Description of Study Sample
Table 1 presents the demographic and socioeconomic characteristics of the household and the mothers. From Table 2, the percentage of households reporting ASHA home visits was lower than that of AWWs or other CHWs in all four states and was lowest in AP (4.72%). Only in Odisha did the percentage of households receiving ASHA home visits reach 24.50%. AP had the highest rate of AWW and other CHW home visits (53.94% and 54.00%, respectively) compared to other states. Home visits conducted by AWWs were more common than other types of health care workers in all four states, with percentages from 31.20% to 53.94%. However, the percentage of no CHW visits was also high, ranging from 34.19% to 51.65%.
For the seven health outcomes assessed in this study, the adoption rates of practices varied by state. Overall, more than 50% of mothers achieved four out of the seven health outcomes, with the lowest adoption rate for complete immunization (7.78%) (Table 2). Among the health outcomes, institutional delivery was the second most adopted outcome overall (70.75%), being particularly high in AP (94.39%). AP also had the highest rate of exclusive breastfeeding for the first six months (73.54%), continued breastfeeding during the child’s illness (77.83%), and awareness of NHDs (63.44%). Chhattisgarh had the highest rate of adopting timely complementary feeding (85.38%), and UP had the highest rate of handwashing (80.73%).
Table 1. Mother and Household Demographics, Overall and in Four Statesa
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Overall
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Andhra Pradesh
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Chhattisgarh
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Odisha
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Uttar Pradesh
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House typeb
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Kuchcha
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1617 (48.56)
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140 (14.74)
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497 (62.61)
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655 (73.99)
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325 (40.19)
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Semi-Pucca
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1117 (31.37)
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73 (49.43)
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190 (23.2)
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96 (10.72)
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358 (44.58)
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Pucca
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720 (30.06)
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337 (35.83)
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122 (14.19)
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136 (15.29)
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125 (15.23)
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Region
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Urban
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531 (14.63)
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234 (24.15)
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104 (12.12)
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60 (6.97)
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133 (16.1)
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Rural
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937 (26.87)
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252 (26.77)
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352 (44.61)
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254 (25.8)
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79 (10)
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Tribal
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1987 (58.5)
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464 (49.08)
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353 (43.27)
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573 (67.24)
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597 (73.9)
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Caste/Tribe
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Scheduled Tribe
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886 (20.72)
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138 (17.48)
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297 (39.56)
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446 (53.21)
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5 (0.88)
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Scheduled Caste
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665 (20.98)
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160 (20.69)
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115 (14.1)
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118 (13.85)
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272 (38.06)
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Other Backward Caste
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1364 (42.06)
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433 (53.94)
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305 (39.56)
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285 (30.22)
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341 (48.19)
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Other Caste
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241 (7.24)
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70 (7.89)
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56 (6.781)
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25 (2.71)
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90 (12.87)
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Sex of Index Child
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|
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Male
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1743 (50.39)
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514 (54.35)
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408 (49.67)
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413 (47.04)
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408 (50.86)
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Female
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1712 (49.61)
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436 (45.65)
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401 (50.33)
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474 (52.96)
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401 (49.14)
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Care Ratioc
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1.11±0.01
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0.77±0.02
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1.19±0.03
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1.18±0.02
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1.30±0.03
|
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(N=3323)
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(N=848)
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(N=802)
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(N=885)
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(N=788)
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Household Size
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5.06±0.07
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3.28±0.05
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5.87±0.08
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5.22±0.06
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5.80±0.07
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(N=3454)
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(N=950)
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(N=809)
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(N=887)
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(N=808)
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Religion of the Head of the Household
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Hindu
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3705 (89.2)
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840 (88.43)
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648 (80.74)
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856 (96.51)
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731 (90.37)
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Muslim
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126 (3.51)
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26 (2.65)
