INDIA - Linknca

KHAKNAR BLOCK, BURHANPUR, MADHYA PRADESHPublication: December 2014Photo Rajarshi MITRA https://creativecommons.org/licenses/by/2.0/RE FINPO ALRTINDIA

The author :Blanche MatternLink NCA ExpertFrom a pluridisciplinary backrground in human sciences,Blanche used to work in Asia on crisis and post-emergencycontexts and on research projects, such as topics relatedto the Sri Lankan conflict.She also worked on technical capacity building programsfor Indian NGOs.She joined the Link NCA Technical Unit after implementingtwo Link NCA in the ground, in India and in the Philippines(2014/215). After those two studies, Blanche Mattern hasbeen Link NCA Technical Advisor in Paris Action AgainstHunger Headquarters since February 2015.

Link NCA Final ReportApril August 2014Khaknar Block, Burhanpur, Madhya Pradesh, IndiaBlanche Mattern, NCA Expert

AcknowledgementsThe Nutrition Causal Analysis (NCA) was undertaken with funding from ECHO. The study wasled and managed by ACF NCA Expert, Blanche Mattern with the support from the NCA RiskFactors Survey (RFS) Program Manager, Radhika Soni.ACF Technical Advisors: Gaelle Faure and Abhishek Singh in India and Francesca Corna, JulienEyrard, Victor Kiaya and Yara Sfeir in France, provided key information and support throughoutthe project. Sophie Aubrespin, Mental Health & Care Practices (MHCP) Expert and MathiasGrossiord, Nutrition Program Manager, offered an important technical support during thehypothesis design process. The NCA would not have been possible without the support of ACFIndia Delhi and Burhanpur logistic staff, Mukesh Kumar and Bhupendra Kumar. As well, theNCA workshop would not have been so well organized without the inputs of Capacity BuildingManagers Minh Tram Le and Dr Narendra Patil. In addition, ACF Head of NCA ResearchProject Julien Chalimbaud technically guided and supported the observation and implementationof the NCA methodology.The NCA expert would like to give a special thanks to each member of the field team for theirdedication and hard work in gathering high quality data for the survey.In addition, the NCA team would like to thank technical experts from CSH/CIRAD, Technicalgroup of NRHM, French Institute of Pondicherry, IIP Patna, IIP Kharagpur, INCLEN, JNUUniversity, MP Institute of Social Science Research, WFP and other NGO partners includingCECOEDECON, MSF, Naandi Foundation, Real Medicine Foundation, Sangath, Save theChildren, Valid International, Vikas Samvad and Water Aid. All of them participated andprovided key inputs through the NCA preliminary and final workshops.Most importantly, ACF India would like to thank each of the respondents who gave time toparticipate in this survey and shared valuable information.I

Table of contentAcknowledgementsIAbbreviations and Acronyms1Glossary2Executive summary31.Introduction1.1 Study Area1.2 Context of the study1.2.1 Malnutrition1.2.2 Food Security and Livelihoods1.2.3 WASH1.2.4 Child Care Practices1.2.5. Child Health1.2.6 Status of women92.NCA objectives1.1 Main study objective2.2 Specific study objectives173.NCA Methodology3.1 Overview of the NCA approach3.2 Study design3.3 Sample3.3.1. Selected method and sample size calculation3.3.2 Number of household to be surveyed3.3.3 Selection of number of clusters to be surveyed3.3.4. List of Khaknar Block villages and random selection of clusters3.4 Data collection methods3.4.1 Risk Factors Survey3.4.1.1 Training of surveyors and supervisors3.4.1.2 Random selection of Households3.4.1.3 Information collected within selected households3.4.1.4 Severe Acute Malnourished children identification3.4.2 Qualitative survey3.4.2.1 Research instruments and methods3.4.2.2 Data collection3.4.2.3 Stakeholder consultations3.4.3 NCA team composition3.5 Data Management and Analysis3.5.1 Quantitative data management and analysis3.5.2 Qualitative data management and analysis3.5.3 Rating Causal Hypotheses3.5.4 Final Stakeholder Workshop3.6 Research Ethics3.7 Limitations184.NCA Findings304.1 Preliminary Technical Expert Workshop4.1.1 Validated and Ranked Causal Hypotheses4.1.2 Identification of nutrition vulnerable groups and causal hypotheses by the technical experts4.1.3 Hypothesis reviewed and validated by the technical experts4.1.4 Nutrition Vulnerable Groups4.2 NCA Quantitative Survey Results4.2.1 Household 323242525252627272828282828292930303132323333II

