The document discusses strategies to strengthen nutrition actions in India. It outlines interventions implemented by JEEViKA in Bihar to improve complementary feeding practices, including behavior change communication sessions, feeding demonstrations, home visits, and community events. Evaluation found the interventions improved minimum dietary diversity and minimum acceptable diet indicators. Concurrent measurement confirmed scale-up was also effective. Additionally, an independent survey showed significant improvements in these complementary feeding indicators in blocks where JEEViKA implemented the package of interventions.

1. Strengthening Nutrition-related Actions
Strengthening Base Implementation; Incorporating Nutrition Goals; &
Integrating Nutrition-Specific Actions into Nutrition-Sensitive Platforms
14th February 2019
Stepping up to India’s Nutrition Challenge: The
Critical Role of District Administrators | LBSNAA
1Indrajit Chaudhuri, Chief of Party and Assistant Country Director, PCI

2. Undernutrition
is a cause of 45%
of under 5 child
deaths
2

3. 3
National Health Mission:
Incorporating Nutrition Goals:
PRIORITIZED & HOLISTIC TO CHANGE OUTCOME
TAPPING MISSED OPPORTUNITIES

4. Maternal and Child Nutrition in Bihar (NFHS-4, 2015) – a constant story of missed opportunity across the 1000
days window of opportunity
Source:: NFHS-4 2015-16(sample size: 568,200)
89.6%
9.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Antenatal Care
Last birth protected against neonatal
tetanus
Consumed iron folic acid for >100 days
79.9%
80.2%
53.5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Children, 12-23 months, received 3 doses of DPT
Children, under age 6 months, exclusively breastfed
26.7%63.8%
34.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Institutional births
Children, under age 3 years, breastfed
within one hour of birth
28.9%
Infant careDelivery Care
4

5. Health System Platforms: Opportunities & gaps
Missed Opportunities
Sources: National Family Health Survey - 4
ANTENATAL CARE
Nutrition counseling
Weight gain tracking
IFA supplementation
Calcium supplementation
Infection control
Intermittent presumptive
treatment of malaria
DELIVERY
Delayed cord clamping
Initiation of breastfeeding
within one hour
Skin-to-skin contact
POSTNATAL CARE
Counseling:
Maternal nutrition
Breastfeeding
Complementary feeding
Vitamin A supplementation
Screening and referral for
acute malnutrition
Zinc supplementation and
diarrhea management
0
20
40
60
80
100 Antenatal Care vs Iron Folic Acid Supplementation
(%)
ANC-4+ IFA Supplementation
0
20
40
60
80
100
Skilled Attendance at Birth vs. Early Initiation of Breastfeeding
(%)
Skilled BirthAttendant at births Early Initiation of Breastfeeding
5

6. 6
NHM: Strengthening Base Implementation:
FOCUS
SYSTEMS THINKING &
CONCURRENT MONITORING OF RIGHT INDICATORS

7. 7
SURPRISE!!!
Having food DOES NOT Guarantee Nutrition
Families having food availability are also not
providing to their children

8. Foods
6-8 age group of children 9-11 age group of children
Mean no. of days Gap
(Missed
Opportunity)
Mean no. of days Gap
(Missed
Opportunity)
Food available at
home in last 7 days
Fed to child
in last 7 days
Food available at
home in last 7 days
Fed to child in
last 7 days
Rice / roti / Khichri 6.94 3.66 47% 6.96 5.62 19%
Roots/Tubers 5.77 0.99 83% 5.77 2.26 61%
Pulses 4.87 2.42 50% 4.87 3.75 23%
Milk 4.23 2.6 39% 4.23 2.89 32%
Other Vegetables 3.03 0.39 87% 3.01 0.88 71%
Green leafy vegetables 2.58 0.28 89% 2.54 0.67 74%
Other fruit 0.62 0.19 69% 0.67 0.33 51%
Curd , butter-milk , paneer 0.57 0.03 95% 0.57 0.06 89%
Fish 0.49 0.06 88% 0.49 0.13 73%
Meat/Chicken 0.37 0.04 89% 0.37 0.1 73%
Egg 0.33 0.07 79% 0.34 0.14 59%
Yellow / orange fruits or red
colour vegetables or fruits
0.31 0.06 81% 0.31 0.13 58%
Almond, Groundnuts 0.29 0.025 91% 0.3 0.05 83%
Oatmeal 0.11 0.02 82% 0.12 0.04 67%
Source: CARE ‘LQAS+’ Round-7
Considerable GAP between food availability in HH and feeding to the child: 70-80% gap for most
food groups – So, there is issue with Feeding Behaviour and Not Just Availability…
8

