Keystone V by World Vision India

A Q ua rt e r ly R e s e a r c h P u b l i c at i o n f ro m Wo r l d V i s i o n I n d i a

ISSUE NO. 5 | O C TO b e r â&#x20AC;&#x201C; D e c e m b e r 2 0 1 7

World Vision India

Table of contents

Keystone | December 2017

EVALUATION BRIEF Community based Management of Acute Malnutrition: Jharkhand

Page 04

RESEARCH PAPER Child labour and education in India: An overview of issues and directions

Page 11

DESCRIPTIVE STUDY Open Defecation Free A community perspective: Narsinghpur

Page 16

ASSESSMENT REPORT Training need assessment of ASHAs and AWWs: Madhya Pradesh

Page 24

Introduction Keystone was born out of discussions around how to make World Vision India’s evidence of impact and expertise in work reach out to a larger audience. Every issue of this quarterly research publication aims to capture the essence of World Vision India’s work with the most vulnerable children and communities across more than 160 districts of India. Through evidencebased articles from different technical functions within the organization, Keystone seeks to highlight our expertise to our stakeholders as well as promote a culture of learning among ourselves.

This issue of Keystone contains four articles. The first article summarises the impact of World Vision India’s collaboration with Jharkhand State Nutrition Mission in implementing Community based Management of Acute Malnutrition (CMAM) program in the blocks of Chas and Chandhankeyari (Bokaro District, Jharkhand) which was commenced from January 2017. The second is a research paper focussing on the relationship between child Labour and education in India. This has been published in the Journal on the Rights of the Child, by National Law University, Odisha.

The third piece is a study exploring the use of available sanitation facilities in households of open defecation free communities in Narsinghpur, Madhya Pradesh. It also looks at contributing factors, attitudes and perceptions of regular latrine use in these communities. The fourth one is an assessment of training needs of ASHA and Angwanwadi workers of Madhya Pradesh. Making use of the primary data, the study assesses the gaps and suggests appropriate training methods for front line workers.

World Vision India

Community Based management of Acute malnutrition Grana Pu Selvi This evaluation brief gives the impact of World Vision Indiaâ&#x20AC;&#x2122;s collaboration with Jharkhand State Nutrition Mission in implementing Community based Management of Acute Malnutrition (CMAM)

Introduction Jharkhand has been plagued with some of the highest number of children with undernutrition over the years. More than 90% expectant mothers in rural areas are unaware of health and nutrition issues, the Jharkhand Economic Survey 2015-16 has shown. The state has one of the countryâ&#x20AC;&#x2122;s worst maternal mortality rates. In Jharkhand, for every 100,000 live births 208 mothers die during delivery, compared to the national rate of 178, while the under-five mortality rate among children is at a high 51 per thousand live births. Severe acute malnutrition (SAM) is a life threatening situation. Children with SAM are up to 9 times more likely to die than healthy children Children who are wasted are more likely to become stunted. The most cited causes for malnutrition are income disparity, lack of public hygiene, sanitation and health education. It is also true that

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lifestyle choices, cultural beliefs and regional practices play a big role in exacerbating the problem. It was in this context World Vision India collaborated with Jharkhand State Nutrition Mission and implements Community based Management of Acute Malnutrition (CMAM) program in the blocks of Chas and Chandhankeyari (Bokaro District, Jharkhand). The current program at Bokaro District, was commenced from January 2017. This program in the two blocks reached out to 20,525 children in 2 blocks and worked with 650 Anganwadi workers and ASHA. WHY CMAM? Globally Community Management of Acute Malnutrition (CMAM) has been acknowledged as a proven program to rehabilitate the children with severe acute malnutrition. It was endorsed by the

WHO in 2007, and has been implemented in over 70 countries. It is implemented through outreach at the community level with community involvement. It involves early detection, referral of cases of acute malnutrition and follow up of children who has complications. Those children aged 6-59 months with severe acute malnutrition and without any medical complications are rehabilitated at the outpatient care. Ready to Use Therapeutic Food is a core part of treatment for acute malnutrition. This needs to be viewed as a medicine and not as a food. This did not have any microbial growth even when opened and is very safe and easy for mothers to use at home. The four important components of CMAM are Community mobilization and active case-finding Outpatient care for SAM

without complications Inpatient care for SAM with complications Inclusion of management of moderate acute malnutrition (MAM) where possible

Methodology

FGDs

The methodology used was Mixed methods, implicit design Quantitative - routine monitoring data, Project

Mothers with children enrolled in CMAM program (3 FGDs) Mothers with children notenrolled in CMAM program (from the communities where the CMAM program is running) (1 FGD) ASHA workers (1 FGD) AWW-OTP (to include AWW whose sites were not visited, 1 FGD)

Enrollment process Acute malnutrition

With complications

Without complications

Severe

Malnutrition/ nutrition rehabilitation center

EVALUATION World Vision India evaluated the CMAM project in the month of September 2017. The evaluation team was led by a nutrition expert and they evaluated this project to capture important lessons and to stay accountable to the communities we worked with.

Out patient treatment

Moderate

Supplementary feeding program

Model QA tools Qualitative: FGDs, KIIs with project stakeholders. Qualitative data was collected through key informant interviews and focus group discussions. The following groups/individuals were interviewed:

Key Informant Interviews

AWW (6), ASHA (3), ANM (2), PRI member (2), MTC, Child Development Program Officer & Lady supervisor (3) District Social Welfare officer, BDO. Conclusions & Recommendations The project was appropriately designed, generally in accordance with global CMAM standards. Operational

Discharge category Bokaro CMAM project (n) Sphere Standards Cured/Recovered

61% (72)

>75%

Died

<10%

Defaulted

39% (46)

