“Work load has increased, but it is good for society. We cannot stop this”: Frontline worker perceptions and experiences delivering micronutrient powders in Bihar, India Open Access

Hoenig, Sarah (Spring 2019)

Permanent URL: https://etd.library.emory.edu/concern/etds/n009w336c?locale=en



Childhood malnutrition is a critical public health issue in India. In Bihar, it is estimated that over 50% of children under three are stunted, 33% are wasted, and 87% of children 6-35 months are anemic. These high levels of malnutrition can likely be attributed in part to poor infant and young child feeding practices. Use of micronutrient powders (MNPs) have been shown to improve nutrition status in children in many settings but not yet in Bihar.


This study took place in Bihar, India. Four health sub-centers (HSCs) were selected based on program performance level. A total of 12 qualitative interviews were conducted with frontline workers (FLWs). In-depth interviews were conducted with Auxiliary Nurse Midwives (n=4) from each HSC and focus group discussions (FGDs) were conducted with Accredited Social Health Activists (n=4) and Anganwadi Workers (n=4) from each HSC. Some key questions included, perceptions on importance of MNPs, role of FLWs, MNP distribution, and perceived community acceptability and utilization. Thematic qualitative data analysis was completed utilizing MAXQDA.


The main factors that influenced FLWs ability to implement MNPs were work environment, community understanding of MNPs, and supply and distribution of MNPs. The increased work burden of the MNP program and lack of compensation made it difficult for some FLWs to balance their home and work lives. Additionally, education of beneficiaries and misconceptions regarding MNPs made it challenging for FLWs to deliver MNPs in some households. Lastly, supply of MNPs was not a common issue but there were challenges related to MNP distribution. FLWs reported feeling motivated because their work was fulfilling and made a difference in their communities.


Key barriers and facilitators for FLW delivery of MNPs in Bihar were identified. Motivation was a central theme which was enhanced by community and personal perceptions of perceived benefits of MNPs. Inadequate compensation and challenges in delivering MNPs decreased FLW motivation. FLW delivery of MNPs in Bihar is a promising delivery platform, but future work should address the key challenges identified.

Table of Contents

Introduction and Background. 1

Global burden of childhood malnutrition. 1

Childhood malnutrition in India. 1

Childhood malnutrition in Bihar 2

Use of micronutrient powders (MNPs) to improve nutrition. 2

Frontline worker role in nutrition in Bihar 4

CARE India Family Health Initiative. 5

Rationale and Public Health Significance. 7

Methods. 8

Study Setting. 8

Study Population, Sample Size, and Data Collection. 8

Ethics. 9

Data Analysis. 9

Results. 11

Conceptual Framework Overview.. 11

Work Environment. 12

Community Understanding of MNPs. 15

Supply and Distribution of MNPs. 18

Discussion. 19

Summary of Findings. 19

Comparison to Existing Literature. 20

Strengths and Limitations. 22

Program gaps and Recommendations. 23

Future studies 24

Conclusion. 25

Appendices. 26

Appendix 1. Qualitative in-depth interview guide with ANMs 26

Appendix 2. Qualitative focus group discussion guide with FLWs. 30

Appendix 3. Analysis plan. 35

Appendix 4. Thematic quote matrix. 37

References. 41

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