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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 2  |  Page : 130-135  

Evaluation of village health and nutrition day program in a block of Hooghly District, West Bengal: A mixed-methods approach


1 Junior Resident, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
2 Director - Professor, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
3 Associate Professor and Head, Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India

Date of Submission31-May-2020
Date of Decision18-Feb-2021
Date of Acceptance07-Apr-2021
Date of Web Publication14-Jun-2021

Correspondence Address:
Pritam Ghosh
50, Collootolla Street, Kolkata - 700 073, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_621_20

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   Abstract 


Background: Village Health and Nutrition Day (VHND) is a community participation program focusing on pregnant women, lactating mothers, children (0–5 years), and adolescent girls. Objectives: To assess the status of VHND functioning in the rural areas, and to determine the facilitators and barriers of health care service utilization among the beneficiaries. Also, to explore the challenges faced by the front-line workers while conducting the program. Methods: A cross-sectional descriptive study with a mixed-methods approach was conducted among the beneficiaries and the service providers in twelve selected VHND sessions from March to July 2019 in Singur, Hooghly district, West Bengal. Both quantitative and qualitative methods of research were applied to assess the status of the functioning of 12 VHNDs. Results: Among the beneficiaries who attended the sessions; 28.57% were pregnant women, 16.53% were lactating mothers and 17.44% were under-five children. Nonavailability of line-list of adolescent girls and nonavailability of Vitamin A in oil were major observations. Barriers leading to poor service utilization among beneficiaries were the long-distance of the VHND session site, lack of counseling on proper lifestyle practices, poor and inadequate infrastructure. House visits by the Accredited Social Health Activists regarding the information on VHND sessions found to be an important facilitating factor for beneficiaries. Major challenges identified among the healthcare workers were lack of logistics supply, inadequate workforce, and improper the maintenance of the VHND session site. Conclusion: Proper resource mobilization, maintenance and cleanliness of the session sites, appropriate and wholesome counseling can vastly improve the quality of VHND with the concurrent improvement of maternal and child health.

Keywords: Evaluation, mixed-methods, qualitative, rural, village health and nutrition day


How to cite this article:
Jha SS, Dasgupta A, Paul B, Ghosh P, Yadav A. Evaluation of village health and nutrition day program in a block of Hooghly District, West Bengal: A mixed-methods approach. Indian J Public Health 2021;65:130-5

How to cite this URL:
Jha SS, Dasgupta A, Paul B, Ghosh P, Yadav A. Evaluation of village health and nutrition day program in a block of Hooghly District, West Bengal: A mixed-methods approach. Indian J Public Health [serial online] 2021 [cited 2021 Aug 2];65:130-5. Available from: https://www.ijph.in/text.asp?2021/65/2/130/318366




   Introduction Top


Maternal and child health carries the onus for a healthy society and also for the economic growth of the country. In India, the National Health Mission (NHM) aims at the improvement of the health status of mothers, children, and adolescents through the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) program.[1],[2] Under this framework, Village Health and Nutrition Day (VHND) organized at the Anganwadi Centre preferably, once in every month has become a key strategy in building the link between the health system and the community effectively coupled with inter-sectoral convergence to deliver comprehensive health and nutrition services to pregnant women, lactating mothers, children (0–5 years) and adolescent girls.[3] The basic objective of organizing VHND is to provide services like early registration, ante-natal care, counseling, family planning services, immunization, nutritional assessment, provision of medicines, menstrual hygiene, etc., leading to good maternal, child, and adolescent health.

