The following report presents the results of a Nutrition Causal Analysis undertaken in Jhirniya Block, Khargone District, the State of Madhya Pradesh and which was conducted from November 10^th 2014 till November 28^th 2014. The survey followed the methodology developed by ACF and their scientific partners. The NCA was conducted with funds from ECHO as part of a programme implemented from May 2013 to December 2014 by local NGO Jan Sahas. The NCA was lead and managed by NCA Consultant Ellen Poolman with support from Jan Sahas Programme Coordinator Harshal Jariwala. Thanks to Rakesh Shrivastava, Project Coordinator, Welthungerhilfe for organizing this survey.

The study would not have been successful without the initial technical support from ACF staff Julien Chalimbaud (ACF Head of NCA Research Project), Tram Le Minh (ACF Head of Nutrition Department, India) and Blanche Mattern (ACF NCA Specialist). In addition, the support from all the field staff of Jan Sahas who played a role in the planning, logistics and actual field work could is crucial to crucial to acknowledge, with a special recognition of thanks to Krishna Sisodiya.

Also of significance to recognise are all who were willing to share their input during both the primarily workshop as well as the final workshop, which includes persons from Jan Sahas, WHH, ACF, CLTS, ICDS, Water Aid, and CECOEDECON.

Finally, and of paramount gratitude, is to all the participants who were involved during the field study, for their patience and their willingness to share their knowledge, thoughts and perspectives in order for this NCA to be conducted.

ACF definition of Nutrition Causal Analysis

This current NCA is based on the NCA methodology as developed by ACF. So as to introduce the reader to the framework of the ACF NCA, a quote of the ACF NCA methodology guidelines can be found below:

“A NCA is a structured, participatory, holistic study, based on the UNICEF framework of malnutrition causality, to build a case for nutrition causality in a local context.

Causality is defined as the concern with establishing a causal connection between variables, rather than mere relationships between them (Bryman, 2008: 691).

Quantitative analysis must rely on causal inference based on common sense or theoretical ideas, but here is always the risk that the inference is wrong (ibid, 156). Bradford Hill defined causal association based on: strength, consistency, specificity, biological gradient, plausibility, coherence and temporality (see Lucas & McMicheal, Bull WHO 83: 79205).

Qualitative analysis on the other hand can assist with causal analysis by enhancing contextual understanding and exploring connections, interactions, and causal relationships.

The NCA gathers both quantitative and qualitative data on a range of risk factors and pathways to under nutrition as well as the interactions between them. This mixed-methods approach amalgamates a range of evidence on the causes of malnutrition in a particular context for a) triangulation (to identify areas where the evidence from various sources is complementary, mutually reinforcing, and/or contradictory), and b) through a participatory process, for developing a shared understanding of likely causes in a specific context. With this approach, the methodology proposed is indeed a causal analysis, although it does not purport to statistically demonstrate causality.”

Current approach to the ACF NCA methodology

As can be read in the above-mentioned definition of the ACF NCA methodology, the NCA is developed in such a manner that there is both a quantitative as well as a qualitative component to the study design. The quantitative comprises two components: 1) a SMART survey and, 2) a risk factor survey. In addition, the qualitative component encompasses Key Informant Interviews, Focus Group Discussions (FGDs) and case study interviews.

As a SMART survey was previously conducted in September 2013 by an external consultant for Welthungerhilfe in the exact same area as the current NCA, it was decided that this current NCA would not need to conduct a SMART survey.

At the time of the previously mentioned conducted SMART survey, two risk factors were also assessed, being Infant and Young Child Feeding (IYCF) practices and Diet Diversity Scores (DDS). The information gathered regarding the prevalence of these two risk factors is not exhaustive for the current NCA however, due to significant time constraints faced by Welthungerhilfe it was decided that a risk factor survey would not be included in the current NCA. With this decision made, it was realised that this current NCA would have the limitation of missing data on the risk factor survey, and would therefore not be able to create an analyses based on both the prevalence of risk factors as well as on the perspective and understanding of community members regarding under nutrition and its hypothesised causes. Instead, this analysis will singularly describe the qualitative component of the NCA according to the ACF methodology.

Introduction

Welthungerhilfe (WHH) has been active in India for several years and works with the mandate to “help people help themselves”. In collaboration with local NGO partner Jan Sahas, WHH has been active in Madhya Pradesh since 2011. This collaboration resulted, amongst others, in the implementation of nutrition related programmes in two districts of Madhya Pradesh: Panna District and Khargone District. In order to facilitate and contextualize the implementation of future programmes designed to the specific environment of the area (Jhirniya Block, Khargone District) and to target interventions based on apparent causes of malnutrition, WHH along with their implementing partner decided to conduct a Nutrition Causal Analysis (NCA) which was funded by ECHO

1.1 Study area

Madhya Pradesh, translated as ‘Central State’, is the second largest state of India and has a population that grew from 60 million in 2001 to a population of about 72 million in 2011. Close to 11 million of this population is under the age of 6 years old[1], and the state has a prevalence of 21.1% Scheduled Tribe (ST) population, which is a higher prevalence than in India overall.[2]

Of the total population in Madhya Pradesh, 72% live in the villages of rural area. A percentage of 48.6 of the entire population of Madhya Pradesh live below the poverty line.[3] In addition, the State Hunger Index (WHH/IFPRI 2008) shows the hunger index for 17 of the Indian states and described Madhya Pradesh as being in an ‘extremely alarming situation’[4].

The present NCA is conducted in Jhirniya Block, Khargone District. Jhirniya Block was selected for this NCA as WHH and Jan Sahas are planning for future implementation programmes in this particular area. Jhirniya Block has a population of 151,498 of which 80% belong to a ST.¹

1.2 Context of the study

Data described are based on studies conducted on both national as well as state level. As Madhya Pradesh seems to be a very heterogenetic state, most of the literature review and data analysis conducted is based on District level (the District of Khargone) as well as on Block level (the Block of Jhirniya) where a SMART survey[5] was conducted in 2013 by an external consultant for WHH. In addition, interviews with Key Informants that have worked for more than several years in the field in one of the sectors described, have been used to complete the description of the context of the study.

1.2.1 Malnutrition

The previously mentioned State Hunger Index published by IFPRI (based on prevalence of child malnutrition, child mortality rate and the proportion of calorie deficiency) shows that there are major public health issues in the State of Madhya Pradesh, resulting in the State being in an ‘extremely alarming situation’. In addition, high malnutrition prevalence is an issue on both District level and Block level in Jhirniya Block. As a result of this, the government of Madhya Pradesh established Nutrition Rehabilitation Centres (NRC) in the State during the mid-2000s. As stated in the Operational Guidelines on Facility Based Management of Children with Several Acute Malnutrition, published by the Ministry of Health and Family Affair in 2011, the NRCs have the mandate to reduce child mortality, and with that do not influence the nutritional status of children within the communities.

The National Family Health Survey-3 (NFHS-3) conducted in 2005-2006 by the Ministry of Health and Family Health showed a prevalence of 50% stunted children in the State of Madhya Pradesh. A survey conducted by the National Institute of Nutrition (NIN) in 2011 on district level, showed a prevalence of 50.6% stunting (<-2 SD in height-for-age measurement) in children under the age of 5 year in Khargone district. A prevalence of 22% of the under-5 year olds was found to be severely stunted (<-3 SD) in this same survey. The same NIN study showed that the prevalence of stunting was higher (56.6%) among children belonging to Scheduled Tribe population and Scheduled Cast population compared to children belonging to the so-called other backward classes (OBC) population (43.5%) and other populations (29.5%). The SMART survey conducted for WHH in Jhirniya Block in 2013 showed a prevalence of 57.3% (52.3 – 62.1 95%CI) global chronic malnutrition (height-for-age <-2 SD) from which a prevalence of 25.7% (20.9 – 31.1 95% CI) was indicated as sever chronic malnourished (height-for-age <-3 SD) in children at the age of 6 to 59 months.

The NFHS-3 showed a prevalence of 35% children being wasted in the State of Madhya Pradesh, while the 2011 NIN survey conducted showed a prevalence of 31% wasting (<- 2 SD in weight-for-height measurement) in children under the age of 5 years in Khargone district and a prevalence of 8% of severely wasting (<- 3 SD) in the same study group. A SMART study conducted for WHH in September 2013, showed a prevalence of Global Acute Malnutrition (GAM) of 31.0% (26.8 – 35.5 95% CI) in children 6 to 59 months old in the Block of Jhirniya and a prevalence of Severe Acute Malnutrition (SAM) of 6.6% (4.6 – 9.5 95% CI) in the same age group.

[1] Madhya Pradesh Census 2011, 15^th National Census by the Census Organisation of India

[2] Analytical Report on Primary Census Abstract, 2011 – Chapter 6, Demography on Scheduled Tribes

[3] State Planning Commission, Madhya Pradesh, 2005

[4] International Food Policy Research Institute, Washington DC, USA, India State Hunger Index 2008

[5] SMART Nutrition and Mortality Survey, Madhya Pradesh, Khargone District - Jhirniya block, Welthungerhilfe and Jan Sahas, September 2013

1.2.2 Food Security and Livelihoods

The survey conducted in September 2013 for WHH, had a risk factor component for DDS at both household as well as target group (6 to 24 month aged children) level. The household DDS gives information on the economic access to food that a household experiences. The risk factor survey on DDS revealed that there is a discrepancy between DDS at household level and that of the level for children aged between 6 and 24 months, where in this last group 35.8% of the children had consumed from at least 4 different food groups in the 24 hours prior to the survey conducted compared to 96,0% on household level.

The survey also showed that the top three most consumed food groups in Jhirniya Block are cereal, miscall and oil. The least consumed three food groups showed to be egg, fish and meat. The DDS does not give information on quantity of consumed food groups. An example is that the survey showed that 54.5% of the population consumed milk products, but after observation and qualitative inquiry it was found that the amount consumed is only a very small quantity which is used in tea. During the survey, 60.4% of the population was said to had eaten vegetables in the 24 hours prior to the survey. After observation, it turned out that mainly cucumber was consumed.

Another study done by WHH in 2012 showed that 60% of the population in Jhirniya Block have an average intake throughout the year under the threshold of 2100kcal a day. In addition, 75% of the households don’t reach an intake of 2100kcal during the hunger season, which may last up to 6 months for the most poor in a community.

