Research Methods for Nutrition Programs Scientific Reports Series No

Research Methods for Nutrition Programs Scientific Reports Series No. 1 0 of the UGC/DSA Program of F.N. Department INTEGRATION OF QUALITATIVE AND QUANTITATIVE RESEARCH FOR PROGRAM DESIGN, IMPLEMENTATION AND EVALUATION FOR NUTRITION-HEALTH PROMOTION : EXAMPLES FROM INDIA Shubhada Kanani Department of Foods and Nutrition Faculty of Family & Community Sciences A WHO Collaborating Centre for Anaemia Control and Diet Related Non-Communicable Diseases THE MAHARAJA SAYAJIRAO UNIVERSITY OF BARODA VADODARA 390 002 – INDIA 2008 Department of Foods and Nutrition The M.S. University of Baroda 0 Kanani 2008 Research Methods for Nutrition Programs FOREWORD Significant progress has been made in ou r understanding and application of various research methodologies for elucidating the nature of nutrition and public health problems in resource poor communities as well as for designing interventions and assessing their impact. In particular, the use of quantitative, qualitative and participatory research has been extensively documented. However, though descriptive studies covering various facets of nutritional disorders or diseases affecting vulnerable groups are frequently reported, much less is known of applications of integrated use of various research tools for program design and in particular, program evaluation. This report aims to bridge this gap. Our department is one of the unique departments in the field of Nutrition in the country which is teaching the course of Nutritional Anthropology; a course which sensitizes students and young researchers to the socio-cultural and gender perspective of malnutrition and poor health. Our department’s Research Methods courses and training programs also include various qualitative and participatory research tools. The efforts of Dr. Shubhada Kanani, Professor in our department and other colleagues are appreciated for enabling our department to pursue a holistic approach in public health nutrition research and training. Prof. U.V. Mani Professor, Department of Foods and Nutrition, Coordinator, UGC-DSA Programme, and Coordinator, WHO CC for Anemia Control and Diet Related Communicable Diseases Department of Foods and Nutrition The M.S. University of Baroda 1 Kanani 2008 Research Methods for Nutrition Programs ACKNOWLEDGEMENT I acknowledge with thanks the support of the UGC-DSA program of the Department of Foods and Nutrition, M.S. University of Baroda, which has made it possible to produce this scientific report focusing an application of research tools for program design and assessment. I thank the co -ordinator of the UGC-DSA program Prof. U.V. Mani and the Head of the Department Prof. Pallavi Mehta, for their encouragement and constructive inputs. I also appreciate the sincere and dedicated efforts of my students and project team mates who have been a part of the action research presented in this report, especially Vaishali Zararia, Jai Ghanekar, Meghana Daxini, Minal Sharma, Smita Maniar and the ECDLRC team. I extend my thanks to Ms. Varsha Mistry for her timely and meticulous typing of this report. My experience in the use of various qualitative and quantitative methods in program settings has been enriched through my association as technical resource person in various projects and I acknowledge them with thanks: ? ICDS-Social Assessment Project of Department of Foods and Nutrition, The M.S. University Of Baroda (Supported by Government of Gujarat and UNICEF) ? ECDLRC Project of Department of Human Development and Family Studies, The M.S. University Of Baroda (UNICEF Supported) ? JSI-Mothercare Project of Baroda Citizens Council (USAID Supported) ? Linkages Project of Academy of Educational Development (USAID supported) ? Adolescent Anemia Control Program of Government of Gujarat (supported by UNICEF and Technical Support Unit, PSM Department, Vadodara Medical College) ? WOHTRAC project at the Women’s Studies Research Center Foundation supported) (Ford Finally, all the wonderful community members of the rural and urban areas where we worked are remembered with gratitude, without whose time and willing participation all these studies would not have been possible. Dr. Shubhada Kanani Professor, Department of Foods and Nutrition Department of Foods and Nutrition The M.S. University of Baroda 2 Kanani 2008 Research Methods for Nutrition Programs CONTENT Title Page No. 4 6 21 1. 2. 3. Introduction Section-A: Qualitative and Quantitative Research: An Overview Section-B: Experiences in Use of Multiple Methods in Program Settings 3.1 3.2 Pregnancy Anaemia Control in an Urban Health System A Multi-Method Approach for Program Evaluation: Social Assessment of ICDS 21 30 3.3 Trials for Improved Practices (TIPS) for Designing Behaviour Change Communication Programs 38 3.3.1 3.3.2 The TIPS experience in Angarah Block, Ranchi (Bihar) Trial for Improved Practices (TIPS) for Evolving the ECC-SGD Program 41 48 4. Adolescent Anemia Control Program in Gujarat: The Pilot Study in Vadodara District 56 5. 6. Concluding Remarks References 68 70 Department of Foods and Nutrition The M.S. University of Baroda 3 Kanani 2008 Research Methods for Nutrition Programs INTRODUCTION Listen to the people… understand what they say Do not think you have all the answers…let them show you the way. These lines aptly sum up the spirit of qualitative research and emphasize the need for first truly understanding what community members perceive about the nutritional or health problem we are trying to address and about the programmatic interventions in place to control these problems. Whether a program is in the planning stage or has been around for many years; its imperative to collect appropriate information through a mix of methods to aid program design, facilitate implementation and ongoing monitoring and carry out the summative evaluation or annual program reviews. Qualitative or Quantitative? In the eighties and nineties, there were animated debates about which is superior: Quantitative or Qualitative Research. However, today its more a question or how to best integrate the two streams as it now accepted that both have their unique strengths and also their limitations, and the complementary use of methods from both streams strengthens the validity of the research as well as its application in program settings. This monograph is both for the novice and the experienced. The novice (could be a student, a new recruit in nutrition or health care program or a young researcher) will be helped to gain an insight into what is Qualitative (QL) and Quantitative (QN) research all about in the realm of health and nutrition. The experienced researcher or program manager will be enabled to get a deeper understanding of how QL and QN research tools have been used in practice for program design or program monitoring and evaluation, through the examples narrated in the pages that follow. All the examples and program cases cited are based on the various projects I have been associated with during the nineties and in this decade. The experiences narrated are my own blended with those of the project team members. Section -A presents a conceptual overview of the two streams of QL and QN and Section -B describes the application of QL and QN in program settings. Box 1 presents briefly some concepts in the domain of anthropology and qualitative research. Department of Foods and Nutrition The M.S. University of Baroda 4 Kanani 2008 Research Methods for Nutrition Programs Box 1 SOME CONCEPTS IN ANTHROPOLOGY Etic and Emic View The ‘etic view’ is the ‘outsider view’ or the ‘expert scientific view’ held by subject matter specialists; or the outside researchers. It may be quite uniform in various regions, such as standard definitions, or the scientific explanations for phenomena such as ‘reasons for diarrhea’; or ‘why a child loses weight’. The ‘emic view’ on the other hand, is the ‘insider view’ or the perceptions of the community people – the traditional way of looking at and understanding events and phenomena. For example, understanding people's perceptions regarding whether they think that their children under 3 years are well nourished or malnourished and why. The ways of looking at the world may vary across cultures; however, each way has a basic rationality that organizes the world coherently. The anthropological approach seeks to discover this basic rationality, this ‘emic’ system. For example, the etic view related to diet in pregnancy is that the woman should eat more to enable normal growth of the fetus. In contrast, many communities believe that the woman should practice ‘eating down in pregnancy’, i.e. eating less than before to enable easier delivery and less risk to the mother. Triangulation Triangulation refers to the process of using multiple research tools in a study or action -research with the aim of looking at the similarities and differences among the findings emerging from the various methods. Triangulation helps to strengthen the validity of the data and h elps the confirmation of important findings by different methods. Quantitative methods (QN) in research result in numeric information, which can be analyzed by accepted statistical tests and models. QN data are most often analysed on computers using standard softwares. Most QN data is presented as tables, graphs or subjected to other forms of structured analysis. Quantitative methods can be used to draw empirical conclusions about an entire population based on a sample. Survey methods usually generate quantitative information, which is gathered by asking the same set of closed -ended questions to a specific sample of a reference population, with answers recorded in numeric codes or actual numbers. However, open-ended questions with narrative answers may also be included in surveys; for example in semi-structured interviews Department of Foods and Nutrition The M.S. University of Baroda 5 Kanani 2008 Research Methods for Nutrition Programs Qualitative methods (QL) in research include usually open-ended questions and result in textual or narrative information that is most often descriptive, and presented as running text organized by selected themes or flow charts; matrices, diagrams or other visual forms. Qualitative methods cannot be used to draw statistical or empirical inference, but can be used to draw logical or analytical inference. Just as QN methods may include qualitative, open ended questions, QL tools may also include quantitative dimensions and may present data in frequencies or percentages. It is worthwhile to remember that QN is not entirely quantitative nor is QL entirely qualitative; it the relative degree to which quantification or open-endedness/narrative format is attempted in QN and QL. A. QUALITATIVE AND QUANTITATIVE RESEARCH: AN OVERVIEW There are basic differences in the world view and paradigm of the two streams which are given below. These attributes of QN and QL methods may overlap; and the differences between them may narrow down or widen depending on the purpose and the context in which research is applied. Table 1. Attributes of Quantitative and Qualitative Methods* Quantitative 1. Deductive 2. The outsider’s perspective (etic view) 3. Verification and outcome oriented 4. Measurement tends to be objective 5. Technology as instrument (the researcher is distant from data) 6. Reliable 7. Usually generalizable 8. Population oriented; larger sample sizes *Based on Steckler et. al. (1992 ) 1. Inductive 2. The insider’s perspective (emic view) 3. Discovery and process oriented 4. Measurement tends to be subjective 5. Self as instrument (the researcher is close to the data) 6. Valid 7. Usually not generalizable 8. Case oriented; smaller sample sizes Qualitative Department of Foods and Nutrition The M.S. University of Baroda 6 Kanani 2008 Research Methods for Nutrition Programs Let us understand these differences between QN and QL. Inductive and deductive: Inductive research starts from the particular and builds a model or generates a theory based on what is observed from within (for example, the various dimensions of the community views). The inductive approach of the qualitative methods is associated with discovery, description, and logical inference. The knowledge, attitudes and practices of a community or groups of communities offer a basis from which to build theory; to understand and even predict how and why people act in different situations. This is in contrast to the more predominant deductive reasoning of quantitative research, which starts out with the general - a theory, a model or hypothesis, and then fills in the explanations. Quantitative methods are largely associated with a hypothesis-driven, deductive approach to research that emphasizes prediction, control, and statistical inference. Etic and Emic: While the QN tools focus on understanding and describing the etic or ‘outside, expert’ perspective, the QL tools primarily aim to understand the emic or ‘insider, community perspective.’ Process and Outcome: While QN data seeks to verify; prove/disprove hypothesis, finds answers to the ‘what is” and focuses on outcomes; QL data is process oriented, exploratory and descriptive; seeks to find answers to the question ‘why is this so..’ and provides explanatory models. Objective and Subjective: QN research tools- being standardized, relatively structured, uniformly used by the team of researchers using standard procedures - yield predominantly numerical, objective data. QL tools - being relatively unstructured, flexible and iterative – yield relatively subjective data. However, QN research also is subjective to the extent that it is influenced by the researcher’s own world view and convictions. Similarly, with careful planning, training and methodological guidelines, QR tools can be systematically applied with minimal bias and across various sites. The researcher relatively is more distant from the data in QN as compared to QL research; in the latter, the nature of data very much depends on the researcher skills in getting information in an open-ended way. Reliability and Validity: Because of the relative objectivity and consistency of QN research where technology, equipments and structured tools are used with uniform procedures, reliability is considered strength of QN research. On the other hand, validity is considered a strength of QL data since data validity implies ‘truth’ or the reality as it exists. In the realm of public health, community nutrition and related services, its people’s view of reality that counts. QL data present the reality being investigated in all its complexity and from the community (insider) perspective. This is not to imply that QN research is not valid or that QL cannot be replicated; rather the issue is of relative strengths of each stream and the desirability of integrating the two; which is discussed later. 7 Department of Foods and Nutrition The M.S. University of Baroda Kanani 2008 Research Methods for Nutrition Programs Generalizability (external validity): QN research, through processes of random sample selection and methods for ensuring representativeness of the data, enables findings to be generalized to the larger population from which the sample is randomly drawn. QL research on the other hand, does not have the principal goal of generalization and is meant rather, to understand and elucidate in-depth and from varied dimensions, the nature of the problem being studied or the program being monitored/evaluated. However, QN studies are also done on small purposive samples and may not necessarily aim for generalization of findings. Similarly, multiple QL research studies conducted using similar protocols, can yield recognizable patterns or trends which have pred ictive abilities. The Rationale for Integration Both the qualitative and quantitative paradigms have weaknesses which, to a certain extent, are compensated for by the strengths of the other. As indicated in Table 1, the strengths of quantitative methods are that they produce factual, reliable outcome data that are usually generalizable to some larger population. The strengths of qualitative methods are that they generate rich, detailed, valid process data that usually leave the study participants' persp ectives intact. Qualitative methods also provide contextual understanding of health behaviors and use of program services. Social interventions, such as health, nutrition, education and promotion programs, are complex phenomena which require the application of multiple methodologies in order to properly understand or evaluate them. Further, the complementary use of qualitative and quantitative approaches provides a greater range of insights and perspectives and permits triangulation or the confirmation of findings by different methods, which improves the overall validity of results. The use of multiple methods also improves the quality of each of the components of data, and makes the study of greater use to the various stakeholders or the users of the data. Figure 1 illustrates four ways that qualitative and quantitative methods might be integrated in health, nutrition or education including program formulation or evaluation. These have been described by Steckler et. al, (1992). In the first possible approach (model 1) qualitative methods are used initially to help develop quantitative measures. For example, it is now common practice to conduct focus groups before developing a structured questionnaire. In a formative research study on adolescent anemia, we first conducted focus groups with school girls before developing the structured questionnaire used on larger samples to collect baseline data prior to initiating an intervention. Department of Foods and Nutrition The M.S. University of Baroda 8 Kanani 2008 Research Methods for Nutrition Programs In the second approach (model 2), a study or evaluation is predominantly quantitative and qualitative results are used to help interpret and explain the quantitative findings; or are useful to develop a subsequent qualitative research phase required for a program application. For example, in a study on feeding -health -care practices among families for under-3 year olds, we conducted first a structured baseline survey in the sampled families. The data on undesirable practices emerging from this survey was used to develop messages for behavior change in a TIPS (Trials for Improved Practices) phase that followed, which are described in the next section. The third approach (model 3) is the reverse of model 2 in that quantitative results are used to help interpret predominantly qualitative findings. For example, in an operations re search study on quality of iron-folate supplementation implementation as part of antenatal care, we observed that despite adequate supplies of IFA tablets, distribution by health functionaries was erratic and irregular. After collecting detailed process data, we also collected hemoglobin data and quantitative estimates of the average number of tablets consumed by the recipient women to obtain impact data and corroborate what we found in the process evaluation. The final possible approach (model 4) is when the two methodologies are used equally and parallel. When both methods are used equally, often the results from each approach are used to cross-validate the study findings. That is, researchers and evaluators analyze the results of each method separately and then decide if the results from each method suggest the same conclusions. If they do then the researcher's confidence in the results and conclusion is strengthened. If they do not, then the researcher tries to understand why, and tries to determine which results are the more valid. For example, formative research or program evaluation research frequently makes simultaneous use of multiple methods to be able to better formulate an intervention or get valid data on a program’s performance. We have especially found simultaneous use of multiple methods very useful in nutrition education and communication programs. Department of Foods and Nutrition The M.S. University of Baroda 9 Kanani 2008 Research Methods for Nutrition Programs Figure 1. Four possible ways of integrating qualitative and quantitative methods Model 1 Qualitative methods are used to help develop quantitative measures and instruments QUALITATIVE QUANTITATIVE RESULTS Model 2 Qualitative methods are used to help explain quantitative findings QUANTITATIVE RESULTS QUALITATIVE Model 3 Qualitative methods are used to help explain quantitative findings QUALITATIVE RESULTS QUANTITATIVE Model 4 Qualitative and quantitative methods are used equally and parallel. QUALITATIVE RESULTS QUANTITATIVE Source: Steckler et. al. (1992) Department of Foods and Nutrition The M.S. University of Baroda 10 Kanani 2008 Research Methods for Nutrition Programs The toolbox of methods – varied objectives and varied applications1 Various combinations of methods have emerged over the years, known by different names depending on the context and purpose for which they were first used. For example, Rapid Rural Appraisal or RRA; Participatory Rural Appraisal or PRA; Participatory Learning for Action or PLA. Many of these research approaches (in particular rapid appraisals) emerged because earlier applications of methods (whether qualitative or quantitative) tended to be very time -consuming and were not of practical value in program settings, especially as regards using findings to plan a program or improve an existing one. Rapid Appraisal methods were thus developed to gather important information quickly- either quantitative or qualitative information, which could be put to use without long delays. Participatory research (PR), which could be considered an offshoot of Qualitative Research, emerged out of a need felt to allow communities to be active partners in the research process rather than passive respondents merely answering a series of questions posed by the researcher. The basic philosophy of PR is empowerment; the emphasis is not just gaining information, but gaining information that will empower the community to do something in response to the problem under study. In PR, the process is owned and dominated by the community itself, rather than being dominated by the researcher. The ‘researcher’ and ‘researched’ are equal partners in the process. PR methods use a variety of techniques that allow participants to respond in their own language; to reflect and analyse their problems; to even present data in their own way. The role of the outside researcher is primarily that of a facilitator. Ownership and empowerment issues in contrast, are not usually concerns of survey research or epidemiological approaches. The Challenge of Integration of Multiple Methods2 Several challenges confront mixed-method applications. Some are given below. 