How the fight against malnutrition is becoming a JanAndolan in India?
By: Dr. Ananya Awasthi
Policy makers, academics and practitioners around the world are focusing their attention, effort, and resources on answering one basic question- how do you change human behaviour? While it sounds simple, changing behaviours can be one of the most daunting tasks. This is especially significant owing to non-stop media exposure, inequitable access to economic resources and diverse socio-cultural environments that different communities experience. Generating evidence to answer this question, has given rise to an entire field of enquiry called the Social &Behavioural Change Communication (SBCC). More commonly recognized by its acronym- BCC, it denotes strategic use of communication to change knowledge, attitudes, beliefs, and ultimately human behaviors.
One of the pioneer programs that have integrated the science of SBCC into policy action is the POSHAN (Prime Minister’s Overarching Scheme for Holistic Nourishment) Abhiyaan or the National Nutrition Mission. Launched in 2018, the most unique feature of this mission is its focus on social and behavioral change for improving nutritional outcomes amongst women and children. The stated objective is to improve the inter-linkages between communities and the Anganwadi systems to create a people’s movement for promoting transformative change, referred as the “Jan Andolan”. Jan Andolan, which literally translates into Community Mobilization, is essentially an SBCC strategy to generate bottom-up demand for improved nutrition seeking behaviours, particularly relying on convergence between front line Anganwadi Workers, ICDS (Integrated Child Development Services) officers, development partners, influencers, volunteers, civil society and the communities at large.
Led by the Ministry of Women and Child Development (MoWCD), which is the nodal Ministry for POSHAN Abhiyaan, there are 12 major themes or areas of action under the campaign for Jan Andolan. These include, promotion of healthy diets and dietary diversity, antenatal care of pregnant women, optimal breastfeeding for infants until the age of 6 months followed by initiation of complimentary feeding, anemia prevention, vaccination, and even other social determinants of nutrition like sanitation and mother’s education. Evidence-based messaging on these nutrition priorities, is being delivered through various channels or platforms including inter-personal counselling and home visits by Anganwadi Workers, convergence with (VHNDs) Village Health Sanitation and Nutrition Days, mobilization of Mother Groups and Self-Help Groups, conducting Community-based Events (CBEs) and, use of folk and mass media.
Moreover, “PoshanPakhwada” (March/April) and “PoshanMaah” (September) have been established as annual pillars for repeated exposure to messaging on nutrition promoting behaviours. Over the past 5 years, these milestones have been celebrated across major themes including: ‘PoshankKePaanch Sutras’ (5 Strategies for Nutrition) which prioritized the first 1000 days of the child, anemia control, diarrhea management, sanitation, and dietary diversity (2019); ‘Increasing Engagement of Men in POSHAN Abhiyaan to Improve Nutritional Indicators’ (2020); ‘Addressing Malnutrition through Kitchen Gardens and Food Forestry’ (2021) Coming to the scale of operations, the most recently conducted PoshanPakhwada in April 2022, covered almost 30 million SBCC activities across the country with a focus on anemia prevention, gender governance for water management and health benefits of traditional diets. Additionally, to inculcate a collective sense of responsibility towards addressing the burden of malnutrition, a dedicated “Poshan Anthem” and “Poshan Pledge” too is being promoted, especially amongst school going children.
A novel feature of the Jan Andolan campaign has been the recognition of cultural context and its role in shaping beliefs and practices of the communities. To improve the uptake of evidence-based nutrition interventions amongst communities, POSHAN Abhiyaan is utilizing traditional cultural platforms for educating pregnant and lactating women along with their families about the importance of antenatal care of the mother and complimentary feeding of the child. Of the two major platforms, “Godhbharai”, or a traditional baby shower, is being promoted by Anganwadi Workers as a platform for counselling of pregnant mothers on the need for healthy diets during pregnancy, taking IFA (Iron Folic Acid) tablets for anemia prevention, preferring institutional delivery, and maintaining hygiene. Second is the “AnnaprashanDiwas” or the ‘grain initiation day’, an age-old socio-cultural practice which celebrates the initiation of semi-solid food into an infant’s diet. It is being revived as cultural platform to generate awareness amongst mothers and instill responsibility amongst family members to initiate UpariAhaar /Complimentary Food when the infant turns 6 months old. Counselling efforts at AWCs include supervised feeding of children using measures like a “katori” and educating mothers about locally available nutritious food for young children.
The next big priority for improving the nutritional outcomes is targeting the widespread anemia amongst women and children. Moving beyond counselling, SBCC activities in this regard have taken the form of Test-Treat-Talk (T3) Camps for Anemia Prevention. For example, in Jharkhand, ICDS functionaries in collaboration with the civil society have been organizing such camps in schools where trained health personnel measure the hemoglobin levels, provide IFA tablets for those in need, counsel them on the need for iron rich diets and finally refer those children that might need health supervision. Whereas in Assam, a unique solution has been identified to promote consumption of iron rich diets during pregnancy. With the support of local administration, development partners and volunteers have trained local women to produce homemade “Amla-Gur” (Gooseberry- Jaggery) Candy for improving intake of iron, vitamin C, and potassium amongst pregnant women.
