Integrated Child Development Services scheme (ICDS) and its impact on nutritional status of children in India and recent initiatives

Integrated Child Development Services (ICDS) scheme is the largest national programme for the promotion of the mother and child health and their development in the world. The beneficiaries include children below 6 years, pregnant and lactating mothers, and other women in the age group of 15 to 44 years. The package of services provided by the ICDS scheme includes supplementary nutrition, immunization, health check-up, referral services, nutrition and health education, and pre-school education. The distribution of iron and folic acid tablets and megadose of vitamin A is also undertaken, to prevent iron deficiency anaemia and xerophthalmia respectively. The scheme services are rendered essentially through the Anganwadi worker (AWW) at a village centre called "Anganwadi". The ICDS had led to (i) reduction in prevalence of severe grades of malnutrition and (ii) better utilization of services of national nutritional anaemia prophylaxis programme and the national programme for prevention of nutritional blindness due to vitamin A deficiency by ICDS beneficiaries. The ICDS scheme is being modified continuously to strengthen the programme.     

Impact of ICDS on health and nutritional status of children

The Integrated Child Development Services (ICDS) in India comprises health, nutrition, and education human resource development in 1745 rural, 716 tribal, and 235 urban projects in about 45% of community development blocks of the country. Research studies have found that in ICDS areas there were fewer children suffering from Grades S II and IV malnutrition compared with non ICDS areas and the percentage of normal children has increased. 6.8% of children aged 0-3 years and 4.0% of children aged 3-6 years in ICDS areas were in Grades III and IV of malnutrition. The ICDS treatment for malnutrition is administration of 16-20 gm of protein and about 600 calories and monitoring monthly; there are 13.9 million children presently receiving supplementary nutrition in the ICDS program. The nutrition program in general aims to provide health and nutrition inputs to expectant mothers throughout the gestation period in order to prevent low birth weight babies; the nutrition supplement distribution has improved, but chronic malnutrition among pregnant mothers persists. The ICDS program provides regular health checkups, immunization, detection of malnutrition, treatment of diarrhea, and deworming of and for children. These services have contributed to improved health among children in ICDS areas. The infant mortality rate (IMR) of 71.3/1000 live births in 1992 in ICDS areas was found to be lower than national estimates in 1989. In ICDS projects more than 3 years old, IMR was found to be 84.5; further decline in IMR in 1990 were found in projects older than 5 years. Morbidity and mortality have been fund to be higher in non-ICDS areas, and declines have been observed in ICDS areas. The incidence of vaccine preventable diseases was not found to have declined in ICDS areas, in spite of increased immunization. ICDS provides anganwadi community workers (AWWs) and services through a network of Primary Health Centers and subcenters, which are not optimally used. However, when compared with non-ICDS areas, prenatal services are used by 71.9% of the pregnant population compared with 40% in a non-ICDS control group. In 1992, there was 90% coverage of children aged 0-6 years with health check ups; this level of usage may be due to the availability of medicine kits through AWWs. ICDS provides potential for enhancing the survival of children.     

Immunization coverage in India for areas served by the Integrated Child Development Services programme. The Integrated Child Development Services Consultants.

The Integrated Child Development Services (ICDS) programme was launched by the Indian government in October 1975 to provide a package of health, nutrition and informal educational services to mothers and children. In 1988 we studied the impact of ICDS on the immunization coverage of children aged 12-24 months and of mothers of infants in 19 rural, 8 tribal, and 9 urban ICDS projects that had been operational for more than 5 years. Complete coverage with BCG, diphtheria-pertussis-tetanus (DPT) and poliomyelitis vaccines was recorded for 65%, 63%, and 64% of children, respectively, in the ICDS population. By comparison, the coverage in the non-ICDS group was only 22% for BCG, 28% for DPT, and 27% for poliomyelitis. Complete immunization with tetanus toxoid was recorded for 68% of the mothers in the ICDS group and for 40% in the non-ICDS group. Coverage was greater in the urban and lower in the tribal projects. Scheduled castes, scheduled tribes, backward communities, and minorities (groups that have a high priority for social services) had immunization coverages in ICDS projects that were similar to those of higher castes.     