Most of the community members in Khargone district are depended on agricultural work. The prevalence of landless people in Jhirniya Block is almost 32% with another 33% of the population owning small pieces of land measuring between 0 and 2.5 acres of land.[1] However, a study done by WHH in 2012 showed a prevalence of 50% of the people in Jhirniya Block being landless. Not owning land seems to mainly affect the people with poorer wealth, which in turn influences the food sources as can be seen in figure 3 below.

[1] Baseline Assessment Study, Goat Rearing, Jhirniya Block, Khargine District, Madhya Pradesh, South Asia, Pro Poor Livestock Policy Programme, NDDB/FAO, January 2014

Depending on the size of the land people own and on the season, people will work on either their own fields and/or work as labourer for people who own bigger pieces of land. In addition, a livestock survey showed that households in Jhirniya Block own an average of 2 cattle per household.⁶ In India, access to land exemplifies the gender inequality. Rights are mediated by men and often results in lack of rights for women to own land and also the right to use land.[1]

Livelihoods are very dependent on water access, and NGO field workers find that small animal farmers do regularly face the challenge of water shortages. As a reply to this risk of water shortage, NGOs support farmers with the possibility to change their crops to a less water-needy crop. It addition, it is aimed for to construct more adequate irrigation systems as well as crop land close to water sources. Many crops in Madhya Pradesh are however cash crops; crops with a focus on only a couple of different produces which result in a large amount of crop fields that give harvest and which are not necessarily consumed by community members.

The Integrated Child Development Services (ICDS), which had its inception in 1975, is in place with the purpose to improve the health, nutrition and development of children in India. One of its mandates is to offer complementary foods to children under the age of 6 years old and to pregnant women and lactating women. In what are called anganwandi (“garden”) centres (AWC), children in the age group of 3 to 6 years are meant to be offered preschool hours during which they receive a meal through the ICDS programme which is often prepared by a Self-help Group (SHG). Children at the age of 6 months to 3 years and pregnant and lactating women are meant to receive on a weekly base a take-home ration as supplement to their ordinary diet.

In addition, the Public Distribution System (PDS) was established under the Ministry of Consumer Affairs, Food and Public Distribution and is a distribution of essential commodities for people living under the poverty line. People holding a BPL-card have the right to the ration distributed under the PDS scheme, which is made available once a month.

The Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGA) was created with the aim to ensure the right of work with equal opportunities for men and women, in order to ensure secure livelihoods in rural areas. This scheme was also initiated in Madhya Pradesh. A study done by IFPRI found that short-term participants of the scheme consumed more calories and more protein than non-participants. On long-term participants, it was found that participants used their wages to buy assets, which in turn would have the potential of a positive effect on food security.[2]

Khargone District, and Jhirniya Block, are well known for their high levels of migration. Depending on the season, whole families or just the men from a family might decide to leave the household in order to find work elsewhere.

1.2.3 WASH

The survey conducted in 2011 by NIN showed that as sources of water, 63.8% of the people used a pipe well, 29.5% of the people had a tap and 6.7% of the population had an open well. It is normally the women in a community that have the responsibility of collecting water for the family members as well as for cattle. Water is mainly collected from water pumps in the village, but due to the geographical spread of communities within Madhya Pradesh, it might occur that women spent approximately 3 to 4 hours per day involved in collecting water. In the situation of a drought, it is not uncommon that women spend a much higher amount of time in the activity of collecting water which they have to walk a longer distance to collect. Surveys conducted by organisations that implemented WASH activities have regularly found that the water collected meant for drinking water as well as water for the use of livelihoods, is consistently contaminated with faecal matter.

[1] Standing her Ground, Rights of Women to Land, Livelihood and Natural Resources, Welthungerhilfe South East Asia, 2012

[2] Yifei Liu and Maria MacNeil; Shared during the POSPHAN/IFPRI conference, New Delhi, October 29 and 30, 2014

According to the NIN survey, latrines were present and being used by 11.8% of the study population. Even though latrines are being built, many people tend not to use a latrine. Field workers have mentioned that the reasons for not using latrines are due to the lack of awareness around hygiene regarding the use of latrines (and with that the lack of hygiene by open defecation), as well as the lack of willingness to keep the latrines clean, as water would have to come from a source further from the latrine.

The NIN survey also showed that hand washing with soap before feeding a child happens in 23.6% of the cases and in 76.4% of the cases there was no activity of hand washing with soap before feeding the child. In addition, 13.5% of the cases found that the child’s hands were not washed at all, 60.3% found that even though the child’s hands were being washed, they were washed without soap and only 8.3% recorded the child’s hand were washed with soap prior to the child taking food. According to the answers taken during this survey, 65.9% of the caretakers would wash their own and their child’s hands with soap after defecation and the other 34.1% did not. Information from field-workers in the State of Madhya Pradesh reveal that that even though people have soap it is not being used and instead, the field workers report that they commonly observe people hand washing after defecation with either soil or ashes.

1.2.4 Child Care Practices

Infant and Young Child Feeding practices (IYCF) are considered part of child care practices and are adequate when breastfeeding is initiated within one hour after birth and followed by exclusive breastfeeding for the first 6 months of life. In addition, from the age of 6 months complementary feeding should be offered in an adequate, safe and age appropriate manner in an appropriate quality and quantity, while breastfeeding is continued till a minimum age of two years old.

The NIN survey done on Khargone District level showed that 30.8% of the children received breast-feeding within 1 hour after birth and 83.5% received colostrum. Solely breastfed children in the age range of 0 to 5 months counted for 30.5% whereas 1.4% of the children at the age of 6 to 11 months were solely breastfed.

The afore-mentioned SMART survey conducted by WHH also conducted a survey on IYCF practices. This survey showed that 27.4% of the children in the age group of 0 to 23 months were early breastfed (within the first hour after birth). In addition, 37.9% of the mothers reported that their child received colostrum. Nevertheless, it was found that 47.2% of the children surveyed received another liquid than breast milk within the first three days after birth. In addition, it was found that 5.6% of the children were exclusively breastfed up to the age of 6 months. This would lead towards the observation that complementary feeding is often introduced too early, being before the child has reached the age of 6 months. A total of 56.3% of the children received breast milk till the age of two years. Reasons for mothers to stop breastfeeding their child were because of new pregnancy (21.2%) or because the child would be considered too old to receive breast milk (15.8%). When breastfeeding is ceased, this would happen abruptly in 28.6% of the children.

1.2.5 Child Health

One or more of morbidities such as fever, acute respiratory infection (ARI) and diarrhoea were recorded to have occurred in 16.9% during the preceding fortnight of the NIN survey conducted. To seek treatment for their sick children, around 12% of the mothers went to governmental health post where about 88% reported to have sought treatment from a private practitioner. In addition, a survey conducted by UNICEF in 2009[1] showed that in rural areas of Madhya Pradesh in 29.4% of the ARI cases treatment was not sought in addition to 36.7% of acute diarrhoea cases for which no treatment was sought.

The NIN study revealed that 96.0% of the children till the age of two received full immunization (including BCG, DPT, polio and measles vaccine) where 1.3% did not receive any immunization at all. The UNICEF data however, showed a coverage of full vaccination among children 12 to 23 months of just over 40%, with approximately 6% of the children in that age group not having received any vaccination.

In addition, the NIN study done showed that 79.0% of the children in the age group of 9 to 59 months received at least one dose of vitamin A supplementation in the year of the survey where the UNICEF survey showed a coverage of 44.7% of one dose of vitamin A supplementation during the 6 months prior to the survey.

The SMART survey conducted in Jhirniya Block assessed a retrospective mortality rate, assessed over an 87-day recall period. This showed a crude mortality rate of 0.35/10.000/day and an under-5 mortality rate of 1.06/10.000/day. Both these rates are above the alert cut-off.

1.2.6 Status of Women

As stated by USAID[2]: “In families in which women play an important role in decision making, the proportion of family resources devoted to children is greater than in families in which women play a less decisive role (Thomas, 1990; Duraisamy and Malathy, 1991; Bruce, Lloyd, and Leonard, 1995; Blumberg, 1991). This notion of ‘maternal altruism’ assumes that power in the hands of women will lead to better child outcomes (Mason, 1986).”

In the Jhirniya Block, there is the tradition that women have to cover their head and face when speaking to an elder family member or her husband among other practices, as a way to show respect. In addition according to tradition, the mother of a child has no decision-making power within a family with decisions being made by either the mother-in-law or older men. The mother’s workload is high as it is her responsibility to look after the household and family members on top of working in agricultural activities.

Boys and girls have equal rights to education. However the NIN survey showed a prevalence of 38.0% of the mothers being defined as literate. In comparison, 56.0% of the fathers were defined as literate.

As mentioned previously, in India access to land emphasises on the gender inequality. Rights are mediated by men and often results in no right for women to own land, but perhaps the right to use land.[3]

Regarding wellbeing during pregnancy, the NIN survey conducted in 2011 showed from records assessed, that of the mothers having children under the age of 6 months 76% went for antenatal care (ANC) during their last pregnancy as opposed to92.3% according to the UNICEF survey conducted in 2009. A total of 64.5% were registered for ANC before 16 weeks of gestation. In addition, IFA tablets were received by 75% of the women. About 29% of these women received 90 tablets or more from whom 24% consumed 90 tablets or more. The UNICEF survey found 14.3% of the women consuming 100 tablets or more during their pregnancy and 39% consuming between 31 and 99 tablets during pregnancy. According to the findings of the UNICEF survey, 77.4% of the women that live in rural areas had an institutional delivery. In addition, from all deliveries (both institutional as well as home delivery), 79.5% of the deliveries was attended by a skilled birth attendant. To promote institutional deliveries, a governmental scheme supports every institutional delivery by giving the mother 1400 rupees. Furthermore, according to the NIN survey conducted in 2011 there was a prevalence of 22.3% low birth weight in Khargone District.

[1] 2009 Coverage Evaluation Survey (CES 2009), Madhya Pradesh Fact Sheet, UNICEF

[2] A Focus on Gender, Collected Paper on Gender Using DHS Data, ORC Macro, August 2005, USA

[3] Standing her Ground, Rights of Women to Land, Livelihood and Natural Resources, Welthungerhilfe South East Asia, 2012

2. NCA objectives

2.1 Main study objectives

The main objective that led to the implementation of this current NCA, was to identify the main causes to under nutrition apparent in Jhirniya Block, Khargone District, affecting the target group of children under the age of 5 years.