There have been several studies to assess the VHND services. While Panigrahi et al. assessed the stakeholder component related to VHND, Biswas et al. focused on the quality aspect of the program.[4],[5] Mahanta et al. on the other hand focused on the assessment of the process with a component of client satisfaction.[6] Pati et al. conducted a mixed-methods study focusing on the barriers of a successful implementation of VHND services in the district of Odisha.[7] Several other studies have assessed the functioning of such programs in both the eastern and western parts of the country.[8],[9]

A qualitative assessment of the VHND sessions carries special significance in adding to the diversity of shortcomings analyzed in quantitative research. An important part in the assessment of such a program as VHND is to corroborate the findings of quantitative research with qualitative research. This process gives an exploratory, in-depth and lucid evaluation of the functioning of this program, and helps to assess the extent to which it fulfills its principle objective. Taking care of the identified lacunae of this program will in the long run help the health administrators and policymakers to take a giant step in improving the utilization of health care services by the general population. The VHND is an effective platform for providing first-contact primary health care and bring about the much-needed behavioral changes in the community, and also induce health-seeking behavior in the community leading to better health outcomes. With this background, the current study was conducted to assess the status of VHND functioning in the rural field practice area of All India Institute of Hygiene and Public Health (AIIH and PH), and determine the facilitators and barriers of health care service utilization among the beneficiaries. The study also explored the challenges faced by the front-line workers while conducting the program.


   Materials and Methods Top


Study design, setting, and population

A descriptive cross-sectional study was conducted using mixed-methods approach (convergent parallel design) among the beneficiaries and service providers of the VHND sessions from March to July 2019 in the field practice area of AIIHPH, Singur of Hooghly district, West Bengal. There were twelve service units in the mentioned area. The researchers attended twelve VHND sessions during the period of data collection.

The quantitative part of the study comprised of an assessment of resources and services at the twelve VHND sessions, with the help of a predesigned pretested checklist. The researchers physically verified the items, their availability, and functioning during the observed sessions.

The qualitative component involved focus group discussions (FGDs) and in-depth interviews (IDIs) of informants. FGDs were conducted separately among the four beneficiary groups (ante-natal mothers, lactating mothers, adolescent girls, mothers of under 5 children) using predesigned FGD guide. IDIs were conducted among 12 Auxiliary Nurse Midwife (ANMs), 10 Accredited Social Health Activists (ASHAs), and 4 Anganwadi Workers (AWWs) using pre-designed IDI guide. Participants for the FGDs and IDIs were chosen purposively and includes those who gave informed written consent.

Ethics

Approval had been obtained before the beginning of the study from the Institutional Ethics Committee of AIIH and PH, Kolkata.

Conceptual framework

The conceptual framework for the current study was developed based on Andersen's healthcare utilization model, the health governance framework of Brinkerhoff and Bossert, the framework for the determinants of health facility committee performance offered by McCoy et al., and an Indian study by Srivastava et al. which analyzed the system performance of VHSNCs.[8],[10],[11],[12],[13] [Figure 1] depicts the conceptual framework built on the systems approach, dividing the program into Input, Process, Output, and Feedback components. Input includes policy and resource allocation. The process comprises of skill and attitude of the health workers related to beneficiary mobilization and nonattendance. Enablers and inhibitors act on the whole Process. Output is determined by the utilization of services in terms of attendance to VHNDs and satisfaction towards services. The feedback component elicits beneficiary needs and suggestions for improvement extracted from beneficiaries and the health workers. Input, Process, and Output applies for both quantitative and qualitative results whereas Feedback for only qualitative part.
Figure 1: Conceptual framework for the study.

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Data analysis

Codes were used to extract information from the FGDs and IDIs. The assessment was done regarding the status of the VHND program from the transcripts of the recorded FGDs and IDIs. The field notes were put along with the transcript to understand the phenomenological framework associated with the research questions. The responses of the participants were coded based on the guides developed beforehand. The similar codes were put together and themes were generated. Simultaneously, the field notes were also considered side by side to put the codes in appropriate context. Similar themes were clubbed together and placed under appropriate domains.