<15%

Non-recovered

n/a

Referral to MTC

22% (34)

n/a

guidelines were drafted to guide project implementation. In areas where World Vision India is not operational, community mobilization was a challenge. An MoU between World Vision India and the State Nutrition Mission (WCD department) was signed for this project; however, given the important role of the Health department for the management of acute malnutrition, a tri-partite agreement: State Nutrition Mission – Health department– WV India, would help to create the necessary enabling environment to support implementation. Mass MUAC screenings mobilized through the AWCs is a feasible and recommended approach for identifying SAM cases, as opposed to a house-to-house census. Though meaningful participation of local stakeholders was initially slow, at the time of the evaluation, there was a clear understanding of the importance of the program and the respective roles that each stakeholder needed to fulfil. Caregivers, AWWs, and community members attested to the visible improvements (weight gain, improved disposition) in the health of the children enrolled in the OTPs. Caregivers were willingly attending the

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OTP. Efforts are needed to address the high default rate, strengthen referral mechanisms and to improve the medical/clinical care through better integration with the health department (routine antibiotic provision, assessment of clinical signs). A summary of recommendations is provided in relation to the design, efficiency, effectiveness, sustainability and relevance of the project. Dedicated CMAM coordinator (field-based) with experience in CMAM and technical nutrition skills required. Clear expectations of work required and incentives for volunteers are needed Tri-partite agreement (ICDS – Health – WV) required at the State level to create an enabling environment Greater emphasis needed on community mobilization for future projects (e.g. home visits, community feedback mechanisms, community outreach). Ensure operational guidelines are shared and followed by all stakeholders. Make note of where guidelines need to be altered/ updated to reflect the implementation context.

Use mass MUAC screenings organized through AWCs to identify SAM cases for enrollment in CMAM. Do not do an exhaustive house-tohouse screening. Ensure routine monitoring and supervision systems for ICDS are used for CMAM, with a supportive role provided by WV India. Improving CMAM protocol adherence, RUTF consumption, follow-up visits for slow responders, medical care will increase treatment effectiveness. Better integration of the health system for provision of routine antibiotics, medical assessment by ANMs, is required Provide training for AWWs on counselling skills to support home visits Investigate reasons for defaulting and identify with the community feasible solutions CMAM should only be undertaken at the request of the government, and where there is permission to use RUTF Leadership of local government (District Collector) required for commitment and engagement of local stakeholders, regular review meetings ensure accountability

IMPACT The project screened a total of 20,525 children below 5 years and identified 217 children with SAM. At the end of â&#x20AC;&#x201C; months, 61% of them were cured.

20525 children screened 217 SAM cases identified 650 AWW & ASHA trained 85 PRI Members and Village leaders were oriented 51 Out Patient Therapeutic Programme site (OTP) site established 158 children enrolled in OTP 61% children cured No child died

39% defaulted 34 children referred to MTC 13 children referred from MTC to OTP* (as on September, 2017)

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In tandem with CMAM programming, underlying causes of malnutrition need to be addressed through complementary programs (e.g. WASH, food security, livelihoods) Lessons Learned from the Evaluation Process The use of RUTF and CMAM programming remains a hot topic of discussion in India. In August 2017, the national government recirculated

a directive indicating that RUTF is not approved for use. This notice was retracted in November 2017, when the Prime Minister’s Office advised that it was up to the State to decide upon the use of RUTF. Several States have allowed the product and are supporting CMAM implementation. Given the high burden of SAM, the barriers to access and use of inpatient treatment, along with the lack of scalable, evidenced-based alternative solutions, CMAM should be

considered the preferred approach for treatment acute malnutrition in high burden districts, where use of RUTF is approved by State Government.

Stories of change For many children in the village of Kumardi (Bokaro District), breakfast is generally a pack of five biscuits. Most of the parents rely on seasonal agriculture for their economy and hence leave the younger children in the custody of older children. These children almost starve until evening or wait until their parents come home and prepare food. Meera was born at home and weighed 2 kg at birth. Right after her birth, Meera was not breastfed - she was given cow’s milk instead. Her mother started breast-feeding her only after a day of birth, which continued up to 4 months after the birth. Beyond the 4th month, Meera was given complementary food such as biscuits, chips, etc. As Meera’s mother was not aware about the right time and method of starting complementary feeding for the child, Meera’s health started to degrade. Meera suffered from recurring episodes of diarrhea and as a result, Meera had reached a state of severe malnutrition and looked thin, pale and weak by the time she was screened. Meera is one among the children residing in Kumardi Village of Chas Block- Bokaro, presently covered under the CMAM project of World Vision India. The Anganwadi worker Ms. Senani Devi of Kumardi Village identified Radhika (18 months) malnourished. Radhika just weighed 5 Kg’s when she was covered under the CMAM program of World Vision India. On completion of 3 weeks at the OTP, Radhika’s MUAC measurements showed signs of improvement indicative that she is on the road to recovery. Sabatan, 3 years old was the third child in her family, with MUAC 11.4 cm as on 26th April, 2017. Her mother has been actively involved in feeding the RUTF along with other energy dense foods cooked at home and practicing health and nutrition behaviors provided through household level counseling. She was in the program only for a period of 8 weeks from the date of enrollment. Her MUAC has increased to 14 cm as on 30th November.

Keystone | December 2017

Child Labour and Education in India - Sarojitha Arokiaraj, Bestin Samuel

This paper focusses on the relationship between child Labour and education in India. This has been published in the Journal on the Rights of the Child, National Law University -Odisha.