1. The challenge of ‘adding on’ The use of truly complementary methods is not equivalent to simply including an "add-on" component. Simply adding a different kind of data collection method fails to capture the full potential of a complementary approach. To benefit from the full potential of complementary approaches, the research team has to understand and embody not only the skills or tools of both sets of methods, but also the principles underlying different approaches to methods, and there are major differences in these principles, and differences in outcomes, as have just seen in the basic attributes of the methods. 1 2 Scrimshaw and Gleason (1992); Allen and Yoddumnern-Attig (1994) Maxwell (1998) 11 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs 2. Selection of methods It requires considerable reflection and decision making in selecting methods in such a way that the results of each method are improved by the use of the other, and also for determining the best sequence of the use of complementary methods according to the objectives of the study. 3. Sensitization and skill development of the research team Each member of the research team needs to respect the different streams of methods. The epidemiologists fond of ‘hard data’ need not look down upon the ‘soft data’ of QL research nor use the QN methodology as a ‘standard’ or ‘norm’ for good quality research. Similarly, the anthropologists or qualitative researchers should not be skeptical of the truthfulness or validity of ‘quick superficial surveys’ and should make all efforts to be systematic and unbiased in their research approach. When one type of method follows another, there is need to orient and reorient the focus of the research team from one approach to the other and then back again. Skill in the use of various methods through proper training and ongoing supervision is essential. 4. The time and resources used The time it takes to properly analyze qualitative (ethnographic) data is considerable. If the quantitative data also is huge, adequate analysis of both will take up time. It is said that equal (if not more) time should be allocated for data analysis as for data collection. The time, monetary resources and human power used does not depend so much on whet er a research is QN or QL, h but rather on the scope, objectives, sample size, location of study sites and other logistics. 5. The expectations raised by research. This is especially the case in participatory research which aims at community empowerment and problem solving. By merely doing one PR study, one is unlikely to be able to bring about the community empowerment required for people to solve their problems or even begin the steps of problem solving, even if the problem and potential solutions are well defined by the study. Hence, is it unethical to claim that one is using PR or PLA when what is really being done is using the tools of PR but not actually following the philosophy of PR. This issue needs to be addressed; perhaps it is better to admit tha t PR tools are being used more within the paradigm of qualitative research to get better data rather than to really empower people. One solution (perhaps a partial one) is to design and carry out the research in collaboration with NGOs or representatives of local government. Efforts can be made to build research, program implementation and community participation capacity within the staff of the NGOs of government staff, so that follow-up could be provided by organizations with presence and commitment in the Department of Foods and Nutrition The M.S. University of Baroda 12 Kanani 2008 Research Methods for Nutrition Programs communities. Community capacity building is a long term process and should be viewed as such. However, the issue of raising community expectations is not limited to PRA types of studies. Survey respondents are equally eager to know in what way, if any, the study is going to benefit them and their community, and may be equally disappointed if the research team makes no follow-up or does not even share their findings and recommendations with the community. At the very least, research teams should disseminate their findings with the people who have given their time and make some efforts to quench their thirst for information by conducting awareness sessions or answering their queries. Integration of QN and QL in the Field of Public Health-Nutrition – Employing the Strengths of Anthropological and Epidemiological Approaches Nutrition is one of the most interdisciplinary fields covering virtually every area within the biological sciences, social sciences and the humanities. Yet surprisingly, nutrition s tudies and nutrition training have over the years mainly focused on food consumption and nutrient intake as related to the human body’s biological needs and how food is handled in the body (biochemical aspects) or, the economic aspects of food production a food intake. Fortunately, in recent nd years, the relationship of food to culture, and the behavioral aspects of nutrition have begun to be investigated and understood. Greater interdisciplinary collaboration between nutritionists and specialists in the social and behavioral sciences is evident today since nutrition has come to be recognized as a biosocial and bio -cultural field and not one which has only biological implications. When the study of cultures and ways of living (anthropology) is applied to the discipline of nutrition, we get rich insights regarding how communities following varied cultures and age-old traditions make their food choices and why; what is the people’s understanding of various nutritional disorders and food properties (the emic or cultural view) and how this understanding differs from our own understanding (the etic or ‘outsider’ view or ‘expert’ view). We also are better able to understand why rural, tribal or urban poor communities do not utilize some of the nutrition or health s ervices offered by the government or other organizations; as often they conflict with traditional perceptions or are perceived to be harmful rather than beneficial. In other words, the discipline of Nutrition Anthropology – through the use of open ended qualitative tools- helps enhance our understanding of not only how culture and food interact and what is its impact, but also of how to better organize and implement programs for alleviation of poor health and malnutrition in women, adolescents and children. Nutrition Epidemiology- by employing predominantly quantitative tools and statistical tests - plays an equally important role Department of Foods and Nutrition The M.S. University of Baroda 13 Kanani 2008 Research Methods for Nutrition Programs by describing the prevalence, causes and control measures of widespread nutritional disorders. A synergistic use of both epidemiological and anthropological approaches in program settings is likely to give best results. Towards Improving Quality of Care and Program Implementation Quality is a key element in the provision of health or nutrition care and a factor closely related to its effectiveness, compliance and continuity of care. The concern for quality of health care applies just as much at the program level as it does at the level of the grassroots health worker. Unfortunately, perceiving quality to be a luxury in resource-poor settings, it is not uncommon for international donors, national policy makers and program managers to focus on expansion of services and pay meager attention to the quality of those services. However, it is being increasingly realized that implementation and evaluations of programs should consider not only the quantity, accessibility and distribution of services, but also the quality aspects. It is for this reason that employing a mix of various research tools is of immense value for program design and evaluations that include all these concerns. Services for Women Despite widespread agreement on the value of providing health services of adequate quality, the care available to women in the developing world is far from satisfactory. While men may also receive poor services, women are presumed to suffer disproportionately, reflecting pervasive gender discrimination and their marginal status in many societies. Frameworks for Quality of Care (QOC) Bruce (1990) defined quality of care for family planning an d related reproductive services. Building on Bruce’s framework, Mensch (1993) specified the components of a quality of care framework within the larger domain of women’s health, which includes antenatal care. The elements of Mensch’s framework along with their corresponding indicators are given below3. 1. Provider – woman information exchange: ? conveying information to women, i.e. explanation of diagnosis, information on treatment options, the therapeutic regime and side effects of medications ? listening to a nd understanding women -background, preferences for treatment 2. Provider competence: ? accurate knowledge about the disease problem or condition ? technical proficiency in providing safe, appropriate clinical treatment ? knowledge of procedures for referring ca ses which cannot be adequately managed 3 Mensch et. al. (1993) 14 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs 3. Interpersonal relations: ? sensitive treatment of women including privacy and confidentiality ? respectful and responsive provider behavior ? encouragement of women’s participation in decision making ? avoidance of moral judgements, ? limited waiting time ? adequate amount of time spent with woman. 4. Mechanisms to encourage continuity of medical care: ? information about when to return and, if possible, other locations where services and medications can be obtained ? specific fo llow up procedures including future appointments and home visits. QOC for Safe Motherhood4 According to WHO (1996), quality of health care should be seen as a continuous provision of care throughout women’s lives, rather than as a series of isolated interventions. Quality of care for safe motherhood – as it is the most vulnerable period in a woman’s life – depends first on correctly identifying the needs of women in the community before, during and after pregnancy. Once the precise needs are known, services should be specified that meet those needs appropriately. When the services are implemented they must be evaluated to check whether they really are doing what they are supposed to do; that is, whether the needs were identified correctly and whether the services met those needs. Needs should be viewed especially from the perspective of the women using the services. Based on program evaluations and ongoing monitoring, strategies should be readjusted to improve the quality of service. WHO’s Mother –Baby Package specifies the elements that make up quality of care for safe motherhood. These elements add further details to the Mensch (1993) framework given above. 1. Promotion and protection of health: People (men and women) need to know about pregnancy and child birth and understand the danger signs and symptoms. 2. Accessibility and availability of services: Women should understand the full range of services available to them and receive care at the lowest appropriate level of the system close to where they live. 3. Acceptability of services: Women need privacy and confidentiality and may prefer to consult a female health worker. 4. Technical competence of health care providers: Technical competence depends on regular training and retraining, and on clear guidelines for clinical treatment. 4 WHO (1996) 15 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs 5. Essential supplies and equipment: Norms and standards should be established for the necessary supplies and equipment at each level of care and their availability should be ensured. 6. Quality of client-provider interaction: Providers must treat clients with respect, be responsive to their needs and avoid judgemental attitudes. 7. Information and counseling for the client: Clients should have the opportunity to talk to health care providers and should be offered guidance on any health problems identified. 8. Involvement of clients in decision -making: Providers should see clients as partners in health care and should involve them in decision -making as active participants in their own health care. 9. Comprehensiveness of care and linkages to other reproductive health services: Maternal health care is a unique opportunity to provide women with comprehensive reproductive health care and to address issues such as nutrition and sexually transmitted diseases. 10. Continuity of care and follow up: Maternal health care should be part of a continuum of care comprising pre -pregnancy, prenatal, delivery and postpartum care. Clients must be seen as people with needs that continue throughout their lives. 11. Support to health care providers: At all levels health care provide rs themselves need the back-up and economic-social support of the authorities and the communities in which they work. While Quality of Care frameworks have been developed in the areas of family planning, women’s health, and safe motherhood programs, they have not been adequately studied for nutrition related services with an inclusion of the perspectives of both the provider and the user. Nor do see much documentation of the data gathering tools which can help plan programs and evaluate them from a QOC perspective. In a published paper I wrote on QOC framework for child health, I elucidated the various methods that could be used to plan and evaluate Child Health Programs 5. An excerpt is given below. Table 2. Qualitative and Quantitative Research Methods For Planning and Evaluating QOC in Child Health Programs Indicators of Suggested Methods from the Health Sciences Quality of and Social Sciences Care Client needs are ? Key informant interviews with clients and understood and service provide rs met ? Free lists and pile sorts of needs as expressed by clients ? Proportion of planned needs met by the child health programme: Semi-structured interviews and focus group discussions (FGDs) 1 5 Kanani (1998) 16 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs 2 Indicators of Quality of Care Services are culturally appropriate; reduce gende r bias against girls Suggested Methods from the Health Sciences and Social Sciences ? FGDs with community groups and service providers ? Matrix ranking of services ? Analysis of difference - access to care for girls and boys; ? Direct observations of health service: providers and child caregivers ? Scrutiny of the routine recording system for gender disaggregated service delivery and service utilization data ? FGDs with service providers ? Direct observations of service implementation ? Review of secondary data - monthly reports 3 Service meet: short term goals and long term goals Which Program Management Components are likely to Adversely Affect Quality of Care of Reproductive Health including Antenatal and Maternal Nutrition Services? 1. Poor Training: Inadequate pre -service training as well as irregular and cursory in-service training of health care providers is an important factor underlying poor impact of many nutrition -health programs throughout the world. 2. Lack of Clarity Regarding Job Functions: Many a times the health care providers are not clear about what exactly they are expected to do as their specific job functions are not properly stated by the higher authorities. Often there is a very thin line between the job description of health workers and their supervisors, adding to the confusion regarding ‘who is to do what.’ 3. Inadequate Supervision: Inadequate supervision is frequently reported as a major factor underlying ineffectiveness of health and nutrition programs in developing countries. Lack of understanding the value of supportive supervision for building and ma intaining workers’ motivation; multiplicity of records and ineffective Management Information System (MIS) keep the programs from being successful. 4. Irregular and Inadequate Supplies and Equipment: Supplies and equipment are often not in accordance with the services offered at each level of care nor are standards set or followed to ensure the quantity and quality of supplies. For example, there is are frequent breakdowns in the supply chain of iron-folate tablets, nor is the distribution timely and need based. Weighing scales are not working; IEC material is inadequate where it is needed. 