Six indicators were used for quantitative measurement of VHND functioning, “Services to the Pregnant and Lactating Women,” “Services to the Under-5 children and Adolescent Girls,” “Counselling Services,” “Working equipment during VHNDs,” “Availability of medicines during VHNDs,” and “Availability of vaccines during the VHNDs.” Services to the Pregnant and Lactating Women were assessed in terms of the following components i.e., registration of pregnant women, blood pressure measurement, weight measurement, TT/Td immunization, abdominal examination, estimation of hemoglobin, Iron and folic acid (IFA) tablet distribution, calcium tablet distribution, and advice on health, hygiene, and nutrition. Services to the Under-5 children and Adolescent Girls were measured in terms of weight measurement, growth monitoring, immunization, and TT/Td immunization; while Counselling Services were measured by lecture and interactive session or health education, and IEC material used. The components of Working equipment during VHNDs were working sphygmomanometer, adult weighing scale, salter scale, measuring tape, hemoglobin color scale, and urine pregnancy test kit. Availability of IFA tablet, IFA Syrup, ORS, paracetamol, anti-helminthic, oral contraceptive, calcium tablet, and Vitamin A in Oil were noted to assess the domain of availability of medicines during VHNDs. Similarly, to assess the availability of vaccines during the VHNDs; pentavalent vaccine, OPV, IPV, TT/Td, DPT (B), and syringes and vaccine carrier with ice packs were considered.

For each unit, services rendered were scored. A score of 1 was given for each service provided and 0 for service not provided. A total score was calculated for each unit. A percentage score out of the applicable services for each unit was calculated for the purpose of bringing uniformity and a standardized comparison amongst the units. A similar method of scoring was done for all the indicators. Now for each unit, unweighted average of all these indicator scores was calculated. The performances of the units were compared with the help of these unweighted average scores.


   Results Top


Beneficiaries, study participants and their characteristics

Majority pregnant women were primigravida (82.22%). Among the participating beneficiaries, 87.73% were Hindus and 53.49% belonged to joint family. Among the frontline workers interviewed, 95.31% were Hindu by religion, and all of them were educated at least till secondary level.

[Table 1] describes the beneficiary profile in each unit. Unit 2 was found to have a higher number of eligible beneficiaries. In Units 3,4 and 7; attendance of pregnant women was 50% and more. A notable finding was that in six out of twelve units there was no line list available for the adolescent girls. Among the total beneficiaries in each group; 28.57% of the pregnant women, 16.53% lactating women, and 17.44% under-five children attended the observed sessions.
Table 1: Beneficiary attendance in the 12 village health and nutrition day sessions

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Quantitative assessment of unit functioning in observed village health and nutrition day sessions

[Figure 2] shows the overall functioning of each VHND observed with respect to the selected service and resource indicators. The overall performance depicts that 8 out of 12 VHND sessions had a score of 50% or less. As per the mean scores of percentages of maximum applicable score obtained, unit 3 was the best performing unit (mean value of 74%). However, the performance of unit 1 was considered poor as the mean percentage of maximum applicable score obtained in this unit was 11% which was the lowest among all the units. Only 4 units scored more than 50%.
Figure 2: Performance of the Village Health and Nutrition Days as per service and resource indicators.

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Availability of vaccines during VHND sessions and services to under-5 and adolescents were the major areas lacking in the majority of the units. According to the availability of selected vaccines, units 3 and 5 were the best performers followed by units 2 and 4. However, in the remaining units vaccines were not available at the session site. As per the availability of working instruments, units 9 and 10 were best with a score of 80%. Unit 2 on the other hand did not have any of the selected instruments in working condition. Sphygmomanometer was available in seven units. Weighing scales– adult and/or Salter in working condition were available in eleven units. Urine Pregnancy test kit and hemoglobin color scale in working condition were available in four units each. As per the availability of medicines, unit 9 was the best performing unit. However, in unit 1, the selected medicines were not available. ORS was available in nine units. IFA in tablet and/or syrup form was available in eleven units. Vitamin A in oil was not available in any of the units.

