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Abstract The Integrated Child Development Services (ICDS) programme has been the central focus of the POSHAN Abhiyaan to combat maternal and child malnutrition under the national nutrition mission in India. This paper examined the linkages between utilization of ICDS and underweight among children aged 6–59 months. The study utilized data from two recent rounds of the National Family Health Survey (NFHS‐4 [2015–2016] and NFHS‐5 [2019–2021]). Descriptive analyses were used to assess the change in utilization of ICDS and the prevalence of underweight at the national and state levels. Multivariable logistic regressions were performed to examine factors associated with the utilization of ICDS and underweight. Linkages between utilization of ICDS and underweight were examined using the difference‐in‐differences (DID) approach. Utilization of ICDS increased from 58% in 2015–2016 to 71% in 2019–2021. The prevalence of underweight decreased from 37% to 32% in the same period. Changes in ICDS utilization and underweight prevalence varied considerably across states, socioeconomic and demographic characteristics. Results from decomposition of DID models suggest that improvements in ICDS explained 9%–12% of the observed reduction in underweight children between 2016 and 2021, suggesting that ICDS made a modest but meaningful contribution in addressing undernutrition among children aged 6–59 months in this period.

BackgroundIndia's 1.4 million community health and nutrition workers (CHNWs) serve 158 million beneficiaries under the Integrated Child Development Services (ICDS) programme. We assessed the impact of a data capture, decision support, and job-aid mobile app for the CHNWs on two primary outcomes-(1) timeliness of home visits and (2) appropriate counselling specific to the needs of pregnant women and mothers of children

IntroductionCommunity health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services.ObjectivesWe examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge.MethodsWe used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong.ResultsAmong 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge.ConclusionHigher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes.Trial registrationTrial registration number:  https://doi.org/10.1186/ISRCTN83902145.

BackgroundAnganwadi Workers (AWWs) are a group of 1.4 million community health workers that operate throughout rural India as a part of the Integrated Child Development Services program. AWWs are responsible for disseminating key health information regarding nutrition, family planning, and immunizations to the women and children in their catchment area, while maintaining detailed registers that track key beneficiary data, updates on health status, and supply inventory beneficiaries. There is a need to understand how AWWs spend their time on all of these activities given all of their responsibilities, and the factors that are associated with their time use.MethodsThis cross-sectional study conducted in Madhya Pradesh, collected time use data from AWWs using a standard approach in which we asked participants how much time they spent on various activities. Additionally, we estimated a logistic regression model to elucidate what AWW characteristics are associated with time use.ResultsWe found that AWWs spend substantial amounts of time on administrative tasks, such as filling out their paper registers. Additionally, we explored the associations between various AWW characteristics and their likelihood of spending the expected amount of time on preschool work, filling out their registers, feeding children, and conducting home visits. We found a positive significant association between AWW education and their likelihood of filling out their registers.ConclusionsAWWs spend substantial amounts of time on administrative tasks, which could take away from their ability to spend time on providing direct care. Additionally, future research should explore why AWW characteristics matter and how such factors can be addressed to improve AWWs' performance and should explore the associations between Anganwadi Center characteristics and AWW time use.

INTRODUCTION:Millions of children in India still suffer from poor health and under-nutrition, despite substantial improvement over decades of public health programmes. The Anganwadi centres under the Integrated Child Development Scheme (ICDS) provide a range of health and nutrition services to pregnant women, children

Abstract Introduction Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services. Objectives We examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge. Methods We used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong. Results Among 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge. Conclusion Higher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes. Trial registration : Trial registration number: https://doi.org/10.1186/ISRCTN83902145

Abstract The National Nutrition Services of Bangladesh aims to deliver nutrition services through the primary health care system. Little is known about the feasibility of reshaping service delivery to close gaps in nutrition intervention coverage and utilization. We used a scenario‐based feasibility testing approach to assess potential implementation improvements to strengthen service delivery. We conducted in‐depth interviews with 31 service providers and 12 policymakers, and 5 focus group discussions with potential beneficiaries. We asked about the feasibility of four hypothetical scenarios for preventive and promotive nutrition service delivery: community‐based events (CBE) for pregnant women, well‐child services integrated into immunization contacts; CBE for well‐children, and well‐child visits at facilities. Opinions on service delivery platforms were mixed; some recommended new platforms, but others suggested strengthening existing delivery points. CBE for pregnant women was perceived as feasible, but workforce shortages emerged as a key barrier. Challenges such as equipment portability, upset children and a fast‐moving service environment suggested low feasibility of integrating nutrition into outreach immunization contacts. In contrast, CBE and facility‐based well‐child visits emerged as feasible options, conditional on having the necessary workforce, structural readiness and budget support. On the demand side, enabling factors include using interpersonal communication and involving community leaders to increase awareness, organizing events at a convenient time and place for both providers and beneficiaries, and incentives for beneficiaries to encourage participation. In conclusion, integrating preventive and promotive nutrition services require addressing current challenges in the health system, including human resource and logistic gaps, and investing in creating demand for preventive services.