It is an informative as well as an appalling exercise to determine the number of children working in India. As per Census 2011, the number of Indian children (between 5-14 years of age) working is 4.35 million. The number almost doubles – to 8.22 million- if marginal workers are also included. The figure touches 35.38 million if we were to include children in the age group of 5-19 years. Significantly, the non-economic contribution of children is often not counted – girls who stay at home to take care of younger siblings and tend to domestic needs. The point to be noted here is that the National Policy for Children defines a child as an individual below 18 years of age. International Labour Organisation (ILO) defines the term child labour as: “…work that deprives children of their childhood, their potential and their dignity, and that is harmful to physical and mental development. It refers to work that is mentally, physically, socially or morally dangerous and harmful to children; interferes with their schooling by depriving them of the opportunity to attend school, obliging them to leave school prematurely, or requiring them to attempt to 11

combine school attendance with excessively long and heavy work.” Child labour has a huge economic impact on the country; it is estimated that the annual loss of income globally because of lost years of schooling and children’s involvement in hazardous work is equivalent to $97.6 billion. However, the impact on children is beyond economic terminology and political considerations. Locating child labour Locating India’s child labour in an occupation or industry spectrum throws up largely predictable results, not dissimilar to trends among adults. Majority of children are engaged in agricultural labour. According to Census 2011, 40.1% children were engaged as agricultural labourers, 31.5% as cultivators and 23.8% in other areas of work. The other sectors include manufacturing, construction, trade and hotels, community and social services. Increasing number of children are trafficked for labour to work in the embroidery sector, domestic work (especially girls), sweetmeat shops, beedi & cigarette making, fireworks, brick kilns, mines, quarries

and other unorganised occupations often in extremely exploitative work environments. Home-based sectors also hold a substantial number of children in work. A report on Bonded Child Labour in India says that historical economic relationships based on the hierarchy of caste also contributes to bonded child labour. In the current context of globalized economies, bigger industries are broken down to smaller units and exploit the poverty of families by engaging the whole family in labour including the child. Industries at risk of child labour in supply chain include carpet making, mining, clothing and textiles, ship breaking and cotton supply. Supply chains form a crucial location in the context of child labour. A study notes that 64% of supply chain auditors have encountered child labour during their onsite inspections. Maplecroft Child Labour Index 2012 which evaluated the extent of child labour in countries, highlights the supply chain of companies are exposed to the risk of child labour. Emerging economies like India are classified as under extreme risk.

The social location of children involved in work also needs to be considered, especially since children from Scheduled Castes/Scheduled Tribes (SC/ST) communities are most likely to be child labourers. Children from STs are twice as likely to work as child labour than the children from the upper castes. The retention rates of children enrolled in class 1, till they complete class VIII are lower for SC and ST children than the national average. Only half of the ST children enrolled in Class I are able to complete Class VIII. A detrimental impact While poverty is the most important driver of children being pushed into labour, other reasons ranging from absence of quality education systems, caste based discrimination in schools, displacement due to development projects, distress migration due to failing agriculture and disasters and absence of adequate social protection measures are also prevalent. How exactly does this complex and multi-layered phenomenon impact childhood? It is very difficult to measure the magnitude of loss that a child faces due to child labour. However, it is estimated that children who forego school in order to work reduce their potential lifetime earnings by an estimated 13-20% and increase their likelihood of being poor in later life by as much as 30%. Thus the vicious cycle of poverty and

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lack of opportunities keep these families trapped in deplorable living conditions.

Education and an apathetic relationship

The effect is not restricted to mere income poverty; it shrinks the human capabilities necessary for human development. It has been observed that most children who work are enrolled in schools in their neighbourhood but they rarely attend classes. In spite of being in schools, these children hardly learn, play or have leisure. Working from home means their work hours extend till late in the night and begin early in the morning, affecting their health and development. To be able to meet the target set by middlemen/contractors the whole family engages in strenuous labour so that they will earn their basic minimum for survival.

Education and child labour are inextricably linked. Child labour robs a child of their chance to access quality education by affecting school attendance and learning capacity, resulting in low literacy rates and poor scholastic performance which leads to dropping out from school. Consequently, it perpetuates the cycle of poverty by increasing the risk of unemployment. Considering this, government initiatives had been aiming to both increase enrolment as well as retention - Sarva Siksha Abhiyan and the Right of Children to Free and Compulsory Education (RTE) Act, 2009 have in fact enabled more children to access schools in the country than ever. However, Census 2011 says that 29 million child labourers below 19 years were either just literate or below matriculation level. It is evident that access to schools alone has not ensured retention or quality of education.

Another factor pushing children to work is the climate related disasters, where children are usually the most vulnerable. A study concluded that householdsâ&#x20AC;&#x2122; coping mechanism to manage shocks have negatively impacted on childrenâ&#x20AC;&#x2122;s wellbeing by increasing their vulnerability to malnutrition, school withdrawal, exploitative forms of child labour, inadequate parental care and nurture and, ultimately, poverty. Education stands tall among most of the other ill-impacts, as one of the most potent as well as life-defining.

This assumes significance against the backdrop of the fact that a sound education system is essential to mitigate the ill-effects of child labour. Questions rise regarding the quality and capacity of the Indian education system on the whole â&#x20AC;&#x201C; is it equipped to prevent/address child labour? A report from the Government of India finds that quality deficiencies in Early Childhood Care and Education (ECCE) services, low enrolment rates in elementary and higher

education, higher dropout among children from disadvantaged groups in elementary and secondary education, deficiencies relating to teacher quality, unsatisfactory level of student learning and teacher attendance as issues that need immediate attention for every child to have quality education. A study by Michigan University concluded that the most qualified or effective teachers are disproportionately concentrated in the schools and classrooms of wealthier children. 13

Education becomes a mandatory prerequisite for sustained income. While child labour, materialising out of a debilitating need for additional income, might offer a bare minimum for survival, it cannot in the least substitute a skillbased job. Indiaâ&#x20AC;&#x2122;s need for skilled manpower by 2020 is estimated to be 109.73 million. According to the National Sample Survey (NSS) 68th Round (published in September 2015), only 2.4% of persons aged 15 years and above

have technical degrees or diplomas or certificates, despite 46.1% of literates having completed levels of secondary education and above. It also notes that more than 40% of people aged 5-29 years were not â&#x20AC;&#x2DC;currently attendingâ&#x20AC;&#x2122; any educational institution. Almost all child labourers fall into this category, and lose out on the narrative of economic growth by virtue of losing out on education.

