Understanding how the strategic use of data can improve the implementation of Maternal Nutrition Interventions in Uttar Pradesh (UP), India Öffentlichkeit

Abstract

Objective: Maternal undernutrition remains high in India and is associated with maternal mortality and adverse birth outcomes. To address this challenge, Alive & Thrive (A&T) aimed to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in UP. The nutrition-intensified ANC (I-ANC) intervention facilitated regular use of data to enable corrective actions. We aimed to understand how maternal health data was used for improving the delivery of maternal nutrition services and to identify factors associated with data use.

 

Methods: In-depth interviews (N=35) were conducted among sub-district government staff, frontline worker (FLW) supervisors and A&T staff in two districts in UP. Systematic coding of verbatim transcripts and detailed summaries was undertaken to elucidate themes and patterns related to data use and facilitators and barriers.

 

Results: Sub-district government staff reported using government data (i.e. HMIS) to estimate demand for prenatal supplements. Sub-district government staff, FLW supervisors and A&T staff used government and intervention monitoring data to understand the impact and reach of services delivered to women. Key indicators on the attendance of pregnant women at community health events and number of women receiving adequate supplements was discussed with FLWs in monthly review meetings. Data review guided identification of areas of low FLW performance (i.e. monitoring weight gain) and prompted refresher trainings. Facilitators of data use included collaboration between sub-district health department officials on data analysis and monthly review meetings to provide feedback on improving performance (including counseling topics and stock of supplements). Barriers to data use included staff vacancies, education level of FLWs and conflicts between FLWs and supervisors.

 

Conclusions: Use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Collaboration facilitated the use of data, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions.

 

Funding Sources: Bill & Melinda Gates Foundation (through Alive & Thrive, managed by FHI 360) and Emory University

Table of Contents

CHAPTER 1: INTRODUCTION ............................................................................................................................. 1 

INTRODUCTION AND RATIONALE ........................................................................................................................................ 1 

MATERNAL NUTRITION IN INDIA ........................................................................................................................................ 1 

UTTAR PRADESH, INDIA ................................................................................................................................................... 2 

PROBLEM STATEMENT ..................................................................................................................................................... 2 

PURPOSE STATEMENT ...................................................................................................................................................... 4 

SIGNIFICANCE STATEMENT................................................................................................................................................ 4 

DEFINITION OF TERMS ..................................................................................................................................................... 5 

CHAPTER 2: LITERATURE REVIEW ...................................................................................................................... 7 

GLOBAL BURDEN OF MATERNAL MORTALITY AND MATERNAL MALNUTRITION ............................................................................. 7 

MATERNAL MORTALITY AND MALNUTRITION IN INDIA............................................................................................................ 8 

CONSEQUENCES OF UNDERNUTRITION FOR WOMAN AND CHILD .............................................................................................. 9 

DETERMINANTS OF UNDERNUTRITION .............................................................................................................................. 10 

SOLUTIONS FOR UNDERNUTRITION ................................................................................................................................... 11 

PARENT STUDY IN UTTAR PRADESH, INDIA ........................................................................................................................ 12 

STRATEGIC USE OF DATA ................................................................................................................................................ 14 

CHAPTER 3: METHODS ................................................................................................................................... 16 

INTRODUCTION ............................................................................................................................................................ 16 

POPULATION AND SAMPLE ............................................................................................................................................. 16 

Figure 1: Sampling diagram for program staff, government block-level staff, and FLW supervisors ............... 17 

Table 1: Key indicators of program activity ........................................................................................................ 18 

Table 2: Scaled scoring system for indicator percentages in intervention monitoring data .............................. 19 

Table 3: Selection of high and low-performing blocks ....................................................................................... 19 

ETHICAL CONSIDERATIONS ............................................................................................................................................. 21 

INSTRUMENTS .............................................................................................................................................................. 22 

DATA ANALYSIS ............................................................................................................................................................ 23 

LIMITATIONS ............................................................................................................................................................... 24 

CHAPTER 4: RESULTS ...................................................................................................................................... 25 

DATA SOURCES ............................................................................................................................................................ 25 

Figure 2: UP HMIS and HMIS data sharing chain ............................................................................................... 27 

Table 5: Summary of government monitoring data sources .............................................................................. 27 

Figure 3: Flow of IPEG intervention monitoring data sources ............................................................................ 30 

Table 6: Summary of IPEG intervention monitoring data .................................................................................. 30 

Figure 4: Sequence of MN Block Card creation .................................................................................................. 32 

Table 7: Summary of MN Block Card .................................................................................................................. 32 

CONCEPTUAL FRAMEWORK ............................................................................................................................................ 33 

Figure 5: Pathway for the collection and use of data with respective barriers and facilitators ........................ 33 

DATA COLLECTION AND QUALITY...................................................................................................................................... 34 

USE OF DATA ............................................................................................................................................................... 42 

SUPPLY CHAIN MANAGEMENT ......................................................................................................................................... 50 

Figure 6: Micronutrient supply chain management from the state to the household level .............................. 51 

Figure 7: Summary of facilitators and barriers for maintaining IFA and calcium supply ................................... 56 

CHAPTER 5: DISCUSSION ................................................................................................................................ 57 

SUMMARY OF KEY FINDINGS ........................................................................................................................................... 57 

IMPLICATIONS .............................................................................................................................................................. 62 

STRENGTHS & LIMITATIONS............................................................................................................................................ 65 

RECOMMENDATIONS FOR PROGRAM IMPLEMENTATION ....................................................................................................... 66 

RECOMMENDATIONS FOR FUTURE RESEARCH ..................................................................................................................... 67 

SUMMARY CONCLUSION ................................................................................................................................................ 68 

APPENDIX A: TABLES ...................................................................................................................................... 69 

Table 4: Raw percentage data for high and low-performing blocks on twelve key indicators of program activity for May 2019 .......................................................................................................................................... 69 

APPENDIX B: TOOLS ....................................................................................................................................... 70 

ORAL CONSENT FORM................................................................................................................................................... 70 

ALIVE & THRIVE IN-DEPTH INTERVIEW (IDI) GUIDE ............................................................................................................ 71 

IPE GLOBAL PROGRAM STAFF IDI GUIDE.......................................................................................................................... 75 

IPE GLOBAL BLOCK COORDINATOR IDI GUIDE ................................................................................................................... 79 

BLOCK-LEVEL PROGRAM STAFF IDI GUIDE ........................................................................................................................ 81 

FRONT LINE WORKER (FLW) SUPERVISOR IDI GUIDE ......................................................................................................... 85 

APPENDIX C: ANALYSIS PLAN .......................................................................................................................... 89 

APPENDIX D: SAMPLE BLOCK CARD................................................................................................................. 91 

REFERENCES .................................................................................................................................................. 99 

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Nutrition
Stichwort	maternal health maternal nutrition program evaluation qualitative research india
Committee Chair / Thesis Advisor	Melissa Fox Young, PhD, Emory University

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