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Making a Difference A document on a project for tribal adolescent girls inDhar District, Madhya PradeshForeword In terms of the gender-related development index, India ranks 99 among the 130 countries included in the index (UNDP 1995). Gender inequality begins even before birth and is consistently adverse throughout the life of the Indian women in more than one way. The most dramatic manifestation of discrimination is during childhood, adolescence and the child-bearing age. The large proportion of the malnourished children of the eighties are today’s adolescents who are at the threshold of adulthood. They will turn into adults who have not grown physically or mentally to their genetic potential, adversely affecting their productive and reproductive life. Before reaching this irreversible situation, there is one last opportunity to save the generation—the period of their adolescence. Adolescent girls face more problems than boys, largely due to socio-cultural factors. Adolescent girls are deprived of adequate health care, good nutrition and opportunity for schooling. Stunted anaemic girls with inadequate knowledge of personal care, family planning or child rearing practices enter into marriage and motherhood, thus perpetuating the problems of malnutrition and poverty to the coming generation. Although women are the major actors in human resource development, they are neither adequately recognised nor supported by their families or the society. Women represent the major segment of the poor, the malnourished and the illiterate. The adolescent period of women offers great opportunities for making good some of the lost opportunities. It provides a chance to improve their nutrition and health status, besides preparing them to become productive, confident adults. This requires human empowerment where they are equipped to make their own choices. The United Nations’ World Food Programme (WFP) commissioned a project, ‘Empowerment of Tribal Adolescent Girls’, to empower tribal adolescent girls with:
The project was implemented in the Dhar district of Madhya Pradesh in four ICDS blocks, Gandhwani, Nalcha, Sardarpur and Tirla from December 1994 to January 1996. This phase of the project was based on the model evolved in the pilot project in Jhabua (funded by WFP), which was built on the understanding gathered through a situation analysis of adolescents in the context of their influencing variables. The Jhabua and Dhar projects were able to demonstrate that by using appropriate techniques, it was possible to:
The post-phase assessment of the project confirmed that the participants were able to appreciate the learning approaches which were participatory, learning which was linked to their own lives, learning through entertainment and learning through skill development. We hope that these micro-level projects will have far-reaching implications in terms of providing a replicable model for working with adolescents. The experiences gathered through this project has thrown open a number of issues which can be addressed through the Government, NGOs and international agency partnerships.
Angela Van Rynbach Country Director World Food Programme New Delhi, April 1997. Abbreviations
Glossary
Acknowledgement
The District Collector and the District Women and Child Development Officer of Dhar District offered tremendous support in every phase of the project. The sincere participation of the Child Development Project Officers, Supervisors, Anganwadi Workers and Helpers of the ICDS Scheme needs special recognition. Without their support, this project would not have been a reality. Our special appreciation for the Bal Niketan Sangh (BNS), Indore, for successfully implementing the project under very difficult circumstances. It was certainly a fruitful experience for the Bal Niketan Sangh for attempting the village-based training. The role of Ms. Shalini Moghe, Director, BNS and Ms. Kalpana Gajre, who coordinated the entire training in the tribal villages, deserve special mention. We are also thankful to the Dr. Baba Saheb Ambedkar National Institute of Social Sciences, Mhow, Madhya Pradesh, particularly Dr. Priti Taneja, for conducting the pre and post-phase assessments of the project. Dr. Minnie Mathew of the World Food Programme, is one of the pioneers in developing field-based interventions for deprived adolescents. She not only designed the project but was keenly involved in every stage, giving guidance and support for its implementation. She is also the principal author of this report. The report was benefited by field reports received from the Bal Niketan Sangh and the Dr. Baba Saheb Ambedkar National Institute. We are thankful to New Concept for their careful editing, and imaginative designing which tries to capture the ethos of those who are being written about.
Summary
The World Food Programme, therefore, attempted a project in Madhya Pradesh, initially for training and placing adolescent girls in the Integrated Child Development Services (ICDS) scheme. The communication package was based on a detailed situation analysis of the local knowledge, attitude, practices and culture of the tribal population. The situation analysis highlighted the need for certain other interventions, such as training in entrepreneurship skills for adolescent girls and improving the management skills of the ICDS functionaries. These interventions were undertaken in order to increase impact. These components have been documented separately. The training of the tribal girls was organised at the village level which, despite being the best choice, was a challenging one for the trainers. The highlights of the training were the use of participatory techniques; learning made easy for persons with no literacy; learning through entertainment; and learning by doing. An important consideration was to have a selective approach to contents rather than including all pertinent issues. The modules demonstrated a high level of learning possibility among the illiterate girls. The need for periodic reinforcement was evident from the post-phase assessment of the training. It was also evident that certain deep-rooted tribal practices can only be expected to change over a longer span of time, since intervening variables will have to be influenced. It may be derived from the Madhya Pradesh experience that for making an impact, it is important to ensure complementary thrusts through critical interventions. A multi-sectoral approach is recommended involving Governmental and NGO action. Status of Girls in IndiaIn India, girls are socialised from the very beginning to accept the culture of male supremacy which, willingly or unwillingly, subjects them to discriminatory practices. This means that, not only are girls and women socially and ideologically ill-equipped to retaliate against the implicit and explicit injustice to which they are subjected, but, in the absence of alternative models of role and conduct, they actually adopt, support, promote and transmit, inter-generationally, the dominant social and cultural values which militate against the interest of their gender. Data available show that adolescent girls face more problems than boys. This is largely due to prevalent socio-cultural factors. Adolescent girls remain deprived of adequate access to basic health care. Studies indicate that fewer resources are invested in girls’ health. They are taken to health centres less often and too late for treatment. Better and more timely medical care for boys may be the most important factor explaining high survival among males compared to females.