World Vision India

The State and the school In the global stage, India has ratified the United Nations Convention on the Rights of the Child (UNCRC) where the Article 32 demands the government to protect children from work that is dangerous or might harm their health or their education. India has also recently decided to ratify ILO’s Minimum Age Convention, 1973 (No. 138) and the Worst Forms of Child Labour Convention, 1999 (No. 182). The Sustainable Development Goals also commits to take immediate and effective measures to elimination of the worst forms of child labour and by 2025 end child labour in all its forms. In the context of India’s legal and policy framework, the key cogs which heavily influence child labour include, apart from the Constitution, the Child Labour (Prohibition and Regulation) Amendment Act, 2016 prohibiting all forms of child labour for children below 14 years. This was the amendment of the landmark Child Labour (Prohibition and Regulation) Act, 1986. Apart from this, the main legislations are the RTE Act, 2009, guaranteeing education for all children in the 6-14 age group and the Juvenile Justice Care and Protection Act 2000 (amended in 2006 and 2011) protecting children from exploitation.

Keystone | December 2017

In spite of all these commitments, Section 5 of the recently amended child labour act remains a cause of concern. Primarily, the Act now legitimises the idea that certain levels of child labour are acceptable as long as they don’t interfere with formal schooling, despite the fact that all forms of child labour have serious impacts on children. It needs to be noted that A Young Lives longitudinal study found that children spending three or more hours at work at age 12, are highly unlikely to complete secondary education. The exceptions proposed in the Act feature the apparently ‘non-hazardous’ family enterprises and audiovisual entertainment industry. Considering the highly decentralized and unregulated nature of the so-called “family enterprises,” identifying and responding to violations becomes virtually impossible. The exceptions made to the Act only strengthen the structure of this vicious circle of the ‘child labour-exists-due-tosocio-economic-conditions’ notion. Significantly, the government release said that “while considering a total prohibition on the employment of child, it would be prudent to keep in mind the country’s social fabric and socio-economic conditions.” This would reinforce the caste-based hierarchy of labour and children inheriting occupation from parents.

Higher rates of school dropout and higher percentage of out of school children are prevalent among the most marginalized communities. This would increase the equity gap and leave them without much scope to improve their situation and the caste based hierarchy of labour and children inheriting occupation from parents. Despite having legislations and policies in place which evidences a huge commitment to protection of children - it is imperative that it has to be backed by adequate budgetary allocations, a systemic capacity to deliver, political will and attitudinal change. The budgetary provisions for children that have usually seen a very low share around 4% of the total budget, saw it further going down to 3.2% in the Union Budget 2017-18. Of this, 2.34% is for education and a mere 0.05% for child protection. Despite the recommendations for a 6% GDP spending on education from the Kothari commission half century ago, the allocation remains less than 3%. Equitable, quality education – the way forward John Dreze and Amartya Sen shed light on one of the most pressing questions – why are so many children out of school in India? According to them, the first

myth related to this is that poor parents lack interest in education – a vast majority of Indian parents in fact value education for their children. The second myth, Dreze and Sen say, is that the poor are dependent on child labour. The time and effort required of poor parents to send their children to school is a massive investment, and causes easy discouragement when they face poor access to and quality of education. In the context of child labour, this amply highlights the reason for not just the high prevalence of child labour but also the critical value of quality and access to education. Economies that don’t respond to child labour effectively condemn children, families and their communities to a bleak future both socially and economically. Strengthening the policy environment where every child under the age of 18 would have access to free, quality education is most essential to address child labour. As Weiner states, “compulsory primary education is the policy instrument by which the state effectively removes children from the labour force.” Facilitating a total elimination of child labour up to the age of 18 is crucial. Ageappropriate rehabilitation for children engaged in labour is necessary if they are to be integrated to the mainstream non-working population

below 18 years of age. These needs to be supported by an efficient implementation of Right to Education Act along with a higher budgetary allocation of 6% GDP, an access to quality ECCE through Integrated Child Development Scheme (ICDS) to prepare the child for school, providing vocational / skill training for children in the age group 15-18 years and addressing social determinants to ensure an equitable access to education to be by bridging gender and social divides. That child labour is a direct result of poverty is obvious – equally obvious should be the fact that healthy household incomes and guaranteed social protection schemes are the best antidotes. Social protection schemes like Mahatma Gandhi National Rural Employment Guarantee Scheme (MNREGS), Public Distribution System (PDS) need to be implemented effectively so that these could be a buffer in times of economic shocks, for the most vulnerable populations. A collective social participation is also essential if any of these efforts are to bear fruit. Community participation in planning, implementation and monitoring of services for children, especially, strengthening the functioning of School Management Committees is of paramount importance. Fully functional Child Protection Units across the country (at district, village and ward levels) would

greatly contribute to microlevel monitoring. In order for children continue to remain in school even during times of crisis or shocks, welldesigned social protection services need to be in place. The most frustrating as well as fearsome aspect about child labour is that it does not achieve what it apparently sets out to achieve - a departure from poverty. While poverty remains the push factor, child labour does not resolve the issue but rather compounds it. At this juncture access to quality education assumes significance as a route out of the circle of poverty. However, quality education must not stop at primary level if young people are to be adequately prepared for the labour market and for decent work within it, rather than being confined to low-skilled, unprotected jobs in the informal economy. It needs to be noted that there is no single solution per se for eradication of child labour. As ILO notes, a combination of economic growth, respect for labour standards, universal education and social protection, together with a better understanding of the needs and rights of children, is essential . For the country with the highest number of people below 25 , access to quality education holds the biggest stake in this narrative of redemption and is indeed the best way forward.

OPEN DEFECATION FREE A Community Perspective - Sherin Daniel. This study explores the use of available sanitation facilities in households of open defecation free communities in Narsinghpur, Madhya Pradesh.

