Factors Associated with Accessing ICDS Services among Women in Rural Rajasthan, India

Background: The Integrated Child Development Services (ICDS) Scheme, launched in 1975 by the Government of India, provides various health services to children and their mothers at ICDS centres. Objectives: The purpose of this study is to understand 1) the extent to which women living in Rajasthan, India utilize services provided by ICDS centres and 2) the factors that are associated with their use. Methods: Freedom from Hunger and Freedom from Hunger India Trust, in collaboration with two local partners in Rajasthan, India, conducted a baseline assessment with 403 pregnant women and women with young children belonging to self-help groups to compare use of ICDS centres with key demographic variables and measures of poverty, food security and nutrition, curative care related to diarrhea, coping strategies, and household decision-making. Results: The results revealed that households that accessed ICDS services were more likely to report receiving nutrition information from ICDS centres, to purchase ORS in the last year, and to give oral rehydration solution (ORS) to children who had diarrhea. Women who decide how much food to serve each family member or spend money without discussing it first with someone else were more likely to receive benefits from ICDS centres. Those who spoke with their spouse about household nutrition needs were less likely to report accessing ICDS services. Conclusion: Interventions aimed at increasing utilization of ICDS centres in this region may find it beneficial to increase female participation in health care decisions, likely through spousal communication and gender relations.


Introduction
Although India has experienced an increase in food grains accompanied by economic growth, child malnutrition continues to remain higher than in many African countries [1] [2]. This paradox has become known as the "India enigma" [2]. According to latest survey conducted by the Ministry of Women and Child Development, 38.7% of children in India were stunted, 29.4% were underweight, and 15.1% were wasted in 2013-2014 [3]. While the causes of malnutrition in India are complex and interconnected, they include food insecurity, gender inequality, early marriages, teen pregnancies, poor fetal nutrition, female illiteracy, poor breastfeeding practices, frequent infections, and inadequate health care [4].
In an effort to decrease rates of malnutrition, the government of India implemented three primary approaches aimed at increasing food access. These approaches include: 1) providing price controls on staple foods, 2) providing income support through food-for-work opportunities, and 3) providing nutrition supplementation for children. The Integrated Child Development Services (ICDS) Scheme, which was launched in 1975 by the government of India, is the largest of India's nutrition supplementation programs [1]. The ICDS Scheme provides the following services: supplementary nutrition, pre-school non-formal education, nutrition and health education, immunization, health check-up, and referral services. These services are provided at ICDS centres, which are locally known as Anganwadi centres [5].
Recent research has evaluated ICDS centres by their facilities, the knowledge possessed by their workers, or the effectiveness of specific services [1] [6] [7]. However, few studies have assessed the extent to which ICDS centre services are being utilized [8] [9]. Rao found that pregnant women living in ICDS areas were more likely to seek ante-natal care (50.2%) and immunizations (46.2%) compared to pregnant women who were not living in ICDS areas [8]. Chudasama et al. found that among participating ICDS centres, 61.7% had reported an interruption in the supply of nutrition supplements (in the last six months), 20% reported complete preschool education coverage, 10% had record of immunizing all children, 18.3% provided referral slips, and 8.3% actually referred sick children [9]. The purpose of this study is to understand 1) the extent to which women living in Rajasthan, India utilize services provided by ICDS centres and 2) the factors that are associated with utilizing these services.  is a cross-sectoral project designed to build on the existing women's self-help group (SHG) movement to supplement standard savings and agricultural livelihood activities with key nutrition-related interventions to reach at least 8000 SHG members and their households (an additional 28,000 family members) in Banswara and Sirohi.

Participant Selection
In May 2015, a sample of women was selected to participate in the 400 interviews planned for the baseline study. To be selected for participation, women had to meet the following criteria: 1) be SHG members from PRADAN or VAAGDHARA, 2) be in their second or third trimester of pregnancy or be mothers of children less than two years of age, and 3) live in Banswara or Sirohi district. The results of a census of all SHG members who fit the criteria revealed that 1394 women had children between 0 -2 years of age and 250 women were pregnant.
These numbers were used to determine the final distribution of interviews.
Specifically, it was decided that a simple, representative random sample would be applied, where 85% of the respondents would be mothers with children be-Health tween 0 -2 years of age and 15% would be women who were currently pregnant.
Consequently, 249 mothers and 48 pregnant women from Sirohi and 91 mothers and 12 pregnant women from Banswara were interviewed for the baseline study.
Respondents were notified of their selection to participate in the study by means of in-person introductions made between the research team and the field staff of VAAGDHARA and PRADAN.

