The Table 1. Illustrate the demographic characteristics of the study participants, average age of the participants was 31 years, approximately 89% of them were in married reaming 11% were unmarried. Regarding their educational background, more than eight out of ten participants (86.2%) had received secondary education or higher. The majority, or 80%, were engaged as housewives, while the remaining 20% were employed in various occupations.
Table 1
Demographic Characteristics of Focus groups discussion (FGD) participants.
| Characteristics | Number | Percent |
|---|
| Age | | |
| 19–25 | 9 | 16.4 |
| 26–30 | 24 | 43.6 |
| 31–35 | 10 | 18.2 |
| > 35 | 12 | 21.8 |
| Marital status | | |
| Married | 49 | 89 |
| Unmarried | 6 | 11 |
| Education | | |
| Primary | 7 | 12.8 |
| Secondary | 12 | 21.8 |
| Higher & above | 36 | 65.4 |
| Occupation | | |
| Housewife | 44 | 80 |
| Service | 11 | 20 |
Causes of malnutrition
The study outlined the possible factors contributing to malnutrition within the study area, establishing a basis for addressing malnutrition among children enrolled in ICDS program. These identified causes of malnutrition lay the groundwork for comprehending malnutrition management amidst the challenges posed by the COVID-19 pandemic. Notable factors included limited childcare time, insufficient awareness and adherence to cultural beliefs, and inadequate maternal health, all of which emerged as significant drivers of malnutrition. Table 2 presents the primary themes and underlying sub-themes that surfaced concerning child malnutrition management within the study area. Prominent issues such as limited maternal childcare time, insufficient awareness, cultural beliefs, and maternal health challenges emerged as major contributors to child malnutrition. Challenges in effectively identifying malnutrition included the need for multiple rounds of child screening and inadequate involvement of parents in treatment. Malnutrition management was impeded by barriers like inadequate nutrition counselling, reduced follow-up visits, and suboptimal service effectiveness. Additionally, challenges encountered by both caregivers and service providers during malnutrition management encompassed food insecurity, restricted food choices, and mismanagement of self-produced crops
Table 2
Barriers to management of pre-school children malnutrition during COVID-19 in Buldhana District of Maharashtra
| Major Themes | Sub-themes |
|---|
| Causes of Malnutrition | Low child caring time to mother |
| | Lack of awerness |
| | Cultural beliefs |
| | Poor maternal health |
| Difficulties in child Identification | Multiple rounds of child screening |
| | Poor treatment from child parents |
| Difficulties in managements | Nutrition counselling |
| | Reduced follow-up visits |
| | Low effectivity of services |
| Difficulties faced by mothers or caregivers | Food insecurity and lack of food choice |
| Difficulties faced by services providers | Mismanagement of self-produced crops |
| | Cultural Gaps |
Low child-caring time to mother
The dual burden faced by mothers hampers their capacity to adequately care for their children. Moreover, the daily earnings of laborers constrain the amount of time they can dedicate to childcare.
“As a mother of two children, I find myself juggling dual responsibilities within my family. As a daily wage labourer, I need to leave home around 9:30 to 10:00 AM and return between 6:00 to 6:30 PM, taking on the responsibility of caring for my children and other family members. On top of this, I am also tasked with preparing meals, going to the market, collecting firewood, and fetching water. These multiple tasks significantly restrict my capacity to adequately provide nourishment to my child." (Mother, 27 years old).
Additionally, AWW has reported instances where mothers overlook the counseling sessions offered by the AWW.
“The majority of mothers are occupied during the morning hours as they engage in various responsibilities like preparing breakfast, bathing their children, and collecting water. Unfortunately, the timing of most counseling sessions does not align with their availability, leading to inadequate participation or disregard from the mothers. Consequently, these constraints limit the mothers' ability to fully engage in childcare and feeding activities for their children." (AWW 35 years old).
Lack of awerness
Certain participants highlighted that the susceptibility of child malnutrition grew due to insufficient knowledge regarding child feeding, nutritious food, hygiene, and sanitation.
“The primary concern for many mothers focus on the quantity of food rather than its nutritional value, leading to deficiencies in essential nutrients and calories. This, in turn, contributes to persistent hunger and malnutrition " (Anganwadi workers 45 years old).
"The majority of children play in open spaces with poor sanitation and unhygienic regularly since no one is there to look after them. As a result of that, in turn, increases kids vulnerability to infectious disease and contributes to child malnutrition" (Mother 22 years old).
Cultural belief
In society, there has been a longstanding belief that malnutrition is not considered an illness but rather a sign of weakness in children. However, when a child's vulnerability escalates into a serious problem, it becomes a matter of significant concern.
