Clinical Epidemiology and Global Health 12 (2021) 100815

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Clinical Epidemiology and Global Health

journal homepage: www.elsevier.com/locate/cegh

Assess the knowledge, utilization, level of satisfaction of utilization and

barriers of non-utilization regarding Integrated Child Development Services
(ICDS) among women of Ernakulam District, Kerala, India
Preethy Jawahar a, *, Sudha A. Raddi b
a
Dept. of Community Health Nursing, M.O.S.C. College of Nursing, Kolenchery, Kerala, India
b
Faculty of Nursing, KLEU Institute of Nursing Sciences, Belgaum, Karnataka, India

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: The integrated child development scheme (ICDS) was launched in 1975 to provide an integrated
Knowledge package of services to aid the holistic development of the child. The beneficiaries of this scheme are children
Utilization below the age of six, pregnant and lactating women in the age group of 15–45 years.
Satisfaction
Objectives: The objectives of the present study were to assess the knowledge, utilization, level of satisfaction of
Barriers
ICDS
utilization and barriers of non-utilization regarding Integrated Child Development Services (ICDS) among
Women women.
Methods: This study adopted a quantitative approach using a descriptive survey design. Convenience sampling
technique was used to collect data from 553 women between the age group of 18–45 years residing in Ernakulam
district, Kerala, India. Five tools were used to collect the data. The obtained data from 553 women entered in
data sheet using SPSS version 20 and was analyzed by using descriptive statistics.
Results: Majority women (68.5%) had average knowledge regarding ICDS services. Mothers who had under five
children utilized more ICDS services (90.5%) compared to pregnant women (48.7%) and lactating mothers
(27.2%). Majority women (75%) were highly satisfied with utilization of ICDS services. The first and foremost
barrier for non-utilization of ICDS services among women was lack of time due to work (60%).
Conclusion: The ICDS programme is a globally recognized community based programme, which addresses the
basic interrelated needs of young children and mothers, in a holistic manner.

1. Introduction development is a pre-requisite for economic development of any nation.

As per an Indian census conducted in 2011, there is approximately
India is home for the largest child population in the world. The 163.81 million children below the age of six out of which many doesn’t
development of children is the first priority of the country’s agenda, not still have access to proper health care, nutrition, sanitation, child care,
because they are the most vulnerable, but because they are our supreme early stimulation, etc.1
assets and also the future human resources of the country. As per the The integrated child development scheme was launched in 1975 to
Tenth Five Year Plan (2002–07), the future of India depends on the provide an integrated package of services to aid the holistic develop­
future of Indian child population. The first six years in a child’s life is ment of the child. The beneficiaries of this scheme are children below
crucial as the foundations for cognitive, social, emotional, physical, the age of six, pregnant and lactating women in the age group of 15–45
motor and psychological developments are laid during this stage. Child years. The aim of the scheme is to improve the nutritional and health
survival, growth and development can be achieved adequately through status of vulnerable groups by providing a package of services which
a holistic approach. Between education, health and nutrition, there is includes preschool education, immunization, supplementary nutrition,
necessity for a balanced link between education, health and nutrition, health checkup, referral services and health education. ICDS is a multi-
which is essential for the proper development of a child. It is now sectoral program and involves several government departments. The
globally acknowledged that investment in human resources ICDS services are coordinated at the village, block, district, state and

* Corresponding author.
E-mail address: [email protected] (P. Jawahar).

https://doi.org/10.1016/j.cegh.2021.100815
Received 3 May 2021; Received in revised form 7 June 2021; Accepted 14 June 2021
Available online 27 June 2021
2213-3984/© 2021 The Authors. Published by Elsevier B.V. on behalf of INDIACLEN. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
P. Jawahar and S.A. Raddi Clinical Epidemiology and Global Health 12 (2021) 100815

