Post Event Coverage Survey (PECS) of Vitamin A Supplementation in Chhattisgarh, India

UNICEF Office for Chhattisgarh, Raipur Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India © United Nations Children’s Fund (UNICEF) Chhattisgarh, India 2017

Cover photo: ©UNICEF India/2014/Altaf Qadri

UNICEF Office 503, Civil Lines Raipur 492001 www.unicef.in August 2017

Suggested citation: United Nations Children’s Fund (UNICEF), ‘Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India’, UNICEF, Chhattisgarh, India, 2017. Post Event Coverage Survey (PECS) of Vitamin A Supplementation in Chhattisgarh, India

August, 2017

Disclaimer: This is a working document. It has been prepared to facilitate the exchange of knowledge and to stimulate discussion. The text has not been edited to official publication standards and UNICEF accepts no responsibility for errors.

The designations in this publication do not imply an opinion or legal status of any country or territory, or of its authorities, or the delimitation of frontiers.

CONTENTS

Foreword...... 7 Preface...... 8 Acronyms...... 9 Executive Summary...... 11 Introduction ...... 15 Methodology ...... 21 Study Findings...... 27 Recommendations and Way forward.....41 Annexures

Annexure 1: Statistical table...... 44

Annexure 2: List of Clusters...... 45

Annexure 3: List of Enumerators and Team Leaders.....46

Annexure 4: Copy of consent letter...... 47 Acknowledgements...... 48

Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India 3

List of figures

Figure 1: Coverage of VAS in Chhattisgarh through bi-annual campaigns 17

Figure 2: Comparison of VAS coverage across health surveys in Chhattisgarh 18

Figure 3: Comparison of Measles and Full immunization coverage in Chhattisgarh 19

Figure 4: Clusters covered in the PEC Survey in Chhattisgarh 24

Figure 5: Sampling and final enrollment 28

Figure 6: Percent coverage of Vitamin A 31

Figure 7: Children received Vitamin A in VAS campaign VS Wealth quartiles 31

Figure 8: Deworming coverage 36

Figure 9: Antigen wise immunization coverage 39

Figure 10: Reasons of failure of full immunization 40

Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India 5 List of tables

Table 1: Survey indicators for coverage of VAS in Chhattisgarh 17

Table 2: Characteristics of Child 29

Table 3: Characteristics of Caregiver 29

Table 4: Community Leader surveyed 30

Table 5: Health workers covered 30

Table 6: Quartile table 30

Table 7: Vitamin A coverage 30

Table 8: Coverage of VAS by gender 31

Table 9: Coverage of VAS by wealth quartile 31

Table 10: Location from which Vitamin A received 32

Table 11: Knowledge of caregiver about Vitamin A 32

Table 12: Knowledge of caregiver about benefits of Vitamin A 32

Table 13: Reasons for failure of VAS 33

Table 14: Knowledge of health worker on benefits of VAS 33

Table 15: Knowledge of health worker on dosage of Vitamin A 34

Table 16: Knowledge of health worker on various methods to combat Vitamin A deficiency 34

Table 17: Knowledge of community leader of SSM campaign 35

Table 18: Coverage of Albendazole 35

Table 19: Knowledge of caregiver on benefits of Deworming 36

Table 20: Reasons for not receiving Deworming tablet 37

Table 21: Knowledge of health worker on dosage of Albendazole 37

Table 22: Coverage of IFA 38

Table 23: IFA Coverage by gender 38

Table 24: Knowledge of health worker on dosage of IFA 38

Table 25: Antigen wise coverage 39

6 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Foreword

Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India 7 Preface

As part of UNICEF’s partnership with Government of Chhattisgarh, a Post Event Coverage Survey on the implementation of Shishu Sanrakshan Maah was conducted with the support of Helen Keller International, an internationally renowned organisation for Post Event Coverage Surveys. Shishu Sanrakshan Maah is a flagship campaign of the State government which focuses on Vitamin A Supplementation and other services aimed to better child health in the State.

The survey has collected data on the coverage of Vitamin A, IFA, deworming and immunization and also attempted to find out the barriers for achieving universal coverage of all these services. The comprehensive survey was done using android-based phone technology for data collection which substantially reduced processing time, with minimal errors and enabled geo-spatial analysis to identify barriers to high and equitable coverage.

The survey findings have highlighted the pivotal role of community mobilisation in improving access to services. It also calls for the need to continue to build capacities of frontline workers.

I am confident that the findings of the survey will further strengthen government’s efforts to increase demand generation and improve service delivery and the methodology and tools used in the survey will have greater scope of replication to evaluate other nutrition and health interventions in Chhattisgarh as well as other states in India.

UNICEF sincerely acknowledges the contribution of Department of Health and Family Welfare, Government of Chhattisgarh in conducting this study and I believe that the department will find the recommendations of the study useful.

On behalf of the UNICEF team, I appreciate the efforts of Helen Keller International and the team of CF SHORE (Christian Fellowship Society for Health Opportunity Rehabilitation and Empowerment) for the timely and successful completion of the survey.

Prasanta Dash Chief Field Office UNICEF Office for Chhattisgarh

8 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Acronyms

AHS Annual Health Survey

ANM Auxiliary Nurse Midwife

ASHA Accredited Social Health Activist

AWW Anganwadi Worker

CES Coverage Evaluation Survey

CF Shore Christian Fellowship Society for Health, Opportunity, Rehabilitation and Empowerment

CG Chhattisgarh

CM&HO Chief Medical and Health Officer

DLHS District Level Household and Facility Survey

HKI Helen Keller International

HMIS Health Management Information System

HW Health Worker

IFA Iron and Folic Acid

MPW Multi-Purpose Worker (Male)

NDD National Deworming Day

NFHS National Family Health Survey

PECS Post Event Coverage Survey

PPS Probability Proportion to Size

RSOC Rapid Survey on Children

SSM Shishu Sanrakshan Maah (VAS bi-annual round)

UNICEF United Nations Children’s Fund

VAS Vitamin A Supplementation

VAD Vitamin A deficiency

VHSND Village Health Sanitation and Nutrition Day

Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India 9

Executive Summary Introduction Methodology

Vitamin A deficiency (VAD) is considered as one A cross-sectional randomised 30 x 30 clusters of the most prevalent micronutrient deficiencies survey was conducted between 21st February 2017 worldwide, mainly affecting the children in and 1st March 2017 where sampling was done as developing countries. It is estimated that Vitamin per probability proportion to size (PPS). The primary A deficiency is affecting 190 million children under objective of the study is to obtain and validate the five years of age. VAD predisposes children to coverage of VAS and deworming in Chhattisgarh. increased risk of a range of problems, including The study also aimed to characterise children respiratory diseases, diarrhoea, measles, and vision missed from such services as a basis to plan better problems, and it can lead to death. The recent strategies to reach them in future. Cochrane review of 2017 highlights that Vitamin A reduces overall risk of death and death due to A total of 1068 persons were interviewed which diarrhoea by 12% specifically by reducing new includes 978 caregivers of children aged 9-59 occurrences of diarrhoea and measles. Vitamin months, 60 health workers and 30 Community A supplementation is associated with a clinically leaders. Households with children between 9 and 59 meaningful reduction in morbidity and mortality in months of age as on December 2016 was considered children (Cochrane, 2017) which has been strongly as the inclusion criteria for the household. corroborated WHO as well. Results Since 2006, Government of Chhattisgarh, following the national policy, is implementing the The evaluated coverage of VAS was 71.9% for the supplementation of Vitamin A to children under five age group of 9-59 months against the reported years of age through a bi-annual campaign called coverage of 88.9% indicating a 19.12% decrease Shishu Sanrakshan Maah (SSM) which has led to in the validated coverage against the reported a progressively increasing reported coverage of coverage. The figure went up to 75.2% for children Vitamin A supplementation (VAS) in Chhattisgarh. provided with Vitamin A in last six months which is However, population based survey shows that very close to the NFHS-4 figure of 70.2%. Two main the coverage of VAS is not optimal and below the reasons for children not receiving Vitamin A are the universal coverage limit. Evidences have shown family not aware about the session and place and that effect of vitamin A supplementation may be time of the session which highlights the poor use reduced when interventions is not delivered with of social mobilisation strategies. fidelity. Based on the experience of conducting post campaign validation surveys in the last two The coverage of deworming in children aged 12-59 rounds of SSM, UNICEF wanted to bring the months who have received Albendazole during the most scientific methodology available for this National Deworming Day (February 2017) was 63% exercise and collaborated with Helen Keller against the reported coverage of 84.8%. International (HKI) to plan, design and implement Post Event Coverage Survey (PECS) in Chhattisgarh SSM campaigns were used as a platform for so that the model can work as a guiding tool for distribution of IFA syrup. Only 25.6% of children Chhattisgarh as well as other states across the received IFA syrup from the last SSM campaign, out country. Thus, UNICEF with support from HKI of those who have received, only 20.8% of caregivers conducted the third round of validation in the have given it in correct dose and frequency. This month of February 2017 based on the globally shows a very low effective coverage of IFA accepted PECS methodology. supplementation for children under five years of age.

