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Wed, Dec

Fight Against Malnutrition: The Need to Look Beyond Feeding Children

Disruptive Innovations
Typography

Community demonstration of food basket with nutritious food 
Photo Credit: United Way Mumbai

The Complex Problem of Malnutrition in India 

Of the 57 million malnourished children in India,1 20 percent are under five years of age and suffer from wasting due to acute undernutrition. 43 percent of Indian children under five years of age are underweight and 48 percent (61 million children) are stunted due to chronic undernutrition. It is alarming that India accounts for three out of every 10 stunted children in the world.2

The threat of malnutrition in India is real, rapidly growing, and getting more complex with every passing day. The state of Maharashtra has been in the news due to the severe malnutrition and related deaths in tribal and rural communities. Some of the worst affected communities are in Palghar, Raigad, and Karjat, districts that are barely 100 km to the north of Mumbai, India’s financial capital.   

Malnutrition is a recurrent health crisis which demands interventions that go beyond feeding children. Such interventions are aimed at community management of malnourished children. As is the popular belief, it takes an entire village to bring up a child. Providing nutrition, albeit critical, is part of the solution and not the solution unto itself. A child, healthy or malnourished, requires an enabling environment for growth and development. This environment consists of parents, extended family, neighbors, village members, and public health workers among others.

United Way Mumbai’s fight against malnutrition in tribal and rural communities in Maharashtra works on this belief and has endeavored to empower family members and caregivers to stop the cycle of malnutrition through a community-centric approach. 

Leveraging Existing Community Infrastructure and Resources 

Establishing partnerships with the Integrated Child Development Scheme (ICDS) of the Government of India is the first step in leveraging existing community infrastructure and resources. ICDS is the State’s flagship program with a mandate to deliver health services for children below six, pregnant and lactating women, and adolescent girls. The health services include nutrition, immunization, and early childhood education. These services are offered through an Anganwadi (courtyard shelter) center, by a field worker called the Anganwadi Worker. Typically, a center is available per 1,000 people, thus making it not only the largest free service provider in the world, but also the most accessible one. Such a partnership addresses the dual needs of creation or running of an infrastructure and human resources to cook, store, and distribute the food. 

Identification of Undernourished Children

This includes a scientific method of checking the nutritional status of all children under the age of five in a community by tracking their growth parameters, through anthropometric measurements of age, weight, height, and mid upper arm circumference (MUAC) taken every month. The focus is not only on the severely undernourished (SAM) but also on a preventative approach for those children who are moderately undernourished or are in a borderline state of undernourishment and at risk of falling into the malnutrition trap. More often, for varied reasons, many project interventions target, only severely undernourished children. However, moderate or borderline undernourished children are highly susceptible of becoming SAM and thus the vicious cycle of malnutrition continues. Hence, it is imperative to work with this group of children as well, to prevent incidences of malnutrition. 

Nutritional Supplements

One of the most critical aspects of alleviation of malnutrition is provision of nutritional supplements fortified with micronutrients and protein which are therapeutic in nature. On many occasions, the nature of nutritional supplements is determined without consulting the community itself. This raises three critical questions: 

  • Is the food provided acceptable in the community? More importantly is the food acceptable to children who will eat it? Will they like it? What is the dietary preferences of the family? Answers to these questions will address major issues pertaining to why undernourished children remain the way they are or why parents won’t enroll their children in such a program.  
  • Is it accessible? Are raw materials available in the community itself? Is the community aware of how to cook these food items? Is it something that they have used previously or can cook on their own in future? 
  • Is it affordable? Can parents who are poverty stricken afford the food being provided after the intervention ends? Is the raw material within their reach, economically? 

Answers to these questions can be arrived at by initiating community conversations, including house-to-house interactions. Dietary recall (assessing what the community members eat on a 24-hour basis), and participatory rural appraisals for community mapping of resources are some tools that help to serve this purpose. Based on this, a nutritious meal plan is arrived at which is acceptable, accessible, and affordable for the community being intervened. 

Preventing the Cycle of Malnutrition: Using Cultural Practices in the Community 

Enhancing awareness of mothers, caregivers, and community members on maternal care and nutritional needs of children is essential if under-nutrition is to be reduced and controlled. Cultural context and community platforms for providing these messages and building community support to enable the practice of related behavior needs to be created and where they exist, needs to be strengthened. 

One such platform is Godh Bharai, a ceremony that celebrates the impending motherhood of a woman, similar to a baby shower, to welcome the soon to-be-born baby to the family. Godh Bharai literally means to “fill the lap” with abundance. It is conventionally celebrated in the seventh month of pregnancy, and also marks the event after which a lady departs for her maternal home for the delivery. 

While this is traditionally celebrated at home with a few relatives in attendance, we use this opportunity to celebrate motherhood publicly at the Anganwadi centers. This complements existing traditional practices and rituals, and adds cultural flavor to project intervention, thus making it extremely welcoming among women. Community women are invited for the blessing of the pregnant women by offering flowers, vermilion (sindoor), coconuts, bangles, and more, according to local tradition, while keeping in consideration religious and community sentiments. 