Sex Ratio The sex ratio in India has been consistently unfavourable to women due to the increasing preference for boys. Deprived since childhood, they enter into the adult roles of reproduction and rearing, besides productive roles within and outside the household. In India, a high female mortality rate persists upto the age of 30. There is distinctly higher mortality among the adolescent girls than boys. There are wide disparities in mortality among states and within states and between rural and urban areas. The sex ratio is most unfavourable in the states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. Complications in pregnancy and childbirth result largely in maternal deaths. According to the National Family Health Survey (NFHS), 1992, the maternal mortality rate in India is estimated to be 437 per 100,000 live births. The situation in rural and tribal areas is much worse, where poor health and inadequate health services make each pregnancy dangerous. The access to health care is very low in tribal areas owing to distances, topography and transport. Most of them rely on traditional systems of caring during labour and delivery, contributing towards high infant and maternal mortality rates. Marriage Statistics suggest that marriages in India take place at a relatively young age. 38 per cent of adolescents in India, aged between 15 and 19, are married. While in urban areas, 21 per cent in this age-group are married, in rural areas, it stands at a high 45 per cent. Early marriages are common in Madhya Pradesh, Andhra Pradesh and Bihar where more than 50 per cent are married. In Haryana and Uttar Pradesh 40 to 44 per cent of the adolescents are married. The legal age for marriage is not widely known among women in India. According to the NFHS (1995) data, only one-third of the respondents correctly identified 18 as the legal minimum age for marriage for females, and only one-fifth could correctly identify 21 as the legal minimum age for marriage for males. Early marriage enlarges the girl‘s fertility span. Deprived of her childhood and compelled into early marriage and child-bearing, the young girl’s prospects for all-round development are severely constrained. Malnourishment, combined with early pregnancy, results in physical wastage, birth complications and the delivery of underweight babies with reduced chances of survival. Pregnancy Pregnancy is dangerous for those in their early teens or those chronically malnourished, because their pelvic growth is not complete. This may cause prolonged or obstructed labour which is one of the causes of maternal death. Teenage pregnancy interrupts the physiological growth spurt during that time. Their skeletal and reproductive systems being immature, have the competing demand for their own growth and development in addition to foetal growth. Among the married teenagers, 58 per cent have been reported to be bearing children. Overall, 17 per cent of the teenagers have been estimated to be at the child-bearing stage, with wide interstate and urban-rural differences. Contraception According to NFHS (1992-93), more than a third of the girls of the age 13-14 either did not know about any modern method of family planning or were not aware of the source of any method of contraception. Among adolescents aged 15 to 19, 20 per cent were not aware of contraceptive measures. Knowledge of contraception was shown to increase with literacy. A very low rate of contraceptive use, varying from 2 to 6 per cent, was observed among young married women below 20 years. A wide range of problems are associated with the use and non-use of methods of contraception by sexually active adolescents. Ignorance about contraceptives, lack of access and use, lead to unwanted pregnancies. The use of unsuitable methods may pose undesirable side-effects or future in fertility. Childbirth Great hazards are involved in childbirth among adolescent mothers. The chances of premature delivery and low birth weight (LBW) babies, leading to higher neonatal mortality, are greater among adolescent mothers. Infant mortality is higher in the case of mothers under 20. Infant mortality rates would decline if early child-bearing could be controlled. Nutritional Status of Adolescents The normal growth of adolescents is adversely affected by inadequate diet, and physical and psychological stress. Malnutrition during the growth spurt period of adolescents, a period of high energy requirements, results from a combination of inadequate intake of nutrients combined with infection. Dietary Intake: The inadequacies in the nutritional intake among female children has been attributed to discrimination within the family. Several studies have established the fact that boys have access to higher value foods, and are given the first priority for the available food within the family and have more opportunities for food from outside the family. Nutritional Status: Since adolescence is a period for gaining weight and height, nutritional status has great significance during this period. A poor nutritional status causes stunting, posing obstetric problems during the reproductive period. More than half the adolescents in India are undernourished. Nearly 48 per cent of the children and adolescents suffer from moderate degrees of protein energy malnutrition and about 9 per cent suffer from extreme forms of malnutrition. Growth: The child who arrives at adolescence in a stunted state because of early malnutrition, has the innate potential to achieve, during the adolescent growth phase, an even higher growth velocity than the non-stunted child who has not suffered early malnutrition. For such higher growth velocities to actually materialise and reach their full peak, additional nutritional inputs over and above the normal diet may be necessary over an extended period. In the absence of these additional inputs, the physiological opportunity provided by adolescence to correct childhood growth deficits may not happen, and the child would end up as a stunted adult, thus missing the second and the last opportunity. According to a study conducted by the Nutrition Foundation of India (1989), at 17 years the absolute difference in the mean heights of the rural girls and the urban affluent girls was over 7 cm., and the corresponding difference in the mean weight was around 6.5 kg. It is estimated that 35 per cent of the rural girls have weights below 38 kg., and 23 per cent girls have heights below 145 cm. According to the ICRW/USAID (International Centre for Research on Women/United States Aid for International Development) study (1994), 32 per cent of the adolescents were reported to be stunted. The gender difference was high with more girls being stunted (45 per cent) as compared to boys (20 per cent). This difference is explained by the deep-rooted gender discrimination. Micronutrient Deficiencies: Since teenage pregnancy is common among Indian adolescents, anaemia can lead to reproductive failure, miscarriage, stillbirths, premature births, low birth weight, perinatal mortality and maternal mortality during childbirth. Nutritional anaemia, due to iron and folic acid deficiency, is directly or indirectly responsible for maternal death (Ministry of Health and Family Welfare, 1991). With the onset of menarche, young girls are highly susceptible to anaemia in the absence of adequate dietary iron. Anaemia is usually caused by a combination of low iron intake and poor absorption, aggravated by malaria and hookworm infection. Adolescents may develop iron deficiency anaemia because of rapid growth and the start of menstruation. Anaemia during pregnancy accounts directly for 15 to 20 per cent of all maternal deaths in India. The ICRW/USAID study showed a 55 per cent prevalence of anaemia among adolescents in India. A large number of adolescent girls are reported to have riboflavin deficiency. Vitamin A deficiency, which is linked to high mortality and morbidity in children, is likely to be an underlying cause of high levels of respiratory and genito-urinary tract infections in women. Calcium deficiency has also been documented among adolescent girls. Nearly 40 million