POST GRADUATE DIPLOMA IN PUBLIC

HEALTH MANAGEMENT

PROJECT REPORT

Assessment of Weight Gain of Children Admitted to

Nutrition Rehabilitation Center
& Afterwards for Two Years
Sangareddy, Medak (Telangana State)

Dr K Sarala Kumari
Under the guidance of
Dr Suresh Munuswamy

Indian Institute of Public Health, Hyderabad

(Public Health Foundation of India)
Hyderabad, India – 500 033
2014 – 2015
 DECLARATION

I hereby declare that the thesis entitled “Assessment of Weight Gain of Children
Admitted to Nutrition Rehabilitation Center at Sangareddy (Medak) & Afterwards
at for Two Years” submitted by me for the award of the Degree of Post Graduate
Diploma in Public Health Management of Indian Institute of Public Health,
Hyderabad, is original and it has not been submitted previously to this or any
other institute/university/ organization for any Degree, Diploma or Associateship.

Place: Hyderabad Dr. K Sarala Kumari

Date:
 CERTIFICATE

Dr. Suresh Munuswamy

Assistant Professor/Program Coordinator
Indian Institute of Public Health
Hyderabad – 500 038

Certified that the dissertation entitled “Assessment of Weight Gain of Children Admitted to
Nutrition Rehabilitation Center at Sangareddy (Medak) & Afterwards at for Two Years”
submitted for the award of the Degree of Post Graduate Diploma in Public Health Management
of Indian Institute of Public Health, Hyderabad is a record of research work done by Dr. K Sarala
Kumari under my guidance and it has not been submitted previously to this or any other
institute/university/organization for any Degree, Diploma or Associateship.

Place: Hyderabad Dr. Suresh Munuswamy

(Research Supervisor)

Date:
 ACKNOWLEDGEMENTS
I am happy to Acknowledge Dr. G. V. S. Murthy, Director IIPH, Hyderabad for his continuous
care and support.

I express my extreme gratitude to Dr. M. Jayaram, Academic Register and Senior Administrative
Officer IIPH, Hyderabad, for his moral support and continuous co-ordination and guidance.

My Sincere thanks to Dr. J. K. Laxmi and Dr. Srikrishna, course coordinators PGDPHM of IIPH, for
their continuous encouragement and support. I am expressing my heartfelt respect and honor
to my course guide Dr. Suresh Munuswamy for his precious guidance and continuous
monitoring throughout the course of the project with great interest and timely support.

I thank Mr. Stephen Raj (Masters, Health Informatics Department) for his in data analysis and
support in thesis formulation.

I am extremely thankful to all the faculty members of IIPH, Hyderabad, who enlightened me on
course modules and oriented on research work during my course.

I am very much thankful to Dr. K Raju Goud, Superintendent of Government District Hospital
Sangareddy for his support, guidance, and granting me permission for the study at the Nutrition
Rehabilitation Center (NRC) Center.

I thank Medical Officer and Nutrition Counsellor and all the staff at NRC for their support and
feedback extended in doing the project work.

Dr K Sarala Kumari
ABSTRACT
BACKGROUND
Under nutrition is an important factor contributing to the death of young children. If a child is
malnourished, the mortality risk associated with respiratory infections, diarrhea, malaria,
measles, and other infectious diseases is increased. In Andhra Pradesh State (latest data
available is from before bifurcation of the state) according to NHFS-3 National Family Health
Survey (2005-2006) data 12.2% (3.22 lakh) of children in the state are suffering from Severe
Acute Malnutrition (SAM).

MATERIAL AND METHODS

The present study was conducted from 15th of September 2015 to 15th November 2015. One
hundred and eighty seven (187) children admitted at the NRC at Sangareddy District Hospital
were observed during the study period. Facilities at the NRC were assessed. Check list based
on Operational Guidelines on Facility Based Management of Children with Severe Acute
Malnutrition (Anon., n.d.) was used to assess the facilities at NRC. Observational notes and
secondary data collected from NRC was used for the research study. Semi structured Interview
Guide was used for the service providers and beneficiaries.

RESULTS
The infrastructure parameters and the human resources were found to be less than adequate
but functional. The study included 187 children in the age group of 0-5 years. There were 79
boys and 108 girls, out of which the highest representation was from the age group of 1 to 12
months. A 38% of study population belonged to BC, ranking next is SC at 35%, OC at 24% and
the lowest was SC at 3%. The average weight gain during the stay at the Center was 430 g. The
median length of the stay at the Center was 11 days with 60% of patients leaving the facility
prematurely (before 14 days). A 30% of the mothers of the children felt that infection was the
cause while only 10% thought that inadequate diet was the cause of malnutrition. A 60% had
no knowledge about cause of malnutrition. Mothers lacked adequate information on
composition of therapeutic diets, although 85% learnt about time interval between feeds.

CONCLUSION
NRC provides a great platform for treating SAM children, but is not utilized by all intended
population. There is lack of uptake of services due to low awareness in the community and
poor service due to lack of timely release of funds. So, community awareness and participation
has to be scaled up while management should act more responsibly in releasing the funds on
time and with proper supervision.
CONTENTS
INTRODUCTION ..................................................................................................................................................... 9

BACKGROUND ..................................................................................................................................................... 10

ESTABLISHMENT OF NUTRITION REHABILITATION CENTERS ................................................................................ 11

OBJECTIVES OF NRC.....................................................................................................................................................11

NRC IN TELANGANA STATE .................................................................................................................................. 12

PREVALENCE OF MALNOURISHMENT IN TELANGANA STATE ............................................................................12

OBJECTIVES .............................................................................................................................................................13
REVIEW OF LITERATURE ..........................................................................................................................................13

DEMOGRAPHICS OF SANGAREDDY, MEDAK ........................................................................................................ 15

GEOGRAPHY OF SANGAREDDY, MEDAK .............................................................................................................. 16

MAP OF TELANGANA ....................................................................................................................................................16

MAP OF SANGAREDDY ..................................................................................................................................................17
STUDY DESIGN ....................................................................................................................................................18
STUDY LOCATION ...............................................................................................................................................18
TOOLS USED .......................................................................................................................................................18
PARTICIPANTS/SUBJECT SELECTION ...................................................................................................................18
EXCLUSION CRITERIA ..........................................................................................................................................18
DATA COLLECTION .............................................................................................................................................18
DATA ANALYSIS ..................................................................................................................................................18

FUNCTIONAL ANALYSIS OF NRC AT SANGAREDDY ............................................................................................... 19

ADMISSION CRITERIA .........................................................................................................................................19

FACILITIES AT NRC ..............................................................................................................................................21
LOCATION OF THE NRC ......................................................................................................................................21

HUMAN RESOURCES ............................................................................................................................................ 22

MEDICAL OFFICER ..............................................................................................................................................22

NURSING STAFF ..................................................................................................................................................22
NUTRITION COUNSELLOR ...................................................................................................................................22
COOK CUM CARETAKER .....................................................................................................................................23
ATTENDANTS/CLEANER ......................................................................................................................................23
MEDICAL SOCIAL WORKER .................................................................................................................................23

EQUIPMENT AND SUPPLIES CHECK LIST ............................................................................................................... 24

ESSENTIAL WARD EQUIPMENT ..........................................................................................................................24

OTHER WARD EQUIPMENT ................................................................................................................................24
KITCHEN EQUIPMENT.........................................................................................................................................24
KITCHEN SUPPLIES ..............................................................................................................................................25

OBSERVATION ON HYGIENE PRACTICES ............................................................................................................... 26

CHECK LIST FOR MONITORING HYGIENE ............................................................................................................26

 OBSERVATION ON WEIGHING AND FEEDING PROCEDURES ..............................................................................29
CHECKLIST FOR MONITORING WARD PROCEDURE ............................................................................................29
ANTIBIOTICS AND MEDICAL SUPPLEMENTS ............................................................................................................31
ANTIBIOTICS, MEDICATIONS, SUPPLEMENTS .....................................................................................................31
WARD ENVIRONMENT .......................................................................................................................................31
PHARMACY SUPPLIES ..............................................................................................................................................32

