the) population among the total population of the block. Number and percentage of scheduled castes and scheduled tribes (Rural) population in Blocks, 2011 SR. No. Name of Block Total Total Total Percentage of Percentage Population scheduled scheduled scheduled of castes tribes castes scheduled population population population to tribes total population population to total population 1 0001-Vijaypur 215041 38005 44514 17.67 20.7 2 0002-Sheopur 235584 46059 30787 19.55 13.07 3 0003-Karahal 129884 7736 81926 5.96 63.08 Source: District Census Handbook for Sheopur Year 2011 Distribution of villages according to land use , 2011 SR. No. Name of Block Number of Total area (in Percentage of cultivable area to total inhabited Hectares) area villages
1 0001-Vijaypur 162 194241 20.29 2 0002-Sheopur 235 134405.09 66.87 3 0003-Karahal 119 206151.69 12.79
Source: District Census Handbook for Sheopur Year 2011 The Karahal block receives less rainfall. Only 12.79 % of the land in the Karahal block is cultivable as a percentage of total area.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Distribution of workers in four major categories of Economic activity- block wise
Name of Block Persons/ Total Total Males/ Population Workers Category of Workers Females (Main+ marginal Workers ) Agricultural Household Industry Cultivators Labourers workers Other Workers Number % Number % Number % Number % 0001-Vijaypur Persons 215,041 97,967 50,515 51.56 37,456 38.23 534 0.55 9,462 9.66 Males 115,353 59,103 32,337 54.71 19,502 33 317 0.54 6,947 11.75 Females 99,688 38,864 18,178 46.77 17,954 46.2 217 0.56 2,515 6.47 Persons 235,584 90,082 40,952 45.46 39,837 44.22 1,058 1.17 8,235 9.14 Males 122,548 64,116 34,818 54.3 22,655 35.33 536 0.84 6,107 9.52 0002- Sheopur Females 113,036 25,966 6,134 23.62 17,182 66.17 522 2.01 2,128 8.2 Persons 129,884 55,821 12,019 21.53 34,958 62.63 950 1.7 7,894 14.14 Males 67,459 33,066 9,656 29.2 17,781 53.77 473 1.43 5,156 15.59 0003-Karahal Females 62,425 22,755 2,363 10.38 17,177 75.49 477 2.1 2,738 12.03 Source: District Census Handbook for Sheopur Year 2011
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Annexure 4
Village Selection
Village selection was carried out following probability proportionate to size (PPS) sampling approach. Probability proportion to size is a sampling procedure is also used by the World Health Organization. It is generally used in studies under which the probability of a unit being selected is proportional to the size of the ultimate unit, giving larger clusters a greater probability of selection and smaller clusters a lower probability. In order to ensure that all units (ex. individuals) in the population have the same probability of selection irrespective of the size of their cluster, each of the hierarchical levels prior to the ultimate level has to be sampled according to the size of ultimate units it contains, but the same number of units has to be sampled from each cluster at the last hierarchical level. This method also facilitates planning for field work because a pre-determined number of individuals are interviewed in each unit selected, and staff can be allocated accordingly.
It is most useful when the sampling units vary considerably in size because it assures that those in larger sites have the same probability of getting into the sample as those in smaller sites, and vice verse. Since the estimated sample of 400 children between the age 1 and 6 years was required for the study, it was decided to draw a sample of 30 villages from the list of 139 villages in Karahal block. Since most of the villages in this block have a reasonable percentage of scheduled tribe population and situation of literacy and poverty is almost homogenous, no further stratification on these criteria was done.
Serial Name of the village Serial Number Name of the village Number 1 Jharer 16 Nimania 2 Kalarna 17 Meharbani 3 Bhela 18 Parond 4 Bagbaaj 19 Baragwa 5 Semalda Haveli 20 Goverdha
6 Aavda 21 Goras 7 Malipura 22 Reechhi 8 Verdha 23 Panbada 9 Nimoda Madh 24 Bamori 10 Bawdi Chapa 26 Budhera 11 Vardha Khurd 27 Moraban 12 Bhoorwada 28 Morai 13 Soosbada 29 Sesaipura 14 Chakrampura 30 Piprani 15 KhiriKhiri 30 Sarari Khurd Sampling interval rounded off -4385, random number generated-3972
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Annexure 5
Data collection and identification of household
In villages Saharia households that have children in the age group 1-6 years were identified and mapped on the village map. A central point in the village was drawn on a rough map and two Saharia and two Non-Saharia eligible households were identified. From this centre point the village was divided into three parts ensuring that all habitations in the confines of the villages were covered.