12 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Immunization services are found to be performing l Sector level meetings of health workers to well as 90.7% of children assessed between 12 and be used effectively for micro-planning of 23 months are fully immunized. the activities. Important protocols like age appropriate dose, other health and nutrition Conclusion education components and standard procedures should be shared prior to each round. Having valid coverage estimates is critical for l Efforts need to be continued to strengthen monitoring VAS programs and determining whether monitoring mechanism for delivery of quality programs are reaching their objectives. In addition services for improved and equitable coverage to providing more valid coverage estimates, PECS of services during Shishu Sanrakshan Maah have provided essential information to improve (SSM). VAS delivery. The rapid aggregation of PECS data l Convergence workshops to be conducted for provided timely feedback about program operations orientation of frontline functionaries. such as planning, implementation, and supply chain l True reporting to be encouraged and the management. findings of the reporting to be shared back with necessary guidance at every level. Lack of awareness of caregivers about the benefits l Effective strategy to be kept in place to capture of the supplementation programme is clearly seen the children who got missed out during the from the results. Capacity building of health workers SSM day. Mitanins can be engaged to serve is required to make the health workers understand the missed out children within next couple of the benefits of the programme and also the days and its reporting should be accounted. appropriate dosage and frequency of administration. l Preparatory activities prior to the round should More investment is required for the publicity of VAS include orientation meetings for ANMs and campaign. The supply and equitable distribution of AWWs – in spite of the fact that they have been IFA syrup needs to be ensured. oriented earlier about SSM and that they are aware about the same. This would help frontline Twice-yearly delivery of VAS through Shishu functionaries refocus on the importance of the Sanrakshan Maah (SSM) achieved consistently high SSM round, and avoid complacency to set in. and equitable coverage in Chhattisgarh. Universal l It has been observed that the key activities coverage may be achieved through continued focus of SSM have been limited to immunization on communication and targeted outreach to hard-to- and micronutrient supplementations. Other reach areas during these SSM rounds. most important activities such as growth monitoring, screening of severely malnourished Key recommendations are as follows: children, IEC, health and nutrition education and l The main reasons cited by the respondents counseling are losing its required focus which who failed to avail the service are the lack can be strengthened with due support and of information about the place and time of collaboration with ICDS. All these activities must the session. More focused strategies to be be stressed repeatedly to retain its seriousness. adopted so that timely information is reached l Simple poster or chart displaying the correct to all care givers. age appropriate doses of micronutrient in the l In order to track uptake of services, the session site will help minimizing the confusion availability of immunization card per eligible amongst health care providers. child needs to be ensured and to be l Information about the benefits of the program timely updated by the respective frontline is not properly reaching to the intended workers. This would enable the immunization beneficiaries. Even some of the health workers card to be considered as a self-monitoring also failed to inform about the benefits. and demand generating tool from the l Involvement of community leaders in the mothers/caregivers. campaign would help in improving coverage.

Executive Summary 13

Introduction Background children (6–59 months old); however other countries struggle to reach and sustain high Vitamin A Deficiency (VAD) is considered VAS coverage6. VAS coverage estimates as one of the most prevalent micronutrient provide a reasonable measure of assessing deficiencies worldwide, mainly affecting programme success as against status, children in developing countries1. It is considering the cost, invasiveness and estimated that globally about 30% of logistical difficulties of blood collection, children under 5 years of age are Vitamin A storage and analysis, the difficulties of deficient2. A recent Cochrane published meta interpreting biological markers of Vitamin analysis of 19 trials comprising of more than A, and the poor responsiveness of serum 1.2 million children indicates that there is a retinol to VAS. 12% observed reduction in risk of all-cause mortality for vitamin A3. VAD is also a major Coverage estimates can come from tally cause of preventable childhood blindness. sheets completed during the distribution, with the data incorporated into the Health Due to Vitamin A’s influence on immune Management Information System (HMIS) or function, supplementation with a high-dose from district or national level representative of Vitamin A is designed to reduce mortality population-based surveys, or possibly sentinel associated with measles, diarrhea, and surveillance. other illnesses4. Thus, WHO recommends all children aged 6-59 months in vitamin Most countries, including India and A deficiency areas receive a preventive Chhattisgarh state, use a tally sheet system, dose of VAS every 4-6 months. At present, which records the doses administered at more than 80 countries worldwide are VHSND, health post, sub-center or other implementing universal VA supplementation location, and then aggregates these upward (VAS) programmes targeted to children to the next level (e.g. district, state, country) 6–59 months of age. Global experiences to provide a total numerator (i.e. total number also indicate that achieving consistent of doses administered). When applied to coverage over 80% is necessary to achieve the total number of children in the target the mortality reduction demonstrated by age group at each level, this provides a efficacy studies5. Some countries have coverage estimate for any given round. This achieved high coverage of twice yearly approach can provide valuable information distribution of Vitamin A to preschool aged allowing coverage comparisons by district,

1 World Health Organization. Global Prevalence of Vitamin A Deficiency in Populations at Risk 1995– 2005; World Health Organization: Geneva, Switzerland, 2009. Available online: http://apps.who.int/iris/ bitstream/10665/44110/1/9789241598019_eng.pdf 2 Stevens, G.A.; Bennett, J.E.; Hennocq, Q.; Lu, Y.; De-Regil, L.M.; Rogers, L.; Danaei, G.; Li, G.; White, R.A.; Flaxman, S.R.; et al. Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: A pooled analysis of population-based surveys. Lancet Glob. Health 2015, 3, e528–e536. 3 Imdad A, Mayo-Wilson E, Herzer K, Bhutta ZA. Vitamin A supplementation for preventing morbidity and mortality in children from six months to five years of age. Cochrane Database of Systematic Reviews 2017, Issue 3. Art. No.: CD008524. DOI: 10.1002/14651858.CD008524.pub3 4 Beaton, G.; Martorell, R.; Aronson, K.; Edmonston, B.; McCabe, G.; Ross, A.; Harvey, B. Effectiveness of Vitamin A Supplementation in the Control of Young Child Morbidity and Mortality in Developing Countries; Administrative Committee on Coordination–Subcommittee on Nutrition (ACC/SCN): Geneva, Switzerland, 1993. 5 Ross DA (2002) Recommendations for vitamin A supplementation. The Journal of nutrition 132: 2902S–2906S. 6 Dalmiya N, Palmer A (2007) Vitamin A Supplementation: a decade of progress. United Nations Children’s Fund.

16 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India state, region or country overtime, and be led to a progressively increasing reported used to identify and focus attention on low coverage of VAS in Chhattisgarh. The coverage areas. Tally systems, however, can coverage figures for various rounds are also suffer from some intrinsic weaknesses highlighted in Figure 18. related to inaccurate population estimates for a given location, human error in counting and In addition to the health department's own calculating, and delayed, incomplete or missing reported coverage, various national surveys reports from districts leading to inaccurate have been conducted in the State and provides coverage estimates7. VAS coverage with varied denominators. The results of these surveys are provided in The bi-annual strategy, recommended by Table 1. The latest survey of NFHS-4 (2015-16) WHO and UNICEF, through a campaign shows the coverage of VAS as 70.2% approach (except for August 2011, when amongst children between 9 months and 59 “VAS-through-VHND” approach was used) months of age in the State of Chhattisgarh.