"AWWs informed me that my girl is malnourished, but she is behaving like a normal girl in all activities." (Mother, 33 years old)
“Cultural norms discourage mothers from seeking and receiving counseling. Traditionally, it is considered taboo for anyone other than close relatives or immediate family to meet the child's mother during the initial two weeks after childbirth, as outsiders are believed to bring negative influences (referred to as "Upshagun") to the child.” (AWW, 43 years old).
Poor Maternal health
Most AWWs emphasize that child malnutrition often stems from maternal health issues and early marriage, a viewpoint shared by specific AWWs.
“During the course of a child nutrition study, a 20-year-old woman who already had two children was expecting her third child. I attempted to communicate to her husband the possible implications of having a third child. Regrettably, he did not regard the matter seriously, and as a result, the newborns arrived with a weight of merely 1700 grams.” (AWW 29th years old).
Difficulties faced in identification of child with malnutrition during COVID-19
Findings from the study, as reported by both AWWs and participating mothers, indicate that AWWs monitor children's growth up to two years of age or until the child reaches a length of 82 centimetres. This involves regular measurements of child weight and height on a quarterly basis during the first year, and subsequently, for children above two years of age or those exceeding a height of 82 centimetres, measurements are taken semi-annually. However, AWWs and mothers encountered difficulties in identifying malnourished children during the COVID-19 pandemic. These challenges encompassed the disruption of several rounds of growth assessments conducted at Anganwadi centers’ (AWCs), limitations on home visits for children, and inadequate cooperation from children's families in the management and treatment of malnutrition
Multiple rounds of screening in Anganwadi centres (AWCs)
Due to the limitations imposed by COVID-19, AWWs noted that they were compelled to conduct multiple iterations of child screening within AWCs.
"Child screening predominantly involves a monthly assessment of the child's weight, and subsequent categorization as either underweight or within the normal range. This classification is determined using the ICDS growth chart or the POSHAN Tracker application.” (AWW 33 years old.)
Many participants observed that the impact of the COVID-19 pandemic led to reduced functioning of AWCs, resulting in the need for multiple screening rounds for children. Moreover, parents displayed reluctance to leave their children alone at AWCs, leading them to attend child screenings whenever it was convenient for them or their caregivers. A significant proportion of AWWs disclosed that the frequency of child screening had decreased due to the pandemic. Furthermore, all AWWs were assigned additional duties related to COVID-19 containment measures, such as organizing awareness camps, conducting screenings for COVID-19 symptoms, and facilitating vaccination drives in their respective service areas. Consequently, most parents were reluctant to send their children for regular screenings at AWCs. Periodic child screening is sometimes conducted by charitable trusts or non-governmental organizations (NGOs); however, it occurs only once or twice a year, and the reliability of the results is not assured. Service providers AWWs also undertake regular visits to children's homes for nutritional health assessments. These visits occur at the request of the child's parents or caregivers
“I conduct nutritional assessments for children below the age of two by visiting households directly. In cases where children are severely malnourished, I make weekly visits to their homes to monitor their nutritional well-being.” (AWW, 29th years old).
Poor treatment during child screening
Due to concerns related to COVID-19, certain AWWs noted instances of mistreatment by family members of the children, especially during the door-to-door visits for child screening.
“My task involves conducting weekly growth assessments of children and providing updates to my supervisor, particularly for children classified as SAM. However, some parents or caregivers expressed dissatisfaction with the recurrent home visits for screening. The COVID-19 pandemic heightened parents' concerns about the potential increased susceptibility of children to COVID-19 infection. Although initially, a family member allowed me to enter their home, their sentiment changed over time, and they became discontented with my frequent visits.” (AWWs 39 years old).
“During the child screening process, the AWW encountered mistreatment from my father-in-law. This occurred as he had asthma and was concerned about potential COVID-19 infection due to the screening.” (Mother 26 years old).
Difficulties faced in management of child malnutrition during COVID-19 pandemic
Most participants displayed a lack of comprehensive understanding regarding malnutrition, citing a range of symptoms such as low weight, dry skin, distended abdomen, and frail physique. Additionally, they recognized that AWCs offer nutritional supplements in the form of sweet balls (Ladu). One mother shared her child's existing malnutrition care measures, which included counseling sessions and subsequent follow-up visits. It was also noted that in cases of severe malnutrition, a child should be referred to a Nutrition Rehabilitation Center (NRC) at the district level. The participants also addressed gaps in malnutrition management services. Mothers or caregivers perceived challenges, particularly during the COVID-19 pandemic, in accessing counseling and other necessary resources for effective malnutrition management
Nutrition Counselling
As per accounts from mothers or caregivers, counseling stands as the foremost approach to managing malnutrition. This counseling encompasses imparting knowledge about nourishing feeding practices and techniques for preparing different food components in ways that preserve their nutritional content. The counseling sessions also encompass guidance on maintaining proper child health, sanitation, and hygiene practices. Mothers or caregivers of children detailed their experiences of receiving counseling services during child immunization, the Poshan Abhiyan campaign in September, as well as home visits by AWWs. However, the advent of COVID-19 has markedly affected malnutrition counseling initiatives.