1.0 INTRODUCTION Water, sanitation, and hygiene are basic needs and rights of the people. Unfortunately, seven decades since Independence, India still struggles to ensure the equal accessibility of toilets, safe drinking water and total sanitation to more than half of its population. One of the paramount challenges in achieving ‘Clean India’ target is country’s reprehensible state of open defecation. According to NFHS IV 48.4% households have access to improved sanitation facility in India. In the state of Madhya Pradesh, only 33.7% households have access to improved sanitation facility. As per all India baseline survey conducted by Ministry of Drinking Water and Sanitation in 2012-13, 1.39 crore of the total 7.41 crore household toilets were dysfunctional in India. It is alarming to note that one in 10 deaths in India is due to poor sanitation, according to the World Bank as cited in a global magazine “The Economist” in September 2017. Women and girls suffer more in absence of sanitation facilities. Dasra’s report “Spot On” indicates that 66% of the girls in India manage their

Keystone | December 2017

period outside or in an open field due to the absence of a household toilet, while 23% of girls drop out of school for the same reason. Furthermore, about 334,000 children, aged less than five years, die every year due to diarrheal diseases caused by abysmal status of sanitation. According to a May 2017 factsheet prepared by World Health Organisation, about 321 children under five years of age, died every day due to diarrhoea in 2015. It is proven that lack of sanitation results in loss of productive potential for not only those affected but also other members of the family, especially women, who are compelled to take care of the unwell. Thus, open defecation is a huge challenge in terms of social and cultural sensibilities, behaviours, infrastructure, capacities, resources and governance in India. WASH initiatives of World Vision India focuses on community-led total sanitation (CLTS) approach to generate demand, change behaviour, build self actions and integrate with Clean India.

2.0 Objectives of the Study The study was intended to discern behaviour change in terms of use of toilets, adoption of hygienic practices, like washing hands with soap at critical timings and demand for toilets generated through community-based processes as mentioned above. The study included following objectives • Assessment of the utilisation of available sanitation facilities in households of open defecation free communities. • Assessment of the factors hindering utilization of available sanitation facilities. • Assessment of the attitude and perception around regular latrine use. 3.0 Methodology The study was conducted with cross sectional approach to gain insight into efficacy and impact of WASH initiatives. It selected 384 households spreading over 30 open defecation free villages covered under Area Development Programme in Narsinghpur district, in Madhya Pradesh. Seven households from each of the 30 villages

were selected using simple random sampling method. Community volunteers from within the community were trained and engaged in data collection process under supportive supervision of World Vision India team. It facilitated data accuracy and quality. Study used structured questionnaire and field observation as tools to generate the data on key aspects like defecation frequency & place, knowledge and awareness regarding use of toilets, toilet use pattern, toilet design and types, cleaning of toilets, disposal of faecal, availability of the water in toilet and hand wash with soap practice. 4.0 Study Area Madhya Pradesh, the largest state situated in the central India, has about 38.3% of its population living under the Below Poverty Line (BPL) against the national average of 27.5%. An analysis of the causes of demographic indicators in the state shows that the high levels of poverty, low level of literacy, particularly the female literacy and abysmal conditions of water and sanitation contribute to poor health. According to the NFHS 4 2015-16 data, only 33.7% households in Madhya Pradesh have access to improved sanitation facilities, while in urban areas the figures on the same indicator stood at 66%. It is lower than national average. Narsinghpur district is situated in the central part of Madhya Pradesh and has total

population of 1092141 with 13% scheduled tribes (ST) and 12.60% scheduled caste (SC) as per Census 2011. According to NFHS IV data, Madhya Pradesh has 40.7% households with access to improved sanitation facility, 27.4 % girls who are married before attaining legal of 18 years, and a complete child immunisation of just 54.2%. World Vision India is working in the district with community-based and convergence-driven approaches to improve conditions especially among children, adolescents and women. As a part of its WASH initiatives, it is focusing on CLTS linked micro planning, community resources like volunteers and groups, capacity building, behaviour change communication and mainstreaming with Clean India Mission. It is worth mentioning here that World Vision India has interconnected community level WASH initiatives with Clean India Mission initiatives to improve drinking water, sanitation and hygiene conditions in its project villages in the district. 5.0 Study Findings It is proven that success of growing investment and efforts for construction of toilets can be achieved only with change in behaviours among the people. This study digs multiple aspects and interconnections at householdsâ&#x20AC;&#x2122; level to understand the factors and reasons which contribute in existing situation of

toilet use. The study brings multiple aspects like knowledge, behaviours, practices, advantages and disadvantages as perceived by the community regarding defecation practices and toilet use pattern. It provides insights into interconnections in community mobilisation, behaviour change communication, and sanitation facilities like toilets in the given rural settings. Brief description of the findings is as follows:5.1 Toilet use and defecation frequency

It is encouraging to note that sampled households demonstrated 100% use of the toilets across the 30 villages representing 30 clusters of villages covered under Area Development Project being implemented by the World Vision India in Narsinghpur district of Madhya Pradesh. This achievement is attributed to community sensitisation and behaviour change communication processes initiated by the World Vision India and integrated with toilet construction under government schemes. It validates the fact that mere construction of toilets is not enough to ensure its usage. Behaviour change at individual, household and community levels is an essential factor to achieve absolute open defecation free status. In regards to frequency of the defecation, while 70% family members reported to defecate twice in a day, about

30% households preferred not to respond. Interestingly, 75% households claimed to use toilet every time for the defecation, whereas 25% did not respond either due to their inhibitions in speaking about defecation or they may not be using the toilet regularly.

use of the toilet may lead to early filling of the toilet pits leading to closure of the toilet for use. Less than 1% told that use of toilet may pollute the water sources. It shows that majority of the community members are convinced with the advantages of toilet use.