The Integrated Child Development Services (ICDS) programme has been the central focus of the POSHAN Abhiyaan to combat maternal and child malnutrition under the national nutrition mission in India. This paper examined the linkages between utilization of ICDS and underweight among children aged 6–59 months. The study utilized data from two recent rounds of the National Family Health Survey (NFHS‐4 [2015–2016] and NFHS‐5 [2019–2021]). Descriptive analyses were used to assess the change in utilization of ICDS and the prevalence of underweight at the national and state levels. Multivariable logistic regressions were performed to examine factors associated with the utilization of ICDS and underweight. Linkages between utilization of ICDS and underweight were examined using the difference‐in‐differences (DID) approach. Utilization of ICDS increased from 58% in 2015–2016 to 71% in 2019–2021. The prevalence of underweight decreased from 37% to 32% in the same period. Changes in ICDS utilization and underweight prevalence varied considerably across states, socioeconomic and demographic characteristics. Results from decomposition of DID models suggest that improvements in ICDS explained 9%–12% of the observed reduction in underweight children between 2016 and 2021, suggesting that ICDS made a modest but meaningful contribution in addressing undernutrition among children aged 6–59 months in this period. Key messages: Utilization of ICDS services among children aged 6–59 months increased from 58% (2015–2016) to 71% (2019–2021) nationally. The programme's expansion was prominent in urban areas, showcasing progress across states.The prevalence of underweight among children in India declined by 5 percentage points from 2016 to 2021, but almost one‐third of children are still underweight.Increase in coverage and service delivery strengthening of ICDS explained 9%–12% of the observed reduction in underweight between 2016 and 2021.The findings suggest that optimizing quality of interventions under ICDS can have a modest but meaningful contribution in reducing childhood underweight in India. [ABSTRACT FROM AUTHOR]

India has been on a steady march to address malnutrition in the last decade. The nutrition community has worked on building consensus on key actions, implementation platforms were put in place and financing for nutrition slowly increased. Under the strong leadership of the Prime Minister, a revolutionary program to address malnutrition was launched in 2018. As actions under the mission accelerated, the COVID-19 pandemic arrived in early 2020. Affecting health systems, food systems, nutrition programs, social safety nets, and the economy, the pandemic has the potential to exacerbate the challenge of malnutrition in multiple ways. India can mitigate some of the possible ways in which COVID-19 will affect malnutrition but will require strong leadership and continued commitment, adaptation of the national nutrition mission, strengthening of the social safety net and innovative evidence-based data to take informed decisions, implement them and ensure feedback to take necessary corrective action. In this article, we outline some challenges and key areas for action. We conclude that India's nutrition journey is too important to be derailed by a crisis like COVID-19. This is a clarion call for the nutrition community in India to rally strongly to support continued attention to malnutrition in all its forms, to generate relevant evidence, and to support and engage all of society to urgently and adequately address malnutrition in the context of the COVID-19 pandemic. We have come too far to turn back now.

Abstract Background Anganwadi Workers (AWWs) are a group of 1.4 million community health workers that operate throughout rural India as a part of the Integrated Child Development Services program. AWWs are responsible for disseminating key health information regarding nutrition, family planning, and immunizations to the women and children in their catchment area, while maintaining detailed registers that track key beneficiary data, updates on health status, and supply inventory beneficiaries. There is a need to understand how AWWs spend their time on all of these activities given all of their responsibilities, and the factors that are associated with their time use. Methods This cross-sectional study conducted in Madhya Pradesh, collected time use data from AWWs using a standard approach in which we asked participants how much time they spent on various activities. Additionally, we estimated a logistic regression model to elucidate what AWW characteristics are associated with time use. Results We found that AWWs spend substantial amounts of time on administrative tasks, such as filling out their paper registers. Additionally, we explored the associations between various AWW characteristics and their likelihood of spending the expected amount of time on preschool work, filling out their registers, feeding children, and conducting home visits. We found a positive significant association between AWW education and their likelihood of filling out their registers. Conclusions AWWs spend substantial amounts of time on administrative tasks, which could take away from their ability to spend time on providing direct care. Additionally, future research should explore why AWW characteristics matter and how such factors can be addressed to improve AWWs’ performance and should explore the associations between Anganwadi Center characteristics and AWW time use.