Integrated training of health functionaries in ICDS scheme

India's Integrated Child Development Services (ICDS) was first implemented in October 1975, in 33 experimental blocks and expanded to include 2499 projects by March 1991. ICDS is multisectoral and coordinated at the village, block, district, state, and central government levels. Program responsibility is vested in the women and child development department at the center level and at a variety of different departments at the state level (social welfare, rural development, tribal welfare, or health and family welfare departments). The target population is children under 6 years of age and lactating women aged 15-44 years. Program objectives include improving the nutritional and health status of children aged 0-6 years; providing a foundation for proper psychological, physical, and social development of children; reducing the incidence of mortality, morbidity, malnutrition and school dropouts; effectively coordinating policy and implementation among relevant departments; and enhancing mothers' capabilities to provide for the normal health and nutritional needs of their children. "Anganwadi" workers at the local level and supportive personnel from health departments administer services, which include the following: supplementary nutrition, immunization, health checkups, referral services, treatment of minor illnesses, nutrition and health education for women, preschool education for children aged 3-6 years, and cooperation with improvement in supportive service such as water supply and sanitation.     

Past,present and future of Integrated Child Development Services (I.C.D.S.)

India's Integrated Child Development Services (ICDS) was established in 33 projects in 1975 and is spread over 22 states; 67 additional projects were begun in 1977, and over the next 2 years; 100 additional projects were added. By 1991=92, coverage was almost 50% of the country with 2696 projects; the expectation is for 100% coverage by the year 2000. An infrastructure chart identifies the organization and integration between level and social welfare and health departments. Objectives are clearly identified and the departments functionally linked. Linkages are achieved by shared space and activities at various levels. Over the past 17 years, services have included minimum needs programs, integrated rural development and poverty alleviation, national health policy and education policy, universal immunization, and the development of women and children in rural areas. ICDS is sponsored 100% by the status and uniquely relies on the honorary anganwadi worker (AWW), who is a woman, recruited and chosen by the community, aged 21-45 years and middle-school educated. The AWW was responsibility for 2000 households or 1000 persons in rural areas and 700 persons in tribal areas. The AWW is crucial to the functioning of the program and receives an honorarium of Rs. 225-275/month for implementing the ICDs program; AWWs have helpers who are paid Rs. 110/month. Training over a 3-year period is conducted at the Bal Sevika Training Institute by the Indian Council of Child Welfare. Additional health personnel and their role and the number of persons/per area AWWS are responsible for, equipment, and functions are also described. The AWW is responsible for nonformal preschool education, organization of supplementary nutrition feeding, health and nutrition education of women and families, immunization of women and children, treatment and referral of common illnesses, growing monitoring, and community participation. Presently, there are 2506 central sector projects and 190 state sector projects and 250,000 AWWs. The preschool education, health, and nutrition programs are summarized. Future directions will encompass future child and mother development and expansion to cover all 90 districts having a birth rate higher than 39/1000. Lessons learned from the past will be integrated and may involve cost containment, acceleration of development of services, alternative services, and giving mothers more responsibility for improving health and nutrition.     

Integrated Child Development Services (ICDS): harbinger of safe motherhood and child development

Editorial comment was provided on the features that made the Integrated Child Development Services (ICDS) program in India unique and on whether or not the system could focus on younger age groups (e.g., 2-3 years of age). As part of a worldwide effort, India's ICDS program has been directed to human resource development. Over the past 17 years, the program has expanded to include almost 50% of the country's most vulnerable and deprived population. The focus on children aimed to improve their nutrition and health by reducing the incidence of morbidity, mortality, malnutrition, and school dropouts. The concern encompassed physical, social, and psychological development. The focus on mothers stressed enabling them to better care for the health and nutrition of their children. The program included prenatal care, safe delivery, and post natal concern for lactation, breast feeding, and physical growth monitoring in the early years. The program's unique features were its voluntary membership of community health workers, integrated services, and targeted coverage of economically weaker and deprived populations during critical child development periods. Indigenous Indian resources provided the primary financial support. Nation coverage was given for universal immunization, family welfare, child and maternal health, diarrheal disease control, vitamin A supplementation, and anemia screening and treatment. The multisectoral nature of the program has been realized at the village, sector, block, and district levels with linkages within Health, Education, and Social Welfare sectors, and with the Medical Colleges and Home Science Colleges. Feedback from operations research studies and other research activities was provided at the local program level, and interactions occurred between students in training programs and health care delivery systems. The program will be expanded to include the entire country. Health and nutrition education were considered the weakest part of ICDS. IEC has been expanding, but community participation has not kept pace. The strong community based infrastructure needs additional support particularly from the health sector. Program expansion into adolescent health and sex education was considered desirable. ICDs should be viewed as a development activity at the village level to astute women an integrated learning for life experience.     