In terms of services to pregnant and lactating women Unit 8 did not provide any of the selected services. Among the selected services observed, the abdominal examination was done in one unit only. Calcium tablet distribution was done in two units only. With respect to the four selected services to the under-5 children and adolescent girls, unit 5 was the best performing unit followed by unit 3. While weight measurement was done in five units, growth monitoring was however done in two units. In six units adolescent girls attended sessions. Out of these six units, three units provided TT/Td immunization. Except unit 5 all the units provided some counseling services through lecture and/or demonstration of IEC materials.

Qualitative assessment of overall program functioning

Resource and service availability

The experiences shared by the field workers revealed lack of resources as a major issue. The themes that emerged were lack of logistics supply, lack of manpower and support staff, and inadequate importance on the maintenance of the VHND session site.

A 35 years old ASHA in this context said that,

"Sessions are usually planned regularly, but the supply for sessions never come in time or sometimes never come at all."

Enablers and inhibitors

The utility statements regarding VHND varied among the beneficiaries. While ante-natal mothers found utility in thorough counseling and care delivery, the lactating mothers believed the fact, that VHND sessions were aimed at vaccination of their children only.

"VHND sessions are primarily for maternal and child health care. The main focus of such sessions is vaccination of the children and nothing more. Sometimes the ASHAs don't even inform the date and time.” said a 32 years old mother.

On the other hand, diverging opinion was given by a 22-year-old primi-gravida expectant beneficiary,

"ASHAs provide information regarding the date and time of VHND sessions. The counselling provided in such sessions is very helpful for us. What to do and what not to do during pregnancy is discussed."

Mobilization and nonattendance

The characteristic themes were house visits by the ASHAs regarding the information on VHND session for mobilization, and lack of provisions of vaccination and immunization services for nonattendance. A 21-year-old primi-mother responded in an FGD,

"ASHA workers visit houses regularly…VHND is a source of information for us."

The distant location of VHND session was also an important factor contributing to beneficiary nonattendance, as opined by a 28-year-old lactating mother. The key finding was interestingly the existing barriers in utilizing VHND services among adolescent girls. The majority of the adolescents mentioned that the timing of VHNDs was inconvenient for them. A 12-year-old girl responded,

"Due to school and tuitions it is not possible to attend the session. Even during the school holidays because of tuition, we cannot attend the VHND."

Services

On the aspect of service provision and the domain of skill and attitude of the frontline health workers the issues discussed were difficulty in community mobilization and rooting of the hostile behavior by the families of the beneficiaries in resistant areas, an ANM revealed,

"Some families are not at all welcoming…It is very difficult to reach them and convince them."

Pregnant mothers were satisfied with the explanations of MCPC as provided by the health workers in contrast to the lactating mothers. The statement by a 22-year-old lactating mother was:

"We are not always made aware of the contents of MCPC. They tell us to see it but we don't know what to see."

This was further established in an IDI of an AWW who said,

"Usually the ante-natal mothers are told about the MCPC in detail. Due to time-shortage sometimes some mothers are not detailed about the contents of the card."

Mother of a 2 years old child said “Importance is not given regarding counseling of mothers of older children (under-5 years children)."

A 14-year-old girl who attended a session said,

"Only general health information is given. It would be better if special advices like diet and physical activity are given to us."

Beneficiary needs

The context of the maintenance of the VHND site was highlighted during the FGDs among the beneficiaries. One major theme that emerged in the domain of beneficiary needs was cleanliness and proper set-up of the VHND session site. A 27-year lactating mother in this context stated,

"Session site should be clean. There is no fan in the room with lack of ventilation leading to sense of suffocation."

While analyzing the beneficiary needs, the other major themes that emerged were, arrangement of proper health check-up, availability and provision of important medicines and injections, and adequate counseling with health service delivery. The health workers also perceived this as a key need along with the supply of important medicines and vaccines. The health workers during IDIs remarked about the scarcity in the availability of medicines, stock-out of Vitamin A-in-oil, and some vaccines. Regarding proper health check-up of the beneficiaries, emphasis was on the presence of a doctor. Twenty-five years old ante-natal mother in an FGD session said,

"It will be better if complete examination is done for pregnant mothers. Presence of a doctor in the session is always needed."