adolescents are either suffering from goitre or are in the danger of being affected. Educational Status of Girls Education develops basic skills and abilities and cultivates a value system promoting and supportive of national development goals, both long-term and immediate. Female literacy is considered to be one of the most sensitive indexes of social development. The education of girls is a worthy objective in itself which does not need any further justification. The number of out-of-school children increased from 29 million in 1966, to 48 million in 1981. The high level of female illiteracy, 61 per cent (Census of India, 1991), is co-mpounded by the high drop-out rate for girls, which is estimated to be 55.5 per cent at the primary stage and 77.7 per cent in the middle school stage. States with female literacy below the national average, especially Rajasthan, Bihar, Uttar Pradesh and Madhya Pradesh, hold about 55 per cent of all out-of-school children in the country. The “lost years” of adolescence, it has been observed, can be harnessed fruitfully, and girls can be equipped for a better and more productive citizenship. Since adolescence is a period of rapid personal, physical and intellectual development, and the effects of poverty, illiteracy, as well as lack of nutritional and health care are further magnified by gender discrimination, girls of this age-group need to be addressed as a special target category by development programmes. They need to be given an education that would give rise to their self-esteem, confidence and decision-making skills. This would have far-reaching implications for the status of women in the coming generations. Awareness among Adolescents A study conducted in 12 north Indian villages with 400 girls in the 10-16 year age-group showed that they had a low self-image. Since they dropped out of school early, on attainment of puberty, their exposure to information was limited to their own households. This was particularly due to their restricted mobility after puberty. In the case of educated girls also, formal education had not modified their social attitudes. They were not informed about the uses of facilities such as banking, postal services and public transport. They had limited knowledge about their bodies and bodily functions. They were unaware of the basic facts of contraception, child-bearing and rearing. They had to submit unquestioningly to their parents’ decision to marry them early. Activities of Adolescents in Tribal Areas
Adolescents in tribal areas were found to be over burdened with household chores and hardly had any leisure. Though they were involved in farm labour, they neither had access to nor knowledge of modern agricultural operations.The story is more or less the same in most of the rural areas. For rural Indian girls, adolescence can best be defined as, the period which starts with the early end of education and ends with the premature start of pregnancy and the child-bearing stage. Strategising for Environment
The government of India (GOI) has voiced its concern for the girls of the adolescent age-group through various action plans. The Plan of Action for Women (1976) of the Ministry of Health and Family Welfare, recommended that the education given to girls through the school system should aim to prepare them for a better motherhood. The National Policy for Children (1974), the National Plan of Action on Children (1992) and particularly the National Plan of Action for the SAARC Decade of the Girl-child, 1991-2000 AD, reaffirm the Government of India’s commitment towards the adolescent girls in the country. The broad objectives of the new scheme introduced in 1990 for adolescent girls as a part of ICDS are to:
Through this scheme, it is hoped to make the adolescent girls ready for a safer motherhood by improving their nutritional status through diet and iron supplementation, in addition to providing skill-training in home-based skills, non-formal education—particularly nutrition and health education. Under this scheme, three girls will be identified from among the eligible adolescent girls in the 11-15 year age-group in an Anganwadi area. The practical training of these girls in the areas of health, nutrition and education would be provided at the Anganwadi Centre for a period of six months. At the end of the six months, a new set of girls will be attached to the centre. During this period they will have a significant role, sharing work and decision-making responsibilities with the Workers and Helpers. The scheme entitles them to a supplementary meal everyday. They are also entitled to immunisation, health check-up, referral services, treatment for minor illnesses, de-worming, prophylactic measures against anaemia and goitre. The National Nutrition Policy of the Government of India (1993) talks of the need to intensify the Government’s new initiative of including adolescent girls within the ambit of the Integrated Child Development Services (ICDS). It is hoped to cover all adolescent girls through ICDS by 2000 AD in all Community Development blocks of the country and 50 per cent of the urban slums. The Nehru Yuva Kendra Sangathan of the Department of Youth Affairs and Sports, Government of India, has planned to set up Health Awareness Units in 135 districts. Through these units, it is hoped to create awareness on aspects such as ideal age for marriage, child-bearing, child spacing, reproductive health, safe motherhood and child care. Education
Non-formal Education From the Third Five Year Plan onwards, provisions have been made for the non-formal education of women. It is only through ICDS that non-formal education has been included for adolescents. Under the programme, it is hoped to provide adolescents with the required skills to stimulate a desire for more social exposure and knowledge and to help them improve their decision-making capabilities. The outreach under this scheme is however quite limited. Vocational Training Training of Rural Youth in Self Employment (TRYSEM), a scheme under the Government of India (1987), aims to provide technical skills to rural youth to enable them to become self-employed in the fields of agriculture, industries, services, business, etc. During the Seventh Plan, about 10 lakh youth were trained under TRYSEM, of which 47 per cent took up self-employment and 12 per cent wage employment. The Nehru Yuvak Kendra Sangathan, under the Department of Youth Affairs and Sports, organises and supports NGO efforts for vocational training programmes for the rural youth. Vocational training has been included as a component of the Balika Mandal, a scheme for adolescent girls in the 15-18 year age-group, under the Department of Women and Child Development.
Awareness Creation
Through the National Service Scheme and exhibitions for the youth, the Department of Youth Affairs has been creating general as well as health awareness through the youth. The ICDS scheme also has a component on nutrition and health education which is meant for women in the reproductive age. Messages specially focused on adolescent girls is limited to selected ICDS projects.
A second component was also launched for girls in the 15-18 year age-group. From each ICDS block with programme - I, 10 per cent of the AWCs with active Mahila Mandals will be selected for the scheme. Twenty girls will be identified for enrolment in the Balika Mandal for a period of six months. During this period they will receive supplementary food and health education, besides training in vocational skills.
The Madhya Pradesh Scenario
Madhya Pradesh (MP) is the largest Indian state covering an area of 443,446 sq. km. It has 45 revenue districts, 459 blocks and 70,884 inhabited villages according to the 1991 census. Madhya Pradesh is one of the most backward states in the country. Although much progress has been made towards poverty eradication, nearly 10 per cent of the absolute number of people living below the poverty line in India reside in the state of Madhya Pradesh. Female literacy, school enrolment, school drop-outs, per capita income and infant mortality rates fall far below the national average.
