I recently completed my Youth for India fellowship journey. And since the year is ending, I thought it was a good time to reminisce and reflect on all the experiences and learning I had during the past 13 months of my fellowship tenure.
During the fellowship programme, I worked extensively on issues pertaining to the public health domain, focussing specifically on maternal and child malnutrition in the tribal regions of Palghar district in Maharashtra, India. For my project, I was based out of Walwanda village in the Jawhar block.
My fellowship project was based on – Social behaviour change communication (BCC) and community mobilisation (CM) to address the issue of malnutrition.
My project was broadly aimed at developing community-based malnutrition awareness interventions, that is, providing health awareness to the tribal village residents via nutrition-sensitive awareness, community mobilisation and food and nutritional security. Along with that, I conducted awareness sessions and campaigns focussing on vulnerable sections at the village and household level and providing health promotion and health literacy at the tribal school targeting adolescent girls and boys.
Further, the focus group included mothers, pregnant and lactating women (PLW), newborn, children (under the age of five) and adolescents. The target group at the village and household level were children with severe acute malnutrition (SAM) and adolescent school children studying in standard 8th and 9th, at the school level.
Malnutrition is a multi-dimensional and an inter-generational phenomenon. The vicious cycle of malnutrition leads to the health crisis and is no less than an epidemic. Thus, there was an urgent and persistent requirement to address the critical health issue of malnutrition plaguing the tribal population in Jawhar.
The preliminary stakeholder meetings held with including, inter alia, the primary health centre and village health sub-centre officials, Anganwadi workers (AWW), Accredited Social Health Activists (ASHA), Auxiliary Midwives (ANM), women self-help groups (SHGs), community resource personnel (CRP), the village community, school children, adolescent girls and boys, the Gram Panchayat (GP) Samiti officials and Gram Sewaks, Gram Panchayat leader (sarpanch), the Panchayat members and the local NGOs, all pointed towards the major health concern of malnutrition in Jawhar.
Malnutrition, by far, has been the primary cause of deaths among children aged 0-5 years. Lack of proper nutrition, early marriages, frequent births, high fertility rate and a lack of proper birth spacing has led to widespread anaemia, related diseases and worsening health conditions among the pregnant and lactating women. This has further resulted in exacerbation of the maternal mortality and child mortality rates in Jawhar.
Factors such as early marriage, seasonal migration and meal intake were some of the factors that featured high above, amongst rest of the factors that also contributed to poor nutrition among children, adolescent girls and mothers. Other factors that have led to abysmal health profile of people in the tribal villages is lack of awareness of institutional deliveries (home deliveries carried out by the inexperienced traditional birth attendants due to un-affordability and inaccessibility to health care facilities), lack of both antenatal and postnatal care, cultural barriers and superstitions, among others.
Albeit the conventional belief is that malnutrition is caused due to nutritional deficiencies of certain macronutrients and micronutrients, my understanding is that other non-conventional factors (in addition to the factors listed above) such as poor sanitation and hygiene, poverty, unemployment and poor environmental health conditions are equally vital and critical factors contributing to the menace of malnutrition in Jawhar, Palghar.
Thus, my project intervention strategies focussed on nutrition-sensitive interventions rather than only nutrition-specific interventions.
The dual aims of my project were to
a) mitigate the extent and severity of malnutrition among mothers, PLW and children under the age of 5 via behaviour change communication and community mobilisation; and
b) ensure information and knowledge dissemination, improve health and hygiene literacy and increase the awareness levels about malnutrition and malnutrition prevention among adolescent children via interpersonal communication, among others.
The methodology that I devised to conduct planned interventions and impact assessment of the project included institutional and stakeholder mapping; community needs assessment; conducting baseline surveys (pre-intervention surveys at the village, households and the school); designing project structure at the school and village and household level; implementing project interventions based on the project structure; and monitoring and evaluation of the project interventions.
