Foreword

Keeping in good health is an essential factor, and the lack of it can drastically bring down the well-being of a person. Undernutrition is a critical worldwide public health problem that has urged nations to ensure Zero Hunger and pave the way for its people's Good Health and Well-being as steps towards achieving the Sustainable Development Goals (SDGs) by 2030. Although India has been making a modest progress in the maternal and child health and nutrition sector for the past few years, a lot needs to be done to be at par with the global standards. According to the recently published data from the National Family Health Survey (NFHS) 2019-21, the fifth in the series, significant improvements in critical maternal and child-related indicators are not observed. The data shows that the percentages of severely wasted children under five, obesity among children and adolescents, anaemia among children within the age group of 6-59 months and anaemic women aged 15-19 years have increased from the previous survey (NFHS 4, 2015-16), calling the attention of the policymakers and other stakeholders.

Adding to the concern, the ongoing pandemic poses an increased threat to maternal and child undernutrition and compels us to reflect on the cause-and-effect factor while reanalysing the interventions and delivery mechanisms. With yet another COVID-19 wave expected to hit the country, the uncertain and unexpected movement restrictions may again make it difficult for the people to access crucial healthcare and its related services, thereby leading to a further regression.

Therefore, it has become crucial, now more than ever, to channel our attention towards addressing these critical issues prevailing in the country. World Vision India, as an organisation, is committed to child well-being in the country and has been actively engaging with communities across the nation through various projects that have benefitted thousands of children. Being a child-focused organisation, child health and nutrition programmes are carried out in multiple locations that cater to the children and their mothers and adolescents.

Keystone is a flagship research publication of the organisation that seeks to provide its readers with articles and research findings, with the optimism to initiate evidence-based discourses on child well-being at various levels. With Health and Nutrition as its theme, this edition of Keystone comprises articles that discuss various aspects such as factors influencing breastfeeding practices among young mothers, the impact of behaviour change communication programmes on mothers and communities and significant learnings from our evaluations and assessments that helped in improving our interventions. The issue also features a policy brief on the Anaemia Mukht Bharat programme and a collection of short case studies from across the country that affirm the effectiveness of our key intervention programmes and models.

Investment into this sector and creating the last-mile link are important for early childhood development and a better future for the nation. We hope that this issue would ignite compelling and pivotal conversations among policymakers and other stakeholders that would lead to a change wave, leading India to achieve the SDGs by 2030.

Happy Reading!

Contents

THE CARE GROUP MODEL: Using Behaviour Change Communication to Address Malnutrition

WORLD VISION INDIA'S CHILD HEALTH AND NUTRITION PROGRAMMES: Impact and Learnings

IMPACT OF MATERNAL FACTORS AND SOCIO-DEMOGRAPHIC DETERMINANTS ON EARLY INITIATION OF BREASTFEEDING PRACTICES IN RAJASTHAN

THE ANAEMIA MUKHT BHARAT PROGRAMME: A Policy Brief

ENABLING COMMUNITIES TO BECOME CUSTODIANS OF HEALTH: Case Studies From Across India

The Care Group Model

USING BEHAVIOUR CHANGE COMMUNICATION TO ADDRESS MALNUTRITION IN ODISHA

By Emershia Sharmine - Senior Technical Specialist, Child Health & Nutrition and Dr Subramania Siva – Research Officer, Strategy & Research

This article was developed with the support of Dr Anjana Purkayastha, Dr Neil Devasahayam, Ciju Daniel, Marseibor Lyngdoh, Srilekha Chouhan and World Vision India's Bhubaneshwar Project Monitoring Office Team and the Area Development Programme Teams of Sambalpur, Narla, Khariar and Loisingha

MATERNAL AND CHILD HEALTH IN INDIA

The status of maternal and child health (MCH) indicators broadly defines the quality of health in any region. Adequate nutrition is regarded as a definitive tool for achieving maternal and child health targets. With an aim to meet the Sustainable Development Goals 2 [1] and 3 [2] by 2030, India has a long way to go despite steady progress in recent years. Globally, 14.6% of all live births are with low birth weight and one in five under-five children are stunted, as reported in the Global Nutrition Report 2021 [3]. According to the National Family Health Survey (NFHS) 5, 35.5% of Indian children under five years are stunted, 32.1% are underweight, while 19.3% suffer from wasting [4]. Although efforts to address malnutrition are implemented at various levels, the state of Odisha continues to be plagued by a high level of malnourishment. Almost 31% of children under five are stunted, 18.1% are wasted and 29.7% are underweight [5]. Across the country, despite an improvement in the Antenatal care (ANC) coverage, the percentage of pregnant mothers consuming the recommended 180 iron-folic acid (IFA) tablets is low and there is a wide variation across states [6].

The World Health Organisation has several recommendations for Infant and Young Child Feeding (IYCF) practices for children aged 6-23 months. The key IYCF indicators measure the adequacy of dietary diversity and meal frequency for breastfed and non-breastfed children. In India, only 11.3% of children aged 6-23 months receive an adequate diet, which comprises both diet diversity and minimum meal frequency [7]. Child-under¬nutrition is caused not just by inadequate nourishment but also by frequent illnesses, poor caring, feeding and health-seeking practices, insufficient maternal nutrition and lack of access to health and other social services. The first 1,000 days from the start of a woman's pregnancy until her child's second birthday offer a unique window of opportunity to shape healthier and more prosperous futures. Proper nutrition during this 1,000-day window can have an enormous impact on a child's ability to grow, learn, and rise out of poverty [8].

WORLD VISION INDIA'S CARE GROUP MODEL

Behaviour change communication (BCC) to mothers and key decision-makers in the family is an effective strategy to address the issue of malnutrition as most of the feeding, caring and health-seeking activities are carried out by them. World Vision (WV) India has been implementing various proven models to bring positive behaviour change at the community level. The Care Group Model (CGM) is one such example. It is a peer group-based health promotion programme that quickly and effectively improves health behaviours and outcomes in low-resource communities.

A "care group" comprises 10-15 volunteers from the community, including pregnant women and mothers with children under two. These volunteers facilitate the mothers' group and engage in BCC and are supported, monitored and trained by WV India's project staff known as Care Group promoters and coordinators.

Since 2017, WV India has implemented this first-of-its-kind model in Andhra Pradesh, Telangana, Odisha, and West Bengal. In Odisha, the model was implemented at the block level, whereas it was implemented only in the primary focus areas in the other three states. This research was carried out in Odisha to find out the potency of the model with its objective to improve Maternal and Child Health and Nutrition (MCHN).

STUDY OBJECTIVE

To study the effectiveness CGM on the status of knowledge and practices on MCHN in WV India's operational areas in Odisha.

METHODOLOGY

The baseline for this study was taken in 2017 and the endline was conducted in 2019. Using cluster sampling, the sample was drawn from 30 clusters identified through a random process. The sampling frame constituted all the communities in the intervention area. The communities were listed and the sampling interval was calculated starting with an initial random number. The study covered both intervention blocks and control block.

The first household in each cluster was chosen using the spin-the-bottle technique and thereafter, using the right-hand rule, 14 consecutive households were selected. However, only households with children up to two years were picked, as they were part of the care group. The table below shows the sample size for this study:

KEY FINDINGS

The findings present a comparison between the status of knowledge and practices of the mothers/caregivers on MCHN practices in intervention blocks (Khariar, Loisingha, Narla, Sambhalpur) and non-intervention block (Muniguda). WV India's interventions in the operational blocks started much before this study; hence, some baseline indicators recorded a moderately higher starting point. Compared to the baseline, a significant improvement could be observed in the endline due to the implementation of care groups in the intervention blocks. Overall, these blocks fared better than the non-intervention block. The key indicators discussed in this section are the uptake of ANC services by the mother during her last pregnancy, breastfeeding practised by mothers for children less than six months and diarrhoea management.

