Mdm Final

Background According to the National Family Health Survey 2005-06 , about thirty eight percent of all Indian children are undernourished.

Hunger and under nutrition ruin children’s

health, undermine their learning abilities and impair their lives in many other ways. In world very few countries have such high levels of child under nutrition. Simeraly, Education statistics are also alarming. At least 20 per cent of Indian children (in the 614 age groups) are out of school. This too, impairs their future in many ways. The well being of children is everyone’s responsibility – not just that of their parents. Indeed, parents alone are not always able to protect their children’s interests, especially when they are weighed down by poverty, illiteracy, poor health and social discrimination. This is one reason why the protection of children’s rights depends crucially on social arrangements, such as universal schooling, school based provision of health care and nutrition etc. . These arrangements are typically initiated by the state, but their effectiveness depends in many ways on the involvement of the public at large.

For

instance, the success of a village school depends a great deal on what the teachers, the parents, the Gram Panchayat and the village community actually do for it.

Even the

physical presence of a school often requires organized demand from the village community in the first place. The provision of cooked, nutritious midday meals in primary schools is an example of social arrangement geared to the protection of children’s rights. Their primary objective is to promote the right to food and the right to education, but they can also serve many other useful purposes today, every child who attends a government or government-assisted primary school is entitled to a nutritious midday meal, as per recent Supreme Court orders. However, this entitlement is far from being realised: the coverage of midday meals is close to universal, but their quality is still very low in most states. The idea behind implementation of the MDMP was to enroll more students with regular attendance. It’s a fact that a hungry child is less likely to attend school regularly as hunger drains him/her will & ability to learn. Chronic hunger can lead to malnutrition, which will result a child not only more susceptible to diseases like measles, diarrhea, respiratory infections etc. but also increases the severity of various diseases . And even if a malnourished child does attend school, their ability to concentrate and participate in the teaching/learning activities in the school remains poor. Hence malnutrition hampers the overall growth & development of the child.

. MDMP is an also effective tool for reducing the gender gap as it considerably enhances female school attendance. With a view to enhance enrollment, retention and attendance and simultaneously improve nutritional levels among children, the National Programme of Nutritional Support to Primary Education (NP-NSPE) was launched as a centrally sponsored scheme on 15th August 1995, initially in 2408 blocks in the country to children in Classes I-V of govt/govt aided, local body schools, etc. It consisted free supply of food grains @ 100 gms/child/school/day and subsidy for transportation of food grains up to a maximum of Rs. 50/quintal. In addition to food grains, MDM involved two other major inputs, i.e. cost of cooking (cost of ingredients, fuel, wages/remuneration to personnel or to an agency responsible for cooking) and provision of essential infrastructure (kitchen-cum-store, adequate water supply for cooking/drinking, washing, cooking devices, utensils etc). In September 2004, the NP-NSPE was revised to provide cooked mid day meal with 300 calories and 8-12 grams of protein to all children studying in class I-V in government and aided schools and EGS/AIE centers. The revised scheme provided central assistance with improved costing guideline for cooking cost, transport subsidy, management/m & e, provision of mid day meal during summer vacation in drought affected areas. Today, the NP-NSPE is the world’s largest school feeding programme reaching out to about 12 crore children in over 9.50 lakh schools/EGS centers across the country. Several independent evaluation studies were conducted which testify to the increase in enrollment, particularly of girls and to the narrowing of social distance. Following the main difficulties like Rs 1/- towards cooking cost was found to be inadequate for meeting the cost of nutritious meal, absence of kitchen sheds in schools leads to classrooms to be used for storage and cooking purposes, and existing nutritional norm was felt to be inadequate to meet the growing needs of young children, the NP-NSPE was revised during June 2006.