9. 9
Complex Problem
Simple Behavior
Far reaching Impact

10. 10
Story of JEEViKA in Bihar:
What is JEEViKA doing in Bihar?
And, why we are excited?

11. 11
Nutrition Indicators, specifically the Complementary
Feeding indicators historically didn’t show much
improvement in Bihar even after the efforts of
various stakeholders

12. Complementary Feeding indicators (specifically, dietary diversity) hasn’t changed in Bihar for long time;
In Parivartan also we didn’t find very encouraging results in two areas – FP and CF
PARIVARTAN Results – Not very impressive
EndlineBaseline DID
76 77
88
80
-9-20
0
20
40
60
80
100
SHG Only SHG+Health Impact (adj. difference)***
Timely initiation of Complementary Feeding
(Children: 6-11 months )
13
65
20
72
0
20
40
60
80
100
Child minimum dietery diversity (6-11
months)
Woman minimum dietery diversity
***
***
Minimum Dietary Diversity of Child & Woman
Source: Population Council
Complementary Feeding – has not changed over the years
Source: CARE ‘LQAS+’
5%
15%
6%
13%
5%
13%
0%
10%
20%
30%
6- 8 Months 9-11 Months
Minimum Dietary Diversity of Child
2014 (N=15687) 2015 (N=15644) 2016 (N=15667)
5%
10%
6%
13%
5%
11%
0%
5%
10%
15%
20%
25%
30%
6- 8 Months 9-11 Months
Minimum Acceptable Diet
2014 (N=15687) 2015 (N=15644) 2016 (N=15667)
12

13. 13
JEEVIKA implemented a package of interventions for
Complementary Feeding
(BCC Sessions and Feeding Demonstration; Line Listing; Nudging Mothers;
Rallies; Video Shows; and, Recipe Demonstration)
targeting 6-11 months old children
rolled-out through its community institutions in 101 blocks in 2017-2018

14. 101 HN Intervention Blocks
Interventions to improve Complementary Feeding practices across 101 blocks
14
BCC Session Roll-out Collective Cooking and Feeding Demonstration
Module roll-out on CF
Cooking & Feeding
demonstration
BCC Session roll-out
1

15. 101 HN Intervention Blocks
Interventions to improve Complementary Feeding practices across 101 blocks
15
Line-Listing of Target Beneficiaries Home-Visit
Targeted Reinforcement
through Home-Visits
2
Line Listing Home Visits

16. 101 HN Intervention Blocks
Interventions to improve Complementary Feeding practices across 101 blocks
16
Rallies Recipe Demonstration
Community Level CF Event
3 Pico-Projector
Show
Recipe
Demonstration
Rally
Pico-Projector Show
Follow-up through
home-visit

17. 17
Efficacy Testing
of BCC Session Roll-out on Complementary Feeding
and Feeding Demonstration provided the
proof of concept

