Introduction:
In the pursuance of the National Policy for Children, the Government of India launched 'Integrated Child Development Services' (ICDS) scheme on 2nd October 1975 in 33 pilot projects. With immense success in the initial years it was periodically expanded to the extent that in the Tenth five year plan, ICDS scheme was universalized in the whole country.(1) Each project aimed at delivery of a package of services in an integrated manner to preschool children, expectant and nursing mothers and women in the age group of 15-44 years through the Anganwadi Centers (AWC). One of the objectives of ICDS is to improve the nutritional and health status of the above mentioned beneficiaries and thereby reduce the prevalence of malnutrition and related morbidities and mortalities.(2)
But merely increasing the infrastructure and availability of services does not increase the utilization of services from the AWC. The utilization of ICDS scheme varies from place to place and depends on involvement of the community in the programme.(3)
There are 10 ICDS blocks in an adopted urban field practice area of a rural tertiary health care facility in Wardha district of Maharashtra. Though ICDS is the world’s largest community-based child nutrition and development programme, even after more than 35 years of its implementation the dilemma still exists regarding the extent of utilization and quality of services provided through these anganwadi.(4) Therefore, the present study was designed to determine the extent of utilization of anganwadi services by the beneficiaries, to explore out factors influencing optimal utilization and the reasons for non/under utilization of services. The present study will give factual background at grass root level.
Materials and Methods
The present community based cross-sectional study was conducted in three well defined adopted urban field practice areas of a rural tertiary health care facility in Wardha namely Sane Guruji Nagar, Gajanan Nagar and Indira Nagar. The study started after taking approval from Institutional Ethical Committee. The area was selected based on high socio-economic heterogeneity to yield greater external validity. The study period was 4 months including the period of data collection from January to April 2014.
Cluster sampling method was used for data collection. One cluster comprising of 40 households was identified in each area. Consecutive households with a women in reproductive age group (irrespective of whether she is received services from the AWC or not) were selected for inclusion in the study. If any household found to have more than one woman in reproductive age group, all of them were included in the study. The households not fulfilling the above criteria were excluded and the subsequent household was selected till collection of 40 such households from each of the area. Overall 120 households were included in the study which comprised of 140 women of reproductive age group which constituted the sample size.
Data was collected in a predesigned structured proforma. Interview of women was taken in local language. The relevant information regarding the socio-demographic structure of the family, utilization of ICDS services by them was recorded. The data regarding the extent of utilization of services by the beneficiaries such as women in reproductive age, children of to 0 to 6 years age, pregnant or lactating etc. were collected. Immunization status for children was checked by using immunization cards if available. Modified B Prasad’s scale used for socioeconomic status assessment.
At the end of interview, health education regarding importance of supplementary nutrition, health check up, growth monitoring, immunization was given and an attempt was made to solve the problems associated with it.
Data entered into the spreadsheet program and further analyzed using Epi-Info version 3.5.1 CDC. SYSTAT 12.0 used in multivariate analysis for factors influencing optimal utilization of AWC. Statistical methods used were: Proportions and Chi square test.
Results
Out of these 140 women respondents in reproductive age, 13 (9.29%) were pregnant, 22 (15.71%) were lactating mothers and 45 (32.14%) had at least a child of 0 to 6 years age and rest 60 (42.86%) women in reproductive age did not have any children beneficiaries.
Sociodemographic profile of respondent women
Out of total 140 study participants, majority 99(70.7%) were in age group 21-30 years age. Mean age of women respondents was 29.05 years. Only 5(3.5%) women were illiterate while rest of them was literate. Homemakers were 62.15% as compared with 37.85% of working women. 91.65% respondents were belonging to lower socioeconomic status (Class IV and V).
Availability and awareness of anganwadi services
Regarding the approachability to AWC, it was observed that 43(30.72%) women had AWC within half Km from their residence and 97(69.28%) had it between 0.5 – 2 Kms.
When the study participants were asked regarding the ‘home visits’ by anganwadi worker (AWW), majority of them 103(73.57%) reported they had.
The results showed that the majority of the respondents (85.7%) had knowledge regarding the antenatal care, followed by nutrition supplementation (81.43%), and immunization (80%). Moreover, 32.14% of them had awareness about nutrition education as shown in Table 1.
