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When healthcare workers advocating for better nutrition meet mothers, they find that the right communication strategies can solve several problems.

How women can be empowered with information to fight malnutrition
Delve Health Monday, August 20, 2018 - 12:56

Urmila Zanke (50) is a mother of four. Sitting with her cherubic two-year-old grand-daughter on her lap, she narrates how little she knew about nutrition while raising her four children. “I gave them glucose biscuits dunked in milk since they were three months old,” she explains. It is only now, after being exposed to research on the benefits of exclusive breastfeeding in the first six months of a child, that she understands it was wrong. “With my granddaughter we have done things differently,” Zanke says, as the young girl sits quietly on her lap. 

Zanke has learnt a lot during a three-year long pilot project of the Maharashtra government, funded by Tata Trusts, that looked for ways to handle the problem of malnutrition better. Called the Urban Nutrition Initiative (UNI), the project asked a simple question - can malnutrition rates be brought down by focusing on methods like encouraging mothers to breastfeed, giving them nutritional advice and providing them with counselling and support?

Local anganwadi centres, where children below the age of six and pregnant and lactating mothers receive nutrition, were used as the training grounds in Mumbai, Thane, Nashik and Nagpur. Existing government infrastructure was strengthened by roping in NGOs. The trained mothers then took the knowledge back to their communities and helped each other out, a trend researchers have noticed in other countries as well. 

“We were able to reduce the number of cases of severe acute malnutrition (SAM) by 3.6% and Moderate Acute Malnutrition (MAM) by 7.1% across all the cities,” says Chhaya Rade of the CCDTrust that implemented the project in Mumbai.

The answer to the question the project was raising was thus a cautious yes. 

UNI focused on increasing referrals when a child with malnutrition was found, and Rade says that one of the key lessons learnt was that there was no need to duplicate existing services. A group of mothers which would support each other was also formed. 

As a result of that, even women like Zanke - middle-class and usually thought of as not necessarily in need of counselling about malnutrition - also found that they learnt a thing or two they did not know about nutrition. 

The approach is called community-based management of malnutrition. In this approach, the family is made the focal point of providing care rather than lengthy stays in the hospital, except in unavoidable cases.

“When I had doubts, I always turned to my mother-in-law. That’s the only way I learnt,” Zanke recounts, a sentiment that was all too common among new mothers.

Marketing against malnutrition

Focusing on solutions like breastfeeding might appear a simplistic solution to a complex problem, but here’s what scientific evidence backed by UNICEF says: While breastfeeding the first one hour after birth saves lives, delaying it by a mere 2-23 hours increases the risk of death for newborns by 1.3 times. Waiting a day more to initiate breastfeeding pushes the risk of death up by two times.

It is not just death we are talking about but also risks of infections. Every minute that breastfeeding is delayed after birth the rate of infection steadily rises. Yet when mothers are recommended formula milk they are never informed that it does not counter any of these risks, only makes them worse by replacing nutrient-rich mother’s milk with a high calorie and high sugar diet, a risk UNICEF wants mothers to be aware of before making a choice.

The encouraging news for public health in India is that the rates of breastfeeding have doubled to 41.5 per cent in 2015 from the 23.1 per a decade ago.

Saily Bhurav, a community organizer who worked as a part of the UNI project frequently met new mothers to counsel them about nutrition. No, you don’t need the expensive formula food unless you can’t produce enough milk, she would find herself telling the mothers. Often, she encountered scepticism. Our doctor recommended formula milk, some mothers would say. For the community organizer it was a tall order to convince mothers struck by decades of marketing blitzkrieg and conflicting advice from their healthcare providers

Then something unexpected came to her rescue. “Oh, you are right, I saw the UNICEF advertisement by actor Madhuri Dixit,” one mother said. 

“Yes, that advertisement,” Bhurav latched on. “That is exactly what I mean.”

Bhurav found that where door-to-door convincing failed, Bollywood actors like Amitabh Bachchan telling mothers about immunization and Dixit talking about breastfeeding delivered results. One marketing message helped to counter the other. 

French humanitarian organization MSF, also known as Doctors without Borders, that works to fill healthcare gaps across the world also studied if there was a low-cost way to handle malnutrition cases. 

Their first challenge was to train the community to consider malnutrition a ‘disease’. Next, in the remote, resource-starved areas, they worked with what they had. They advised breastfeeding where possible and directed mothers to nutritious locally grown, cheap food and taught them about basics of hygiene. For severe cases, mothers were given a therapeutic milk or paste to feed their children by an Indian manufacturer. MSF sought to find out if we can replace a hospital stay with regular follow ups and still be effective.

A study in Bihar by MSF on community-based management of malnutrition showed that this method was in a majority of cases more effective than treating children in the hospital. This reduced the strain on family and was a cost-effective way to bring down malnutrition – something India needs because roughly one in threechildren below the age of five are stunted and under-weight.

Using tech against malnutrition 

At IIT-Bombay, a lab with over 70 people – most of them women – is working to use technology to solve one of India’s biggest public health problem: malnutrition. Some are busy brainstorming in one corner, others working on their computers. This is the lab where videos for the Spoken Tutorial project, funded by the HRD ministry of the government, are produced. These free of cost videos mostly cover topics related to IT and in Prof Kannan Moudgalya’s words, “should allow any girl in rural India, sitting by herself at midnight to study, understand the concepts.”

Proff Kannan

But he is now taking the project in new directions. Working with pediatrician Dr. Rupal Dalal and a team of nutritionists a new set of videos are being produced. They cover topics like the right way to breastfeed and will soon be expanded to include other aspects of nutrition. These videos are currently available in six languages and Prof Moudgalya’s team is constantly adding more.

The basic idea is to see if technology can help solutions to public health issues reach the masses faster and more effectively.  

Dalal is already using these videos to train ASHA workers, the foot soldiers in villages who implement the government’s healthcare schemes, as well as the anganwadi workers, who monitor the pregnant and lactating women and young children.

A typical video can take two-three months to be developed because of the research that goes into it. To Prof Moudgalya, this is not just a great utilization of the tax payers’ money, but also a way to quickly reach maximum healthcare workers and scale up learnings about nutrition. “These videos can be downloaded in a zip file and then used to train healthcare workers in remote areas even if internet connectivity is bad,” he says. 

The initiative is bang on time because as a part of the Indian government’s new National Health Mission, every aganwadi worker will now be equipped with a smartphone to help data gathering. This opens up several avenues on what technology can do in far flung areas. 

In a separate project, again run by IIT-B, a helpline answers any nutrition related questions mothers might have. In its pilot phase at the moment, a team of about a dozen nutritionists, nurses and doctors 1800-200-2098 have been fielding distress calls, often having to make new mothers unlearn the marketing messages

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India’s National Nutrition Mission has taken on the task of getting the basics right. The government aims to cut the percentage of stunted children in India from 38.4% to 25% by 2022 and mobilizing masses to focus on nutrition – by empowering them with information - is key in this regard.

In a recent development, the state of Rajasthan, where nearly 40% of children under the age of five are stunted and under-weight, kickstarted a campaign to promote breastfeeding. Interestingly there is also clear evidence that when the delivery is a C-section the chances that the mother will be able to breastfeed soon after birth is much lower when compared to a vaginal birth, for countries like India it is half.

Meanwhile, even though the pilot project in Mumbai has wrapped up, Zanke on her part continues the efforts. She tells new mothers in her area in Mumbai’s western suburbs about her learning lessons. “Who knew breastfeeding was good for the child’s mental growth as well,” she says. But now that she knows better, she is excited to keep the cycle going by talking to more mothers.

 

 

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