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26 (2.68)
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0
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74 (9.25)
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Tribal
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136 (4.17)
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15 (1.75)
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112 (13.9)
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9 (1.26)
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0
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Others
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117 (3.12)
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69 (7.17)
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23 (2.68)
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22 (2.23)
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3 (0.39)
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Highest Education Completed by any Adult in the Householdd
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|
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None
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1161 (26.06)
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267 (28.99)
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150 (18.37)
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257 (30.5)
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208 (25.87)
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1-4 years
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157 (4.72)
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20 (2.13)
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39 (4.78)
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81 (9.33)
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17 (2.10)
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5-10 years
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1684 (48.79)
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425 (44.55)
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437 (54.38)
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412 (45.91)
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410 (50.69)
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11-12 years
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340 (9.57)
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100 (10.06)
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97 (12.09)
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61 (6.34)
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82 (10.14)
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13+ years
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392 (10.87)
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138 (14.26)
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86 (10.38)
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76 (7.92)
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92 (11.21)
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Age of Mother
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25.32±0.09
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24.12±0.10
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24.59±0.14
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25.97±0.15
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26.55±0.15
|
|
(N=3455)
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(N=950)
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(N=809)
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(N=887)
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(N=809)
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Mother’s Paid Employment Statuse
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|
|
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No
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1653 (46.8)
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445 (46.12)
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366 (44.19)
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507 (54.91)
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335 (40.97)
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Yes
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1800 (53.2)
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505 (53.88)
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443 (55.81)
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379 (45.09)
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473 (59.03)
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a. The data are shown as N (%) except care ratio, household size, and age of the mother presented as Mean±SE.
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b. House types defined as Pucca house, Semi-Pucca house and Kuchcha house. A pucca house is made with high quality materials, including roofs, floors, and walls. A kuchcha house is made with low quality materials such as mud and thatch.
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c. Care ratio is the number of children under 5 years of age divided by the number of adult females in the household.
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d. An adult defined as a person aged 16 or older
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e. Mother’s paid employment status: No represents a mother who is a housewife only and yes represents a mother who has any paid job.
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Table 2. Percentage of Home Visits by Types of CHWs & Health Practices, Overall and in Four States
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Overall N (%)
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Andhra Pradesh N (%)
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Chhattisgarh N (%)
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Odisha
N (%)
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Uttar Pradesh N (%)
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Home Visits
|
|
|
|
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ASHAs
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375 (12.17)
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42 (4.72)
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54 (7.79)
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206 (24.50)
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73 (9.51)
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AWWs
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1434 (41.07)
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520 (53.94)
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252 (31.20)
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337 (38.77)
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325 (40.50)
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Other CHWs
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1004 (27.99)
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520 (54.00)
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99 (11.64)
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179 (21.18)
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206 (25.62)
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Multiple Visits
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936 (27.83)
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426 (45.52)
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99 (13.56)
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228 (27.21)
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183 (23.55)
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|
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Health Practices
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|
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Institutional Delivery
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2484 (70.75)
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899 (94.39)
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410 (50.22)
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630 (69.43)
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556 (68.88)
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Complete Immunization
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256 (7.78)
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170 (20.35)
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22 (3.32)
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8 (0.78)
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56 (7.43)
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Exclusive Breastfeeding for First 6 Months
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1639 (46.39)
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700 (73.54)