5. Poor Rapport with Clients: Health service providers who do not treat beneficiaries with respect or depict rude/indifferent behaviour, are likely to discourage people from seeking Department of Foods and Nutrition The M.S. University of Baroda 17 Kanani 2008 Research Methods for Nutrition Programs health care or nutrition services. Giving a woman iron tablets to take but not explaining what they are for, or how to manage side effects, is not likely to motivate her to take them. 6. Ineffective and Sporadic IEC: Effective health-nutrition education using the IEC approach can make individuals and communities aware of the menu of services available to them and enable them to choose the appropriate ones. However, despite being a component of all major health and nutrition programs of India, IEC remains largely ineffective and generally neglects important aspects of maternal and child nutrition. VALUE OF QL RESEARCH Specifically, let us see the usefulness of QL and open-ended ways of data gathering to develop and implement interventions relevant to the lives of the communities and sensitive to their culture; it is such interventions which are more likely to be successful. QL data helps us in many ways. ? Gain valuable insights as to why people behave the way they do; how do; they interact with the trad itional and biomedical health resources. IEC programs for example can benefit from such insights by tailoring messages to be more persuasive and culturally appropriate. Behaviors are sometimes driven by the incentive to avoid pain or sometimes by wanting t o experience a sense of pleasure and well-being; sometimes they are in accordance with beliefs and sometimes not. For example, we have often heard aged women in the family say that even though they believe that certain foods should not be eaten in pregnancy, they in practice do not adhere to this belief and allow women to eat whatever is available. Or their knowledge of the importance of ORS in diarrhea management fails to convince them to act on this knowledge. ? Direct Observation method helps us to uncove r the discrepancy between reported and real behavior. For example, in interviews, respondents rarely will truly report on hygiene behaviors and will give socially desirable answers like ‘we wash hands before feeding child’; or an anganwadi worker will say ‘I counsel mothers at the time of weighing children’. Direct observations will help us find out the real situation. ? Understand gender based differences in feeding and health care practices of boys and girls; of different time and activity patterns of men a women; intra-household food distribution nd which may not favor women and girls– all these influence the state of nutrition and health. To implement gender sensitive programs, such information is essential. ? Understand health care seeking behaviors; the perceived severity of a condition (concept of ‘normalcy’), home remedies, appropriateness of various treatments according to the people. For example, in many rural communities, locally available oil or herbal paste is rubbed on the Department of Foods and Nutrition The M.S. University of Baroda 18 Kanani 2008 Research Methods for Nutrition Programs sunken fontanel of an infan t to heal it; whereas this condition is due to dehydration (usually seen in a malnourished child). Similarly, if anemia is not perceived to be a ‘problem’ in pregnancy and thought to be ‘normal part of pregnancy’, treatment for it is not likely to be sought. ? Gain valuable understanding and information, from a socio-cultural context, as to why programs fail or succeed . For example, the quality of interaction between client ( patient) and provider (or practitioner) and nature of counseling given by provider may have a greater impact on the use of services and impact than the biological efficacy of the services given. For instance, anthropological studies help us understand why compliance of iron supplementation among pregnant women is so low despite the proven benefits of the supplements. Health personnel often do not adequately address women’s anxieties about the possible ‘harm’ of taking IFA nor do they counsel women about dealing with side effects of IFA or do not motivate them to take these supplements by explaining their benefits. Some examples of integrating the emic perspective in programs ? Promotion of optimal breast feeding practices should be built upon the existing cultural practices which anyway encourage breast feeding. Similarly, postnatal care should consider the traditional practices for the care of the lactating mother – encouraging the positive ones like compulsory isolation and rest of the new mother for the first six weeks; understanding and then addressing the food taboos in lactation. ? Complementary feeding, hygiene care and diarrhea management interventions for the below three year olds should take into account the existing beliefs and their underlying reasons and find out ways of effectively addressing the harmful practices by partnering with the community leaders and local health care practitioners. ? Antenatal care services- especially anaemia control, improving dietary intake and ensuring weight gain in pregnancy – require sensitivity to cultural beliefs of what people believe is safe and good for the mother and the unborn child. If the family elders tell the woman to eat less in pregnancy out of anxiety of prolonged or difficult labor and danger for mother and child, then these anxieties need to be resolved first before people will consider allowing the pregnant woman to eat more or eat a variety of foods. ? Diarrhea management programs need to address the prevailing perceptions among people, especially the concept that diarrhea during the teething phase is ‘normal’ and will take care of itself. Similarly, cultural concepts of what constitutes hygiene behavior and what causes diarrhea also need to be understood by educators as part of promoting ORT. ? Gender discrimination should be effectively addressed so that both boys and girls benefit fro m services. Also, women sensitive care needs to be given; if not, services will be underutilized. Department of Foods and Nutrition The M.S. University of Baroda 19 Kanani 2008 Research Methods for Nutrition Programs ? Sensitivity to the priorities that people give to their health and related problems is also necessary. For us, TT immunization or ensuring safe deliveries are important as they contribute to reduction in maternal and neonatal mortality. However, it appears equally clear that many women often do not consider maternal mortality as their main problem, even if they are aware of the risk of mortality for all women who become pregnant. It is still a relatively infrequent occurrence compared to, for example, child deaths, and women might think mortality is something over which they have little control. Therefore, they may put a higher priority on more chronic and frequent ailments that undermine the quality of their daily lives. Reconciling the two health agendas primarily means making services more appropriate. If women prefer to give birth at home because of the warm, supportive environment home birth affords and if health institutions are at a considerable distance, an alternative is to take train and support TBAs to conduct safe deliveries. In brief, then, what is required is respect and acceptance of the ethno-medical model of health, disease, and health-care and a realization that people are not ignorant in the sense of knowing nothing but that they have a rich body of knowledge which is simply different from ours. Where people are clearly misinformed or are pursuing dangerous or harmful practices, they should be educated and informed and given the alternatives of safer and better practices. The section that follows gives examples of nutrition care programs which have used multimethod approach and have been an integral part of larger health systems or nutrition -health communication projects. The value of using the toolbox of methods and factors contributing to success as well as challenges faced are pointed out. First I describe a project which assessed quality of implementation of pregnancy anemia control program in an urban health system and attempted to improve quality of implementation of this program as part of Ante-natal Care. This is followed by a Social Assessment Study of the Integrated Child Development S ervices in Gujarat State. Thereafter two studies describe the methodology of TIPS (Trials for Improved Practices) which we have found invaluable for designing IEC materials and strategies. Here we used TIPS to develop interventions for improving maternal and young child nutrition and care. Finally, I briefly present interventions planned and evaluated for adolescent anemia control using a mix of QL and QN tools. Department of Foods and Nutrition The M.S. University of Baroda 20 Kanani 2008 Research Methods for Nutrition Programs B. EXPERIENCES IN USE OF MULTIPLE METHODS IN PROGRAM SETTINGS 1. Pregnancy Anaemia Control in an Urban Health System Anaemia due to iron deficiency in pregnant women is known to increase risk of maternal mortality; low birth weight newborns and subsequent impaired mental function, growth and development in children born to these mothers. Among the various strategies for controlling anaemia, daily iron supplementation is the most beneficial and widely tested approach to control anaemia during pregnancy. However, few large scale programmes to control pregnancy anaemia have been found to b e operationally effective. Research evidence from developing countries clearly points out to several drawbacks in the health system as being the primary factor responsible for poor quality of care in the government implemented anaemia control programme. For example, factors influencing beneficiary compliance and poor quality of care in iron supplementation programmes have been reviewed in literature 6. The health service provider related factors which adversely affect quality of implementation of anaemia control programmes include : low priority, lack of political commitment and financial support given to iron supplementation programmes at the government level, inadequate training of health functionaries and their supervisors on anaemia and the field level implementation of the anaemia control program, inadequate supplies or unevenly distributed iron tablets, more focus on other programmes like family planning and immunization, infrequent and cursory monitoring and supervision, and insufficient availability and use of information-education-communication (IEC) material. Further, the grassroots level health functionaries also lack counselling skills to motivate and support women to complete the course of iron supplements. The client related factors as highlighted through anthropological research reveal that several pregnant women perceive anaemia as normal in pregnancy and usually do not seek treatment for anaemia. Women may also misunderstand instructions and get frustrated about the frequency and number of tablets to be consumed. They may discontinue taking the tablets due to several reasons such as side effects, fear of having big babies, belief that tablets are ‘hot’, irregular antenatal visits because of long distances from home and absence of transport facilities. They also lack family support. All these components are a part of the overall health system. Extensive programme experience clearly indicates a need for viewing the anaemia control programme in the overall context of the 6 Galloway and McGuire (1994) 21 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs health system through which it is implemented. Therefore the present health systems research intervention study was carried out in the urban health centres of the Vadodara Municipal Corporation, Vadodara, India using the IDRC/WHO (1992) health systems research approach. This study7 (supported by JSI/Mother Care/USAID) integrated qualitative and quantitative research methods in the formative research which aimed to understand perceptions of health functionaries and pregnant women regarding anaemia, as well as the drawbacks in the health system which adversely affected the quality of implementation of the anaemia control services. The intervention design was based on the findings emerging from formative research. Background The Corporation's Health System The Vadodara Municipal Corporation's Health Department offers antenatal care services at no cost to slum dwelling pregnant women through its Health Posts and Family Welfare Centres. Iron supplementation under the anaemia control program is provided at the Mater and Child Health nal (MCH) clinics held at the Health Posts and Family Welfare Centres. Under this program, pregnant women are advised to consume IFA tablets (containing 100 mg of elemental iron and 0.5 mg of folic acid) for at least 100 days. These tablets are distributed at the health facilities and also through home visits by the health functionaries. Methods The quantitative methods included estimating the haemoglobin levels of 153 pregnant women who were enrolled in the study from eight representative slum areas using the cyanemthemoglobin method, and also taking their anthropometric measurements (weight and height). This was done at enrolment (20-24 weeks of gestation) and during late pregnancy (32+ weeks). The qualitative and participatory methods used in the formative research were used with the functionaries at selected health posts in the different areas of the city (n=8 centres). Methods included key informant interviews with the Corporation’s health officials, secondary data review and scrutiny of records, focus group discussions and semi-structured interviews with the health functionaries and pregnant women, and matrix ranking/scoring exercises with grassroots level health workers (Auxiliary Nurse Midwives or ANMs). The methods conducted among the health functionaries and their supervisor was for seeking information on the position of the nutrition related services in the Corporation's antenatal care 7 Kanani, Ghanekar, and Maniar (1998). 22 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs program, implementation of these services by the health functionaries, difficulties faced by them, and the priority given to these services. The purpose of using secondary data in the present study was to obtain information regarding the availability of IEC material on the nutrition related services, e.g. charts or posters on importance of consuming IFA tablets during pregnancy, and records or registers maintained at the MCH clinics regarding the utilization of these services, e.g. total number of women receiving IFA tablets on a particular clinic day. The aim of focus groups with pregnant women was to gain information regarding their perceptions of common health problems during pregnancy, anaemia and iron supplementation, their awareness of various antenatal care services, and changes in their diet and work pattern during pregnancy. Results Formative Research Data The prevalence of anaemia among the pregnant women was very high at 88% (Haemoglobin < 11 g/dl). The percentage of women having severe anaemia (Hb<7 g/dl) was also quite high (11%). Most women had haemoglobin levels between 9 and 10 g/dl. The mean height of the women studied was 151.36 cm and the mean weight of the pregnant women at enrolment was 46.58 kg. One third women (39%) had BMI below 18.5 The findings indicated the need to focus on anaemia control and monitoring of weigh t gain during pregnancy in the ANC services. Salient findings of the qualitative and participatory research highlighting the unsatisfactory quality of iron supplementation programs are given below. Key informant interviews with health officials and functionaries and a scrutiny of the records, supervision and monitoring systems gave insight regarding the functioning of the IFA supplementation program. ? Supply of IFA tablets from the Central Government was regular. ? Training was a weak component especially with regard to giving adequate information on anaemia to ANMs and building their skills for effective distribution of IFA tablets to pregnant women. ? The existing IEC material covered mostly family planning and there was a total absence of materials on anaemia and benefits of iron supplementation Department of Foods and Nutrition The M.S. University of Baroda 23 Kanani 2008 Research Methods for Nutrition Programs ? The records maintained contained information only on the number of tablets distributed and not on compliance with the iron tablets. Matrix Ranking/Scoring Exercise The ANMs gave highest scores to TT immunization, distribution of IFA tablets and NHE as according to them they provided these services regularly to the women. These services were also considered beneficial by the ANMs. However, direct observations by project staff revealed that tablet distribution was in practice, irregular and unplanned. With regard to utilization, only TT immunization received the highest score whereas IFA was a ‘fairly utilized’ service. consumed by the women. Focus Group Discussions and semi-structured interviews brought to light the contrasting views of ANMs and pregnant women regarding compliance with iron supplementation as evident from the voices given below: Benefits of iron supplements ? ANMs “Many traditional people believe only in God and do not want to take any type of medicine” “I try to convince women but they just do not understand benefits of the iron tablets” ? Pregnant Women “These iron tablets give strength.... we can work more” “Dizzyness stops by taking these tablets” “These tablets improve blood.... make us feel hungry” “The child is born healthy” Distribution and receipt of iron tablets ? ANMs “Women do not want to leave their housework to come to the centre” “Often we are not able to meet the women..... they leave for work” ? Pregnant Women “Government nurses do not pay attention to us” “These tablets are free of cost so they will not be good” “ANMs should give women all types of information (regarding services)” “We do not know anything about the health centre. The health worker should come home and give us medicines” None of the informants knew whether iron tablets were regularly Department of Foods and Nutrition The M.S. University of Baroda 24 Kanani 2008 Research Methods for Nutrition Programs Compliance with iron tablets ? ANMs “Often despite explaining they do not take the tablets..... throw them away” “Many times women just do not want to eat the tablets” “If we explain, women will understand but the elders in the family do not want them to take the tablets” ? Pregnant Women “I take iron tablets but get them from Sayaji Hospital..... Mody Clinic.....Anganwadi” “In my first pregnancy I did not take tablets so had a lot of trouble..... now I am taking” It is clear that unless the iron supplementation is taken seriously by the health system and concerted efforts made to understand perceptions of women, the gap between what the women want and what the ANMs give will remain. The formative data pointed out to several lacunae in the urban health system. These drawbacks and the interventions planned to address them are summed up in Table 3. It is evident from the table that the improvements in the anaemia control programme were envisaged in the context of the ANC services which were again a part of the overall job functions of the ANMs and their supervisors. Further, the interventions took into account the competing priorities of the various health services which the health functionaries were expected to fulfil in a given time frame. Also, these interventions were not additions to their existing job functions but were rather qualitative improvements in the job functions. Response of the Health System to the Interventions for Improving Anaemia Control Program (ACP) - A Process Evaluation Process evaluation of the interventions was carried out in the following ways: ? Intensive follow-up visits to the Health Posts and Direct Observations of health functionaries at work. These aimed at assessing whether the health post staff could operationalize the modified strategies for improving the ACP (for which they had been trained) within the context of their overall responsibilities and the system in which they worked. ? Supervision and Monitoring - Checking of records and registers maintained by the ANMs and their supervisors and observations of the monthly meetings at the Family Welfare Bureau. Direct Observation Method for Time and Activity Patterns of the Functionaries During the process evaluation of the intervention, direct observations helped us to verify reported data and also gave additional insights regarding the work organization and time scheduling of the functionaries and the importance given to antenatal care and nutrition related activities in their routine work. The observations were carried out in 2 weekly cycles wherein the work of the Department of Foods and Nutrition The M.S. University of Baroda 25 Kanani 2008 Research Methods for Nutrition Programs functionaries during the entire day for all working days was observed and recorded using a semistructured format. Table 3. Lacunae in the Health System and Interventions Implemented to Address Them Lacunae in the Health System Interventions implemented ? Lack of clarity regarding job functions for ? Formulation and dissemination of specific ANC, especially anaemia control at all job functions by the health authorities to levels the health functionaries ? Low priority according to ANC and ? Training to increase awareness and to anaemia control services in the highlight the importance of nutrition government health system related ANC services with a focus on anaemia control ? Intensified monitoring of ANC services by senior health officials ? Virtually absent supervision and lack of ? Changes in the workload of supervisors monitoring of the nutrition care services by health officials to enable better supervision. ? Simple modification of the ANC and Home Visit registers to incorporate data on nutrition counseling, and distribution as well as consumption of IFA tablets by the pregnant women ? Unplanned distribution of iron ? Streamlining the distribution system: a supplements and infrequent home visits combination of clinic and home based by the functionaries approach. Minimum 3 visits and 100 IFA tablets to each pregnant woman were emphasized ? Absence of IEC material on maternal ? Production of IEC material on pregnancy nutrition services in the government anaemia health system, especially maternal ? Training of ANMs and their supervisors in anaemia counseling skills ? Incorporation of the use of IEC material in the routine job functions of the ANMs Our observations threw light on the nature of functioning of ANMs, their supervisors and the Medical Officer (LMO) of the centre as summarized below. 