Virtually every survey has re-confirmed the urgent necessity to address the issue of poor nutrition, from the National Family Health Survey-4 and Global Nutrition Report of 2016 to the Global Hunger Index 2017. India was ranked 100th out of 118 countries in the latter, highlighting our ‘serious’ hunger problem. Data from national level surveys reflect some progress, however, the pace of decline is far below the desired rate.
To catalyse progress, the Government of India (GoI) launched its National Nutrition Mission, also known as the POSHAN Abhiyaan, in December 2017. The initiative seeks to reduce levels of stunting, malnutrition, and low birth weight by two percent each, and anaemia by three percent. It aims to reduce stunting from 38.4% (NFHS-4) to 25% by 2022. The goal is to achieve improvement in the nutritional status of children under six years, adolescent girls, pregnant women and lactating mothers in a time-bound manner, over three years.
Breaking the cycle of Malnutrition
Socio-cultural beliefs, customs and attitudes, as well as social structures like caste, class and gender have a significant influence on food consumption habits, thereby affecting the nutrition status of individuals and families. They may also influence the systems of food sharing and distribution within the family. For example, the distribution of food markedly affects the dietary intake of women in the family.
Supply-side and systemic challenges are often overshadowed by the need to address the behavioural changes required to generate demand for nutrition services. The POSHAN Abhiyan gives prominence to demand generation and community mobilisation as key determinants to address nutrition. However, equitable improvements in nutrition will not be possible without changes in the everyday behaviour of people, which are shaped by the norms of society. Merely providing knowledge and information to individuals have not and may never influence the achievement of the desired changes in malnutrition status. Genuine effort is needed in nutrition and health education to change people’s attitudes and practices.
The most efficient way to achieve POSHAN Abhiyaan’s targets is to use all available, sustainable and effective approaches. Changing behaviours is a complex process and requires solutions that are community centric and already available within the community. Bottoms-up, community-based focused behaviour change interventions that involve the transference of positive behaviour are required. Instead of going to a village and looking at the 80% individuals who are malnourished, this approach flips it around.
The focus is instead on the 20% who are not malnourished, despite the same socio-economic status and same risk. It is important to understand what these 20% are doing differently and then encourage them to educate the suffering 80%. It involves studying individuals who grew and our well-nourished despite adversity, identifying uncommon or model practices such as age-appropriate feeding practices or hand washing practices and then designing interventions to transfer these behaviours to others. These behaviours are affordable, sustainable and acceptable.
Why is this approach to behaviour change important?
This approach can be implemented within the current health system (AWW/ASHA) in India with the support of community members. It will serve as an important tool to only reduce malnutrition but also implant sustainable positive behaviour in communities.
Discovering local solutions. It is imperative to recognise that community members discover solutions to address malnutrition, which are within their means and don’t need outside resources.
Participatory adult learning. This means that the community will be engaged from the beginning and this will encourage community ownership of the programme.
Seeing is believing. Witnessing change will motivate families to continue the practice at home.
These sessions should not be considered as being rehabilitation practice for reducing malnourishment. Instead, they should be a regular practice that increases the community’s contribution and awareness around improving the status of their health. Such an approach to community engagement can be utilised as an important community-based tool in enabling the POSHAN Abhiyaan to combat undernutrition among children.