SOCIO DEMOGRAPHIC PROFILE FOR PARTICIPANTS ............................................................................................ 33

NUMBER OF PARTICIPANTS ...............................................................................................................................33

SEX DISTRIBUTION OF CHILDREN .......................................................................................................................34
WEIGHT DISTRIBUTION ON ADMISSION ............................................................................................................35
CASTE DISTRIBUTION .........................................................................................................................................36

PARENTS BACKGROUND ...................................................................................................................................... 37

ECONOMIC STATUS OF PARENTS .......................................................................................................................37

EDUCATION STATUS OF PARENTS ......................................................................................................................38
LEVELS OF KNOWLEDGE AMONG MOTHERS OR BENEFICIARIES ATTENDING THE NRC ....................................39

IMPACT OF NRC ON SAM CHILDREN .................................................................................................................... 44

AVERAGE WEIGHT GAINED ................................................................................................................................44

AGE WISE DISTRIBUTION OF AVERAGE WEIGHT GAINED IN BOTH SEXES .........................................................45
AVERAGE WEIGHT AT ADMISSION AND DISCHARGE FOR GIRLS ........................................................................46
AVERAGE WEIGHT AT ADMISSION AND DISCHARGE FOR BOYS ........................................................................47
LENGTH OF STAY ................................................................................................................................................48
DEFAULTERS .......................................................................................................................................................49
REFERRAL PRACTICES .........................................................................................................................................50

INTERVIEWS WITH SERVICE PROVIDERS .............................................................................................................. 51

TRAINING ...........................................................................................................................................................51
TYPES OF SERVICES .............................................................................................................................................51
CHALLENGES FROM HEALTH SYSTEM PERSPECTIVE ..........................................................................................52

DISCUSSIONS ....................................................................................................................................................... 53

CONCLUSION ....................................................................................................................................................... 55

LIMITATIONS ....................................................................................................................................................... 55

RECOMMENDATIONS AT COMMUNITY LEVEL ..................................................................................................... 56

SERVICE PROVIDERS (STAFF) INTERVIEW GUIDE .................................................................................................. 61

MEDICAL OFFICER & NUTRITION COUNSELLOR INTERVIEW GUIDE ...................................................................... 63

QUESTIONNAIRE FOR BENEFICIARIES................................................................................................................... 67

CHECK LIST FOR FUNCTIONAL PRACTICES ............................................................................................................ 68

MONITORING HYGIENE ...........................................................................................................................................68

WARD PROCEDURE .................................................................................................................................................70
ANTIBIOTICS, MEDICATIONS, SUPPLEMENTS .........................................................................................................72
PHOTOS ............................................................................................................................................................... 73

NRC AT SANGAREDDY GOVERNMENT HOSPITAL, MEDAK .................................................................................73

PATIENT AREA AT NRC .......................................................................................................................................74
CHARTS AND DISPLAYS AT THE CENTER .............................................................................................................75
MEASURING MID UPPER ARM CIRCUMFERENCE (MUAC) .................................................................................76
MEASURING HEIGHT OF THE CHILD ...................................................................................................................77
DEMONSTRATION OF PREPARATION OF NUTRITIOUS FOOD TO THE MOTHERS...............................................78
EXPLAINING THE IMPORTANCE OF NRC, 14-DAY STAY, AND NUTRITIOUS FOOD TO THE MOTHERS ................78
LIST OF TABLES ........................................................................................................................................................79
LIST OF FIGURES ......................................................................................................................................................79
ABBREVIATIONS ......................................................................................................................................................80
INTRODUCTION
India is one among the many developing countries where child malnutrition is severe and also
malnutrition is a major problem. This accounts for large number of child mortality in India.
Various studies and surveys have been conducted to find out the root causes of child
malnutrition. All these studies including the three National Family Health Surveys (NFHS) reveal
that malnutrition is not the result of a single cause; the problem is multi-factorial, the causes
acting in combination with other complex factors like poverty, health inaccessibility, illiteracy
and other social determinants.

Nutrition being the core pillar of Human development. The high mortality and disease burden
resulting from undernutrition requires call for urgent need for implementation of interventions
to reduce their occurrence and consequences.

Undernutrition encompasses Stunting children are too short for their age group compared to
the WHO child growth standards (chronic malnutrition). Wasting (acute malnutrition) resulting
from failure to gain weight or actual weight loss and deficiencies of micronutrients (essential
vitamins and minerals).

Severe Acute Malnutrition (SAM) is an important contributing factor for most deaths amongst
children accounting for under-five child mortality.

NFHS 3 shows that the proportion of children who are stunted or underweight increases rapidly
with the child’s age from birth to age 20-23 months; peaking at age 20 months. Even during the
first six months of life, when most infants are breastfed, 20-30 percent of children are
underweight. It is notable that by age 18-23 months, when many children are being weaned
from breast milk, 30 percent of children are severely stunted and one-fifth are severely
underweight.

According to the national survey (NFHS-3, 2005-06)

Forty three percent of children under age five years are underweight (low weight for age).

Forty eight percent of children under age five are stunted (low height for age).

Twenty percent of children under five years of age are wasted (low weight for height); over 6%
of these children are severely wasted (< -3SD). Since ‘wasting’ denotes acute malnutrition,
these children are said to have Severe Acute Malnutrition.
BACKGROUND
Undernutrition is an important factor contributing to the death of young children. If a child is
malnourished, the mortality risk associated with respiratory infections, diarrhea, malaria,
measles, and other infectious diseases is increased.

More than half (54 percent) of all deaths before age five years in India are related to
malnutrition.

Because of its extensive prevalence in India, mild to moderate malnutrition contributes to more
deaths (43 percent) than severe malnutrition (11 percent).

In Andhra Pradesh State according to NHFS-3 National Family Health Survey (2005-2006) data
18.7% are severely stunted and 24.0% are moderately stunted.

A 3.5 % are severely wasted and 8.7% are moderately wasted.

A 9.9% are severely underweight and 22.6 % are moderately underweight.

Deaths amongst SAM children are preventable, provided timely and appropriate actions are
taken.
ESTABLISHMENT OF NUTRITION REHABILITATION CENTERS
Under nutrition is an invisible problem. It jeopardizes children survival, health, growth and
development. To combat this menace, the Government of India is working with the United
Nations Children Fund (UNICEF) aimed at identifying and treating malnourished children.

To prevent deaths among Severe Malnourished children under five years of age (0-5), identified
under the drive, the Government further started the Nutrition rehabilitation Centers (NRCs)
with support from UNICEF.

Objectives of NRC
 To provide clinical management and reduce mortality among children with severe acute
malnutrition, particularly among those with medical complications.

 To promote physical and psychosocial growth of children with severe acute malnutrition
(SAM).

 To build the capacity of mothers and other care givers in appropriate feeding and caring
practices for infants and young children

 To identify the social factors that contributed to the child slipping into severe acute
malnutrition.
NRC IN TELANGANA STATE
PREVALENCE OF MALNOURISHMENT IN TELANGANA STATE
In Telangana State the prevalence of Severe Acute Malnourishment (undernourished children
0-5 years) in children remains high despite overall economic growth.

It is estimated that 3.22 lakh children in the state are suffering from Severe Acute Malnutrition,
a condition associated with high mortality and morbidity that requires specialized treatment
and sustained follow-up.

It was also observed that majority of children with SAM suffer silently without access to
appropriate treatment.

Hence, the government has decided to establish the NRCs to ensure that every child is born
healthy and grows and thrives to realize his/her full potential. The objective is to ensure that
children with SAM have access to inpatient treatment.

The Government with intention to provide medical care to the SAM children established 30
NRCs.

The objectives of the program are to control malnutrition among the children aged 0-5 years in
the state and to bring down the percent of severe malnourished children.

One NRC is present in every district hospital. In Telangana State, there are 10 such NRCs
providing services to SAM children. These are all 20-bedded NRCs.