4.2.2 Composition of the population4.2.3 NCA Risk Factor Results by Causal Hypotheses4.2.3.1 Causal Hypothesis 1: Inappropriate breastfeeding practices4.2.3.2 Causal Hypothesis 2: Inadequate complementary feeding practices4.2.3.3 Causal Hypothesis 3: Low Birth Weight4.2.3.4 Causal Hypothesis 4: Caregivers’ level of education4.2.3.5 Causal Hypothesis 5: Caregivers’ workload4.2.3.6 Causal Hypothesis 6: Maternal wellbeing4.2.3.7 Causal Hypothesis 7: Inadequate family income management4.2.3.8 Causal Hypothesis 8: Poor psychosocial care of children4.2.3.9 Causal Hypothesis 9: Inappropriate reproductive health4.2.3.10 Causal Hypothesis 10: Inadequate sanitation4.2.3.11 Causal Hypothesis 11: Inadequate access to drinking water4.2.3.12 Causal Hypothesis 12: Lack of hygiene4.2.3.13 Causal Hypothesis 13: Poor health seeking behaviour4.2.3.14 Causal Hypothesis 14: Lack of health care regarding the treatment of undernutrition (MAM/SAM)4.2.3.15 Causal Hypothesis 15: Low agricultural production4.2.3.16 Causal Hypothesis 16: Land size v/s ownership4.2.3.17 Causal Hypothesis 17: Poor diet diversity4.2.3.18 Causal Hypothesis 18: Poor access to food4.2.3.19 Causal Hypothesis 19: Low Income4.2.3.20 Causal Hypothesis 20: Traditional beliefs4.2.3.21 Causal Hypothesis 21: Women Empowerment4.3 NCA Qualitative Results4.3.1. Background characteristic of participants in qualitative study4.3.2 Key Stakeholders consultation and community consultation4.3.3 Local definition and understanding of malnutrition4.3.4 Description of Livelihoods and Food Security Situation4.3.5 Description of health situation and practices4.3.6 Description of Child Care Practices4.3.7 Description of Psycho-social situation of women4.3.8 Description of WASH environment4.3.9 Seasonality of risk factors4.3.10 Risk factor historical trends4.3.11 Positive Deviant Behaviours4.3.12 Risk Factor Rating Exercise4.4 Local causal model5. Ranking causal hypothesis896. Conclusions and Recommendations93Annex 1: Map of selected clusters for the NCA survey95Annex 2: List of participants to the initial technical workshop96Annex 3: Hypothesis (Reviewed and validated by the initial technical workshop)97Annex 4: NCA risk factor indicators figures100Annex 5: NCA risk factor indicators diagrams106Annex 6: List of participants to the final technical workshop111Annex 7: Criteria of NCA ranking exercise112Annex 8: Preliminary Ranking by the NCA Expert114Annex 9: Seasonal 7III

List of tablesTable 1 - Indicators to be measured and population targeted for each indicators19Table 2 - Calculation of household sample to be surveyed20Table 3 - Combinations number of clusters and survey duration21Table 4 - List of the selected villages for the Risk Factors Survey (RFS)22Table 5 - List of the selected villages for the qualitative survey23Table 6 - Summary of qualitative data collection26Table 7 - Classification of causal hypotheses28Table 8 – Causal Hypotheses rating and ranking30Table 9 – Hypothesized risk factors and pathway identified by the technical experts31Table 10 - Household Composition Indicators33Table 11 – Breastfeeding Indicators36Table 12 – Complementary Feeding Indicators37Table 13 – LBW Indicators39Table 14 – Education Indicators39Table 15 – Workload Indicators41Table 16 – Maternal wellbeing Indicators42Table 17 – Children psychosocial care Indicators43Table 18 – Reproduction health Indicators44Table 19 – Sanitation indicators46Table 20 – Water and health Indicators48Table 21 – Hygiene, sanitation and health indicators49Table 22 – Access to health services indicators51Table 23 – Agriculture production indicators53Table 24 – Diet diversity indicators57Table 25 – Access to food indicators59Table 26 – Women empowerment indicators62Table 27 – Community risk factor rating exercise86Table 28 – NCA expert rating and expert confidence note89Table 29 – Technical experts rating and discussion90IV

List of figuresFigure 1 – NCA team composition27Figure 2 – Distribution of the population34Figure 3 – Level of education40Figure 4 – Contraceptive methods45Figure 5 – F-Diagram, disease transmission routes45Figure 6 – Barriers to health center51Figure 7 – Culture repartition54Figure 8 – Food origin54Figure 9 – Food origin (ST)55Figure 10 – Ownership56Figure 11 – Non Tribal Ownership56Figure 12 – Tribal Ownership57Figure 13 – Khaknar block food diversity profile58Figure 14 – Khaknar block, ST food diversity profile58Figure 15 – Palasur, historical trends79Figure 16 – Shankarpura Khalan, historical trends80Figure 17 – Local causal model to undernutrition94V

Abbreviations and BCPDSRCRFSSAMSCSMARTSTSTDTHRUCIVHNDAction Contre La Faim / Action Against HungerAnteNatal CareAuxiliary Nurse MidwifeAcute Respiratory InfectionAccredited Social Health ActivistBellow Poverty LineCentre for Community Economics and Development Consultants SocietyCommunity Health and Nutrition WorkerConfidence IntervalCommunity Management of MalnutritionFood Consumption ScoreFocus Group DiscussionFair Price ShopFood Security and LivelihoodsGlobal Acute MalnutritionHousehold Dietary Diversity ScoreHouseholdIntegrated Child Development SchemeIndividual Dietary Diversity ScoreIntrauterine DeviceInfant and Young Child FeedingLow Birth WeightLitres per capita per dayLower Confidence IntervalMonths of Adequate Household Food ProvisioningModerate Acute MalnutritionMaternal Depression InventoryMidday MealMental Health and Care PracticesMahatma Gandhi National Rural Employment Guarantee ActMid Upper Arm CircumferenceNutrition Causal AnalysisNational Family Health SurveyNational Institute of NutritionNational Nutrition Monitoring BureauNational Programme of Nutritional Support to Primary EducationNutritional Rehabilitation CentreNational Rural Health MissionOther Backward CastesPublic Distribution SystemReplacement clusterRisk Factors SurveySevere Acute MalnutritionScheduled CastesStandardized Monitoring and Assessment of Relief and TransitionsScheduled TribesSexual Transmission DiseasesTake Home RationUpper Confidence IntervalVillage Health Nutrition Day1