Women in the community at God a Bharai ceremony.
Photo Credit: United Way Mumbai 

This provides an exceptional opportunity to have a conversation around safe birth; establish a plan to act swiftly in case of a medical emergency; and provide information about caring for a healthy baby at birth and complementary feeding, malnutrition, and details of various entitlements available for the woman and her family to make use of (services provided by ICDS). 

A nutritious food basket is available for demonstration purposes to the women. The food basket includes food items procured from the community to show that the nutrition that they and their children need is within reach at minimal or no cost. 

Parents Counselling

Picture this; we are sitting in a remote hamlet in a difficult to access tribal area in the mountains. While talking to a group of women who have gathered at the Anganwadi center, we ask what do they spend most of their money on, daily? One of them hesitatingly points to the only shop in the village, which has grocery items and provisions. We are intrigued and want to know on what and how much? 

Then comes the reply, “Up to Rs. 50 (up to 80-90 cents USD) daily to buy chips and cold drink.” This, in a village where the average household income is around two USD per day.  

A few questions later, we realize, they think that since such food products are costly, they must be good, especially when kids seem to love these items and enjoy them happily, and in contrast are reluctant when tasked with eating homemade food. 

We inform them about the nutritious substitutes for these food that would be welcomed by their children that are within their reach. One such food snack is Chikki, a sweet snack made with ground nuts and jaggery. Children eat this happily because it tastes sweet and parents welcome it because it is cost effective and nutritious. 

A recent study by doctors from the All India Institute of Medical Services (AIIMS), and the Sitaram Bharatiya Hospital, both premier medical institutions in Delhi, India, has shown that almost one-third of children with SAM recover with just nutritional counselling of parents and referrals to the nearest primary health center.3 Parents’ counseling through home-based interventions on aspects related to nutrition, health, hygiene, and medical referrals is vital in providing an enabling environment for the children. Of critical importance is inculcating a culture of safe and hygienic food handling at home and general cleanliness in the local environment. Equipping parents and the caregivers in the family to help in growth monitoring to detect growth anomalies helps in timely medical intervention. Parents are educated in the use of MUAC tap, to assist in detecting health issues in their children. 

Capacity Building of Anganwadi Workers 

Capacity building of Anganwadi Workers or the frontline health workers is a step towards sustainability. The success of most of the malnutrition alleviation programs in India depends on the effectiveness of frontline health workers in empowering communities with improved child care practices through counselling, home visits, as well as effective inter-sectorial service delivery. Hence periodic trainings and exposure to best practices is critical. Motivation of the Anganwadi workers is a key factor in efficient delivery of the ICDS objectives. A few ways this can be achieved is to promote a spirit of healthy competition. The. ‘Swachh Anganwadi’ or Clean Anganwadi competition helps to promote cleanliness and hygiene practices among the workers. Winners get recognized among their peers with prizes such as pet jars, cooking gloves, and other household items that enable them to work efficiently.  

All of these interventions are undertaken in an integrated manner to create an enabling environment for the overall development of undernourished children. Success of such interventions can be demonstrated empirically and gauged by the reduction in number of incidences of malnutrition. It is imperative to keep the community at the center while designing interventions to combat malnutrition.  

About United Way Mumbai 

United Way Mumbai is a non-profit organization, part of the United Way Worldwide movement spread across more than 40 countries and territories and engaged in 1,800 communities. United Way Mumbai (UWM) works closely with a network of more than 400 NGOs and a large number of corporations through their CSR programs, workplace giving campaigns, and other events. This includes the designing of CSR policies and strategies, due diligence of NGO partners, program implementation, employee volunteering, impact assessments, and financial and programmatic reporting. 

Over the past 16 years, we have partnered with more than 300 companies and more than one million individual donors investing close to INR 312 crore (approximately 48 million USD) for community development projects. Our six areas of focus are education, health, income, environment, public safety, and social inclusion; and we work in both urban as well as rural communities. Our endeavor is to address the kinds of problems that are too large or complex for any one agency to solve alone. Our role in the development sector is that of a catalyst that drives social change, and the glue that binds together the many stakeholders needed to create it. Through this collective impact model, we aim to facilitate lasting social impact.

Author bio

Anil Parmar is the Director of Community Investment at United Way Mumbai. Anil has wide-ranging experience in program designing, management, monitoring and evaluation, impact assessment, and reporting. He has a keen interest in demonstrating visible community impact through a multi-stakeholder approach -- including government, NGOs, corporate partners, and community stakeholders. Anil has an MBA in Social Entrepreneurship from NMIMS, Mumbai; is a post graduate from the College of Social Work, Nirmala Niketan, and leads the Community Investment projects team at United Way Mumbai. An avid development professional, he is passionate about implementing and scaling high impact projects and pragmatic public advocacy on health and education issues affecting communities.

Works Cited 

1 The Hindu, www.thehindu.com   
Updated March, 22, 2012 15:31 IST 

2 UNICEF India  unicef.in

3 epaperbeta.timesofindia.com  Jul 14 2017 : The Times of India (Delhi) Rema Nagarajan