It is important to address the nutritional needs of children early, to ensure long-term health outcomes, writes Dr. Hemlata Jiwnani, Assistant General Manager – Research, ARMMAN.
India has worrying levels of undernutrition contributing to a third of the global burden. As per National Family Health Survey-5 (2019-21), 35.5% of the children under 5 years of age are stunted, 19.3% are wasted and 32% are underweight, leading to complications that prevent them from realising their full potential as adults. These figures show that undernutrition is a major challenge to the fastest growing economy in the world.
Reasons for malnutrition are multi-pronged, poor socio-economic and minority status being the most common factors. Hunger in general is normalised for those who cannot afford to have three meals a day. Undernutrition not only involves lesser meals but also food with low nutritional value and dietary diversity. Adding to this are the myths and cultural practices like giving water to child, mixing of water to milk, feeding ‘dal ka pani’ (lentil soup) and ‘chawal ka pani’ (rice water) as complementary food, during the years when the child should be fed breastmilk exclusively.
Malnutrition generally begins even before the child is born. Health status and weight gain in a mother predetermine weight of the baby at birth. An anaemic and underweight mother having low access to quality and quantity of nutrition during her pregnancy jumpstarts the cycle of malnutrition, leading to underweight children who are prone to more illnesses. Sick children miss out on regular education and also stay undernourished throughout their life, including their adolescence and adulthood, further leading to a mother who is undernourished. Poverty, minority status and poor living conditions exacerbate the situation, especially in slum areas where hygiene and sanitation are major challenges to navigate through. This vicious cycle can be reversed at any stage by empowering families with adequate knowledge on nutrition that is acceptable and suited to the local community context.
Mid-day meal programme via Anganwadis under the genesis of the Integrated Child Development Scheme (ICDS) programmes is the main national health programme to target malnutrition in India. In recent years, the Government’s initiative of declaring September as the Poshan Maah (National Nutrition month) has given the necessary impetus to nutrition programmes with both the Government and the Non-Governmental Organisations (NGOs) organising a multitude of targeted awareness activities during this month every year.
Intervene early to prevent severe malnutrition
While the Government mechanism to combat malnutrition in the form of Anganwadis and Nutritional Rehabilitation Centres (NRCs) is targeted more towards severely malnourished children and for those who are of schooling age, action needs to be taken much before a child shifts into a critical stage of malnourishment.
The vision behind ARMMAN’s Swasth Kadam programme arose from the fact that intervention needs to take place before the child reaches the stage of severe undernutrition. Pre-school children generally do not come in much contact with the healthcare system especially after nine months where most of the immunisation and vaccination takes place. This phase of 6 months to 1 year is very crucial as complementary feeding begins and the infant transitions from breastfeeding to having meals. In terms of growth and development also, this is an important stage where a child learns to sit up, crawl and some even start walking in addition to sensory exploration. The quality and quantity of nutrition being provided to a child undergoing growth spurts is crucial and this is also the time where the symptoms of underweight start setting in along with the feeding habits.
Swasth Kadam is aimed at caregivers of Moderately Underweight (MUW) children (as per WHO definition), who are between 6 – 36 months. The programme uses mHealth interventions to screen and identify MUW children and counsels their caregivers for improved outcomes.
Programme Design
Children who are moderately underweight are surveyed via a baseline survey and their caregivers are enrolled for a live counselling programme with an informed consent. A mobile application is used by the field staff for surveying children and screening eligible participants. House to house survey is conducted to screen children, the case is assigned to a particular counsellor and analogue weighing machine is used to record the weight. The survey helps in obtaining socio-demographic information, details of the child’s health history, dietary intake, feeding and caregiving, phone access and digital literacy.
Based on the field survey, Swasth Kadam provides live counselling services to caregivers on best practices in child health, development and nutrition encompassing breastfeeding, complementary feeding, dietary modification, early childhood development, hygiene, sanitation, common childhood illnesses and family planning. The caregivers are contacted via counsellors who provide live counselling calls on weekly basis to the primary caregiver, usually the mother for 13 consecutive weeks. These calls cover various topics customised as per age and developmental stage of the child. Referrals and linkages to government health systems such ICDS and NRCs are done by the counsellors as per the needs identified.
The goal is to handhold women (our field experience informs us that primary caregivers are mostly mothers) and provide enough information via these calls so as to empower them with knowledge to improve the health status of their children. Calls are made by trained counsellors and the conversation is tailored as per the specific needs of the caregiver.
All caregivers need support, so why leave anyone out?
The programme launched a WhatsApp channel in May 2023 which provides generic information related to nutrition for all the children who are profiled irrespective of their health status. Messages in the form of audio, video and posters are sent to mobile numbers provided at time of profiling after obtaining consent. The messages are in Hindi or Marathi based on the preference of the caregiver enrolled. In addition to the information, monthly birthday messages are sent to the caregivers mobile informing about the minimum weight of the child as per the corresponding age for that month. The WhatsApp channel is a 2-way chatbot where queries can be sent by the beneficiaries. All those who send a query are assigned a counsellor who responds to the query. On request, counselling services are extended to those who require it.
In India, the fabric of family and community in India is changing rapidly. Going from joint families to nuclear families, migrating to cities for work, living in cramped small spaces, hygiene, cleanliness and many multi-fold challenges, it is the health of women and children which ends up taking a backseat. Most new mothers are not aware about the need for antenatal care (ANC), the Government services with regard to ANC, where and how to access these services. Living alone, they are looking for someone to help ease their worries, as they move through the beautiful phase of pregnancy and then watching their children grow into adults.
ARMMAN’s Swasth Kadam programme ensures these women receive critical information about infancy through their mobile phones, and they are able to monitor their children’s health. The programme is attempting to break the intergenerational cycle of malnutrition for improved healthier outcomes as these children grow up into adults, while nurturing the caregiver towards long-term behaviour change.