Two-tiered project interventions were conducted, that is, one at the village and household level and the second at the school level. Broadly, the project interventions were categorised as nutrition-specific and nutrition-sensitive. Some of the vital interventions that I conducted are as follows –
This intervention was based on providing health promotion and education with a specific focus on spreading awareness about malnutrition and its implications. This was done through community engagement, participation and mobilisation via an Anganwadi centre in the village. The target group, that is, the SAM households was the primary focus of this intervention.
A comprehensive BCC approach (utilising all communication channels such as posters, banners, handbills and leaflets, pamphlets, among others) was devised to disseminate vital knowledge among the households, specifically and the village community, in general.
The main purpose of this intervention was to achieve higher awareness and health literacy levels among the target group, that is, ‘at-risk’ SAM households. Weekly health communication sessions (Swasthya Samwad) were carried out at the village AWC with the help of AWWs.
This intervention was carried out in collaboration with the partner NGO BAIF and the village community resource person. The nutrition garden concept involved procurement and distribution of seeds of perennial food crops/vegetables such as lady finger, spinach, among others, to the SAM households and the Anganwadi centre.
Furthermore, the SAM households were mobilised to set up nutrition gardens at their household/farmland.
Various health awareness campaigns were conducted at regular intervals in collaboration with the village health sub-centre and the Anganwadi centre. The health campaigns comprised of conducting general health check-up camps, immunisation camps, awareness about mobile medical units and medical centres and awareness on environmental health (open defecation, sanitation and general hygiene practices).
In this intervention, the primary focus was to provide the target group essential knowledge about overall good health practices to address the malnutrition issue.
Traditional medicine is critical and has contributed tremendously to the healthcare of both the mother and the child in tribal regions. Jawhar block in Palghar district is a tribal block having rich biodiversity, especially rice varieties having specific characteristics and uses. But during the last two decades or so there has been a gradual loss of practical knowledge about traditional medicine and healing practices in the tribal regions, during the past couple of decades. This has resulted in the poor health status of the most vulnerable sections of the tribal population.
In this intervention, the tribal farmers were encouraged to cultivate diverse rice varieties for purposes such as food security, instant energy provision during peak workload and medicinal use. Further, various ongoing studies conducted by the NGOs such as BAIF Development Research Foundation in different tribal belts across Maharashtra found some rice varieties having specific medicinal properties and uses. For instance, one rice variety called ‘Mahadi’ has multiple health benefits; one of them is to cure weakness in women post pregnancy. Other rice varieties include ‘Rajghudya’ and ‘Kali Kudai’ (used to increase breast milk in lactating women); ‘Kali Khadsi’ (for child’s growth and nutrition); ‘Kasbai’ (used for nebulisation, which gives instant relief from cough) and ‘Dangi’ (used for instant energy boost), among others.
The main purpose of this intervention was to utilise the wonderful diversity of rice and form the basis of a nutritious and secure diet for the vulnerable groups of the tribal population, that is, mothers, pregnant and lactating women and children (under the age of 5) via knowledge dissemination through face-to-face interactions with the tribal farmers.
At the school level, focused health literacy and health promotion sessions (nutrition-sensitive interventions) were undertaken at the Walwanda Tribal High School. The interventions included providing awareness on a balanced diet, girl education, child marriage, water, sanitation and hygiene and malnutrition awareness.
The main objective of this health training module was to impart knowledge about the food types, food uses (i.e. strength, growth and immunity), importance of micronutrients (i.e. Vitamin A, Iodine, Iron, etc.), food hygiene (i.e. washing raw vegetables and eating properly cooked food), importance of exclusive breastfeeding for six months and balanced diet.
Specific focus was given to awareness on micronutrient deficiency and balanced diet. These two factors were critical from the standpoint of malnutrition.
Students were encouraged to adopt a balanced diet and healthy eating practices. For this purpose, various activities and creative learning techniques were devised to spread awareness about food and nutrition.
Here, the children were educated about the importance of food and nutritious food items and inter-linked with colours of the Indian national flag (i.e. saffron, white and green).
In addition to the above, the students were introduced to the concept of BMI and its calculation method (in order to calculate their own BMI regularly). Further, health education material was distributed among the target group.
The interventions that were conducted in this module were class discussions, essay-writing, awareness on hand-washing, drinking water, open defecation, waste management, among others.