1. Many of the health functionaries did not come on time (9 am) to the Health Post. On most days the LMOs did no t come at 9 am and they left early. The functionaries left at 5 pm on almost all days but often during the afternoon they did not do any work and often chatted with each other till 5 pm. All the Health Post staff took at least a day’s leave during the week long observation period. 2. One Health Post suffered from staff shortage as 2 ANMs were transferred to another Health Post. 3. Considerable time was expended in completing entries in a lot of registers, with ANMs often transferring beneficiaries’ names from one register to another. In one Health Post, the staff spent an entire week preparing their monthly report. As their LMO was absent, one of them 26 Department of Foods and Nutrition The M.S. University of Baroda Kanani 2008 Research Methods for Nutrition Programs tried to prepare the report but got confused about what to fill in and hence she asked for advice from he r colleagues, and filled in whatever she could; in places entering incorrect information. 4. At the Health Post where the vaccinator did the vaccination, he came only for 2 hours during the vaccination period and the FHWs were dissatisfied that nobody said anything to him despite the fact that he did not come for the specified period of time. 5. As regards iron tablet distribution, iron tablets were observed to be given to women only during the MCH clinic and rarely through home visits. During the follow up visits to the Health Posts, informal conversations were carried out with the functionaries. Their frequent responses to us as we interacted with them during one year are summarized below, with our comments in parentheses. ? We have a lot of work such as surveying our areas, filling up various registers; visiting slums for distribution of iron tablets, ORS sachets, oral pills and condoms and immunizing children. We have a large population (approximately 10,000 per worker) to cover, and unless it is reduced, it is impossible for us to do good quality work and achieve the family planning targets. In fact, clarifying our job functions has increased our work. (This statement was made despite the fact that the Lady Medical Officers heading the health posts and the Chief of the Health department had reiterated to them several times, “These activities for anemia control and good ante-natal care are nothing new ...you are any way expected to perform them” ? We are constantly busy with so many unexpected, unplanned activities to perform in between our routine work because of number of vertical campaigns or other programs such as pulse polio campaign, school health program, malaria control program, and leprosy elimination campaign. These programs take up a lot of o time as we have to plan before for the ur program and do pre -program preparation. During the implementation all our time is devoted to it and after the program gets over we prepare the reports. Also, we have our routine activities of family planning, arranging medical camps, and routine immunization work. So where is the time to use the flip chart on anaemia or to write in the daily diaries? We cannot make any schedules for our work. We do not even remember what we did last week. (The movement register wa s supposed to be filled every time the health functionaries went out of the Health Post for some work. This included visits to their respective field areas and to private practitioners’ clinics/hospitals for taking down the number of family planning opera tion cases. In the movement register, we noted that the entries were incomplete. Many a times they asked their colleagues to fill the movement register for them. ? Pregnant women in the slums do not consume the iron tablets even though we make visits to the ir houses. Some women do not take iron tablets at all because they are ignorant, have Department of Foods and Nutrition The M.S. University of Baroda 27 Kanani 2008 Research Methods for Nutrition Programs cultural beliefs and sometimes their mothers-in-law do not permit them to take the tablets. (However, though this was partly true, our direct observations of functionarie s and interaction with women revealed that contacts with women and counseling efforts were few and far between.) Observation of Monthly Meetings The staff of all Health Posts attended a meeting on second of every month at the Family Welfare Bureau. The purpose of these meetings was the assessment of work carried out by the Health Posts in the previous month. They also received their salaries on this day. We observed that the Family Welfare Medical Officer asked ANMs of each center only regarding their performance of family planning activities and survey of households in their respective areas. She did not ask about other MCH activities, including distribution of iron tablets to pregnant women. Regarding immunization she told them to vaccinate children and women whereas often the vaccinator did not arrive at the health posts. One FHW angrily commented “Kitna bhi kiya to daant milti hain. Sab FP ka hi dekhte hain. Kitna clinic kiya, kitna iron diya, koi nahin poochhta”(How much ever work we do, we get sco lded. Everybody asks about family planning targets achieved. No one asks about how many (ANC) clinics we have conducted or how many iron tablets we have distributed). Exit interviews of the pregnant and lactating women who visited the MCH clinics In order to assess the type and quality of antenatal care given through the Health Posts, a total of 148 exit interviews were conducted with women who visited the MCH clinics at Health Posts. Specifically the purpose of these exit interviews was to elicit information from the women regarding the types of services and advice received by them at the clinic especially with regard to ANC services and IFA supplementation. After a few interviews, it became evident that rarely do pregnant women come to the clinic but several lactating women come for their child’s immunization. Hence it was decided to conduct exit interviews with lactating women to find out what services they received during their pregnancy in the recent past. Results of the exit interviews are summarized below: It was found that out of the 148 women, 14 were visiting the Health Post for TT immunization during their current pregnancy and the rest were mostly lactating women who came for vaccinating their children. As regards the lactating women (having children below 1 year of age), only 11 had visited the Health Post during their pregnancies. Thus out of the 148 women interviewed only 25 (17%) women visited the Health Posts during pregnancy for TT vaccination (n=12), for checkup and TT vaccination (n=12), for checkup only (n=1). Of these 25 women, a majority (n=11) had visited the clinic only once, 8 twice, and 6 of them came to the clinic thrice or Department of Foods and Nutrition The M.S. University of Baroda 28 Kanani 2008 Research Methods for Nutrition Programs more. The women visited the MCH clinic mostly during late second trimester or third trimester. Many of them did not know that antenatal checkup was done at the MCH clinics, as evident below in their own words: “ Ahi tapas thay chhe aevu khabar j nathi, balak ni rasi muke chhe, etli khabar chhe” (I did not know at all that ANC checkup is done here, I only knew that child immunization is done) The exit interview data clearly reveals that the weekly MCH are really child immunization centres where care of women is neglected. The community perceives these clinics as a place where children are supposed to be brought for immunization. A few women in the exit interview did say however that a few ANMs and LMOs asked them to come to the centre for ANC checkup, immunization and IFA. With regard to MCH clinics as a source of IFA tablets, women who come to clinics do receive the tablets but rarely the full course firstly because they do not make the requisite number of clinic visits and secondly home visits are infrequently made by the FHWs. Shortage of supply of IFA is a problem but less so; erratic distribution because of low priority of this program was a more important factor. Only one third women received 50 tablets; the others received fewer tablets. Among the women who received tablets, consumption of tablets varied from ‘negligible’ to ‘the full course’. One reason could be the several misconceptions regarding the tablets and lack of counselling as evident from exit interviews. “Mane kidhu ke shakti ni goli chhe, ratre jamya pachhi levani” (I was told that they are strength giving tablets, to be consu med after dinner). “Koi salah nathi aapi, lakhwama padya chhe” (No instructions were given, they are busy writing). “Khali goli aapi, kasu kahyu nathi” (They just gave tablets, didn’t give any instructions). Direct observations of the MCH clinics corroborated the data of the exit interviews. The beneficiary perspective was also studied post intervention but is not reported here. This study continued into the advocacy phase which included a dialogue with the State Government authorities and resu lted in more specific guidelines for anemia control. Though the RCH program accords priority to anemia control in principle, in practice it continues to be poorly implemented. Department of Foods and Nutrition The M.S. University of Baroda 29 Kanani 2008 Research Methods for Nutrition Programs Integration Of Research Tools: Advantages And Challenges Faced in this project On the plus side, integration of qualitative and quantitative methods validated the data from different sources and greatly enriched the data by giving us several perspectives of the health system, of the anemia control program within the system and on th e other side, the perceptions of women and their family members, in their own words. Especially valuable was the use of direct observations and exit interviews to get a sense of the quality of care of these programs during the process evaluation and to make us forcefully realize that program sustainability of any intervention or innovation is not possible unless it becomes an integral part of the system and is supported by it. But there were challenges to be met. Using a multiplicity of methods greatly in creases the time required for documentation and analysis which should be budgeted in as we go along or else we will drown in the data. Translators who know both English and the local language should be a part of the team from the beginning. Also, training and practice, and more practice is an absolute must. We often wished we had more practice and felt lost at times. But our training helped. Also at times our high hopes from a method were not entirely met, but again the flexible, iterative nature of our research helped us to overcome methodological limitations to the extent possible. 2. A Multi-Method Approach for Program Evaluation: Social Assessment of ICDS 8 The Integrated Child Development Services (ICDS) is the largest national program for child survival, health and nutrition as well as for women’s health and development. The impact of ICDS on nutritional and health status of women and children is dependent upon full utilization of all ICDS services by beneficiaries, which in turn depends upon quality of care and management of ICDS by functionaries. We with UNICEF (GOG) support carried out a Social Assessment of the Integrated Child Development Services (ICDS), in Gujarat from . Specifically the study aimed to determine – ? the accessibility, quality and utilization of ICDS services by the beneficiary communities and their contribution to ICDS; ? the perceptions of ICDS functionaries-Child Development Project Officers (CDPOs), Supervisors, Anganwadi Workers (AWWs) regarding the administration of ICDS and its effect on community utilization and impact; ? maternal and child health care and nutrition: beliefs and practices as expressed by mothers. 8 Kanani and Zararia (1996) 30 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs The overarching goal was to generate data which the Government of Gujarat, in partnership with other concerned organizations, could use to improve the program with regard to quality of care and to empower families to take measures to reduce maternal and child malnutrition. Though this study was conducted about a decade ago, the valuable information and insights it generated (not only about ICDS as people view it but also on effective use of multiple methods of gathering data), is as relevant today as it was at that time. In fact, our current field experience suggests that little has changed in ICDS on the ground over the years. Methodology A key strategy used in this program evaluation study was to build capacity among ICDS functionaries themselves by training them to conduct Social Assessment (SA) and guiding them during data collection. Thus, 5 teams of ICDS supervisors in addition to the Foods & Nutrition (M S University) Department resource team, conducted SA with women and men, community leaders and ICDS functionaries in 5 regions of Gujarat state: Chhota Udepur (tribal), Danta (drought prone-rural), Dwarka (coastal), Viramgam (rural) and Vadodara (urban). Two anganwadi centres per site and their field areas were included in the sample (10 AWCs). Each team was assigned Anganwadi Centers (AWCs) other than their own in a nearby region to avoid bias. Further, the functionary perspective was also obtained by the external M S University team. Training for SA was accomplished through two workshops - one for QR/PR data collection and one for data analysis. Modules in Gujarati, regarding objectives and use of the various methods, were given to each team. A mix of qualitative and participatory (QR/PR) methods were used to get data from varied perspectives as outlined in Table 4. Table 4. Sample and Tools of Social Assessment Research Tools Objectiv e: To obtain Source of Information community perceptions on the followingBeneficiary Perspective Focus Group ? Infant and child feeding ? Pregnant and Discussions with practices Lactating women Mothers# ? Common illnesses prevalent ? Mothers of children among infants and below 3 years preschoolers ? Childcare during illness Matrix Ranking# ? Accessibility/availability and ? Pregnant and ? Utilization of all ICDS Lactating women services by the different ? Mothers of children beneficiary groups below 3 years Key Informant ? ICDS Services available and ? Community leaders Interviews with utilized in the community ? Individuals Preference ? Community help to ICDS knowledgeable 31 Sr No. A 1 Number of Methods (All 5 areas) 18 2 13 3 30 Department of Foods and Nutrition The M.S. University of Baroda Kanani 2008 Research Methods for Nutrition Programs Sr No. Research Tools Objectiv e: To obtain community perceptions on the following? Suggestions for improvement of ICDS Source of Information Number of Methods (All 5 areas) Ranking 4 Semi-Structured Interviews with Preference Ranking Community Mapping# about ICDS ? Pregnant and Lactating women ? Mothers of children below 3 years ? Community members, especially women 113 5 6 B 1 2 ? Community mapping and identification of ‘poor’ households - cultural criteria of poverty ? Reach of ICDS to the most needy ? Community contribution to ICDS Venn Diagram ? Various health care facilities (‘Samosa’ available to the community Diagram)# especially health functionaries ? Relative importance of ICDS fun ctionaries in the health care system of the community Functionary Perspective Observation ? Quality of care of ICDS Checklist Services Semi-Structured Interviews with Anganwadi Workers Focus Group Discussion with Supervisors# ? Knowledge, attitudes and skills of Anganwadi workers regarding execution of ICDS Services and community participation in ICDS ? Suggestions for improvement of the program 4 ? Community members 4 ? Anganwadis selected for the Social Assessment ? Anganwadi Workers 10 10 3 ? Supervisors 4 # These are group based methods. Each group consisted of 10-12 participants Results The results are summed up in terms of profile of study areas, availability, and utilization of ICDS, contribution to ICDS; and management issues. Finally, specific strategies are recommended to improve the program. Profile : The study areas whether rural, tribal, coastal or urban - comprised chiefly socioeconomically deprived communities. From the Venn diagrams, it was evident that a variety of allopathic and indigenou s health practitioners (an average of 18) were available in each community studied, who can be motivated and trained to join hands with ICDS for health care of people. Attributes of practitioners which made them popular among people were stated as: Department of Foods and Nutrition The M.S. University of Baroda 32 Kanani 2008 Research Methods for Nutrition Programs ‘good’ (effective) treatment, availability even in emergency, inexpensive/free service and rapport with people. The community mapping exercise revealed that the Anganwadi Centers (AWCs) were usually located close to the underprivileged communities. It was usually the poorer households who availed of ICDS more than the others because of the AWW’s efforts to motivate them or because other options of health and nutrition care were not affordable. The ICDS services Matrix Ranking, Preference Ranking and Key informant interviews gave us valuable insight on availability and use of services. The more regularly available ICDS services were food supplementation, pre -primary education, immunization and growth monitoring while the least available services were vitamin A supplementation, antenatal care and referral services. Services available but not very regular were nutrition health education (NHE), medical checkup and iron-folic acid (IFA) supplementation. Even when available, services at times were not necessarily well implemented; for example, supply and distribution of iron tablets. Among the various beneficiary groups, food supplementation and pre-primary education were more available to the 3-6 year olds while immunization and growth monitoring (followed by vitamin A supplementation) were more available to 0-3 year olds. IFA supplementation, medical check up and referral services were rarely available to child beneficiaries. Most groups listed only immunization and IFA supplementation as regular services to pregnant women; followed by food supplementation and NHE. Lactating women were the most neglected beneficiary group; only a few groups mentioned food supplementation and NHE as being available to these women. Utilization of services by the beneficiaries depended on several factors. Frequently utilized services were those which were - regularly available; implemented by dedicated AWWs who motivated people to use services; an acutely felt need especially in poverty stricken areas; or, considered bene ficial. According to community members, services were poorly utilized by them if there existed a lack of awareness of the services, irregular availability or poor quality; or, implementation was done by `indifferent’ or `invisible’ functionaries. Time constraint was also a reason stated, which however, was related to perceived need or quality of services; for example, busy women spared time for immunization but not for NHE or food supplementation. ? Fig 2 gives an example of the results of the Matrix Ranking Exercise that we carried out with beneficiary groups in Chota Udepur. More the black dots next to a service, more is its availability/utilization. These dots represent stones that the group used to rank the availability Department of Foods and Nutrition The M.S. University of Baroda 33 Kanani 2008 Research Methods for Nutrition Programs of service: 8 or more (good); 5-7 (average or fair); 4 or less (poor). The discussion that followed gave us the reasons for varying availability or use of the services according to the beneficiaries themselves. The community members who participated became much better informed of ICDS services and said they would now use them. A frequent remark in matrix ranking exercise was, “So many services! We did not know they existed!”