Table 1: Distribution of women respondents according to the availability and awareness of anganwadi and its services |
Parameter |
No (n=140) |
% |
Approachability to anganwadi center (Distance from house) |
<1/2 Km |
43 |
30.71 |
˝ to 1 Km |
59 |
42.14 |
> 1 Km |
38 |
27.14 |
Home visits by anganwadi worker |
Yes |
103 |
73.57 |
No |
37 |
26.43 |
Knowledge about services provided by anganwadi* |
Antenatal care |
120 |
85.71 |
Postnatal care |
99 |
70.71 |
Immunization |
112 |
80.00 |
Pre-school education |
108 |
77.14 |
Supplementary nutrition |
114 |
81.43 |
Nutrition education |
45 |
32.14 |
Growth monitoring |
102 |
72.86 |
Health check up |
86 |
61.42 |
| *Multiple responses |
Utilization of anganwadi services:
Out of total 140 study participants, 125(89.29%) utilized one or more services by the AWC. Beneficiary-wise type of services availed from AWC revealed that out of 13 pregnant women, 11(84.61%) utilized the antenatal services and TT immunization. Lactating mothers 19(86.36%) utilized postnatal care services. Out of 45 women having children of 0 to 6 years of age, 41 (91.11%) availed one or more service for their children in the last one month. Among these services growth monitoring, immunization services utilized by majority of them 37(90.24%). Out of rest, 54(90%) women of reproductive age group availed nutrition education, health check up and referral services. Out of total 125 participants utilizing the AWC services, majority i.e. 103(82.4%) were satisfied with services of AWC. (Table 2, 3).
Table 2: Factors influencing utilization of anganwadi services |
| Characteristics of women of reproductive age (15-45 years) |
Utilization |
Total (%)
(n=140) |
Significance* |
YES (%)
(n=125) |
NO (%)
(n=15) |
Age |
<20 yrs
21-30 yrs
31 – 40 Yrs
>40 yrs |
2 (01.60)
90 (72.00)
26 (20.80)
7 (05.60) |
0 (00.00)
9 (60.00)
3 (20.00)
3 (20.00) |
2 (01.42)
99 (70.70)
29 (20.70)
10 (07.14) |
χ2=1.23
d.f.=1
p=0.267 |
Education |
Illiterate
Up to Primary schooling
Up to higher secondary
Up to Degree
>Degree |
4 (03.20)
6 (04.80)
58 (46.40)
45 (36.00)
12 (09.60) |
1 (06.67)
4 (26.67)
4 (26.67)
3 (20.00)
3 (20.00) |
5 (03.57)
10 (07.14)
62 (44.29)
48 (34.29)
15 (10.71) |
Χy2=6.53
d.f.=1
p=0.01 |
Socio-economic status |
Class I
Class II
Class III
Class IV
Class V |
4 (03.20)
20 (16.00)
24 (19.20)
75 (60.00)
2 (01.60) |
0 (0.00)
1 (06.67)
0 (0.00)
5 (33.33)
9 (60.00) |
4 (2.86)
21 (15.00)
24 (17.14)
80 (57.14)
11 (07.86) |
Χy2=4.62
d.f.=1
p=0.03 |
No. of children |
No children
One child
Two children
Three children
= Four children |
3 (02.40)
59 (47.20)
45 (36.00)
16 (12.80)
2 (01.60) |
1(06.67)
8 (53.33)
5 (33.33)
1 (06.67)
0 (00.00) |
4 (02.86)
67 (47.86)
50 (35.71)
17 (12.14)
2 (01.43) |
χ2=0.58
d.f.=1
p=0.44 |
Age at marriage |
<18 yrs
18-20 yrs
>20 yrs |
13 (10.40)
61 (48.80)
51 (40.80) |
9 (60.00)
4 (26.67)
2 (13.33) |
22 (15.71)
65 (46.43)
53 (37.86) |
Fisher Exact test
d.f.=1
p= 0.0000321 |
Working woman |
Yes
No
|
43 (34.40)
82 (65.60) |
10 (66.67)
5 (33.33) |
53 (37.85)
87 (62.15) |
Χy2=4.63
d.f.=1
p=0.03 |
Type of family |
Nuclear
Joint |
69 (55.20)
56 (44.80) |
5 (33.33)
10(66.67) |
74 (52.86)
66 (47.14) |
χ2=2.57
d.f.=1
p=0.1 |
Religion |
Hindu
Muslim |
117(93.60)
8 (06.40) |
15 (100)
0 (00.00) |
132(94.29)
(05.71) |
- |
| Χy2 - Chi square with Yates correction. |
Table 3: Factors responsible for non/under utilization of anganwadi services in multivariate model |
| Variable |
Odds ratio |
95% CI |
P value |
Age |
0.4398 |
0.1703 |
1.1355 |
0.0896 |
Working women |
3.7091 |
1.3174 |
5.5844 |
0.0204 |
Education |
1.0463 |
0.5223 |
2.0960 |
0.8984 |
Family type |
0.3808 |
0.0952 |
1.5231 |
0.1722 |
No. of children |
1.4775 |
0.6654 |
3.2807 |
0.3375 |
Socio-Economic status |
1.2790 |
1.6424 |
2.5462 |
0.0347 |
| # Rows merged for calculation of significance. |
Reasons for non-utilization/underutilization of Anganwadi center
By using the univariate model, the results showed that the women with low educational levels (illiterates and those with education less than primary schooling), women with low socioeconomic status (class IV and V), women married in teen age and working women had significantly higher proportion of non/under utilization of ICDS services.
In multivariate logistic regression, the results showed that the working women and those with lower socio-economic status had significantly and independently lower/non utilization of AWC services.
