SBI Youth for India Fellowship 2016-17 - Final Report

Title: “Social behaviour change communication and community
mobilisation to address the issue of maternal and child malnutrition in
Palghar district, Maharashtra”
Author: Ankur Chhabra
MSc. Economics and Finance (Durham University, England); Business
Management (XLRI-Jamshedpur, India)
Email: ankur_chhabra@yahoo.co.uk
Blog: www.ankurchhabrablog.wordpress.com
LinkedIn: https://in.linkedin.com/in/chhabraankur
Local Mentor: Dr. Anita Lindait
Associate Programme Manager - Health
BAIF Development Research Foundation
Domain Mentor: Mr. Sandip Kakade
Programme Officer
BAIF Development Research Foundation
Report submitted to: SBI Youth for India
Date: October 7, 2017

Declaration
I, Ankur Chhabra, „SBI Youth for India‟ Fellow of 2016/17 cohort, hereby declare that the project report
titled “Social behaviour change communication and community mobilisation to address the issue of maternal and child
malnutrition in Palghar district, Maharashtra” carried under the supervision of Dr. Anita Lindait and Mr.
Sandip Kakade of BAIF Development Research Foundation is a bonafide work undertaken by me and is
not submitted to any other institution or university for the award of any degree/ diploma or published
any time before.
Place: Jawhar block, Palghar District Ankur Chhabra
Date: October 7, 2017 Fellow - SBI Youth for India

SBI Youth for India Fellowship 2016/17
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Social behaviour change communication and community mobilisation to address the issue of maternal and child
malnutrition in Palghar district, Maharashtra
Acknowledgements
The fellowship project on ―Social behaviour change communication and community mobilisation to address the issue of
maternal and child malnutrition in Palghar district, Maharashtra‖ has been possible only with the support,
guidance and cooperation of many individuals and organisations.
Foremost, I would like to express my sincere gratitude to the State Bank of India Foundation and SBI-
Youth for India Fellowship team for giving me this life-changing experience of working with the rural
and tribal community of India. It has indeed been a wholesome experience of experiential learning and
self discovery.
I would like to thank my local mentor Dr. Anita Lindait, for her support and guidance in helping me
complete this project. She has been a source of motivation and encouragement.
I would also like to thank my domain mentor Mr. Sandip Kakade, for his guidance and supervision and
Mr. Sanjay Patil, for his invaluable insights on the project.
I wouldn‘t have been able to achieve my objectives if not for the constant support of the village
community members and the households. A special thanks to Mr. Mavanji Pawar (Community Resource
Person); Mr. Bhore (Gram Sewak-Gram Panchayat) for giving me invaluable insights on the community
issues; Mr. Dumada (Agriculture Officer); Dr. Patil (Medical Officer in-charge – Walwanda village health
centre); Ms. Nanda (Auxiliary Nurse Midwife); Ms. Alka Tukaram Kuvra (Anganwadi worker); Mr. Vilas
Gole (Principal-Walwanda Tribal High School) and the very supportive school teachers.
This acknowledgment would be incomplete if I don‘t thank my family and my co-fellows and friends
Niharikaa N. and Liju George for their unswerving support and encouragement throughout the
fellowship journey.

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Abstract
This project report examines the interventions, outcomes and impact achieved in addressing the issue of
maternal and child malnutrition in the Palghar district of Maharashtra. Palghar is infamous for having a
high rate of maternal and child malnutrition and Jawhar block is no exception. The target village chosen
for project intervention is Walwanda village. Broadly, the focus group includes mothers, pregnant and
lactating women (PLW), newborn, children (under the age of 5) and adolescents. The target group at the
village and household level is children with severe acute malnutrition (SAM) and adolescent school
children studying in standard 8th and 9th, at the school level.
The motive is to address the issue of malnutrition with social behaviour change communication (BCC)
and community mobilisation (CM). The project entails both qualitative and quantitative analyses of the
multiple conventional and non-conventional factors that directly or indirectly result in malnutrition.
The project broadly aims at developing community-based malnutrition awareness interventions, that is,
providing health awareness to the tribal village residents via nutrition-sensitive awareness, community
mobilisation and food and nutritional security; conducting awareness sessions and campaigns focussing
on vulnerable sections at the village and household level; and providing health promotion and health
literacy at the tribal school targeting adolescent girls and boys.
The dual aims of the project is to: a) mitigate the extent and severity of malnutrition among mothers,
PLW and children under the age of 5 via BCC and CM; and b) ensure information and knowledge
dissemination, improve health and hygiene literacy and increase the awareness levels about malnutrition
and malnutrition prevention among adolescent children via interpersonal communication, among others.
Impact assessment at the village and household level, is categorised into two sub-sections – (i) Nutrition-
sensitive interventions assessment (nutrition-sensitive factor analysis) and Nutrition-specific interventions
assessment (nutrition garden initiative). The three evaluation factors were weight, height and mid-upper arm
circumference (MUAC).