An ANM in consonance responded to the interviewer that,

"It will be helpful for us if a doctor attends the session, as the mothers always ask for a doctor."


   Discussion Top


Both quantitative and qualitative research identified resource limitation as the main determinant for poor utilization of VHND services, even though these sessions were all pre planned. While beneficiary mobilization was rigorously attempted by the ASHAs in the block, some areas were however very resistant in terms of service acceptance. In consonance, Biswas et al. in their study found out that planning was present for the sessions and identified ASHA and AWW as the key mobilizers.[5] While they noted that line list was available for sessions,[5] in the current study, it was not the case in most of the sites especially in case of the adolescent girls. Dohare et al. assessed the resource availability in VHND sessions through mixed-method design.[14] While immunization and childcare services were found to be adequately available, they noted some constraints in the availability of equipment.[14] However, in the current study immunization and childcare services were also observed to be lacking in many sessions. Saxena et al. in their quantitative assessment ascertained that immunization services to children were the main event in the VHNDs,[15] which was also major feedback from the mothers in the current study. Nonavailability of vitamin-A in oil was in synchrony with the current findings.

In the mixed-method study by Pati et al. the proportion of beneficiary participation in VHND sessions was higher as compared to the current study.[7] In consonance with the present findings, they identified nutritional assessment, immunization services, disease-related counseling to be sub-optimal.[7] The study with a prepost design by Mahanta et al. in Dibrugarh was synchronous with the present study in terms of counseling services.[6] However, Biswas et al. noted the adequacy of counseling services.[5] Distance of the VHND session site was a major determinant for beneficiaries in attending the sessions. The lack of availability of medicines and some vaccines shaped the attitude of the mothers towards attending the sessions in a negative way. In a similar note, Pati et al. also reported domestic objections, distance, lack of sitting space, lack of medicine supply as important determinants.[7] In contrast to their findings, the issue of prolonged waiting time was not observed in the current study.

Barua et al. in their study from Assam found gaps in the utilization of services mainly in relation to postnatal care, growth monitoring, and counseling for family planning.[16] From their quantitative assessment, they observed a higher proportion in ever utilizing the services.[16] This was discordant with current findings. However, the reason behind such apparent discrepancy is that the current study observed only the proportion of beneficiaries who currently attended the sessions; whereas Barua et al. noted the cumulative incidence of attending the sessions.[16] In the review article by Das and Das sub-optimal availability/estimation of hemoglobin as ante-natal care and child weighing were observed similar to what the current article demonstrates.[17]

The present study with qualitative assessment helped in revealing an in-depth understanding of the promoting factors, barriers and challenges in the context of successful VHND program implementation at the grass-root level. Strength in this analysis can be noted in enlightening the special needs of the adolescents and challenges in the mobilization of adolescent girls to healthy lifestyle.

The quantitative component here is a cross-sectional survey. Therefore, the issue of resource availability and infrastructure status may not reflect the overall trend in the block throughout the year. A repeated cross-sectional study in this regard can be a cost-effective design for evaluation. Another major limitation of the study was the noninclusion of the nonattendees. The component of client satisfaction has not been worked upon in detail and this may be ascertained in future studies with both quantitative and qualitative outlook.


   Conclusion Top


The current findings of the study unequivocally speak for the dire need for enhanced resource mobilization from the administration. Doctors, who are the cardinal pillar in healthcare delivery, may be roped in for some of the sessions for robust program implementation and service utilization at the targeted grass-root level. There is a need for supportive supervision of the sessions regularly and stringent monitoring of the infrastructure and services of the VHNDs. A planned structured intervention with regularized supportive follow-up will improve the program with full attendance of all the line listed clients with systematic utilization of all the services meted out by the VHNDs to the mother, child, and adolescent girls.

Acknowledgment

The authors would like to acknowledge the participants of the study for their cooperation. The authors would like to thank the Officer-in-charge and staff of RHUTC, Singur for their cooperation and help in conducting the study.