2.2 Specific study objectives

The specific study objectives were set as follows:

1) To identify the main causes of wasting and stunting in order to inform the technical strategy and programmes for the prevention of the same at local level, by way of:

¥ Determination which possible risk factors and pathways to under nutrition are most likely most influential to the high prevalence of under nutrition in Jhirniya Block;

¥ Understanding the local perception of under nutrition and its causes

¥ Understanding the local seasonal pathways to wasting and stunting;

2) To support technical advocacy on causes of wasting and stunting so as to plan technical strategy based on modifiable risk factors.

3. NCA Methodology

3.1 Overview of the NCA approach

The NCA as developed by ACF, is a structured, participatory, holistic, multi-sectorial study, based on the UNICEF causal framework, to build a case for nutrition causality in a local context. The following is a description of how this is set up:

Structured: the steps of the methodology are precisely defined and have all been tested in the field.

Participatory: a study with the opportunity for national technical experts as well as caregivers from the community to express their opinion on the causes of under nutrition and to discuss, review and validate the conclusions of the study.

Holistic: under nutrition is studied globally to avoid a sectorial approach and to highlight the inter-relations between risk factors.

Multi-sectorial: a NCA investigates and presents a multi-sectorial overview of the contributing factors that affect the nutritional status within a particular community.

Specific to the local context: The NCA goes beyond generic interventions by identifying context specific causes for under nutrition.

3.2 Study design

The NCA methodology involves four steps which were followed during the current NCA:

1) Preparatory phase: to insure timely recruitment, clear objectives and appropriate methodology

2) Phase of generating causal hypothesis: based on literature review, secondary data review and stakeholder interviews, an overall understanding was developed on the context of malnutrition in Madhya Pradesh and specifically Jhirniya Block from which 15 hypothesised causal risk factors of under nutrition were generated. This list of hypothesised risk factors were presented during a Technical Expert workshop held in Dewas on November 4^th, 2014, in order to discuss and validate the finalised list of hypothesised risk factors to under nutrition in Jhirniya Block.

3) Data collection phase: qualitative data was collected from November 10^th till November 28^th, 2014 in Jhirniya Block. Data collected focussed on the community’s perspectives on under nutrition, the key risk factors apparent in this particular context and the community’s current practices and constraints.

4) Identification of most important risk factors and its current influence on under nutrition: with the data collected, an analysis was conducted resulting in the ranking of the initially hypothesised risk factors and their influence on under nutrition in Jhirniya Block. The results were presented on December 9^th in Dewas during the Final workshop. Here, technical experts and the NCA Analyst debated arrive at a consensus on the most important risk factors for under nutrition in Jhirniya Block and the recommended list of priorities which require action upon.

An additional end presentation was organised in New Delhi on December 15^th. Stakeholders from several INGO’s attended this presentation, during which the participants were invited to give their feedback which were used for the final write-up as depicted within this current document.

3.3 Sample

According to the ACF Methodology on which this study was based, a sample of 4 villages was needed to conduct the qualitative survey in. From the official list of villages in Jhirniya Block as used during the WHH/Jan Sahas SMART survey conducted in September 2013, a random sample of 4 villages was selected using Excel software. The villages selected can be found in table1 below.

Name village	Number of population	Qualitative survey number
Borkheda	290	Village 1
Karaniya	1174	Village 2
Bhavsingh Pura	2422	Village 3
Pakhalya	1642	Village 4

Though Jan Sahas is active in implementation of programme within Jhirniya Block, none of the villages selected were covered by current Jan Sahas implementation programmes.

3.4 Data collection methods

For this particular study as previously mentioned, only the qualitative component of the NCA ACF Methodology was implemented. The aim of the qualitative component is to create a better understanding of the local community’s perception and understanding of the concept of under nutrition, its causes and whether or not this is an issue within the local community. The information from this study is complementary to the data gathered during the implementation of the SMART survey done in September 2013 in the same area. In four villages FGDs as well as in-depth interviews were conducted over a period of 20 days.

3.4.1 Research instruments and methods

The following objectives were the basis on which guides were developed to be used during the FGDs and in-depth interviews:

1) To develop an understanding regarding the local definition and understanding of under nutrition

2) To develop an understanding regarding the local food security, health, and care practices in the community

3) To comprehend the communities perception on the causes of under nutrition and their understanding of the consequences of poor food security, health, and care practices in regards to under nutrition

4) To understand the practices pre- and postnatal of caregivers of positive deviant children

5) To identify seasonal trends in risk factors to under nutrition

6) To develop insight in how the community perceive the influence of each risk factor regarding the prevalence of under nutrition.

With this, 8 themes were created on which the FGDs focussed per session. The themes were divided as shown in table 2.

FGD# and relating theme
FGD 1: Basic under nutrition	FGD 5: (Child) Care practices
FGD 2: Food security and livelihoods	FGD 6: Maternal health
FGD 3: Water, hygiene and sanitation	FGD 7: Seasonal trends
FGD 4: Health	FGD 8: Rating of risk factors according to local influence

The guides were created to have a consistency in questions asked and topics covered. In addition, the FGDs as also the in-depth interviews were conducted as semi-structured in order allow the facilitator to create the possibility to gain more information in detail and/or to have the freedom to include new ideas coming up during the activity.

3.4.2 Data collection

Qualitative data collection took place in four villages in Jhirniya Block from November 10^th till November 28^th, 2014. For every village a timespan was available of 6 days, with a flexibility of 7 days in total. During the days in the villages, in-depth interviews were conducted with key stakeholders including community leaders, teachers, Anganwadi workers, ASHA workers[1], Auxiliary Midwife Nurses (ANM), doctors, traditional healers and an Anganwadi supervisor as well as with caretakers of positive deviant children, severely acute malnourished (SAM) and moderate acute malnourished (MAM) identified children. In addition, the FGDs took place with mothers, grandmothers, fathers and grandfathers of children under the age of five as also with pregnant women. Per village, it was determined to what tribe or caste the majority of the community belonged to, and whether it was needed to conduct FGDs in separate groups for community members from different ethnical groups, or whether these could be mixed in one group. In practise, it was seen that villages were often divided into a main village and one or more hamlets. Often, this was marked by the majority of tribe or caste represented in such a community. In order to react to the heterogenetic situation between tribes and caste, and often therefore between main village and hamlet. At many occasions, separate FGDs were conducted resulting in FGDs in the main village as well as separate in the hamlets.

A sixth day was available for every village in order for the NCA team to return to the village to present the primary results of the analyses and to validate the conclusion regarding the most influential causes of under nutrition for that specific village. Unfortunately, due to the peak in harvest season, there was a low-to-no response to the inquiry of this activity, which made that after a completed group of FGDs participants were presented the initial conclusion drawn from the information of that particular group after which they were invited to share their feedback and comments.

In total, 104 FGDs and 24 key interviews were held over the four villages of this study. It was aimed for to see the female groups over 3 consecutive days during which 2 or 3 of the FGDs would be held. However, during the activities in the first village, it was found that often participants would not return on the second and/or third day, leaving the FGD with only a handful of participants. With this experience, it was decided at the beginning of activities in a village, that the participants would be asked if they preferred to stay for a longer period of time per FGD or whether they preferred to be attending FGDs over 2 or 3 consecutive days, but over a short period of time for each FGD. This approach was first done in the hamlet of village one, which showed to be effective and was therefore implemented in the remaining three villages as well.

3.4.3 Stakeholder consultations

It is a key aspect for the ACF NCA methodology to have the involvement of stakeholders during the process of the implementation of the NCA. WHH and Jan Sahas stakeholders were represented by several local as well as international NGO’s and government representatives. Therefore, before the start of the NCA, stakeholders were interviewed in order enable them to be involved by sharing their experiences and providing their input. Then, an initial workshop was conducted as well as a final workshop during which stakeholders were invited to again share their experiences and opinions regarding the matter of under nutrition in Jhirniya Block and in general, Madhya Pradesh.

3.5 NCA team composition

The data collection during this survey was led by the NCA consultant with the assistance of one female translator and facilitator (mastering the local language), two male translators and note takers, and two field staff per village acting in the capacity of community mobilizers. All, but the NCA consultant were Jan Sahas staff).

3.6 Data management and Analysis

3.6.1 Qualitative data management and analysis

During each FGD two people were in charge of note taking. After each FGD, the note takers, facilitator and NCA consultant would sit together to ensure that the notes were correct according to the facilitator and the note takers. If any doubt was of existence, the audio recordings would be listened to in order to ensure the quality of the data. At the end of each day, the NCA consultant would reread all the notes of that day to ensure clarity and completeness of the notes to reduce the possibility of ambiguity or missing data . Data was coded according to core themes after completion of a village, using Excel software.

3.6.2 Ranking causal hypotheses

Based on the secondary data and literature review, the association found in literature between risk factors and malnutrition, as well as the input of technical experts and the data gathering during the survey, the NCA Analyst made a ranking of all risk factors according to the NCA ACF methodology. This resulted in a ranking based on the importance as factor (as a pathway) to malnutrition. The ranking distinguished between ‘minor’, ‘important’, and ‘major’.

3.6.3 Final stakeholder workshop

A final workshop was conducted in Dewas on December 9^th in order to present the findings of the field study as well as to finalise the proposed ranking of risk factors. In addition, a presentation was organised in Delhi on December 15^th during which stakeholders were presented with the NCA conducted.

3.7 Research ethics

The NCA study was a component of a bigger project conducted by WHH with the implementing partner Jan Sahas. With the approval of this bigger project, approval was also received to conduct this particular NCA.

During the Key Informant Interviews, FGDs and case studies, participants were explained what the study was aimed for, what information from participants would be used for and that the information shared would be kept anonymous. All participants gave their verbal consent.

3.8 Limitations

The results of the current NCA can only be perceived as valid for the population living in the villages in Jhirniya Block, Khargone District, Madhya Pradesh. The results cannot be taken beyond this geographical area.

Though the term causal analysis may be perceived as showing causality, this current NCA does not make the attempt to show an epidemiological causality to malnutrition. Hypothesised risk factors are ranked with confidence notes by the technical experts, and therefore can only perceived as high or low. In addition, due to the lack of a risk factor survey, the current findings are singularly based on the Jhirniya Block previously conducted SMART survey and the qualitative data gathered during the current study. Therefore, findings cannot be linked to actual prevalence of risk factors in the study area.