central government levels. These services are provided through com­ ICDS services. The content validity of the five tools were obtained by
munity based anganwadi centres.2 submitting the tools to 11 experts in the field of medicine and nursing.
A significant number of these children survive in an economic and Tools were translated to Malayalam and retranslated to English by a
social environment which hinders or delays the child’s physical and language expert. Structured interview schedule was used to collect the
mental development. The contributing factors include poverty, poor data. Pretesting of the tools were done by administering the tools to 5
environmental sanitation, diseases, infections, inadequate access to women to determine the clarity of the items, presence of ambiguous
primary health care, inappropriate child caring, feeding practices etc. terms, time required and the feasibility of the tools. Tools were
Fact is that these lives can be improved with better child care facilities. administered to 20 women to determine the reliability by test-retest
The main goal of ICDS program is to improve the nutrition and health method. The reliability co-efficient (r) value of tools were 0.92 (tool
status of children, antenatal women, postnatal mothers, other women 2), 0.96 (tool 3), 0.88 (tool 4) and 0.93 (tool 5) respectively.
and adolescent girls through direct intervention mechanism.4
Mother is a primary care provider and therefore her education and 2.5. Pilot study
access to information will help her in caring her infant. As children
constitute the most important and vulnerable segment of our popula­ Pilot study data was conducted to assess the feasibility and study was
tion, the mothers is the most important health worker as far as child found to be feasible.
health is concerned. The mothers play a major role in promoting the
health of children below the age of five and child care activities. Child 2.6. Data collection procedure
care includes knowledge regarding prevention of childhood diseases,
proper growth, development and basic needs of the children. The Main data collection was done among 553 women. Data was
mother is the key person in the family who promotes the child’s well- collected from February 1, 2017 to June 30, 2017. Administrative
being to prevent diseases. The mother will get information regarding permission from the concerned authorities was taken. Permission was
child care through health care professionals, family members, neigh­ obtained from Institutional Ethical Committee (IEC) and District Medi­
bors, and mass media.9 cal Officer, Ernakulam District. Written consent was taken from women.
The investigator noted that only a few number of children are
coming to the centre regularly and utilizing the services. It was noted 2.7. Details of data analysis
that ICDS services were not fully utilized by the mothers with children
below the age of five because of lack of knowledge on ICDS services. So The obtained data from 553 women entered in data sheet using SPSS
the investigator felt the need to assess the knowledge, utilization, level version 20 and data was analyzed for all the objectives by using
of satisfaction of utilization and barriers of non-utilization regarding descriptive statistics (Measures of frequency like frequency & percent­
ICDS among women. The improvement of knowledge related to ICDS age and Measures of central tendency like mean & standard deviation).
services will help the mothers to involve positively and utilize the ICDS Descriptive statistics was the useful method to summarize the survey
services adequately. The mother’s positive approach will bring healthier data and responses.
children to the nation. The strength of the nation depends on healthy
families and children who are destined to be successful citizens of 3. Results
tomorrow.12
3.1. Description of sample characteristics
2. Methods
As shown in Table 1, majority women i.e. 40.7% belonged to the age
2.1. Study design group of 26–30 years, all women were married (100%), majority women
(58.2%) were having diploma level of education, 58% women were
This study adopted a quantitative approach using a descriptive sur­ housewives, 72% women belonged to nuclear family and 53.7% women
vey design. were Christians.
As shown in Fig. 1, out of 553 women, 78 (14%) women were
2.2. Setting and Participants pregnant and remaining 475 (86%) were not pregnant. Out of 553
women, 66 (12%) were lactating mothers and remaining 487 (88%)
The study setting was women residing in Ernakulam district, Kerala, were not lactating mothers. Out of 553 women, 542 (98%) women had
India. Data was collected from 553 women between the age group of under five children. Remaining 11 (2%) women had no children and
18–45 years residing in Ernakulam district, Kerala, India. they were primigravidas. Women were mutually inclusive in all the
three groups (pregnant women, lactating mothers and women who had
2.3. Inclusion and exclusion criteria under five children).

Convenience sampling technique was used to collect data. Inclusion 3.2. Description of knowledge score of women regarding ICDS services
criteria were primi and multi gravida women, lactating mothers be­
tween 0 to 6 months, mothers who were having at least one living child The structured knowledge questionnaire regarding ICDS services was
below five years of age and between the age group of 18–45 years were administered to 553 women to assess their knowledge. The knowledge
included. Women who were not willing and not available during the scores were categorized as poor (1–10), average (11–20) and good
time of data collection and women who were not able to speak or un­ (21–30) based on arbitrary method. The maximum score was 30.
derstand Malayalam were excluded. As shown in Table 2, 28% women had good knowledge, 68.5%
women had average knowledge and 3.5% women had poor knowledge.
2.4. Data collection tools Out of a total score of 30, the mean and standard deviation of total
knowledge score were 18 and 4 respectively.
The tools used were Tool 1: Demographic proforma, Tool 2: Struc­
tured questionnaire to assess the knowledge on ICDS Services, Tool 3: 3.3. Description of utilization of ICDS services
Checklist to identify the utilization of ICDS services, Tool 4: Satisfaction
scale to find the level of satisfaction regarding the utilization of ICDS Data was collected from 553 women using a structured questionnaire
services and Tool 5: Checklist to assess the barriers of non-utilization on regarding utilization of ICDS services. As shown in Fig. 2, among