Background Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020. Methods We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August–October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2. Results In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by Conclusions Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.

Abstract Designing survey questions that clearly and precisely communicate the question's intent and elicit responses based on the intended interpretation is critical but often undervalued. We used cognitive interviewing to qualitatively assess respondents' interpretation of and responses to questions pertaining to maternal and child nutrition intervention coverage. We conducted interviews to cognitively test 25 survey questions with mothers (N = 21) with children less than 1 year in Madhya Pradesh, India. Each question was followed by probes to capture information on four cognitive stages—comprehension, retrieval, judgement, and response. Data were analysed for common and unique patterns across the survey questions. We identified four types of cognitive challenges: (1) retention of multiple concepts in long questions: difficulty in comprehending and retaining questions with three or more key concepts; (2) temporal confusion: difficulty in conceptualizing recall periods such as “in the last 6 months” as compared to life stages such as pregnancy; (3) interpretation of concepts: mismatch of information being asked, meaning of certain terms and intervention scope; and (4) understanding of technical terms: difficulty in understanding commonly used technical words such as “breastfeeding” and “antenatal care” and requiring use of simple alternative language. Findings from this study will be useful for stakeholders involved in survey design and implementation, especially those conducting large‐scale household surveys to measure coverage of essential nutrition interventions.

Objectives The COVID-19 pandemic has profound negative impacts on people’s lives, but little is known on its effect on household food insecurity (HFI) in poor setting resources. This study assessed changes in HFI during the pandemic and examined the interlinkages between HFI with child feeding practices and coping strategies.Design A longitudinal survey in December 2019 (in-person) and August 2020 (by phone).Setting Community-based individuals from 26 blocks in 2 districts in Uttar Pradesh, India.Participants Mothers with children

Objectives Existing health and community nutrition systems have the potential to deliver many nutrition interventions. However, the coverage of nutrition interventions across the delivery platforms of these systems has not been uniform. We (1) examined the opportunity gaps between delivery platforms and corresponding nutrition interventions through the continuum of care in India between 2006 and 2016 and and (2) assessed inequalities in these opportunity gaps.Methods We used two rounds of the National Family Health Survey data from 2005 to 2006 and 2015–2016 (n=36 850 and 190 898 mother–child dyads, respectively). We examine the opportunity gaps over time for seven nutrition interventions and their associated delivery platforms at national and state levels. We assessed equality and changes in equality between 2006 and 2016 for opportunity gaps by education, residence, socioeconomic status (SES), public and private platforms.Results Coverage of nutrition interventions was consistently lower than the reach of their associated delivery platforms; opportunity gaps ranging from 9 to 32 percentage points (pp) during the pregnancy, 17 pp during delivery and 9–26 pp during childhood in 2006. Between 2006 and 2016, coverage improved for most indicators, but coverage increases for nutrition interventions was lower than for associated delivery platforms. The opportunity gaps were larger among women with higher education (22–57 pp in 2016), higher SES status and living in urban areas (23–57 pp), despite higher coverage of most interventions and the delivery platforms among these groups. Opportunity gaps vary tremendously by state with the highest gaps observed in Tripura, Andaman and Nicobar islands, and Punjab for different indicators.Conclusions India’s progress in coverage of health and nutrition interventions in the last decade is promising, but both opportunity and equality gaps remained. It is critical to close these gaps by addressing policy and programmatic delivery systems bottlenecks to achieve universal coverage for both health and nutrition within the delivery system.