Due to the lack of professional translators with mastery of the English language as well as Hindi and the local language, information might have been lost during the several translation processes.

Furthermore, due to the timing of the current NCA, which was conducted at the time of a peak of harvest as well as at the beginning of a migration period, it was shown at times to be challenging to have a significant amount of participants during the FGDs as well as the availability of mothers of both positive deviant as well as identified malnourished children. Therefore, one cannot state with certainty anything regarding selection bias.

[1] An “ASHA worker” is a trained Accredited Social Health Activist and plays a role between the community and the public health system. ASHA’s fall under the National Rural Health Mission, set up under the Ministry of Health and Family Welfare. There is supposed to be one ASHA per village, preferably a female worker, who works on the basis of remuneration.

4. NCA findings

4.1 Preliminary technical expert workshop

On November 4^th, 2014, a preliminary technical workshop took place in Dewas, Madhya Pradesh with the aim to come to consensus on hypothesised risk factors and their pathways to under nutrition present in Jhirniya Block. This workshop was attended by experts from several different sectors and with a variety of experience in both the field, management as well as programme planning (Appendix I). Based on literature review, secondary data analysis as well as key informant interviews, the NCA Analyst generated a list of 15 hypothesised risk factors and their pathways to under nutrition in the specific context of Jhirniya Block. During the workshop, participants were asked to brainstorm about 1) the vulnerable groups of under nutrition, and 2) hypothesised risk factors and their pathways to under nutrition. After the brainstorm session which was performed in small working groups, the hypothesised risk factors and pathways generated by the NCA Analyst prior to the workshop were presented during which the participants had a chance to modify, add or take out aspects till consensus was reached on each individual hypothesis. At the conclusion of the session, the participants individually rated the list of hypothesised risk factors by assigning each hypothesis a number from 1 (not influential to the prevalence of under nutrition in this particular area) to 5 (very influential to the prevalence of under nutrition in this particular area).

4.1.1 Initial hypotheses

The compiled hypotheses as generated prior to the technical workshop can be found in table 3 below.

Hypothesis 1: Inappropriate breastfeeding practices

Hypothesis 2: Inadequate complementary feeding practises (IYCF)

Hypothesis 3: Poor access to food

Hypothesis 4: Poor diet diversity

Hypothesis 5: Inadequate access to safe water

Hypothesis 6: Lack of hygiene

Hypothesis 7: Poor sanitation

Hypothesis 8: Poor health seeking behaviour

Hypothesis 9: Low birth weight

Hypothesis 10: Maternal well being

Hypothesis 11: Poor psychosocial care for children

Hypothesis 12: Caregivers workload

Hypothesis 13: Poor reproductive health

Hypothesis 14: Women empowerment

Hypothesis 15: Poor micronutrient supplementation

Table 3 Hypotheses of risk factors generated prior to technical workshop

4.1.2 Identification nutrition vulnerable groups by technical experts

During the workshop, the participants identified the following vulnerable groups:

¥ All children under 5 years of age, with emphasis on children under 2 years of age

¥ Migrant families, especially their children

¥ Particular tribes

¥ Families that do not own land

¥ Children from malnourished mothers

¥ Specific gender groups, depending per tribe or caste

Based on this information, as well as the feasibility within this current NCA, it was decided to focus the current NCA on:

¥ All children under 5 years of age, with emphasis on children under 2 years of age

¥ Migrant families, especially their children

¥ Particular tribes

In addition, with the aim of assessing the vulnerability of people from a specific gender as well as landless people, the qualitative survey was designed.

4.1.3 Identification causal hypotheses by technical experts

During the workshop, the participants had 90minutes to brainstorm and generate hypotheses on risk factors and their pathways on the causes of under nutrition in Jhirniya Block. The working groups had some lively discussion and came up with several risk factors and pathways, but were challenged in categorising these in risk factor or pathway and in addition how to link these two. The risk factors that were brought up were mainly breastfeeding and complementary feeding practices, practices regarding water, hygiene and sanitation and vaccine usage.

4.1.4 Reviewed and validated hypotheses

With the information gathered from the brainstorm conducted by the working groups on causal hypotheses, the hypotheses generated prior to the technical workshop were presented and feedback provided from the experts. With prompting of the participants in thinking about certain themes, they came up with significant input for the hypothesised risk factors and pathways. Changes made to the initial generated hypothesised risk factors and pathways are shown in table 4:

	Number hypothesis
Validated	1, 5, 6
Reviewed	2, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15
Added	16

The hypothesised risk factors with the pathways identified and with consensus received, can be found in appendix II.

4.1.5 Rating of hypothesis

After consensus was reached on the hypothesised risk factors and pathways, the participants were asked to individually rate the risk factors on their influential level on under nutrition. Table 5 below shows how these risk factors were rated. As can be observed, the range between the several ratings is not vastly different, leading one to wonder how effective the participant’s rating exercise actually was conducted.

Hypothesised risk factor with consensus	Average rate
Hypothesis 6: Lack of hygiene	4.4
Hypothesis 7: Poor sanitation	4.3
Hypothesis 16: Poor usage of vaccine	4.1
Hypothesis 1: Inappropriate breastfeeding practices	4.1
Hypothesis 8: Poor health seeking behaviour	3.9
Hypothesis 2: Inadequate complementary feeding practises (IYCF)	3.9
Hypothesis 15: Poor supplementation to prevent micronutrient deficiencies	3.9
Hypothesis 9: Low birth weight	3.8
Hypothesis 5: Inadequate access to safe water	3.8
Hypothesis 4: Poor diet diversity	3.8
Hypothesis 13: Poor reproductive health	3.8
Hypothesis 12: Caregivers workload	3.8
Hypothesis 11: Poor psychosocial care for children	3.8
Hypothesis 10: Maternal well being	3.8
Hypothesis 3: Poor access to food	3.6
Hypothesis 14: Lack of women empowerment	3.5

Table 5 Risk factors according to rating

4.2 NCA qualitative survey results

The qualitative survey was conducted with the aim to achieve the objectives as described in section 3.4.1. In order to achieve these, a total of 24 key informant interviews were conducted in the previously mentioned 4 villages in Jhirniya Block, as well as 90 FGDs with female participants and 14 with male participants. In addition, 10 case studies were conducted with mothers of positive deviant children as well as mothers with children identified as moderate or severely malnourished children.

4.2.1 Characteristics of participants

FGDs were conducted for different type of participants. Male and female participants were all included for this study as it was learned that in this particular area both parents as well as grandparents play a significant role in not only the upbringing of the under 5 year olds, but the entire household management. Due to local living arrangements male participants were taken separate for participation of the FGDs, in addition to having separate FGDs for mothers and grandmothers. In none of the communities was there an objection to this particular approach.

Furthermore, when it was observed that people from different tribes or castes were geographically living separate from each other (meaning, living in the main village versus one or more hamlets), there were separate FGDs organised for the different communities.

The majority of the population of the four villages was ST population, representing the Barela and Bheel tribes. FGDs also consisted of people from the OBC caste, with only few from SC and general caste.

Even though the majority of the participants were not completely sure about their age, all participants were able to provide an estimated age. The female participants were in an age range of 18 to 80 years with grandmothers having an estimated average age of 54 years and for the mothers, an average age of 25 years. The male participants were consisted of both fathers and grandfathers and had an estimated average age of 39 years old. Households were organised as joined families living together with an average of 7 people living in one household. The average number of children under 5 in households of the participants were between 1 and 2 children.

The majority of the participants described themselves as labour workers, where within the male participants there seemed to be a higher occurrence of farmers working on their own land. The majority of the grandparents reported still to be working on the land. The majority of the participants reported to migrate once or several times per year reporting different locations and durations of migration. Mainly, participants of the lower caste and tribe population reported to be migrating.

Education performances differ between no education illiteracy and 12^th grade. Of the female participants, 12.4% mentioned to have had formal education with an average achievement of 7^th grade. For the male participants there was assessed to be a same average grade, however with a prevalence of 57.4% participants who had had education.

4.2.2 Key stakeholders and community consultation

Every village was planned to be visited for a maximum of 6 consecutive days (or less if saturation of data was reached prior to 6 days). In every village, the initial activities conducted were key informant interviews. Interviews were held with Sir Panch (main village leader) and/or his secretary, the Patel (“troubelshooter”), Anganwadi worker, ASHA worker, ANM, teachers and, if available, a local healer. In addition, in one village the team had the chance to have a short interview with an Anganwadi supervisor.

Sir Panch and his secretary

Village chief’s and their secretaries mentioned their attendance in the village as their main responsibility and mentioned that they also should make sure that that children get their ration from the AWC and some take the responsibility upon themselves to make sure that the ambulance is called when a women is in labour. In addition, education is often mentioned as important. One of the village chiefs secretaries makes it a duty to counsel parents in sending their children to school.

Most village chiefs and secretaries have their observations of malnutrition, being a child that looks thin, with emphasis on thin legs and hands and limited weight. But, all of them mentioned that in their particular village there are hardly any children malnourished.

As causes of malnutrition are mentioned food and the lack of food, poverty, lack of breastfeeding, poor mother’s health (both during pregnancy as well as during the breastfeeding period) and ‘cleanliness’. One of the village secretaries mentioned that he tries to motivate community members with malnourished children to go to the NRC for admission. His experience though is that people don’t go and that the one’s that do go have complains about the type of food received as well as the time the food is served to both mother as well as child.

One of the secretaries mentioned that the dirty environment, caused by open defecation, causes illness in the community which in turn influences malnutrition. According to him there are some latrines built by people using a government scheme, but he mentioned that “60% only are actually using these”.

What needs to change according to them is the service of the AWC with a better cooperation between the different levels of leadership, the weighing moments as well as giving out food packages to children and pregnant women should be better monitored.

Patel

The Patel of a village is also known as “troubleshooter”, he is the one to make sure conflicts are resolved in the village. In previous times he was also the one responsible for collecting taxes from the community members. In most villages the Patel was interviewed as a way to have influence people involved in the survey, in order to ensure the communities commitment to the study. Most of the Patel’s would not speak about health and malnutrition from the perspective of their responsibilities, but if they would speak about this it would be from their own family experiences. Two of the three Patel’s interviewed mentioned not to know anything about malnutrition not practices needed to keep a child healthy. One Patel mentioned that he will make sure that children stop eating soil, has he says to know that this causes malnutrition.