2
P. Jawahar and S.A. Raddi Clinical Epidemiology and Global Health 12 (2021) 100815

Table 1 Result of item analysis showed that, among pregnant women, 44%
Description of sample characteristics of women in terms of frequency and per­ utilized supplementary nutrition from the anganwadi centres, 25%
centage (n = 553). pregnant women utilized health and nutrition education from the
SI. No Socio-demographic variables Frequency (f) Percentage (%) anganwadi centres, 100% pregnant women utilized TT immunization
1 Age in years
from the government centres and private hospitals and none from the
18–25 97 17.50 anganwadi centres, 15% pregnant women utilized health checkup from
26–30 225 40.70 the anganwadi centres, 5% pregnant women utilized referral services
31–35 188 34.00 from the anganwadi centres and 7% pregnant women utilized iron and
36–40 43 07.80
folic acid tablets given from the anganwadi centres. Among lactating
41–45 00 00.00
mothers, 10% utilized supplementary nutrition from the anganwadi
2 Marital status centres, 43% lactating mothers utilized health and nutrition education
Married 553 100
from the anganwadi centres, 4% lactating mothers utilized health
3 Education checkup and referral services (weight checking) from the anganwadi
Upto 9th standard 49 08.80
centres. Among mothers who had under five children utilized 80%
SSLC 16 02.80
Plus Two 12 02.10 supplementary nutrition from the anganwadi centres, 76% mothers who
Diploma 322 58.20 had under five children utilized non formal education from the angan­
Graduate 98 17.70 wadi centres, all children (100%) were immunized up to the age and
Post graduate and above 56 10.40 immunizations were taken from government centres or private hospi­
4 Occupation tals. 78% mothers who had under five children utilized pulse polio and
House wife 321 58.00 vitamin A immunizations from the anganwadi centres, 65% mothers
Coolie worker 13 02.35
who had under five children utilized health checkup (height and weight
Unprofessional 109 19.70
Professional 106 19.10 checking) from anganwadi centres.
Student 04 00.85

5 Type of family 3.4. Level of satisfaction in utilization regarding ICDS services

Nuclear 398 72.00
Joint 155 28.00
Out of 553 women, 498 utilized atleast one service from the ICDS
6 Religion and 55 did not utilize any service from ICDS. By using satisfaction scale,
Christians 297 53.70 data related to level of satisfaction of utilization regarding ICDS services
Hindus 242 43.90
Muslims 14 02.40
Table 2
Frequency and percentage distribution, mean and standard deviation (SD) of
pregnant women utilized 48.7% ICDS services from the anganwadi, total knowledge score (n = 553).
lactating mothers utilized 27.2% ICDS services from the anganwadi and SI. Knowledge Range of Frequency Percentage Mean SD
mothers who had under five children utilized 90.5% ICDS services from No category score (f) (%)
the anganwadi. Mothers who had under five children utilized more ICDS 1 Poor 1–10 19 03.50
services (90.5%) compared to pregnant women (48.7%) and lactating 2 Average 11–20 379 68.50 18 4
mothers (27.2%). 3 Good 21–30 155 28.00

Fig. 1. Bar graph showing percentage distribution of women based on type of beneficiaries (n = 553).

3
P. Jawahar and S.A. Raddi Clinical Epidemiology and Global Health 12 (2021) 100815

Fig. 2. Bar graph showing the percentage of utilization of ICDS services by women (n = 553).