. Department of Foods and Nutrition The M.S. University of Baroda 34 Kanani 2008 Research Methods for Nutrition Programs Fig 2 – Matrix Ranking in Chhota Udepur Department of Foods and Nutrition The M.S. University of Baroda 35 Kanani 2008 Research Methods for Nutrition Programs Contribution of communities to ICDS, in the form of voluntary time, materials to run the AWCs and organization of special events, was forthcoming in those areas in which the AWCs were running satisfactorily according to the people; where the AWW was motivated and in close contact with the people. NGOs also helped such AWCs. Community contributions however were constrained by factors like poverty, lack of time or attitude of some community members that it is a ‘Government program and hence they alone will run it’. Administration and management of ICDS was a key factor affecting quality of care which in turn influenced utilization and impact of services in communities: ? Training of ICDS functionaries is constantly reviewed and improved yet it was stated to be inadequate by functionaries in terms of developing requisite skills for field level implementation; supervision and monitoring to ensure quality of care. Absence of two way communication between field functionaries and trainers often made sections of the training irrelevant to their actual job functions. ? Other factors adversely affecting quality of care in ICDS were o infrastructure related; e.g. absence of basic materials to run AWCs, poor quality of food ingredients, lack of NHE materials o functionary and beneficiary related; e.g. overburdened AWW, indifferent doctors, less available ANMs, non co-operative mothers o monitoring and supervision related; e.g. lack of positive support and resources to AWWs from supervisors, infrequent supervision, focus of records on quantity not quality of service. Traditional breast feeding, weaning and health care practices appear to have undergone little change over time, with several deleterious weaning practices still widely prevalent in the impoverished communities. However, frequent community contacts by ICDS functionaries do appear to bring about favourable changes. Child morbidities like diarrhoea, upper respiratory tract infections and fever continued to top the list; varied treatment seeking behaviours were reported for these illnesses. The recommendations that emerged from the ICDS evaluation are applicable today as well since problems facing ICDS have not markedly changed. The comments in italics in parenthesis are added by me in light of current challenges in ICDS. Department of Foods and Nutrition The M.S. University of Baroda 36 Kanani 2008 Research Methods for Nutrition Programs Key Recommendations to Improve ICDS Sr. Recommendations Specific Strategies No. A. Human Power Development 1 Equip functionaries from ? Review and modify curriculum (The training duration CDPOs to anganwadi is too less for volume of training content) workers with skills in ? Training of trainer - focus on problem solving at service delivery and field level interpersonal ? Link training with programme implementa relationships through tion : Two way feedback training, that is; ? Decentralize training for all the above strategies ? practical and field based, ? matches their actual job functions, ? is conducted by competent trainers 2 Ensure supervision is ? Train supervisors in supportive skills supportive, provides on- ? Monitor quality and frequency of supervision the-job training, ? Review supervisor’s workload to ensure adequate monitors quality of care supervision (Fill in vacant positions,of supervisors and and not merely other cadres) quantitative achievements 3 Motivate grass roots ? Implement an impartial and merit based reward functionaries and system for good performance reward good ? Motivate through appreciation, recognition, performance opportunities for self development Expect realistic ? Improve their working conditions-remuneration, performance, do not facilities for mobility in field work, maintenance of burden anganwadi basic infrastructure worker with too many ? Set upper limits of time which AWW should devote to duties, especially non -ICDS functions. outside of ICDS B. Infrastructural Development 1 Equip anganwadies to ? Ensure anganwadi centres have enough space and deliver services with a are not too far from community focus on quality of care ? Provide basic facilities to execute services ? Provide basic civic amenities at AWC: water, toilet facility ? Have adequate maintenance a nd repair funds 2 Improve logistics of ? Ensure timely and adequate procurement of supplies supplies - especially food ingredients, vitamin A, IFA tablets and ensure need based distribution C. Monitoring and Evaluation (M&E) 1 Include in M&E ? Sensitize decision makers, senior programme indicators of quantitative implementors and field level functionaries to the need achievements as well as for both process and impact evaluation of ICDS quality of care ? Review and modify MIS to include both process and impact indicators ? Focus on development of practical skills for M&E in training ? Involve ICDS functionaries (especially supervisors) in participatory evaluation of ICDS Department of Foods and Nutrition The M.S. University of Baroda 37 Kanani 2008 Research Methods for Nutrition Programs Sr. Recommendations Specific Strategies No. D. Community Participation and Empowerment 1 Ensure that ? Communicate to people all the available ICDS communities use ICDS services and their benefits through interpersonal and services, contribute to mass media ICDS wherever possible ? Ensure that services are regular and well and are facilitated to implemented improve household ? Make specific requests to beneficiaries, community health and nutrition leaders or local organizations for contribution to ICDS practices ? Ensure that nutrition health education (NHE) focuses on communication of messages especially care giving behaviour of mothers ? Ensure that home level counseling is an important component of NHE ? Prioritize NHE in field work, in M&E E. Government Commitment Towards Improved ICDS 1 Government authorities ? Constitute an advisory group or task force comprising at all levels need to of decision makers, programme implementators, prioritize ICDS and experts from universities and NGOs to advise ensure adequate government and facilitate action resources for its ? Bring about institutional changes in the ICDS system improvement so as to make it possible to implement changes such as modified expected job tasks of functionaries, budgetary provisions, improving trainer competencies, changes in the monitoring system and others. 3. Trials for Improved Practices (TIPS) for Designing Behaviour Change C ommunication Programs TIPS: What it is all about? Developing strategies to change behavior related to nutrition or health and care practices in a community requires knowledge of nutrition-health-care problems in vulnerable groups and information about improved practices that are acceptable and feasible for families. All practices should be tested, ideally in people’s homes, before they are recommended and before IEC materials and communication strategies are put in place to change behaviors. One effective methodology to accomplish this purpose is called Trials for Improved Practices referred to as TIPS. Thus, Trials of Improved Practices (TIPS) is an important step in strategy development for behavior change in nutrition-health communication. In the TIPS approach, the recommendations are tested in homes by ? Discussing the suggested improved practices – all the options to be recommended for behaviour change Department of Foods and Nutrition The M.S. University of Baroda 38 Kanani 2008 Research Methods for Nutrition Programs ? Negotiating specific practice changes and helping the target group (e.g. women) to decide to try out a few practices from the options suggested ? Following up to record the experiences of target groups with the new practices and their reactions. The families participate in identifying ways in which practices can be improved and sustained over time by them. On the basis of the TIPS experience, planners and implementers are better equipped to design nutrition – health communication materials and implement strategies that are likely to have impact on behavior change. Thus behavior change communication (BCC) strategies can greatly benefit by including TIPS in the planning process. Not doing so could mean that BCC efforts may not really be able to change behavior even if they increase knowledge and expensive mistakes could be made by producing ineffective materials and spending time on activities that do not work. I had the good fortune to be associated with the AED-LINKAGES project (USAID supported) in 9 selected rural sites in Bihar as part of the technical resource team and was primarily responsible for developing the TIPS strategy, data collection, training and documentation. Subsequently, as a TIPS trainer and facilitator, I again could enrich my experience in using TIPS in a project of ECDLRC of the M.S. University of Baroda 10. Presented in the pages that fo llow a summary of these two TIPS experiences and the methodology followed by us in Ranchi (Bihar) and Vadodara (Gujarat). The Ranchi TIPS aimed at improving maternal nutrition practices and the Vadodara TIPS aimed at improving child nutrition, health and care-giving behaviors. The objectives of TIPS are ? To test individual responses to recommendations for improving practices and thereby determine which are the most feasible and acceptable. ? To investigate the constraints on individual’s willingness to change nutrition -health patterns and their motivations for trying and sustaining new practices. The primary aim of TIPS is to understand contextual factors, which may hamper behaviour change, as well as factors, which may facilitate behaviour change. The information and insights obtained from TIPS process helps in evolving materials and strategies, which are relevant, and target the most likely resistance of the target group. The advantage of TIPS, particularly for refining recommendations, is that the mothers/caregivers are given a choice of recommended practices to try. Families also participate in identifying ways by which feeding or caregiving practices can be improved. The mother/caregiver is subsequently 9 10 Kanani (1998) ECDLRC (2003) 39 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs followed up to assess whether the recommended practices agreed upon were tried. The mother/caregiver is asked to give feedback on tried behaviors, modifications made, if any and reasons for not trying. Box 2 clarifies some of the doubts raised with regard to TIPS by those unfamiliar with this methodology. Box 2 Questions Commonly Asked About TIPS 1. The period given for behaviour change trials is only 2 -3 weeks. How can one reliably conclude anything from the TIPS results given this short period? The trials are only what the name suggests : A trying out of a new practice by the women and families. TIPS have a specific limited purpose of learning from the experiences of those who have tried the new or modified behaviours so as to recommend better, more relev and ant feasible behaviour changes in long term IEC strategies. For the purpose of trying out a behaviour at home, (especially since most suggested practice changes are simple modifications of existing behaviours), a 2 to 3 weeks trial period is sufficien t. 2. Can one learn anything about sustainability of the behaviour change; especially since the TIPS last for only a few weeks and further, involve intensive one-to-one counseling which may not be feasible in a larger program with limited staff? Again, testing the sustainability of the behaviour change is not the aim of TIPS. For sustainability, several programmatic factors are important which have to be looked at in the long term program. However, lessons learnt from TIPS are valuable for ensuring that the factors contributing to successful and long term behaviour change do find a place in IEC strategies, such as: ? the types of communication and counseling skills required to be given to the educators through training; ? types of visuals likely to be more effective in IEC materials; ? role of the family as the support system for behaviour change. 3. Sample sizes are small in TIPS. Can they yield valid data? As the purpose of TIPS is testing a short term behaviour trial and as the process involves intensive one-to-one interaction and counseling with the family, large sample sizes are not essential nor feasible for TIPS. Further, a small sample that is representative of the variability in ethnicity, or other socio-economic differences of the region, gives data that are valid as far as the objectives of TIPS are concerned. Source: Kanani 1998 Methodology of TIPS TIPS is usually preceded by formative research which helps to understand the community beliefs and practices with the underlying reasons, and the socio-cultural context in which behaviors take place. Ex isting data from secondary sources like available reports as well as new Department of Foods and Nutrition The M.S. University of Baroda 40 Kanani 2008 Research Methods for Nutrition Programs data from rapid appraisals (quantitative and qualitative) are included in the initial formative research phase. They help to decide which are the undesirable practices that need to change and what is the specific counseling content for each targeted behavior change which will be conveyed to the participating households. The preparatory phase prior to TIPS thus involves the following: o Deciding the specific behaviors targeted for change in TIPS based on the formative research – list of options. o Preparing a counseling guide for each behavior which includes message content, motivators for encouraging change, likely resistance factors which may obstruct change and counseling points to overcome such resistance. o Preparing the data collection tools – the protocols for TIPS o Selecting the participating households. o Training the field teams in the application of the TIPS method and its detailed documentation. o Deciding the logistics of field work, roles of supervising teams and other arrangements. Implementing TIPS: The behavior change trials usually last for about 6 weeks of which about 23 weeks is the trial period during which the families to implement the new practices. The week before the trial comprises the counseling and negotiation phase and the week after the trial is the follow up phase. In the TIPS studies in selected rural sites in Ranchi and in rural-urban-tribal sites near Vadodara, the following was the sequence of events: Round I (1 week) Pre-trial Counseling and Behavior Selection 3 week Trial Period Round II (1 week) Post-trial Feedback on Behaviors Tried and Not Tried I. The TIPS Experience in Angarah Block, Ranchi (Bihar) 11 TIPS was carried out by the AED-LINKAGES team jointly with CARE-Bihar which was a LINKAGES partner and was implementing the project in Angarah block, Ranchi, Bihar. It was initiated after the formative research phase and other preparatory work as described earlier. The 11 Kanani (1998) Department of Foods and Nutrition The M.S. University of Baroda 41 Kanani 2008 Research Methods for Nutrition Programs main objective was to bring about favorable improvements in dietary practices of pregnant and lactating women. TIPS in the field consisted of the following broad steps: ? Training field personnel. ? Identifying study informants (pregnant or lactating women). ? The first visit to the household of the selected women– a rapid assessment regarding family background, dietary patterns; frequency of intake of certain protective fruits and vegetables, and other essential data. Based on this information, counselors decided on which behaviors to recommend to the woman; counseled the woman and other family members regarding the various behavior change options, got their reactions and negotiated trial practices; that is, persuaded women to agree to try out some of the options presented (Round I). ? Debriefing sessions were regularly held with the field team to discuss reactions of community women to the recommendations and options selected for trial. ? After the trial period, follow-up visits to the same households to assess reactions of clients to the new practices – whether practices tried out or not; with reasons. ? Analysis of results and their application to designing the BCC materials and strategy. Methods Site and Sample Following formative research surveys, 32 pregnant and 30 lactating women were visited for TIPS in Round I. Of these, in Round II, 24 pregnant and 27 lactating women could be contacted. The format given below was followed for the trials in Round I (pre -trial) and Round II (post-trial). Highlights of Training given to the field teams and other tasks Pre -Trial Training (before Round I) research trials ? Communication and Counseling questions in the interviews: role play protocols ? Preparing for the field visits; logistics Post-trial Training (before Round II) ? How to obtain feedback plays using the protocols ? Documentation of feedback sessions and preliminary assessment of findings English ? Sharing the results of the formative ? Importance of feedback from women ? Introduction to the concepts of behavior ? Familiarization with the protocols – role ? Practice in communication skill; how to ask ? Debriefing ? Pretesting the protocols and modifying ? Translation issues – local language to Department of Foods and Nutrition The M.S. University of Baroda 42 Kanani 2008 Research Methods for Nutrition Programs Resource Material Given to Each Team Each team was given a counseling guide. The counseling guide contained the following guidelines for each behavior selected for the trials. 1. The stepwise process of obtaining relevant information from each woman; counseling her regarding the benefits of the proposed behavior as well as the hazards of the current behavior; negotiating with her and facilitating her to accept selected behaviors for trial, and finally also enlisting the support of family members present. 