1. Ante-natal Care Services

Respondents with children less than two years were asked if they made a minimum of four visits to receive ANC services during their last pregnancy. An increase in the proportion of women who received four ANC visits was observed, with Loisingha showing the highest surge (Figure 1). Sensitisation of mothers and key decision-makers within the families on the importance of ANC checkups and early registration of pregnant women in the Anganwadi centres and Primary Health Centres had led to improved coverage. Peer group experience had been instrumental in motivating pregnant women to receive four ANC visits. Over time, strengthening linkages with the government healthcare services enabled pregnant women to receive various maternity benefits and services. The care group volunteers promoted these services and collaborated with the Accredited Social Health Activists (ASHA) workers at the community level.

2. Breastfeeding Practices

Mothers with children under six months were asked if they exclusively breastfed their child. The 24-hour recall method was administered to check the list of foods/liquids given to the child to identify the exclusive breastfeeding practices. As shown in Figure 2, the proportion of mothers reporting exclusive breastfeeding showed a remarkable increase across all districts in comparison to the baseline figures. Among the intervention blocks, both Khariar and Loisingha demonstrated significant improvement, from 5% and 1.29% to 88.9% and 77.5%, respectively. Following correct breastfeeding skills is essential; as every mother undergoes stress and difficulties in breastfeeding, they would require a proper support system at the health facility and the household level. The CGM was designed in such a manner that the demonstration of some practices was inbuilt, especially positioning and attachment, which were presented within the group meetings for pregnant and lactating mothers. The household visits by the care group volunteers proved to be vital in sensitising the grandmothers and men, which then enabled them to provide the necessary physical and psychological support for effective breastfeeding.

3. Diarrhoea Management

The mothers did not frequently practice administration of Oral Rehydration Solution (ORS) during diarrhoea as per the baseline assessment. It was found that almost all the intervention blocks had shown significant improvement in ORS use during diarrhoea in the endline assessment. ORS availability was also made to the ASHA workers, known to be the "ORS point". The mothers and caregivers were sensitised through the care groups on the effective use of ORS during diarrhoea and were linked to the ORS point at the community level. In group meetings, preparation of ORS was demonstrated, which helped the mothers in the easy preparation of the same. These interventions resulted in an improved usage of ORS for diarrhoea management.

HIGHLIGHTS OF THE MODEL IN ODISHA

• In the initial stage, Information, Education and Communication materials in the form of storybooks were developed based on the barrier analysis done for three behaviours – using toilets, family planning methods, and complementary feeding. Modules were developed and adapted to the local context and translated into the regional language of Odia.
• The Care Group coordinators and promoters were hired from the community to facilitate and network with the people and other local stakeholders. The coordinator's role includes training, monitoring and supervising the promoters while the promoters support the volunteers who train, monitor and manage the care group volunteers.
• After the group formation, consisting of women from the neighbourhood, one of the mothers is selected as the care group volunteer/leader. She facilitates the BCC for the group and the household visits.
• These groups meet once a month and discuss one necessary behaviour change using the books provided. The Care Group facilitator helps in the identification of barriers and solutions from within the group. The group leaders also engage with the key decision-makers to facilitate behaviour change.

DISCUSSION

Findings from the study show that the CGM has been instrumental in bringing about positive behaviour among the community women in the intervention areas concerning receiving ANC services, exclusive breastfeeding and diarrhoea management. Not only has there been a significant improvement between the baseline and endline assessments, but the intervention blocks have shown twice the improvement when compared to the control block in the endline. The study proves that the CGM has been effective in improving the behaviour, thereby addressing the issue of undernutrition.

The ongoing government programmes have been crucial in bringing progress between the baseline and the endline data in the control block. The CGM, on the other hand, has brought about a higher level of progress as it has facilitated BCC within the community, by the community.

A research study from Bangladesh reports that mothers whose neighbours participated in a nutrition BCC intervention scored higher on a measure of infant and young child knowledge and were more likely to feed their children with legumes and nuts, vitamin A-rich fruits and vegetables, and eggs [9]. Thus, BCC is vital and it also identifies the barriers that make mothers practice the promoted nutrition behaviours. There will also be enablers that facilitate the adoption of these behaviours. The CGM is one of the BCC strategies that builds the local community resources by training a pool of mothers from the community, who can facilitate the meeting with their neighbourhood women and identify the barriers and enablers to practice the behaviours. Peer pressure and support within the group enable mothers to adopt behaviours, which is the model's strength. This approach has been well received in the community as mothers meet in small groups with their peers and follow up at the household level.

RECOMMENDATIONS AND CONCLUSION

Through the study, it can be concluded that the improvements observed among the selected indicators point towards establishing the CGM as a viable and effective model which has the potential to be implemented at other locations with a similar setting for a more significant impact. The following recommendations can be considered by policymakers and civil societies to address the issue of malnourishment in their locations -

1. Peer pressure, which is the crux of the CGM, has brought significant improvements in the behaviour of the women and the community. Policymakers can consider replicating this model in remote locations across the country since the government has a wider reach. The low monetary cost requirement makes this a sustainable model and can be easily and quickly initiated in multiple locations.
2. As this model is primarily a non-incentive approach, activities such as exposure visits and talent shows can be periodically arranged to keep the volunteers motivated and enhance their knowledge.
3. Civil society organisations working in this sector can consider replicating this model in their intervention areas and study its effectiveness by drawing a comparison between the baseline and endline data sets. The model can be altered to suit the regional specifications and needs, making it a viable option for organisations.

Improving maternal health is key to saving the lives of more than half a million women who die due to complications from pregnancy and childbirth each year . Strengthening maternal and newborn care, expanding nutrition policies and programmes and implementing innovative methods are crucial in the fight against malnutrition in India. Access to adequate diets, safe water and sanitation facilities, basic literacy and health services during pregnancy and childbirth is vital for the mother and child. Good MCHN practices need to be promoted and followed to ensure that the underweight, stunting, and wasting among young children is reduced.

The CGM has shown improved results not only in Odisha but also in other states. With more mothers in the communities having the power of knowledge and awareness on the best practices during pregnancy and childbirth, the strategy of BCC can be adopted to bring a positive change in the MCHN sector for the better growth and development of children in India.

ENDNOTES

1. Ensuring Zero Hunger
2. Good Health and Well-Being for All
3. Global Nutrition Report 2021 downloaded from https://globalnutritionreport.org/reports/2021-global-nutrition-report/assessing-progress-towards-the-global-nutrition-targets/#section-1-1
4. National Family Health survey – 5 (2019-21). Downloaded from http://rchiips.org/nfhs/NFHS-5_FCTS/India.pdf
5. National Family Health Survey – 5 (2019-21). Downloaded from http://rchiips.org/nfhs/NFHS-5_FCTS/Odisha.pdf
6. https://www.orfonline.org/research/the-5th-national-family-health-survey-of-india/
7. Ibid
8. https://in.one.un.org/task-teams/first-1000-days/
9. Ishita Ahmed et.al, Behavior change communication activities improve infant and young child nutrition knowledge and practice of neighboring non-participants in a cluster-randomized trial in rural Bangladesh, John Hoddinott , PLOS ,Published in June 21,2017, https://doi.org/10.1371/journal.pone.0179866

Only the key variance indicators are given in this article. For the complete report of this study, please reach out to: Emershia_Sharmine@wvi.org.