Figure 1 Coverage of VAS in Chhattisgarh through bi-annual campaigns

100

89.4 88.9 90 86.4 84.3 85.8 80 71.5 69.2 68 70.2 70 67.1 65.5 66.8 60 61.2 53.9 57 50

40

30 31.4

20 19.6

10 8.3

0 Jan. 11 Apr. 15 Jan. 12 Apr. 07 Apr. 08 Jun. 10 Jun. 16 Oct. 07 Feb. 14 Jun. 09 Oct. 08 Oct. 06 Oct. Mar. 13 Nov. 15 Aug. 11 Aug. 12 Dec. 16 Nov. 09

7 Nyhus Dhillon C, Subramaniam H, Mulokozi G, Rambeloson Z, Klemm R (2013) Overestimation of Vitamin A Supplementation Coverage from District Tally Sheets Demonstrates Importance of Population-Based Surveys for Program Improvement: Lessons from Tanzania. PLoS ONE8(3): e58629. https://doi.org/10.1371/journal.pone.0058629 8 The denominators for calculating the coverage is based on projected population based on Census 2001 and 2011 figures of population of children 9 months to 5 years and the decadal growth rate; and not against the target children identified by the Government based on annual survey at the beginning of the financial year conducted by ANM.

Introduction 17 Table 1 Survey indicators for coverage of VAS in Chhattisgarh

Indicator Source Year % Children aged 9 months and above who received at DLHS-2 2002-04 32.4 least one dose of Vitamin A Children aged 12 to 35 months given Vitamin A NFHS-3 2005-06 14.4 supplements in last 6 months Children aged 6 to 59 months given Vitamin A NFHS-3 2005-06 9.1 supplements in last 6 months Children aged 9 months and above who received at DLHS-3 2007-08 65.1 least one dose of Vitamin A Children aged 12 to 23 months who received at least CES 2009 67.3 one dose of Vitamin A Children aged 12 to 23 months who received one dose CES 2009 56.2 of Vitamin A during last 6 months Children aged 6 to 35 months who received at least one AHS 2010-11 71.7 Vitamin A dose during last 6 months Children aged 6 to 35 months who received at least one AHS 2011-12 68.6 Vitamin A dose during last 6 months Children aged 6 to 35 months who received at least one AHS 2012-13 68.3 Vitamin A dose during last 6 months Children aged 6 to 59months who received at least one RSOC 2013-14 44.7 Vitamin A dose during last 6 months Children aged 9-59 months who received Vitamin A NFHS 4 2015-16 70.2 dose in last 6 months

Figure 2 Trends in VAS coverage across various health surveys in Chhattisgarh (2010 - 2016)

100

80 71.6 68.6 68.3 70.2

60 44.7 40 Prevalence (%)

20

0 AHS AHS AHS RSOC NFHS 2010 -11 2011-12 2012-13 2013-14 2015-16

The last three rounds of AHS and RSOC of each survey as highlighted in Table 1, the shows a declining trend of VAS coverage in coverage figures of each survey should not be Chhattisgarh. The coverage has remained compared with another. However, the trend stagnant between 2011 and 2013. It then is showing that the coverage of VAS is not declined to 44.7% in 2013-14 (RSOC). The optimal and below the universal coverage limit. latest figure from the NFHS-4 survey shows an improvement in the coverage rates. Since The coverage of measles and proportion there are differences in the denominators of children who are fully immunized are

18 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Figure 3 Comparison of Measles and 2006 under the aegis of Shishu Sanrakshan Full immunization coverage in Maah (SSM) similar to Child Health Days; Chhattisgarh followed by subsequent rounds at six monthly intervals. The 18th SSM round in Chhattisgarh 100 93.9 was conducted in December 2016. 90 85.7 80 74.9 76.4 The strategy was implemented by the 67.2 Department of Health and Family Welfare, 60 Government of Chhattisgarh; with support from UNICEF and Nutrition International 40 (former Micronutrient Initiative). The strategy was initiated across the State since inception. 20 However, difficult and hard to reach areas (High Risk Areas-HRAs) were specially focused 0 Measles 1 Fully immunised through intensified planning and monitoring in the State. This bi-annual approach was

AHS 2012-13 RSOC 2013-14 NFHS 2015-16 gradually expanded to strategically bundle additional services that could be delivered together at six monthly intervals. Thus, the menu of services that are provided presently consistent in all three annual health surveys in the State through the bi-annual approach as shown in Figure 3. included the following: l Vitamin A Supplementation Statement of the Problem & l Deworming (with Albendazole) Rationale for Survey l Catch up of immunization and antenatal The National Prophylaxis Programme for care services the Prevention of Nutritional Blindness l Iron Folic Acid (IFA) supplementation for due to VAD has been operational since children 1970s and was revised by Government l Screening and referral of SAM children of India in 2006 and covers all children 6 months to 5 years for VAS. Under the Since 2006, Chhattisgarh has been conducting programme, children 6 months to 5 years bi-annual VAS campaigns and has used a are administered VAS every 6 months. A tally sheet system to estimate coverage child should receive a total of 9 doses of and has consistently reported VAS coverage Vitamin A by his/her fifth birthday. In view around 70%. Although, the last three rounds of operational feasibility, the administration reported the VAS coverage above 85%, the of first dose of VA was linked to measles last three rounds of AHS survey reported that immunization and hence in Chhattisgarh, the Vitamin A coverage level in Chhattisgarh has target group of beneficiaries in Chhattisgarh plateaued around 70% and further declined for Vitamin A is children aged 9 months to to 44.7% in 2013-14 as shown in Figure 2. 5 years. Encouragingly, the survey results of NFHS-4 indicates a better coverage at par with the In order to improve the coverage of VAS, previous years in the State. a bi-annual strategy through a campaign approach was adopted by the State in order To validate the reported coverage, to deliver services at six monthly intervals. In Department of Health and Family Welfare Chhattisgarh, the bi-annual Vitamin A strategy and UNICEF conducted a state representative was initiated for the first time in October randomized 30 x 30 cluster survey following

Introduction 19 the campaign conducted in April 2015. The Objectives validated coverage showed a 31 percentage points decline of both VAS and deworming Primary objective from the reported coverage. This survey also To assess the effectiveness of interventions explored various operational bottlenecks. employed to improve campaign services in For the second round of campaign of 2015 uptake and coverage of VAS and deworming. which was conducted in November 2015, The primary outcome of the survey is the UNICEF conducted a similar 30 x 30 cluster coverage of children aged 9-59 months old validation survey as one step forward towards consumed VAS during the SSM campaign UNICEF’s technical support for value addition December 2016 and January 2017 and in strengthening the implementation of 12-59 months children with deworming on Shishu Sanrakshan Maah in the State. the National Deworming Day (10th and 15th February 2017) in Chhattisgarh. Based on the experience of conducting post campaign validation survey in the last two Secondary Objectives rounds of SSM, UNICEF aimed to bring the l To assess the effectiveness of most scientific methodology available for this community health mobilisation strategy exercise and collaborated with HKI to plan, l To identify the characteristics of children design and implement Post Event Coverage who missed VAS, deworming, IFA and Survey (PECS) in Chhattisgarh so that the immunization to formulate a better model can work as a guiding tool for other strategy to reach the vulnerable ‘hard to states across the country. HKI, in the past, reach’ populations have conducted similar PECS for VAS in many l To assess knowledge of Vitamin A other countries especially in African region among caregivers, health workers and and thus possess the expertise for the same. village leaders In this context, UNICEF with support from l To understand barriers and boosters HKI conducted the third round of validation in for participating in VAS campaign by the month of February 2017 in the month of caregivers as well as the health workers. February 2017 (after the completion of recent VAS round that started on 20 December, 2017) based on the globally accepted PECS methodology.