Madhya Pradesh’s expenditure on education was only 18.2 per cent of the total state budget in 1993-94, of which 98.5 per cent was spent on staff salaries alone. A study conducted by Govinda and Varghese (1991), has pointed out that most under-staffed schools were in the rural, backward areas, which were attended by children having no parental support and guidance and thus required more focused attention. In Madhya Pradesh, 70 per cent of the primary schools have only one or two teachers. For days on end, a school may remain closed because the teacher has been called for some other duty. Tribal education assumes special importance in Madhya Pradesh since almost one-fourth of the population is constituted of Scheduled Tribes (1.5 crores out of a total of 6.6 crores), according to the 1991 census. Apart from the inevitable nexus between the existing low demand for education, low infrastructural facilities in schools, and disadvantaged family backgrounds, another factor which requires attention is the alienating nature of education given to them. Madhya Pradesh is quite backward in the field of health. The IMR was 98 per 1000 live births in 1994, compared to the all-India figure of 73 (Statistical Outline of India, 1996-97). Crude birth rate is 33.4 and crude death rate is 12.8, which are higher than the all-India rates (Sample Registration System, 1991). According to the National Family Health Survey conducted in 1992, the IMR of Madhya Pradesh was only 85.2. The CBR and CDR of the state has shown a steady fall over the last three years. The indicators of maternal and child health have, however, not shown similar improvement. While the state has made substantial progress in immunisation, other areas of child survival and safe motherhood have not received equal attention. According to NFHS, only one quarter of the pregnant women get antenatal check-ups from doctors. Only half of them get tetanus toxoid immunisation, and less than half receive iron and folic acid tablets. This is one of the main reasons for a large proportion of babies being born with low birth weight and neonatal tetanus in Madhya Pradesh. In terms of the health care delivery infrastructure, the situation is far from satisfactory. Madhya Pradesh has a severe problem of protein energy malnutrition (PEM). According to NFHS, the practice of continuing breastfeeding till almost two years is widely prevalent. Yet, the low level of exclusive breastfeeding for the first three months and introduction of bottle feeds is rather high. Most of the children are not given supplementary semi-solid food along with the breast-milk. These are some of the reasons for the increase in the number of malnourished children. Though Madhya Pradesh has surplus food production, it also has a very large population suffering from PEM. To take care of this problem, the state government runs supplementary nutrition programmes through ICDS and the Special Nutrition Programme (SNP). According to the Rajiv Gandhi Mission, iodine deficiency is prevalent in the entire state, but is significantly great in the eastern part of the state and the two western districts of Dhar and Jhabua. Other major diseases in Madhya Pradesh are malaria, tuberculosis and blindness. In 1991, Madhya Pradesh had a gender/sex ratio of 931 females to 1000 males, the national figure being 929. The reasons for the unfavorable sex ratio are sex selective death rates and migration patterns. The analysis of age-specific sex ratio data indicates that the sex ratio is lower in late childhood, early adolescence and in the post-reproductive ages. Census age-specific sex ratios reflect the mortality that may have occurred in particular cohorts, and a study of district-level age-specific sex ratio data indicates that sex ratios are abysmally low in the late adolescence and middle-adult age-groups. These reflect a high mortality of girl children and mothers.If the survival and well being of women is to change significantly, it is necessary to concentrate resources, care and concern on adolescent girls. The World Food Programme (WFP) provides food assistance to 35 ICDS blocks in MP, with 330,000 beneficiaries. These are spread over the three tribal districts of Jhabua, Dhar and Khargone (West Nimar). WFP and other international agencies such as The World Bank, UNICEF, UNESCO and CARE are actively involved in the development efforts in MP and have initiated several intervention programmes.
The ProjectThe Project Design This is a follow-up to a pilot project pioneered by WFP in Jhabua District in Madhya Pradesh in 1989. Details of the project can be read from the report, “Adolescent Girls in Tribal Integrated Child Development Services”. While replicating the project, changes were incorporated based on the lessons learnt through the participatory evaluation of the pilot project. Project Objectives
Project Area Subsequent to the introduction of the pilot project in Jhabua, the Government of India, in 1990, introduced a scheme for adolescent girls in selected ICDS project districts, including Jhabua. Since the adjoining district was not included under the GOI scheme, WFP selected Dhar for implementing this phase. The district has 13 blocks, 12 blocks of which are under the ICDS scheme. Four ICDS schemes, Tirla, Nalchha, Gandhwani and Sardarpur, were identified for implementation of the project. Statistics regarding the population and the beneficiaries under the ICDS scheme in these four blocks are provided hereunder:
Source: Department of Women and Child Development, 1995 Project Participants
Project Features
The Pre-phase AssessmentA baseline study was conducted in the project area prior to the implementation of the training programme in order to understand KAP among the adolescent girls and their parents, their cultural values, socio-economic background and their motivation and aspiration levels, besides gaining an insight into the functioning of the Anganwadi Centres (AWCs) in the area. The study particularly focused on: (a) problems among adolescent girls and their aspirations, (b) their family influences and aspirations for their daughters, (c) the possible interventions, (d) the promises and failure of the programmes, viz., ICDS, through which the intervention was to be made. Both the pre and post-phase assessments were carried out by the Dr. Baba Saheb Ambedkar National Institute of Social Sciences. The assessments were carried out on 10 per cent of the AWCs in the four ICDS projects. Profile of the Anganwadi Workers Around 55 AWWs were interviewed. 90 per cent of the AWWs had received training once or more than once. The rest have been working for five or more years without being trained. AWWs did not live in the neighbourhood of the AWCs. Around 52 per cent AWWs took more than half an hour to reach the AWC, indicating that they did not live in the same village. Since a time shedule was not maintained in half of the Anganwadis, the children were not attracted or came late, and that too only to collect the supplementary food. The local dialect was understood and spoken by 87 per cent of the AWWs, facilitating easy communication with the community. 49 per cent of AWWs were illiterate and, therefore, unable to maintain the Anganwadi records on their own. They paid a remuneration of Rs. 50 to a literate person of the village to complete the registers. Only 9 per cent of the AWWs were aware of the criteria for the selection of beneficiaries for ICDS. Delivery of Services The services offered by the centres included supplementary nutrition, health check-up, immunisation, non-formal pre-school education, nutrition and health education and referral services. What is interesting is that supplementary nutrition was the only service which was delivered by all AWWs. Corn Soya Blend (CSB) was cooked with jaggery and it was observed that the preparations were of a satisfactory quality. Nutrition and Health Education (NHED), was found to be a weak component in service delivery. A third of the AWWs expressed their inability to organise nutrition and health education because they were unable to meet the mothers during home visits, as they were busy in the farms. For several months, some of them migrate to places in search of work. The most important reason for the poor implementation of the component could be attributed to the lack of basic information on the right messages and the skills to impart NHED. Although 49 per cent AWWs realised the importance of health check-ups, it was not possible for them to provide the service since Medical Officers did not visit the AWCs regularly. Check-ups were being organised only in 42 per cent of the AWCs and that too irregularly. Only 16.6 per cent of the AWWs were referring malnourished children to doctors. Only 22 per cent of the beneficiaries went for immunisation on the scheduled dates. The out-reach of services to remote villages was weak. Poor maintenance of records made it difficult to monitor the immunisation status of children in AWCs. Maintenance of records of pregnant women was still worse. According to AWWs, growth monitoring was initiated as early as the second month by 36 per cent of the AWWs. Around 18 per cent of them responded that they started growth monitoring after 6 months of age. 65 per cent weighed children below 3 years on a monthly basis while others weighed quite infrequently. It was observed that they could not fill in growth charts. Only 2 per cent were able to fill the growth chart correctly and 7 per cent had never filled a growth chart. Although weighing was done, growth cards were filled by only 2 per cent. Mothers were not present at the time of weighing in 67 per cent of the cases, reflecting the absence of the counselling of parents on the basis of the growth trends of their children. The lack of growth monitoring skills is amply demonstrated by this data. Supervision in this regard was found to be weak. Iron and folic acid was distributed in only 44 per cent of the AWCs. Distribution of Vitamin A was more frequent in 82 per cent of the AWCs. Pre-school education was another weak area. The quality of non-formal pre-school education was found to be poor. There were hardly any outdoor games. Little attention was paid to the cognitive development of the children. Priority of services as viewed by the AWWs A majority of the AWWs