2. A matrix for each behavior giving: 1 The hazards of the current ‘problem behavior’ 2 Proposed behavior change 3 Benefits of proposed behavior - to mother - to child Data Management and Analysis Being primarily behavior change oriented and qualitative in nature, with considerable variation in responses, the data were manually analyzed. The aim of the analysis was to determine which behaviors changed/did not change in the trials and why; the common trends in responses and the variations; the similarities and differences in behavior change among different groups; nature of support of family members. An important purpose was also to learn important lessons for intervention strategy. 4 Expected objections (resistance to change) 5 Response to resistance; convincing for change Findings of Tips Only a few illustrative results are given here from a methodological perspective. As an example, the following table shows the behaviors tried and not tried by the pregnant women. Table 5. Frequent Responses of Pregnant Women Who Tried the Various Behaviours (N=24) Sr. No. Behaviour Women who tried behavio ur (n) 18 Various ways in which behaviour was followed (n) Benefits experienced (n) Help rendered by husband or mother -in-law (n) 6 ? 6 ? Purchased saag from market Obtained from field or vegetable garden Will continue with behaviour till… (n) 6 Available in season 3 7 1 Saag (green leafy vegetables): Increase Frequency and amount ? ? ? Ate as vegetable (Bhunj ke ) Ate with rice water ( Maad) Purchased from market 7 ? ? 4 ? 4 Feel stronger Feel better (well being) Cannot experienc e benefit in short 5 Department of Foods and Nutrition The M.S. University of Baroda 43 Kanani 2008 Research Methods for Nutrition Programs Sr. No. Behaviour Women who tried behavio ur (n) Various ways in which behaviour was followed (n) Benefits experienced (n) Help rendered by husband or mother -in-law (n) Will continue with behaviour till… (n) period 2 Papaya; Increase frequency of intake; eat ripe fruit Pumpkin: Increase frequency of intake; eat ripe fruit 3 ? Ate raw papaya as vegetable 3 ? ? ? ? ? Milk production improved Cannot experienc e benefits Feel better Cannot experienc e benefits in short time 1 ? 2 ? 2 ? 2 ? encourage d her to eat Purchased from market Purchased from market Borrowed from neighbour Obtained from plant in vegetable garden; 1 ? 1 Infant grows up 2 3 6 Ate raw pumpkin as vegetable 5 3 ? ? 1 Available in season Child is delivered 2 1 4 Egg : Increase frequency of intake; eat egg yolk 13 ? ? Ate as omelette or vegetable Ate boiled egg 5 ? ? 4 ? Feel stronger Did not experience benefits Feel better (well being) 4 ? 4 2 8 ? ? Affordable Child is delivered 2 1 6 7 Corn Soya Blend (CSB): Anganwadi ration Eat your ration yourself; do not share; make monthly ration last for the month :eat CSB laddu/halwa (30 g) daily Iron folic acid tablets – one tablet daily after meal till delivery 12 ? ? Ate in the form of halwa Ate as laddu 6 2 ? ? ? Feel stronger Feel better (well being) Feel like working 6 2 1 - ? Available at AW centre 8 2 ? Feel stronger 1 ? Child is delivered 1 Application of TIPS From the TIPS Findings emerged directions for ntervention Development; in particular the I messages and communication strategy which were considered by CARE-Bihar, and are highlighted in table 6. Department of Foods and Nutrition The M.S. University of Baroda 44 Kanani 2008 Research Methods for Nutrition Programs Table 6. An Overview of the Behaviour Trials: Some Ideas for Message Content for the IEC Intervention Strategy Sr. No. 1. Behaviour Saag : Increase frequency and amount Facilitating or Motivating Factors ? Already a commonly practised behaviour ? Women experience the benefits (Less symptoms of tiredness, giddiness, nightblindness) ? Family gi ves support by plucking home available saag or buying saag ? Available in home or neighbourhood ? As it is not a ‘treat’ to be given to children, maybe promoted as especially useful for mother ? Husband purchased from market Barriers ? Popular practice of eating in ‘maad’ (liquefied rice), hence quantity eaten is less ? Supply may become a constraint because recommended behaviour is to increase frequency and amount of saag eaten Message Focus ? Saag will reduce your problems of - night blindness, tiredness ? Eat more in quantity in maad, add more dried saag ? Eat saag ‘bhunj ke’, add saag to rice,eat 2 kadchul 4-5 times / week ? Husbands and mother in-law : Help her (women) by getting saag for her, encouraging her to eat ? Eat a big piece of ripe papaya 2-3 times/week; ripe papaya will strengthen eyes, reduce night blindness; raw will not. Ripe pumpkin has similar benefits ? Good for eyes of newborn or breast feeding infant if mother eats ripe papaya or ripe pumpkin ? Husband, mother-in law: Get ripe papaya/pumpkin for her ? Encourage intake of fruit as such; in form of vegetable curry it is shared ? Good for eyes (to reduce night blindness), increasing strength ? Good for eyes of newborn infant ? Eat twice a week (buy from market and eat boiled or omelette) ? Encourage intake of whole egg because in curry form it is shared ? Husband, Mother-in law: -Encourage her to eat - m ore egg - Buy for her -Increase her share in vegetable curry 2. Papaya; Pumpkin: Increase frequency of intake; eat ripe fruit ? Eaten raw ? Not sufficiently aware of benefit of ripe papaya. Therefore, did not make adequate effort (may not like taste of ripe papaya?) ? Pumpkin believed to be harmful in early lactation ? Sell ripe fruit 3. Egg : Increase frequency of intake; eat egg yolk ? Common part of diet : if affordable by family ? Will use home available eggs or buy, if convinced of benefits ? Can be eaten by women without sharing : example; in the market itself ? Husband may purchase if counseled ? Costly, therefore frequency of intake is less ? More common to sell eggs or hatched chicks than to eat egg ? Shared if eaten as vegetable curry ? Not sufficiently aware of benefit Department of Foods and Nutrition The M.S. University of Baroda 45 Kanani 2008 Research Methods for Nutrition Programs Sr. No. 4. Behaviour Meat, Fish : Increase frequency of intake; Keep liver portion for women Facilitating or Motivating Factors ? An existing practice ? Eaten by some families if affordable Barriers ? Expensive ? Eaten infrequently in small amounts ? Women gets negligible share ? If eaten in family, liver not eaten as separate piece by woman ? Time cost : getting it even once a month ? Not aware of its benefits, hence do not make efforts to obtain. ? AWW does not reach out to remote areas (peripheral outreach poor) ? Sharing in family because of poverty ? How to cook daily ration of CSB from month’s supply is not adequately known ? Supply from government is irregular ? Low status food ? Not liked (taste) ? Perceive as difficult to digest ? Not aware of benefits ? Availability is seasonal Message Focus ? Husband, Mother-in law: increase the woman’s share in meal 5. Corn Soya Blend (CSB): Eat your ration yourself; do not share; make monthly ration last for the month :eat laddu/halwa (30 g) daily ? Is not purchased, available free from government ? Get monthly ration with oil , hence frequent visit to Anganwadi Center not needed ? CSB is mother’s special food ? Do not share with other family members ? It is required for Child the one in your womb; your breastfeeding child ? Cooking CSB : roast in oil one week’s quota, everyday make one laddu with warm water and eat it yourself 6. Madua (Ragi) Roti: Eat one roti in addition to usual meals ? Less cost ? Grown in area ? May be promoted as mother’s food ? Benefits are -Increases strength -Good for child -Strong bones (calcium rich) ? Husband, Mother-in law: ? -Encourage her to eat roti daily ? Promote as special ‘mother’s food’ Implications for strategy based on the TIPS results with pregnant and lacta ting women In terms of implications of these findings for the intervention strategy, a few recommendations emerged from the Ranchi TIPS: 1. Ensure adequate training of counselors in communication and interpersonal skills especially, benefits of a behavior and feasible ways of adopting it. 2. Ensure that the strategy allows for enough time to make frequent contacts with vulnerable women and their family members. 3. Develop simple and focused visual aids like flip charts to awaken and sustain interest of women, family and community. 4. Ensure availability of government health services by AWWs and ANMs especially distribution of IFA; and curative services for morbidity control. 5. Integrate the nutrition communication programs with ongoing programs. 6. Develop simple and effective process and impact evaluation indicators. Department of Foods and Nutrition The M.S. University of Baroda 46 Kanani 2008 Research Methods for Nutrition Programs The LINKAGES Project – The India Picture The TIPS experience described here was a part of a larger AED-LINKAGES project in India. Its useful to see what was the overall strategy of LINKAGES in India which contributed to its success. What were the factors underlying success in the BCC strategies used by LINKAGES and their PVO partners in India? 1 Each of LINKAGES’ PVO partners followed a tested sequence of steps to design and implement BCC strategies to improve infant, child, and maternal nutrition. These steps are listed below: 1. Formative research to understand reasons for sub -optimal practices, identify simple changes in practices that are affordable and culturally acceptable, and test strategies for their efficacy. Formative research involved developing and pre-testing qualitative research instruments and protocols; training interviewers; collecting information using semi-structured interviews, 24-hour food recall, observation of feeding practices, and focus group discussions. Data analysis and report of formative research formed the basis for recommending specific behavior changes appropriate to the partner sites. 2. Field trials of improved practices (TIPs) to test the recommended behaviors and identify practical and feasible actions with the target audience 3. A baseline survey to establish benchmarks on key project indicators; this chiefly consisted of quantitative indicators 4. A strategy development workshop to design a detailed implementation plan based on the formative research and field trials, outlining the BCC strategy and monitoring and evaluation plan for the project 5. Project implementation, including development of appropriate audio and visual materials, design of training and monitoring tools, training of staff and partners; 6. A final qualitative and quantitative evaluation to assess impact and review implementation processes. Over 7 years the LINKAGES project achieved improvements in infant, child, and maternal and nutrition; strengthened the BCC capacity of partners, government and nongovernmental organization (NGO) staff; and mainstreamed the LINKAGES BCC methodology into partner programs in India and beyond. Source: AED- Linkages – India Final Report (2004) Department of Foods and Nutrition The M.S. University of Baroda 47 Kanani 2008 Research Methods for Nutrition Programs II. Trial for Improved Practices (TIPS) for Evolving the ECC-SGD Program12 Care of children below three years primarily occurs at home and the primary caregiver is the mother. Therefore programs and policies need to focus on strengthening capabilities of mothers and families to care for young children, so as to promote survival, growth and development of children. In this context, it is important to understand childcare and development of infants in terms of child-rearing practices. With this perspective, the early Child Development – Learning Resource Centre, Department of Human Development and Family Studies, Faculty of Home Science (now re -named as Faculty of Family and Community Sciences), undertoo k a project on Early Childhood Care – Survival, Growth and Development (ECC-SGD). The main goal of the study was to understand prevailing care practices and evolve viable intervention and communication strategies, which could promote care behaviours for optimal growth and development of infants (age 0-2 years). Prior to designing the intervention and communication package and materials an important process of TIPS (Trial for Improved Practices) was undertaken. Dr. Shubhada Kanani (Department of Foods and Nu trition in the same faculty) was the technical expert for guiding the TIPS process. The locale of the study was three ICDS blocks of Baroda district representing urban, rural and tribal areas which included Baroda city (Urban), Padra (Rural), Chotta Udepur (Tribal). The study was conducted in three phases. In the first phase of the study, a formative and baseline survey (FR-BS) was conducted mainly to understand the magnitude and prevalence of practices related to child health, nutrition and care; in which a quantitative structured survey questionnaire was used to interview the selected respondents (not reported here). The baseline survey helped to evolve a list of 27 behaviours which needed to improve. Thus the TIPS process formed the second phase. TIPS trials were conducted for 27 behaviours, across the five care areas of Breast feeding, Complementary feeding, Hygiene practices, Health practices and Psycho-social care. In the third phase of the study, the communication package was developed on the basis of the insights and experiences gained through the TIPS process in the second phase. Preparation prior to TIPS The preparation prior to TIPS involved selecting and finalizing the behaviours for TIPS, formulation of tools and counselling matrix and a training for conducting TIPS. 12 ECDLRC (2003) 48 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs As stated, on the basis of data obtained from the FR-BS, a total of 27 behaviours critical for the survival, growth and development of infants were selected. Further, these behaviours were grouped for five age groups i.e., birth 0 -2 months, 3-5 months, 68 months, 9-12 months and 13-23 months according to the relevance of the behaviours to each age group. The selected behaviours were reviewed for their criticality by a team of interdisciplinary experts and subsequently finalized for TIPS. The next important step in the preparation for TIPS was formulation of tools for TIPS trials. A separate set of tools was prepared for Round 1 and Round 2. To aid the process of counseling the mothers and families in Round 1, an elaborate counseling matrix was also prepared for each of the optimal behaviours selected for TIPS. The counseling matrix included current practice emerging from the FR-BS, suggested optimal behaviours, benefits of practicing optimal behaviours, hazards of not practicing th em, expected resistance to behaviour change from the mother/family, and response to such resistance. Prior to conducting the trials, the ECD-LRC staff and ICDS functionaries were trained by Dr. Kanani to use the tools, counsel the mothers and document the process. A pilot study was carried out during this training programme. It provided valuable insights into the practical aspects of the TIPS procedure and tools, and accordingly required changes were made in the tools. Methodology For the TIP S trials, 10 villages from each of the study sites, i.e., urban (Baroda city), rural (Padra), and tribal (Choota Udepur) areas were selected. These 10 villages were selected from the 20 villages, which were included in the FR-BS. The criteria for selecting the mothers for TIPS were – (1) Mothers having their last born infant in any one of the age groups – 0-2 month, 3-5 months, 6 months, 9-11 months, and 12-23 -8 months (2) Pregnant mothers in the last month of their pregnancy; (3) These mothers should be ICDS beneficiaries. In Round I, 146 mothers from urban, rural and tribal areas formed the total sample for TIPS. However, in Round -II only 122 mothers could be contacted as there were quite a few dropouts due to various reasons like unavailability of mothers at home, inability to contact mothers as they were working in far away fields. The negotiation process of Round -I In the first home visit from among the selected mothers, their background information was obtained including current child rearing practices. Based on this information, the counselor identified those behaviours, which were currently not being practiced by the mother, but are Department of Foods and Nutrition The M.S. University of Baroda 49 Kanani 2008 Research Methods for Nutrition Programs critical for Survival, Growth and Development (SGD) of the infant. The counselor then selected 45 of these behaviours to recommend to mother on a trial basis. When the mother agreed to practice (some or all of these) behaviours, a trial period of three weeks was given to them. The counseling guide was very helpful in the counseling process. Feedback obtained in Round-II After the trial period, these mothers were contacted again to get their feedback on the behaviours tried out by them during the trials. During the second home visit the mothers were first asked to recall the behaviours that they had agreed to try; whether they tried/not tried the behaviours. Then, for each of the behaviours detailed information was obtained along with the reasons for change (or lack of change). To process of data collection in each of the study sites was completed within a span of one week each for Round I and II. Results The TIPS results have been summarized to get an overview of the behaviours which were most frequently recommended to mothers for trial; those most frequently (commonly) practiced and not practiced during the trials. Implications of TIPS findings for developing the communication strategy are discussed. Major outcomes ? The total number of behaviours frequently recommended to mothers in round-I was higher in the rural area, as compared to the urban and tribal areas. This suggests that mothers in the rural area did not practice several critical/optimal behaviours in all the five care areas i.e., breastfeeding, complementary feeding, hygiene, health and psychosocial care. ? A higher number of behaviours within the care area of breast feeding and complementary feeding were frequently recommended to mothers. ? The results of TIPS Round–II that revealed there was a high rate of compliance by mothers and majority of the mothers across urban, rural and tribal areas had practiced the recommended behaviours during the trials. This implies that the behaviours recommended to the mothers were practical, feasible and doable. Breast feeding ? The following behaviours were most frequently recommended: a) Initiate breast feeding within one hour of birth b) Do not feed prelacteals to the child c) Feed colostrum to the child d) Exclusively breast feed the child up to six months of age Department of Foods and Nutrition The M.S. University of Baroda 50 Kanani 2008 Research Methods for Nutrition Programs e) Empty one breast before offering the other every time while you feed ? The results of TIPS round-II show that majority of the mothers had practiced these behaviours during the trial period and hence these are amenable to change. Complementary feeding ? The following behaviours were most frequently recommended to mothers for trial: a) Start giving home -cooked food at 6 months of age. b) Increase the amount of food given c) Increase the frequency of feeding d) Give one seasonal fruit or vegetable daily e) Sit near the infant and see to it that he/she finishes given amount of food ? It was seen that majority of the mothers in the rural and tribal areas, initiated complementary feeding only between the ages of 9 to 12 months. Therefore the behaviour – “start giving home cooked food by six months of age” was highly recommended to these mothers ? Encouragingly, the results of round-II showed that majority of the mothers had tried out the frequently recommended behaviours within the care area of complementary feeding. ? However, in the tribal area, a few mothers were not able to practice behaviours – sit near the infant and see to it that he/she finishes given amount of food and give one fruit or vegetable daily to the child. One of the possible reasons could be lack of time as most of the mothers in the tribal area go out to work in the fields. However, the main