Funds will be provided from the allocations made under National Rural Health Mission (NRHM).
RESEARCH STUDY TOPIC
Assessment of Weight Gain of Children Admitted to Nutrition Rehabilitation Center at
Sangareddy (Medak) & Afterwards at for Two Years.

OBJECTIVES
To assess facilities at Nutrition Rehabilitation Centers.

To evaluate the services being provided under facility based nutritional interventions.

To assess the knowledge of mothers of children admitted at Nutritional Rehabilitation Center at

the time of study period.

REVIEW OF LITERATURE
There are few studies for the evaluation of services provided at NRCs which was a specific
initiative program by the Government under NRHM to combat malnutrition.

These studies were conducted in the states of Madhya Pradesh Uttar Pradesh Bihar and Orissa
where the prevalence of SAM children was high and children were severely malnourished. NRC
Centers were set up in these states with the support from United Nations Children Fund
(UNICEF). The concurrent assessments of NRCs in selected states have come with some results
and recommendations.

The findings of this study conducted on effects of NRC showed that the NRCs were effective in
improving the condition of admitted children, but the effects of interventions were not
sustained for longer durations following discharge which reflected through high drop-out rate
and lack of adequate parental awareness. There is an alarming need to link these centers with
community-based models for follow-up and improve health education measures to maintain
the gains achieved.

The study conducted in Uttar Pradesh on “Experiences of Nutrition Rehabilitation Centers in

Management of SAM children” says that NRCs provided lifesaving care for the children
admitted with SAM. However two program outcomes – the high defaulter rate and the low
recovery rate are of particular concern. The study also recommended a community-based
therapeutic care for children with uncomplicated SAM needs to become a key component of
the continuum of care for children with SAM.

This study in the districts of Madhya Pradesh sought to explore design issues of nutritional
rehabilitation centers in order to inform its effectiveness in settings where the prevalence of
chronic poverty and malnutrition is high. Limited success was obtained (marked by poor cure
rates and high non-responder rates) to high prevalence of chronic malnutrition, particularly in
nutritional rehabilitation centers located in peripheral areas. There is a failure to recognize
severe chronic malnutrition as an epidemiological entity and gear wide-ranging programmatic
and social interventions.
STUDY AREA
DEMOGRAPHICS OF SANGAREDDY, MEDAK

Description 2011

Actual Population 3,033,288

Male 1,523,030

Female 1,510,258

Population Growth 13.60%

Area Sq. Km 9,699

Density/km2 313

Proportion to Telangana Population 8.59%

Sex Ratio (Per 1000) 992

Child Sex Ratio (0-6 Age) 952

Average Literacy 61.42

Male Literacy 71.43

Female Literacy 51.37

Total Child Population (0-6 Age) 367,603

Male Population (0-6 Age) 188,312

Female Population (0-6 Age) 179,291

Literates 1,637,137

Male Literates 953,406

Female Literates 683,731

Child Proportion (0-6 Age) 12.12%

Boys Proportion (0-6 Age) 12.36%

Girls Proportion (0-6 Age) 11.87%

GEOGRAPHY OF SANGAREDDY, MEDAK
Map of Telangana
Map of Sangareddy
METHODS AND METHODOLOGY
STUDY DESIGN
A Facility based cross sectional study.

STUDY LOCATION
At Nutrition Rehabilitation Center (NRC) Sangareddy District Hospital of Medak District.

TOOLS USED
1. Check list based on Operational Guidelines of Nutrition Rehabilitation Center to assess the
facilities at NRC.

2. Observational notes and secondary data collected from NRC were used for the research
study.

3. Semi structured Interview guide for the service providers and beneficiaries.

PARTICIPANTS/SUBJECT SELECTION
Service providers at the Nutrition Rehabilitation Center and mothers of children admitted at
NRC at the point in time of the study will be included in the study.

EXCLUSION CRITERIA
Beneficiaries who stayed for less than three days at NRC were excluded from the study.

DATA COLLECTION
Data collection was carried out over a period of two months, during 15 September 2015 to 15
November 2015. Initially the required permissions were taken from the Superintendent of
Sangareddy District Hospital, Medak. After the approval for the study was given, I have
approached the concerned medical officers of the NRC and sought for their cooperation.

DATA ANALYSIS
The analysis of the quantitative data collected as the part of the research study was carried out
with Microsoft Excel and Google Maps. The qualitative data was transcribed, translated and
manually analyzed according to the themes identified.
RESULTS & OBSERVATIONS
FUNCTIONAL ANALYSIS OF NRC AT SANGAREDDY
Nutrition Rehabilitation Center (NRC) also called as AKSHAYA AROGYA PUNARJEEVANA
KENDRAM. The approach to NRC is very feasible located near the registration for O.P. The
Center is near the pediatric ward hence patients do not have any difficulty in accessing the
Center. Written on the entrance is “Akshaya Arogya Punarjeevana Kendram” in local language,
Telugu. The Center is properly ventilated and spacious. Infrastructure at the facility was
assessed as per the NRHM Operational Manual for infrastructural parameters: building,
available rooms, kitchens, play areas, toilets, counselling area, staff position, clinical equipment,
kitchen equipment and pharmacy supplies. Items on observational checklists included hand
washing, general hygiene, laundry, waste disposal, feed preparation and weighing. Knowledge
levels of admission, monitoring and discharge criteria were also assessed. They were found to
be adequate and functional.

Drawings and displays charts for personal hygiene practices and feeding practices are displayed
on the walls which makes the Center more welcoming and interesting for the children.

Severe malnourished children are recognized in their respective localities by the frontline
workers (ANM, ASHA, AWW’s, CHW’s, MSW, OP and PGW) and PHC Medical officers and are
referred to NRC.

ADMISSION CRITERIA
Admission in to NRC for SAM children is done according to admission criteria.

Children 6-59 months

Any of the following:
MUAC < 115mm or 11.5 cm with or without any grade of edema
WFH < -3 SD with or without any grade of edema
Bilateral pitting edema +/++ (children with edema +++ always need inpatient care)
WITH
Any of the following complications 1. Anorexia (Loss of appetite)
2. Fever (39 degree C) or Hypothermia (<35 C)
3. Persistent vomiting
4. Severe dehydration based on history and clinical examination
5. Not alert, very weak, apathetic, unconscious, convulsions
6. Hypoglycemia
7. Severe Anemia (severe palmar pallor)
8. Severe pneumonia
9. Extensive superficial infection requiring IM medications
10. Any other general sign that a clinician thinks requires admission for further assessment or
care
FACILITIES AT NRC
At NRCs, the children are admitted and nutritionally rehabilitated for a minimum period of 14
days using therapeutic feeding diets.

Therapeutic feed (F-75, F-100 and SF) is prepared using locally available foodstuff. Supervised
feeding of therapeutic diets is done by the NRC staff Feeding Demonstration is given by the
Cooks under the supervision of nutrition counsellor and medical intervention is provided by the
doctor in charge and the nurses at the Centers.

The mothers of the children are made to stay at the Centers where counselling sessions
focusing on health, personnel hygiene and nutrition aspects are conducted for them.

Mothers or care takers of the SAM children are also given wage compensation of Rs 100 per
day for the stay and are offered two meals per day. Anthropometric indicators [weight, height,
and mid upper arm circumference (MUAC) are measures and noted down immediately in the
case sheet and are monitored to observe the effect of interventional measures on the health
status of the admitted children. Anthropometric assessment of the children is done by the NRC
staff using standard validated measurement techniques. Weight of the children is taken using
electronic weighing scales and height is measured.

LOCATION OF THE NRC

One NRC unit with 20 bedded is situated in the Sangareddy District Hospital (Medak) for the
whole of Medak district. NRC also called “Akshaya Arogya Punarjeevana Kendram” is easily
accessible and located near the OP registration area, and is near to the pediatric ward.

The NRC has the patient area to house the beds. Mother and child are kept in the same bed so
that mother can be with the child.

It has a counselling area and audiovisual equipment (TV and DVD player) which plays rhymes
for children.

There are toys available but no separate play area for the children.

Kitchen and storage area is attached to the ward with enough space for cooking.