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Post-evaluation of the project interventions (nutrition-sensitive) resulted in 50% children showing
improvement in the MUAC indicator. All the children showed improvement in the height indicator,
except two children where there was no change and three children actually lost an average weight of ~1
kg. Whereas, the success rate for the nutrition-specific interventions was 58%.
At the school level, highest positive impact could be seen in terms of enhancement of awareness levels
about ‗meal intake‘ and ‗balanced diet‘, followed by ‗hygiene‘ and ‗waste management‘. Girls fared much
better in awareness levels when compared to the boys. Further, the project interventions at the school
have shown the importance and benefits of adequate health literacy among adolescent school children,
especially girls.
Keywords: Behaviour Change Communication (BCC), Community Mobilisation (CM), Pregnant and Lactating Women
(PLW), Severe Acute Malnutrition (SAM), Mid-Upper Arm Circumference (MUAC)

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Table of Contents
Acknowledgements...........................................................................................................................1
Abstract............................................................................................................................................ 2
List of Figures.................................................................................................................................. 5
List of Tables ................................................................................................................................... 7
List of Abbreviations........................................................................................................................ 7
Executive Summary......................................................................................................................... 9
CHAPTER 1: Introduction.............................................................................................................12
1.1 Project Location .................................................................................................................12
1.2 Project Background............................................................................................................13
1.3 Project Rationale ................................................................................................................18
1.4 Project Objectives...............................................................................................................20
1.5 Project Scope......................................................................................................................21
1.6 Project Methodology..........................................................................................................23
1.7 Project Limitations.............................................................................................................24
CHAPTER 2: Literature Review ....................................................................................................27
2.1 Health Promotion and Behaviour Change.........................................................................27
2.2 Community Engagement, Participation and Mobilisation................................................29
2.3 Nutrition-specific factors ...................................................................................................31
2.4 Nutrition-sensitive factors..................................................................................................32
CHAPTER 3: Methodology............................................................................................................33
3.1 Community Needs Assessment .........................................................................................33
3.2 Behaviour Change Communication...................................................................................35
3.2.1 BCC – Strategy.......................................................................................................35
3.2.2 BCC – Approaches.................................................................................................35
3.2.3 BCC – Processes....................................................................................................36
3.2.4 BCC – Preparation of Materials.............................................................................37
3.3 Baseline survey data...........................................................................................................37

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CHAPTER 4: Project Interventions ...............................................................................................41
4.1 Village and Household – Interventions .............................................................................41
4.1.1 ‘Swasthya Samwad’................................................................................................41
4.1.2 Nutritious Food Recipes .......................................................................................42
4.1.3 Perennial Nutrition Garden...................................................................................43
4.1.4 Heath Awareness Campaigns................................................................................45
4.1.5 Traditional Healthcare Awareness ........................................................................46
4.2 School – Interventions........................................................................................................47
4.2.1 Food, Nutrition and Balanced Diet.......................................................................47
4.2.2 Girl Education .......................................................................................................50
4.2.3 Child Marriage.......................................................................................................51
4.2.4 Water, Sanitation and Hygiene..............................................................................52
4.2.5 Malnutrition Awareness.........................................................................................55
4.2.6 Health Promotion Events......................................................................................57
CHAPTER 5: Impact Assessment .................................................................................................60
5.1 Impact Assessment – Village and Household ...................................................................60
5.2 Impact Assessment – School .............................................................................................65
CHAPTER 6: Discussion ...............................................................................................................69
CHAPTER 7: Conclusions and Recommendations.......................................................................71
7.1 Conclusions........................................................................................................................71
7.2 Recommendations .............................................................................................................72
References.......................................................................................................................................73
Appendix.........................................................................................................................................76
List of Figures
Figure 1.1: Map of Jawhar block, Palghar district, Maharashtra ....................................................12
Figure 1.2: UNICEF’s Conceptual Framework for Malnutrition...................................................13
Figure 1.3: Comparative analysis of malnutrition status of children under 5 in India ...................17