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World Vision India's Child Health And Nutrition Programmes

IMPACT AND LEARNINGS

By Ciju Daniel - Strategic Lead, Child Health & Nutrition; Rebecca David - Head, Policy and Research; and Dr Anjana Purkaystha - Senior Director - Program Quality, Strategy and Research

BACKGROUND

Over decades, the problems of malnourishment among children and its related clinical illnesses have been a cause of significant concern across the globe, especially in developing and under-developed countries. The term 'malnutrition' has been used to describe a deficiency, excess or imbalance of a wide range of nutrients, resulting in a measurable adverse effect on body composition, function and clinical outcome [1]; although the term ‘malnourishment’ can be used to include individuals who can either be under or overnourished, this term is often used synonymously with 'undernutrition', as in this article.

A common assumption among many is that the Sub-Saharan African region is home to most malnourished children. However, according to a recently released report by United Nations Children's Emergency Fund (UNICEF), the South Asian region has an equal or more proportion of children with undernutrition [2]. The Sub Saharan African region has a population of 1.13 [3] billion spread among 46 countries. In contrast, South Asia has an estimated 1.85 billion people living in eight countries, where India alone holds more than 70% (approx. 1.3 billion [4]) of the total population. Ranking 101 among 116 countries in the Global Hunger Index 2021 [5], India is a massive contributor to the proportion of children with undernutrition globally, emphasising the need for more investment in the Child Health and Nutrition (CHN) sector in the country.

The Government of India has initiated several programmes to improve the nutritional status of children. The National Nutrition Mission, started in 2018, is a flagship programme of the government that illustrates its deep commitment towards achieving the SDG 2 - Zero Hunger [6]. This mission aims to integrate all the efforts towards improving the nutrition status of children and give importance to Social Behavioural Change Communication (SBCC). In 2021, the Ministry of Women and Child Development inaugurated the Poshan 2.0, combining several other services under the umbrella of the scheme. The improvement in several indicators due to these initiatives can be ascertained with the findings from the latest National Family and Health Survey (NFHS) report (Figure 2).

Though the country implements good programmes and community-level delivery structures, there is scope for improvement. At the community level, an Accredited Social Health Activist [7] (ASHA) worker and an Anganwadi (Early Childhood Development centre) worker [8] are allotted for every 1000 population. However, there are several challenges for these workers, which present a significant risk to the design's success and sustainability [9]. Ill-equipped primary healthcare centres to which ASHAs are linked and gaps in the awareness level and performance in the delivery of health and nutrition programmes by the Anganwadi workers [10] are some of the issues that can cause communities to question the reliability and credibility of these community workers. Along with the government, numerous civil society organisations are carrying out interventions across the nation to combat malnourishment among children and improve the well-being of adolescents for a healthier tomorrow. World Vision (WV) India implements various projects in some of the most vulnerable pockets of the country. Through the Area Development Programmes (ADPs), CHN interventions are carried out in 59 locations across the country at the community level by the organisation.

WV INDIA'S PROGRAMMES FOR IMPROVING CHILD HEALTH & NUTRITION (2016 TO 2020)

The key objectives of WV India's CHN programme are aimed at reducing the prevalence of Stunting (less height for age), Wasting (less weight for height), and Underweight (less weight for age) among children less than five years of age in the primary focus areas of each ADP. The strategies adopted for addressing CHN include -

A. Positive Behaviour Change

Nutrition care and support during pregnancy, early identification of danger signs and appropriate antenatal care and institutional delivery are some critical factors that determine an acceptable birth weight for a newborn. The post-delivery early initiation of breastfeeding, exclusive breastfeeding till six months, initiation of complementary feeding after six months, continuous breastfeeding till two years and beyond, and ensuring timely feeding and sufficient diet diversity are required for a child's healthy growth. Positive behaviour changes to adopt these practices must be followed by the communities, and WV India works with community-level volunteers to bring these changes to reduce the incidence of undernutrition. The volunteers and community workers are also trained to coordinate with the Anganwadi centres to ensure that healthcare and nutrition services are provided to all the beneficiaries in the focus area.

WV India follows two project models for behaviour change - the Timed and Targeted Counseling (ttC) and Care Group (CG) model. In ttC, the community level worker visits the beneficiary at fixed time intervals during the gestational period and after birth until the child becomes two years old. In the Care Group, community-level workers are trained to conduct small group meetings with pregnant women and mothers of under two years where information on pregnancy care, health and nutrition is provided. They also visit the households of the target group to support the families to adopt healthy behaviour. The community-level workers also support in growth monitoring at the Anganwadi centre and follow-up with children who are malnourished. Food baskets are also provided to the families who have severely wasted children.

B. Assistance To Improve Nutritional Resilience

Improving food security and nutritional resilience at the household level are essential for an increased diet diversity in houses. Skill development training and financial assistance are provided to selected low-income families to have an additional income from farm or non-farm activities for a limited period to increase their ability to procure diverse food products. To promote diet diversity, household-level nutrition garden and backyard poultry are also supplied to selected beneficiaries.

C. Improving Safe Drinking Water Availability, Sanitation and Awareness on Hygiene

Since hygiene, sanitation and safe drinking water play an important role in child nutrition, WV India invests in improving infrastructure related to safe drinking water in the communities. This includes the construction of borewells, rejuvenating existing water sources, extending pipe connection, provision of water filters wherever required, etc. The construction of toilets was carried out by partnering with the government through various schemes. Along with this, awareness programmes on improving the safe handling of water and handwashing behaviour are organised regularly.

D. System Strengthening

The system-strengthening efforts include training Anganwadi workers on effective communication and growth monitoring, construction and repair of Anganwadi centres, advocacy efforts to improve the service quality delivered through Anganwadi centres, etc.

PROGRAMME IMPLEMENTATION

In 2016, the organisation focused on the selection, orientation and training process of the project staff and community workers so that the foundational aspects of the interventions are effectively grasped. The implementation of the programmes started in 2017.

To make programmatic decisions for improving the interventions, the organisation carries frequent and rigorous evaluations wherein the data collected at the field level is analysed and compared with various datasets for an in-depth understanding. With the COVID-19 pandemic causing a major global disruption, rapid assessments were conducted in the operational areas to assess and monitor the impact of the situation at the grassroots to design appropriate response measures. This article has been developed using CHN-related statistics from the 2016 and 2019 evaluation data and the 2021 rapid assessment datasets to provide the readers with an illustration of evidence-based programmatic adaptation carried out by WV India to address CHN issues.

STUDY METHODOLOGY

The baseline assessment, conducted in 2016, and the endline study, carried out in 2019, adopted the random cluster sampling method to select respondents. The baseline data includes information from 64 ADPs, while the endline data contains data from 58 target locations since six ADPs phased out during the period. A sample of 600 households with children aged between 0 and 59 months were selected from each ADP. A structured questionnaire having multiple sections applicable to different cohorts was used for data collection by trained facilitators. The same survey tool was used for both baseline and endline assessments. Data cleaning and analysis were carried out by the evaluation team of WV India.

In August 2021, the rapid assessment survey primarily of the COVID-19 context was conducted with 5726 households in 102 locations across the country. The study samples were from the geographical locations covered by the ADPs for interventions. The quantitative study tool was a structured questionnaire and focus group discussions were organised to collect qualitative information.

FINDINGS

1. Baseline and Endline study

A baseline study for the CHN programme was done in 2016 and, nearly four years after the initial assessment, an endline study was done in 2019, and following were the major indicators measured for the study and the results achieved as a result of the programmes -

*For the indicators like stunting, wasting and underweight, the aim is to reduce the prevalence. But for the behaviour change indicators, the objective is to increase the magnitude.