Survey and Data Collection
The survey instrument was administered to 403 women, due to slight oversampling. The survey comprised questions covering several topics such as poverty, food security and nutrition, curative care related to diarrhea, coping strategies, and household decision-making. Poverty was measured using the India Progress out of Poverty Index ® (PPI) Scorecard [10]. Coping strategies were measured using the Coping Strategies Index (CSI) [11], which uses 13 variables to assess respondent's coping behaviors during a food shortage. Additional health questions were taken from the FFH Health Outcomes Performance Indicators project [12] and India's Demographic and Health Survey [13].
Use of ICDS centres was assessed using the following questions. First, the in-

Statistical Procedures
The International Poverty Line (IPL) $1.25/day, IPL $2.50/day, and National Tendulkar indices were each constructed using values from the PPI Scorecard.
Raw values were generated based on question responses, summed, and were then matched with probability ranges using PPI documentation [10]. While the IPL $1.25/day and $2.50/day represent households living under international poverty lines of $1.25/day and $2.50/day, the National Tendulkar represents households living under India's national poverty line.
Coping scores were computed using guidelines provided in the CSI [11]. Examples of coping behaviors assessed included relying on less preferred or expensive foods, borrowing food or relying on help from relatives, sending household members to beg, and limiting portion size at mealtimes. Participants were assigned a value of 1 if they indicated they had participated in the coping behavior and a value of 0 if they indicated they had not participated in the coping beha-

S. F. Davis et al. Health
vior. Scores were summed to generate an overall index score for coping strategies (0 = least number of coping behaviors used, 13 = most number of coping behaviors used). SAS (version 9.4) was used to conduct all statistical analyses. Descriptive statistics were computed to describe the study sample. Unadjusted and adjusted logistic regressions were run to describe potential factors associated with accessing ICDS services.

Discussion
The purpose of this study was to assess ICDS centre usage among women in rural Rajasthan and characteristics of households accessing these centres. Most of the decision-making variables assessed in this study were not significantly associated with ICDS service use. One exception was female involvement in health care decisions, which was positively associated with ICDS use. Predictors of female participation in household health care decisions include increased number of children, education, and age [17]. Increasing female participation in household health care decisions may be an efficient tactic to increase not only ICDS service use, but use of other health services. Research indicates that female participation in health care decisions influences participation in important health care services, including reproductive and prenatal care [18]. Addressing household decision-making patterns usually involves addressing gender norms [19]. While increasing numbers of interventions targeting harmful gender norms strive to involve men, research suggests that the most successful interventions to improve gender relations and decision-making norms still revolve around empowerment, including increasing access to educational and economic resources and reducing child marriage [19].
Another decision-making variable that was significantly associated with assessing ICDS services was speaking with spouse about household nutrition needs. Those who spoke with their spouse about these needs were less likely to report accessing ICDS services. One possible explanation for this finding is that women who discuss household nutrition needs are at a financial advantage . Perhaps due to con-Health flicting research, ICDS centres have faced major budget cuts, including a 7% reduction in 2016 [24]. As ICDS centres are one of the most prominent programs for improving childhood health in India [6], future studies of both access to and effectiveness of ICDS programs, especially in the face of major resource shortages, are important. This study should be interpreted within the context of a few limitations. First, the survey question measuring ICDS centre access asked participants whether they had accessed services over the past 12 months. This timeframe may overestimate or mischaracterize true use of ICDS centres. Further studies measuring ICDS use over time may be beneficial in order to accurately reflect use. Second, many decision-making questions, including inter-gender communication, were included in this study. The survey neglected to measure the role of other gatekeepers involved in decision-making, especially mothers-in-law, who are often involved in important household decisions. The results of this study may inaccurately reflect decision-making patterns among households in this region. Further study of third-party influences on decision-making may be of importance.

Conclusion
Our findings suggest that in rural Rajasthan, the majority of individuals access ICDS centres, especially supplementary food services. While supplementary food services can be effective in reducing childhood undernutrition, ICDS services in this region may consider increasing focus on other cost-effective and underutilized services, including breastfeeding education. Many hypothesized determinants of ICDS centre use in this study proved insignificant, the reasons for which are unclear. However, interventions aiming to increase utilization of ICDS centres in this region may find it beneficial to increase female participation in health care decisions, likely through improved spousal communication and gender relations.