20 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Methodology General Design villages in the State available from website of Census of India (Census 2011) for the State The study was a cross-sectional cluster of Chhattisgarh. The sampling interval and sample survey. To establish a state level sample needed was determined based on representative sample of households, 30 the total population of the State. A random clusters were randomly selected across the number between one and the sampling State of Chhattisgarh using PPS sampling of interval was then selected to determine the administrative units, the smallest unit for which first cluster. This methodology was used to there is population data (i.e., ward or village select 30 representative clusters from around level) from Census 2011. These sampling units 20,000 villages in the State. (villages) selected are called as clusters. The list of clusters selected is given in Annexure 2. Sample size The sample size for the survey has adapted Survey tools cluster sampling methodology of 30 clusters Four types of informants surveyed: by 30 individuals (n=900) for coverage estimate of VAS. In order to obtain more l Caregivers of children aged 9-59 months information about children missed by the l Health workers (ANM/MPW) VAS distribution, this sample was extended l Frontline workers (AWW or Mitanin/ASHA) to include two additional children per cluster, l Community leaders (Sarpanch, Panch members etc.) or 30 clusters X 32 individuals (n=960), which increased the precision of the coverage There were three questionnaires developed estimate and allowed for more robust analysis especially for conducting PECS in Chhattisgarh of the children who were missed. as detailed below: Considering the request from Chhattisgarh Questionnaire 1 Caregivers/mothers state Department of Health and Family Questionnaire 2 Health workers (ANM/MPW) Welfare, age appropriate sub-groups such Frontline worker (Mitanin/ as 12 months to 59 months and 12 months to AWW) 23 months were also enquired on deworming Questionnaire 3 Community leaders. and immunization status respectively. No separate sampling and selection process All three survey tools for data collection were considered for this. Similarly, all those were in digital forms, bilingual - developed children sampled for Vitamin A were also in both English and Hindi (the local language asked for their compliance to IFA syrup which of Chhattisgarh) pre-tested and adapted was mandated to be 1 ml consumption bi- according to expected responses, nature of weekly as per Ministry of Health and Family how respondents understand the questions Welfare guidelines for National Iron Plus and settings. The tools were prepared in Initiative (NIPI). joint consultation with nodal officer from Directorate of Health Services, HKI and Household selection UNICEF. Before field testing of the tools, all Five teams with three enumerators each the surveyors were oriented on the tools and were employed for the survey data collection. methodology. Each team also had one team leader and a supervisor. Upon arrival in the village, the Cluster (village/urban ward) team leaders met with the village leaders to selection explain the purpose of the survey and obtain The sampling frame was developed in one necessary approval and consent to conduct stage using the census list of all registered the survey in the village. Necessary letters

22 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India were also sent ahead of time to the Chief present, their location was enquired, and the Medical and Health Officer (CM&HO) where house was re-visited when possible. If the the 30 clusters were located. caregiver was not in proximity, the house was skipped due to time constraints. This Using a map, each cluster was divided into method was repeated in all quadrants in each four quadrants. In each quadrant, one of five of the 30 clusters sampled across the State starting points was chosen at random. At of Chhattisgarh resulting in a total estimated each starting point, a water bottle was spun sample size of 960 households. to determine the direction of the households for selection. Once the direction was Selection of frontline workers determined, the number of households from In addition to caregivers in the sample, the starting point to the end of the quadrant three other types of informants were in the direction of the bottle was estimated sampled in each cluster including one health and a house was selected at random as the worker (ANM/MPW), one frontline worker starting household. Following the direction of (Mitanin/AWW) and one community leader the bottle spin from this first household, the (Sarpanch, the village chief-person or select next eligible households were interviewed by Panch member). Auxiliary Nurse Midwives the enumerator. This process was repeated (ANMs) and Multipurpose Workers (MPW) in each of the four quadrants of the cluster are managing the lowest unit of public health untill all required number of households were system in India which is called sub-centre covered. which covers about 3000 to 5000 population based on the geographic area. ANMs are Sampling of caregivers female health workers and MPWs are Households were screened for eligibility male health workers who have got specific based on having a child 9-59 month of age health related tasks to perform in the at the time of the December 2016 - January community. Mitanins are community health 2017 round of supplementation. Within each volunteers, similar to Accredited Social eligible household, only one eligible child Health Activists (ASHA) who are selected was selected to be the focus of the survey. from the community itself and are working in If multiple children lived in the household, the a population of 300 to 500.If Mitanins were selection of the child was done at random not available, Anganwadi Workers (AWW) by writing the names of all eligible children were interviewed. In cases where there was on slips of paper, placing them in a bag, and more than one Mitanin in the cluster; chit picking one out. The age of children was system was used to select one Mitanin to verified by MCP - Mother and Child Protection be interviewed. Card or Health cards whenever possible and when unknown, was estimated using life Sarpanch is an elected head of a village-level event calendars. statutory institution of local self-government called Gram Panchayat (village government) Caregiver is the person who usually takes in India. care of the child. Parents usually the mother were the caregiver in most of the cases. Interviews with health worker, frontline Sometimes the grandparents or elder siblings worker and community leader were carried were also be qualified to be the caregiver out by the team leaders. The selection of for the survey if they have information about health worker was done purposively by the health care of the child and also had the identifying the one who caters the sampled MCP (Mother and Child Protection) card clusters and provides services for routine with them. If a primary caregiver was not immunization and VHSND in that village.

Methodology 23 PECS validation team and in their respective division, as instructed, validation survey period they moved to other divisions which had The validation of the VAS coverage was more number of clusters. The survey completed within six weeks of the (December team consisted of three enumerators and 2016 - January 2017) Shishu Sanrakshan one team leader and one supervisor. The Maah (SSM) campaign. The survey was enumerators did the interviews of the conducted between February 21, 2017 to caregivers and the team leader interviewed March 1, 2017. the health worker, frontline workers and the community leaders. It was under the Since the State of Chhattisgarh is divided supervision of the team leaders that the administratively into five divisions, five cluster map was prepared and was divided teams were constituted. Each team had to into four quadrants. The team leaders do the PEC survey in allocated six clusters. assigned the enumerator the location If the team had less number of clusters (quadrant) they had to cover.

Figure 4 Clusters covered in the PEC Survey in Chhattisgarh

24 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India The responsibility of the supervisor was to During the training, the enumerators, team monitor the entire field level data collection leaders and the supervisors were given activity. The supervisor accompanied the orientation on VAS programmes and related enumerators and team leader to ensure the interventions which were covered under the methodology was properly followed and the ambit of this survey. Followed by this, the quality of data collection was maintained. The teams were also provided with information on supervisors were the link between the central the survey methodology, sampling, selection monitoring team (which consists of UNICEF of target beneficiaries and questionnaires representatives and HKI team) and survey and whole modality of implementing the team. The supervisors maintained continuous PEC survey on field. The questionnaires contact with the central monitoring team were loaded in their mobile phones. A day in for guidance and support and received training was dedicated to providing hands-on clarifications in case of any doubt or issues training on the android based mobile phone. coming across during data collection. As part of the training, a field visit was Since the data was collected through mobile organised to give the enumerators field smartphone application and were uploaded exposure and pre-test the questionnaire. to the server on a daily basis, a real time There was a demonstration by the facilitators monitoring of the collected data was possible from HKI and UNICEF on the methodology and was done every evening by the central followed to select the caregiver and how to monitoring team and the feedback was given conduct the interview of caregiver and other to the survey team through the supervisor community level respondents included in the if there was any requirement. List of team survey. Post field visits the questionnaires members from field and at central level were discussed and modifications were involved is placed in the Annexure 3. done. Role plays were part of the training so that every participant was thorough on Training the questionnaire and trained on how to ask The training sessions were conducted by questions during the data collection. representative from HKI and UNICEF. Twenty enumerators and team leaders along with All team members were provided with the the five supervisors were trained for the consent form which was taken as a hard copy PECS. Supervisors along with the central (Annexure 4). A survey plan was developed team were invovled in designing of survey, at the end of training which was followed for development of tools/questionnaire etc. The data collection. The enumerators and team leaders were selected by CF SHORE (Christian Fellowship Data collection Society for Health Opportunity Rehabilitation The data collection was done through and Empowerment), the local field partner for android application installed in mobile UNICEF in Chhattisgarh. These enumerators phones of the enumerators. In this survey, were already having some prior experience ONA App (www.ona.io) was used for data in data collection. Team leaders for the five collection. At the time when Chhattisgarh teams were selected from these enumerators planned to use mobile based technology who performed better during the training with for survey data collection, Open Data Kit substantial experience of team management. (ODK) was the prevailing option for quick, A three days training was conducted in the easy, and free mobile data collection campus of CF SHORE in Rajnandgaon district startup. As an open source framework, of Chhattisgarh. ODK has inspired a variety of non-profit