The findings showed a reduction of 4.95% in stunting and about a 2% decrease in the prevalence of underweight children, but wasting had increased by 2.6%. A significant difference was observed in the behaviour change indicators, which are some of the key influencers for the nutrition status of children. The exclusive breastfeeding rate, which is purely a practice related indicator, increased from 58.3% to 72.8%. An improvement in the coverage of essential vaccines and skilled care during delivery was detected; both these indicators depend heavily on the availability of the service and quality of service delivery. Along with behaviour change messages, system-strengthening and advocacy efforts could have been an added influence for these indicators. The augmented household diet diversity (from 50.13% to 71.46%) is a possible result of the behaviour change interventions along with the additional support provided to enhance the purchasing power of the families. The regular awareness programmes on reducing open defection and using toilets have been critical in increasing the sanitation facilities, which is crucial for improving the nutrition status of children.

The anthropometric results showed a wide scope of improvement when compared with the behaviour change indicators. An increase in the prevalence of wasting among children was identified (from 15.40% to 18.05%). Since the assessment designs did not probe into the exact reasons for this anomaly, further studies would be carried out to identify the causes responsible for the increased prevalence of wasting among children.

2. COVID-19 Rapid assessment study

The rapid assessment survey, carried out in August 2021 after the onset of the COVID-19 pandemic, contained critical questions related to the CHN sector, such as the availability of services, changes in breastfeeding practices, diet diversity affordability and knowledge on COVID-19 among mothers. Following are the key findings from the assessment -

It was observed from the findings that pandemic had negatively affected the communities by reducing the progress created by the CHN programmes. Around 19% of mothers (with children less than two years) had stopped or reduced the breastfeeding frequency and about 50% reported that weakness due to lack of nourishment was the sole reason. Only 46.9% of mothers were confident that the COVID-19 virus would not get transmitted through breast milk. Diet diversity, which is vital for combating malnutrition among children, was affected in a majority of the households as they were unable to afford protein-rich food items. The qualitative study revealed that the coping mechanism included less consumption of expensive products like non-vegetarian food, eggs and, in some cases, milk.

LEARNINGS

• Though the survey results on behaviour change showed increased progress, it could not be translated to the expected rate in reducing the key indicators of stunting, wasting, and underweight among children under five years.
• The COVID 19 rapid assessment study results showed there could be accessibility issues for CHN services and a reduction in the following of healthy practices if there are continued restrictions. The lack of appropriate knowledge was a concern, as well as a reduced diet diversity due to losses in livelihood.
• The reasons for the increased wasting need to be studied. During the field visits, it was observed that the children preferred consuming packed foods from the local shops, such as fries, sweets, etc., rather than home-cooked food. Excess consumption of these unhealthy treats may affect children's appetite, bringing down their appeal towards home-cooked food. Intensive behaviour change communication must be carried out to address this rising concern.
• Management of children with wasting should not be limited to referral to Nutrition Rehabilitation Centres (NRC) and food basket distribution. Unique personalised approaches need to be identified based on the reasons for undernutrition at the household level to build the resilience of the families to manage those situations.
• Exclusive breastfeeding was a challenge for working mothers, especially those who worked in unorganised sectors, including agriculture. Hence, interventions needed to be adapted to find plausible solutions to the problem and increase awareness among this group.
• The knowledge of the community-level workers had increased through the capacity building programmes done by WV India. However, it was found that there are limitations in communicating messages to the beneficiaries. Interventions to convey messages to the beneficiaries in a better way by using audiovisual communication methods that can trigger discussions with beneficiaries could be more effective.
• Strengthening the existing community-based health delivery system was required to improve the effective utilisation of services. This included observing Village Health Sanitation and Nutrition days, coverage of campaigns like Iron and Folic Acid programmes for pregnant women and adolescent girls, Vitamin A supplementation, National Deworming Day, Intensive Diarrhoea Control Fortnight etc.

ADAPTATIONS IN NEW PROGRAMME CYCLE (2021 TO 2025)

Based on the learnings from the three assessments, the following adaptations are now included in the current programme cycle of WV India to improve the CHN indicators-

1. Assessment checklist: All children identified as Severe Acute Malnourished (SAM) will be assessed to determine the possible reasons for the child being malnourished. The assessment will be done after visiting the child's house by a community worker of WV India who will identify, with a structured checklist, the reasons (such as lack of food or appropriate care, issues related to possible infections, individual and environmental hygiene, etc.). Based on this, appropriate interventions like providing a food basket, counselling for better care and hygiene or supporting the family to get healthcare in the case of infections will be provided.
2. Improvement in communication: Sometimes, the messages will not be conveyed effectively to the beneficiaries due to the poor communication skills of the community workers. A specific focus on improving communication skills will be given during their training sessions. Using short animated videos, along with the storybooks, would be taught to the community workers conveying messages to the beneficiaries.
3. Increased partnerships and collaborations: The organisation will support the existing government programmes by providing human resources at the Block, District and State levels through partnerships with bilateral organisations like UNICEF.
4. Boost awareness levels: Challenges in accessing government schemes and programmes by the community related to child health and nutrition were observed in the studies. Hence, the organisation will proactively promote awareness and support the communities in accessing government schemes and projects.
5. More emphasis on diet diversity: Communication materials on cooking demonstrations on improving diet diversity among children to be developed and distributed to households. These materials would be helpful to the mothers in preparing healthy and tasty food for their children. Interventions to improve the purchasing power of families will have the consumption of protein-rich food items as one of the indicators as a target.
6. MUAC training: More mothers will be trained on identifying the nutrition status of their children using the Mid Upper Arm Circumference (MUAC) tape, which would be beneficial to them in case they are unable to access the necessary services.

CONCLUSION

The theory of change adopted by WV India to reduce the prevalence of malnutrition among children is a well-accepted one and is similar to the conceptual framework recommended by the UN standing committee on nutrition 2008. There is always scope of improvement in the programme interventions based on the situation. WV India's Child Health and Nutrition programmes are implemented in 13 states spread across the country. Every communication material developed by WV India is available in six different languages and can be adapted based on the community's needs. Improving maternal, infant and young child nutrition expands opportunities for every child to reach their full potential. Based on the learnings, WV India had adapted its programmes to provide the best response and work with the government, complementing its efforts to improve the coverage so that every child in the country can experience the fullness of life.

ENDNOTES

1. Elia M, editor. Guidelines for detection and management of malnutrition. Malnutrition Advisory Group, Standing Committee of BAPEN. Maidenhead: BAPEN, 2000.
2. State of World’s Children, October 2021, UNICEF
3. State of World’s Children, October 2021, UNICEF
4. Report on technical group on population projection, Population projection of India and States, Census of India 2011. https://main.mohfw.gov.in/sites/default/files/Population%20Projection%20Report%202011-2036%20-%20upload_compressed_0.pdf
5. Global Hunder Index India 2021. https://www.globalhungerindex.org/pdf/en/2021.pdf
6. Sustainable Development Goal. https://sdgs.un.org/goals
7. ASHA workers are appointed by Department of Health and Family welfare. One ASHA worker is for 1000 population, they are compensated by incentives.
8. Anganwadi worker is under Department of Women and Child development. They are working in the ECD centers at community level which is the basic delivery point for child nutrition and pre primary education.
9. Saprii, L., Richards, E., Kokho, P. et al. Community health workers in rural India: analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles. Hum Resour Health 13, 95 (2015). https://doi.org/10.1186/s12960-015-0094-3
10. Manhas S, Dogra A. Awareness among Anganwadi workers and the prospect of child health and nutrition: a study in integrated child development services (ICDS) Jammu, Jammu and Kashmir, India. Anthropologist. 2012;14:171–175. https://doi.org/10.1080/09720073.2012.11891235

Contact Ciju Daniel at ciju_daniel@wvi.org for more details.