Strategies for nutritional improvement

India has achieved self-sufficiency in the production of food grains, yet the production of milk, legumes, vegetables, oils and fats, eggs, and meat is far short of the needs of the population. The Indian diet predominantly comprises cereals, and the diets of expectant and nursing mothers as well as children are grossly deficient in protective foods. Serious nutritional inadequacies have resulted in low birth weight, retarded growth, and nutritional deficiencies (protein energy malnutrition in preschool children, vitamin A deficiency, iron deficiency in women of reproductive age, and iodine deficiency disorders among neonates and schoolchildren). General malnutrition is prevalent in 25% of the rural and 20% of the urban population. Deficiency symptoms of vitamin B complex and vitamin C are also not uncommon. 37% of the population of India lives below the poverty limit, the literacy rate is only 52.1% (39.4% for women), safe drinking water is scarce, nutritional ignorance is rampant, there is a lack of personal hygiene, and poor sanitation all account for malnutrition. A number of government and nongovernmental organizations' programs have attempted to raise the level of nutrition and the standard of living of the people. Some of them include the integrated child development services, special nutritional program, national vitamin A deficiency prophylaxis program, national anemia prophylaxis program, national goiter control program, midday meal program, special class feeding programs, universal immunization program, nutritional and health education through the mass media as well as the observance of world food day and world health day. The national health policy gives high priority to the promotion of family planning, the provision of primary health care, and the acceleration of welfare programs for women and children. As a result of policies and programs of health and nutrition, the infant, child, and maternal mortality rates have declined and life expectancy at birth has risen.     

Nutrition advocacy and national development: the PROFILES programme and its application.

Investment in nutritional programmes can contribute to economic growth and is cost-effective in improving child survival and development. In order to communicate this to decision-makers, the PROFILES nutrition advocacy and policy development programme was applied in certain developing countries. Effective advocacy is necessary to generate financial and political support for scaling up from small pilot projects and maintaining successful national programmes. The programme uses scientific knowledge to estimate development indicators such as mortality, morbidity, fertility, school performance and labour productivity from the size and nutritional condition of populations. Changes in nutritional condition are estimated from the costs, coverage and effectiveness of proposed programmes. In Bangladesh this approach helped to gain approval and funding for a major nutrition programme. PROFILES helped to promote the nutrition component of an early childhood development programme in the Philippines, and to make nutrition a top priority in Ghana's new national child survival strategy. The application of PROFILES in these and other countries has been supported by the United States Agency for International Development, the United Nations Children's Fund, the World Bank, the Asian Development Bank, the Micronutrient Initiative and other bodies.     

Nutritional standards for preschool child care units--are there any?

In the UK the number of places for full-day care of preschool children is increasing and many young children receive their meals in nurseries and other child care facilities. Some young children spend up to five days each week at nurseries or with childminders and may have their breakfast, lunch and tea there, as well as snacks. Good nutrition in the preschool years is increasingly regarded as important for children's present and future health. Nutritional problems are common in this age group: iron deficiency anaemia is more common than in older children, constipation is common, dental caries are prevalent and rates of obesity are rising. In the UK, only Scotland has comprehensive national nutritional guidelines for 1-5 year olds and these are not obligatory. Although local authority or health bodies and a few voluntary organisations have produced nutritional guidelines or policies, there are no mandatory standards monitored by an external agency, such as exist for school meals. This situation should be remedied to safeguard the health of preschool children. In addition to national standards, training and support from registered dietitians is desirable as many nurseries and childminders do not have the expertise to ensure the required nutrients for this vulnerable age group.     