5.2 Toilet use pattern and perception

5.3 Water and sanitation:

A complete paradigm shift in the attitudes and perceptions is essential in making substantial strides to make the communities open defecation free. Communities have to be mobilised for not just using toilets but in maintaining and cleaning them as well. The responses indicate that behaviour change in terms of toilet use is well appreciable at the community level. About 93% households stated that all the members in their family used the toilet every time they went for defecation. This indicates that they have overcome their open defecation practice. Around 7% are either not using the toilet or were hesitant in sharing their responses in this regard. Encouragingly, all households covered under the study are aware of advantages of the toilet usage. They noted a wide range of advantages including safety of women, dignity and respect, time efficiency, no dirt and germs spread leading to a clean village in true sense. About 99% households feel that there is no any harm in using the toilet. Over 23% of the respondents are apprehensive that regular

The study shows that 91% toilets are available and used at household level, while 9% households use community toilets which can be reached within 30 minutes from their houses. About 51% toilets, including households and community, were reported to have water connectivity. As many as 93% toilets including both household and community have facility for hand washing after defecation and 98% households indicated availability of soap for hand wash. It is encouraging to note that there is an increased awareness on hand washing with soap at critical timings like after defecation. This finding is substantiated with the availability of soap for washing hands in more than 90% cases. It also reflects that hand washing is being practiced in the households. Water availability in toilets continues to be an issue across the country. The study also validates this fact. The analysis indicates that around 50% toilets lack the running water facility, a major deterrent in using the toilet. It is reflected in other section of the report related to difficulties faced and perceived by the toilet users.

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5.4Access to latrine and behaviour change

It is reassuring to note that majority (83%) of the households do not feel any kind of difficulty in accessing the toilet at the time of their requirement. It also reflects on cooperation within the family in regards to use of the toilet. On the other hand, remaining 17% households may be facing difficulties in accessing the toilet due to more users in the family, improper time planning for use, lack of water or cultural reasons. 97% households indicated that they use toilet only for the defecation. It reflects on behaviour change leading to open defecation free community. It shows that increasingly the practice of using toilet is gradually getting internalised among people at community level. It is a welcoming development towards achieving and sustaining open defecation free communities in rural areas where it has been a tough challenge to change age-old behaviours and myths regarding use of toilets. This success is attributed to communitybased mobilisation processes and communication systems developed by the World Vision India in its operational areas. 5.5 Health and toilet

Unsafe drinking water, poor sanitation and unhygienic conditions are crucial risk factors for diarrhoea. Thus, toilet use and hand wash practice are linked with this high value indicator. Study

shows that 71% households

life threatening disease. Over

are aware of correlation between diarrhoea and defecation practice. They responded that it is less likely to happen as they are using toilets and reduced level of open defecation in the community. Around 27% households have fear of occurrence of this disease and only 1 % feels it is very likely. Further analysis shows that 67% households perceive diarrheal disease as a serious problem and believe that it should never be taken lightly, whereas 21% do not find it a

12% households consider it as a problem but not a serious one. It shows that there is increased awareness on diarrheal disease among the people. However, 33% people still do not seem to be serious about protection from this deadly disease. Earlier, people were considering open defecation not as a risk as it was a traditional practice passed down through the ages. Even in families that owned toilets; some of them relieved themselves outdoors through force of habit.

Interestingly, this perception is gradually changing and there is an increased awareness towards the life-threatening disease like diarrhoea. 5.6 Community alert system for toilet use

Several interventions in the past have established that community ownership and accountability make a pragmatic difference. The communities and local governance institutions have to shoulder the responsibilities to ensure

quality of construction, proper usage and maintenance of the toilets, and understanding the several impediments stopping the people in using toilets and subsequently devising strategies to address them. The study indicates that 80% of the households believe that community alerts and regular monitoring influences the defecation behaviour. It shows that community volunteers and groups developed by the World Vision India are engaged in mobilising the community members towards the use of toilets. Similar observations have been made in various villages that have achieved open defection free status across the country. Community level monitoring committees, whistle blowers, volunteers and SHGs play a very significant role in motivating and counselling the people to discard the practice of open defecation and start using toilets. Community Led Total Sanitation exercises conducted by the World Vision India have also contributed significantly in sensitising the community and building a collective opinion that advantages construction and usage of toilets. It pushes the toilet users to convince nontoilet users to abandon the practice of open defecation. 5.7 Toilet type and use pattern

Study reveals that all the households use flush or pour water after using toilet. Data on types of toilet indicates that flush-based toilet facility

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is being used commonly among the households. Usage of pit-latrine without slabs, composting toilet and ventilated pit-latrine are comparatively less. Data indicates that 93% households use flush and pit-latrine with slabs, 5% pit latrines without slabs and 2% use flush and ventilated latrines. Some of the households using the above type of latrines use buckets as well, though it is very rare. Study noted that 93% households have no difficulties in using the toilets on their own. The ease of access was mapped in terms of going to the toilet, putting the water in toilet, waiting to ensure safety, etc. Only 7% of the households reported that support was needed for using the toilet. It may be related to children, old family members, physically challenged and sick persons. In absence of the required assistance some of the family members admitted that they defecate in open. 5.8 Toilet use and children

Study reveals that use of toilet among children below 5 years still remains a critical issue. Over 35% children in this age group are assisted to use the toilet, 6% defecate in open, and around 59% were not able to comment on use of toilet by children. It was also noted that 78 % of the children wear sandals/ slippers to cover their feet while using the toilet. The study further learnt that disposal of children faeces is not safely managed. Only 16% households dispose

the children faecal in toilet, which can be considered as safe disposal. As many as 84% used harmful disposal practices, including 13% disposing in segregated waste, 3% in domestic waste, 5% throwing in open and 63% use other methods. It is imperative to mention here that disposal of faecal in any form other than using the toilet is unsafe. 5.9 Toilet cleanliness and maintenance

The study notes that mere availability of toilet is not enough. Its regular use, cleanliness and maintenance are equally important. Cleaning of the toilet is indication of toilet use. Study indicates that 70% households clean their toilets once in a week, 10% every day, 9% sometimes or occasionally, 2% after every use and less than one percent never cleans the toilet. This data reveals that 99% households clean their toilets at different intervals. It may be correlated with the growing use of toilets. Regarding cleaning of toilet pits, study reveals that 87% households empty the pits manually and 4% use mechanised or semimechanised methods to clean the toilet. Around 9% reported that they discard the toilet once their pits are full. Thus, it can be inferred that majority of the households use and clean the toilets on their own. It may be related with ownership of toilet at household level.