reason for not giving fruit and vegetables was food restrictions based on cultural beliefs. Hygiene ? The behaviours which were most frequently recommended were: a) Wash hands with soap after stool handling, b) Wash hands with soap before feeding, c) Feed clean water with clean spoon/glass d) Cut the child’s nails regularly ? Majority of the mothers in urban area reported practicing this behaviour during the trial period. However, in the rural area and tribal areas a few mothers were not able to practice this behaviour possibly because the benefits of this behaviour are not immediate and concrete. In such a case, mothers might have failed to realize the importance of this behaviour and might have become less motivated to practice them. ? In the tribal area, the behaviour – ‘feed clean water with clean spoon/glass’ and in rural area the behaviour ‘cut the infant’s nails regularly’ were also not practiced by few mothers during the trial period as recommended. Department of Foods and Nutrition The M.S. University of Baroda 51 Kanani 2008 Research Methods for Nutrition Programs Health ? In rural and tribal areas, mothers were frequently recommended the behaviour “Get the child weighed once a month at the Anganwadi” and majority of the mothers reported practicing this behaviour during the trial. A few mothers in the rural area did not practice behaviours of continuing breastfeeding when ill and giving more home-cooked foods during illness. One of the main reasons mentioned by the mothers was the child’s refusal to eat food or to take breast milk during illness. Psychosocial care ? Following Behaviours were most frequently recommended: a) Touch and caress while breast feeding. b) Point out and label objects in surrounding environment c) Encourage the infant to talk in 2-3 word sentence ? It is interesting to note that majority of the mothers in urban, rural and tribal areas tried out these recommended behaviours during the trial period. One of the possible reasons can be that other family members supported the mother in the psychosocial care of the child and therefore, even if the mother was busy in work or did not have time, other family members practiced these behaviours related to psychosocial care. The method of home -based counseling also provided scope for involving the family members. The family members were not only counseled about the importance of recommended behaviour but also about their role in supporting the mother. A few Conclusions The Vadodara TIPS was attempted in several areas of care giving and it was found that TIPS methodology led to relatively better impact in the care area of Nutrition. It was possible for mothers to experience and observe benefits of behaviors in area of nutrition, in the short period of 2 -3 weeks. On the other hand, it was difficult to observe positive effects of most behaviors in care area of health, hygiene and psychological development in given period of time. More experience is required as regards application of TIPS in various areas of care giving behaviors. In this project, TIPS proved to be an important step prior to designing communication package for bringing about behavior change. The posters, booklets and flash cards subsequently developed by ECDLRC project, and printed with UNICEF support, are being widely used. Department of Foods and Nutrition The M.S. University of Baroda 52 Kanani 2008 Research Methods for Nutrition Programs What Are The Factors That Facilitated Or Obstructed Behavior Changes – Learning From The TIPS Experience ? Impact of Counseling In Ranchi, just as effective counseling appeared to motivate women to agree to try out some selected behaviors in Round I, so also counseling definitely helped women to actually change behavior (especially to increase the frequency of food intake), as several women said that the information given to them helped them to overco me their fear of adverse effects (e.g. certain types of saag are not good) or helped them realize that these foods are beneficial to them and their infants and hence should be eaten in greater quantities. As one pregnant women said regarding consumption of Kohda (pumpkin) grown in her own garden; and eggs: “Aapne bataya to khaane ka man kiya to tod liya aur nau-das roj khaye the. Kabhi kohda kaddu khaate hain. Pahle nahi khate the, aap bataye tab se ande khate hain… acha lagta hai” (You told me so I felt like eating the pumpkin and I got it plucked from the garden… we had it for 9-10 days. Sometimes I eat pumpkin sometimes gourd. We collect the eggs now… earlier I did not eat but ever since you have told me I eat eggs… feel good.) One woman was innovative in that when she sold wood in the weekly market, she used part of the money earned to buy and eat a boiled egg in the market itself! One team member said, “Women seem to be thinking differently now; are more concerned about their health. Some women told us that we will make use of the information you have given us.” In Vadodara, through use of TIPS the importance of one-to-one interaction and home -based counseling was forcefully realized. The method of one -to-one interaction helped understand each mother’s current behaviors, familial background, contextual factors and problems faced by her, based on which behaviors for recommendations were selected. It led to need -based counseling. Further, such inter-personal coommunication also provided scope for clarification of mother’s misconceptions and doubts, which influence mother’s decision to try/not try a recommended behaviour. In terms of the implications for the subsequent development of the communication package, TIPS results not only helped in identifying counseling points, which were most convincing for the mothers, but also helped in understanding mother’s resistances towards behaviour change. Ideally, in the TIPS process, negotiation with mothers and families should be the basis for bringing about behaviour change. However, the field experiences of Vadodara suggested that the mothers were hesitant to bring forth their resistance or doubts; and participation of some Department of Foods and Nutrition The M.S. University of Baroda 53 Kanani 2008 Research Methods for Nutrition Programs mothers was luke-warm. One possible reason for this can be that mothers perceive the counselors to be “more informed” and hence felt obliged to accept whatever was told to them. This reconfirms the vital need to build rapport with the target group which regular community contacts can facilitate. ? Availability, Affordability and Acceptability In Ranchi, easy availability (such as GLVs, pumpkin or papaya grown in garden) helped behavior change while at the same time for other women poor availability or high cost of the same foods like ripe papaya or pumpkin, or egg in the market constrained behavior change. One field investigator said, “A woman we counseled said that one ripe pumpkin (whole) costs Rs. 30 so how can we afford it”. Ragi also continued to be unavailable during the trial in some families. Foods like snacks from market or ICDS ration were shared, hence the amount available to the women was limited. Inadequate availability of food ration and IFA from government sources was a major constraint. In Vadodara, rather than affordability, certain complementary foods were not given to the child as ‘vegetables are spicy’; ‘child refuses to eat’; ‘mother is busy’. Hence, time constraint, food acceptability were some factors obstructing change. ? Family Support In Ranchi, just as family support was stated as an important factor for behavior trial in Round I so also it was equally important in Round II. The data clearly show that some of the behavior changes were facilitated by the help given by family members. On the other hand, disapproval or lack of support from husband or mother-in-law was stated as a reason for not trying out the behavior by some women. As one field worker said, “Elders in the family including the mother-inlaw have traditional views and believe some foods to be taboos – to be avoided by women. Some family members who were supportive said that they did not know earlier the importance of these foods and after being aware, they either purchased, or encouraged women to eat foods like papaya, pumpkin or saag. They also perceived these foods to be beneficial to the woman or the infant. One mother-in-law said, “I do not like my daughter-in-law to be in bed like a patient… if she eats well and is healthy, I too will like it.” The Vadodara TIPS confirmed the importance of involving the significant family members as the support system for behaviour change. ? Traditional Beliefs In Ranchi, besides food restrictions during morbidity, the belief system of ‘hot’ and ‘cold’ foods also prevented some women from trying out the recommended behavior Department of Foods and Nutrition The M.S. University of Baroda 54 Kanani 2008 Research Methods for Nutrition Programs “Ahbi bachha bara din ka hai. Bacche ka pet garm ho jayaega is karan kohada nahi khaye hai” (My child is only 12 days old. His stomach will become ‘hot’ if I eat pumpkin hence I have not eaten it). “Papita thanda hai is karan khane ke liye mana kiya hai” (Papaya is cold so I am not allowed to eat). In Vadodara, traiditional beliefs for many foods prevailed and these foods were not given by some mothers to their children such as banana. However, an equally important determinant was characteristics of the children themselves; such as ‘fussy about food’; ‘dislikes certain foods’; ‘slow eater’; ‘refuses to eat during illness’. ? Experience of Benefits Believing that increasing the intake of the recommended foods has increased their strength; decreased fatigue; illness, and symptoms like night blindness, or has increased breast milk… seemed as a motivating factor for change. One woman stated that: “ Saag khane se bukhar nahi aata hai” (I do not get fever after regularly eating saag). One the other hand, during morbidity episodes, some women were disallowed the selected foods by faith healers who were treating them: “Bimari hai isliyae oza log kaddu, sag, murhi-chana khane se mana kiya hai” (As I am ill, the healer (oza) does not allow me to eat pumpkin, saag, murhi chana). Though several women did mention benefits like feeling stronger or getting more breast milk, it is not certain whether these were real benefits or, ‘answers given which we wanted to hear’. Some women candidly said that time was too short for any benefit to be seen. In Vadodara also, one limitation of TIPS methodology realized was that it is a self-report method. The mothers may provide socially desirable answers and there is no way to ensure whether mother’s responses are genuine or based on social desirability. TIPS method can be made more effective by interweaving cross-checks in it through use of other methods such as the direct observation method. Even if some of the self-reported responses are not accurate or are ‘socially desirable’, the overall trends in responses, and behaviour change data, clearly establish the usefulness of the TIPS methodology. Department of Foods and Nutrition The M.S. University of Baroda 55 Kanani 2008 Research Methods for Nutrition Programs 4. Adolescent Anemia Control Program in Gujarat: The Pilot Study in Vadodara District 13 The Government of Gujarat (Department of Health & Family Welfare and Department of Education) initiated the “Adolescent Girls’ Anaemia Reduction Program” for the adolescent girls in all the secondary and higher secondary sections of Vadodara District from March 1 st 2000 with technical and financial support from UNICEF and the Department of Preventive and Social Medicine, Medical College Vadodara. The Program Aimed to ? To institute school based, supervised weekly IFA supplementation with an in -built compliance monitoring system to reduce anaemia prevalence. ? To provide nutrition education to the beneficiary girls and teachers in order to effectively modify dietary behaviour and thereby improve the intake of iron available from the food. The Intervention under the Program The secondary schools, with support of the Education and Health- Family Welfa re departments, carry out the weekly supplementation of IFA for the girls on fixed days (Wednesdays) under the direct supervision of class teachers or class monitors. Each IFA tablet contains 100mg elemental iron and 0.5 mg folic acid. Nutrition education is imparted with the help of the IEC material prepared for every girl child and every teacher. The Department of Foods and Nutrition (the M.S. University of Baroda) provided technical support in IEC material design and in the qualitative research component in the formative stage of this program. A pilot project was carried out in Vadodara district prior to the initiation of this program. A baseline survey was conducted by the Department of Preventive and Social Medicine, Medical College, Vadodara. Formative research was considered to be meaningful as part of this survey in view of the fact that in this program both IFA tablets and IEC material are important components. If the IEC material is adequately and effectively used by teachers to educate themselves and the girls, one can expect gain in knowledge among teachers and girls after the intervention. 14 This section describes the qualitative research study , which aimed at assessing perceptions regarding anaemia among the adolescent girls and teachers as well as their views with regard to program implementation, especially the anticipated compliance to IFA consumption by the girls. 13 14 Kotecha et al (2002) Kanani ( 2002) 56 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs Methods The qualitative research was conducted in 9 schools (3 each from urban, rural and tribal area) which were randomly se lected from the 30 schools selected in the larger survey. Various qualitative methods and sample of informants are indicated in table 7. Table 7. Qualitative Methods Used in the Study Method Number of Informants Semi-structured Interviews 92 girls (SSIs) Key Informant Interviews 27 teachers (KIIs) Perceptions regarding anaemia and iron folate tablets Information Sought Drawing and Dialogue (DAD)* 85 girls (7 sessions) Awareness of things which make (a) blood red, healthy, strong (b) blood pale and weak ? Perceptions regarding anaemia and iron folate tablets ? Benefits of iron folate tablets ? Categorization of foods into (a) iron rich (b) vitamin C rich Focus Group Discussions 8 groups of girls (FGDs) combined with ? Free Listing (FL) ? Pile Sorting (PS) 96 girls 96 girls * In the DAD method, in small groups, each girl was given drawing paper and sketch pens. She was asked to draw on one side of the drawing sheet ‘things which make blood red, strong and healthy’ and on the other side ‘things which make blood pale and weak’. In the discussion that followed, girls explained what they drew and why; giving insights about their perceptions on causes of anaemia. Findings Perceptions of Adolescent Girls Regarding Anaemia – Causes, Consequences and Treatment Most of the adolescent girls (78%) interviewed were not aware of the term ‘anaemia’ or ‘pale blood’ (phiku lohi). One tenth of the girls mentioned terms such as jaundice or malaria to describe anaemia, perhaps associating the yellow pallor of jaundice with ‘pale blood’. One half of the girls interviewed associated anaemia with pallor (either general pallor or paleness of eyes, face, palms, tongue and nails), probably because anaemia is commonly identified as ‘pale blood’. One third of the girls mentioned symptoms such as weakness, tiredness, decreased strength, and decreased appetite. “ Tene ashakti laage, thaak laage” (She feels weak, tired). A Department of Foods and Nutrition The M.S. University of Baroda 57 Kanani 2008 Research Methods for Nutrition Programs few girls from all the three areas mentioned that due to ‘pale blood’ work performance in school, at play and household work is affected. ? “Kaam na thaye, dodiye to thaki jaaye” (Cannot work, if she runs she gets tired) ? “Lesson na thaye, kaam karata thaki jaaye, dhyaan na raahe ” (Cannot do school lessons, gets tired while working and cannot concentrate). Almost one half of the girls did not respond as regards the causes of anaemia. A majority of the remaining girls mentioned ‘inadequate’ or ‘inappropriate’ food intake a the main cause of anaemia. None of the girls were aware of which specific food components – if inadequate – cause anaemia. It was interesting to note that a majority of the girls (88%) believed that they themselves did not suffer from anaemia, with a higher proportion being the rural girls. In contrast, hemoglobin data from the results of the larger study indicated that 74.7% of the girls were anaemic. As regards treatment, about one third of the girls said that one should consult a doctor (doctor ne batavu joiye) or take medicine from a doctor (doctor paase thi dava levi joiye). One third of the girls mentio ned increased consumption of green leafy vegetables. However, one third of the girls also associated red or orange colored vegetables such as beet root, tomatoes, carrots with foods that ‘make blood red’. A few girls mentioned various cereals, pulses and fruits. When specifically asked to list iron (lohtatva) rich foods, more than half could not respond. As regards sources of vitamin C, almost half of the girls interviewed, especially from the urban and tribal regions, were aware that sour fruits such as amla, lemon, oranges, raw mangoes are rich sources of vitamin C, perhaps because it is included in the school curriculum. The pile sorts and interviews further revealed that the adolescent girls are not adequately aware of iron and vitamin C rich foods, but many do have information about green leafy vegetables and citrus fruits as sources of iron and vitamin C respectively. When asked about the relationship between tea drinking and anaemia, a majority of the girls (47%) did not respond. The IEC material distributed to the girls includes food -based approaches to control anaemia, which assumes importance in light of the poor knowledge on anaemia and diet among the girls. Drawing and Dialogue (DAD) Drawing and Dialogue gave valuable insight into what girls perceive as factors causing ‘red and strong blood’ and ‘pale and weak blood’. Department of Foods and Nutrition The M.S. University of Baroda 58 Kanani 2008 Research Methods for Nutrition Programs ‘Things which make blood pale and weak’. A majority of the girls showed that insufficient intake of green leafy vegetables and other vegetables such as tomatoes and carrots cau se the blood to become pale and weak. Many girls drew or stated in words that intake of excessive amount of spices/chillies, salt, chocolates/desserts, oily foods, unhygienic food (especially bought from street hawkers); potatoes, brinjal and onions and certain fruits, cause blood to become weak and pale (fig 1) Voices of girls..... ? “Vaasi khorak khava thi lohi phikku thai jaye chhe ” (Blood becomes pale because of eating stale food) ? “Jyaada nimak khaane se, maansik tension se aur kam khaana khane se, pandurog hota hai, kamshakti lagti hai” (By eating more salt, due to mental tension and by taking less food, we get anaemia, weakness) ‘Things which make blood healthy and strong’. Many girls considered that red/orange foods like tomatoes, carrots, beetroot a nd vegetables help blood become strong and healthy and red. Most girls also drew apples and a few drew bananas, orange, pomengranate, grapes and mangoes (fig 2). Voices of the girls: ? “Telelu khavathi lohi bali jaay chhe, mate lohi phiku pade chhe” (By eating fried foods the blood gets burnt and hence it becomes pale). ? “Doodh per pani peevathi phiku lohi thay chhe” (Drinking water after consuming milk causes pale blood). ? “Vadharanu mithu levathi lohi phiku thay chhe, lohi nu paani thaye chhe ” (By consuming excess amount of salt blood becomes pale, blood becomes like water). ? “Mulani bhaji thi lohi lal thay chhe, suvani bhaji thi lohi lal thay che” (Blood becomes red by consuming radish leaves and shepu leaves). ? “Dudh levathi anek prakar na vitamins male chhe mate lohi lal bane