There is an attached toilet and bathroom facility for the mothers and children and is properly
maintained and cleaned twice a day. There is 24-hour uninterrupted water and power supply.
Ward has a Nursing Station.
HUMAN RESOURCES
The NRC has adequate staff for smooth functioning of NRC with two medical officers, a
nutrition counsellor, three staff nurses, two cooks/caretakers, two attendants and a vacant
position for a medical social worker.

MEDICAL OFFICER
There are two medical officers. The senior medical officer underwent training for three days. It
was facility based training and he was trained on screening of SAM children, admission criteria
for SAM children, on therapeutic feeding practices and treating the SAM children with any
other medical complications.

Staff Position Number for 20 In Position Vacant

Medical Officer 02 02
Table.1

NURSING STAFF
Out of required eight staff nurses only three are in position and there is requirement for staff
nurses. The three nurses work on rotation duties and are overburdened with work. The facility
needs to fill in this gap and the vacancies.

Staff Position Number for 20 In Position Vacant

Staff Nurses 08 03 05
Table.2

Nurses posted in the ward are responsible for weight recording, recordings of MUAC, timely
supervision of patient condition and distribution of oral drugs and IV fluids. They also assess
clinical signs and record the information in the case sheet.

NUTRITION COUNSELLOR
Two nutrition counsellors with a diploma in nutrition were recruited and trained for three days.
The duty of the counsellor is to prepare the specific therapeutic diet chart according to the
requirement for individual child in consultation with the medical officer each day, also
responsible for monitoring the preparation, demonstrate the distribution of complimentary
foods to the mothers/caregivers. They assess the feeding problems in each child and give
counselling to mothers. They also give counselling on sanitation, feeding practices and personal
hygiene.

Staff position Number for 20 In position Vacant Trained

Nutrition Counsellor 02 01 10 Yes
Table.3
COOK CUM CARETAKER
Two cook cum caretakers are responsible for the kitchen maintenance. They prepare the
special diet for the children under the supervision of nutrition counsellor and medical officer.
They also demonstrate preparation of food to the mothers. They are responsible for kitchen
store and purchasing of the food items and kitchen supplies accordingly.

Staff Position Number for 20 In position Vacant Trained

Cook cum Caretaker 02 02 0 Yes
Table.4

ATTENDANTS/CLEANER
Two attendants working in the shift duties are responsible for the keeping the ward clean.
Cleaning of the ward floors twice daily and cleaning and discarding the dustbins. They help in
maintaining the cleanliness of the NRC.

Staff Position Number for 20 In position Vacant

Attendants/Cleaner 02 02 0
Table.5

MEDICAL SOCIAL WORKER

The Medical Social Worker (MSW) position is vacant in the NRC unit. The medical social
worker’s role is to counsel the parent, create awareness and make social assessment of family.
The MSW also counsels the frontline workers about their role of identifying SAM children at
field level and the importance of NRC.

Staff Position Number for bedded In position Vacant

Medical Social Worker 01 00 01
EQUIPMENT AND SUPPLIES CHECK LIST
As the NRC is newly established in 2012, all the essential supplies and equipment are present.
The list of the equipment is as under.

ESSENTIAL WARD EQUIPMENT

Equipment Availability
Glucometer (1) Present
Thermometer (2) Present
Weighing Scales (Digital) Present
Stadiometer Present
Resuscitation Equipment Present
Suction Equipment Present
Table.7

OTHER WARD EQUIPMENT

Equipment Availability
IV Stands Present
Almirahs Present
Dustbin Present
Room Heaters Present
IEC – Audio/Visual Materials (TV; DVD player) Present
Toys for Structural Play Present
Clock Present
Calculator Present
Reference Height and Weight Charts Present
Table.8

KITCHEN EQUIPMENT
The supplies and stores in the kitchen were found to be adequate and stored properly Table.9

Equipment Availability
Cooking Gas Present
Dietary Scales (to weigh to 5 g), Present
Measuring Jars Present
Electric Blender (or manual whisks) Present
Water Filter Present
Refrigerator Present
Table.9

Utensils (large containers, cooking utensils, feeding cups, saucers, spoons, jugs, etc.)
KITCHEN SUPPLIES

Supply for making Starter and Catch up Diet

Equipment Availability
Dried Skimmed Milk Present
Whole dried milk Present
Fresh whole milk Present
Puffed rice Present
Vegetable oil Present
Table.10

Foods similar to those used in home for teaching/use in transition to home.

OBSERVATION ON HYGIENE PRACTICES
The unit has three attached bathrooms and a separate hand wash area. Mothers are given
instructions on personal hygiene. They are explained about the importance of washing hands
and maintenance of personal hygiene. Mothers have place to bathe and they use it. Most of
the mothers/caretakers are satisfied with the cleanliness and services.

The staff has provision for hand wash and the maintain cleanliness and hygiene during the
preparation of food and during handling and distribution of food.

Bedding is changed once in three days or whenever it gets wet/soiled. Mothers have to do the
laundry outside.

Food is stored properly. Food is prepared and served hot and whatever leftovers there are, are
discarded.

Over all general maintenance of the ward is clean and tidy.

CHECK LIST FOR MONITORING HYGIENE

OBSERVE YES NO COMMENTS

HANDWASHING

Are there working hand washing Yes

facilities in the ward

Does staff consistently wash hands Yes

thoroughly with the soap

Are their nails clean Yes

Do they wash hands before handling Yes

food

Do they wash hands between each Yes

patient

MOTHERS CLEANLINESS

Do mothers have a place to bathe, Yes

and do they use it?
Do mothers wash hands with soap Yes
after using the toilet or changing
diapers

Do mothers wash hands before Yes

feeding children

BEDDING AND LAUNDRY

Is bedding changed every day or Changed when

when soiled/wet wet/once in three
days

Are diapers, soiled towels and rags, Yes

etc., stored in a bag, then washed or
disposed of properly

Is there a place for mothers to do Yes Not in the ward but

laundry outside

Is laundry done in hot water No

OBSERVE YES NO COMMENTS

Are floors swept Yes Twice a day

Is trash disposed of properly Yes

Is the ward kept as free as possible of Yes

insects and rodents?

FOOD STORAGE

Are ingredients and food kept Yes

covered and stored at the proper
temperature?

Are leftovers discarded? Yes

DISHWASHING

Are dishes washed after each meal? Yes

Are they washed in hot water with No Only Soap

soap?
Washed under running water with Yes
soap

TOYS

Are toys washable? Yes

Are toys washed regularly? No

Table.11
OBSERVATION ON WEIGHING AND FEEDING PROCEDURES
It is observed that the existing staff in the NRC is following the established norms of weighing
and feeding.

Children are weighed at the screening into NRC for the admission criteria. The weights of the
child are noted down immediately on the case sheets. They are weighed on the standardized
electronic weighing scales. Staff takes care to adjust the zero reading before weighing each
child.

The weights are recorded daily to see the improvement of the interventions and are noted
down in the case sheets to see the result.

CHECKLIST FOR MONITORING WARD PROCEDURE

OBSERVE YES NO COMMENTS

Are correct feeds served in correct Yes

amounts

Are feeds given at the prescribed Yes

times, even on nights and weekends

Are children held and encouraged to Yes Mothers are

eat (never left alone to feed) counselled

Are children fed with a cup (never a No They are fed with
bottle) bottle

Is food intake (and any No

vomiting/diarrhea) recorded
correctly after each feed

Are leftovers recorded accurately No

Are amounts of Starter diet kept the Yes Special feed is

same throughout the initial phase, given
even if weight is lost

After transition, are amounts of Yes

Catch-up diet given freely and
increased as the child gains weight
Table.12
WARMING
OBSERVE YES NO COMMENTS

Is the room kept between 25° - 30°C Yes

(to the extent possible)

Are blankets provided and children No

kept covered at night

Are safe measures used for re- Yes

warming children

Are temperatures taken and Yes

recorded correctly
Table.13

WEIGHING
OBSERVE YES NO COMMENTS

Are scales functioning correctly Yes

Are scales standardized weekly Yes

Are children weighed at about the Yes

same time each day

Are they weighed about one hour No

before a feed (to the extent
possible)

Do staff adjust the scale to zero Yes

before weighing

Are children consistently weighed No

without clothes

Do staff correctly read weight to the Yes

nearest division of the scale

Do staff immediately record weights Yes

on the child’s case sheets

Are weights correctly plotted on the Yes

Weight Chart
Table.14
ANTIBIOTICS AND MEDICAL SUPPLEMENTS
Before children are admitted into the NRC are screened by the medical officer for any other
medical complications and are treated accordingly. Medications and nutrition supplements are
prescribed and given. The staff immediately notes down the prescribed medication to be given
on the case sheets, which is monitored and recorded daily.

