SUGAM Project Qualitative Evaluation
SCAD & SOTE
Tuesday 2nd June – Friday 5th June 2015
SCAD and SOTE staff have carried out qualitative research to identify how the SUGAM Nutrition
pilot project has been progressing towards its aims and objectives over the last 12 months.
Planning for the focus groups was carried out by the SUGAM team’s Ms Thirumalaiselvi and Ms
Manimala, SCAD Monitoring Information Systems staff Mr Aruldurai, representatives from SOTE Kate
Hartley and Anne Walker and SCAD Senior Management Mr Naga and Dr Kannan over the course of 2
days. 9 key topics linked to the project aims, objectives and inputs were identified and within each topic
area approximately 6 questions with sub-questions were decided upon. The aim was to create a neutral
unbiased environment without leading questions where mothers could freely share their honest
thoughts.
14 focus group discussions were held from 7 pilot villages (coastal, saltpan and agricultural) involving
81 women aged between 18 and 38.
3 one-to-one interviews were held with a Panchayat leader, Anganwadi Worker (AWW) and the
husband of a project beneficiary.
1 large group discussion was held with all 20 Village Nutrition Activists.
The interviews were facilitated by Mr Aruldurai, (SCAD MIS staff), Anne Walker (SOTE trustee) and
Kate Hartley (SOTE Development Manager). There were SUGAM project staff present for the first 4
focus group discussions.
We fully acknowledge that the information collected is limited in that it only includes the views of
mothers who were able and willing to attend these meetings.
The full English transcript of 7,400 words was typed up and each paragraph coded according to the
project aims and objectives. A summary of the information gleaned from our discussions and interviews
is as follows.
Aims:
IMPROVE CHILD GROWTH
Mothers stated that they had come to know about their child’s weight and height only after the
initiation of the project. Mothers could clearly explain why measurements were taken. Mothers
identified a link between the nutrition mix and increased weight gain and growth. Some women stated
the exact weight increase over the course of the project and others used the WHO colour band to
describe changes. 4 out of 5 mothers who were asked could tell us their child’s weight.
Outcomes of child growth identified were a reduction in sickness and increased strength. One mother
used the example of her young son now being able to carry stones outside the house. Mothers say that
their children are more active and have better concentration. Mothers are happy for measurements to
be taken because “we have come to learn about weight of our child”. All groups identified some form of
weight gain in their children.
INCREASE MOTHER’S WEIGHT
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Before the project started women said that they only knew their weight during pregnancy. Now women
said that they have learnt what their weight is. 4 out of 5 women asked could tell us their weight.
However, they do not know what their weight should be. They identified increased weight gain linked
to consumption of the nutrimix. Women identified training and change in diet as having an impact on
their weight.
“I keep attending the training and my weight has gone from 35kg to 42kg, this is all because of the
project.”
One woman identified that she has to gain weight to keep herself healthy in order to keep her child
healthy.
Objectives:
IMPROVE FEEDING PRACTICES
Mothers could clearly state the items they were supposed to eat on a daily basis, which included
vegetables, fruit, egg, millets, dhal and chicken. They also identified that they were supposed to drink
more water. One woman said that her child had now adopted this and takes water to their cow too.
Groups said that their change in diet had a knock-on effect on others; one woman shared that her sister
has changed her child’s diet as a result of seeing increased weight gain.
Fishing restrictions for 45 days in coastal villages are having an impact on consumption of fish and
mothers said that often there is no fish which means they struggle financially. In this coastal village
women said that they used to have a largely fish only diet (when fish was available) but now they eat
more vegetables and they eat dhal twice a week. “We changed our diet because we were not much aware
of these things before”. “I am not strong because in the past we didn’t know about these things but I want
our children to learn these things.”
All women said that family members were supportive of a change of diet. The husband interviewed said
the change he had noticed was that his wife was eating more vegetables and identified beans and
carrots.
When asked, women were able to describe the main ingredients included in the mix, as well as a few
others that are not present. Recipe demonstrations by VINAs were identified as being key to being able
to prepare a variety of dishes in order to find something that the children liked.
All women could confidently explain exactly who the mix should be consumed by and how frequently.
Mothers said that VINAs would ask them who was taking the mix, make sure they were not giving away
the mix and enquire about how often it was taken. One group said that “they would shout at them if
they were not taking it”. Other family members approve of the mix. One woman’s husband sometimes
has it when he gets in from work and is tired. Another woman’s five year old demands it. Two women
from different groups said that their children got diarrhoea when they started taking the mix but that
on the advice of the VINAs they kept taking it and it cleared up. Women state that with the government
mix children do not consume all of it because of the taste but with the SCAD mix child consume a higher
quantity. They identified increased immunity (“immunization power”) as a result of the nutrimix. One
group shared that they have reduced buying snacks for the children and instead prepare the mix. One
agricultural village said that they wanted to visit the nutrimix unit to see how the mix is made.
A number of groups mentioned the kitchen garden seeds given for free that have been very useful. One
woman said that she got 2kg of bitter gourd. One group were asked if they sell or eat the vegetables and
they all eat the vegetables and share them with extended family. Several women were growing
vegetables in pots, including greens. A number of women identified space as an issue for growing
vegetables and also the climate.