Uttarakhand The government of India launched a new ‘centrally-sponsored scheme’, the National Programme of Nutritional Support to Primary Education. Under this programme, cooked mid-day meals were to be introduced in all government and government-aided primary schools within two years. In the intervening period, state governments were allowed to distribute monthly grain rations (known as ‘dry rations’) to schoolchildren, instead of cooked meals. Six years later, however, most state governments were yet to make the transition from dry rations to cooked meals. The Supreme Court gave them a wake-up call on November 28, 2001, in the form of an order directing all state governments to introduce cooked mid-day meals in primary schools within six months. Once again, most state governments missed the deadline, and even today, some states (notably Bihar, Jharkhand and Uttar Pradesh) are yet to comply. Nevertheless, the coverage of mid-day meal programmes has steadily expanded during the last two years, and cooked lunches are rapidly becoming part of the daily school routine across the country. The state of Uttaranchal was created by combining the northwestern hill area districts of Uttar Pradesh. The state has 13 districts, 49 tehsils, 95 blocks and 16,414 villages. It has a population of 8.5 million. Its Total area is 53,483 Square kilometers, which is 18th in terms of area and its density of population is 159 per km .The state is 11th most sparsely populated state in the country. The literacy rate age 7 and above is 84% for males, 60% for females, and 72% for the total population. As per NFHS-3 survey, 78% of the population of Uttarakhand lives in rural area and rest 22% lives in urban area. The 87% of households are Hindus, 7% households are Muslims, 5% households are Sikh, and 1% belongs to other religions. One third of Uttarakhand household and population are the highest wealth index and only 7% of household are in the lowest wealth index. The Administrative and Demographical profile of Uttarakhand Divisions

:2

Districts

: 13

Development blocks

: 95

Gram panchayats

: 7261

Villages

: 16742

Uninhabited villages

: 954

Population

: 8.49 million

SC population

: 17.9 % of the total

ST population

: 3.0 % of the total

BPL population

: 34.66%

Literacy rate

: 72.28% Male literacy

: 84.00 %

Female literacy

: 60.26%

Total population of children (6-11)

: 11,89,062

Total Children enrolled

: 11,85,372

According to NFHS 3 1. Status of anemia amongst children 6 to 35 months is: State: 61.5% Rural: 62.0% Urban: 60.2% 2. Undernutrition Stunting Waisting 2. IMR: Urban – 17; Rural - 50 In Uttarakhand till may 2002 the Dry rations distribution pattern was adopted for MDM scheme however, most state governments were yet to make the transition from dry rations to cooked meals. The Supreme Court gave them a wake-up call on November 28, 2001, in the form of an order directing all state governments to introduce cooked midday meals in primary schools following the order of the honorable Apex court the Government of Uttarakhand started the MDMP in the Sahaspur block of Dehradun district in May 2002 – November 2002 as first phase covering 107 schools 10494 student. Based on first phase outcome and experiences the scheme was extended in November 2002 as Phase–II to cover 26 Blocks in 13 district (2 block each district) extending the coverage to 3196 schools & 2, 37,248 student. after successful implementation of phase-II in selected blocks, In Phase –III from July 2003 onwards the government of Uttarakhand has started implementation of the MDMP scheme in all the blocks of all thirteen district covering all Primary schools of states, in phase–IV EGS/AIE centers, were also included in the scheme and now during 2007-08 11698 Primary school, 1442 EGS has been covered under Mid day meal scheme And from January 2008 onwards the Mid day meal programmes was also launched in upper primary school of 21 educationally backward blocks in Uttarakhand and from April 2008 the scheme is also being implemented in all upper primary schools of state.

S.N

Category of schools

1

Govt.

2 3

(local bodies/Govt. aided) No. of EGS Center No. of AIE Center

No of Primary schools

Enrollment

12141

1124467

1609 187

41431 10062

Objective of the study This study primarily will focus to understand the impact of fortification schemes on the quality of education and health status of the children. Furthermore, it will provide information

regarding

its

impact

on

children

enrollment,

retention

and

their

performance. It will also focus on comparative analysis between midday meal and fortification schemes in different geological settings. The study will also explore the alternatives of fortification base on available resources in the state and their financial viability. The main objectives of study as following; 1.

To assess the effectiveness of the fortification to reduce micronutrient

deficiencies with special reference to iron, folic acid and vitamin A & incidence of morbidity of diarrhea, pneumonia and fever episodes among the target children. 2.

To determine the impact of midday meal in students enrollments,

retention, attendance, performance and quality of education. 3.

To find the scope of practical & financial feasibility for up scaling the

fortification progrmme in other districts. 4.

To find the scope of better alternative for fortification of MDM through local

foods, vegetable and fruits. 5.

To assess the community perception about the implementation and effect

of MDM and fortified MDM.