Methodology 25 initiatives and for-profit service providers This was instrumental in reducing the survey to emerge, giving organisations a plethora time especially in data entry. of options to choose from. There are many android applications such as ONA, Kobo, Statistical Analysis Dimagi etc who use ODK as their operating platform. The use of ONA Collect is not During the data collection, teams uploaded a formal endorsement of the tool, but the data on a daily basis, when they had rather a coincidental circumstance. The access to mobile internet network. The data questionnaire was available in both Hindi retrieved from ONA application was verified and English. The enumerator could select and converted to Excel and SPSS files for data the language based on his/her choice of analysis. The SPSS software (version 22) was language. The application was pre-installed used for statistical analysis and appropriate with filters and logical skips to minimise graphical presentations were created in MS errors in data collection. The location of the Excel 10. data collection is also encrypted in the survey process which can facilitate mapping of the The detailed statistical analysis made it possible respondents in a Geographical Information to identify the reasons for not receiving Vitamin System (GIS) equipped map. Data collection A, deworming, IFA and immunization services. using mobile phone technology didn’t require The statistical significance at the end of the separate data entry since it was happening tests was determined at the error threshold while collecting data in the phones itself. of not more than 5%.

26 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Study Findings Enrollment and Final Sample

After collection of data, the final sample included caregivers of 978 children, out of which 313 children aged 12-23 months, 60 health workers which included ANMs, Male Health Worker, Mitanin and Anganwadi worker and 30 community leaders. For Vitamin A and IFA syrup, analysis was done for children aged 9-59 months of age at the time of the December 2016- January 2017 distribution round in the State. For full immunization the analysis was restricted to children of age group 12-23 months and analysis of deworming interventions was restricted to children between 12-59 months of age. There was no deliberate attempt to collect samples of a specific age group to cover immunization and deworming. The sample analysed for immunization and deworming were subgroups of the total sample selected.

Description of Sample

The mean age of the sampled children is 28.7 months (27.84 -29.57, 95%CI). The age group of 12 to 23 months has maximum sample size; 32% as shown in Table 2. The gender distribution for both girls and boys is almost equal in the all age groups. Nearly 73% of caregivers could show the Mother and Child Protection Card (MCP Card) which showed that a good number of parents are sensitised about the health of their children. Among the caregivers interviewed 88% were the parents of the children (73.1% are mothers). As many as 28.1% of caregivers were not educated. Most of the children covered in the survey belonged to other backward caste or scheduled tribe. The proportion of children from general caste was very less among the sampled children.

The wealth quartile division of the sampled children was based on amenities at their household. The total households were divided into four wealth quartile with quartile one is the lowest and quartile four being the highest. There was an equal representation from all the wealth quartiles for the sampled children.

Figure 5 Sampling and final enrollment

Final Sampling and Enrollment Caregivers | Community Leaders | Community Health Workers | Health Workers

Caregivers interviewed Community leaders Community health workers/health workers (N=978) (N=30) completed (N=60)

VAS ANM (N=978) (N=30)

Deworming Mitanin (N=887) (N=30)

Immunization (N=313)

IFA (N=978)

28 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Table 2 Characteristics of child

Child characteristic N Percent Age group of children 9 to 11 months 91 9.3% 12 to 23 months 313 32.0% 24 to 35 months 270 27.6% 36 to 46 months 175 17.9% 47 to 59 months 129 13.2% Gender Male 500 51.1% Female 478 48.9% Mother and child protection (MCP) card available Yes 711 72.7% No 267 27.3%

Table 3 Characteristics of caregiver

Caregiver characteristic N Percent Relationship Mother 715 73.1% Father 146 14.9% Grandmother 60 6.1% Grandfather 30 3.1% Sibling 15 1.5% Relative 6 0.6% Other (specify) 6 0.6% Education None 275 28.1% Less than 5 years complete 146 14.9% 5-7 years complete 137 14.0% 8-9 years complete 201 20.6% 10-11 years complete 119 12.2% 12 or more years complete 100 10.2% Religion No Religion 18 1.8% Hindu 915 93.6% Muslim 1 0.1% Christian 5 0.5% Traditional/Animist 17 1.7% Don't know 22 2.2% Caste Schedule Caste (SC) 131 13.4% Schedule Tribe (ST) 379 38.8% Other Backward Class (OBC) 429 43.9% General 32 3.3% Don’t know 7 0.7%

Study Findings 29 Table 4 Community Leader surveyed

Community Leaders N Total numbers of community leaders covered in the study 30

Table 5 Health workers covered

Health workers covered (n = 60) N % ANM 22 36.7% Mitanin 26 43.3% AWW 4 6.7% Male Health Worker 8 13.3%

Wealth Quartile

Wealth index is used to link the coverage of VAS and deworming to the socio-economic status of child’s household. The wealth index has been developed and tested in many countries in relation to inequalities in household income, use of health services, and health outcomes (Rutstein et al., 2000). It is an indicator of the level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The economic index was constructed using household asset data and housing characteristics.

After analysis, Table 6 shows household wealth index in this PECS sample:

Table 6 Quartile table

Quantile N % Lower 95% CI Upper 95% CI 1 244 24.9 22.4 27.7 2 245 25.1 22.3 27.7 3 245 25.1 22.1 27.8 4 244 24.9 22.1 27.6 Total 978 100.0 100.0 100.0

Coverage of VAS

The evaluated coverage of VAS is 17 percentage points less than the coverage reported for the Dec 16-Jan 17 round of SSM. The reported coverage from State government through the compiled reports received from all the districts is 88.9%. The evaluated coverage of VAS is 71.9%. The coverage of VAS is 75.2% when accounted for children who have received Vitamin A in the past six months prior to survey. The gender based difference in the coverage of Vitamin A is negligible as shown in Table 8.

Table 7 Vitamin A coverage

Vitamin A coverage N Percent 95% Confidence Interval Lower Upper Coverage of last campaign 703 71.9 69.0 74.8 Coverage of 6 months 735 75.2 72.4 77.7 Life time coverage 809 82.7 80.2 85.2

30 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Figure 6 Percent coverage of Vitamin A 82.7

75.2

71.9

Coverage of Coverage of last Life time last campaign 6 months coverage

Table 8 Coverage of VAS by gender

Sex of the child Statistics Male Female Chi square Probability Coverage of last campaign 360 72.0% 343 71.8% .007 .933 Coverage of last 6 months 380 76.0% 355 74.3% .393 .531 Life time coverage 419 83.8% 390 81.6% .835 .361

Coverage of VAS by wealth quartile The distribution of coverage by wealth quartile shows that slightly more coverage is reported from the households representing quartile 3 and 4. A huge difference is not seen between different quartiles.

Table 9 Coverage of VAS by wealth quartile

Quartile 1 Quartile 2 Quartile 3 Quartile 4 Total

Not received N 71 84 55 65 275 Vitamin A in last % column 29.1% 34.3% 22.4% 26.6% 28.1% campaign % line 25.8% 30.5% 20.0% 23.6% 100.0% N 173 161 190 179 703 Received Vitamin A % column 70.9% 65.7% 77.6% 73.4% 71.9% in last campaign % line 24.6% 22.9% 27.0% 25.5% 100.0% Total N 244 245 245 244 978

Figure 7 Children received Vitamin A in VAS campaign VS Wealth quartiles

Vitamin A received percentage

77.60%

73.40% 70.90%

65.70%

Quartile 1 Quartile 2 Quartile 3 Quartile 4

Study Findings 31 Where was VAS received Anganwadi centres are shown to be the place from which majority of children received VAS. This is obvious as the VAS has happened as an activity within in the VHND which was happening at Anganwadi centres. Other major places where children received Vitamin A were the sub-centre or urban health post and home (in some places the health workers visited the household and provided the Vitamin A syrup).