Introduction Childhood stunting has declined in India between 2006 and 2016, but not uniformly across all states. Little is known about what helped some states accelerate progress while others did not. Insights on subnational drivers of progress are useful not just for India but for other decentralised policy contexts. Thus, we aimed to identify the factors that contributed to declines in childhood stunting (from 52.9% to 37.6%) between 2006 and 2016 in the state of Chhattisgarh, a subnational success story in stunting reduction in India.Methods We examined time trends in determinants of stunting using descriptive and regression decomposition analysis of National Family Health Survey data from 2005 to 2006 and 2015–2016. We reviewed nutrition-relevant policies and programmes associated with the drivers of change to construct a policy timeline. Finally, we interviewed multiple stakeholders in the state to understand the changes in the drivers of undernutrition.Results The regression decomposition analysis shows that multiple factors explain 66% of the change in stunting between 2006 and 2016. Improvements in three key drivers—health and nutrition services, household assets, and sanitation and hygiene—explained 47% of the change in stunting. A shared vision for impact, political stability and capable bureaucracy, state-level innovations, support from development partners and civil society, and community mobilisation were found to contribute to improvements in programmes for health, poverty and sanitation.Conclusion Change in multiple sectors is important for stunting reduction and can be achieved in subnational contexts. More work lies ahead to close gaps in various determinants of stunting.

Globally, there remain significant knowledge and evidence gaps around how to support Community Health Worker (CHW) programmes to achieve high coverage and quality of interventions. India's Integrated Child Development Services scheme employs the largest CHW cadre in the world-Anganwadi Workers (AWWs). However, factors influencing the performance of these workers remain under researched. Lessons from it have potential to impact on other large scale global CHW programmes. A qualitative study of AWWs in the Indian state of Bihar was conducted to identify key drivers of performance in 2015. In-depth interviews were conducted with 30 AWWs; data was analysed using both inductive and deductive thematic analysis. The study adapted and contextualised existing frameworks on CHW performance, finding that factors affecting performance occur at the individual, community, programme and organisational levels, including factors not previously identified in the literature. Individual factors include initial financial motives and family support; programme factors include beneficiaries' and AWWs' service preferences and work environment; community factors include caste dynamics and community and seasonal migration; and organisational factors include corruption. The initial motives of the worker (the need to retain a job for family financial needs) and community expectations (for product-oriented services) ensure continued efforts even when her motivation is low. The main constraints to performance remain factors outside of her control, including limited availability of programme resources and challenging relationships shaped by caste dynamics, seasonal migration, and corruption. Programme efforts to improve performance (such as incentives, working conditions and supportive management) need to consider these complex, inter-related multiple determinants of performance. Our findings, including new factors, contribute to the global literature on factors affecting the performance of CHWs and have wide application.

Abstract Background Convergence of sectoral programs is important for scaling up essential maternal and child health and nutrition interventions. In India, these interventions are implemented by two government programs – Integrated Child Development Services (ICDS) and National Rural Health Mission (NRHM). These programs are designed to work together, but there is limited understanding of the nature and extent of coordination in place and needed at the various administrative levels. Our study examined how intersectoral convergence in nutrition programming is operationalized between ICDS and NRHM from the state to village levels in Odisha, and the factors influencing convergence in policy implementation and service delivery. Methods Semi-structured interviews were conducted with state-level stakeholders (n = 12), district (n = 19) and block officials (n = 66), and frontline workers (FLWs, n = 48). Systematic coding and content analysis of transcripts were undertaken to elucidate themes and patterns related to the degree and mechanisms of convergence, types of actions/services, and facilitators and barriers. Results Close collaboration at state level was observed in developing guidelines, planning, and reviewing programs, facilitated by a shared motivation and recognized leadership for coordination. However, the health department was perceived to drive the agenda, and different priorities and little data sharing presented challenges. At the district level, there were joint planning and review meetings, trainings, and data sharing, but poor participation in the intersectoral meetings and limited supervision. While the block level is the hub for planning and supervision, cooperation is limited by the lack of guidelines for coordination, heavy workload, inadequate resources, and poor communication. Strong collaboration among FLWs was facilitated by close interpersonal communication and mutual understanding of roles and responsibilities. Conclusions Congruent or shared priorities and regularity of actions between sectors across all levels will likely improve the quality of coordination, and clear roles and leadership and accountability are imperative. As convergence is a means to achieving effective coverage and delivery of services for improved maternal and child health and nutrition, focus should be on delivering all the essential services to the mother-child dyads through mechanisms that facilitate a continuum of care approach, rather than sectorally-driven, service-specific delivery processes.