Segment A: 2 Saharia and 2 Segment B: 2 Saharia and Non-Saharia eligible 2 Non-Saharia eligible households households
In each segment (including Centre: 2 Saharia and 2 the central part) effort was Non-Saharia eligible done to identify one Saharia households child who is malnourished,
one Saharia normal child, one Non-Saharia malnourished child and one Non-Saharia Segment C: 2 Saharia and 2 child who is normal Non-Saharia eligible households
For every Saharia household identified to be eligible for the study, closest Non-Saharia household that is eligible was selected. Focused discussions held with the personnel at the health facilities - District Hospital, Community Health Centre Karahal and at the NRC. This was centered on quality and coverage of child health and nutrition services, and their overall experiences. Discussions were held with the personnel at the health facilities - District Hospital, Community Health Centre Karahal and at the NRC.
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Annexure-6
Balanced Diet for Adults-Sedentary /Moderate/Heavy Activity (Number of Portions)
Type Of Work Sedentary Moderate Heavy G/Portio Mon Woman Man Woman Man Woman n No. of portions Cereals & 30 12.5 9 15 11 20 16 Millets Pulses 30 2.5 2 3 2.5 4 3
Milk & 100 ml 3 3 3 3 3 3 Milk Products Roots & 100 2 2 2 2 2 2 Tubers Green leafy 100 1 1 1 1 1 1 Vegetables Other 100 2 2 2 2 2 2 Vegetables Fruits 100 1 1 1 1 1 1
Sugar 5 4 4 6 6 11 9
Fat 5 5 4 6 5 8 6
To calculate the days requirement of above mentioned food groups for an individual, multiply grams per portion with number of portions.
Particulars Prevalence Infants And Preschool Children (%) Low Birth Weight 22 # Kwashiorkor/Marasmus <1 # Bitot's Spots 0.8-1.0 Iron deficiency anaemia (6-59 months) 70.0 Underweight (Weight For Age)* (<5 Years) 42.6 # Stunting (Height For Age)* (<5 Years) 48.0 # Wasting (Weight For Height)* 20.0 Childhood Overweight/Obesity 6-30
Particulars Prevalance
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Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe
Adults (%) Chronic Energy Deficiency (BMI<18.5) Among # Rural Adults Men 33.2 Women 36.0 * Tribal Adults Men 40.0 Women 49.0 Anaemia (%) # Women (NPNL) 75.2 # Pregnant Women 74.6 Lodine Deficiency Disorders (IDD) Goiter (Millions) 54 Cretinism (Millions) 2.2 Still Births Due To IDD (Includes Neo Natal Deaths) 90,000 Prevalence Of Chronic Diseases Over Weight/Obesity (BMI>25) (%) # Rural Adults Men 7.8 Women 10.9 * Tribal Adults Men 2.4 Women 3.2 Urban Adults Men 36.0 Women 40.0 Hypertension Urban 35.0 #Rural 25.0 Men 25.0 Women 24.0 *Tribal 24.0 Men 25.0 Women 23.0 Diabetes Mellitus (%) (Year 2006) Urban 16.0 #Rural 5.0 Coronary Heart Disease (%) Urban 7-9 *Rural 3-5 Cancer Incidence Rate (Per 100,000) Men 113 Women 123 * Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 79 Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe Annexure 7 Data downloaded from MNREGA website and other websites Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 80 Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe Block wise comparison within the district Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 81 Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 82 Study of malnutrition among under-6 children of Sheopur district with 2018 special focus on Saharia tribe Name Population Districts covered Baiga 1, 31,425(23.86 %) Mandla, Shahdol, Dindori, Umariya, Anuppur, Balaghat Saharia 4, 17,171(75.76%) Gwalior, All districts of Chambal Division Bharia 2,012 (0.37%) Patalkot, District Chhindwara Source: Website of Tribal Welfare Dept, Govt of Madhya Pradesh Atal Bihari Vajpayee Institute of Good Governance & Policy Analysis, Bhopal 83