Health promotion in kindergarten children: an assessment of evaluated projects in Germany

Aim Health problems in childhood, which can be altered by basic preventive measures, are dramatically increasing. Therefore, effective primary prevention programmes beginning in early childhood are increasingly regarded as important. In this field a great deal of action, activities and interventions exist. The kindergarten setting is a particular field for integrated intervention. The special public health focus is to involve not only the children but also their parents, siblings, and teachers.Methods The aim of the project was to establish an inventory of health promotion measures as well as prevention programmes in kindergartens in Germany. The objective was a stock-taking and a critical assessment of evaluated programmes for preschool children with a main focus on obesity prevention, promotion of physical activity and nutrition education. This complete overview involved extensive literature research, internet research and interviews with experts.Results Regarding obesity prevention intervention programmes, only 13 evaluated measures were identified. Concerning promotion of physical activity and nutrition education, 41 measures were listed. A programme evaluation has been carried out very rarely. Only nine projects have had a documented qualified evaluation. With regard to cooperation with a research institution, the evaluation were competent. Nevertheless, the proportion of integrated projects with a sustainable character was quite small. For the most part, interventions are aimed at prevention at the behavioural level; activities at the conditional level are uncommon.Conclusion The results show an enormous demand on evaluated intervention programmes for kindergarten children, their relatives, and teachers. For future intervention programmes an evaluation is obligatory. Standardized measures are justified, because only such evaluated interventions were proved effective and successful. It is necessary to link existing projects, and not to create new programmes. A scientific analysis has shown that success is possible.     

Impact of a community-based comprehensive primary healthcare programme on infant and child mortality in Bolivia

Community-based comprehensive primary healthcare programmes are a widely-promoted strategy for improving child survival in less-developed countries, but limited documentation exists concerning their effectiveness in actually reducing child mortality. This study examined the impact of a community-based comprehensive primary healthcare programme on child survival in Bolivia. Mortality rates from two intervention areas where Andean Rural Health Care (ARHC) had been conducting child-survival activities for 5-9 years were compared with those from two geographically-adjacent comparison areas that lacked such activities and that were virtually identical to the intervention areas in socioeconomic characteristics. Vital events were registered at the time of regular visit to all homes. In the comparison areas, limited services were available which reached only a small percentage of the population, while in the intervention areas, prenatal care, immunizations, growth monitoring, nutrition rehabilitation, and acute curative services were readily available to the entire population. In 1992-1993, the annual rates of mortality of children, aged less than five years, were 205.5 per 1,000 and 98.5 per 1,000 in the comparison and intervention areas respectively. The absolute difference in mortality of 107.0 deaths per 1,000 (95% confidence interval [CI], 72.7-141.3 per 1,000) represented 52.1% (95% CI, 35.2-68.8%) lower mortality of children aged less than five years in the intervention areas compared to the control communities. These results suggest that the provision of community-based, integrated health services can significantly improve child survival in poor countries. Better-designed and larger field trials of community-based comprehensive primary healthcare programmes in multiple regions of the world are needed to provide a stronger scientific basis for developing this approach further in developing countries.     

The Narangwal Nutrition Study: a summary review.

Between April 1968 and May 1973 the department of International Health of The Johns Hopkins University carried out investigations into the interactions of malnutrition and infection and their effects on preschool child growth, morbidity and mortality in 10 villages of Punjab, North India. Base line surveys before the introduction of services revealed a high prevalence of malnutrition and undernutrition and infectious disease morbidity, as well as lack of accessibility, underutilization and poor population coverage of governmental health services. Study villages were selected in separate clusters and allocated to a control group and three service groups in which nutrition care and medical care were provided singly and in combination by auxiliary health workers resident in each village. Outcome effects were measured through means of longitudinal and cross-sectional surveys. Service inputs and service costs were similarly monitored. Results showed significant improvement of growth (weight and height) and hemoglobin levels of children. Perinatal mortality was reduced by nutrition supplementation to pregnant women. Medical care significantly reduced postneonatal and 1 to 3 mortality, and decreased illness duration of all six conditions examined in this paper. The auxiliary health worker capably managed more than 90% of health needs on her own and referred the rest safely to the physician. Analysis of cost per child death averted showed that cost-effectiveness declined with increasing age of the child. Prenatal nutrition care to pregnant women was most cost-effective in preventing perinatal deaths followed by medical care for infants, and then medical care for the 1 to 3 year age group. The relevance of the field research to national or international endeavors to solve present health problems of developing nations and the timeliness of projects such as the Narangwal Nutrition Study is also evaluated.     