Discussion:
The ICDS is the world’s largest community-based child nutrition and development programme, aimed at holistic development of children (0-6 years), expectant and nursing mothers from disadvantaged sections belonging to poorest of the poor families in backward areas by providing a package of services comprising supplementary nutrition, growth monitoring, immunization, health check-up, referral Services, pre-school education and health and nutrition education.
In the present study respondent women were interviewed to ascertain their opinion on various aspects like approachability to AWC, utilization of the service by the beneficiary and their satisfaction towards services provided by AWC.
In the present study, the findings showed that for the majority of respondents (42.14%) the AWC was up to 1 Km, which is inconsistent with a previous study that showed 63.08% of the participants were residing within 1/2 Km, and 36.92% children were residing 1/2 to 1 km from AWC.(4) This might be predicted as the reason for non-utilization of service by AWC.
In the present study majority (73.57%) appreciated the home visits by AGW while (26.43%) disagreed this. Similarly in a study conducted by A Davey et al(5) on perception regarding quality of ICDS services in urban ICDS blocks of Delhi, 89% respondents mentioned that AWW visited them in last year while 51.3 % said that their frequency of visit was once in three months.
In a previous study, 84.2% of the mothers were aware of any ICDS services and 78.3% of them were aware about supplementary nutrition, while (21.7%) of mothers were aware about preschool education.(6) In this study, most of the participants (85.71%) had information regarding the antenatal care services provided by AWC, (81.4%) had information about nutrition supplementation, and (77.1%) had information about preschool education.
In the present study, 89.3% of the participants utilized one or more services by the AWC. Among the services for children, the majority of them (90.2%) utilized growth monitoring and immunization services. These results of a previous study found that most of the mothers received health checkup (90.3%) and supplementary nutrition services (94.2%). Non-formal preschool education imparted to (91.6%) of children and (70.3%) of children received supplementary nutrition. Health education was imparted to only (43.5%) of women.(7) Another study found that all mothers utilized the supplementary nutrition services for their children from AWC, while 56.6% mothers availed growth monitoring services for their children in the last 6 months and only 15.9% utilized immunization services.(5) Moreover, a previous study reported that 36.3% of the AWW were not able to monitor growth of the children. Only 42.3% of children had access to non-formal education in AWC but that on an irregular basis.(8) Another study found that only (24.3%) of children received supplementary nutrition and only 34.5% of children eligible for preschool education received it, which could be related to the fact that the AGW and her assistant did not visit house to house daily and the AWC remains closed most of the time.(4)
Furthermore, according to NFHS-III survey (9), only 28% of the children had received any service from an AWC. In most states, the proportion of children who had received services was less than one out of every three. Only about one in five mothers had received any services from an AWC during pregnancy or during the lactation period.
With regard to these differences or variation in utilization of ICDS services, it has also been mentioned that the AWCs which are working for more than 10 years have positive influence on the utilization of services. New centers needing to develop the confidence in the community may be the reason for lower rates of utilization of services in some of the studies.(10)
These differences might also be related to the fact that utilization of ICDS scheme varies from place to place and depends on involvement of the community in the programme.(3) The package of MCH services promoted by the scheme is either not properly utilized by the community due to lack of their knowledge or lack of aptitude and devotion of AWW. Thus periodic assessment of the functioning of the whole system and correction of specific areas of deficiencies are major requirements.
In the present study, 82.4% women expressed their satisfaction with services of AWC, in which a previous study showed that 47.5% of women were satisfied with the service.(5) Another study found that 75% of the women were not satisfied with ICDS services.(4)
The findings of the present study reported that the various reasons for the non-utilization of services of AWC were women married in teen age, working women and those with lower socioeconomic status, which were consistent with previous studies.(5,11,12) Other reasons noted were, inadequate space in AWC, poor quality of food, irregular preschool education, no change in recipe, lack of health education activity on newborn care and supportive services. Thus it seems that the client satisfaction about quality of services influences the acceptance and utilization of services.
Conclusion:
The study participants were aware about the different ICDS services. They had also utilized it and expressed satisfaction regarding the same. Among the women not utilizing the services; the reasons for non-utilization need to be addressed for optimal utilization of AWCs.
Acknowledgement:
The authors would like to thank all the study participants for sharing their time for the Interview. The authors are also grateful to authors/editors of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Conflicts of Interest: None.
References
- Government of India. Nutrition and food. 10th five year plan, 2002; page 341-346.
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- Sharma A. National consultation to review the existing guidelines in ICDS scheme in the field of health and nutrition. Indian Pediatrics. 2001;38:721-731.
- NFHS-III, International Institute for Population Sciences (IIPS), Government of India, 2005-06.
- Thukral M, Chandrashekhar. Role of anganwadi centers in improving the status of full immunization in Madhya Pradesh. Indian Journal of Preventive and Social Medicine. 2008;39(1,2):86-90.
- Agnihotri SP, Pandey D N, Nandan D. The impact of rural health services in Agra. Indian Journal of Public Health. 1984;28(1):25-29.
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