Table 10 Location from which Vitamin A received

Places N % Anganwadi centre 564 80.2% Outreach post (Sub-centre/Urban Health Post) 66 9.4% Home 40 5.7% School 14 2.0% Panchayat Bhawan 8 1.1% Health facility/health hospital (PHC/CHC/District hospital/ 2 .3% Urban Health Post) At the street/at the road 6 .8% Don’t remember/don’t know 3 .4%

Knowledge of Caregiver on benefits of VAS Only 540 caregivers out of total 978 have heard about Vitamin A. Out of them, merely half know about any benefits of Vitamin A. Among those who could tell any benefits of Vitamin A, 58 and 44% responded that it protects child health and improves child immunity. Only 42% responded that Vitamin A prevents blindness and improves vision. This clearly indicated that around 50% were not aware of the actual benefit of Vitamin A. This gap needs to be reduced for better coverage of Vitamin A.

Table 11 Knowledge of caregiver about Vitamin A

n % Caregivers heard about Vitamin A 540 55.2% Caregivers know about benefits of Vitamin A 272 50.3% Caregivers do not know about the benefits of Vitamin A 268 49.6%

Table 12 Knowledge of caregiver about benefits of Vitamin A

Caregiver knowledge about benefits of Vitamin A n % (N= 272) Protects against disease/boosts immunity 158 58% Improves child health 120 44% Prevent blindness/helps vision 114 42% Helps with growth 20 7% Boosts appetite 15 6% Gives the child strength/energy 20 7% Protects from anemia 12 4% Others 18 7%

32 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Reason for VAS failure For those who could not receive Vitamin A in the December 2016-January 2017 round, the reasons of failure were assessed as shown in Table 13. Around 45.5% had not heard about the campaign, place and/or time of session unknown (13.8%) and unawareness of need of VAS (8.7%) were found to be of major concerns.

Table 13 Reasons for failure of VAS

Reasons of VAS failure Out of those who didn’t receive Vitamin A n N % Did not hear about the campaign 125 275 45.5 Place/time of session unknown 121 275 44.0 Did not know the child needed it 24 275 8.7 Other (specify) 16 275 5.8 Did not know the importance of VAS 10 275 3.6 Too much work at home/busy 8 275 2.9 Was at work 7 275 2.5 Caregiver or/and child was not at home 7 275 2.5 No one available to take the child 5 275 1.8 Long distance to health facility/outreach post like AWC, 3 275 1.1 VHND site, Sub-centre Did not know the need to return for subsequent doses 1 275 0.4 Child was supplemented prior to the campaign 1 275 0.4 Caregiver or/and child was sick 1 275 0.4

Knowledge of health worker on benefits of VAS Regarding the knowledge on the benefits of VAS among the health workers, 83.3% responded that it prevents blindness. This means more than 16% of health workers were not aware about actual benefit of Vitamin A.

Table 14 Knowledge of health worker on benefits of VAS

n % Prevents blindness/helps vision 50 83.3% Protects against disease/boosts immunity 38 63.3% Helps with growth 24 40.0% Improves child health 17 28.3% Gives the child strength/energy 12 20.0% Don’t remember/don’t know 8 13.3% Protects from anemia 7 11.7% Reduces risk of death 7 11.7% Boosts appetite 6 10.0% Others 3 5.0%

Study Findings 33 Knowledge of health worker on dosage of Vitamin A Among the health workers interviewed 68.3% knew about correct time of initiation of Vitamin A to the children, 83.3% knew the correct frequency of Vitamin A, 86.7% had knowledge on age appropriate dose for Vitamin A. However, only 35 health workers out of 60 interviewed (58.3%) knew all three aspects, i.e. time of first dose, frequency and age appropriate dosage of Vitamin A. This indicates that capacity building is required for all on correct frequency and age appropriate dose of Vitamin A.

Table 15 Knowledge of health worker on dosage of Vitamin A

Indicators n % Correct knowledge of health worker about time of 1st dose of 41 68.3% Vitamin A Correct knowledge of health worker on frequency of VAS dosage 50 83.3% Correct knowledge of health worker on age appropriate VAS dosage 52 86.7% Correct knowledge of health worker about all three aspects, i.e. 35 58.3% time of first dose, frequency and age appropriate dosage

Knowledge of health worker on various methods to combat VAD Responses regarding the knowledge level of health worker to combat VAD shows that 76.7% responded consumptions of Vitamin A rich food can be one of the method and 68.3% responded that IYCF and introduction of complementary feed in right amount and quantity can be a method to combat Vitamin A. These were the major responses given by the health workers. Only 10% responded supplementation as a method to combat Vitamin A.

Table 16 Knowledge of health worker on various methods to combat VAD

Various methods to combat VAD as perceived by health n % workers IYCF/complementary feeding 41 68.3% Exclusive breastfeeding up to 6 months 15 25.0% Control/prevention of infectious diseases 7 11.7% Nutrition/health education 11 18.3% Consumption of Vitamin A rich food 46 76.7% Food fortification 16 26.7% Supplementation 6 10.0% Don’t know 6 10.0%

Knowledge of community leader on VAS campaign Effective implementation of a campaign can only be achieved when there is a good participation from the community. Involvement of the community leader can be one of the factors for the success of the campaign. In this survey, 67% of community leaders responded that they are aware of the SSM campaign.

34 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Table 17 Knowledge of community leader of SSM campaign

Parameter/indicator n % Community leader aware of VAS campaign 20 67% Community leader not aware of VAS campaign 10 33% Community leader heard about Vitamin A 17 57% Community leader not heard about Vitamin A 13 43% Sensitisation meeting happened 12 40% Sensitisation meeting not happened 18 60%

Around 57% of community leaders had heard about Vitamin A meaning that as high as 43% were unaware of Vitamin A. More information about Vitamin A within the community is required.

Only 40% of the clusters visited had a sensitisation programme on Vitamin A as reported by the community leader interviewed, while. 60% of the clusters had not conducted or received any sensitisation programme. Proper sensitisation of the community members may bring more coverage to the programme.

Coverage of deworming National Deworming Day was celebrated in Chhattisgarh on 10th February and 15th February 2017. Children and adolescents were provided with deworming tables (Albendazole) on these days. The coverage and effectiveness of the distribution of Albendazole tablets for deworming among children of age group 12 to 59 months was included in this survey.

Out of a total of 887 beneficiaries, around two-third (63%) children received Albendazole tablets for deworming during the National Deworming Day held in February 2017. As per the PEC survey, nearly 40% of children did not receive Albendazole for deworming during the campaign. Almost equal proportion of girls and boys had received the tablets and the coverage also indicated a similar pattern in all wealth quartiles.

Table 18 Coverage of Albendazole

95% Confidence Interval N % Lower Upper Not received Albendazole and not sure of 328 37.0 33.9 40.2 receiving Albendazole Received Albendazole 559 63.0 59.8 66.1 Total 887 100.0 100.0 100.0

Comparison of reported coverage and evaluated coverage of deworming The reported coverage of deworming during the National Deworming Day is 83.5% for targeted beneficiaries between 1 and 5 years. This is 20.5% higher than the PECS validated coverage assessed amongst children between 1 and 5 years of age in the sample population.

Study Findings 35 Figure 8 Deworming coverage

100 90 84.8 80 70 63 60 50 40 30 20 10 0 Reported coverage of NDD Validated coverage assessed (1-5 years across State) amongst 1-5 years children in sample population

Knowledge of caregiver on benefits of deworming A large proportion (57.9%) of caregivers did not have any idea about the benefits of deworming or Albendazole. One third of the caregivers think that Albendazole is given to prevent the child from sickness. Only 9% of caregivers believe that deworming tablet prevents blood loss or anemia. Table 19 shows the huge gap in the knowledge level of beneficiaries regarding benefits of deworming.