Anganwadi workers

All Anganwadi workers have been working as such for over 12 years. Differences that they mentioned to have noticed between 10 years ago and now is that pregnant women and mothers are now more aware of vaccinations and are more willing to make us of this service as well as the use of birth spacing methods, and then in particular a tubal ligation.

A malnourished child is by them recognised as a child that is weak, has a low weight, is irritated, has a wrinkled skin, has thin arms and legs, deeper laying eyes, lack of hair on its head, with nails and ‘a lack of blood’. One Anganwadi workers mentioned to recognise malnutrition by conjunctivitis.

As causes of malnutrition, they mentioned the workload of the mothers and the consequence this has, being that either children are left alone home with no caretaker or left home with a caretaker who is too young to take upon that responsibility. In addition, the lack of caretaking of children by parents is mentioned as cause, a late health seeking behaviour, improper feeding practices by pregnant women, including the lack of iron tablet consumption, hygiene, food availability, inappropriate breastfeeding practices and the feeding practice of jaggery water to young children.

Regarding the NRC it is mentioned that it is their responsibility to refer mothers to the NRC, but that families are not willing for a mother to stay with the child for 14 days.

They say it is their responsibility to weigh the children once a month and to take the MUAC measurement. In addition, it is mentioned that is the helpers duty to mobilise the children during the days of weighing as well as the days that vaccination takes place. One Anganwadi workers also commented that it is her responsibility to counsel mothers one how to ensure that children are fed well with ‘fruits and other good foods’ and this same Anganwadi workers advices mothers on getting a tubal ligation done.

In two of the four centres the Anganwadi workers says to have the ‘kindergarten’ open 6 days a week from 9am to 2pm during which the children can play but also learn things like for example songs and the alphabet. In addition, every day a meal is supplied to the children at the AWC, supplied by the self-help group (SHG) active in the village. One Anganwadi worker doesn’t have a centre at the moment and fulfil her duties in front of a community member’s house. Some of the Anganwadi workers mentioned that they observe that families share and consume the package which is meant to be eaten by children under the age of 3 years.

One Anganwadi worker mentioned that in her village there are children identified as moderate and severely malnourished, but according to her malnutrition is not a problem: “I always have enough packages and I will go for a house visit if the mother doesn’t come. There is a SHG active for meals for the school as well as the AWC”.

ASHA

Only two ASHA workers were found to be available for an interview. One of them explained that she choose to put herself up for selection as she has the aim to support the community to reduce malnutrition and to raise awareness among community members.

As their responsibilities they mentioned to ensure that children and pregnant mothers receive their vaccinations, to counsel on eating habits concerning nutritious foods for pregnant women, lactating women and children, and to send children to the AWC. In addition, they advise pregnant women to go to hospital for delivery, however the challenge of mothers perceiving that as a waste of time is often faced.

A malnourished child is described as a weak, thin, mostly ill child, a child with less weight, and a child that does not eat well. Also mentioned are swelling in arms, legs and face, a large stomach all in combination with a child that feel annoyed and has a poor appetite. When height and weight don’t increase for a child, ASHA workers say to refer them to the NRC.

Factors that are mentioned causing malnutrition are poor economic stability of the household, parents that don’t take care of a child, no vaccine usages and when a child is left at home when the parents are in the field. They explain that if the economic status would be better, instead of working in the field the family would have time to take care of the child and take vaccines in time. In addition, the mother’s health is referred to as being a cause for malnutrition in children. However, one of the ASHA workers states: “But malnutrition is not a problem because it can be treated”.

ANM

Two ANMs were spoken to of whom one finished 12^th grade and the other has a master’s degree in Sociology. As responsibilities they mentioned to counsel the community members, inform them about feeding practices, colostrum feeding, that a child should be breastfed 6 to 8 times per day and the start of complementary feeding at an age of 6 months, starting with broth of lentils, rice and porridge. Mothers are advised to spend a lot of time with their children. In addition, they ensure that pregnant women receive IFA tablets. In addition, they mentioned to supply children aged 9 to 59 months with vitamin A twice a year, together with mabendazole. ORS is only given to those mothers who request this as their child has diarrhoea.

A malnourished child is recognised by measuring the child’s weight, by observing a thin, tired child that doesn’t play and has a wrinkled skin. In addition, it is mentioned that if the eyes are not red, the blood is dried up.

Causes mentioned for malnutrition are a low economic status and poverty, lack of education, parents not spending time with the children and the fact that some children are factual malnourished from birth on.

One of the ANMs emphasises on the need of birth spacing and the fact that she counsels community members on the use of such as she believe that “birth spacing means that the mother is not at high risk, she can give proper care for her children and she will not have a malnourished child.”

Teachers

The influence teachers say to have on a child’s health and the prevention of malnutrition are mainly to keep the child clean, have them bath before school as well as coming to school with combed hair and cut nails and in addition have them wash their hands with soap before they have a meal at school and after defecation.

A malnourished child according to the teachers seems weak, has a low weight, weak eye sight and poor appetite. The two teachers of one particular school mentioned to recognise malnutrition from both physical weakness as well as a child that is in active and tends to forget things.

The teachers mentioned poverty, social condition, lack of resources overall in the country, migration and mainly lack of education as causes for malnutrition, as well as the parent’s workload and insufficient and singly typed food available. Also mentioned is that children born from a mothers with a low weight and/or short length are prone to be malnourished.

Traditional healer

There were found two traditional healers available for an interview, of which one of them stated “I don’t know anything about malnutrition, I don’t know what it is and I don’t know how to treat it”. A traditional healer in a different village mentioned that malnutrition is a weakness that comes along with a high pulse rate, diarrhoea, smelly stool and a loose skin. When he is shown a picture with two children of which one stunted and one appropriate height for age, he mentioned not to know that that is and to see it very often. He wonders if it has anything to do with lack of mother’s milk and food.

Causes of malnutrition mentioned are a lack of nutritious foods, lack of mother milk and lack of birth spacing. Nutritious foods are mother’s milk and green vegetables. Lack of birth spacing causes malnutrition as it influences the quantity of mother’s milk negatively. Methods of birth spacing he is aware of are oral contraceptive pills and condoms. He see it as his responsibility to advice couples on the use of birth spacing, and leaves it up to them to request it from medics.

SHG

In three out of the four villages it was mentioned that there is an (active) SHG. In two of these villages women cooking for the SHG were interviewed. In both villages the current SHG was established more than 6 months ago, where the previous SHG was replaced. In both cases the SHG is managed by someone from OBC. One woman interviewed earns 500rupees per month. In her previous job as cloth maker, she earned around 350rupees per day, but she gave this up in order to be able to spend more time with her new born. The woman in the other village earns 1000rupees per month. Even though she gets her payment often only after two or three months, and even though her mother doesn’t like her doing this job as she would earn more with daily labour work, she chooses to keep up this job in order to be there for her two children and to sustain her governmental job.

Doctor

One homeopathic doctor was found in one of the village that was available for an interview. He is the doctor in one of the hamlet to whom most community members would refer to from both the hamlet as well as the main village, if treatment is required. He mentioned to always refer a malnourished child to hospital, rather than giving it treatment himself. In some occasions he would prescribe the child calcium or iron. He would recognise a malnourished child by the looks of the child, as it will look weak, an enlarged stomach, a dry skin and it would not be able to walk at an age of 1.5 years old. He was not able to mention any different types of malnutrition. As causes, he said to know that malnutrition is caused by eating habits of the child as well as of pregnant women.

Anganwadi supervisor

By coincidence, one Anganwadi supervisor came on her round while the team was present in one of the village. She shared that she had been an Anganwadi supervisor for the last 7 years, after she graduated from her master’s degree in mathematics. She is responsible of the supervision of 25 AWCs and 80 hamlets and says to visit every AWC once every two months. As causes of malnutrition she raises poverty and lack of awareness, stating “if awareness fails, the whole programme will fail”. She would however not expand on what ‘raising awareness’ means. In addition, she mentioned that it would be needed for Anganwadi workers to counsel the community members, suggesting that this is something she observes is not being done so far. As last comments, she shares that she thinks it is important that the two ministries (being the Health department under which the AWC falls and the Women and Child department under which the ASHAs and ANMs fall) have a stronger and more effective communication in order to strengthen the activities on community level.

4.2.3 Local understanding of under nutrition

When speaking about malnutrition with community members, there are three terms they tend to use.

“Kamzori”: this is a clear cut term for everyone. It is weakness that overcomes children and in cases adults. Everyone agrees that kamzori can also happen to pregnant women. It is featured by general weakness, thinness, tiredness and in some cases people would mentioned enlarged stomach.

“Chhatti”; this is less clear and received several different descriptions which can generally be categorised in two, being 1) malnutrition described as a child being very thin, weak, in active, with a wrinkled skin and with poor appetite, and 2) a worship. In most of the cases, when chhatti is perceived as a disease, it is mentioned that the only cure to this can be done by a traditional healer in the manner of threads and mantra’s and in some cases it is perceived as being caused by black magic or superstition.

“Sukha”; this is very often said to be the same as chhatti, however it is perceived more or less perceived as a disease that can be cured and prevented and with that has nothing to do with black magic or superstition.

In either case, chhatti and sukha are both regularly linked with tuberculosis by the community members, but there is not clear direction given into which of the two comes or is caused by tuberculosis.

In order to ensure use of the right term used during each individual FGD, the first FGD per participating group would always start with the participants describing the difference between kamzori, chhatti and sukha with addition of pictures shown of what the nutrition society perceives as malnutrition in both the form of wasting as well as stunting. In this document, the term “malnutrition” will be used, even when participants would use either of the other terminologies mentioned previously. In all cases, limited growth in height was not perceived as a problem and some would say this is comes along with the parent’s height where others would mentioned that inappropriate eating habits and breast feeding practices would be the cause of limited height growth in a child. The majority agreed that malnutrition is a disease, and half of the participants believed that it is a contagious disease where the other half mentioned it not being a contagious disease. In addition, the majority said that malnutrition can affect adults as well, whereas a fourth of the participants said that malnutrition only affects children and can’t affect adults. In addition, one group of women agreed that malnutrition can affect both children as well as adults, but chhatti can only affect children. All participating groups had different answers to the questions who the most vulnerable are to malnutrition in their community. Often children are mentioned, but these are mentioned in different age ranges. The groups that believe that malnutrition can affect both children as well as women, said that everyone who falls ill can be affected by malnutrition. Another group specifically mentioned as vulnerable those children that are born soon after each other due to lack of use of birth spacing methods.

