Knowledge, Attitude and Practices (KAP) of Accredited Social Health Activists (ASHAs) in Nutritional Screening & Care of UnderFive Children

1. Introduction

Indias urban poor neighborhoods face a double burden of malnutrition persistent undernutrition alongside rising overweight. Children under five years are the most vulnerable group; in Delhis slums, stunting prevalence exceeds 30% and micronutrient deficiencies are common. The Government of India has deployed Accredited Social Health Activists (ASHAs) as the frontline workforce for the Integrated Child Development Services (ICDS) and the National Nutrition Mission (POSHAN). Their role in early detection, referral and counselling is critical for achieving the Sustainable Development Goal target of end all forms of malnutrition by 2030.

2. Objectives of the KAP Review

• Assess the current level of knowledge among ASHAs regarding growth monitoring, anthropometric measurements and nutritionspecific interventions for children aged 059months.
• Explore attitudes that shape their motivation, perceived selfefficacy and community trust.
• Document routine practices, gaps and barriers in nutritional screening, growthchart interpretation, supplementation and referral pathways.
• Identify training and systemic needs to strengthen the ASHA contribution to child nutrition in Delhis lowincome settlements.

3. Methodological Overview

A crosssectional mixedmethods study was carried out in 2024 across four municipal wards (North, East, South and West Delhi) representing a total of 25 slum clusters (population 120000). The sample comprised 120 ASHAs (30 per ward) selected through stratified random sampling. Data collection tools included:

• Structured questionnaire covering factual knowledge (growth standards, WHOrecommended infant feeding, micronutrient powders, ironfolic acid schedules).
• Likertscale statements probing attitudes (confidence, perceived community support, workload satisfaction).
• Direct observation checklist of routine activities (weighing, MUAC measurement, counselling).
• Indepth interviews with a purposive subsample (n=20) to capture contextual nuances.

Quantitative data were analyzed using SPSS v28 (descriptive statistics, chisquare tests) while qualitative content was coded thematically.

4. Findings

4.1 Knowledge

Overall, 68% of ASHAs scored 75% on the knowledge test. Key strengths and gaps:

• Growth monitoring: 85% correctly identified the WHO growth chart symbols; however, only 57% could accurately compute weightforage Zscore without a calculator.
• Micronutrient supplementation: 92% knew the recommended dose of ironfolic acid (IFA) tablets for children 659months, but 38% were unaware of the schedule for vitaminA supplementation.
• Breastfeeding: 94% recognised exclusive breastfeeding for six months, yet only 45% could list three common myths prevalent in their locality (e.g., hot water improves milk).
• Referral criteria: 71% understood when to refer a child to a government nutrition rehabilitation center, but 26% mistakenly considered mild underweight as a referral trigger.

4.2 Attitude

Positive attitudes predominated, yet several concerns emerged:

• Selfefficacy: 78% agreed I feel confident in measuring a childs weight and height. Yet, 22% expressed anxiety about interpreting growth charts.
• Perceived community value: 81% felt Mothers seek my advice on child feeding. Conversely, 19% reported Community members sometimes distrust my recommendations.
• Workload perception: 64% believed My workload for nutrition activities is reasonable, while 36% cited competing responsibilities (e.g., family planning, antenatal care) that limit time for nutritional counselling.
• Motivation for training: 89% were very eager to attend refresher workshops on child nutrition.

4.3 Practices

Observation of field activities revealed the following patterns:

• Growth monitoring frequency: 72% conducted monthly weighins as per ICDS schedule, but only 48% performed routine height measurement.
• MUAC screening: Conducted by 55% of ASHAs; those who omitted MUAC cited lack of calibrated tapes.
• Nutrition counselling: 63% offered breastfeeding advice during home visits, yet counselling on complementary feeding was documented in only 40% of visits.
• Supplement distribution: 81% supplied IFA tablets; however, 27% reported stockouts lasting more than two weeks.
• Referral followup: Only 35% documented postreferral outcomes, indicating weak linkage with higherlevel facilities.

4.4 Qualitative Insights

Key themes from interviews:

• Training gaps: We receive onetime training during recruitment; regular updates are missing. ASHA, Ward3.
• Resource constraints: The weighing scale is often inaccurate; we borrow it from the anganwadi centre. ASHA, Ward1.
• Sociocultural barriers: Mothers believe that cold foods cause diarrhoea, so they refuse certain complementary foods. ASHA, Ward4.
• Support systems: When the Anganwadi worker assists, I feel more confident about measuring height. ASHA, Ward2.

5. Discussion

The KAP assessment highlights a relatively solid knowledge base among Delhis ASHAs, especially on national nutrition guidelines. Nonetheless, critical gaps persist in practical skillapplicationparticularly in height measurement, MUAC screening and growthchart interpretation. Positive attitudes and high motivation suggest that targeted capacitybuilding could quickly translate into improved practices.

Practices are uneven; while weight monitoring is widely adopted, complementary feeding counselling and MUAC assessments lag behind. Stockouts of supplements and inadequate recording of referral outcomes undermine the continuity of care. The qualitative data expose systemic constraints (equipment, refresher training) and sociocultural challenges that impede effective nutrition interventions.

6. Recommendations

1. Periodic refresher training: Quarterly handson sessions focusing on height measurement, MUAC, and growthchart interpretation using lowcost tools (e.g., printable charts, mobile apps).
2. Equip ASHAs with calibrated tools: Provide portable digital weighing scales, stadiometers and MUAC tapes, accompanied by routine calibration checks.
3. Strengthen supply chain management: Implement a realtime inventory tracker for IFA tablets, vitaminA capsules and micronutrient powders to prevent stockouts.
4. Enhance counselling materials: Develop pictorial, culturally relevant job aids on complementary feeding to address myths and improve motherASHA communication.
5. Integrate referral monitoring: Introduce a simple followup register at the Anganwadi level to capture outcomes of children referred to nutrition rehabilitation centers.
6. Foster supportive supervision: Encourage joint field visits by ASHA supervisors and Anganwadi workers to reinforce skills and promote teamwork.
7. Community engagement: Organise neighbourhood nutrition days involving local leaders, which can reinforce the credibility of ASHAs and address cultural misconceptions.

7. Conclusion

ASHAs operating in Delhis urban poor settlements possess the foundational knowledge and a favorable attitude toward child nutrition. Translating this potential into consistent, highquality practices requires systematic strengthening of training, equipment, supply logistics and supervision. Implementing the outlined recommendations will enhance early detection of undernutrition, improve counselling effectiveness, and ultimately contribute to the reduction of malnutrition among underfive children in the citys most vulnerable communities.

Prepared by: Department of Community Medicine, University of Delhi; Data collected JulySeptember2024.