Building capacity for parent involvement through school-based preschool services

This study investigated whether experience with school-based preschool services would build parents' capacity for school involvement. The research design compared parent involvement in kindergarten across school sites differing in the availability of preschool services, including sites with (1) multiple, integrated school-based preschool services, including seamless child care, family support programmes, and kindergarten (MS); (2) a single preschool family support programme; and (3) no preschool services. Parent surveys were employed with 206 parents of four-year-old and five-year-old children to investigate whether the site types differed in terms of several dimensions of parents' involvement: (1) feelings of efficacy in helping their children succeed in learning, (2) perceptions of their responsibilities in communicating with the teacher, and (3) perceptions of whether their children's school works with them. Parents in the MS sites reported feeling more efficacious, more welcomed by, and more responsibility to link with the school.     

A Night Without Stars (Book)

Children with disabilities need adequate nutritional intake to survive and thrive. Many are at risk and in need of nutritional intervention. In this study we evaluated the outcomes of nutrition services for children with disabilities and their families using an integrated model of feeding and nutrition. Thirty-five children and families who received nutrition intervention services participated in the study. Children with disabilities and inadequate nutrition significantly benefited from nutrition interven- tion services. Children increased in weight-for-height ratios. Families reported in- creased alertness for their children with improved nutritional status. Families of children with greater feeding difficulties experienced increased stress and decreased social support. These findings can help families and professionals work in partnership to meet the nutrition needs of children with disabilities and chronic health care problems before a child becomes severely malnourished or a family becomes dys- functional.     

Helping Families Meet the Nutritional Needs of Children With Disabilities: An Integrated Model

Children with disabilities need adequate nutritional intake to survive and thrive. Many are at risk and in need of nutritional intervention. In this study we evaluated the outcomes of nutrition services for children with disabilities and their families using an integrated model of feeding and nutrition. Thirty-five children and families who received nutrition intervention services participated in the study. Children with disabilities and inadequate nutrition significantly benefited from nutrition interven- tion services. Children increased in weight-for-height ratios. Families reported in- creased alertness for their children with improved nutritional status. Families of children with greater feeding difficulties experienced increased stress and decreased social support. These findings can help families and professionals work in partnership to meet the nutrition needs of children with disabilities and chronic health care problems before a child becomes severely malnourished or a family becomes dys- functional.     

Capacity of state health agencies to meet nutrition objectives in maternal and child health

Public health nutritionists in 54 official state health agencies were surveyed in 1987 to determine to what extent they were prepared to implement the Model State Nutrition Objectives developed by the Association of State and Territorial Public Health Nutrition Directors. Objectives related to services to the maternal and child health (MCH) population were the focus of one part of the survey. One half of all states have plans for nutrition services integrated into their state MCH plans. More than 75% of state agencies collect data on the nutritional status of pregnant and lactating women, infants, and preschool children. Fewer than half collect data on dietary intake patterns or nutrition knowledge. Thirty-one agencies reported a formal quality assurance program for one or more subsets of the MCH population. At least 75% of all states provide dietary intake recommendations, screening and assessment protocols, and policies concerning referrals to maternal and infant health programs. State health agencies are already involved in activities that will facilitate adoption of the model state nutrition objectives.     