18. Cluster Randomized Control Trial: Encouraging results in important CF outcome indicators
Source: PCI CML data
More than two-fold difference in dietary diversity outcome was observed between the intervention and control arm
after the intervention on session roll out and demonstration of complementary feeding.
18
10.7%
25.6% 29.5%
15.9%
Control
(N=297)
Intervention
(N=300)
Exposed
(N=217)
Non-Exposed
(N=83)
Practice of Minimum Acceptable Diet among children
% of children 6-23 months old receiving appropriate frequency and
diversity in CF
21.1%
50.1%
58.0%
30.0%
Control
(N=297)
Intervention
(N=300)
Exposed
(N=217)
Non-Exposed
(N=83)
Minimum Dietary Diversity
% of children 6-23 months old receiving 4 out of 7 food groups in CF
82.5
63.3 62.6
3.4 3.4 9.1
30.0
94.7 83.0
65.3
7.7 16.0 28.7
46.3
Group-1: Grains & White
roots and tubers and
plantains
Group 2: Pulses,beans,
peas and lentils & Nuts
and seeds
Group 3: Milk and milk
products
Group 4: Organ meat ,
Meat and poultry & Fish
and seafood
Group 5: Eggs Group 6: Dark green leafy
vegetables , Vitamin A-
rich vegetables & fruits
Group 7: Other
vegetables& Other fruits
Practice Indicators (% of children given foods in the last 24 hours)
Control VOs (N=297) Intervention VOs (N=300)
Food group wise analysis: encouraging increase in intake of eggs; and, scope for further increase

19. 19
Concurrent Measurement
of Package of CF Interventions is
confirming the result
of efficacy testing
when implemented at scale

20. Concurrent Measurement confirms encouraging results even after the scale-up
14.7%
30.2% 28.3% 26.0% 25.1% 28.8%
38.6% 35.5%
28.0%
36.4%
24.0%
Proxy Baseline
for Bihar*
January
(N=374)
February
(N=371)
March (N=365) April (N=366) May (N=354) June (N=347) July (N=321) August (N=346) September
(N=324)
October
(N=292)
Minimum Dietary Diversity
% of children 6-11 months old receiving 4 out of 7 food groups in CF
14-15%
^ All the percentages given are Weighted
^ Exposed comprises of those who participated in all the three activities namely –
Home Visits, Video Show and Recipe Demonstration
Source: Household Survey data of PCI CML: Monthly Concurrent Tracking of Program Quality for assessing CF outcomes, January 2018
* No baseline is conducted for this separately. Proxy Baseline is computed as captured from different baselines done by PCI CML; congruent with
other available data
20
Significant improvement in dietary diversity outcome observed in the post assessment of the community level event
Monthly assessment is being done to measure the impact of interventions on outcome indicators – after completion
of all interventions. Measurement Methodology – Every month approximately 350 events are being conducted covering
more than 700 VOs. Out of them 35 events (70 VOs) were randomly selected to study the effectiveness of package of CF
intervention. The data is collected through HH survey recruiting mothers of 6-11 months old children
5.3%
13.1% 14.0% 16.7% 15.3% 15.3% 19.0% 21.8% 19.4%
26.5%
17.5%
Proxy Baseline
for Bihar*
January
(N=374)
February
(N=371)
March (N=365) April (N=366) May (N=354) June (N=347) July (N=321) August
(N=346)
September
(N=324)
October
(N=292)
Practice of Minimum Acceptable Diet among children
% of children 6-11 months old receiving age appropriate frequency and diversity in CF
5-6%

21. 21
Recent results of very large-scale independent data from
CARE’s HH Survey (LQAS) Round-10 (Jan-2019)
is indicating the significant improvement at scale