gave primary importance to supplementary nutrition followed by non-formal
pre-school education and immunisation. Health check-up, nutrition and health
education and cleanliness among children were of low priority. Referral
services did not have primary, secondary or tertiary levels of importance.
Details are as under:
Community Support and Participation Around 47 per cent of
AWWs did not receive any kind of support from the community towards Anganwadi
activities. Details of community participation are as under:
58 per cent of the workers did not even discuss the AWC activities with local leaders. The rest who did, did not receive any response from 70 per cent of the community. Only 9 per cent received cooperation for activities such as Anganwadi construction, improving attendance at the AWCs and creating awareness among the community. 43 per cent AWWs reported that attendance improved due to community participation; 22 per cent helped in creating awareness about immunisation; 8.6 per cent helped in bringing about attitudinal changes among the community; 4.3 per cent brought about improved cooperation. Only 60 per cent of AWWs had formed Vigilance Committees and 55 per cent had formed Mahila Mandals. The Vigilance Committees reflected the highest interest in the supplementary nutrition component. 72 per cent of the children had to be brought to the centre by the Helper, implying that parents were not adequately motivated to participate in Anganwadi activities. Views on the Adolescent Girls’ Project All AWWs had very positive views towards the training of adolescent girls. They felt that it would change attitudes among their family members as well. It was also felt that their participation in the Anganwadi activities would motivate the children at the AWC and improve their participation. Profile of the Adolescent Girls Socio-economic
Background:
Most families belonged to low socio-economic groups. 81 per cent of them
belonged to different tribes—Bhil, Bhilala, Patalya and Mankar, and the rest
belonged to Scheduled Castes (SC) or Other Backward Communities (OBC). 93 per
cent of the adolescent girls belonged to large families, with members as can
be seen as under:
Most of the girls worked as casual labour which helped them earn between 16 to 20 rupees, which they gave to their parents. Others who belonged to families of marginal farmers, worked in their own fields or grazed cattle. Their contribution to the economy of their families was substantial.
Habits of Hygiene: While questioning girls about their health habits, it was found that 82 per cent of the girls brushed their teeth daily, while the remaining 18 per cent did not. Only 24 per cent girls had a daily bath. Reasons for not bathing varied: lack of time (40 per cent); did not think a daily bath was necessary (20 per cent); traditionally did not take a daily bath (30 per cent). Only 10 per cent mentioned shortage of water as a reason for not taking bath daily. 95 percent of the girls said they washed their hands before eating food. Personal hygiene was gauged to be rather poor. They had no awareness of illness due to lack of hygiene. Infant Feeding Practices: When asked about infant feeding practices in their families, 77 per cent of the girls did not know when breastfeeding should be initiated for a new born child. Nearly 20 per cent said breastfeeding was initiated on the second or the third day. Only 2 per cent said that the new borns were breastfed on the day of their birth. The reasons ascribed for not feeding the new born with colostrum on the first day were: lactation does not start, according to 52 per cent; 40 per cent did not know the reason; while 6 per cent said that delayed initiation of breastfeeding was their tradition. Childhood Diseases: Regarding children’s illness in their family, 8 percent were unable to give any response while 63 per cent said that children in their family suffered from diseases. Of these, 94 per cent said that the children who were ill, were taken to the hospital or to the doctor for treatment. A small percent (4 per cent ) were reported to be going to traditional healers. It was also observed that none of the girls knew about Oral Rehydration Therapy (ORT) and were unaware about the treatment given for childhood diarrhoeal diseases. Immunisation: As far as immunisation was concerned, it was revealed that 80 per cent of the girls did not know whether immunisation was a requirement or not. Only 18 per cent girls were able to tell that it was important. Of these, 39 per cent were not able to recall the origin of their information. The remaining said that they had known it either from the AWW or the media or the family members. 49 per cent of the girls confirmed that children in their families were immunised against childhood diseases but were unable to give details. Girls who had no knowledge on immunisation were 28 per cent. There were also some 10 per cent who reported that in their families, immunisation had not been done for small children as their parents were unwilling. 77 per cent of the girls had no idea if pregnant women in their families were immunised or not. Age of Marriage: On the question of the age for marriage, girls were unable to express any opinion. The majority of them said that they would be married when they had their menarche. Discrimination: While some girls were not aware about discrimination (basically, it is an accepted way of life), 49 per cent felt that they were discriminated against in their daily lives in terms of special food, education, clothes, physical work performed, parental love and affection. Profile of their Families Socio-economic
Aspects:
Twenty per cent of the families were landless or owned insufficient land for
farming. They were forced to work as farm labourers on others' farms. The
majority (65 per cent) were marginal farmers. Out of them, 49 per cent
undertook limited agricultural activities and Education of the Girls: During interviews with the parents of the adolescent girls, it was found that in 92 per cent of the cases, the decision not to send girls to school, was a joint one taken by both the parents. Only in 2 per cent of the cases it was the father who had refused to send the girls to school. At the time of interview, most of them (87 per cent) did realise that they had made a mistake by neglecting the education of their daughters. 48 per cent of the parents wished that their daughters had received some education or some sort of training that would enable them to lead a better life and equip them better to look after themselves and their families in the future. Mothers, particularly, did not wish their daughters to be subjected to hardships which they experienced themselves. Aspirations for the Girls: On the needs and aspirations of their adolescent girls, 53 per cent of the parents felt that their daughters had some special needs. According to them, girls need to improve their abilities, skills and knowledge of household affairs. The majority of the parents interviewed felt that if they married off their daughters before menarche, they would be highly relieved. Only a few mothers (10 per cent) felt that their daughters should be married 5 or more years after attaining menarche, so that they would be mature enough to shoulder their responsibilities as wives and mothers well. Views on the Adolescent Girls’ Training Programme: Expectations from the programme were very high for 95 per cent of the parents. The rest were prepared to comment only after the training was over. 80 per cent of the parents expressed hope that through the training, their daughters would learn many new things that would bring improvement not only to their own lives, but also to their family members. Some parents (16 per cent) were convinced that with the training, their daughters would acquire skills that would enable them to work efficiently and get good jobs. Thus, it was evident that there was an overall enthusiasm about this training programme and a lot was expected from it. Project Components that Emerged from the Pre-phase Assessment Certain project inputs were included on the basis of the pre-phase assessment. They were:
Identifying the Role of Adolescent Girls in ICDS The adolescent girls could not be expected to undertake tasks which the AWWs themselves found difficult, owing to their own lack of skills or knowledge. However, it was felt that the adolescent girls could play a complementary role, thereby strengthening the hands of the AWWs. Some of the activities
identified for them were: Participation and Training In order to get the perception of the community on ongoing interventions and to outline the future line of action for involving adolescent girls, a series of community meetings were organised in the tribal block. A total of 64 community meetings were organised in different sectors of the four project areas. Local leaders, other influential people of the villages, members of the local government (Panchayat), health functionaries, other government functionaries related with women and child welfare schemes, and volunteers of other developmental programmes, alongwith the parents of the adolescent girls, were specially invited to participate in these meetings. The meetings were generally arranged in the evenings after dinner, so that the participants were in a relaxed mood and could actively take part in the discussions. These meetings were broken into two sessions— the first session was organised before the training and the second was organised after the completion of the training. In the first session, details of the intended project were discussed. A video cassette made on the pilot project was screened in these meetings, for the people to get a clear idea of the project objectives and activities. They were also exposed to excerpts from the training, such as puppet shows, songs and stories. As these songs and stories were in the local language, they were understood well and were appreciated. After the show, informal discussions were held in order to understand the views of the community members about the programme. During discussions, issues such as gender discrimination with regard to schooling, early marriage, etc., were discussed. The main objective of the second session was to let the parents of the girls and other community members perceive the effect of the training on their daughters. In these sessions, the girls usually enacted some songs and stories they had learnt during the training. They also demonstrated some of the new skills and knowledge they had acquired during the training. Community Meeting—Some Unique Experiences In the first few meetings, the attendance was poor. Only Panchs, Sarpanchs (leaders of the local government), officials from the block and health department and a few villagers were present. When the word spread that there would be a film show (video cassette on the pilot project) and a ‘Kathputli ka Naach’ (a puppet show), the whole village turned up. The video cassette and puppet show proved to be very helpful in attracting the community to the meetings. As the project progressed, it was heartening to see that Sarpanchs, Panchs, local leaders and others from the nearby 8 to 10 villages had come by bicycles, motorbikes, tractors or even walking from 10-12 km. distances to attend the meeting. It was not possible to arrange a community meeting in every village.
It was difficult to reach some villages even by jeeps. The Sarpanchs and Panchs arranged to take the organisers on motorcycles and tractors. Weekly markets in the tribal villages were attended by people from all the neighbouring villages. On market days, the tribals normally do not go for their daily wages but devote their day to shopping. When community meetings were organised on the day of the local market, they were well attended. After going through the preview of the training, the community felt that the training would be beneficial to the adolescent girls by helping them lead a better life. They felt that the training was all the more necessary since they themselves were illiterate and did not have enough time or knowledge. They would therefore not be in a position to impart such knowledge to their daughters. Later, when the girls demonstrated to the community what they had learnt during the training, it was fascinating to see the expressions on the faces of the community members, particularly the parents of the girls who had participated in the training. They felt very proud and some even had tears of joy when they saw what their daughters had learnt. Other parents, whose daughters could not be included in the training, inquired if their children would have some opportunity in the future for receiving this sort of training. Many complained, “Why were only three girls selected when all the girls of this age-group needed this sort of training?” Others were of the view that the duration of the training should be of at least 15 days. Training Content and Materials Indigenous knowledge, attitudes and practices of the tribals, gathered through the pre-phase assessment, were used systematically in designing training materials for the adolescent girls. A special manual was developed for imparting nutrition and health education. Considering that these adolescent girls would be assisting the AWWs at AWCs in organizing activities for children and other community-related activities, the main stress, in their eight days' training, was laid on: nutrition and health education and non-formal pre-school education. All the problems identified through the pre-phase assessment could not be addressed through the training packages owing to resource and time constraints. It was also thought not to have an ambitious coverage of issues which the adolescent girls would be unable to cope with. Only crucial aspects were selected: (a) significance of adolescence; (b) personal hygiene and environmental sanitation; (c) feeding of babies; (d) diarrhoea management; (e) growth monitoring; (f) immunisation; (g) prevention of anaemia; and (h) care in pregnancy. The selection was based on prioritisation of the problems. A great deal of similarity existed between Dhar and Jhabua, which are neighbouring districts. Many belonged to similar tribes, with a similar social environment, lifestyle and customs. Therefore, the basic issues covered in the Jhabua pilot project could be used with minor modifications to suit Dhar District. For each of the selected topics, the manual described:
Since the adolescent girls hardly possessed any literacy skills, the training was done with the help of audio cassettes accompanied by puppetry. Audio cassettes which were produced in Bhili for the pilot project in Jhabua, were useful for certain tribal pockets inhabited by the Bhils. It was, however, necessary to produce the communication material in the Malwi dialect as well, since the majority in Dhar spoke and understood Malwi. Therefore, a fresh set of cassettes were produced in Malwi with the help of local artistes. Suitable changes were made in the communication style and language. Puppets were also produced to suit the Malwi culture. For non-formal pre-school activities, audio programmes developed by the National Council of Educational Research and Training (NCERT) such as “Khilte Phool”, were used. Programmes, were selected to offer variety by covering a wide range of themes. The Bal Niketan Sangh played an active role in identifying the activities and methodology to be followed. They also developed a kit for non-formal pre-school education which were provided to all the AWCs in the four ICDS projects. Different activities for the development of different faculties were included. These activities were: free conversation, action songs and poems, story telling, and games and creative activities. The participation of the adolescent girls in non-formal pre-school education was expected to be an added advantage to their own cognitive development. They would also be able to provide a better teacher/student ratio when they helped the AWWs in organising non-formal pre-school activities for children at AWCs. The Trainers A field coordinator, assisted by an assistant field coordinator, were recruited by the Bal Niketan Sangh (BNS) to coordinate the project in the field. After several discussions, BNS and WFP jointly concluded that the ICDS Supervisors of the project area would make the best trainers. As the Supervisors were already working in the areas where the training camps were to be organised, their familiarity with the local people, customs, lifestyle and language had a distinct advantage. After discussion with the Government of MP, all the Supervisors of the four ICDS programmes were provided with the training of trainers.