ANTIBIOTICS, MEDICATIONS, SUPPLEMENTS

OBSERVE YES NO COMMENTS

Are antibiotics given as prescribed Yes

(correct dose at correct time)

When antibiotics are given do staff Yes

immediately make a notation on the
daily care charts

Is folic acid given daily and recorded Yes

Is vitamin A given according to Yes

schedule

Is a multivitamin given daily and Yes

recorded

After children are on Catch-up diet Yes

for 2 days, is this correct

Dose of iron given twice daily and Yes

recorded
Table.15

WARD ENVIRONMENT
OBSERVE YES NO COMMENTS

Are surroundings welcoming and Yes

cheerful

Are mothers offered a place to sit Yes

and sleep

Are mothers taught/encouraged to Yes

be involved in care

Are staffs consistently courteous Yes

As children recover, are they Yes
stimulate and encouraged to move
and play
Table.16

PHARMACY SUPPLIES
The following medicines are available at NRC.

ANTIBIOTICS
Ampicillin, amoxicillin, benzylpenicillin, chloramphenicol, cotrimoxazole, gentamicin,
metronidazole, tetracycline or chloramphenicol eye drops, atropine eye drops

SUPPLEMENTS & VITAMINS

ORS

Electrolyte and minerals, potassium chloride, magnesium chloride/sulfate, iron syrup

Multivitamin, folic acid, vitamin A syrup

Zinc sulfate or dispersible zinc tablets

Glucose (or sucrose)

IV FLUIDS
Ringer’s lactate solution with 5% glucose; 0.45% (half normal) saline with 5% glucose; 0.9%
saline (for soaking eye pads)

CONSUMABLES
Cannulas, IV sets, pediatric nasogastric tubes.
SOCIO DEMOGRAPHIC PROFILE FOR PARTICIPANTS
NUMBER OF PARTICIPANTS
The 2014-2015 data included 187 children, with 63 children in the age group of 0-12 months, 73
children in the age group of 13-24 months, 18 children in the age group of 25-36 months, 19
children in the age group of 27-48 months and 14 children in the age group of 49-60 months.

Number of Children
in Each Age Group

5 yrs - 14

4 yrs - 19
1 yr - 63
3 yrs - 18

2 yrs - 73

1 2

3 4

5
SEX DISTRIBUTION OF CHILDREN
The 2014-2015 data included 79 boys and 108 girls, in which 34% of the children were in the
age group of 0-12 months, 39% in the age group of 13-24 months, 10% in the age group 25-36
months, 10% in the age group 39-48, and 7% in the age group 49-60 months.

Gender Distribution

Male 42%
Female
58%

F M

80

70
Gender Distribution
in Each Age Group
60
31

50 25

M
40
F
30

20 42
38
No. of Days

9 10
10 4

9 9 10
0
1 2 3 4 5 Age in Years
WEIGHT DISTRIBUTION ON ADMISSION
The mean weight of children in the age group of 0-12 months is 4.49 kg, in the age group of
13-24 months is 6.73 kg, in the age group of 25-36 months is 8.08 kg, in age group of 37-48
months 10.32 kg, in the age group of 49-60 months is 11.03 kg.

Mean Weight for Each Age Group

12.00
11.03
10.32

10.00

8.08

8.00
6.73 1
2
6.00 3

4.49 4
5
4.00

Mean Weight in Kg
2.00

0.00
1 2 3 4 5 Age in Years
CASTE DISTRIBUTION
Out of total study population of 187 children, 38% of the study population belonged to the
backward caste, 35% belonged to the scheduled caste group, 24% belonged to the other caste
and only 3% belonged to the scheduled tribe caste.

Caste Distribution

BC
38%
OC
24%

ST SC
3% 35% BC
OC
SC
ST
PARENTS BACKGROUND
A semi structured interview schedule was used to interview the mothers of the admitted
children on awareness focusing on nutrition, basic concepts of nutrition, causes of malnutrition,
and the impact of hands on training provided at the center, which focused on the composition
and preparation of therapeutic diets at the center.

ECONOMIC STATUS OF PARENTS

Families were assessed according to their annual income and 78% of them were below poverty
line while 22% were above poverty line.

Economic Status of Parents

Above
22%
A
B

Below
78%
EDUCATION STATUS OF PARENTS
An 80% of the parents of the admitted children were illiterate, while about 10% were educated
up to primary school, and 10% up to high school.

Parents' Education Level

High School
10%

Primary 10%

1
2
3

Illiterate
80%
LEVELS OF KNOWLEDGE AMONG MOTHERS OR BENEFICIARIES ATTENDING THE NRC

Awareness Regarding Malnutrition

About 60% of the mothers had no knowledge about the causes of malnutrition.

Inadequate diet and poor quality of food were considered to be the main reasons responsible
for malnutrition and only 10% of the mothers thought that inadequate diet was the cause of
malnutrition and the rest 30% thought that infection was the cause.

Causes of Malnutrition

Infection
30%

No
Knowledge
Inadequate
60%
Diet
10%

No Knowledge
Inadequate Diet
Infection
Knowledge Regarding Therapeutic Feeding Practices at NRCs
A 10% of subject beneficiaries had knowledge about the type of feed provided at the center.
Only 5% of them knew about the composition of feed and 85% of the mothers knew about the
time interval between feeds.

Therapeutic Feeding

Type of
Feed Composition
10% 5%

Time
Interval
85%
Type of Feed
Composition
Time Interval
Knowledge about Preparation of Complimentary Food
A 55% of the mothers had no knowledge about complimentary food preparation and 45% of
them had knowledge.

Complimentary Food Preparation

Don’t Know
Know 45%
55%

Know
Don’t Know
Awareness on Personal hygiene
About 30% of the mothers had no knowledge about personal hygiene and a good 70% of them
had knowledge.

Personal Hygiene Knowledge

Don’t
Know
30%

Know
70%

Know
Don’t Know
Knowledge about Preparation of Nutritious Food and Feeding Practices
A 45% of the mothers had the knowledge about preparation of nutritious food and 55% had no
knowledge. While about 50% of them had knowledge about feeding practices and 50% had no
knowledge.

Preparation of Nutritious Food and Feeding

Practices Don’t Know
Don’t Know Preparation, 55%
Feeding, 50%

Know Feeding,
50%
Know
Preparation, 45%

Feeding
Know Don’t Know
Preparation
IMPACT OF NRC ON SAM CHILDREN
Performance of NRCs may be assessed based on the criteria described below.

AVERAGE WEIGHT GAINED

Impact of NRC is measured against following criteria.

Achieved target weight - The guidelines prescribe that the children should achieve at least 15%
of their body weight gain from the date of admission to date of discharge.

The complete data including 79 boys and 108 girls were analyzed for the effect of nutritional
interventions at NRC. When the mean and median weight gain was assessed the following
were the observations.

TOTAL MEAN WEIGHT GAIN OF 187 PATIENTS = 430 grams

WEIGHT IN GRAMS MALE FEMALE

MEAN 440 g 430 g
MEDIAN 400 g 340 g
AGE WISE DISTRIBUTION OF AVERAGE WEIGHT GAINED IN BOTH SEXES
Mean weight gain in boys and girls in each age group. The minimum mean weight gain was in
boys in the age group 37-48 months at 320 grams. The maximum mean weight gain was in girls
in the age group 25-36 months at 550 grams.