5.10 Constraints in toilet use pattern

Study reveals that 13% households reported lack of water, 12% its bad odour, 12% congested space as difficulties in using their toilets. 53% households reported constraints other than reasons listed in the questionnaire. These other reasons may be related to social customs, more users at a time and lack of assistance required for using the toilet. It shows that there are constraints related to both demand and supply side. Demand side constraints are inadequate cleaning leading to bad odour, social customs, location of the toilet and the supply side constraints are size, inadequate water arrangement, etc. However, it is encouraging to note that people have started using the toilets and hopefully the above-mentioned constraints will be gradually resolved. Obstacle in toilet usage

(% age of household) No water 13% Small and congested 12% Odour 12% Other 53%

6.0 Recommendation Systematic engagement of individuals, households, communities, local governance institutions,

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government and various service providers like masons can address the huge challenge of open defecation and unhygienic conditions in rural areas. While leveraging resources and opportunities created under Clean India Mission, World Vision India is significantly contributing by engaging the communities, building local capacities, changing behaviours and creating an environment for self-initiatives and linkages to make the rural communities open defecation free. The following recommendations emerging from the study are intended to enrich, sustain and scale the impact of water, sanitation and hygiene indicators in rural settings. 6.1 Behaviour change communication

Community behaviours and practices are major determinants of sustainable open defecation free villages. It is noteworthy that toilet use has grown remarkably to attain the open defecation free status in project villages of World Vision India. Now, the challenge is to sustain this practice and address other unhygienic practices. The study noted that 84% households are using unsafe methods like disposing in segregated waste, domestic waste, throwing in open for disposal of child faecal. 6% households indicated open defection by children and 53% households did not speak on this. 23% households still think that regular use of toilet may fill the pits leading to closure of the toilet for use. These issues need to be addressed

through regular behaviour change communication. It is proven that community alert system like monitoring committees and volunteers play a significant role in internalising and sustaining hygienic practices. It is also experienced that children can effectively influence WASH behaviours at households, community and school levels.Village social maps can also be developed and used to track WASH behaviours including toilets use at household level. Therefore, it is important to build such systems level for regular behaviour change communication in order to internalise this practice and achieve the goal of open defecation free community. 6.2 Water availability in toilets

The study indicates 49% toilets still do not have adequate water supply systems. It is experienced as major difficulty by the community while using the toilet. It also affects regular hand wash with soap after defecation. Therefore, after ensuring availability of the toilets, next steps should be developed water supply facilities in the toilets. It is also suggested that water availability should be seen as an important facility while constructing new toilets. 6.3 Toilets for people with disability

It is a general observation that people with disability are not taken into account while planning and constructing the toilets.

Despite the guidelines under Clean India Mission, uniform design is used for construction of the toilets. They may have different requirements like more space in the toilet. Therefore, it is important to be sensitive to their requirements and construct disabled-friendly toilets. 6.4 WASH in schools, ICDS and health centres

WASH (Water, Sanitation and Hygiene) facilities and behaviours are essentially required everywhere by everyone. Use of toilets at households and community levels is an encouraging step but not enough to end open defecation if schools, ICDS centres and health centres within and around villages are deprived of adequate WASH facilities. Cycle of protection from unhygienic conditions is incomplete if WASH facilities and behaviours at schools are missing. Though this aspect is not covered under this study, several studies across

the country have noted inadequate WASH facilities as a major reason for girls dropping out of schools. It is important to build WASH resources both human and physical to address this problem and achieve the fruits of open defecation free communities in true sense. There needs to be special focus on toilet facilities for girls, especially adolescent girls, in order to achieve desirable figures in social development indicators. 7.0 Conclusion The WASH initiatives of the World Vision India are in line with national commitment to make India open defecation free by 2nd October 2019. The study brings community perspective in terms of their behaviour, strengths and challenges in context of open defecation free villages. It establishes that interconnecting behavioural change with provisions of toilets under Clean India Mission is essential to address the huge problem of open defecation in India.

Community can bring the behaviour change in terms of toilet use and other hygiene practices if local resources like volunteers, monitoring committees are developed and trained in behaviour change communication processes in localised manner. Decentralised community led approach brings synergy among households, community, local governance institutions and government. Social organisations like World Vision India bring specific resources and skills to engage and capacitate the community and build linkages with the government service provisions effectively to achieve long term results. It is evident from the findings of the study. The findings and recommendations emerged through this study may provide inputs in future planning for open defecation free and bridging gaps in existing open defecation free villages.

Training Need Assessment of HEALTH CARE WORKERS - Gabriel Das, Subrahmania Siva This study assesses the training needs of ASHAs and Anganwadi workers, the gaps and suggests appropriate training methods for them.

1. BACKGROUND Madhya Pradesh is one of the Indian states where issues of child health are of a major concern. The infant mortality rate is 51 and the below-5 mortality rate is 65 – both of which are higher than the national average of 41 and 50 respectively. As per the NFHS 4 data, the nutritional status of children in Madhya Pradesh is also worse than the national average. Of the children below 5 years of age, 42% are stunted, 25.8% are wasted and 42.8% are underweight. The primary driver of delivering health care is the Government of India’s National Rural Health Mission (NRHM) which was launched in 2005. The primary objective of the NRHM is to provide accessible, accountable, affordable, effective and reliable primary healthcare, especially to the poor and vulnerable sections of the population. The key person in delivering this at the village level is ASHA who promotes primary health