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159 (19.62)
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598 (66.97)
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182 (22.43)
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Timely Introduction of Complementary Feeding
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2655 (78.70)
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608 (68.33)
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686 (85.38)
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731 (81.63)
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630 (78.53)
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Continued Breastfeeding During Child's Illness
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899 (66.41)
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253 (77.83)
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319 (66.83)
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210 (68.80)
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117 (48.73)
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Handwashing
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1940 (55.57)
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484 (50.68)
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435 (52.85)
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369 (40.35)
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652 (80.73)
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Awareness of NHDs
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1712 (49.43)
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599 (63.44)
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470 (58.36)
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438 (49.54)
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205 (25.62)
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Table 3. Adjusted Odds Ratios of Seven Outcomes in Four States in India, by Type of CHW Visitab
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Andhra Pradesh
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Chhattisgarh
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Odisha
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Uttar Pradesh
|
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ASHAs
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AWWs
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ASHAs
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AWWs
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ASHAs
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AWWs
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ASHAs
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AWWs
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Adjusted OR (95% CI)
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Adjusted OR (95% CI)
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Adjusted OR (95% CI)
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Adjusted OR (95% CI)
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Institutional Delivery
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n=698
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|
n=664
|
|
n=845
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n=665
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0.04***
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0.31
|
|
1.61
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0.81
|
|
0.96
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1.26
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|
1.31
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0.96
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(0.01-0.16)
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(0.07- 1.46)
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(0.75-3.43)
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(0.48-1.36)
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(0.60-1.54)
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(0.71-2.26)
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(0.66-2.63)
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(0.55-1.68)
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Complete Immunization
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n=637
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n=488
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|
n=113
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|
n=622
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1.79
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0.57
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|
1.00
|
4.82**
|
|
0.77
|
1.80
|
|
1.74
|
1.33
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(0.48-6.61)
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(0.21-1.54)
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(1.00-1.00)
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(1.50-15.46)
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(0.10-6.10)
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(0.02-151.81)
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(0.66-4.60)
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(0.62-2.83)
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Exclusive Breastfeeding for First 6 Months
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n=698
|
|
n=664
|
|
n=870
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n=665
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0.62
|
1.71
|
|
0.23*
|
0.68
|
|
0.55**
|
1.04
|
|
0.59
|
1.66
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(0.18-2.16)
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(0.87-3.38)
|
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(0.06-0.84)
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(0.36-1.28)
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(0.36-0.84)
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(0.64-1.67)
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(0.24-1.47)
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(0.86-3.22)
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Timely Introduction of Complementary Feeding
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n=652
|
|
n=663
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|
n=869
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|
n=658
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0.17***
|
1.37
|
|
2.20
|
0.61
|
|
0.64
|
1.19
|
|
0.96
|
1.05
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(0.05-0.57)
|
(0.70-2.67)
|
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(0.59-8.18)
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(0.34-1.10)
|
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(0.37-1.12)
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(0.61 -2.34)
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(0.45-2.05)
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(0.64 -1.74)
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Continued Breastfeeding During Child's Illness
|
n=223
|
|
n=389
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n=300
|
|
n=197
|
1.00
|
0.33
|
|
0.73
|
2.06*
|
|
0.62
|
0.93
|
|
0.57
|
0.98
|
(1.00-1.00)
|
(0.09-1.27)
|
|
(0.27-1.93)
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(1.10-3.85)
|
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(0.32-1.21)
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(0.41-2.13)
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(0.16-2.00)
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(0.49-1.95)
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Handwashing
|
n=698
|
|
n=664
|
|
n=870
|
|
n=665
|
1.41
|
0.40*
|
|
1.37
|
1.35
|
|
1.29
|
1.65*
|
|
1.66
|
0.86
|
(0.22-8.93)
|
(0.17-0.94)
|
|
(0.82 -2.29)
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(0.82-2.22)
|
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(0.81-2.08)
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(1.05-2.60)
|
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(0.50-5.54)
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(0.52-1.43)
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Awareness of NHDs
|
n=698
|
|
n=664
|
|
n=870
|
|
n=665
|
0.11***
|
9.41***
|
|
1.37
|
1.78*
|
|
1.74*
|
2.50***
|
|
0.38
|
2.24**
|
(0.03-0.37)
|
(3.85-23.00)
|
|
(0.75-2.50)
|
(1.06-2.96)
|
|
(1.14-2.66)
|
(1.61-3.90)
|
|
(0.11-1.28)
|
(1.24-4.04)
|
a. The models were adjusted by multiple CHW visits, other CHW's visits, house type, region type (urban, rural, tribal), sex of index child, total household size, the ratio of children under five years of age to the number of adult females in the household, highest education level completed by any adult in the household, mother's age, and mother's employment status.