Recognition malnutrition

A range of descriptions are given regarding the recognition of malnutrition, most frequently mentioned are limited weight, thin arms and legs and the observation of frequently falling ill. Diarrhoea, vomiting and lack of appetite as well as inactive behaviour are mentioned frequently as well regarding the recognition of malnutrition. Wrinkled skin, less hair grow, limited eye sight, short height, limited ability to sit and stand and a lack of blood are mentioned only several times. Malnutrition having the possible consequence of early death is only mentioned twice.

Causes malnutrition

A wide range of causes to malnutrition were given by the participants. As main cause was given the eating habits of a child, whether this was caused by lack of food availability, or not the appropriate food being eaten in either quantity or quality. The high work load for women was mentioned second most often, by indeed male as well as female participants. The perspective is that due to this work load for women (in the field), there is not adequate care for the children as well as not timely feeding moments for children. One more frequently mentioned cause would be the quality of breast milk of a lactating mother, in some cases mentioned to be influenced by the field work conducted by women, which would make the breast milk ‘hot’ which is bad quality breast milk. Other causes to malnutrition mentioned are illness, lack of ‘cleanliness’, diarrhoea, unclean water (that may causes diarrhoea), mothers health (including inappropriate eating habits of the pregnant/lactating mother), children eating soil (mainly when they are teething), and inappropriate breastfeeding practices (linked to lack of breast milk, lack of colostrum feeding, and offering jaggery water instead of breast milk). Less frequent mentioned causes are not timely treatment for children, child marriage and poverty.

Action upon identification malnutrition

Once a child is found malnourished, mothers, grandmothers as well as fathers and grandfathers would mostly refer to a doctor or traditional healer. In this order, being that if they can afford it, they would go for treatment to a doctor, but if they can’t they would choose to see a traditional healer. In addition, if the treatment from the doctor does not improve the child’s health, they would refer to a traditional healer. Other participants mentioned that they would take the child straight to the hospital if it showed symptoms of malnutrition. Those who would not take the child for treatment to either of the three mentioned, would provide the child with nutritious food, described as vegetables (particular spinach), fruits, pulses, porridge, wheat(bread), milk, dry dates and almond milk.

The severity of malnutrition in the particular villages is perceived from not being a problem at all (“there are more dangerous diseases”), to being a major problem and from the perspective of not having any children malnourished in the village, to having several malnourished children in the village.

4.2.4 Characteristics of livelihoods and food security

Livelihoods

As described in the earlier sections on the characteristics of the participants during the FDGs, the majority of the participants are involved in farming or labour work (on basis of daily wage) as main occupation for the maintenance of livestock. This was the same for men as well as women among the participants, with the women besides field work, also mentioned the occupation of housewife. Work for cash (like labour work) is mainly done to have money and be able to pay for treatment and clothes. The MNEGRA scheme is not known by every participant, and the ones that are aware of the scheme say that they don’t use it often. It is mentioned by several groups of participants that there is not often the possibility to work under the scheme due to lack of work made available by the Sir Panch, or due to the fact that Sir Panch would choose to get the work done by machines. Those who are aware of the scheme know that their scheme-booklet says that they should earn 157₹ per day worked under scheme. Everyone though mentioned that they earn less than that, and in addition it is mentioned that even under the scheme women tend to earn less than men.

Land and agriculture

It is mentioned that almost everyone owns at least some land, though it difference a lot per household in the villages whether households own a bigger or smaller piece of land. In addition, some people own very dry land which is challenging to grow crops on, where other households own wet lands, which makes growing crops less challenging and which often has a better yield. The main livestock assets mentioned are the ownership of an ox to manage the land with, cows for milk consumption and sale if there is too much to be consumed by the owning household only, chicken for the eggs to either eat in summer or incubate during the rest of the year, and to eat the meat from when relatives come and visit. In addition, the main crops mentioned to be harvested are wheat and other grains, corn, cotton, pulses, chilli, and less frequently mentioned are soybeans, vegetables, groundnuts and rice, as well as the ownership of goats to be sold during Muslim fests.

Farming is perceived as very challenging and is observed by the community members to increase in it difficulty due to changes in rain fall. It is mentioned that water scarcity makes the field work challenging and influences the crop negatively. In addition, especially over the last year, farmers have faced losses of crops due to the later and short monsoon period.

Food access

Every village has a market available once a week, however the participants share that they will only go to the market if they have money. The consequence is that some people will not go to visit the market for 3 consecutive months. Prioritised foods are spices (including chilli and garlic), salt, oil, sugar, onions, lentils, tea and vegetables. In case there is no money, there is no or less food bought and in some situations community members will only be eating chapatti and chutney (chilli, salt and some oil) only. Others will decide to borrow money from a so-called ‘money-lender’ in order to be able to purchase foods needed. The majority of the participants said it is normally the father-in-law, being the head of the household, to decide what food is to be purchased. In some cases it is the mother, who is responsible for cooking, who decided what food items will be bought.

If there is not enough food for everyone in the household, it would be often the elderly and/or children who would get a meal first, in all cases it is the women who will receive food at last in line of the household members. Overall, food leftover after a meal is used a later moment during the same day or, if stale and old, thrown away or given to cattle. Therefore, no prepared food is kept and stored.

Every participant is aware of the PDS scheme and its ration and will have a household member to go and receive this on a monthly base. It is mentioned that it can be challenging to collect it, as community members sometimes have to wait for a day or two before they actually receive the ration. In addition, for some villages the transport to where the PDS ration can be collected is costly. All groups of participants say to use the ration received from the scheme and one group of participants mentioned that they sometimes sell the ration in order to have cash. The majority of the female participants are aware of the packages given out by the Anganwadi worker, but groups of one particular village mentioned never to receive a package and in other villages participants mentioned not always to have time to go and collect the package. Only one group of participants said to be aware of the availability of a ration from the Anganwadi worker for pregnant women.

4.2.5 Characteristics of water, hygiene and sanitation

Water access and quality

Main water sources for the several villages are the hand pump or well, where some villages have an electric tube well and others have a regular well. Water from both the hand pump as well as from the well is used for all purposes, including washing, cooking, drinking, and land irrigation and for cattle. Two of the groups participating mentioned that some households are connected to a pipe line, and one of the groups mentioned to use the river water for washing purposes and for cattle. In some cases community members have to pay for water, this is in the cases that a tube well is being used (in this case the bill is for the electricity used to pump up the water, being mentioned as 400rupees per year) and when households are connected to the pipe line (participants mentioned a bill of 50rupees per month). There are several mentioning’s around hand pumps drying up and the difficulty of reaching other water sources when the hand pumps indeed do dry up.

Every participant said that the water quality can be assessed by the colour and taste of it, when its colour is yellowish, the water is muddy and the taste is bad, the water overall will be labelled as bad. Al participants said to know that when the water has the described quality, it should not be used and one is supposed to go to a different water source. However, some participants mentioned not always having the ability to use a different source, and therefore do not have a choice other than using the water source that gives bad quality water. In addition, some participants say to filter the water before use with a regular ‘tea filter’. When the water is clear and transparent, this is perceived as good quality water. Consequences of using bad quality water are said to be getting the cold and cough, and/or diarrhoea, vomiting, stomach pain and the fever.

Hygiene and sanitation

The majority of the participants admit to defecate in the open field along the road or river. In none of the villages there are public latrines, and only a handful of people said to have a latrine in the house mostly constructed with the use of a government scheme. After open defecation, participants said to wash their hands and legs, and only a handful said to wash with the use of soap. Some participants said open defecation is no issue, where others mentioned it makes the village look dirty and yet other stated to think that open defecation actually influences the community’s health, giving as example that children play in the soil and eat soil, resulting in illness and diarrhoea for these particular children. In addition, the female participants mentioned that children’s faeces is normally thrown away, either around the courtyard or on the cow dung heap, after which the spot will be swept clean. Without prompting from the field staff, one of the groups of participants verbalised their willingness and commitment to keep latrines clean, if they were to be constructed for public use in the village.

Good hygiene practices for children are by female participants mentioned as most important being regularly bathing and providing clean clothes. Less frequently mentioned are hand washing before eating and after defecation (one group adds to that ‘with the use of soap or ashes’), applying powder, proper feeding and cleaning the living area. When asked about soap use, everyone tended to agree that the use of soap is important and needed on a daily base for body wash, hand wash and washing clothes. The majority of the participants however also shared their struggle with this, as they are not always able to purchase soap and therefore don’t use soap most of the times.

4.2.6 Characteristics of health care and practices

Where giving a description of an unhealthy child seems not to be too challenging, the description of a healthy child is given as ‘good looking’. There are not many challenges mentioned regarding how to keep a child healthy, however the female participants mainly mentioned the challenge of having children that cry a lot and are working against being fed. In addition, having to work in the field challenges the mothers to keep the children healthy as well as having multiple children.

The main illnesses mentioned to be observed within the communities are several types of body pains and aches, vomiting, fever, cold, cough, diarrhoea, sun stroke, dengue fever and malaria, and ‘fast breathing’ in children. Once a child is found to be ill, female participants mentioned the need to take them for treatment to a doctor or hospital, or if there is no sufficient money available to a traditional healer. In two occasions, the need to provide good quality water to the children during illness is mentioned. The majority of both female as well as male participants mentioned that it is the elderly in a household that decide on whether a child can be taken for treatment or not. In most of the cases, if permission is giving, it would be the mother taking the child for treatment or, in some villages and at time it was mentioned that children would go for treatment on their own (this is mainly linked to treatment at the AWC). The majority of the participants mentioned that once treatment is sought for, they will receive medicine or tonic for the child, with no further advice given. Normally, community members would seek treatment on the same day that a child falls ill. However, is there is no money available for treatment they will either wait some days before seeking treatment, or they will first buy some general medicines at a drugstore in the village or a village nearby. In case treatment is being sought with no money available to pay, community members will be reported in a system of the treatment giver and they will have to pay the fee later once they have money available.

Immunisation is perceived as important to prevent pregnant women, unborn babies and children from diseases and developing a status of being disabled. Most of the grandmothers mentioned that they have never received any vaccinations, where the current mothers said they have, as well as their children. Participants said that it is the Anganwadi worker that takes care of the vaccinations.