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Impact Of Maternal Factors And Socio-Demographic Determinants On Early Initiation Of Breastfeeding Practices In Rajasthan

By Harish Chand - Senior CH&N Technical Specialist, World Vision India and Jyoti Sharma - Additional Professor, Indian Institute of Public Health, New Delhi

This article was previously published in the International Journal of Community Medicine and Public Health (August, 2020).

INTRODUCTION

The World Health Organization (WHO) recommends early initiation of breastfeeding (EIBF) within one hour of birth and exclusive breastfeeding (EBF) for the first six months [1]. The EIBF triggers milk production, produces antibodies for newborns and establishes breastfeeding for a longer duration [2]. It is highly beneficial for the child and its mother since it is a crucial predictor of exclusive and continued breastfeeding and facilitates mother-child bonding that controls the child’s temperature, preventing the newborn from the threat of hypothermia and hypoglycaemia in the first week of its life [3].

Sustainable development goal (SDG)-3 recommends reducing neonatal mortality to below 12 per 1000 live births [4]. A systematic review study from multiple countries reveals that if a newborn is breastfed within one hour of birth, about 44-45% reduction in relative risk (RR) of neonatal mortality can be achieved [5]. The study indicates that children who were not breastfed by mothers within the first hour of birth had 2.93 times the odds of neonatal death compared to children who were breastfed within the first hour of birth [6]. A meta-analysis study reveals that newborns who were breastfed after one hour of birth had a 33% higher risk of neonatal mortality. A newborn who was breastfed after 24 hours of delivery was more than twice as likely to die before completing one month [7]. Studies indicate that 22.3% of neonatal deaths could be prevented if EIBF is performed within one hour of birth [8]. To curb neonatal mortality, initiation of breastfeeding within the first hour of birth is a proven high-impact intervention [9]. In India, EIBF nearly doubled from 23% to 41.6%, between 2005–06 and 2015–16, and India reports 41.8% (2019-21) as the current rate of early initiation within the first hour of birth [1,10,11].

RATIONALE*

*Note: The following study was carried out in 2018, before the release of the NFHS 5; hence certain details have been retained as per the original report.

National Family Health Survey (NFHS-5) highlights breastfeeding rate as 40.7% for Rajasthan which is slightly lower than the national average (41.8%). A sharp increase in early initiation of breastfeeding was observed from 28.4% between 2015-16 (NFHS-4) to 40.7% in 2019-21 (NFHS-5) in the state. The data from NFHS-4 revealed that 37.7% of newborns were not breastfed within the first hour of birth, though delivered in the health facilities [12].

In view of the Infant and Young Child Feeding (IYCF) guidelines and current practices of early initiation of breastfeeding, this study explores the underlying causes and factors that influence breastfeeding practices, especially EIBF.

OBJECTIVE

To study the impact of maternal and socio-demographic determinants on early initiation of breastfeeding within one hour of birth in Alwar, Rajasthan.

METHODOLOGY

The study followed a mixed methodology design. The initial data collection was conducted in 2018 in 52 villages from the Rajgarh block of Alwar district in Rajasthan. A census survey was conducted beforehand to determine the sampling frame that consisted of a list of mothers with children < 3 years of age in the estimated 40,000 population in the block. The sample size (n=322) was calculated based on the prevalence of newborns breastfed within one hour after birth (29.8%) [13] , taking into consideration ± 5% precision and 5% non-response rate. The final sample size was 400 based on the availability of the respondents. There were five points to measure the knowledge of the participants towards breastfeeding. Each point in the questionnaire had possible responses, either correct practices or incorrect practices [14]. One mark was awarded for every correct response, zero otherwise. Hence, the score in the knowledge section ranged from 0-5. Qualitative data was collected through a face-to-face interview during the household survey using a pre-defined interview schedule. Mothers of children up to six months were included for analysis of EBF. Mothers who scored a five for knowledge and three for practices on EIBF were considered as having positive knowledge and practices. The data was checked and analysed using statistical software SPSS version 23.0 and data visualisations were done using MS Excel 2007.

Since the initial data collection was carried out in 2018, a follow-up focus group discussion (FGD) was conducted in the four locations of the same block in November 2021. A total of 31 mothers with children below six months of age participated in these discussions. The FGDs were facilitated by trained World Vision (WV) India project co-ordinators and health workers with one moderator and one documenter for each group. The average time spent on each session was 45 minutes and the collected data was synthesised at the block level by the team.

To analyse the association of EIBF with socio-demographic and maternal factors, a multivariate analysis was done using a logistic regression model constructed after adjusting for those factors that had an association as per previous literature. Pre- and post-estimation checks were done on the model. Finally, the adjusted odds ratio (AOR) and 95% confidence interval were reported.

FINDINGS

As per the study design, 400 mothers of children 0-36 months with mean age 14.9 + 7.8 months participated in the study. The average age of mothers was 25.9 + 4.2 years. Around 84% of mothers were of the appropriate reproductive age (20-30 years), while only 12% of the mothers were below 20. Only 11.5% of mothers conceived before their last child reached three years. Less than a quarter (19%) of the mothers had below poverty line cards, whereas less than 1% had Antyodaya ration cards to receive subsidised ration. More than half (63.5%) the respondents lived in a joint family setting (Table-1).

The survey results revealed that more than half of the mothers had heard about colostrum. The majority (97%) of the mothers knew that the mother’s milk is the only food that a newborn should receive after birth, and 47% of mothers knew that EIBF helps the child to suck milk and aids in expelling the placenta. Respondents had expressed that EIBF helped in the emotional bonding of the mother and child, ensuring an easier feeding process. Less than half of the mothers had practised EIBF without any knowledge on its benefits. Caesarean deliveries, children with low birth-weight and engorged nipples were some factors for the delay in EIBF to the newborn, as mentioned by the mothers. The prevalence of EIBF was observed to be significantly higher in Rajgarh block (75.8%) which is WV India’s operational area, as compared to the Alwar district (33.5%, NFHS 5) . The significantly higher percentage captured for this indicator may be attributed to the outcome of the nutrition interventions and collaborations with the district administration being carried out by WV India in the block. The organisation has been working in the block for more than seven years through its projects.

The 2018 survey results showed that around 86% of mothers in the sampled area practised EIBF, whereas 49.5% of mothers did not practice it though they had good knowledge on the subject. Mothers had expressed that many a times even education did not play a critical role in effective breastfeeding, instead adhering to appropriate childbearing age and family support enabled breastfeeding to the newborn. About 77% of mothers in nuclear families practised EIBF, which was higher than mothers living in joint families (74.8%). It was also observed that support from mothers-in-law and family was essential during the first 24 hours of delivery. Mothers-in-law helped with positioning the child, breast attachment and latching, and provided emotional support to the nursing mother. About 77% of mothers in nuclear families practised EIBF, which was higher than mothers who lived in joint families (74.8%). Mothers-in-law, doctors/ANMs and other family members were some of the key sources of breastfeeding information for the new mothers.