Table 19 Knowledge of caregiver on benefits of Deworming

N % Don’t remember/don’t know 514 57.9% Prevents sickness 293 33.0% Prevents blood loss/lack of blood/anemia 80 9.0% Other 80 9.0% Improves growth 46 5.2% Improves school performance 5 0.6%

Reasons for not receiving deworming tablet The main reason for non-utilisation of deworming tablets in the campaign was that the caregivers had never heard of any such campaign or event. This shows that awareness creation about the campaign through IEC materials like banners, posters and announcement by loud speakers could be lacking. If mothers were aware of the campaign, they were not aware about the place and time of the session (13%). Some of the caregivers opined that they did not feel that their child needed it (8%) or were unaware about the importance of the deworming (6%). A small proportion of the caregiver believed that they could not give their child deworming tablets because they were at work or they were busy or child was not at home.

36 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Table 20 Reasons for not receiving deworming tablets

N % Did not hear of the event/campaign 116 35.37% Place/time of session unknown 42 12.80% Did not know the child needed it 26 7.93% Did not know the importance of deworming 19 5.79% Was at work 7 2.13% Caregiver or/and child was not at home 5 1.52% Other 22 6.71%

Knowledge of health worker on dosage of Albendazole Among the health workers interviewed 88% knew about correct time of initiation and frequency of Albendazole. Although 85% had knowledge on age appropriate dose of Albendazole, only 43 health workers out of 60 interviewed (72%) knew all three aspects of dosing, i.e. time of first dose, frequency and age appropriate dosage of Albendazole. This indicates that capacity building is required for health workers on correct frequency and age appropriate dose of Albendazole.

Table 21 Knowledge of health workers on dosage of Albendazole

Indicators N Percentage Correct knowledge of health worker about time of 1st dose 53 88% of Albendazole Correct knowledge of health worker on frequency of dosage 53 88% of Albendazole Correct knowledge of health worker on age appropriate 51 85% dosage of Albendazole Correct knowledge of health worker about all three aspects, 43 72% i.e time of first dose, frequency and age appropriate dosage

Knowledge of community leader on deworming campaign The result from the study shows that 73% (n=22) of the community leaders knew about deworming. This is slightly higher than their awareness of Vitamin A campaign.

Coverage of IFA supplementation in children under 5 years of age

Assessment for the coverage of IFA was done for the children aged 9 months to 59 months. SSM is used as a platform for distribution of IFA syrup for children with proper health education to ensure its compliance. The data shows only a little more than 25% have received IFA syrup during the VAS campaign. The coverage pattern of IFA between male and female is similar. This is a very poor coverage compared to Vitamin A and deworming.

Study Findings 37 Table 22 Coverage of IFA

Frequency Percent 95% Confidence Interval Lower Upper Who haven't received IFA 728 74.4 71.4 77.1 Who have received IFA 250 25.6 22.9 28.6 Total 978 100.0

Though 25% of caregivers informed that they have received the IFA bottle, only 3.8% could show the bottle to the enumerator during the survey. Each bottle can be used for more than six months if correctly used. More information was required to ascertain their actual receipt of IFA bottle.

Effective coverage of IFA Out of 250 children who have received IFA in the last campaign, 52 (20.8%) have been given in correct dose and in correct frequency. This shows the effective coverage of IFA as these beneficiaries were given the dosage as per the guidelines.

Table 23 IFA coverage by gender

Who received IFA Who haven’t received IFA n N % n N % Male 124 500 24.8 376 500 75.2 Female 126 478 26.4 352 478 73.6

Knowledge of health workers on dosage of IFA Among the health workers interviewed 48.33% knew about correct time of initiation of IFA to the children, 50% had knowledge on correct frequency of IFA syrup and 45% had knowledge on age appropriate dose of IFA syrup. However, only 18 health workers out of 60 interviewed (30%) knew both the aspects, i.e. time of first dose and age appropriate dosage of IFA syrup. This indicates that capacity building is required for all on correct frequency and age appropriate dose of IFA syrup.

Table 24 Knowledge of health workers on dosage of IFA

Indicators n Percentage Correct knowledge of health worker about time of 1st dose of IFA syrup 29 48.33% Correct knowledge of health worker on frequency of IFA syrup 30 50.00% Correct knowledge of health worker on age appropriate dose of IFA syrup 27 45.00% Correct knowledge of health worker about all the aspects, i.e time of first 18 30.00% dose, frequency and age appropriate dosage

38 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Coverage of immunization

Assessment of immunization was done for children aged 12 months to 23 months. The immunization coverage of various antigens is shown in Figure 9. The immunization coverage of all the vaccines shows more than 90%. For DPT/Pentavalent and OPV, only the third dose is counted for the survey which is showing a coverage of 93.6% and 96.2% respectively. The result shows the highest coverage of BCG which is 97.1%. This may be because of increased number of institutional deliveries. The coverage of measles is shown to be 93%. Out of 313 children assessed, 90.7% are fully immunized while 9.3% were not fully immunized as shown in Table 25.

Table 25 Antigen wise coverage

Services Who received 95% Confidence Interval n N % Lower Upper BCG 304 313 97.1 95.1 98.8 DTP3/P.V 3 293 313 93.6 90.8 96.2 POLIO 3 301 313 96.2 93.8 98.1 MEASLES 1 291 313 93.0 89.8 95.7 Fully immunized by 12 months 284 313 90.7 87.6 93.8

Figure 9 Antigen wise immunization coverage

100 97.1 96.2 93.6 93.0

80

60

40

20

0 BCG OPV3 DPT3/P.V3 Measles 1

Reasons of failure of full immunization For those who are not fully immunized, the reasons of failure were assessed as shown in Figure 10. Among those who are not fully immunized the prominent reason cited was that they were unaware about the need of immunization (44.8%), 17.2% responded that they were not in the village. Only about 13.8% informed that they had no faith in immunization and an equal percentage was unaware about the need for multiple doses. Only very few percentage were afraid of the side effects. The gap in IEC is evident here and more investment in IEC is required to improve the status of immunization.

Study Findings 39 Figure 10 Reasons of failure of full immunization

Child was ill and not brought for immunization 3.4

Postponed until another time 3.4

Wrong ideas about contraindications 3.4

Time inconvenient 6.9

Place and/or time of immunization unknown 6.9

No faith in immunization 13.8

Unaware of need to return for 2nd or 3rd dose 13.8

Was not available in the village 17.2

Unaware of need of immunization 44.8

40 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Recommendations and Way forward SSM, is a campaign primarily designed to The reasons of failure of VAS and age improve the access and coverage of Vitamin appropriate immunization highlights the key A. This bi-annual approach was gradually issues which need to be addressed through expanded to bundle additional services that effective social mobilisation campaign. could be delivered together with VAS at six monthly intervals. Thus, gradually a basket of Key recommendations are as follows: services is being offered to improve coverage l In order to track uptake of services, the through demand generation. From this round, availability of immunization card per onwards (December 2016-January 2017 eligible child needs to be ensured and round) distribution of Albendazole (deworming to be updated on time by respective tablet) has been delinked from SSM rounds. frontline workers. This would enable the As per Government of India guidelines, the immunization card to be considered as a distribution of Albendazole for deworming self-monitoring and demand generating were conducted on National Deworming Days. tool from the caregivers. l Sector level meetings of health workers The success of such drive necessitates to be used effectively for micro-planning effective social mobilisation campaign, of the activities. Important protocols like micro-planning, monitoring and responsive age appropriate dose, other health and delivery systems. The evaluated coverage nutrition education components and of VAS is 17 percentage points less than the standard procedures should be shared coverage reported for the December 2016 – prior to each round. January 2017 round of SSM. This highlights l Efforts need to be continued to the reporting exaggeration which needs to strengthen monitoring mechanism for be rectified and overall strengthening of the delivery of quality services for improved campaign required to improve its coverage. and equitable coverage of services during SSM. The evaluated coverage of December 2016- l Convergence workshops to be January 2017 round has seen improvement conducted for orientation of frontline for both Vitamin A and Albendazole in functionaries. comparison to the evaluated coverage of l True reporting to be encouraged and the Nov 2015 and Jul 2016 and issues related findings of the reporting to be shared to over reporting of Vitamin A has also back with necessary guidance at every minimised over these two rounds of cluster level. surveys. Similar improvements have also l Effective strategy to be kept in place to been observed in the coverage of antigens capture the children who got missed for immunization and in the proportion of out during the SSM day. Mitanins can children who got fully immunized between be engaged to serve the missed out these two cluster surveys. The improving children within next couple of days and trend of actual coverage is attributed to a its reporting should be accounted. host of factors such as intensification of l Preparatory activities prior to the round Mission Indradhanush in selected districts, should include orientation meetings for strong interventions of communication over ANMs and AWWs; even if they have tele-calling and SMS across the period of two been oriented earlier about SSM and months (supported by Evidence Action and that they are aware about the same. Nutrition International/Micronutrient Initiative), This would help frontline functionaries from preparatory round till report submission refocus on the importance of the SSM after the campaign, targeted at all the frontline round, and avoid complacency to set in. workers, programme and operation staff.