"Prior to the onset of COVID-19, I would seek guidance from AWW regarding topics like sanitation, hygiene, and child feeding. AWWs would also personally visit my home to offer advice. However, owing to the impact of COVID-19, AWWs have transitioned to providing tele-counseling exclusively. On occasion, she shares instructional videos pertaining to nutrition." (Mother 24th years old).
“As per the government COVID-19 guideline all the counselling services are being conducted through either mobile phone or video link, as result of that some of the essential counselling services such exclusive breastfeeding, food and nutrition counselling are disrupted” (Anganwadi Worker 34th years old).
Likewise, the AWWs elaborated on their practice of conducting monthly home visits to nursing mothers, delivering dedicated counseling. These visits encompassed guidance on nutritional food preparation, sanitation, hygiene, child health, and family planning services. However, challenges were encountered by all participants in effectively managing malnutrition services, particularly in relation to the absence of adequate provisions for MAM. Notably, not all children received additional THR or nutrition supplement powder from the AWCs. Even if a child qualified for extra rations, they had to wait until the subsequent cycle of ration distribution.
Reduced follow up visits
All mothers or caregivers concurred that there has been a decrease in the frequency of home visits by AWWs, particularly those related to counseling and monitoring child growth, owing to the restrictions imposed by COVID-19.
“The most recent instance when the AWW visited my residence, she contracted COVID-19 within three days. Following this incident, my husband prohibited further visits from the AWW to our home. As a consequence, this situation has indirectly impacted the counseling services and growth monitoring for my underweight child.” (Mother 27th years old).
A significant proportion of AWWs indicated that they make an effort to minimize home visits for malnourished children due to their responsibilities related to COVID-19. Conducting home visits for malnourished children might potentially elevate their susceptibility to COVID-19 infections. Several mothers also expressed their apprehensions about COVID-19 and hence refrained from permitting AWWs to visit their homes for counseling.
Low Effectivity of Services
Mothers and caregivers conveyed their dissatisfaction with the efficacy of child malnutrition management. Some noted challenges in implementing virtual counseling, finding it less effective compared to the prior face-to-face interactions facilitated by AWWs.
Another noteworthy obstacle was the closure of weekly markets due to COVID-19 restrictions, preventing access to vital items like green vegetables and other essential foods. The pandemic has, to some extent, curtailed household consumption due to reduced family incomes and uncertainties about the future.
"I adhered to the guidance provided by AWWs for a month, yet there was no noticeable enhancement in my child's weight. At times, I find myself questioning the feasibility of the counseling provided by AWWs; however, my options are limited due to COVID-19 restrictions on public transportation. Furthermore, the inability to hire a private vehicle hinders our ability to visit a private hospital." (Mother 34th years old).
Another issue reported by AWWs is that children who are moderately thin or underweight are being ignored by their parents. It does not become a serious concern for them until they reach a frightening degree of malnutrition.
"A four-year-old child was in the MAM category, I gave them correct counselling and AWC nutrition supplements, but they ignored it now that the girl's weight is only 11kg and she falls under SAM" (AWW, 43rd years old).
Some AWWs noted that nutritional content was lost due to cultural beliefs and various food preparation procedures.
"Every September month, we organised Poshan Abhiyan and demonstrated how to create nutritious meals without sacrificing nutritional content. However, regarding the applicability, relatively few people use it" (AWW 27th years old).
Difficulties face by Mother or Caregiver
As per insights from AWWs, mothers, and caregivers, the most challenging aspects of addressing child malnutrition encompassed issues related to food security, limited food choices, and improper handling of available food resources. These significant hurdles hinder mothers and caregivers from effectively addressing infant malnutrition.
Food insecurity and lack of food choice
Amid the COVID-19 pandemic, ensuring access to food has emerged as a pressing issue, particularly for families relying on daily wage labor. Although the Indian government distributed free grains via the Public Distribution System (PDS), it proved inadequate to fully shield certain households from the grip of food insecurity.