Factors such as the mothers’ age, qualification, number of live births, family type, place of delivery, level of knowledge on breastfeeding, monthly income and source of breastfeeding knowledge within first hour of birth were significantly associated with EIBF in the multivariate analysis (see Table 2). Chances of breastfeeding the child within one hour of birth were 4.44 times higher in women with good knowledge than mothers who had no knowledge or poor knowledge of EIBF Mothers who acquired breastfeeding knowledge from health workers were 4.24 times more likely to initiate breastfeeding within the first hour of delivery than those who received knowledge about the same from family members. It was interesting to note that the mothers who delivered in health facilities were less likely to breastfeed newborns within the first hour of birth than those who delivered at home . Kavita from Rajgarh block had expressed during the FGD that she had initiated breastfeeding after three hours due to caesarean delivery. The FGD revealed that only 19.4% (6 out of 31 mothers) delivered their babies in private hospitals.

RECOMMENDATIONS

The prevalence of EIBF was observed to be significantly high, yet less than a quarter (24.7%) of children born in healthcare facilities were not initiated with early breastfeeding. Policy-makers and civil society organisations may consider the following recommendations as a way forward for future interventions and programmes -

1. Policy level decision-makers may consider increasing two additional counselling visits during the third trimester to emphasise and promote EIBF. Appointment of additional maternal healthcare workers (like the Yashoda scheme in Rajasthan) for supporting EIBF in the delivery rooms in every healthcare centre and enhancing their knowledge and skills would have a considerable impact in the communities where proper practices are not followed.
2. Enhance the knowledge of the Auxiliary Nurse Midwives, ASHA and Anganwadi workers through regular training programmes that can be organised by civil societies in partnership with the local governments to mobilise mothers-in-law to support mothers during the intrapartum period and EIBF within one hour of birth.
3. Civil societies can also consider developing behaviour change interventions to address the attitude and myths of mothers and mothers-in-law towards EIBF and EBF, and colostrum feeding.

CONCLUSION

EIBF is a precursor to exclusive breastfeeding and optimal breastfeeding practices. Delay in EIBF is denying the first food of life to the newborn baby. A disparity was observed between EIBF (40.7%) behaviour and institutional births (94.9%), NFHS-5, 2019-2021 in Rajasthan. However, there appears to be an excellent opportunity for the government, Civil Society Organisations and Non-Governmental Organisations to further improve the situation. The state of Rajasthan took an exemplary step to introduce Yashoda (aid to the mother) workers, who support in facilitating EBIF in the delivery rooms. By emphasising on and replicating such critical interventions, we can achieve SDG 3.2 - to end preventable deaths of newborns and under-5 mortality. The factors and barriers associated with the delay of EIBF may be studied further to design specific programmes to increase the practices and avert neonatal mortality and improve child health and survival.

ENDNOTES

1. Young MF, Nguyen P, Kachwaha S, Tran Mai L, Ghosh S, Agrawal R, et al, It takes a village: An empirical analysis of how husbands, mothers‐in‐law, health workers, and mothers influence breastfeeding practices in Uttar Pradesh, India, Maternal & child nutrition, 2020 Apr;16(2):e12892.
2. Kenzo T, Togoobaatar G, Erika O, Joao P Souza, Malinee L, Cynthia P C, Prevalence of early initiation of breastfeeding and determinants of delayed initiation of breastfeeding: secondary analysis of the WHO Global Survey, Scientific Report, March 2017
3. Precious A Duodu, Henry O Duah, Veronica M Dzomeku, Adwoa B Boamah Mensah, Josephine Aboagye Mensah, Ernest Darkwah et al., Consistency of the determinants of early initiation of breastfeeding in Ghana: insights from four Demographic and Health Survey datasets, International Health, ihaa017, 3 (2020).
4. The Global Health Observatory, WHO. https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-group-details/GHO/sdg-target-3.2-newborn-and-child-mortality
5. Kanchan Kumar Sen, Taslim Sazzad Mallick, and Wasimul Bari, Gender inequality in early initiation of breastfeeding in Bangladesh: a trend analysis, Int Breastfeed J. 2020; 15: 18
6. Ibid.
7. Emily R. Smith, Lisa Hurt, Ranadip Chowdhury, Bireshwar Sinha, Wafaie Fawzi, el ne, Delayed breastfeeding initiation and infant survival: A systematic review and meta-analysis, PLoS One. 2017; 12(7): e0180722. Published online 2017 Jul 26. doi: 10.1371/journal.pone.0180722
8. Senait G Gebremeskel, Tesfay T Gebru, Berhanu G Gebrehiwot, Hadush N Meles, Betell B Tafere, Guesh W Gebreslassie et al., Early initiation of breastfeeding and associated factors among mothers of aged less than 12 months children in rural eastern zone, Tigray, Ethiopia: cross-sectional study, BMC Res Notes. 2019; 12: 671.
9. Aguayo, Víctor & Gupta, Gagan & Singh, Gayatri & Kumar, Rakesh. (2016). Early initiation of breast feeding on the rise in India. BMJ Global Health. 1. 10.1136/bmjgh-2016-000043.
10. National Family Health Survey-5 2019-2021
11. Sankalp S, P S, Kajal J, Vanita S, Praveen K, Improving First-hour Breastfeeding Initiation Rate After Cesarean Deliveries: A Quality Improvement Study, December 2017.
12. National Family Health Survey-4 2015-2016,
13. NFHS-4, Alwar District, Rajasthan, India, http://rchiips.org/nfhs/FCTS/RJ/RJ
14. Adapted from Food and Agriculture Organization’s (FAO’s) manual, guidelines for assessing nutrition-related knowledge, attitude and practices, incorporated into research questionnaire.

For further information, write to harish_chand@wvi.org

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The Anaemia Mukht Bharat Programme

A POLICY BRIEF

By Rebecca S David, Head – Policy and Research & Ciju Jacob Daniel, Strategic Lead - Child Health & Nutrition

With inputs from Dr Anjana Purkayastha, Senior Director - Program Quality, Strategy & Research

INTRODUCTION

Anaemia is a grave concern in India because it impairs cognitive development, increases morbidity from infectious diseases and stunts growth. One of the most common causes of anaemia globally is iron deficiency. However, other nutritional deficiencies such as folate, vitamin B12 and vitamin A, chronic inflammation, infectious diseases like parasitic infections, malaria, tuberculosis and inherited disorders like glucose-6-phosphate dehydrogenase deficiency, congenital hereditary defects in haemoglobin synthesis etc. can result in anaemia (WHO). The World Health Organization defines anaemia as Hb < 120 g/L for non-pregnant women and < 110 g/L for pregnant women and children. Iron-deficiency anaemia adversely affects the transport of oxygen to tissues and results in diminished work capacity and physical performance. Iron-deficiency anaemia can result in impaired physical growth, poor cognitive development, reduced physical fitness and work performance and lower concentration on daily tasks (MoHFW, 2012; Nambiar & Ansari, 2020). The most dramatic health effects of anaemia, i.e., increased maternal and child mortality risk due to severe anaemia, have been well documented.

India accounts for the highest burden of anaemia, globally (IFPRI, 2018). According to the recently released National Family Health Survey (NFHS-5), the prevalence of anaemia in India is high and, despite efforts, has shot up from the previous NFHS. According to the NFHS-5 (2019-20), 67.1% of children were identified as anaemic; 59.1% of adolescent girls and over half of the pregnant women (52.2%) in the country suffer from the disease. In the last fifty years, despite substantial programmatic efforts, progress has been slow throughout the lifecycle among adolescent girls (15-19 years), women of reproductive age (15-49 years), pregnant women, and children (6-59 months), and it continues to be a major public health problem (IFPRI, 2018). Figure 1 shows the anaemia prevalence from 2015 to now, according to the NFHS.