Average Weight Gain in Males and Females in Each Age Group

0.60

0.50

0.40

Weight in Kg
0.30

0.20

0.10

0.00
1 2 3 4 5F
Age in Years
M
AVERAGE WEIGHT AT ADMISSION AND DISCHARGE FOR GIRLS
A total of 187 children were included in the analysis and 180 girls (58%) were analyzed for the
effect of nutritional interventions at NRC. The maximum average weight gain appears to be in
the age group of 25-36 months at 550 grams. The minimum average weight gain appears to be
in the age group of 37-48 months at 320 grams.

Average Weight of Girls at

Admission vs Discharge
in Each Age Group

12.00 11.29
10.90
10.33
10.01
10.00
8.25
7.70
8.00
6.87
6.40
Weight in Kg

6.00
4.73
4.34

4.00

2.00

0.00
1 2 3 4 5
F
Average of WT ADM
Age in Years
Average of WT DISC
AVERAGE WEIGHT AT ADMISSION AND DISCHARGE FOR BOYS
A total of 187 children were included in the analysis and 79 boys (42%) were analyzed for the
effect of nutritional interventions at NRC. The maximum average weight gain appears to be in
the age groups 13-24 and 37-48 months at 460 grams. The minimum average weight gain
appears to be in the age group of 37-48 months at 320 grams.

Average Weight Gain in Boys in Each Age Group

11.74
12.00 11.35
11.07
10.61

10.00
8.85
8.47
7.64
8.00 7.18

6.00 5.13
Axis Title

4.71

4.00

2.00

0.00
1 2 3 4 5
M
Average of WT ADM
Average of WT DISC
LENGTH OF STAY
The guidelines suggest a 14-day stay for a child’s medical recovery. However the child requires
follow up for another 4-6 months for full recovery, depending upon the child’s progress at
home. The average length of the stay at this NRC was found to be 11 days, with 60% of the
patients leaving before 14 days and out of this set, 60% of them appear to have left on or
before 8th day. The criticality of malnutrition seems obviously of no importance for the parents.

Average Length of Stay

in Each Age Group

14.00
12.70
12.01
12.00
10.39

10.00
8.43
8.05
No of Days

8.00

Total
6.00

4.00

2.00

0.00
1 2 3 4 5
Age in Years

Defaulters' Pattern
20

10 16 18 Total
8 9 11 12 12 8 9 10
7 7 4
0 Total
2 3 4 5 6 7 8 9 10 11 12 13 14
DEFAULTERS
A Defaulter will be a child with SAM admitted to the ward but absent (from the ward) for three
consecutive days without been discharged. There were 126 defaulters (who stayed below 14
days). The observed fact is that parents were only bothered about the symptoms and were
leaving the premises once the symptoms were cured. They had no understanding or interest
on malnourishment and its consequences.

Male and Female Defaulters

in Each Age Group
12

11
10

8
8
No. of Days

7
6
F
5 5
M
5
4 4
4
4

2
2

0
1 2 3 4 5
Age in Years
REFERRAL PRACTICES
Malnourished children are referred to the NRC through frontline community workers like ASHA,
Anganwadi workers, Community Health workers, etc.

Out of 187 children 137 were from Outpatient Department (OPD), 34 were referred from
Anganwadi Workers (AWW) and the rest were distributed according to the graph below.

Referrals Practices in Each Age Group

60

50
No. of Patients Referred

40

30

20

10

0 1
ASHA 2
AWW
CHW 3
NRC Age in Years
4
OPC
OPD 5
OWN
PHC
INTERVIEWS WITH SERVICE PROVIDERS
Interviews with service providers were conducted to check the existing awareness levels and
knowledge levels.

TRAINING
Two Medical Officers, Two Nutrition Counsellor and three Staff nurses underwent training at
“GANDHI HOSPITAL”. It was Facility based training for 3 days.

Training was beneficial for them as they were trained about Functioning of NRC Admission
criteria of SAM children into NRC, about Special therapeutic feeds and feed preparation and
demonstration.

“Apart from treating the patent with therapeutic feeds we also counsel the parents and give
medical treatment for any other complications if any.” (MO, NRC)

“They explained about people and their hygienic conditions responsible for infections in rural
areas. They explained about NRC and its importance.”

TYPES OF SERVICES
Medical Officer, Nutrition Counsellor, and Staff Nurse were aware about the proper admission
criteria for children into NRC.

“When a SAM case comes we examine thoroughly for admission after that they will be given
special feed and checked for appetite test. Then he will be given SF AND F100 EVERY 2ND
hourly.”(MO, NRC).

One of the Nutrition Counsellor stated “Severe Acute Malnourished children, like chidren with
edema, low birthweight, MUAC < 11.5 cm, weight for height” cases are treated at NRC.

Daily morning we prepare the diet plan. Daily we check the weight and according to that we
give above diets. Daily morning we paste the diet in the kitchen.” (NC, NRC)

On enquiring about what kind of counselling aspects are covered. “Nutritional care for young
children, appropriate way of cooking food and how to make nutritious food with available
resources at home. Importance of weighing the children and growth monitoring. Preparation
of complimentary food are covered.” (Nodal Officer, NRC)

“We do cooking and cleaning of the utensils, boil milk, prepare special food and complimentary
food as directed by the madams.” (Cook)

“We have sufficient stock, if no stock available we keep indent and it is seen to be provided
timely.” (Cook)
“We have everything available from spoon to filter and other stocks.” (Cook)

“We clean the ward and the toilets twice daily and also clean the dustbin.” (Attender)

CHALLENGES FROM HEALTH SYSTEM PERSPECTIVE

INFRASTRUCTURE
“Pediatric BP apparatus which is necessary for recording the BP while blood transfusion is
necessary.” (M O, NRC) Better if we have a separate play area (NC, NRC).

HUMAN RESOURCES
Shortage of nurses, only three nurses are being appointed in place of eight. It is difficult to
manage the services

FACED FROM BENEFICIARIES

Even after providing nutritional diet children are not accustomed to that diet so they don’t
follow the diet and even after providing proper counselling mothers are not willing to stay for
14 days.” (MO, NRC).

“Mothers are not co-operative to feed their children in proper way. They do not want to spend
14 days, not much awareness of feeding practices, even after our repeated counselling
sometimes they do not listen to us.” (NC, NRC)

Services are properly accepted by the patients but not the FOLLOW UPS. (MO, NRC).

“They are not aware of Malnutrition, they feel their children are healthy, and malnutrition is
not an issue. They sometimes refuse the admission; they say that we can manage this at
home”. (NC, NRC)
RECOMMENDATIONS FOR
BETTERMENT OF SERVICES
Awareness of symptoms versus actual problem (weight gain).

Complete 14-day stay in NRC is recommended.

ST referrals increased.

Try to reduce the defaulter numbers.

“Increase in manpower and awareness in community, referrals form community and from
private practitioners to be increased.” (MO, NRC).

Increase in beds and awareness about NRC services in the community especially in rural areas.
(MO, NRC)

DISCUSSIONS
The study findings showed that the facilities at the NRC were adequate. The infrastructure and
human resources were not optimal. The nursing staff available were only about 40% (3 out of
8). The social worker position was vacant. The infrastructure parameters assessed on the basis
operational guidelines for facility based management of SAM children showed that the
infrastructure parameters such as building area, patient counselling area, clinical equipment
and medicines (except for pediatric BP apparatus), toilets, kitchen and kitchen supplies, hand
washing and hygienic conditions, feeding and weighing were assessed and found to be
adequate.

Target weight of children not meeting (15% of the body weight).

Female admissions (58%) increased than male admissions (42%).

There is a high default rate with 67% of them leaving before the recommended 14 days.

Symptoms versus weight awareness should be created. A 75% of children left the facility
before 14 days, as soon as the symptoms seem to subside. Only 25% of children stayed for 14
days.

Medical Social Worker (MSW) plays an important role in identifying the SAM children at field
level and encouraging them to visit facility and receive proper treatment. MSW also counsels
the frontline workers about their role of identifying the SAM children. This position being
vacant contributes to the decreased number of cases from field and remote locations.