An eight-day workshop was organised at the district level in order to orient the trainers to the training modules to be used for the training of the adolescent girls. A total of 37 Supervisors participated in the workshop. Supervisors were oriented on the content and the use of the training material. Trainers were given the opportunity to practise each of the sessions. Training was provided on puppetry and tribal dances with the help of local tribal artistes. Suggestions from the trainers on organising non-formal pre-school activities like colour concepts, counting, simple arithmetic, etc., through songs, stories or games, were incorporated in the training.
Training Procedures Training was organised for the adolescent girls alongwith the AWWs and Helpers, so that it could be linked to the roles they had to play at the AWCs. The size of the training batches was restricted to 35-40. The duration of the training was eight days. Information was imparted to the girls through participatory techniques instead of formal lectures. Learning was established through hearing, seeing and doing. There was appreciation of the fact that the girls had hardly attended schools, and so learning had to be geared to illiterates. Active involvement of the trainees was important, not only to sustain their interest, but also to weave in the trainees’ knowledge and experience to the training session. The girls’ experiences were understood through discussions, brain-storming, buzz groups, secret ballots and quizzes. Entertainment was introduced for emotional appeal, enjoyment, changing behaviour and for improving interaction. Puppets also were used in an interactive way. Messages were communicated through songs, stories and drama. The names, situations and the musical beats were all local so that trainees could identify themselves with the programmes. For visual effects, puppets dressed exactly like Bhils were used for dramatising the stories and drama. Training Coverage and Duration The number of AWCs in the four ICDS projects were 640. From each AWC, three adolescent girls and one Anganwadi Worker/Helper were trained. A total number of 2,560 trainees from the selected four ICDS projects were trained in 73 batches over a period of two years. The implementation phase of the project was January 1995 to January 1996. Impact of Training The training influenced certain changes which were captured as snap shots of the training period. A few interesting observations are described below: On the first day of the training, girls seemed very nervous. It was their first opportunity to be away from their homes. When they were asked their names, they blushed and turned their faces away, and when they finally answered, it was a whisper. The ice-breaking sessions helped them to shed some of their shyness and fear. Gradually, the girls began mixing among themselves and were soon speaking without covering their mouths. After the introductions, enthusiasm slowly replaced their anxiety. Girls who were apprehensive at the beginning of the training, did not want to leave the camp after the training was over. This was reflective of the limited exposure of the adolescent girls in the community. The adolescent girls were very accommodating and helpful in the camps. They lived like a family and shared work willingly and eagerly. Once the father of an adolescent girl came to visit her during the camp. The girl refused to see him for she was afraid that he had come to take her home. Only when the AWW (with whom she had come to the training) convinced her that he had come only to see her, and she would not be sent home with him, did she agree to see him. In a session they learnt
the importance of personal hygiene and cleanliness with the help of a song,
‘Bhoori’, about a girl who was beautiful because she was neat When the training was being conducted at Bhopawar in Sardarpur Block (Bhopawar happens to be a place of pilgrimage for Jains—a religious group), a Jain festival was being celebrated. The Jains are a religious cult who are very conscious about personal and environmental hygiene—it is a part of their religious norm. Adolescent girls who were undergoing training at Bhopawar, sang the song of Bhoori. The Jain monks who were present there, also learnt the song and joined in the singing. The monks said that from then on, wherever they went for their religious sermons, they would sing that song. This particular song from the audio cassette became so popular with the people, that at many community meetings the trainers were requested to play the song. It was not an unusual scene to see the tribals dance to the rhythm of this song. Training in a Tribal Setting—Some Interesting Experiences Village level training was the choice for this project, since the girls had never been out of their villages in their lives. Their families were not willing to send them far away from their villages. The entire training was therefore done by moving from one village to another. The village level training, however, posed several challenges. Accommodation was not easy. Food and water had to be arranged. Quite often, water had to be brought from hand pumps which were located at considerable distances from the camp-site.