Women mentioned their own and their child’s growth as an outcome of the change in feeding practices,
and increased concentration and strength were also mentioned.
The groups that were asked about breast-feeding were clearly able to define the Tamil equivalent for
the terms colostrum and exclusive breast-feeding. They were able to say what correct breast-feeding
and complementary feeding practice was and said that they followed this. They learnt about breastfeeding from project staff, doctors and TV advertisements. One group said that their breast-feeding
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practice had not changed since the project. One group wanted to know why some mothers do not
produce milk.
IMPROVE ACCESS TO GOVERNMENT SERVICES
Mothers were able to describe two main government schemes relevant to pregnancy and childbirth.
They were able to state the amount and intervals of payment but did not know the names of these
schemes.
Mothers were able to tell us about the services the government provided and how often particular
services should be accessed, such as immunizations. If mothers skipped the immunizations they said
that VINAs reminded them. They could identify the government nurse, what her role was and they were
happy with the support she is providing. In one group three mothers attended training at the Primary
Health Centre (PHC) but did not find this useful.
Mothers in one agricultural village said that a government doctor came once a month but that he did
not have enough tablets and medication. They asked for a doctor to be provided as part of the project.
VINAs have been identified as assisting the government workers in administering polio drops and
pregnancy referrals. The VINAs’ role in helping with health camps were mentioned by two groups. The
Anganwadi Worker (AWW) we interviewed said that the VINAs were assisting her in delivering polio
drops, holding the medical camps and AWC weight collection.
Problems were identified with the government mix such as the taste and the comparison with the SCAD
mix. Access to this mix was also an issue because of: distance, heat, children being scared of the
Anganwadi centre. One group also said that the government were distributing 1kg of mix per week per
child and said that as she has two children they cannot consume all of this so they eat it as a family.
Mothers said that they were previously unaware of the nutrients in the government nutrition mix.
One woman said she was being helped to get her residency permit by the VINAs. Another woman
mentioned VINAs helping to get a ration card.
Open defecation prevailed in one agricultural village and villagers stated that the government scheme
did not provide enough money for a toilet to be built. The public toilets in their village provided by the
government were not being maintained and used properly.
VINAs shared that they were accompanying pregnant women to government hospitals for delivery and
spending time with siblings during delivery. VINAs also said that they were guiding families on how to
approach government officials. One VINA has been instrumental in initiating the construction of 48
individual toilets with the help of the government in her village since the project started. VINAs said
that they are providing a service to the community for free that government doctors reportedly take a
bribe for. VINAs report that they have a positive relationship with government workers. “They are
friendly. We invite them to our meetings and they invite us to theirs. The AWWs are helping the VINAs.”
IMPROVE WATER SANITATION AND HYGIENE (WASH) IN VILLAGES
All women could confidently say what they were supposed to wash their hands with and when. Many
identified this as the most important thing they have learnt.
They also frequently commented on how they are supposed to keep themselves, their children, their
homes and their vessels (pots, dishes etc) clean in order to reduce sickness. Many women say this has
now become a habit: “As soon as I get out of bed I ask my children to wash and brush their teeth and
now they do it automatically.”
“Before the project started I used to go to hospital almost once in a month to treat my children for
sickness, I have three children. I don’t approach hospitals since the project started because of solutions
that are provided by the VINAs. Like boiling water before drinking, nutrimix, avoiding stagnant water
and herbal medicines”.
Women said that their children were kept entertained while washing their hands through the Happy
Birthday song and now even when water is not available children ask for it. One group told us that they
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have to wash their hands for 20 seconds. When asked about how the project was helping the
community, one group said that they were not aware of hand washing before the project. They said that
cleanliness has improved. Others mentioned that they now notice other people washing their hands and
looking neater. One group said that they try to tell these things to others but that many do not listen.
One group said that “cleanliness has brought a healthy life”. VINAs reported that they never saw people
in the community wash their hands properly before the project started. They themselves did not know
the importance of this.
When asked if they considered sanitation and hygiene important one group said: “We strongly believe
that sanitation and hygiene are important. If children are cared for properly they will not fall sick. If
there is no sickness then there won’t be mental and physical illness.”
Women identified a link between dirty water and diarrhoea in young children.
It was mentioned by a number of groups that they now take a bath twice a day.
A change in children’s toilet practice was described by many mothers. Previously they said that they
were not bothered about their child going to the toilet and now they teach them how to use it. For
Meenavan Colony (a tsunami reconstruction village) all families have toilets and they said that
previously they let their children open defecate but now they teach them to go to the toilet. One group
said that for babies they use a basin.
Changes in toilet practice for women was not mentioned by many groups and one agricultural group
explained the hardship in open defecation but that they were not able to construct their own toilet.
They said that sometimes they don’t eat so they don’t have to go to the toilet too often, especially during
the rainy season.
The VINAs shared that one village with government built public toilets have encouraged the village to
make use of this and asked the village leaders to do something. Other villages with public toilets have
not taken any steps to improve their condition and encourage the community to use them.
