OJHAS Vol. 7, Issue 1: (2008
Responsibilities of Anganwadi Workers and Malnutrition in Rural Wardha
AR, Deshmukh PR, Garg BS,
Dr Sushila Nayar School of
Mahatma Gandhi Institute of
Sewagram – 442 102
Address For Correspondence
Dr Sushila Nayar School of
Mahatma Gandhi Institute of
Medical Sciences, Sewagram
India – 442102
AR, Deshmukh PR, Garg BS. Perceived
responsibilities of Anganwadi Workers and malnutrition in rural
Wardha. Online J Health Allied Scs. 2008;7(1):3
Submitted Dec 31,
Mar 15, 2008; Published: Apr 10, 2008
To find out the nutritional status of under-six children attending ICDS
scheme and to study Anganwadi workers’ (AWW) perceived work
load and operational problems. Material and Methods: A triangulated
research design of quantitative (survey) and qualitative (Venn diagram,
seasonal calendar) methods was used. Nutritional status of children
was assessed by a survey. Participatory methods like Venn diagram and
Seasonal calendars were used to collect qualitative data regarding AWWs
perceived work load and food security with malnourished children.
Results: Overall, prevalence of underweight and severe underweight
among children under-six was found to be 53% and 15% respectively and
among children below three years it was 47% and 15% respectively. Venn
diagram showed AWWs’ multiple responsibilities. In seasonal diagram
exercise, the mothers of severely malnourished children showed enough
food availability in their house across all months of a year.
Conclusion: To efficiently tap the potential of
AWWs for reducing multidimensional problem of malnutrition, ICDS needs
to design and implement flexible, area-specific and focused activities
Underweight, Malnutrition, Mother’s education, Caste, Food scarcity
In India, the
prevalence of child under-nutrition is nearly double the Sub-Saharan
Africa and is among highest in the world.1 Maharashtra, which
is one of the six high prevalence states shows slow decline in child
malnutrition and inter-district variations. Being a signatory of the
Millennium Declaration of the UN Millennium Summit, India has to halve
malnutrition among children below five years by 2015. The achievement of this nutrition
target uniformly across all the states
and districts is important as it would contribute to reduction in child
mortality and Human Poverty Index. Even after 30 years of implementation
of Integrated Child Development Services (ICDS), a single major child
program in India, about half of below three years children in Maharashtra
were found undernourished.2 The present study was undertaken
in all the villages of Primary Health Centre, Anji, which is located
in Wardha district of eastern Maharashtra. The objectives were to find
out the nutritional status of under-six children attending ICDS scheme
and to study Anganwadi workers’ (AWW) perceived work load and operational
2005, the Kasturba Rural Health Training Centre, Anji which is a peripheral
centre of Department of Community Medicine, Mahatma Gandhi Institute
of Medical Sciences, Sewagram used a triangulated design, combining
both quantitative and qualitative (Venn diagram, seasonal calendar)
methods to undertake present study.
survey was undertaken among under six ICDS beneficiaries of all 20
anganwadi of Primary Health Centre, Anji. A complete list of all
anganwadi and a list of under-six beneficiaries was obtained which
was subsequently followed by health check-up at each anganwadi
on given date and time. Out of 2442 children, 1543 (63.1%) were examined
and weighed by a team of trained personnel. The nutritional status of
children was assessed by obtaining weight by Salter scale, provided
by UNICEF. The information on date of birth was obtained from the immunization
card and the records of anganwadi worker. The information on
other background characteristics like education of mother and caste
was obtained from the mother. The data thus collected was obtained by
pre-designed and pre-tested questionnaire. About 52 (3.3%) children
were excluded from analysis due to incomplete information. Nutritional
status of children was assessed by Z-score classification of weight
for age using NCHS standard recommended by World Health Organization.3
Children who were below two Z-score values of the reference median (<
-2 Z-score) were considered to be underweight, and children who were
below three Z-score values of the reference median (< -3 Z-score)
were considered to be severely underweight. The relationship of nutritional
status with age, sex, education of mother and caste was examined. The
data was entered in the software package epi_info version 6.04 and analyzed
by using Epinut programme.
data collection from AWWs and the mothers of malnourished children,
Participatory qualitative methods like Venn diagram and Seasonal calendar
were used.4 After obtaining informed consent, a trained social
worker facilitated a group of eight AWWs who were willing to talk freely
to draw Venn diagram showing their present workload. This exercise was
undertaken during their monthly meeting at Primary Health Centre, Anji.
It provided a visual picture of AWW’s perceived work importance. First
of all, a group of AWWs was asked to prepare a list of their responsibilities.
Later they were asked to assign size and cut paper circles of different
sizes for each of the enlisted responsibility with respect to their
perceived severity. The bigger circles represented important work. AWWs
were asked to name and paste paper circles of their various responsibilities
on chart paper. During the process, facilitator listened to group discussion
and noted it down. The seasonal diagram (seasonal calendar) was individually
drawn with the feasibly selected mothers of 6 severely malnourished
children to understand the changes in livelihood condition in their
village like work load period; food and income availability; illness
period; and expenditure across different months of a year.
1491 under-six children, 776 (52%) were male and 715 (48%) were female.