On one occasion when there was heavy rain, the roof began to leak. The local leaders not only accommodated the girls for the night, but also helped in repairing the roofs. In another village, where security was uncertain, the village leader slept outside the building where the girls were camped. In yet another camp, around 0300 hours, one girl complained of severe pain in her stomach. The village Sarpanch immediately brought a doctor to attend to the girl. From one of the camps, two girls disappeared. As soon as this was brought to the notice of the trainers, they dropped everything they were doing and ran in search of those girls. Some people had seen two girls on their way to their village. When the trainers located the girls at their homes and inquired where they had gone, the girls innocently replied that they had gone to the fields to eat sweet-corn. When asked why they did not tell anyone where they were going, the girls replied, “You don’t permit us to go anywhere during the training, and by the time the training gets over, the cobs will have dried and we would have missed the fun of eating sweet-corn this year.” Experiences were not always positive. In certain villages tribals had reflected animosity. Trainers had to overcome such problems with tact. Other Project Components Placement of Girls
in ICDS:
Three girls were attached to each AWC and they worked for 2 days in a week in
turns. This schedule was flexible to suit their own convenience. Everyday, at
least one adolescent girl participated at the AWC. They continued for a
period of one year. Each one was to be replaced by a fresh batch who would be
trained and placed at the AWCs. In this way, a large number of girls would
benefit. Monitoring and Review: WFP officers, officials of the Government of Madhya Pradesh (GOMP), and the Bal Niketan Sangh monitored the programme. Training in a field situation required a great deal of support and encouragement from everyone. Operational problems were addressed through these visits. Constant feedback on the training also helped in incorporating the necessary modifications. Flexibility of timing and schedule was necessary, particularly because the training was field-based.
The Post-phase AssessmentAfter the completion of the implementation phase, an assessment was done to:
Methodology As in the case of the pre-phase assessment, ten percent of the Anganwadis were randomly selected in the four ICDS projects. The selection was done through interviews and observations. Findings An important change that was visible among the Anganwadi workers themselves was their feeling of self-worth and self-esteem. Most AWWs were happy with the training and were of the opinion that the training techniques were interesting, which made learning a pleasant experience. They felt that they were now better equipped with skills to communicate with the beneficiaries.
Health check-up, referral and immunisation services had improved substantially in the post-phase as compared to the pre-phase. Although pre-school education was reported by a large number of AWWs in the pre-phase, the quality was poor. The post-phase assessment reflected a qualitative improvement and greater interest among the children. According to 40 per cent of AWWs, adolescent girls participated actively in the pre-school education. There was a sea-change in the quality of pre-school education, with the assistance of the adolescent girls. With this additional assistance, it was possible to work in small groups which made learning easier for children. The girls effectively involved children in songs, play, dance, indoor and outdoor games, thus livening up the whole atmosphere and making the AWC a more enjoyable place for the children. Attendance and participation increased. Similarly, NHED was found to be definitely better qualitatively. The sessions were reported to be more meaningful and intense. Children had to be brought to the AWC by the Anganwadi functionaries at the time of the pre-phase assessment. During the post- phase assessment, some of them were brought by the parents to the AWC. This is a reflection of a positive change in attitude among parents towards education and the activities of the Anganwadi itself. Trained adolescent girls were also helpful in getting children to the AWCs.
In the pre-phase situation, the functioning of the AWC was seriously hampered whenever the AWW was absent. When she was occasionally on leave, the trained adolescent girls became involved in the daily functioning of the AWCs. The adolescent girls helped the children in personal hygiene. They were also effectively involved in the immunisation programme by informing the beneficiaries about immunisation days. On the day of immunisation, they called the children and mothers from their homes. Figure 2 gives details of the activities in which the adolescent girls were involved. Weights of children were taken only from the second month at the time of the pre-phase assessment. In the post-phase evaluation, the AWWs reported that they had started weighing from the first month. There was a distinct change in the periodicity of weighing children. In the pre-phase situation, some AWWs had no fixed periodicity for growth monitoring. Some even weighed children once a year. In the post-phase situation, children were weighed either monthly or quarterly. The changes can be seen from Figure 3.
Fifty-two per cent of the AWWs did not know how to fill in the growth charts at the pre-phase stage. Interviews in the post-phase with the AWWs reflected that 53 per cent of them had learnt to fill in the growth chart correctly and even identify the nutritional status of children. During the pre-phase assessment, it was found that none of the AWWs filled the growth chart immediately after weighing. In the post-phase, however, 39 per cent of AWWs had started plotting immediately after weighing, to facilitate communication with the mothers on the growth trend of their children and provide counselling on matters such as diet, immunisation, etc. This is reflective of a positive change in terms of growth monitoring. It can be considered a very important achievement of the programme that AWWs were sensitised on the importance of growth monitoring. Initiative to organise nutrition and health education was taken by only 66 per cent of the AWWs in the pre-phase. A dramatic change seen in the post-phase was that 100 per cent of them had started doing so. Changes in Knowledge, Attitude and Practices among Adolescent Girls Although none of the girls knew the legal age of marriage at the pre-phase stage, 18 per cent of the girls were aware of it during the post-phase assessment. It appears that there is a need to reinforce this message more strongly through nutrition and health education programmes.
During the pre-phase evaluation, 24 per cent girls said that they took a bath daily. In the post-phase, there was an improvement: 33 per cent girls said that they bathed daily. The rest reported that they did not take a bath due to shortage of water and lack of time. In the pre-phase, 95 per cent of the girls said they washed their hands before eating but in the post-phase, 100 per cent girls did so. A similar change was observed with regard to defecation practices. A greater percentage of girls had cleaner habits due to the training. During the pre-phase evaluation, it was seen that none of the girls had knowledge about ORS. In the post-phase evaluation, 68 per cent of the girls were aware about ORS and what it was meant for. Of these, 26 per cent could provide the correct procedure for making ORS. Only 20 per cent of the girls in the pre-phase knew about immunisation and 18 per cent of the girls knew that immunisation was important. In the post-phase, all the girls had knowledge about immunisation and 58 per cent were aware about the process. They knew that immunisation prevented childhood diseases and knew the names of the vaccines. Changes with regard to knowledge on nutrition and health aspects can be seen in Figure 6.
The parents in the pre-phase expected that the training would enable their daughters to get employment and add to the family income. Some parents had initially sent the adolescent girls to assist at the AWCs, but subsequently felt that it was a greater priority to send them to earn daily wages, or to keep them at home to do the household work and take care of the siblings. Parents said that their girls were taught songs, stories and other activities. Some parents, however, had no idea about the training contents.
ConclusionsConclusions drawn from the project experience are summarised below. These conclusions were helpful for making recommendations for future interventions for adolescent girls:
Recommendations
References
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