“ Our family consists of seven members, with only my spouse and myself being the sole earners. My husband used to work as a security guard in a mall, but the abrupt COVID-19 lockdown forced him to return to our village, resulting in the loss of his job. Presently, we are grappling with food insecurity and financial difficulties as neither of us is employed. Consequently, I am unable to provide nourishing food for my child and the other members of our family. " (Mother of 23rd years old).
As stated by AWW, the counseling offered to seasonal migrants tends to be ineffective, as many of them prioritize tangible services such as dry rations and nutritional assistance over counseling.
" The majority of families with limited income in my village are comprised of seasonal migrant laborers, which leaves them without any reliable food security. As they typically do not carry extra food and rely on purchasing it at the weekly market instead. " (AWW 41st years old).
Numerous participants asserted that the COVID-19 lockdown had curtailed their choices for food and had constrained the variety in both their family's and children's dietary routines. The suspension of the village's weekly market in adherence to COVID-19 guidelines over the past year has inadvertently led to a rise in the prices of items like green vegetables, legumes, and non-vegetarian foods due to disruptions in the supply chain.
Mismanagement of self – produced crops
A significant portion of the agricultural activities in the region relies on rainfed methods, and land is often left uncultivated for two seasons following the Kharif season. The preference among a majority of farmers is for cash crops, with soybean being a prominent choice. However, the cultivation of cash crops limits families' capacity to grow food crops, even when they have a substantial yield of cash crops. Many farmers wait for food crop prices to drop before making a purchase, as uncertainty deters them from buying even when they are in need. For instance, the COVID-19 pandemic accentuated food insecurity for many parents due to challenges in effectively managing their self-produced crops.
Cultural gap
Mothers and caregivers encounter an additional obstacle stemming from a cultural disparity, as many AWWs deliver counseling without taking into account the educational background of both the mother and child. Traditional beliefs hold more sway among scheduled tribes (ST), causing them to be less inclined to swiftly adopt external recommendations. As recounted by an AWW, the mother of a SAM child hesitated to bring her child to NRC due to fears of potential COVID-19 infection. Furthermore, a substantial challenge arises from the limited autonomy women have in making food choices, thereby constraining their ability to offer appropriate and healthy nourishment to their children
" On a daily basis, I am compelled to consult my mother-in-law about the meals she has prepared for lunch and dinner, and I find myself obliged to feed those meals to my child regardless of whether they are suitable for her or not. “ (Mother 23rd years old).
The majority of AWWs emphasized that cultural taboos surrounding the acknowledgment of child malnutrition pose a significant impediment for mothers and caregivers in seeking services. As reported by the child's parents, disclosing malnutrition is perceived to diminish the child's dignity.
"In my Anganwadi Center (AWC), there was a child classified as MAM, but the parents declined to have the child's health assessed by doctors. Their reluctance stems from the belief that if the community becomes aware of the child's malnutrition, it will draw attention to the child's severe malnourished condition. Additionally, child malnutrition has transformed into a topic of gossip, which in turn undermines the household's reputation. " (AWW is 35 years old.)
Difficulties faced by service provider
AWWs noted that they had resorted to follow-up activities due to the COVID-19 restrictions that prevented them from conducting house visits. As a result of being primarily engaged in follow-ups, a notable challenge arose: their primary objective of child development had been undermined due to the additional COVID-19-related responsibilities. Integrated Child Development Services (ICDS) mandated AWWs to monitor and report the child's weight to their supervisors, but the outbreak impeded their ability to fulfill this monitoring duty. The suspension of nutritional rehabilitation centres at the district level had a substantial impact on the rehabilitation process for severely malnourished children.
"Two children from my centre was admitted to the Buldhana NRC, but a sudden COVID-19 lockdown forced them to return home. Both children have been suffering from SAM for the past year because their parents cannot provide them with enough nutritious food due to poverty. When I visit them, they always inquire when the NRC would open and they can admit their child in NRC " (AWWs 56 years old).
The limited awareness of malnutrition among mothers and caregivers creates challenges for AWWs in addressing malnutrition and raising concern about the child's well-being. Many mothers in my AWC view hunger as a sign of weakness rather than a health issue. Consequently, they tend not to take my advice seriously, and while they listen when I explain, they often do not put the recommendations into practice. A significant number of AWWs expressed that insufficient support from higher authorities hampers their ability to carry out their responsibilities effectively. The ever-evolving nature of their tasks, with increased involvement in COVID-19-related duties, often leads to neglect of their core responsibilities. Moreover, the lack of local financial support prevents AWWs from efficiently implementing initiatives. For instance, during the Poshan (nourishment) month, participants do not receive any incentives, resulting in low participation in the Poshan Abhiyan campaign. Furthermore, the limited education and inadequate skill levels of AWWs pose additional barriers to effectively managing malnutrition in their service areas.