were collected from 498 women who utilized any one of the ICDS ser­ communication by anganwadi workers (45%), behavior of anganwadi
vices from the anganwadi centres. It is evident from Table 3 that, ma­ workers were not good (33%), distance from anganwadi to home (32%),
jority of women (75%) were highly satisfied with the utilization of ICDS lack of knowledge (24%), family members were not interested to avail
services from the anganwadi centres. anganwadi services (12%). Notion that the services are meant for the
Result of item analysis showed that, majority women were satisfied poor (10%) and anganwadi workers never organize meetings regularly
with the facilities and infrastructure available in the anganwadi. 75% (2%).
women were highly satisfied with the quality of the food supplied
through the anganwadi, 85% women were highly satisfied with pre­ 4. Discussion
school education given to children between 3 to 6 years, 60% women
were highly satisfied with the health checkup, referral services and The present study revealed that 28% women had good knowledge,
growth monitoring services provided in the anganwadi, 56% women 68.5% women had average knowledge and 3.4% women had poor
were highly satisfied with the immunization services provided by the knowledge. Mothers who had under five children utilized more ICDS
anganwadi workers, 88% women were highly satisfied with the clean­ services (90.5%) compared to pregnant women (48.7%) and lactating
liness of the anganwadi, 81% women were highly satisfied with the mothers (27.2%). 75% women were highly satisfied with utilization of
knowledge, skill and expertise of the anganwadi workers, 66% women ICDS services from the AWC and 25% women were satisfied with the
were highly satisfied with attitude of the anganwadi workers, 82% utilization of ICDS services from the AWC. The barriers for non-
women were highly satisfied with the behaviour of the anganwadi utilization of ICDS services included not being able to spare much
workers and 90% women were highly satisfied with the timings of time due to work (60%), lack of proper communication by anganwadi
anganwadi workers. workers (45%) and unacceptable behavior of anganwadi workers (33%).
The present study finding is parallel to the findings of Kumar D et al.4
Low levels of awareness regarding TT immunization (74.2%),
3.5. Barriers of non-utilization of ICDS services
five-cleans (31.9%), post-natal care (75.4%) among lactating mothers.
Knowledge regarding optimal infant and young child feeding practices
Out of 553 women, 55 women did not utilize any of the ICDS services
was poor. Initiation of breast-feeding within six hours (17.4%), colos­
from the anganwadi and their barriers of non-utilization regarding ICDS
trum feeding (34.8%) and exclusive breastfeeding (5.8%). High levels of
services was assessed using a checklist. The barriers for non-utilization
awareness regarding reproductive health parameters (81.6%), legal ages
of ICDS services by the women from the anganwadi included that they
at marriages for girls (84.5%), desired birth interval of three or more
were not able to spare much time due to work (60%), no proper
years (71.7%).4
The present study finding is similar to the findings of Chudasama RK
Table 3
et al.11 Results showed that majority of pregnant (94.7%) and lactating
Frequency and percentage distribution, mean and standard deviation (SD) of
(74.4%) mothers were availing ICDS services.11 The present study
satisfaction score (n = 498).
finding is in line to the findings of Lal S.13 Health checkup utilized by
SI. Categories of Range of Frequency Percentage Mean SD
children less than 5 years increased from 28.2% to 92% and those of
No satisfaction score (f) (%)
pregnant and lactating mothers increased from 18.7% to 38%. Supple­
1 Extremely 20–39 0 0 mentary nutrition utilized by children less than 5 years of age increased
dissatisfied
2 Dissatisfied 40–59 0 0 86 5
from 8% to 50% and that of pregnant and lactating mothers increased
3 Satisfied 60–79 124 25 from 0% to 25%. Immunization utilized by pregnant mothers increased
4 Highly 80–100 374 75 from 1% to 50%.13
satisfied The finding from the present study is not parallel to the findings of

4
P. Jawahar and S.A. Raddi Clinical Epidemiology and Global Health 12 (2021) 100815

Davey A et al.7 52.5% mothers were dissatisfied with the services pro­ Declaration
vided from the AWC for one or more reason. The most common reasons
for dissatisfaction were poor accessibility of the AWC, cramped space at Ethical approval
the AWC (68.6%), poor quality of the food distributed (66.7%) and
irregular preschool education (57.1%) from AWCs.7 The present study Obtained.
findings found no similarity with the work of Chattopadhyay D.8 The
Result showed that mothers were dissatisfied with the services provided
from the AWC.8 Funding
The work of Davey A et al.7 confirmed the present study findings.
Most of the barriers mentioned was the not easy accessibility of the AWC This research did not receive any specific grant from funding
and less space available at the AWC (68.6%), followed by the poor agencies.
quality of the food distributed (66.7%) and irregular preschool educa­
tion (57.1%) from AWCs.7 The present study finding is similar to the
findings of Kapil V et al.10 The major reasons for not utilizing ICDS Conflict of interest
services reported by mothers were the difficulties in carrying the child to
the anganwadi centres and inadequate contact of the anganwadi Authors declare that there is no conflict of interest.
workers with the mother.10
Acknowledgement
5. Conclusion
None.
The Integrated Child Development Scheme is a globally recognized
community programme based on early child care which addresses the References
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