A myriad of interventions were conducted for spreading focussed awareness about malnutrition targeting school children. This included class discussions on malnutrition awareness, animation film on malnutrition awareness, anaemia awareness among adolescent girls, among others.
Another major intervention was the introduction of a self-designed malnutrition board game for providing comprehensive health and hygiene awareness to counter the issue of malnutrition. The board game was designed to ensure the lasting positive impact on health education and health promotion among school children and adolescent girls, through fun and an interactive learning experience. Further, the board game was adopted very well by the school management and school students and thus was made part of the school curriculum.
In addition to the aforementioned interventions, various health awareness sessions were conducted to provide awareness about the importance of immunisation, deworming, among others.
Various village and school sanitation events were conducted regularly to instil the importance of critical facets of environmental health viz. hygiene, cleanliness, waste management, among others.
‘Malnutrition Free India’ event was conducted in August 2017 during India’s 71st Independence Day. The village community, including school children, were mobilised to get their health check-up done. The event was conducted in collaboration with the Savali Charitable Trust and village health sub-centre in Walwanda village.
After the health interventions to provide malnutrition awareness, the selected teachers were given the training on healthy practices and malnutrition. This was done to ensure continuity and sustainability of the project post completion of the fellowship.
Two student health ambassadors from standard 8th of the Tribal High School were selected (based on student elections) to conduct training sessions for the next incoming batch of students. Further, the ‘Health Ambassador’ would conduct health promotion activities with the incoming batch of students, mobilise his/her village community and also take responsibility and ownership of managing and maintaining the resources (such as the training modules, health education material, malnutrition board game, etc.), under the supervision of school teachers and the Principal.
Furthermore, as far as the impact achieved was concerned, the quantitative and qualitative impact assessment results were as follows –
Seven out 12 SAM children were categorized as ‘Normal’ (as per height)
One child transitioned from ‘MAM’ category to ‘Normal’ category
Weight – apart from three children, every child gained weight on an average of 0.6 kg
Height – apart from two children, every child gained height on an average of 5cm
MUAC – An average of 0.4 cm increase in MUAC for half of the children under observation
School Level – Impact Highlights
Importance of Balanced Diet – 100% of the class
Hygiene (personal, food and environment) – 98% of the class
Waste management (94%), child marriage (74%), Anaemia (75%) and importance of micronutrients, specifically Iodine (96%) and Vitamin A (74%) in the diet
General awareness levels about malnutrition shot up to 89% (post-intervention) from 48% (pre-intervention)
There was a positive impact on health literacy levels among adolescent school children, especially girls.
The primary focus of this project was both nutrition-specific and nutrition-sensitive factors. As mentioned in the above sections, malnutrition is a multi-dimensional and an inter-generational issue. Rising malnutrition is not only a health crisis but also a ticking economic bomb.
In summary, it was noted that a combination of nutrition-specific and nutrition-sensitive strategies is an effective approach to prevent undernutrition. Post-evaluation of the project interventions concluded that nutrition-sensitive programmes could help scale up nutrition-specific interventions and create a stimulating environment in which young children can grow and develop to their full potential.
Furthermore, the post-evaluation of the interventions and project objectives and aims proved that the project was successful in providing health awareness to the tribal village residents. The project was successful in both mitigating the extent and severity of malnutrition among mothers, pregnant and lactating women and children under the age of five via behaviour change communication and community mobilisation. The project ensured formal health information and knowledge dissemination and improved health and hygiene literacy and increased the awareness levels for malnutrition and malnutrition prevention among adolescent children via interpersonal communication, among others.
Lastly, there is a lot of scope to work on a large number of factors that lead to chronic malnutrition among the vulnerable sections of the society in the most backward tribal/rural areas of our country. This could be done via formulating specific and targeted project designs and interventions to directly or indirectly address a myriad of critical conventional and non-conventional factors to curb malnutrition in the resource-poor settings in our country.
About the Author: Mr Ankur Chhabra is an economist and a public health commentator and policy analyst. He aspires to be a public health promotion specialist. He writes on public health, social issues and development economics on his blog.