42 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India l It has been observed that the key help minimising the confusion amongst activities of SSM have been limited health care providers. to immunization and micronutrient l The main reasons cited by the respondents supplementations. Other most who failed to avail the service are the lack important activities such as growth of information about the place and time of monitoring, screening of severely the session. More focused strategies need malnourished children, IEC, health and to be adopted so that timely information is nutrition education and counselling provided to all caregivers. are losing its required focus which l Information about the benefits of the can be strengthened with due support programme is not properly reaching the and collaboration with ICDS. All these intended beneficiaries. Some health activities must be stressed repeatedly workers also failed to inform about the to retain its seriousness. benefits. l Simple poster or chart displaying l Involvement of community leaders in the correct age appropriate doses of the campaign would help in improving micronutrients in the session site will coverage.

Recommendations and Way Forward 43 Annexure 1: Statistical table

Demographic Profile of sample population for immunization coverage n N % Child Characteristics Median age in months= 17 Age in months 12-14 88 313 28.1 15-17 63 313 20.1 18-20 85 313 27.2 21-23 77 313 24.6 Sex Male 156 313 49.8 Female 157 313 50.2 Maternal Characteristics Education None 81 313 25.9 Less than 5 years complete 45 313 14.4 5-7 years complete 38 313 12.1 8-9 years complete 76 313 24.3 10-11 years complete 38 313 12.1 12 or more years complete 35 313 11.2 Household Characteristics Urban/Rural Urban 0 313 0.0 Rural 313 313 100.0 Religion No Religion 6 313 1.9 Hindu 293 313 93.6 Christian 1 313 0.3 Traditional/Animist 2 313 0.6 Don't know 11 313 3.5 Caste SC 46 313 14.7 ST 128 313 40.9 OBC 129 313 41.2 General 8 313 2.6 Don't know 2 313 0.6

44 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Annexure 2: List of Clusters

BASTAR DIVISION Cluster Village Block District 1 Mardapal Kondagaon Kondagaon 2 Salepal Tonkapal Bastar 3 Kundanpal Chhindgarh Sukma 4 Khodpani Sarana (Narharpur) Kanker BILASPUR DIVISION Cluster Village Block District 1 Chhindpura Lormi Mungeli 2 Bachhera Kota Bilaspur 3 Pattharkhan Takhatpur Bilaspur 4 Dharashiv Nawagarh Janjgir - Champa 5 Kirari Dabhra Janjgir - Champa 6 Semra Pondiupraura Korba 7 Bijhkot Kartala Korba 8 Deogaon Tamnar Raigarh 9 Banjipali Sarailendha Raigarh Durg-Rajnandgaon Division Cluster Village Block District 1 Jamgaon Saja Bemetara 2 Albaras Durg Durg 3 Bheriya Nawagaon Sanjaribalod Balod 4 Pandariya Bodla Kabeerdham 5 Hardwa Rajnandgaon Rajnandgaon 6 Kilargondi Chowki Rajnandgaon RAIPUR DIVISION Cluster Village Block District 1 Hasda Kurud (Chormudiya) Dhamtari 2 Bijatipali Saraipali Mahasamund 3 Kasahibahara Bagbahara Mahasamund 4 Dharasiv Balodabazar Baloda Bazar 5 Kurud-I (Kurud) Chandkhurai (Arang) Raipur 6 Deopuri Ward No.-0071 Raipur (Dharsiva) Raipur 7 Dharnidhoda Mainpur Gariyaband Surguja DIVISION Cluster Village Block District 1 Dasdumartoli Jashpurnagar Jashpur 2 Kodwa Shankargarh Balrampur 3 Kanchanpur Premnagar Surajpur 4 Maheshpur Batauli Surguja

Annexure 45 Annexure 3: List of Enumerators and Team Leaders

Sl. No Name Position Division 1 Aeman Verma Team Leader Durg 2 Punesh Kumar Verma Enumerator Durg 3 Ram Khilawan Sahu Enumerator Durg 4 Rahul Gupta Enumerator Bilaspur 5 Sanjeev Shukla Team Leader Bilaspur 6 Suraj Gupta Enumerator Bilaspur 7 Madanlal Gilhare Team Leader Raipur 8 Dhanlal Poyam Enumerator Durg 9 Birjhu Purena Enumerator Raipur 10 Tarun Purena Enumerator Raipur 11 Monesh Narang Enumerator Raipur 12 Manoj Kumar Enumerator Surguja 13 Sagar Pal Enumerator Surguja 14 Abhishek Mishra Enumerator Surguja 15 Sanjeet Kumar Gupta Team Leader Surguja 16 Sukhdev Baghel Enumerator Bastar 17 Somaru Ram Kashyap Team Leader Bastar 18 Santu Ram Karma Enumerator Bastar 19 Dhanshu Ram Kashyap Enumerator Bastar 20 Shiv Sharma Enumerator Bilaspur

46 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India Annexure 4: Copy of consent letter

Annexure 47 Acknowledgements

Conceptualisation, analysis and writing Mohamed Lamine Yattara Deputy Country Director, Programme HKI, Helen Keller International, Bamako, Mali Mohamed Turay IT Coordinator Helen Keller International, Sierra Leone Dr. Abner E Daniel Nutrition Specialist, Child Development and Nutrition, UNICEF Office for Chhattisgarh, Raipur Preetu Mishra Nutrition Officer, Child Development and Nutrition, India Country Office, New Delhi Dr. Antaryami Dash Nutrition Officer, Child Development and Nutrition, UNICEF Office for Chhattisgarh, Raipur Ciju Daniel Consultant, UNICEF, Chhattisgarh

Review and inputs Subrat Sahu, IAS Principal Secretary, Health Government of Chhattisgarh, New Raipur, Chhattisgarh R. Prasanna, IAS Commissioner, Health Services Government of Chhattisgarh, New Raipur, Chhattisgarh Prasanta Dash Chief Field Office UNICEF Office for Chhattisgarh, Raipur Arjan de Wagt Chief, Child Development and Nutrition, India Country Office, New Delhi Dr. Ajay Trakroo Health Specialist, Reproductive and Child Health, UNICEF Office for Chhattisgarh, Raipur Dr. Amar Singh Thakur Deputy Director, Child Health Government of Chhattisgarh, New Raipur, Chhattisgarh Neeraj Dewangan Consultant, UNICEF, Chhattisgarh

Data collection support Dr. Thomas Abraham CEO, CF SHORE, Rajnandgaon, Chhattisgarh Tapan Daripa Divisional Consultant, CF SHORE–UNICEF, Raipur Rakesh Kumar Jha Divisional Consultant, CF SHORE–UNICEF, Bastar Asutosh Samal Divisional Consultant, CF SHORE–UNICEF, Bilaspur Dr. Prashant Kumar Divisional Consultant, CF SHORE–UNICEF, Ambikapur

Branding Divya Syam Sudheer Bandi Advocacy and Communication Officer UNICEF Office for Chhattisgarh, Raipur

Layout and pre-press production New Concept Design agency, New Delhi

48 Post Event Coverage Survey (PECS) of Vitamin A in Chhattisgarh, India

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