There is substantial research to show that anaemia affects the life cycle: adolescents, mothers and children. Anaemia in children 'has a complex multifactorial aetiology and is widely prevalent across all socioeconomic groups in India' (Chaparro et al.). An 'analysis of anaemia among mother-child pairs reveals that in 37% of cases both the mother and the child are anaemic, whereas the pair is non-anaemic only in 21% of cases. In 22% of cases, the mother is not anaemic, but the child is anaemic, and in 20% of cases (the) mother is anaemic, but the child is not anaemic. This finding reveals that 63% of paediatric anaemia cases are directly associated with maternal anaemia' (AMB Policy Brief).

'Nutritional anaemias' are a cause of much concern; they result when the intake of certain nutrients is insufficient to cover the demands for the synthesis of haemoglobin and erythrocytes (Nambiar & Ansari, 2020). Nutritional anaemia is a serious public health problem (WHO, 2017). The topmost cause of nutritional anaemia is Iron deficiency; this is identified as the leading cause of anaemia in the Indian context and contributes to 50% of anaemia cases (Balarajan et al., Lancet 2011). From a policy perspective, it is important to note a strong association between anaemia in young children and consumption of 180 or more IFA tablets during pregnancy (Bhatia et al., 2018). In a study published in the Lancet in July 2020, the authors found that 'Folate or vitamin B12 deficiency anaemia' accounted for a quarter of the anaemias among school-aged children and adolescents and almost 20% among 1–4 year-olds (Sarna et al., Lancet 2020). There is also a connection between the non-consumption of deworming tablets and the prevalence of anaemia.

THE ANAEMIA MUKHT BHARAT PROGRAMME

Various initiatives have been tried by the Government of India, over the years. These could be traced to the to the first national anaemia control programme started in 1970, which has subsequently evolved into the ongoing Intensified National Iron Plus Initiative(I-NIPI) over the years. In 1970, the National Nutritional Anaemia Prophylaxis Programme started with three target group beneficiaries, i.e. pregnant, lactating women and children (between 1-5 years). In 2007, a 12-by-12 initiative was launched, jointly undertaken by the Ministry of Health and Family Welfare, WHO, UNICEF and others to ensure that every child would have a haemoglobin of 12 grams by 12 years by 2012 (Bhatia et al., 2018). In 2012, a Weekly Iron Folic Acid Supplementation (WIFS) Programme was launched and adolescent girls were also added to the target group. In 2013, National Anaemia Control Programme and the WIFS Programme were integrated into the NIPI that used the lifecycle approach (MoHFW, 2018). In 2018, to intensify the efforts made towards anaemia reduction, the NIPI was changed to (I-NIPI), popularly known as Anaemia Mukht Bharat (AMB) (Nambiar & Ansari, 2020). The reduction of anaemia is one of the critical objectives of the POSHAN Abhiyaan launched in March 2018, the Prime Minister's overarching scheme for Holistic Nutrition.

The new 6x6x6 strategy of AMB caters to a set of six beneficiaries, six interventions and six institutional mechanisms. The target is to reduce the prevalence of anaemia by three percentage points per annum. The interventions include distributing iron and folic acid supplementation and deworming tablets, intense behaviour change communication for promoting consumption of iron-rich foods and appropriate infant and young child feeding practices, testing and treating anaemia among school-going adolescents and pregnant women and use of IFA-fortified foods in public health programmes. Importantly, other than children, adolescent girls, women of reproductive age, pregnant and lactating women, the AMB also covers adolescent boys aged 15-19.

The programme is carried out in coordination with various ministries: Tribal Welfare, Women and Child Development, Ministry of Rural Development & Panchayat Raj, Ministry of Human Resource Development. The 6x6x6 strategy is summarised in the table below:

WV INDIA'S INTERVENTIONS TOWARDS ERADICATING ANAEMIA

World Vision India's Child Health and Nutrition team works in coordination with the Government to ensure the smooth implementation of the AMB programme, especially in vulnerable and high-risk settings. This is also in alignment with our endeavour to ensure that the Sustainable Development Goals 2 and 3 [1] are met. Through its Timed and Targeted Counselling (ttC) model, WV India works with the community health volunteers who support the work of Accredited Social Health Activists (ASHAs) [2] to ensure that mothers and children are catered to. The ttC model is an internationally proven behaviour change model on child health and nutrition for the first 1000 days. A trained community-based worker visits the beneficiaries' houses in fixed intervals and provides counselling based on the requirement of that time through well-structured communication material. This community worker ensures that women (especially pregnant and lactating women) are counselled and are taking their IFA tablets at correct times; in addition, improving the quantity and quality of food, motivating the pregnant women to attend all necessary ante-natal care sessions, consumption of deworming tablets, the importance of rest for pregnant women, early identification of danger signs and maintenance of personal and environmental hygiene are emphasised on. Positive and negative scenarios in the form of stories are used to educate the families, and a family book is used to record and negotiate for the positive behaviour change in each visit.

KEY RESULTS OF WV INDIA'S TTC PROGRAMME

It is important to note that in the WV India programme area, 44.7% of women reported that they consumed 180 IFA tablets during their pregnancy, whereas according to the NFHS-5, the national average is 26.0%.

The WIFS programme is an initiative under AMB targeted towards improving the anaemia status among adolescent girls in the age group 10 to 19 years. WIFS tables are provided to all school-going girls and boys at government schools; girls who are out of school are provided with the tablets through Anganwadi [3] centres. WV India staff found a hesitancy among the teachers to distribute the tablets fearing adverse events linked to its consumption; additionally, there was no proper monitoring mechanism ensuring that the teachers complied and distribution took place. Further, sensitisation of WIFS was limited to children; it needs to be expanded to the community level and at the level of parents. Based on this concept, WV India is initiating sensitisation of parents (especially of adolescent girls) as part of its nutrition programmes.

RECOMMENDATIONS

• Behaviour change communication is an essential component to fighting anaemia. The WV India's ttC model has worked well because of the investment into each pregnant woman and adolescent, and counselling that goes in.
• For an accelerated reduction in anaemia, effective convergence of several governmental departments like health, women and child development, education, water supply and sanitation is needed. Improved clarity and coordination between departments would ensure proper distribution and reduce stock pile-ups of the tablets.
• Availability and affordability of iron-rich food items and absorption are key factors that need to be looked into. On the availability, one idea often promoted is that of kitchen gardens. In addition, the Government and civil societies must look for ways to enhance livelihoods for families to afford iron-rich foods.
• Nutrition baskets for pregnant women in high-risk areas must be scaled up; these are promoted both by the Government and WV India.
• Delivery of WIFS tablets straight to the school and/or Anganwadi centres and collecting reports directly from the respective schools will help the programme be implemented and reported more effectively. ASHAs and ANMs (Auxiliary Nurse Midwife) must visit schools periodically to understand the issues related to the distribution and consumption of WIFS tablets. It needs to be recognised that a school teacher's primary responsibility is not the distribution of tablets.
• Social and Behaviour Change Communication (SBCC) at the community level, especially targeting parents of adolescents, is required for more acceptance of WIFS tablets. Presently, most communication is limited to adolescent girls only. If there is an increased community demand, the system will be more proactive on the supply side. The state governments should budget and also partner with civil societies and non-governmental organisations to build awareness in the community.
• SBCC is also required for the consumption of deworming tablets; if proper community awareness is not there, there can be negative publicity about the pills which may affect consumption rates. State governments should budget to promote National Deworming Day (NDD) and partner with non-governmental organisations in building awareness in the communities.
• ASHA Workers must be provided with sufficient information, education and communication (IEC) materials that will help them educate pregnant women and lactating mothers on the importance of the consumption of IFA tablets and its minor side effects and the importance of consuming iron-rich food along with proper sanitation and hygiene.
• For children under 5, the ANMs and ASHA workers should demonstrate the functioning of the auto dispenser (attached to the bottle, which provides 1ml) while distributing the IFA syrup to children. For the IFA syrup to be utilised effectively, mothers must be given proper education. Initiatives to improve the taste of IFA syrup for children can be undertaken to increase its acceptability.