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b. ASHAs and AWWs are binary variables. ASHAs represents a mother who was visited by an ASHA (yes/no). AWWs represents a mother who was visited by an AWW (yes/no).
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* p ≤0.05, **p ≤0.01, *** p ≤0.001
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Multivariate Regression Analyses
Institutional Delivery
A visit by any one type of CHW or multiple CHWs did not have a significant effect on the odds of a mother having an institutional delivery among the four states, with the exception of ASHAs in AP. Contrary to the study hypothesis, in AP, holding all else equal in the logistic regression, a mother visited by an ASHA was 96% less likely to have an institutional delivery than a mother not having had a visit from an ASHA (OR= 0.04, 95% CI=0.1-0.16)[i] (Table 3).
Complete Immunizations
Among the CHWs across the four states, only visits from AWWs significantly predicted complete immunizations for the index child. Table 3 illustrates that in Chhattisgarh, the odds of having a child between the ages of 6 and 23 months completely immunized was over four times greater (OR=4.82, 95% CI=1.50-15.46)[2] if the mother received a visit from an AWW, while ASHA visits had no significant effect.
Exclusive Breastfeeding for First Six Months
In both Chhattisgarh and Odisha, visits conducted by ASHAs had a statistically significant negative association with reported exclusive breastfeeding for the first six months of a child’s life. In Chhattisgarh, all else equal, mothers were significantly less likely to report that they exclusively breastfed their child for the first six months of life if they had a visit from an ASHA (OR=0.23, 95% CI=0.06-0.84). In Odisha, mothers who had been visited by an ASHA were 45% less likely to report exclusive breastfeeding (OR= 0.55, 95% CI=0.36-0.84).
Timely Introduction of Complementary Feeding
In AP having an ASHA visit was associated with significantly lower odds of a mother introducing complementary feeding during the recommended period; there was no significant effect in any other state. All else equal, the odds of introducing liquids (other than breast milk), solids, or semi-solids into the index child’s diet between six and nine months (the behavior recommended by the CHWs) was 83% less likely among mothers who had a visit from an ASHA (OR=0.17, 95% CI=0.05-0.57) [3] (Table 3).
Continued Breastfeeding During Child’s Illness
In Chhattisgarh, mothers who received a visit from an AWW were more than twice as likely to report continued breastfeeding during their child’s illness (OR=2.06, 95% CI=1.10-3.85). This sample only included mothers who had reported that their child had diarrhea within the past two weeks, and in Chhattisgarh that included 389 out of 664 mothers surveyed. While it is encouraging that AWW visits had a significant positive association with continued breastfeeding during illness, it is alarming that over 50% of women in the sample for this state reported their children having diarrhea within the past two weeks.
Handwashing
In Odisha, all else equal, a mother was slightly more likely to follow proper handwashing techniques if she was visited by an AWW (OR=1.65, 95% CI=1.05-2.60) than were those not visited by an AWW; however, in AP, the result was the opposite (OR=0.40, 95% CI=0.17-0.94) (Table 3).
Awareness of NHDs
In all four states, mothers who received a visit from an AWW were significantly more likely to report being aware of NHDs held at their local AWC (Table 3). In Odisha, mothers were also 74% more likely to report awareness of NHDs if they received a visit from an ASHA (OR=1.74, 95% CI=1.14-2.66), but in AP, mothers who received a visit from an ASHA were much less likely to be aware of NHDs (OR=0.11, 95% CI=0.03-0.37).
[i] In AP, 42 mothers were visited by an ASHA.
[2] In Chhattisgarh, 22 children had completed immunizations.
[3] In AP, 42 mothers were visited by an ASHA.