Methodology This study will conduct in 56 primary and 24 upper primary schools in Tehri and Nanital districts, Uttarakhand. The blocks were pre decided based on altitude (Upper and lower Himalaya) and the number of school and percentage of student already mentioned in TOR. However, the school with in the block will decide according to distance from the blockhead office and walking distance from the roadside. In this study, more than 50% school will selected from remotest part of the block. This study also conceders 50-50% of boys and girls and adequate presentation of schedule caste and tribe and backward students. The major objectives of the study

Name of the District Tehri

Nanital

Primary school

Upper primary school

Number of student

Devprayag

14

6

40% of children

Bhilangana

14

6

40% of children

Ramnagar

14

6

40% of children

Okhalakanda

14

6

40% of children

Block

Study design The study will conduct in the two blocks of districts Tehri (Bhilangna and Devprayag) which would be controlled district where fortification of MDM is in practice and Nanital (Ramnagar and Okhalanda). The major objective of study is to assess the effect of a Premix,

fortified with iron, Vitamin A, hemoglobin, Iodine on Health indicators and

quality of education (attendance, enrollment, retention etc.). The

will use three

sections, the first section will include health and education status, second one includes lab investigation and third section will investigate financial and physical feasibility of local alternative for fortification. (needs to be reworded)

Information dissemination and legal consent The first step of study will disseminate adequate and appropriate information to all concern authorities such as health and education department at state, district and block level, school staffs and Gram Pardhans. The study will involve block level education officer in the school selection process. The study will also ensure the community’s legal consent from the principal of the school and Gram Pardhan.

Sample size The sample size will depend on the total number of students in the selected 56 primary and 24 upper primary schools. According the TOR, if the total number of students will be less than 50, than all of them will become the study subject

however, if the total

number of student will be more 50, than 40% of the total students will be taken as study subjects (but not less than 50). In case of lab investigation, the study will select

randomly 300 students but not less 75 from each block. At block level, study will investigate 22 students in upper primary school and 53 students in primary school. At school level Stratified random sampling of the students will be done to select the sample population considering the gender and caste (schedule caste, schedule tribe, backward) and general.)

Process of sample selection Process of sample selection will be as per following steps: 1.

Selection of school will be on the basis of distance from the blockhead

office and distance from roadside 2.

The study will select at least 50 student from each school and if the

number of students is more than 50, study will select 40% of students but it will ensure that number should not be less than 50. 3.

Sample size of students for investigation has been decided based on

prevalence rate of anemia, iodine deficiency, vitamin B12 and folic acid and vitamin A deficiencies. however, the student will be randomly selected for the investigations in the school. All the investigations proposed in the study will be carried out in the each of the selected student for the study.(300 students)

Quantitative data collection The quantitative data collection tool will have information on household characteristics, Biodemographic characteristics, school attendance, retention and performance. The quantitative data tool will also

collect the information about subject wise marks and

anthropometric indicators such as height, weight and circumference of upper arm. Tool will also capture the sign and symptoms of the vitamin and mineral deficiency and history of diarrhoea, pneumonia and fever etc. Furthermore, it will provide evidence based data collection on pathological test.

Data processing & Analysis Of quantitative findings The following steps will require to be taken for analysis of data: 1. Verification of questionnaire 2. Identification number 3. Development of variables SPSS for Window, version 16 4. Computer data entry - SPSS for Window, version 16 5. Data Verification and rectification 5. Tabulation plan 6. Frequencies and cross table analysis 7. Development frequency base and correlation graph, Test of significance will be applied to measure the significance of the difference between fortified and non-fortified food. 8. Report writing

Qualitative data collection The qualitative data collections will focus on in depth interviews with teachers- 5 (3 primary and 2 upper primary schools) ABSA -1 and, BEO -1 from each block and WFP programme officer at district level. The qualitative finding and observations will also be collected from community meeting at block level, which will ensure the representation of all the sections of

society.

Data processing & Analysis Of qualitative findings The following steps will require to be taken for analysis of data: 1.

Translation

2.

Free listing

3.

Domain Identification

4.

Coding

5.

Computer data entry

6.

Quantitative marking in Percentage

7.

Qualifiers: The following qualifiers will use for semi-quantitative expressions

and

observations.

8.

Population of Respondents <10 %

Qualifier Used < 1+

Adjectives Used Very few

10 - 24 %

1+

Some

25 - 49 % 50 - 74 % 75 - 89 % ≥ 90 % Report writing

2+ 3+ 4+ 5+

approximately half Majority / Over half Most Almost all.

Pathological investigation

Development of study instrument The study has many objectives hence the study instrument will be developed separately for each objective. Finally, the investigation tool will come in the form of a section wise questionnaire with proper indication for investigators to understand where they have to use or not. 1.

To assess the effectiveness of the fortification to reduce micronutrient deficiencies with special reference to iron, folic acid and vitamin A & incidence of morbidity of diarrhea, pneumonia and fever episodes among the target children.

