Poster presented at the SAIFRN 2015 conference on November 23-24. Visit our webiste for more: www.poshan.ifpri.info

1. Frontline Worker Education, Motivation, Role clarity and Incentives are Drivers of
Maternal Exposure to Complementary Feeding Counselling at Home
RASMI AVULA1, SUNNY KIM2 , SUMAN CHAKRABARTI1, SUNEETHA KADIYALA3 , PURNIMA MENON1
1Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), New Delhi, India; 2IFPRI, Washington DC, USA
3London School of Hygiene and Tropical Medicine, London, UK
INTRODUCTION
CONTACT INFORMATION
• Individual and group counselling by trained frontline workers
(FLWs) with food supplementation is a recommended
intervention to improve complementary feeding (CF) practices
among food insecure populations.
• In India, Anganwadi workers (AWWs) of the Integrated Child
Development Services (ICDS) and Accredited Social Health
Activists (ASHAs) of the National Rural Health Mission
(NRHM), are responsible for counseling mothers on child
feeding at home.
• Service delivery may be influenced by various supply-side
(e.g., FLW workload, motivation, clarity of roles and
responsibilities, incentives, training, supervision, etc.) and
demand-side factors (e.g., beneficiary characteristics).
• Little evidence exists on factors influencing intervention
exposure.
Sampling and data collection:
• 300 villages across 4 blocks (subdivision or town) in 3
districts in Odisha state were randomly selected.
• FLW surveys were conducted with 300 AWWs and ASHAs on
training, record-keeping practices, incentives, availability of
equipment and resources, monitoring, and supervision.
• Household surveys were conducted with 1182 households on
exposure to health and nutrition services.
Odisha
DISTRICT 1
25 villages
Block 2Block 1 Block 4Block 3
4 households
Random Sample
Random Sample
Random sample
0-6 mo– 2 households
6-24 mo - 2 households
DISTRICT 2 DISTRICT 3
SUMMARY & CONCLUSIONS
AIM
• Examine the supply- and demand-side determinants of
maternal exposure to complementary feeding counseling
during FLW home visits.
METHODS
SAMPLE
Data analysis:
• AWW and ASHA data sets were merged with household data
(households with children 6 -24 months) at the village level.
• Multivariate logistic models were specified based on
theoretical considerations, using various independent
variables:
• ln[P/(1-P)] = α0+ α1Controls + α2Supply-side determinants +
α3Demand-side determinants
• P is the probability that mothers of children 6-24 months
were exposed to CF counseling from AWW or ASHA at
home in the last 3 months.
• Control variables: block of residence, child age
• Supply-side determinants: AWW and ASHA caste,
education, experience, workload, motivation, incentives,
training, knowledge, supervision, and role clarity (whether
AWWs and ASHAs agree on their roles in CF counseling).
• Demand-side determinants: maternal caste, education,
socioeconomic status, child age, gender, and number of
children <5 years.
AWW responsibilities
• Provide food supplements
to preganant and lactating
women and children 6mo-
6 years
• Provide pre-school
education for 3-6 years
children
• Conduct health and
nutrition group meetings at
village centre
• Facilitate immunization
• Identify and make referrals
of SAM children
• Conduct home visits to
counsel on child feeding
ASHA responsibilities
• Counsel women on birth
preparedness, importance of
safe delivery, immunization,
child feeding and
contraception.
• Mobilize community and
facilitate access to health
services (immunization, ANC,
PNC, etc.)
• Provide primary medical care
for ailments such as diarrhea,
fevers and minor injuries
• Conduct home visits to
counsel on child feeding
Outcome variable: Exposure to complementary feeding
counseling - Of the 92% of mothers who got at least one FLW
home visit in the last three months, only 32% were exposed to
complementary feeding counseling.
RESULTS
37% FLWs concur on the responsibility of AWWs and ASHAs in
providing CF counseling
DEMAND-SIDE
DETERMINANTS
SUPPLY-SIDE
DETERMINANTS
Exposure to
CF
counselling
Motivation
Reason to be FLW
Knowledge
(Scale: 0-9)
FLW
Education Experience
Workload
No. of
activities
(Scale: 0-22)
Training
Socioeconomic
status
Household
Maternal
Education
Child age
Child gender
Households
and FLW caste
Supervision
No. of children
under five
Theoretical Framework
Frontline Worker Characteristics, Odisha (N=607)
Anganwadi
worker
Accredited
Social Health
Activist
Mean +SD/% Mean +SD/%
Age (years) 39.5 + 8.2 23.8 + 3.3
Work experience (years) 13.6 + 7.7 6.2 + 2.1
Education level
Middle school (6–8 grade) 30.9 60.1
Secondary school 31.5 17.4
Senior secondary 14.8 13.5
College 22.7 2.9
Primary reason for
becoming AWW
Income generation 53.1 22.7
Serving the community 39.9 31.3
Workload (No. of activities) 16.7+ 2.2 17.3+ 2.1
Knowledge of
complementary feeding (0-9
scale) 7.4+1.3 7.9+0.9
Provide CF counselling at
Village Health and Nutrition
Day 59.8 51.7
0
2
4
6
8
10
12
14
16
OddsRatio
Factors influencing maternal exposure to CF counselling
at home
• High exposure to home visits (90%); but exposure to CF
counselling is low (32%).
• Supply-side determinants: AWW education and motivation
for income generation, and supervision were associated
with greater exposure to CF counseling at home while
higher workload was associated with lower exposure.
ASHAs motivation for income as well as to help the
community were negatively associated with maternal
exposure to CF counseling. ASHAs receiving incentives for
immunization was associated with greater exposure to CF
counseling at home.
• Maternal exposure to CF counseling t home was higher
where frontline workers concurred on their roles they play in
CF counseling.
• Demand-side determinants: Mothers with young children
(9-11 months), those with a girl child, and those who
participated in Village Health and Nutrition Days were more
likely to be exposed to CF counseling at home.
• Investments in delineating FLW roles, incentivizing or
regularizing payment for delivery of counseling, and promoting
health-service use could improve CF counseling coverage.
• Furthermore, counseling is a time intense activity and
therefore is likely to be neglected when there is greater
workload. Therefore, it is critical to examine the FLW activities
and help them organize their work.
• Addressing factors influencing service delivery and use is
imperative for achieving adequate coverage and optimizing
health and nutrition impact.
Supply-side determinants Demand-side determinants
• Bill & Melinda Gates Foundation, through Partnerships and
Opportunities to Strengthen and Harmonize Actions for
Nutrition in India (POSHAN), managed by the International
Food Policy Research Institute.
• We thank Dr. Rajani Ved , Smt. Arti Ahuja, Smt. Aswathy, Dr.
Panda, the Technical Management and Support Team,
Odisha; Sambodhi Research and Communications Pvt. Ltd.
and the field research staff for data collection; Kavita Singh,
Elizabeth Becker, Shibani Kulkarni, and Mara van den Bold.
ACKNOWLEDGEMENTS
Rasmi Avula (r.avula@cgiar.org ), Associate Research Fellow,
Poverty, Health and Nutrition Division, IFPRI