22. 26.1%
21.4%
18.4%
16.6%
12.8%
13.7% 13.0% 13.3%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
HN Intervention
Blocks SHG
Members
HN Intervention
Blocks Non-SHG
Members
Other Blocks SHG
Members
Other Blocks Non-
SHG Members
Minimum Dietary Diversity in the last 24 hours
(9-11 months)
R-10 R-8
22Source: CARE’s Household Survey (LQAS+) data, Round-10 (Jan 2019)
19.9%
15.3%
13.1%
11.6%
9.8%
11.2% 10.4% 10.7%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
HN Intervention
Blocks SHG Members
HN Intervention
Blocks Non-SHG
Members
Other Blocks SHG
Members
Other Blocks Non-
SHG Members
Minimum Acceptable Diet (9-11 months)
R-10 R-8
Complementary Feeding indicators demonstrating interesting change when analyzed for HN Intervention
block and SHG members – before and after intervention
More than two fold increase More than two fold increase
Results from two rounds of data of large scale state-wide survey (CARE’s Household Survey / LQAS) was divided into 4
categories of respondents on the basis of HN intervention blocks and SHG membership.
Before nutrition interventions Round-8 data (Jan-2017) showed no difference among different categories;
the Round-10 (Jan-2019) data collected after the intervention is establishing the effectiveness of interventions at scale.
Outcome indicators demonstrated better performance among HN Intervention Block SHG Members compared to others

23. 23
Will the effect Continue?
Investigating stickiness of behavior over time and
adoption of behavior by the next cohort

24. Stickiness Study:
Studying continuation of CF practices among the same cohort three months after intervention
16.7%
43.8% 41.4% 44.1%
Post-Event 6-8 months old
children (N=145)
Post-Event 9-11 months old
children (N=145)
Stickiness among 9-11
months old children (N=145)
Stickiness among 12-14
months old children (N=145)
Minimum Dietary Diversity
among the children of 9-11 and 12-14 months age group
Source: Household Survey data of PCI CML: Concurrent Tracking of Program Quality for assessing stickiness of CF outcomes, April 2018 24
CF behaviours were largely retained
Stickiness study was conducted in April 2018, three months after the roll-out of the package of CF interventions in January
2018, with the same set of mothers
9.9% 15.1%
24.1% 24.8%
Post-Event 6-8 months old
children (N=145)
Post-Event 9-11 months old
children (N=145)
Stickiness among 9-11
months old children (N=145)
Stickiness among 12-14
months old children (N=145)
Practice of Minimum Acceptable Diet
among the children of 9-11 and 12-14 months age group

25. 25
Adoption of behavior among new cohort of children: Whether new set of 6-11 months old children from
in SHG households from intervened catchment are continuing to practice?
Source: Household Survey data of PCI CML: Concurrent Tracking of Program Quality for assessing CF outcomes, July 2018
* No baseline is conducted for this separately. Proxy Baseline is computed as captured from different baselines done by PCI CML; congruent
with other available data
To measure adoption of behavior among mothers of new-cohort of children in SHG Households, a cross-sectional study
was conducted in July 2018 in the same area where the package of CF interventions was rolled-out in January 2018.
The time gap of six months (from January to July) ensured that the new-cohort of children consists of only those children who
have not been directly exposed to the intervention.
14.7%
30.2% 27.5%
Proxy Baseline for Bihar* Among the children who have directly received
the interventions (N=374)
Among the new cohort of children (N=455)
Minimum Dietary Diversity
% of children 6-11 months old receiving 4 out of 7 food groups in CF
• CF behaviour was retained by the mothers, translating into improved practices in new cohort of children, but, the effect size
is reducing.
• This may further reduce unless the intervention is repeated for new cohorts.
• The programmatic assumption is that repeating this intervention for around 6 consecutive cohorts (which will cover 50% of
households having women in reproductive age) may create a sustainable ‘new normal’.

26. 26
- WASH:
- Sanitation
- Hand Washing
- PDS - diversification
- Example of diversification of Food Security Fund in JEEViKA
- Mid Day Meal
- MGNREGA
- Job Card for families with Pregnant women
- Crèche for breast feeding mothers
BRINGING ALL DEPARTMENTS AND INTERVENTIONS (19!!)
FOCUSSED ON 1000 DAYS BENEFICIARY
Other Nutrition-Sensitive Departments / Interventions

27. Thanks