Study instrument a) incidence of b)

Quantitative tools- questionnaire

(…………..household characteristics,

diseases, and anthropometric measurement) Qualitative - Checklist for interview and FGD (teachers, parents and Immediate health providers)

c)

Pathological investigation - For the assessment of effect of fortification food, study will assess the level of HB%, Vitamin A, Iodine and vitamin B12 and Folic acid 1. Hemoglobin

- HB%

2. Vitamin A

- Retinol

3. Iodine

- T3, T4 and TSH

4. Vitamin B12

- Vitamin B12 and Folic

2.

To determine the impact of midday meal on student’s enrollments, retention, attendance, performance and quality of education.

Study instrument a) Quantitative questionnaire - based on school records from 2005 to 2008 marks obtained by students in Hindi and Math subjects at primary level and Hindi, math

and science subjects at upper primary levels will be recorded for

assessing the performance. Besides that enrollments, retention and percentage of dropout students will be assessed based on the school records. b) Qualitative – In- depth interviews with students and teachers will be conducted to assess………… . Selected Psychometric

test

according

to

the

student’s age will be performed to assess their writing, reading, calculation abilities , Tests will also explore status of physical fatigue and

short

term memory of the

students.

3.

To find the scope of practical & financial feasibility for up scaling the fortification progrmme in other districts.

Study instrument a) Analyze and Assess the existing fortification

programme in the state as well

as other part of the state. b) Use “Wings Methods” for analyzing the practical problems such as accessibility, availability, transportation, distribution and preservation. c) The study will incorporate cost benefit analysis to understand the financial feasibility for up scaling the fortification program in other districts. d) Findings from health status, education and lab investigation will be analyzed in the context of socio-economic and geographical point of views.

4.

To find the scope of better alternative for fortification of MDM through local foods, vegetable and fruits.

Study instrument a) Desk review of the literature will be conducted by Nutritionist, Agricultural expert and Ayurvedic practitioners. b) Probable options will be Analyzed for their food value by using food scale method ,a booklet on most suitable food items will be developed (I understand this is the requirement as per TOR) c) The cost effective analysis will be done to understand the practical problems such

as accessibility, availability, processing, preservation transportation and distribution

5.

To assess the community perception about the implementation and effect of MDM and fortified MDM.

Study instrument a) Qualitative - community meeting checklist

Pre- testing of the research instrument After the development of the questionnaire by the expert pool (Public health professionals, statistician,)

educationists,

nutritionists

social

scientists,

psychologists,

and

Pre – testing will be conducted under the close observation of senior

consultant out side the study working area. The pre testing will conduct in one primary and one upper primary schools and the total umber of students will not less than 50. The all members of core team, consultant and investigators will have to participate in pre testing process. The questionnaire /schedule will be finalized in consultation with expert panel members based on the feed back of the pre – testing. The final of questionnaire will send to government of Uttarakhand for their approval.

Recruitment and training

The recruitments of professionals, staffs and technician will be based on their qualification and pervious experiences in research management, data collections and analysis and report writing. The investigators will

have good communication skills,

familiar with local language and dialect. A 4 days orientation programme will be organized for the investigators to orient them about he study and the various schedules tests etc. to be carried out under the study Out of 4 days one day will be kept for the practices of field work.

Fieldwork and monitoring system The entire fieldwork will be completed in two phases. The investigators will visit each select school twice. The first visit will be an announced visit, investigators will collect primary information through the questionnaire and also collect the blood sample for pathological investigation and second visit will an unannounced with a gap of more than a month to assess the child attendance, quality of education and patterns of midday meal. The study coordinator, associated researchers and the senior members from the state will plan minimum three visits for each block to ensure the quality data collection and ensure 20 % spot checks for quality assurance of the fieldwork. The technical group will have to reviewed the 20% of forms for the maintaining the quality of standard.

Data processing The questionnaires will be submitted by the investigators to the head office after the verification from the field monitoring team. The head office will give an Identification number to each form and data will directly enter in statistical packages SPSS for Window, version 16. The missing values will allow for the analysis and frequencies will calculate from the univariate analysis. Bivariate analysis will use to describe the relationship between different variables of interest and the dependent variables.

Analysis and report writing The quantitative analysis of report will do by the help of SPSS window, version 16 according to tabulation plan and base on objectives of the study. The report will submit in a standard research format. The draft report will sent to technical group and Government of Uttarakhand for their suggestions and recommendations. HIHT will submit following reports at the completion of the study 1. Health and education status of school going children in fortified and non fortified districts 2. A report on Financial feasibility for replication of fortification program in the other part of state 3.Alternative models for fortification of MDM through local foods, vegetable and fruits( Including recipe booklet).