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Figure 1.4: The Cycle of Undernutrition ........................................................................................19
Figure 2.1: Health Promotion Emblem ..........................................................................................29
Figure 4.1: ‘Swasthya Samwad’ session at the village AWC ...........................................................41
Figure 4.2: Use of poster for depicting nutritious food items.........................................................42
Figure 4.3: Nutritious Food Recipes ..............................................................................................43
Figure 4.4: Distribution of seed packets.........................................................................................44
Figure 4.5: Demonstrations provided by the CRP and the AWW .................................................44
Figure 4.6: Community members planting seeds in the kitchen garden .......................................45
Figure 4.7: General health check-up camp.....................................................................................45
Figure 4.8: Immunisation camp conducted at the health sub-centre ...........................................46
Figure 4.9: Health clinic and mobile medical unit.........................................................................46
Figure 4.10: Balanced Diet – Pyramid Chart ..................................................................................48
Figure 4.11: Food and Indian Flag..................................................................................................48
Figure 4.12: Use of audio-visual aids for awareness on food and nutrition....................................49
Figure 4.13: Balanced Diet Activity ................................................................................................49
Figure 4.14: Girl Education - Activities...........................................................................................51
Figure 4.15: Child Marriage - Class discussions and essay writing ...............................................51
Figure 4.16: Child Marriage – Issue based film..............................................................................52
Figure 4.17: Sanitation awareness drive engaging school students................................................53
Figure 4.18: WASH awareness via health education film ...............................................................53
Figure 4.19: Use of posters for WASH awareness at school ...........................................................53
Figure 4.20: Essay writing based on WASH awareness class training sessions.............................54
Figure 4.21: Classroom session on WASH awareness via posters and banners .............................55
Figure 4.22: Classroom session on malnutrition awareness...........................................................55
Figure 4.23: Animation film on malnutrition awareness ................................................................56
Figure 4.24: Use of posters for anaemia awareness among adolescent girls .................................56
Figure 4.25: School children playing the Malnutrition Board Game..............................................57
Figure 4.26: ‘Malnutrition Free India’ event held at Walwanda village..........................................58
Figure 5.1: Nutrition Garden – Reasons for not sowing.................................................................64

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Figure 5.2: Nutrition Garden – Success rate...................................................................................64
Figure 5.3: Project Impact – Health literacy and awareness levels ................................................68
List of Tables
Table 1.1: Maharashtra State Nutrition Mission Targets ...............................................................18
Table 1.2: Project Design and Scope ..............................................................................................21
Table 3.1: Stakeholder Mapping and Community Needs Assessment ..........................................33
Table 5.1: Pre-Evaluation Survey - SAM Households ....................................................................60
Table 5.2: Post-Evaluation Survey - SAM Households ..................................................................61
Table 5.3: Impact Assessment – Malnutrition Status.....................................................................61
Table 5.4: Comparative Assessment of SAM Households..............................................................62
Table 5.5: Nutrition Garden - Monitoring......................................................................................63
Table 5.6: Nutrition Garden – Evaluation ......................................................................................63
Table 5.7: School survey – Details ..................................................................................................65
Table 5.8: Health Literacy Intervention – Post-evaluation survey .................................................66
Table 5.9: Health Literacy Intervention – Outcomes.....................................................................67
Table 5.10: Health Literacy Intervention – Impact ........................................................................67
List of Abbreviations
AAQ Average Awareness Quotient
AIDS Acquired Immune Deficiency Syndrome
ANC Ante-natal care
ANM Auxiliary Nurse Midwife
ASHA Accredited Social Health Activist
AWC Anganwadi Centre
AWC Anganwadi Centre
AWW Anganwadi worker
BAIF Bharatiya Agro Industries Foundation
BAQ Boys Awareness Quotient
BCC Behaviour Change Communication
BMI Body Mass Index
CM Community Mobilisation
CMAM Community-based Management of Acute Malnutrition