Knowledge levels of service providers on admission criteria, monitoring and managing of SAM
child and discharge criteria were adequate and their roles were properly described by them as
compared to NRHM guidelines for operation of NRC.

The one year data consisted of 187 children between 0-5 years and children in the age group of
7 to 24 months were found to be admitted in the highest number at 109. This is generally the
age of starting of solid food diet and weaning.

Children were typically admitted for 14 days and discharged (on the 14th day) irrespective of
their attaining/not attaining target weights, but in some cases of inadequate weight gain they
stayed more days. The average length of the stay of children admitted at this NRC was 11 days.

The study results show that most of the children belonged to marginalized population. Most of
them belonged to BC & SC population. This is in accordance with NFHS-3 Survey and the study
by Taneja, et al. Effect of NRCs on Admitted Children which says that children with illiterate
mothers and belonging to caste SC, ST & BC are more malnourished.

The study findings show that 80% of the mothers of admitted children were illiterate. The
mothers attending the Centers had a very limited knowledge about concepts of nutrition.
Mothers are kept in the center so that they can be taught about importance of nutrition and
preparation of nutritious food from locally available food. Mothers are specifically integrated
into the effective care of children and are educated about personal hygiene and to continue it
even after discharge from the center.

A 55% of subject beneficiaries had knowledge about the type of feed provided at the center.
None of them knew about the composition of feed. About 60% of the mothers knew the time
interval between feed. Whereas the study by Taneja, et al. showed that 44% of the mothers
said that they had not been taught the preparation of the therapeutic diets and 56% of the
mothers said that they had been taught the preparation of the therapeutic diets at the center,
although majority of mothers had proper information regarding the time interval of feeds at
the NRCs.

The study findings show there is increase number of defaulters, defaulters being 60% children
in a period of one year. Increase in number of drop outs during each successive follow up is
also a major concern in the study population. A comprehensive review by Ashworth et al.,
comparing inpatient, outpatient, and home-based care and home-based care alone in
Bangladesh revealed a dropout rate of 23% for the inpatient group over a 12 month period, the
highest in the three groups.
NRCs provide care for children with as demonstrated by the high survival rates of the program.
However, outcomes are below optimal. Two program outcomes – the high defaulter rate and
the low recovery rate are of particular concern.

Their average daily weight gain was sub-optimal. Therefore the protocols and therapeutic
foods currently used need to be improved.

CONCLUSION
Facility based in-patient care in treating SAM children is useful for only 25% of the admitted
children as they are the only percentage staying the recommended number of days for effective
treatment.

1. The NRC is effective in improving the condition of admitted children provided they stay
for the recommended length of stay (14 days).

2. The study also shows that parents are focusing only the symptoms rather than on
malnutrition (weight for height).

3. The study also shows that only 3% of the patients are from ST background. This can be
improved by creating awareness among that specific community through
healthworkers, ANMs and AWWs.

4. The female admissions (58%) are more than the male admissions (42%).

However the study found that measures have to be taken to improve the functionality of NRC.
Awareness at community level and community based participation plays a major role for the
success of the program. Treating SAM children requires a multi-sectoral approach to bring in
behavioral change, adaption of hygienic practices, improve child feeding practices. For the
sustainment of the results parental awareness and health education plays a vital role.

LIMITATIONS
Due to very short period of the study of only for two and a half months and shortage of
resources (single person data collection) and high defaulters, data collected is limited. Further
study with large sample size should be done for the proper results.
RECOMMENDATIONS AT COMMUNITY LEVEL
 Community mobilization plays major role. Marginalized population should be reached
through volunteers, ASHAS, Anganwadi workers and other community health workers
and should be made known about facility based treatment for malnutrition at NRCs.
They also should monitor the follow up of discharged children and help in decreasing
the number of dropouts.

 Increase the referral system through 108 services.

 Increase the transport facility from rural areas and interior and unreachable/tribal hilly
areas. Also create awareness to the parents of the SAM children regarding malnutrition
rather than symptoms.

 Train and encourage the health workers, supervisors, AWWs, ASHAs, etc., to create
awareness among the rural people. Conduct convergence meeting monthly once with
all the lane departments (Panchayat raj, ICDS, RWS, Education) and ask them to create
awareness and identify the SAM children for referral and also to follow up after
treatment.

 Create awareness among the parents of SAM children about the daily wage
compensation of Rs. 100/- per day for 14 days along with food and accommodation.

 IEC activities focused on NRC programs mainly for awareness on target specific name
activities.

 Health education programs and programs that include the knowledge about educating
malnutrition at rural areas are advised.

 Promotion of low-cost sustainable solutions like optimal infant and young child feeding
so that SAM does not occur. This can be achieved through promotion of breastfeeding,
education of mothers regarding proper infant feeding practices, transferring the skills in
preparation of low-cost high-energy foodstuffs to mother.

At Health system level.

 Increase the human resources and health care infrastructure to ensure the proper
functionality of NRC.
 The location of the NRC is also at a corner of the district, making it very difficult for the
other side of the population to reach the facility. The geographic distributions shows
that most of the patients admitted are coming from nearby the roadways and highways.
Population in the district interiors seems to be not able to utilize the services.

 There is only one NRC at the District Hospital for the entire district that plays a major
role in combating the issue of malnutrition but as the district is big so the services are
only utilized by the limited number of population. This is also not in a geographically
central point but rather in a corner. It would be of major help if such model is
established at an area hospital on the other side of the district so that it will be
reachable, and might even decrease the defaulter rate and dropouts.

 Impart skill to mothers for preparation of nutritious food.

 Encourage health personnel to use every health contact for providing appropriate
nutritional advice and for appropriate breastfeeding and young feeding practices.

 Ensuring for optimal utilization of health promoting practices like immunization, growth
monitoring and antenatal checkups.

As always, prevention is better than cure! What we need is promotion of low- cost sustainable
solutions like optimal infant and young child feeding so that SAM does not occur. And
encourage in preparation of nutritious diet with locally available energy rich foods.
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Telangana State, India: Ann Hum Biol.2011 Jan;38(1):93-101.
APPENDICES
I. SERVICE PROVIDERS (STAFF) INTERVIEW GUIDE.

II. MEDICAL OFFICER & NUTRITION COUNSELLOR INTERVIEW GUIDE.

III. QUESTIONNAIRE FOR BENEFICIARIES

IV. CHECK LIST FOR FUNCTIONAL PRACTICES

V. PERMISSION LETTER FOR THE STUDY

VI. PHOTOS
SERVICE PROVIDERS (STAFF) INTERVIEW GUIDE
Name:

Age/sex:

Qualification:

Experience:

1) What is your role in NRC.?

2) Have you undergone any training?

3) Was the training beneficial?

4) Training was for how many days?

5) What kind of cares are treated at NRC?

6) Are the children admitted at NRC and to the admission criteria?

7) What kind of therapeutic feeding given?

8) What kind of diet plan is prepared?

9) Is there timely provenience of therapeutic feeding given?

10) Does each nutrition therapeutic feed meet the requirement of the calories needed?

11) Do you give counseling for the benefices?

12) What kind of counseling is given?

13) Do you monitor is the child finishes his/her feed accordingly?

14) What kind of challenges you face from benefices?

15) Is the kitchen monitored (chance for deadliness) and other things?
MEDICAL OFFICER & NUTRITION COUNSELLOR
INTERVIEW GUIDE
Name:

Age/sex:

Qualification:

Experience:

1) What is your role in NRC.?

2) What kind of care is provided at the center?

3) What kind of cases are treated?

4) When malnourished cases come –What is the process?

5) Have you undergone any training?

6) Was the training beneficial –What did you learn?

7) Training was for how many days?

8) What kind of cases are treated?

9) What are the challenges that you are facing?

10) What kind of therapeutic feeding given?

11) Is the therapeutic feeding taken care off?

12) Is there timely provision of therapeutic feeding given?

13) What is your opinion are the construability factors for malnutrition?

14) Does the care takers (Beneficiaries) understand the reason for malnutrition?