Study of impact of nutrition & health day strategy on the coverage rates of supplementary nutrition and health interventions among the ICDS beneficiaries in a rural block of Madhya Pradesh

To study the trends of beneficiary coverage (pregnant and lactating women and children less than two years of age) for utilization of supplementary nutrition and health services in a rural block before and after the launch of a strategy to converge Health & Integrated Child Development Services (ICDS) on a single day christened "Nutrition and Health Day" (NHD). It is a before and after intervention design in rural ICDS block Amarwada in district Chhindwada. As a part of intervention, NHD were organised on which convergent services of Health & ICDS were made available to the beneficiaries. On the weekly NHDs, uncooked supplementary nutrition for the week was distributed to pregnant and lactating mothers and children under two. The Health worker visited the Anganwadi Centre (AWC) and immunized children and pregnant women, distributed IFA, Vitamin A and provided health and nutrition education. The study assessed the impact of these interventions on the coverage rates of the services. Study was conducted between May 97 and March 98. The routine monitoring reports of the ICDS and Health System of the state government were used as study tools. The study sample comprised of AWC beneficiaries in the project area. The total population of the block was 89,476. Participation in the supplementary nutrition program (SNP) increased two to three folds in all categories of the target population. Immunization and Vitamin A coverage levels for children also showed an increase of about 3 and 5-8 times from baseline status respectively in a year's time. Among pregnant women, Tetanus Toxoid (TT) and Iron and Folic Acid (IFA) utilization rates have also shown two and five fold increase respectively.     

Position of the American Dietetic Association,Society for Nutrition Education,and American School Food Service Association--Nutrition services: an essential component of comprehensive school health programs

It is the position of the American Dietetic Association (ADA), the Society for Nutrition Education (SNE), and the American School Food Service Association (ASFSA) that comprehensive nutrition services must be provided to all of the nation's preschool through grade twelve students. These nutrition services shall be integrated with a coordinated, comprehensive school health program and implemented through a school nutrition policy. The policy should link comprehensive, sequential nutrition education; access to and promotion of child nutrition programs providing nutritious meals and snacks in the school environment; and family, community, and health services' partnerships supporting positive health outcomes for all children. Childhood obesity has reached epidemic proportions and is directly attributed to physical inactivity and diet. Schools can play a key role in reversing this trend through coordinated nutrition services that promote policies linking comprehensive, sequential nutrition education programs, access to and marketing of child nutrition programs, a school environment that models healthy food choices, and community partnerships. This position paper provides information and resources for nutrition professionals to use in developing and supporting comprehensive school health programs. J Am Diet Assoc. 2003;103:505-514.     

The societal value of vaccination in developing countries

The vaccination of children against childhood illnesses not only carries the obvious medical and economic benefits, but there exists numerous indirect and often far reaching added societal benefits. In developing countries, vaccination forms the basis of village operated primary health care (PHC) activities leading to a sustained PHC programme. Vaccination programmes provide an opportunity for the provision of other primary care services, as it can be the only recurring activity in primary care, that brings mother and child into contact with health services on a predictable and frequent basis. Vaccination leads to a direct and measurable reduction of child mortality rates and this has been proven to families and communities, resulting in families choosing to have fewer children. Vaccination becomes an opportunity for a higher standard of living as it encourages smaller families and in this way contributes to successes In family planning programmes. The vaccination of children has a great impact on the lives of women in developing countries as they are the principle carers of children. Protecting the lives of children directly through vaccination and through other PHC activities is a major strategy towards improving the lives of women as it liberates their time, energy and resources. The opportunity and provision of vaccination empowers women to protect their own health and that of their children through their own actions, giving an added psychological feeling of control and empowerment in their lives. Therefore, while vaccination services can be delivered alone, they are best delivered along with other services needed by children in their first year of life and by pregnant women: the persons who constitute the priority groups for primary health care services in the developing world. In addition to the monitoring of the growth of the child, the use of oral re-hydration to treat diarrhoea and the promotion of breast-feeding, these services may include malaria treatment and prophylaxis, and counselling with respect to child spacing, nutrition during pregnancy, weaning practices, and clean water and sanitation.     

农村学龄前儿童营养改善效果分析

“儿童营养监测与改善”项目是到目前为止在中国开展的最大规模的针对农村学龄前儿童的营养改善项目,本文着重对项目初期、终期二次监测结果进行比较分析,结果显示,通过五年营养改善工作的开展,使得项目县儿童的营养状况有了不同程度的改善,全国平均发育迟缓发生率下降了２３．１％,低体重发生率下降了２８．６％,贫血患病率下降了４８％,这些改善效果的取得与几年来实施的以营养教育为主线,多种措施并举的改善方案,在一定程度上改变了儿童的不良喂养习惯,提高儿童的膳食质量有着非常重要的关系。