Use of folk media has been another key platform for dissemination of key messages around Infant and Young Child Feeding Practices. These include the use of folk music, folk songs, “NukkadNataks” (folk drama) and “BhajanSandhyas”, as a strategy to improve the uptake of nutrition messaging through the art of “storytelling”. A particular example from Maharashtra is how the Anganwadi Workers are working with “Kirtankars”, to spread the message of breastfeeding and the importance of the first 1000 days (about 2 and a half years) of the child through narration of “kirtans” or Abhangs” (devotional songs)
While in Telangana, Anganwadi workers have innovated with Community-based Events (CBEs), giving rise to “PoshanBathukamma”. This is a 9-day floral festival, celebrated with communities to spread knowledge about the importance of healthy diets and benefits of dietary diversity, through culturally affiliated messaging and demonstrations. Marrying tradition with evidence, nutritious food items like fresh fruits and vegetables are arranged alongside seasonal flowers, to convert the floral Bathukamma into a PoshanBathukamma and increase awareness around the nutritional value of the food on display.
Jan Andolan campaign is also taking on to the streets with the organization of PoshanMelas, PoshanRaths, Millet Melas, Poshan Walks & Cycle Rallies to generate collective intent and action amongst the communities. For example, in UP, Bihar and Rajasthan- Anganwadi workers, schoolteachers and communities have been organizing “PrabhatPheris” (Morning Processions) for delivering nutrition education to the local population.
Given the focus on dietary diversity to improve nutritional parameters, MoWCD has also directed states to host cooking competitions and demonstration of traditional recipes at Anganwadi Centers. With a visual display of locally sourced, nutritious, and colorful food produce and branded as a “DadiNani Ki Rasoi”, such community activities are aimed at targeting young mothers. This SBCC activity deploys “role modelling” by trained mothers and elderly women of the community to educate mothers and their family members about the importance of cooking and consuming nutritionally rich food. Not restricting the responsibility of nutrition to only women folks, Anganwadi Workers in Gujarat have been celebrating “SuposhanDiwas”, specifically targeting husbands of pregnant women and mothers of children below the age of 2 year. The focus of behaviour change communication is to foster responsibility amongst men of the family to enable and practice the uptake of appropriate feeding practices for the mother and child in the household. Additionally, with the MoWCD promoting a plantation drive for PoshanVatikas (nutrition gardens) under Poshan Months, Odisha has been a forerunner with the rolling out of a dedicated program called “Mo UpakariBagicha”- or My Beneficial Garden. In convergence with different departments, especially the livelihoods mission, SHGs have come together to plants vegetables, fruit bearing trees, herbal plants retrofitted with poultry farms to improve dietary diversity of pregnant women and young children.
Moving forward, MoWCD has an opportunity to scale up “PoshanPanchayats” as an innovative platform for action-based community dialogue, thus transforming Jan Andolan in to a movement for “Jan Bhagidari” or community ownership. Expanding the scope of nutrition communication, education and counselling- such dedicated Panchayats for health and nutrition, can be utilized as a bottom-up platform for triggering accountability and social audit of health and nutrition services available at the grassroots, particularly for the most vulnerable populations of the society. Such Panchayats conducted at district, state and central levels- also hold the promise of tracking multi-sectoral convergence across different Ministries overseeing health, food, nutrition, sanitation, water, and social welfare.
Conclusively, the Jan Andolan campaign has played a critical role in agenda setting for Poshan and nudging communities to recognize malnutrition as a social problem. With POSHAN Abhiyaan entering its 5th year, and MoWCD slated to release revised Poshan 2.0 guidelines, government has a unique opportunity to undertake a nationally representative evaluation to understand the impact of the campaign on translating knowledge to behaviour change amongst the target community. While, global evidence shows that inter-personal communication, utilization of peer-to-peer learning, roll modelling and use of television to deliver messages that are clear, easy to recall and at a regular frequency- are most effective in changing behaviours; India needs to generate and utilize evidence that is contextual to India’s social, cultural and economic realities. To build on evidence-based policy action, further enquiry is required on the type of nutrition messages that are most influential, nature of platforms which have the widest uptake and the choice of media platforms that have been most successful in reaching the last mile. Finally, we need to remind ourselves that behaviour change communication alone will not move the needle on the country’s nutritional outcomes. Strategic communication is only a starting point and requires to be complemented with supply side nutrition interventions, access to economic resources, convergence with social determinants and an enabling environment that can pave the way for a “KuposhanMukta Bharat” (Malnutrition Free India).
The writer has a Master’s in public health from Harvard University and is founder-director of Anuvaad Solutions