Financial support and sponsorship

Self-funded by the authors.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Department of Health & Family Welfare. RMNCH+A. National Health Mission. Available from: https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=794&lid=168. [Last accessed on 2021 Feb 20].  Back to cited text no. 1
    
2.
Department of Health & Family Welfare. National Health Mission. National Health Mission. Available from: https://nhm.gov.in/. [Last accessed on 2021 Feb 20].  Back to cited text no. 2
    
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Village Health Nutrition Day:: National Health Mission. Available from: https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=152&lid=228. [Last accessed on 2019 Jul 30].  Back to cited text no. 3
    
4.
Panigrahi SK, Mohapatra B, Mishra K. Awareness, perception and practice of stakeholders in India regarding Village Health and Nutrition Day. J Family Med Prim Care 2015;4:244-50.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Biswas S, Dasgupta S, Ghosh P. Quality of Village Health & Nutrition Day Sessions in North 24 Parganas District, West Bengal, India. IOSR-JDMS 2018;2:8-11.  Back to cited text no. 5
    
6.
Mahanta TG, Baruah M, Mahanta BN, Gogoi P, Baruah J, Gupte S. Process evaluation of Village Health and Nutrition Day observation (VHND) in a block of Dibrugarh District of Assam. Clin Epidemiol Glob Health 2015;3:104-9.  Back to cited text no. 6
    
7.
Pati S, Chauhan AS, Palo SK, Sahu P, Pati S. Assessment of Village Health and Nutrition Day implementation – Findings from a mixed method study in Odisha, India. Clin Health Promot Res Best Pract 2016;6:42-8.  Back to cited text no. 7
    
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Srivastava A, Gope R, Nair N, Rath S, Rath S, Sinha R, et al. Are village health sanitation and nutrition committees fulfilling their roles for decentralised health planning and action? A mixed methods study from rural eastern India. BMC Public Health 2016;16:59.  Back to cited text no. 8
    
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Kamble RU, Garg BS, Raut AV, Bharambe MS. Assessment of functioning of village health nutrition and sanitation committees in a district in Maharashtra. Indian J Community Med 2018;43:148-52.  Back to cited text no. 9
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Brinkerhoff D, Bossert T. Health governance: Concepts, experience and programming options. In: Health Systems 2020 Policy Brief. Bethesda: USAID; 2008. p. 2008.  Back to cited text no. 10
    
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McCoy DC, Hall JA, Ridge M. A systematic review of the literature for evidence on health facility committees in low- and middle-income countries. Health Policy Plan 2012;27:449-66.  Back to cited text no. 11
    
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Babitsch B, Gohl D, Von Lengerke T. Re-revisiting Andersen's Behavioral Model of Health Services Use: a systematic review of studies from 1998–2011. GMS Psycho-Social-Medicine. 2012;9.  Back to cited text no. 12
    
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Andersen RM. Revisiting the behavioral model and access to medical care: Does it matter? J Health Soc Behav 1995;36:1-0.  Back to cited text no. 13
    
14.
Dohare PK, Pal D, Toppo M, Melwani V, Arshad S. Assessment of Village Health and Nutrition Day in District Bhopal, Madhya Pradesh. Int J Prev Curative Community Med 2019;05:8-14.  Back to cited text no. 14
    
15.
Saxena V, Kumar P, Kumari R, Nath B, Pal R. Availability of village health and nutrition day services in Uttarakhand, India. J Family Med Prim Care 2015;4:251-6.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Barua K, Barua R, Saikia Anku M. Awareness and utilization of village health and nutrition day (VHND) services – 'A community based study.' IJHRMLP 2015;1:64-9.  Back to cited text no. 16
    
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Das S, Das M. Quality assessment of maternal and child health services in health and nutrition day (VHND/UHND) in India- a literature review. Int J Health Sci Res. 2018;8(7):321-6.  Back to cited text no. 17
    


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