CONCLUSION

The NFHS-5 paints a very dismal picture of the anaemia situation in the country; the Government and Civil Society need to make concerted and coordinated efforts to address the issue. The civil society support to the Government programmes is the need of the hour; more community-level workers need to support the existing health workers at the village level (ANM, ASHA and Anganwadi Workers) to reinforce behavioural changes and handhold community members towards better health outcomes. While the AMB programme lays out an excellent 6x6x6 strategy at the national level and for states to follow, the actual implementation of the programme at the ground level needs to be strengthened.

ENDNOTES & REFERENCES

1. SDG 2- End hunger, achieve food security and improved nutrition, and promote sustainable agriculture and SDG 3- Ensure healthy lives and promote well-being for all at all ages
2. ASHAs are health activist(s) in the community who create awareness on health and its social determinants and mobilize the community towards local health planning and increased utilization and accountability of the existing health services. They are provided outcome based remunerations and financial compensations.
3. Government-sponsored early childhood development and mother-care centre at village level.

• Anaemia Mukt Bharat | A programme by Ministry of Health and UNICEF (https://anemiamuktbharat.info)
• Avula, R., P.H. Nguyen, S. Scott, A. Agarwal, and P. Menon (2018). 'Tracking anaemia and its determinants from 2006 to 2016 in India: Insights from the National Family Health Survey-4'. POSHAN Data Note 35. New Delhi, India: International Food Policy Research Institute.
• Balarajan Y, Ramakrishnan U, Özaltin E, Shankar AH, Subramanian SV (2011). 'Anaemia in low-income and middle-income countries'. Lancet 2011; 378: 2123–35.
• • Bhatia V, Sahoo DP, Parida SP (2018). 'India steps ahead to curb anaemia: Anemia Mukt Bharat', Indian Journal of Community Health 2018; 30, 4: 312-316.
• Centre mulling over new testing modes after anaemia surge - The Hindu. https://www.thehindu.com/news/national/centre-mulling-over-new-testing-modes-after-anaemia-surge/article37689619.ece
• Chaparro C.M. and Suchdev, P.S., (2019). 'Anemia epidemiology, pathophysiology, and aetiology in low-and middle-income countries'. Annals of the New York Academy of Sciences, 1450(1), p.15.
• Nambiar, Vanisha S. & Ansari, Sabat I. (2020)' Review of Progress towards Anemia Mukt Bharat'. Maharaja Sayajirao Unoverity of Baroda. International Journal of Creative Research Thoughts (IJCRT). ISSN: 2320-2882
• Sarna, A., Porwal, A., Ramesh, S., Agrawal, P.K., Acharya, R., Johnston, R., Khan, N., Sachdev, H.P.S., Nair, K.M., Ramakrishnan, L. and Abraham, R., (2020). 'Characterisation of the types of anaemia prevalent among children and adolescents aged 1–19 years in India: a population-based study'. The Lancet Child & Adolescent Health, 4(7), pp.515-525)
• World Health Organization (2001). 'Iron Deficiency Anaemia: Assessment, Prevention and Control, A guide for program managers'. WHO Guidel [Internet]. 2001;1–114. Available from: http://www.who.int/nutrition/publications/en/ida_assess ment_prevention_control.pdf
• World Health Organization (2017). 'Nutritional Anaemias: Tools for Effective Prevention and Control'. Geneva: World Health Organization, 2017. [ISBN 978‐92‐4‐151306‐7; (http://apps.who.int/iris/bitstream/handle/10665/259425/9789241513067‐eng.pdf?sequence=1)
• MoHFW. Operational Guidelines for Weekly IFA Supplementation Programme for School Based Adolescents • Guidelines for Teachers • Guidelines for Block Education Officers • Guidelines for District Education Officers. 2013;1– 16.
• World Vision International. Timed and Targeted Counseling (ttC) | Health | World Vision International (wvi.org)

For more information, contact rebecca_david@wvi.org

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Enabling Communities To Become Custodians Of Health

CASE STUDIES FROM ACROSS INDIA

Contributors - Praveen Bansode, Lokesh Ram, Maria Hembrom, Narendra Kumar Nayak, Mathew Issac, Suresh Kumar, Ajay Kumar and Alan John

Compiled and edited by Pratima Kollali

INTRODUCTION

One of the key factors that determine a country’s overall development is the status of health of its population. Mothers and children form an essential section of the population that needs proper healthcare and nutrition to build a healthier future. All women need access to antenatal care in pregnancy, skilled care during childbirth and care and support weeks after childbirth. Newborns and infants need proper care and nourishment to grow into healthy human beings and be part of the country’s workforce. For populations to survive and thrive, efforts to provide quality healthcare are taken by the respective government agencies. The Government of India has been focusing on initiatives to improve maternal and child health indicators, and much progress has been made. Several civil societies support the government through various interventions.

World Vision India’s interventions on Maternal and Child Health and Nutrition, in its operational areas, have been positively transforming not only individuals but also communities. Along with providing aid to families living under extreme poverty, the organisation aims to address the issues of child malnourishment at the root by actively engaging with the community and through the community to break the existing practices and adopt established techniques to improve their children’s health status. This article provides a glimpse of some of our proven intervention models, supported by brief case studies, that are cost-effective and replicable and have transformed communities across the country since inception.

ULTRA-POOR GRADUATION (UPG) MODEL

An intervention to improve the purchasing power of families living in poverty.

KEY FEATURES:

• Support is given to start small businesses or practice agriculture.
• Assistance is provided in selecting an appropriate business or agriculture (farm activity, off-farm or non-farm activities) based on skills and interest.
• Skill development, monitoring and follow-ups are provided.
• Beneficiaries are encouraged to start kitchen gardens and backyard poultry coops to improve diet diversity within the household.

CARE GROUP MODEL

An intervention aimed at creating a multiplying effect through social and behaviour change communication to enhance maternal, child health and nutrition outcomes in low-resource contexts.

KEY FEATURES:

• A Care Group has 10-15 community-based female volunteers who are either pregnant women or have children under the age of two.
• Groups receive support, counselling, supervision and training from care group promoters and coordinators of WV India and impart the learning to the neighbourhood women through activities like storytelling.
• Promoters and coordinators are hired from the local community to facilitate and network with the community and other stakeholders.

TIMED AND TARGETED COUNSELLING (TTC) PROGRAMME

A family-inclusive behaviour change communication approach targeting families of young children, especially the most vulnerable and marginalised.

KEY FEATURES:

• Appropriately timed messages delivered using interactive storytelling.
• Dialogue counselling methodology is used to engage with pregnant women and their families
• Promote exclusive breastfeeding practices and a nutritious diet for newborns and infants
• Educate mothers and pregnant women on the importance of the first 1000 days for a child

Write to ciju_daniel@wvi.org for more details regarding our interventions

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About World Vision India

World Vision India is one of the country’s largest child-focused humanitarian organisations. With over seven decades of experience at the grassroots, we employ proven, effective development, public engagement and relief practices empowering vulnerable children and communities living in contexts of poverty and injustice to become self-sufficient and bring lasting change. We serve all children regardless of religion, race, ethnicity or gender.

World Vision India works in 143 districts impacting around 26 lakh children and their families in over 6200 communities spread across 24 states and 2 union territories to address issues affecting children in partnership with governments, civil societies, donors and corporates.

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