As seen in Table I, overall, prevalence of underweight and severe
underweight among children under-six was found to be 53% and 15%
respectively and among below three years it was 47% and 15%
respectively. The prevalence of underweight and severe underweight
significantly increased with age and peaked at age of 12–23 months
where it was 61% and 21% respectively. The girls were more likely to be
severely underweight (17%) than boys (14%) and boys were slightly more
likely to be underweight (54%) than girls (52%). This difference was not
1: Nutritional status of under-six year children according to selected
- 2 Z-score (%)
< - 3 Z-score
Age of child*|
– 11 months
– 23 months
– 35 months
Note: Weight-for-age is
expressed in standard deviation units (SD) from the median of the International
Reference Population. * p < 0.001|
As seen in
Venn diagram exercise (Figure 1), among the three significantly perceived
responsibilities, record keeping got the highest priority followed by
preschool education and supplementary food distribution. Other activities
like growth monitoring, immunization and examination of malnourished
children got relatively poor emphasis. Notably, very little importance
was given to mothers’ health education. Overall, the exercise showed
AWWs’ multiple responsibilities which ranged from Maternal and Child
Health services to participation in various other national health programmes.
Venn diagram showing various responsibilities of
diagram exercise, the mothers of severely malnourished children (Figure 2),
showed enough food availability in their house across all months of a year.
Figure 2: A Seasonal calendar of a mother of severely malnourished
In the present
study, overall prevalence of underweight and severe underweight among
children below six years was found to be 53% and 15% respectively. The
prevalence of underweight children significantly increased with rising
age group. It was found to be significantly associated with maternal
education. The group of AWWs perceived record keeping, preschool education
and supplementary food distribution as their major time consuming activities.
The seasonal calendar drawn by the mothers of severely malnourished
children showed food availability in their house across all months of
and Child health (RCH) program emphasized monitoring of child health
on the basis of their nutritional status. In year 2002, as reported
by Wardha district level health survey under RCH, the prevalence of
underweight and severely underweight children was 53% and 16% respectively.5
The condition worsened with rising age; peaked at the age
group 12-71 months; and had inverse relationship with maternal education.
The present study reported the similar findings.
In the present
study, the prevalence of underweight and severely underweight children
among children below-three years was found to be 47% and 15%, respectively.
NFHS-I (1992-1993) and NFHS-II (1998-1999) survey in Maharashtra have
reported no significant decline in the prevalence of underweight children
where it was found to be 51% and 50% respectively. Recently, In Maharashtra,
NFHS-III has shown overall 10% decline in underweight children.6
The decline is encouraging but needs to be examined in the light of
rural-urban and inter-district variations in decline. Also it is to
be noted that this decline is in below three years children and prevalence
of underweight rises with age.
One of the
main objectives of Integrated Child Development Services Programme (ICDS)
is to improve maternal and child nutrition. The effective delivery of
ICDS services at village level depends on efficiency of AWW. As seen
in Venn diagram exercise AWWs’ most of the workload was due to record
keeping neglecting their primary functions. Ghosh7 have already
pointed out the similar fact and emphasized that AWW’s prime responsibility
should be health and nutrition education. As seen in Venn diagram, amidst
the multiple responsibilities very little time is given for nutrition
education. Ghosh et al8 have also stressed that in-depth
nutrition education regarding feeding with home available foods can
help to improve nutrition. AWW should devote more time for nutrition
education. The arrival of another village level female worker called
Accredited Social Health Activist (ASHA) under National Rural Health
Mission may be trained in effective communication to bridge gaps in
present maternal and child health services.
diagrams exercises, the mothers of severely malnourished children have
shown household food security throughout a year. However, this finding
might be study area specific. This finding suggested that the malnutrition
in study area could be due to faulty feeding practices and not due to
scarcity of food. Hence there is need to educate the mothers about correct
feeding practices. NNMB findings revealed that median intake of proteins
and calories among children between 1-3 years is 81% and 57% respectively
and that of children between 4-6 years is 87% and 61% respectively.
This further emphasizes the faulty feeding practices of mothers.9
Integrated Management of Neonatal and Childhood Illnesses (IMNCI) have
emphasized dietary counseling of the mothers on frequency of feeding
and adding oil/ghee in diet. Kent10 has suggested the right
based approach specifying entitlement of beneficiaries for supplementary
feeding and entitled families should be informed of what services they
are entitled to. Notably, the success of community based Tamil Nadu
Integrated Nutrition Project was in their focused approach on nutrition
intervention including growth monitoring and selective nutritional supplementation.11
the high prevalence of malnutrition, its inverse relationship with maternal
education and socio-economic status and multiple responsibilities of
AWWs a focused, need based strategy is required. To efficiently tap
the potential of AWWs for reducing multidimensional problem of malnutrition,
ICDS needs to design and implement flexible, area-specific and focused
activities for AWW.
the financial assistance from Aga Khan Foundation and USAID under Child
Survival Grant with the cooperative agreement GHS-A-00-03-00015-00.
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M, Gupta MD, Bredenkamp C, Lee YK. India’ sUndernourished Children:
A call for reform and action. Washington DC, The International Bank
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- National Family
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Sciences. Mumbai, India: IIPS Press; l998. Vol 99. p. 17-8.
- World Health Organization.
Measuring changes in Nutritional status. Geneva, WHO: 1983.
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Series [PRA tips on CD-ROM]. Patna (India): Institute for Participatory
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[cited 2007 Apr 18]. Available at http://www.thesouthasian.org/
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A, Ganapathy S. Nutrition education and infant growth in rural Indian
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