15) In your view how are the services received by the beneficiaries?

16) Is counseling given to the beneficiaries?

17) What are the aspects covered during counseling to beneficiaries?

18) What proportion of beneficiaries are complaints with therapeutic treatment?

19) How are the patients referred to NRC?

20) In your opinion do anganwadis (frontline community health workers) have knowledge
about NRC?

21) In your opinion do you think NRC is providing better services for treating malnutrition?

22) Do you face any problems in:

 Infrastructure –

• Human resources –

• Duty rooster –

• Sanitation/cleanliness –

• Others –
23)Do the patient follow the discharge criteria and the follow up

24) What is the cured percentage?

25) Do you provide any special care for medically compromised (HIV/TB/any other
complicated)-children?

26) What are the other complications you generally face?

27) In your opinion any other suggestions that would contribute to the selterment of the
services NRC.
QUESTIONNAIRE FOR BENEFICIARIES
1. Name of the child
2. Name of the parent (father/mother) or guardian
3. Age of the child
4. Sex of the child
5. Number of children
6. Relationship of the guardian with the child
7. Date of delivery
8. Annual family income
9. Education status
10. Occupation
11. Number of children below the age of 5 years
12. Weight of the child at birth
13. Date of birth
14. Place of birth
15. Weight of the child at NRC on day of admission.
16. Weight of child at NRC on day of discharge.
17. Are the service providers at NRC able to explain you about the services that are being
provided at NRC?
18. Can you recall any two services
19. Will you be able to practice at home, the instructions that has been given by the staff?
20. What is the type of feed, composition and time interval of feed at NRC
21. Is the staff able to explain you about personal hygiene and sanitation?
22. What do you know about malnutrition and its causes
23. Is NRC able to create awareness regarding nutritional aspects?
24. Are you able to prepare energy dense child foods using locally available food items?
25. Will you be able to provide nutritious food to the child at home.
26. Are you satisfied with the services delivered from NRC?
CHECK LIST FOR FUNCTIONAL PRACTICES
MONITORING HYGIENE
OBSERVE YES NO COMMENTS

HANDWASHING

Are there working hand washing facilities in the

ward

Does staff consistently wash hands thoroughly

with the soap

Are their nails clean

Do they wash hands before handling food

Do they wash hands between each patient

MOTHERS CLEANLINESS

Do mothers have a place to bathe, and do they

use it?

Do mothers wash hands with soap after using

the toilet or changing diapers

Do mothers wash hands before feeding children

BEDDING AND LAUNDRY

Is bedding changed every day or when

soiled/wet

Are diapers, soiled towels and rags, etc., stored

in a bag, then washed or disposed of properly

Is there a place for mothers to do laundry

Is laundry done in hot water

OBSERVE

GENERAL MAINTENANCE

Are floors swept

Is trash disposed of properly

Is the ward kept as free as possible of

insects and rodents?

FOOD STORAGE

Are ingredients and food kept covered and

stored at the proper temperature?

Are leftovers discarded?

DISHWASHING

Are dishes washed after each meal?

Are they washed in hot water with soap?

Washed under running water with soap

TOYS

Are toys washable?

Are toys washed regularly?

WARD PROCEDURE
OBSERVE YES NO COMMENTS

Are correct feeds served in correct amounts

Are feeds given at the prescribed times, even on

nights and weekends

Are children held and encouraged to eat (never

left alone to feed)

Are children fed with a cup (never a bottle)

Is food intake (and any vomiting/diarrhea)

recorded correctly after each feed

Are leftovers recorded accurately

Are amounts of Starter diet kept the same

throughout the initial phase, even if weight is lost

After transition, are amounts of Catch-up diet

given freely and increased as the child gains
weight
Table.12

WARMING
OBSERVE YES NO COMMENTS

Is the room kept between 25° - 30°C (to the

extent possible)

Are blankets provided and children kept covered

at night

Are safe measures used for re-warming children

Are temperatures taken and recorded correctly

Table.13

WEIGHING
OBSERVE YES NO COMMENTS

Are scales functioning correctly

Are scales standardized weekly

Are children weighed at about the same time
each day

Are they weighed about one hour before a feed

(to the extent possible)

Do staff adjust the scale to zero before weighing

Are children consistently weighed without

clothes

Do staff correctly read weight to the nearest

division of the scale

Do staff immediately record weights on the

child’s case sheets

Are weights correctly plotted on the Weight Chart

ANTIBIOTICS, MEDICATIONS, SUPPLEMENTS
OBSERVE YES NO COMMENT
S

Are antibiotics given as prescribed (correct dose

at correct time)

When antibiotics are given do staff immediately

make a notation on the daily care charts

Is folic acid given daily and recorded

Is vitamin A given according to schedule

Is a multivitamin given daily and recorded

After children are on Catch-up diet for 2 days, is

this correct

Dose of iron given twice daily and recorded

Table.15

WARD ENVIRONMENT
OBSERVE YES NO COMMENTS

Are surroundings welcoming and cheerful

Are mothers offered a place to sit and sleep

Are mothers taught/encouraged to be involved in

care

Are staffs consistently courteous

As children recover, are they stimulate and

encouraged to move and play
PHOTOS
NRC AT SANGAREDDY GOVERNMENT HOSPITAL, MEDAK
PATIENT AREA AT NRC
CHARTS AND DISPLAYS AT THE CENTER
MEASURING MID UPPER ARM CIRCUMFERENCE (MUAC)
MEASURING HEIGHT OF THE CHILD
DEMONSTRATION OF PREPARATION OF NUTRITIOUS FOOD TO THE MOTHERS

EXPLAINING THE IMPORTANCE OF NRC, 14-DAY STAY, AND NUTRITIOUS FOOD TO THE MOTHERS
LIST OF TABLES
Table No Heading Page No
1 Staff position MO 17
2 Nursing staff position 17
3 Nutrition counsellor staff 18
position
4 Cook cum care taker staff 19
position
5 Attender/cleaner 19
6 Medical social worker 19
7 Ward equipment check list 20
8 Other ward equipments 20
9 Kitchen equipment 21
11 Kitchen supplies 21
11 Monitoring hygiene 22
12 Monitoring ward procedures 26
13 Monitoring medical supplements 28,29

LIST OF FIGURES
FIGURE. NO Heading Page No
1 Number of Participants 31
2 Sex distribution 32
3 Mean weight on admission 33
4 Caste distribution 34
5 Parents Income distribution 35
6 Education status of mothers 36
7 Awareness regarding feeding 37
practices
8 Knowledge about causes of 38
nutrition
9 knowledge about therapeutic 39
foods
10 Knowledge about complimentary 40
food preparation
11 Personal hygiene 41
12 Nutritious food feeding practices 42
13 Age wise average weight gained 44
14 Average weight gained –boys. 45
15 Average weight gained-girls. 46
16 Average length of stay. 47
17 Referral practices. 48
ABBREVIATIONS
AHS Annual Health Survey

AWW Anganwadi worker

ASHA Accredited Social Health Activist

CHC Community Health Center

CHW Community Health Worker.

F-IMNCI Facility Based Integrated Management of Newborn and Childhood Illnesses

FRU First Referral Unit

HIV Human Immunodeficiency Virus

HFA Height-for-age

IV Intravenous

IU International Unit

mcg micrograms

MUAC Mid-Upper Arm Circumference

MO Medical Officer

NACO National AIDS Control Organization

NG Nasogastric

NRC Nutrition Rehabilitation Center NFHS National Family Health Survey NC Nutrition
Counsellor

OPD Outpatient Department ORS Oral Rehydration Solution PHC Primary Health Center

RCH Reproductive and Child Health

PGW Pediatric General Ward.

ReSoMal Rehydration solution for malnourished children

SAM Severe Acute Malnutrition

SC Scheduled Caste
ST Scheduled Tribe

SD Standard Deviation

SRS Sample Registration System

SST Supplementary Suckling Technique

TOT Training of Trainers

VHND Village Health and Nutrition Day

WFA Weight-for-age WFH Weight-for-height WFL Weight –for- length

WHO World Health Organization