Community members are clear about the availability of IFA tablets for pregnant women (see section on ‘maternal health’), but there is no clear line in understanding of the availability of other supplementations, like vitamin A or ORS, between the villages. Some of the groups of participants mentioned that they do receive ORS for a child once this child has diarrhoea or is frequently vomiting, others said never to receive ORS with not having a clear understanding what ORS is.

4.2.7 Characteristics of child care practices

Generally, children are taken care of by a female care taker, being in the majority of the households the grandmother and in some cases the mother. The grandmothers mentioned that when they spend time with the children, they take care of them, bath them, play with them and sometimes take them to the AWC. Mothers said that when they have their responsibilities regarding field work, they spend half of the day in the field and half of the day with the children. Most of the female participants mentioned that girls will start with their responsibilities in the household from an age of around 10 to 12 years old, where boys would also start at an age of 10 to 12 years old, or even only from around 18 years old on.

Regarding breastfeeding practices, it is mentioned by everyone that it used to be that a new born would be fed with only jaggery water for the first two or three days. Now-a-days, it is mentioned that most of the mothers start breastfeeding immediately after birth, however there is still a relative big group of women that mentioned to start feeding with jaggery water and start breastfeeding only after two or three days. In addition, mothers and grandmothers said that sometimes the breast milk production has not come up yet immediately after birth and that this only comes up after two or three days. To cover these first two or three days, mothers and grandmothers will feed the new born jaggery water. In addition, the majority of the female participants said to stop with breastfeeding as soon as a mother gets pregnant again as it is said that if she would continue breastfeeding this would have negative influence for the unborn child, the child being breastfed as well as for the mother. If a mother is not pregnant after 1.5 to 3 years (there were a variety of ages mentioned regarding the time to stop breastfeeding), she would also terminate breastfeeding practices. In addition, there does not seem to be one particular amount of times that women breastfeed a child, this has a variety from twice a day and during the night, to seven to eight times a day and on request during the night.

According to the participants, boys and girls are given the same amounts of food, even though this had been different in the past. There is no same answer to when children are being fed with complementary foods, ranging between the start at age 6 months to after 12 months only. In addition, there doesn’t seem to be a clear understanding of what complementary foods are, in some participating groups tea with milk and sugar as well as biscuits are not perceived as complementary foods (and therefore mothers would mentioned the start of complementary feeding only after 12 months, even though tea with milk and sugar as well as biscuits are offered to a child at a younger age than 12 months). Overall, the first foods that a child would be offered are broth from rice and/or lentils, biscuits, cows- or buffalo milk, tea (with milk and sugar), and in some cases ‘dried fruits’ (being almonds). Foods that are perceived as not good for a child are spicy and oily foods, semi cooked food, banana and gave (this would cause a cold and cough), sour foods and stale food.

When caretakers are at home, it is said that children are offered food during the entire day, whereas when caretakers are working in the field the children get offered food in the morning and afternoon only. Food is prepared twice a day, most often by the mother, and she prepares the same foods for children for adults, though the children will use less chillis. Children will be eating the same foods as adults from an age ranging between 7 and 10 years old. Overall, mothers decide on the feeding practices for children, with the majority of the mothers not receiving advice on the matter. In only several cases it is said that mothers receive advice on feeding practices by either her mother-in-law or through adverts on television.

The majority of the mothers and grandmothers are aware of the AWC’s task to weigh children once a month. Most of the female participants say to try to get the child to the AWC for the monthly weighing moment, but also mentioned that sometimes they are not able to take the child. In most of the cases, mothers and grandmothers would wait for a request from the Anganwadi worker or the ‘helper’ to come for a visit to the AWC. In other cases, the helper will come to the household to take the child with her to the AWC herself, this also might happen when there are no caretakers around.

4.2.8 Characteristics of maternal health

The range of age at which a first pregnancy takes place is according to all participants linked to the age of marriage, which is said to be in the range of between 17 and 21 years old. A first pregnancy will always happen within the first year after marriage.

Participants mentioned that now-a-days most of the birth deliveries take place in a hospital, and grandmothers refer back to the time that they were young and went through labour in their own houses with the support from a traditional birth attendant. Some of the current mothers mentioned that they went to hospital using a privately owned vehicle or public transport, but the majority mentioned that they go to hospital by the ambulance express made available by the government.

There is mentioned of specific mantra’s and binding threads during pregnancy, as well as the fact that pregnant women have the same responsibilities as non-pregnant women, though these days some doctors and grandmothers are said to advise a pregnant woman to take more rest and not to lift heavy loads. In addition, pregnant women don’t have specific differences in their eating habits compared to non-pregnant women. An ANC check is perceived as important when a woman is facing difficulties during pregnancy, but it according to the participants not needed if a woman is feeling well and healthy during pregnancy. Pregnancies tend to occur every three years, but this time frame is not planned for by the use of birth spacing methods. However, there are some women that mentioned the use of a hormonal injection that works as anticonception method for 5 years after being injected and most of the women are aware of birth spacing methods, including the anti-conceptive tablets as well as the copper intra uterine device. Even though, the majority of participants don’t use any birth spacing methods, other than a tubal ligation after it is decided to not have any more children. It would be either the elderly in a family to decide whether a couple can use birth spacing methods, or it would be the couple themselves.

Most of the women say that birth spacing is important, reasons for this given are the work load and responsibility women are given when there are more children in a family, the need of more resources when there are more children, and the consequences of weakness in both women (caused by multiple pregnancies) as well as children (caused by early stagnation of breastfeeding due to a new pregnancy of the mother). One participant states “a small family is a happy family”, and her community members seem to agree.

During pregnancy, most of the women mentioned to have been supplied with IFA tablets by the ANM or Anganwadi and everyone, both grandmothers as well as mothers, seem to be aware of the possibility of being supplied with IFA. However, there is a division in the number of women that actually consume these during pregnancy, with the main reason for not using the tables as they believe that consuming the tablets will make them feel nauseas and like vomiting.

Female participants mentioned that the high work load of women in the community can make it challenging for them to take good care of their child. Also men do mentioned regularly negative consequences that the women’s work load has on the child care practises.

All women have the complaint of different types of body aches and tiredness, caused by their high work load. As mentioned previously, pregnant women have the same responsibilities as non-pregnant women, though in some cases female participants mentioned that they think it would be better if women from the 7^th month of pregnancy on could have less responsibilities and then especially in regards to lifting heavy weights. Women’s responsibilities for work in the house are shared among women in the household, as men have their own responsibilities. According to the women, the men are ultimately responsible for everything and for the entire family management. Men have their responsibility for field work as well, and some female participants tell that after men come back from the field, they will rest, where others mentioned that men will support the house hold work. One group of female participants mentioned that it is the boys in the family that should be supported in receiving education.

Most of the women mentioned that there is nothing they have independent access to and that for everything they will need to ask permission from the elderly (men) in the household, except for some women’s access to kitchen supply, in which they are allowed a free go.

Female participants perceive migration as a must, with no space for liking or disliking this. They find it challenging when the husband leaves for migration work, with the women and children left behind. However, mothers also see that joining the migration is hardship for both the mother as well as the children. Most participants agree that migration influences malnutrition in children, as children who have to join migration are less taking care of and inappropriately fed due to the impossibilities that migration comes along with.

There is a division in women stating that there are no issues regarding the lack of decision making power they face, and women saying that this is challenging for them. In addition, some women refer to the pressure they feel from grandparents for having many children and sometimes with the preference of a male child.

When asked about a support system for women, the majority of the women respond by saying that there is nothing like that and even if there was, there will be no one that can make the issues be resolved. Some women would talk to their daughter, another woman of the same age or to their husbands, if he is willing to listen.

4.2.9 Positive deviant behaviours

In all villages, mothers of positive deviant children were sought to interview as well as mothers of children identified as malnourished. The aim for this particular exercise was to explore possible difference between practices of the mothers that might cause certain children not to suffer from malnutrition. Mothers to be interviewed were selected according to information received from the Anganwadi worker per particular village, regarding the identification of healthy and malnourished children under 5 years of age. Using the information received from the Anganwadi worker, it was regularly experienced that the Anganwadi worker would refer the investigating team to a mother of a child who turned out to be incorrectly identified. In total, 5 mothers of positive deviant children were interviewed and 5 mothers of – correctly - identified malnourished children were interviewed. The main differences found were that use of ANC services seem to be different between mothers of positive deviant children compared to mothers of malnourished children, with the latter group having less frequent ANC visits. It must be noted however, that the local understanding of what ANC is might be irregular between community members. Furthermore, mothers of positive deviant children seem to stop (heavy) work 3 to 2 months prior to delivery and would come home from field work to breast feed the child. Lastly, mothers of positive deviant children tend to have a more active approach to the weight monitor moments conducted by the Anganwadi worker. A comparison of the key findings of the case study interviews can be found in table 6 with more comprehensive information regarding these interviews conducted in appendix III.

Mothers of positive deviant children	Mothers of malnourished children
Regular ANC visit	Limited ANC visit
Stop work 6-7 months prior to delivery	Work till day of delivery
Come back from field to breast feed
More active in weight measurement
Mothers of PD have a later start of work after delivery
Breast feeding practices are diverse, but in both group use of jaggery water
Similar hygiene practices
Similar use of ICDS package

Table 6 Key findings from case study interviews

4.2.10 Seasonality

In all villages that qualitative data was gathered, male participants were asked to give their input regarding the information for a seasonal calendar. In this calendar, aspects relating to food security, financial security and health issues are included. The several calendars can be found in appendix IV.

Water availability

All community members from the several village mentioned that rainy season lasts from June till September, with one group expanding this till October. For all communities it is also mentioned that the most difficult time to fetch water is around March till May, as this is the time that water sources tend to dry up. When talking about differences over the past decade, male community members mentioned that the circumstances have become weaker. Monsoon period tends to have a later start as well as a shorter duration, which influences the agriculture businesses and yield negatively.

Food and financial availability

The experience of food scarcity is different per group of male community members, for some groups mentioned the period of mainly May and June and other groups having the emphasis of scarcity around August and September. Harvest of yields are for the villages focussed around the months from April/May to August, with community members observing a gradual shift from grains to soybeans as crop as an reply to the water scarcity. In addition, it is observed by community members that the soil is decreasing in fertility over the years, resulting in a more limited yield.

Market food prices have their peaks around the summer months, but as early as from March/April in till as late as August/September. Milk is available throughout the year, but is not accessible for everyone and some community members mentioned that milk as peaks in price around the end of the calendar year, being November/December.