Time Frame Phase -I

Phase -II

Phase -III

Phase -IV

Phase -V

S.N. 1

Phase 1 1.5 Month (6 Week)

1.1

Study office setup

1.2

Hiring of staff

1.3

Development of Research tools Planning meeting with Study field staff

1.4

Pre testing of & modification of questionnaire

1.5

Pre testing of & modification of questionnaire

1.6

Orientation & Training of investigators & field staff.

1.7

Selection of schools.

1.8

Finalization of School wise sample size based on school records. (B::G ratio / cast proportion)

1.9

Blood Sampling of student on randomly selected basis

1.10

Desk Research / review for Localization fortification of mid day meal.

1.11

Planning meeting for IInd phase Phase 2 1.5 Month (6 Week)

2 2.1

First announced visit to school

2.2

Consent taking from Gram Pradhan

2.3

Field Monitoring

2.4

Questionnaire survey

2.5

Health data collection

2.6

Education Data collection (School records)

2.7

Anthropometric data collection

2.8

Parents interview

2.9

Blood Sampling of student on randomly selected basis

W1

W2

W3

W4

W5

W6

W1

W2

W3

W4

W5

W6

2.10 2.11 3 3.1 3.2

Data collection for local food, vegetables, fruits, cultivation status, availability in number of months in a year, nearest source, Planning meeting for III rd phase Phase 3 1.5 Month (6 Week) Questionnaire verification Development of variables & coding

Data entry

3.4

Data validation / correction

W3

W4

W5

W6

W1

W2

W3

W4

W5

W6

Tabulation plan

3.6

Data analysis

3.7

Draft tabulation

3.8

Gap analysis

3.9

Collecting the results of Blood sampling test

3.10

Micro nutrient availability analysis in available local food, vegetables, fruits. Cost analysis, and financial viability

3.11

Planning meeting for IVth phase Phase 4 1.5 Month (6 Week)

4

W2

Development of variables & coding

3.3

3.5

W1

4.1

Second unannounced visit to school

4.2

Random checking school attendance and performance of Education

4.3.

Random visit before mid day meal

4.4

Focus group discussion with Community

4.5

Focus Group discussion with teacher

4.6

Education Data collection (School records)

4.7

Interview BEO/ABSA/ Principal

4.8

Interview with Bhojan Mata

4.9

Analysis of pathological results

4.10

Preparation of Recipe book for Alternate

4.11

Planning meeting for phase 5

S.N.

Phase 5 2 Month (8 Week) Final verification of questionnaire

5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9

5.10

Addition of new variables Final Data entry Data validation/ verification Data analysis Finalization of tabulation Plan Report writing Draft report submission Feedback / comment Final report submission 1. Quantitative report, 2. Recipe Book, 3. Financial and practical feasibility report for Scaling up

W1

W2

W3

W4

W5

W6

W7

W8

S.N.

Designation

Post

1

Study Coordinator

1

2

Research Associate

1

3

Data entry operator

8

4

Executive assistant/ Accountant

1

5

Field investigator

6

Lab technician

2

7

Public health

1

8

Nutritionist

1

9

Educationist

1

16

Qualification and experience Post graduate in Social science research and Program management with Experience in Social research P.G. in Social science, & experience in Social research Graduate & experience in Computer and data entry / data processing Graduate and experience in Office Management Post graduate in social sciences and experience in research. BMLT/DMLT and experience in blood Sample collection and testing Consultant Post graduate in public health and experience in community Health research Consultant Post graduate in Nutrition and Experience in nutrition Consultant Post graduate in Education and Experience in educational research pedagogy

Major task Overall coordination and Liaisoning and project management. Guidance, Research design, development of research tools, Indicators, data analysis, Report writing Coordination & supervision in the field, data analysis, report writing. Data entry & tabulation. Records management. Support to field staff, logistics & accounts. Conduct field survey, data collection (Interviews, FGDs, Filling questionnaire/Schedule at the field level.) Plan & coordinate all logistics support to Collect blood samples at field level, & ensure the quality control of the samples collected. Technical support to the project

Technical support on nutrition issues to the project

Assist in designing educational tools and pedagogical inputs.

22

Organization

Study Coordinator

Technical Consultant Public health Nutritionist Educationist

Research Associate

Executive Assistant/ Accountant

Field investigator 16

Lab technician 2

Data Entry operator 8

23