chhe” (Milk provides various types of vitamins therefore the blood becomes red). ? “Beet ma thi lohi bane chhe, beet ne vagharela bhat ma bhelavavathi bhat lal thay chhe te rite lohi lal bane chhe” (Beet root helps in making the blood red. When we add beet root to fried rice it makes the rice red, similarly the blood also becomes red). Department of Foods and Nutrition The M.S. University of Baroda 59 Kanani 2008 Research Methods for Nutrition Programs Department of Foods and Nutrition The M.S. University of Baroda 60 Kanani 2008 Research Methods for Nutrition Programs Department of Foods and Nutrition The M.S. University of Baroda 61 Kanani 2008 Research Methods for Nutrition Programs Key Informant Interviews with School Teachers School teachers are important change agents for improving health behaviours of girls. Nearly half (41%) of all the school teachers believed that the primary differences between pale and healthy blood was related to its hemoglobin (Hb) content. A majority of teachers (urban and rural) also related the difference between pale and healthy blood to its physical appearance i.e., viscosity, colour and quantity of the blood is different in a ‘pale’ and ‘healthy’ person. Almost two thirds of the teachers recognized pallor (of eyes, nails, tongue, face, skin) and dullness as signs of anaemia, and a majority stated symptoms of anaemia like weakness, dizziness, and breathlessness. A majority of the teachers gave a non -specific response that poor food intake (either due to poverty or faulty dietary habits) leads to anaemia and that consumption of iron, vitamin C and protein rich foods would help in treatment of anaemia. Consumption of iron and folic acid (IFA) tablets was perceived as a treatment of anaemia by only 22% teachers. Above half of the teachers, (more in urban than in rural and tribal areas), felt that IFA tablets would reduce the symptoms of anaemia mainly weakness, breathlessness and dizziness and that academic performance of girls would improve upon consumption of IFA tablets. When asked if weekly distribution of IFA tablets was feasible in schools, almost all teachers replied in the affirmative. Supervised consumption of IFA tablets by girls, distributed through schools on fixed days, was perceived to be a sustainable strategy. To conclude, ? While the adolescent girls in the secondary schools had experienced adverse effects of anaemia in terms of suffering from its symptoms, yet most of them believed that they were not anaemic. ? The girls and the teachers had very generalized and non-specific information about causes of anaemia; dietary measures and iron -folate supplementation (shakti ni goli) to combat anaemia. A majority of them did not possess correct and specific knowledge to enable them to improve their practices for anaemia reduction. More important, there was no realization about the grave consequences of anaemia and the need to give due attention to this pervasive problem. ? Awareness among most girls that the red tablets (IFA) or shakti ni goli improves strength of blood and health, will help in acceptance of the weekly supplements by the girls. Almost all the teachers also believed that the compliance for iron-folate tablets would be satisfactory. What is required now are effective communication strategies and regular use of IEC material in schools; support and encouragement for cases of side effects or parental resistance, and a Department of Foods and Nutrition The M.S. University of Baroda 62 Kanani 2008 Research Methods for Nutrition Programs monitoring system to ensure an effective IEC intervention, along with the iron-folate tablet supplementation. There is a need to understand anaemia related perceptions of adolescent girls in our region so that culturally sensitive and relevant educational and communication strategies can be developed and implemented to enhance knowledge and improve health behaviours of this group. Quantitative Impact Evaluation of the Pilot Project, Vadodara 15 An Impact Evaluation was carrie d out after one year of implementation. This was done by the Project Support Unit in the Department of Preventive and Social Medical at Medical College Vadodara which provides technical support, research, documentation and overall monitoring of the project with financial assistance from UNICEF. The Impact Evaluation Survey included the same 30 schools taken at Baseline using the stratified random sampling methods Result Highlights Program Coverage The program was operational in 410 schools covering over 65,000 adolescent school girls as beneficiaries. Monitoring for the Compliance The girls, teachers, schools and Education Department as part of an inbuilt system of monitoring carry out for the compliance of IFA tablet consumption at the following levels: ? Individual level – Compliance Card (Self) ? Class level – Register (Class Monitors or Class Teacher) ? School level – Report (Nodal Teacher and Principal) ? Cluster level – Observations + Report (Education Inspectors) Besides this the Medical Officers of the respective areas also provide technical support and supervision of the program as and when required. The average compliance reported for 17 months (July 2000 – November 2001) was about 89%. About 70% of the schools send compliance reports regularly while the other schools continue with the program but are irregular in sending the compliance reports. Common side effects reported by the girls are pain in abdomen and nausea and are usually associated with consumption of tablets on an empty stomach. These effects declined on continuation of tablets and taking the tablets after food. 15 Kotecha et. al. ( 2002) 63 Kanani 2008 Department of Foods and Nutrition The M.S. University of Baroda Research Methods for Nutrition Programs Impact on Anemia Prevalence A total 2766 sample of girls was available for final analysis, including 1016 girls for hemoglobin and 665 for serum ferritin for paired analysis with the baseline data. In the sample of 1016 girls assessed for Hemoglobin levels, anaemia prevalence (Hb<120 gm/l) was recorded as 53% compared to baseline anaemia prevalence of 75%, i.e., a reduction of 21%. The reduction achieved was maximum in rural areas f llowed by urban areas, while the o tribal areas showed less reduction of anaemia perhaps because of higher prevalence of thalassemia trait in tribal girls. Mean rise of hemoglobin was seen to the extent of 6.4gm/L with maximum rise in rural areas followed by urban areas. Relatively the least rise was seen in tribal area. The mean value of ferritin increased by 5 ng/ml across all areas, the improvement again being more in rural areas. As regards paired data analysis on 665 girls, reduction of 21% in anaemic prevalence was seen. Overall the paired data showed similar impact as the total unpaired data. The information obtained from paired data is more convincing as regards impact of intervention as all other confounders are controlled. Benefits and Side Effect of Tablets Mentioned by Girls Initially 30% of the girls had complaints of side effect which reduced to 14% by the end of one year. The common side effects experienced by girls were stomach ache, vomiting, giddiness and nausea. None of the side effects we re serious enough to compel them to discontinue the tablets. About 50% of the girls were able to state benefits experienced (more in rural areas) such as increased work capacity (22%), improved blood (16%), improved health (7%), decreased pallor (5%). Utilization of IEC Material by the participants Brochure Three fourth (72%) of 2766 girls mentioned that they received the brochure: more rural and tribal girls reported this as compared to urban girls. A majority (87%) of the girls had read the brochure, either all by them selves (57%) or with their friends (55%) or with their teachers and friends (23%). Two third (65%) of the girls who received brochure mentioned that at least one of their parents had read the brochure. However, only 53% of girls had the b rochure at the time of the survey which could be because of the gap of 16-18 month after the initiation of the program, when brochures were given. Department of Foods and Nutrition The M.S. University of Baroda 64 Kanani 2008 Research Methods for Nutrition Programs When asked to recall up to 3 messages from the brochure, 56% did not respond. From those who responded 99% h at least one correct message recalled. More urban girls compared to ad rural girls and tribal girls were able to recall at least one message. Posters All the schools were given two sets of three posters each and during the training were also explained where to display them and how to use them for educating girls. However, only 38% of the girls had actually seen posters related to anaemia program in their school – less in urban and tribal schools. When those girls who had seen the posters were further questioned, 75% were able to mention the place of poster display. Of the girls who had seen the posters 43% girls were able to recall at least one correct message from the poster. Knowledge of Girls regarding Anaemia Prevention and Treatment Based on the IEC provided to the girls, questions were asked regarding anaemia prevention and treatment. About Anaemia Majority of those who responded (90%) were able to give correctly the name of condition of pale blood; anaemia or “Pandurog” – the Gujarati equivalent of anaemia. Causes of Anaemia When asked whether deficiency of any nutrient can lead to pale blood, 67% of the girls could correctly reply. However when asked to name the nutrient which leads to pale blood, only 12% of those correctly answered, mentioned iron or “Lohatatva”, while the rest referred to other nutrients like protein, vitamins. Signs, Symptoms and Consequences of Anaemia When asked about of symptoms of pale blood only 44% girl stated one or more signs, symptoms or consequences. Only 8% mentioned 3 or more correct signs or symptoms of anaemia. Treatment of Anaemia When asked about what can we do to prevent or treat pale blood, 37% suggested taking iron tablets or iron rich food or vitamin C rich food or avoiding tea and coffee along with snacks and food. Only 2% stated three correct preventive measures, 21% gave wrong answers and 42% did not respond. Diet and Anaemia About half (46%) of the girls stated that one should avoid taking tea/coffee alongwith food/snacks and only 17% of these girls gave correct reason i.e., tea or coffee inhibits iron absorption/tea or Department of Foods and Nutrition The M.S. University of Baroda 65 Kanani 2008 Research Methods for Nutrition Programs coffee makes the blood pale/tea or coffee causes anaemia/tea or coffee reduces hemoglobin. More urban girls compared to tribal girls and rural girls could give the correct reason. Iron Folic Acid Tablet When asked about the name or content of the tablet given to them, a large number (56%) did not respond to the question. Only 22% referred to iron and 22% gave wrong answer like iodine, calcium, vitamin C. Tribal girls knew the least. About half (52%) of the girls stated benefits of the tablet. Of these girls 95% were able to list at least one advantage of tablet (responses being similar in the three areas) eg. strength giving. Overall, 40% knew three correct benefits of the tablet. When questioned about how to prevent possible side effects of this tablet only one fourth actually knew the preventive action of avoiding to consume tablet on an empty stomach. To summarize, IEC material has been received and read by most of the girls. However the understanding of messages and retention of information are far from desirable. There is neither an inbuilt system nor any effort made to reinforce the messages to the girls from the IEC material supplied. If regular and proper use of IEC material had been made, the reduction in anaemia could have been further enhanced. Conclusions and Recommendations This impact evaluation study after one year of implementation revealed that the coverage of the schoolgirls to an extent of 90% was achieved; reduction of 20% in anaemia prevalence was observed and 74% of the girls improved their hemoglobin level. This success story results from the efforts of the enthusiastic teachers and the interest and enthusiasm of the girls. Girls are enthusiastic everywhere; the crucial determining factor for success is the interest and efforts of the teacher. If the teacher is convinced and committed, the school has efficient program implementation and if the teacher views the program as ‘additional responsibility thrust upon her/him’, the program suffers. This weekly IFA program has changed the quality of life of the adolescent girls. Many of these girls for whom the life was a burden, drudgery, for whom tiredness and lack of interest in life were common are now having new enthusiasm, capacity and interest in work (both mental and physical) and enhanced ability to prosper academically. Efforts and innovative approaches are required to reach out of school girls through enthusiastic ICDS workers, voluntary organizations and through mass media. Department of Foods and Nutrition The M.S. University of Baroda 66 Kanani 2008 Research Methods for Nutrition Programs The IEC component has been less successful. Acquiring correct knowledge on anaemia based on the IEC brochures and posters has not been very satisfactory. What is required is to explore how best can IEC be used adequately. This may mean more motivation by school teachers; systematic monitoring of IEC and enhanced emphasis on the IEC during training. Summary Table Data Before and After Intervention Parameter Before After Intervention Intervention Anaemia (Hb<120g/L) 74.7 53.2 Severe anaemia (Hb<70g/L) 1.6 0.5 Mean + SD (Hb in gm/L) 110.8 + 14.2 117.2 + 12.7 Mean BMI 17.23 + 2.7 17.74 + 2.6 Serum Ferritin less than 12ng/ml 49.7 39.4 Paired Data Before and After Intervention Parameter Before After Intervention Intervention Anaemia (Hb<120g/L) 74.2 53.4 Severe anaemia (Hb<70g/L) 1.4 0.7 Mean BMI 17.04 + 2.7 18.02 + 2.7 Serum Ferritin less than 12ng/ml 50.1 41.4 Statistical significance p<0.001 p<0.001 p<0.05 p<0.001 p<0.001 Statistical significance p<0.001 p<0.05 p<0.001 p<0.001 Based on the experiences from the present project, the State Government has been able to initiate the project in other districts on the same model as applied in the present project. How useful was the integration of the qualitative and quantitative research component in the pilot project? The initial qualitative formative research clearly highlighted the inadequate knowledge of girls on anemia and underlined the importance of IEC material, in particular for bringing about dietary improvements. Unfortunately the IEC component remained weak (and remains weak even today according to our current observations). Nevertheless, at Baseline, integration of both qualitative and quantitative components did give a more holistic picture of the readiness of the beneficiaries to accept the program as well as the need to not only combat anemia through the weekly IFA but also the need to implement effective communication and school based education strategies to improve awareness and home based dietary practices of the girls. Active efforts are also needed to keep up the motivation of the school system to continue to take interest in this program as our present school visits suggest that the program, having become ‘routine’ is suffering from poor quality of implementation in many sco ols. As this program is ongoing universally in the State of Gujarat, rapid appraisals using an appropriate mix of methods will be valuable for monitoring and process evaluation. Department of Foods and Nutrition The M.S. University of Baroda 67 Kanani 2008 Research Methods for Nutrition Programs CONCLUDING REMARKS The foregoing presentation of highlights of some of the interventions and nutrition programs has demonstrated the value of integrating various data gathering tools from the QN and QL streams of research. The synergism of the multi-method approach, in some of the programs described in the preceding section was advantageous in several ways: ? Validating data from different sources – the triangulation advantage. In this regard, the immense value of the direct observation method needs mention; especially when quality of implementation of programs is being assessed, because reported data from interviews of functionaries or beneficiaries more often than not gives a ‘rosy’ picture which is not the field reality. ? The direct observations also give insights regarding the direction in which programs need to improve; whether it is strengthening supervision and monitoring systems (and how) or helping service providers improve their work organization or communication skills. ? The time taken up to carry out the observations, document and analyze them is no doubt substantial but then they need not be on large samples. What is important is to effectively conduct them. Besides, survey data and interviews are also time consuming. It is really a matter of deciding a judicious mix of methods (including sample sizes) to get the maximum benefit within the available time and resources. ? For designing communication materials and strategies in the area of BCC for nutrition or health promotion, the TIPS methodology has a lot of potential which is underutilized. TIPS is however best used as one component of a larger formative research study. Our TIPS training and application experience clearly indicated how the TIPS process resulted in enhancing counseling and interpersonal skills of the service providers/ team members; o o in designing of effective IEC visuals such as posters, flip charts, videos; in making strategies more holistic such as a deliberate inclusion of family members to support change. Besides this, other added benefits we noticed were a sensitization of the service providers and commu nity workers that quality of counseling is indeed important and also a ‘pleasant discovery’ that even resource-poor communities can show favorable change in a short period of time provided we give the right information to them in the right way at the right time. ? Use of participatory research (PR) tools: for empowerment or for data collection alone? Several PR tools, being visual and group based, are powerful in terms of eliciting valid data as the community actively participates in the process. In the ICDS Social Assessment Study, we were conscious of the fact that PR tools were being used to gather data; to assess ICDS from a community perspective; and ‘community empowerment’ was not an objective. Hence Department of Foods and Nutrition The M.S. University of Baroda 68 Kanani 2008 Research Methods for Nutrition Programs ours was more of a ‘qualitative’ than ‘participatory research’, process. However, we were pleasantly surprised to discover that by training ICDS functionaries themselves in the use of PR tools; in a sense they felt ‘empowered’ at the end of the study and motivated to improve their performance. They saw ICDS functioning through the eyes of the people and realized their own shortcomings. The ‘mirror of ICDS and their own role in it’ held out to them by the people made many of them realize that the problem of poor quality is not ‘out there’ but more within the system. ? Finally, a word of caution. Research tools are tools after all. No doubt, whether QN or QL, they are to be used appropriately with carefully thought out research design. But eventually, programs will improve only when the data emerging from evaluative studies is put to use without delay – to strengthen its plus points and address the drawbacks. To end on an optimistic note... ..... let us hope to see more research – program partnerships in future. Department of Foods and Nutrition The M.S. University of Baroda 69 Kanani 2008 Research Methods for Nutrition Programs REFERENCES AED/LINKAGES/India. Final Report (1997–2004). The LINKAGES Project, Academy for Educational Development, Washington DC, 2004 . Allen Attig G and Yoddumnern -Attig B. Nutrition and qualitative research: a marriage over time. 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