Most of the trade takes places during the months of November till February/March. With sell of cattle throughout the year whenever money is needed, with goat owners experiencing a peak of sale of goats during Muslim fests.

Participants mentioned to borrow money whenever this is needed, and male participants share to have the observation that interest rates have gone up in the last decade. Most of the participants are aware of the MNEGRA scheme, though not everyone makes use of the scheme. In addition, community members mentioned that often payments come late and that at time the sir panch would choose to get the work done by machines, which means that either community members earn less on a day compared to when all the work is done manually, or that the work is done at night at which time of the day community members are not aware of the work to be done.

Work and migration

Male community members mentioned to be able to work on the field throughout the year, and experiencing the main availability of labour work during different moments in the year. In addition, most of the migration takes place from October till March, with some communities also mentioned to go on migration during the months of March till June. There was one community surveyed that says never to go on migration.

Child illnesses

Child illnesses mentioned have range of different complaints and illnesses, varying from vomiting and diarrhoea during the raining season and fever in the summer season. In addition, diarrhoea is according to the male participants mainly apparent during the months around August. Furthermore, ARI are seen throughout the year by most communities and malaria is mainly seen during the months around August and September.

Birth peak and other events

According to both female as well as male participants, there is no such thing as a birth peak with new born deliveries occurring throughout the year. Social events other than the Hindu festivals mainly occur in March when a big fair takes places for community members from several villages, as well as at the time of plant seeding and first harvest.

4.2.11 Communities risk factor rating

After the last FGD per individual group of participants was conducted, the participants were asked to rate the risk factors according to their perspective of importance. All participants had their individual say on this, after an average for the group was calculated. Finally, an average of the prioritised rating was calculated per village. Table 7 shows the rating of risk factors per village from most influential to least influential, with an overall rating showing the villages combined.

Borkheda	Karaniya	Pakhalya	Bhanving Pura*	Average
Access to clean water	Caretaker’s workload	Food access	Health seeking behaviour	Access to clean water
Health seeking behaviour	Feeding practices	Feeding practices	Vaccination	Diet diversity
Hygiene practices	Food access	Diet diversity	Food access	Food access
Breast feeding practices	Diet diversity	Access to clean water	Maternal health	Caretaker’s workload
Vaccination	Access to clean water	Hygiene practices		Feeding practices
Sanitation	Birth spacing	Sanitation		Vaccination
Micronutrient supplementation	Micronutrient supplementation	Maternal health		Birth spacing
Maternal health	Vaccination	Caretaker’s workload		Micronutrient supplementation
Diet diversity	Breast feeding practices	Birth spacing		Breast feeding practices
Feeding practices	Sanitation	Women’s decision making power		Health seeking behaviour
Women’s decision making power	Health seeking behaviour	Micronutrient supplementation		Sanitation
Caretaker’s workload	Low birth weight	Vaccination		Maternal health
Birth spacing	Maternal health	Health seeking behaviour		Women’s decision making power
Low birth weight	Women’s decision making power	Low birth weight		Hygiene practices
Food access	Hygiene practices	Breast feeding practices		Low birth weight
* In Bhavsing Pura the participants did not have the time to attend the rating exercise. When asked without prompting what they perceive as the main causes of malnutrition in their community, they gave these four factors, in this order of priority

Table 7 Rating of risk factors by communities

Risk factors mentioned by community members during this exercise other than the risk factors assessed for where 1) poverty, 2) poor child care practices overall, 3) lack of land ownership (referring to the difference of size of land owned and the quality of land, being dry or wet land), 4) lack of medicines available, and 5) lack of accessibility ICDS package for children.

4.3 Local causal framework

Based on the findings from the literature review and secondary data review conducted prior to the field study, in addition to the information received from experts as well as the information received during the field study, a local causal framework was created. This framework aims to visualise the local causes to malnutrition and its pathways. The boxes in blue (both dark and light blue) refer to the UNICEF causal framework. The colour of the other boxes are matched according to the colours used during the ranking, being dark green for major risk factors, light green for important risk factors and yellow for minor risk factors.

5 Final technical workshop

5.1 Ranking of apparent risk factors

Prior to the final technical workshop, the NCA consultant ranked the hypothesised risk factors based on their influences regarding malnutrition, and the specifically under nutrition, in Jhirniya Block. This ranking was done based on the known prevalence from secondary data, the known strength of association with under nutrition from literature, the assessed seasonality of the risk factor, the input given by technical experts during the initial workshop and the information gathered during the qualitative survey conducted (appendix V). According to the NCA methodology developed by ACF, the risk factors were ranked by their importance being either a ‘minor’ cause for malnutrition in the area, an ‘important’, or a ‘major’ cause of malnutrition (see appendix VI). In some cases a risk factor could not be ranked in either of the three ways, due to lack of information. The ranking as done by the consultant, and as presented to the experts during the final workshop, can be found in appendix V.

During the final workshop, participants were present from different organisations (appendix VII) and they were presented with the findings of the field study conducted, ending with the presentation of the proposed raking of hypothesised risk factors. The ranked hypothesised risk factors were discussed and given a confidence note by the participants (where a confidence note of 3 meant ‘in full confidence’ and a 1 meant ‘no confidence in the proposed ranking), which resulted in a final ranking of – now – known risk factors as can be found in table 8.

Risk factor	Final interpretation	Average confidence note	Experts rating
H1 - Inappropriate breast feeding practices	Major	3.0	Major
H2 - Inadequate complementary feeding practices	Major	3.0	Major
H3 - Poor access to food	Important	1.8	Major
H4 - Poor diet diversity	Major	3.0	Major
H5 - Inadequate access to safe water	Major	3.0	Major
H6 - Lack of hygiene	Untested	-	Untested
H7 - Poor sanitation	Major	3.0	Major
H8 - Poor health seeking behaviour	Important	2.5	Important
H9 - Low birth weight	Untested	-	Untested
H10 - Maternal well being	Important	2.9	Important
H11 - Poor psychosocial care for children	Untested	2.1	Major*
H12 - Caregivers workload	Major	3.0	Major
H13 – Lack of birth spacing	Major	3.0	Major
H14 - Lack of women empowerment	Minor	2.0	Major*
H15 - Poor supplementation to prevent micronutrient deficiencies	Minor	2.8	Minor*
H16 - Poor usage of vaccine	Minor	2.2	Important*

Table 8 Risk factors ranked according to confidence notes

As the reader will concern, there are several discrepancies between the analyst’s ranking and the final ranking as done by the technical experts. Where the analyst ranked H3 as ‘important’, the technical experts would propose for this hypothesis to be ranked as ‘major’ as even though food access changes over the season, it is one of the main reasons for community members not to have adequate access to food throughout the year. The analyst could agree with this and therefore it was changed to ‘major’ risk factor. Hypothesis 11 was identified as being untested by the analyst, based on insufficient information on this topic. The technical experts however proposed this to be ranked as ‘major’, based on their experiences in the field. Even though the experts experience is highly valued, the experience and observation is likely to be subjective and the analyst felt it would be inappropriate to rank the hypothesis while there is a recognised lack of information. The hypothesis regarding lack of women empowerment, or more precisely the lack of decision making power for women, brought up an interesting discussion during the workshop. During the initial workshop, every participant agreed to it that women empowerment would likely be a cause to under nutrition in Jhirniya Block. During the field study however, it was mainly the women’s perspective that showed that lack of empowerment/decision making power, is not necessary an issue not limiting their lives. Only some women would say that if they were to have more power to make decision, they would take their children more adequately for treatment. Even though this was mentioned, one might want to provoke the thought of women ‘not knowing other than their current situation’ and therefore not knowing whether a situation could be better, or worse, for that matter. In addition, within the current context in which grandmothers seem to have a relative high decision making power, one might want to explore a separate approach considering women’s decision making power versus mother’s decision making power. Consensus on this particular hypothesis was not reached between experts nor between experts and the analyst.

Hypothesis 15 and 16 (poor supplementation use and poor vaccines usage) were by the analyst ranked as ‘minor’ risk factors as 1) the data found on these two separate matters leaned towards highly contradicting information, and 2) according to the information from community members the coverage of both these issues were relatively high. Concern raised during the workshop were the adequateness of the data as well as the adequateness of the policies and programmes, mainly regarding micronutrient supplementation, in general – wondering whether coverage of micronutrient supplementation is not lacking overall due to a limited policy in micronutrient supplementation.

6 Conclusions and Recommendations

As emphasised on by the health community, this NCA has confirmed that correspondingly Jhirniya Block is in need of a multi-sectorial approach in order to combat under nutrition with in addition attention to seasonal changes that influence the importance of a risk factor. The current NCA has shown the gaps within community member’s perspective, understanding as well as activities in order to fight under nutrition, and also provides a glance on possible interventions that in future could support the combat against under nutrition in Jhirniya Block. Below the recommendations followed from the current NCA are listed. In addition, additional studies would be needed to identify needs and gaps within 1) the health system, its accessibility and adequateness, 2) mother’s wellbeing, 3) psychosocial care for children, 4) hygiene practices, 5) low birth weight, and 6) land rights (especially between tribe and castes as well as gender)

Food security and Livelihoods

In order to improve the communities’ food security and livelihoods, the following recommendations could be further explored and possibly implemented:

- The support of diversification in agricultural practices, with inclusion of community and/or home vegetable gardens

- To raise awareness regarding entitlements of the PDS and ICDS scheme as well as MNREGA

o Advocate for PDS sub-centres

o Advocate for an altered PDS ration, possibly adjusted according to season

o Advocate for improved MNREGA implementation with focus on honest payment, timely payment and work availability

- Improved land irrigation

Water, hygiene and sanitation

With the aim to improved WASH in order to combat under nutrition, one may want to choose to focus on one or several of the recommendations below:

- Improved promotion and education on safe and hygienic defecation practices

- Improved access to latrines

- Improved awareness on hygiene practices for all household members

- Improved access to safe drinking water (with attention to seasonal changes)

Nutrition, health care and health services

For improved nutrition and health care practices conducted by community members, the following recommendations are in place:

- Education and promotion on:

o Appropriate breast feeding practices

o Complementary feeding practices

o ANC visits

o Birth spacing methods

In addition, though not as exhaustively assessed during the current NCA, one might want to explore further possibilities of implementation within the following recommendations:

- Improved knowledge and counselling practices of frontline workers on:

o Recognition of malnutrition