All of the women that were asked now use soap. The soap given as part of the project has finished but
they buy it; they mentioned the price and brands.
A number of groups mentioned that they should reduce stagnant water to get rid of dengue fever.
VINAs reported that if they were able to help more families build toilets then there would be even more
support from the mothers.
Project Outputs:
1. VINAs recruited and given training on nutrition, health and hygiene
VINAs are very active and engaged in the project, which came through the discussions with
mothers and VINAs themselves. Their level of knowledge is good and they could clearly define
what their roles are and the importance of their unique placement in the village. Respect in the
community for the VINAs is very high. The VINAs struggled at first to win over the community
but have made huge steps in combating and improving this. The VINAs have changed their
practice as a result of their gained knowledge. The majority of VINAs stated that increased
awareness in the community was having the single biggest impact on changing things.
2. Anganwadi workers given training on nutrition, health and hygiene
VINAs are checking the AW toilets to make sure they are maintained and clean. They are
working closely with AWWs. (data on training from MPRs)
3. Nutrimix produced and distributed to target beneficiaries
All feedback on the nutrimix was good. Majority of mothers said that their children and
themselves liked the mix. Two groups said that they preferred the original sweeter mix. VINAs
reported that mothers requested more mix. One VINA reported that a mother was receiving the
nutrimix but her husband told her not to take it. She continued to collect it secretly and her
husband found out and scolded her and now she has asked the VINAs not to deliver.
4. Training to community and target beneficiaries on nutrition, health and WASH
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Feedback on training was excellent. Mothers enjoyed it and found it very interesting. One said
that she was longing for the next training. They were clearly able to demonstrate their learning.
One mother said “I have completed 9th standard education but I never knew about these things.
I really learn a lot from the training and the demonstrations. We keep learning and practicing
and we keep our promises.” VINAs said that if they had ID cards it would help their standing in
the wider community.
5. Educating community to access government services
Mothers were aware of their government services despite not knowing the names of two
schemes. They are supported and encouraged to access immunizations etc by the VINAs. There
was negative feedback on the government nutrimix and the challenges they face in getting their
children to eat this. Many women knew about the government services prior to the project.
6. Nutrition camps and demonstrations held
All mothers were positive about the nutrition demonstrations. All groups were able to list some
of the preparations they have learnt. Mothers said that the recipes meant that children’s
consumption of nutrimix was higher. VINAs suggested that the frequency of these be reduced in
order to not demand too much of mothers.
7. Meetings held with government officials and frontline health workers
The relationship between VINAs and the AWW appeared positive and she felt supported by the
VINAs. The AWW said that the VINAs meet her once a month. VINAs were very positive about
this and have clearly been able to make good progress in accessing government services for
their community.
8. Meetings held with Panchayat leaders and village key persons
Interview with a Panchayat leader showed strong support for the project.
9. Referrals to institutions for additional care (primary health centres & government
hospitals)
(data from MPR)
10. Targeted house visits by VINAs
The frequent visits of the VINAs were identified as crucial in making sure that knowledge turns
into practice. All mothers were satisfied with the frequency of the visits, that varied between
once a day to once in two weeks. One group showed concern over the VINAs’ families as the
VINAs were spending a lot of time working. The feeling that mothers had towards their VINAs
was very positive.
11. Kitchen gardens
Some mothers found these useful and were making use of them; others do not have space.
12. Village social mapping
(No information collected on this)
13. Nutrition care and counselling sessions (NCCS) held over 6 consecutive days for targeted
mothers and children
Mothers said that they were not able to attend all of this; they said that it would spoil their
work. They said it was a repetition of other training and two or three days would be enough.
Others felt that mothers of SAM and MAM children should get targeted training. Most VINAs
said that two days would be enough for this. One coastal village (Meenavan Colony) said they
would like three days.
14. Mothers calendar for tracking and engagement
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Mothers asked said they found the calendar useful and were able to check their weight and
height. (More feedback needed on this from VINAs). One group requested that copies of the
handbook are given to each mother.
15. Medical camps held in partnership with local medical institutions
A couple of groups and the AWW mentioned the camp but no real feedback was given on this.
16. Quarterly measurements of mothers and children
Mothers and the one husband said that they were comfortable with measurements being taken
and that they previously were unaware of their own weight and their children’s. VINAs said that
when the government do take measurements they do not feed this information back to mothers.
VINAs would like to give prizes to children to reward and encourage weight gain.
17. Visit to the villages and meetings by Nutrition Management staff
Mothers were very respectful and appreciative of ‘Madam’ the nutrition Manager, Ms Thiru.
VINAs said that visits by Ms Thiru were between two to four times a month during training,
measurements and distribution and that she often does surprise visits. This was sufficient. They
said that she was often late when she came on a bike and that mothers would get impatient if
they had to wait. VINAs suggested that she has a vehicle. One VINA said that after one child died
Ms Thiru came to be with the child’s parents and was supporting them. One VINA said that
when she called about a very sick child Ms Thiru came three days later to see the child.
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