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care services in general and in particular reproductive and child health services such as universal immunisation, referral and escort services for institutional deliveries and other healthcare interventions. The NRHM has designed an induction training program for ASHAs and currently they are in the process initiating periodic trainings (two day refresher trainings every second month). The other critical function at the village level delivering health and nutrition care is the Anganwadi worker (AWWs). Given the health care and nutritional challenges facing the poorest communities, ASHA and the AWW are the most critical player in addressing this. Skill and knowledge for these frontline workers are critical if we need to empower these healthcare workers to deliver their duties efficiently. World Vision India in close collaboration with the state government has been working with these frontline healthcare workers to

improve maternal and child health and nutrition status. In doing so, assessment of training needs of them became the integral part of WVI exercise. To take stock of what knowledge and skills ASHAs and AWWs have gained and retained from the induction training. World Vision India (WVI) along with Bhopal School of Social Sciences (BSSS) conducted need assessment of ASHA and AWWs. 2. OBJECTIVE • To assess the knowledge and practices gap among the front-line workers pertaining to Mother and Child Health and Nutrition • To suggest appropriate training programs for Front Line Workers i.e. AWWs & ASHA/USHA (wherever applicable) 3. METHODOLOGY The study used a crosssectional quantitative study design. The sampling method used is non-

probability sampling. Data was collected from 05 districts (representative of the 5 geographical divisions of Project areas of WVI). Interviews were conducted using structured questionnaires with 138 ASHAs, and 162 Anganwadi workers, to make it a total of

300 respondents. The area of study includes 5 Area Development Programmes locations where World Vision India operates in Dewas, Amarwara, Narshighpur, Bhopal and Sohagpur. A total of 112 questions and 108 questions were asked

to each of the ASHAs and AWWs respectively in the survey, to ascertain their knowledge and skills on various issues pertaining to their functioning in the field. The skill and knowledge wise breakup of the total scores is given below:

Survey tool Item Distribution: Knowledge and Skill Development Total Score on Skills Total Score on Knowledge ASHA

106

AWW

108

Questions asked were related to either of six key issues â&#x20AC;&#x201C; vaccination, prenatal and post natal care, sexual and reproductive health, roles and responsibilities and nutrition. Around 3, 4 or 5

Grand Total

questions on each of these issues were asked in the questionnaire to ascertain the level of knowledge & awareness of ASHSs and AWWs. Areas where training to ASHAs and AWWs took place were checked, and

10 (ten) for ASHAs and 12 (twelve) key area for AWWs were identified for imparting training. Furthermore, the questionnaire contains the questions, each of which was designed to check either the knowledge or skill of the

World Vision India

4. FINDINGS AND DISCUSSIONS

Proportion of ASHAs and AWWs received training:

ASHA

Total

% ASHA

AWW

Total

% AWW

Bhopal

93.33

97.22

Dewas

85.19

88.89

Sohagpur

75.00

95.24

Narsinghpur

94.59

85.71

Amarwada

100

90.91

It could be observed that a very high proportion of ASHAs and AWWs have attended one or the other training session. The least is Sohagpur and most is Awmarwada when it comes to training of ASHAs. If we consider the training done for AWWs, the Narsinghpur block is falling short and Bhopal block is ahead in terms of achieving the objective of conduction of training.

Skill and knowledge gap of ASHAs- ADP wise Location

Percentage of score on skills (pS)

Percentage of score on knowledge (pK)

Bhopal

56.67

48.87

Dewas

52.47

46.70

Nâ&#x20AC;&#x2122;Pur

29.15

50.49

Amarwada

19.51

50.41

Sohagpur

67.26

51.85

The wide gap is visible in Amarwada, followed by Narsinghpur and Sohagpur among ASHAs. Therefore, we suggest that for ASHAs of these areas, trainings should focus on skills building and bridging this skill-knowledge gap. ASHA lacks knowledge on Roles and responsibilities, Delivery process, Pre Natal & Post Natal Care in Madhya Pradesh locations which is evident through this assessment. Whereas in Bhopal, Dewas and Sohagpur has high skill in spite of low level of knowledge.

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Skill and Knowledge gap of AWWs Location

Percentage of score on skills (pS)

Percentage of score on knowledge (pK)

Bhopal

47.07

52.41

Dewas

51.50

50.34

N’Pur

42.59

44.05

Amarwada

50.63

52.29

Sohagpur

41.67

46.36

Child Nutrition and Maternal and Child health are two areas where AWWs know most. There is high variability among AWWs for their knowledge on Sexual & Reproductive Health (SRH). Amarwada and Bhopal AWWs demonstrate best results on knowledge regarding sexual & reproductive health issues, while Sohagpur AWWs show worst of the results. Prenatal care is an area where AWWs need training the most, as they do worst on such issues during the survey.

5. RECOMMENDATIONS

Training Recommendations to the Government for ASHAs

1. The state should prepare operational manual specifically for ASHA workers for conducting the training and ensure post training follow up through Sugam Karyakarta for facilitating the use of skills in field. 2. The knowledge of ASHA on various topics like prenatal and post natal care, social observation. The role and responsibilities (R&R) of ASHA and linkage of ASHA with different stakeholders at the grass root level needs to be reinforced through either monthly meeting, subsequent rounds of trainings and/or one-day reorientation training at CHC/PHC.

Training Recommendations to the Government for AWWs

1. Behavioral Observation (BO), Program Information, Child Health and prenatal care are the most pressing areas for the training of AWWs. In some areas, training on SRH issues is also desirable. 2. AWWs are very strong on pragmatic issues considering their rich work experience, however many of them lack basic education. 3. For AWW training, specific weak areas like MCH, CH and ‘nutrition’ have been identified (see Appendix) and trainings programs should designed on those lines, i.e. in every training event, one component can be pertaining to these common issues.

Common Training Recommendations for AWW and ASHA

1. New and user-friendly training modules are required for the training. 2. State may also like to consider organizing exchange visits to neighboring districts, so they learn from each other and also build a network.

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ABOUT US World Vision is one of the worldâ&#x20AC;&#x2122;s leading child-focused humanitarian organisations. Through development, relief and advocacy, we pursue fullness of life for every child by serving the poor and oppressed regardless of religion, race, ethnicity or gender as a demonstration of Godâ&#x20AC;&#x2122;s unconditional love for all people. With nearly 65 years of experience in India, World Vision works in 185 districts impacting 26 lakh children and their families in over 6200 communities spread across 26 states of India.

Strategy and Research Management, World Vision India For feedback and queries, contact: bestin_samuel@wvi.org