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CRP Community Resource Person
GAQ Girl Awareness Quotient
GHI Global Hunger Index
GP Gram Panchayat
HIV Human Immuno Virus
IEC Information, Education and Communication
IPC Inter-personal Communication
KG Kitchen Garden
MAM Moderate Acute Malnutrition
MCH Maternal and Child Health
MDGs Millennium Development Goals
MNCH Maternal, Newborn and Child Health
MO Medical Officer
MUAC Mid-Upper Arm Circumference
NBC Newborn child care
NCD Non-communicable disease
NFHS National Family Health Survey
NGO Non-Governmental Organisation
NHP National Health Policy
PDS Public Distribution System
PHC Primary Health Centre
PLW Pregnant and Lactating Women
PNC Post-natal care
SAM Severe Acute Malnutrition
SDGs Sustainable Development Goals
SHG Self Help Group
UNESCO United Nations Educational, Scientific and Cultural Organization
UNICEF United Nations Children's Fund
WASH Water, Sanitation and Hygiene
WHO World Health Organisation

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Executive Summary
The project location is Jawhar block, Palghar district in Maharashtra comprising of more than a hundred
villages. The target village chosen for project intervention is Walwanda village, a tribal dominated village
in the newly formed Palghar district. Jawhar is infamous for having a high rate of maternal and child
malnutrition. The worse-affected areas in Palghar are Jawhar and Mokhada blocks, where the number of
infant and child deaths increased historically in comparison to the last two years. Thus, there is an urgent
and persistent requirement to address the critical health issue of malnutrition plaguing the tribal
population in Jawhar.
The National Family Health Survey (NFHS-4) 2015-16 has also revealed that 83,000 children, below the
age of six years, were found to be severely underweight in the state of Maharashtra. Recently, the
National Human Rights Commission had sent a notice to the Maharashtra government over 600
malnutrition deaths that were reported from the tribal belt of Palghar in a year.
Malnutrition is a multi-dimensional and an inter-generational phenomenon. The vicious cycle of
malnutrition leads to health crisis and is no less than an epidemic. The fellowship project is focussed
towards health interventions to tackle malnutrition. The conventional belief is that malnutrition is caused
due to poor nutrition or nutritional deficiencies of macronutrients and micronutrients. However, non-
conventional factors such as early marriage, seasonal migration, poor sanitation and hygiene, poverty,
unemployment, poor environmental health conditions, among others are equally critical factors
contributing to the menace of malnutrition in Jawhar.
Thus, the project intervention strategies focus on nutrition-sensitive interventions rather than only
nutrition-specific interventions.
The motive of the project is to address the issue of malnutrition with the following approaches viz. BCC,
CM, IEC and IPC. The project entails both qualitative and quantitative analyses of the multiple
conventional and non-conventional factors that directly or indirectly result in maternal, newborn and
child malnutrition.
A comprehensive approach was devised to address the issue of malnutrition among the target group. The
methodology devised includes a) Institutional and stakeholder mapping; b) Community needs assessment;

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c) Baseline surveys (pre-intervention surveys at the village, households and school, respectively); d)
Designing project structure at the school and village and household level; e) Implementing project
interventions based on the project structure; and f) Impact assessment of project interventions at the
village, household and school, respectively.
The quantitative and qualitative impact assessment results were as follows –
Village/Household Level – Impact Highlights
 7 out 12 SAM children were categorized as ‗Normal‘ (as per height)
 1 child transitioned from ‗MAM‘ category to ‗Normal‘ category
 Weight – apart from 3 children, every child gained weight on an average of 0.6 kg
 Height – apart from 2 children, every child gained height on an average of 5cm
 MUAC – An average of 0.4 cm increase in MUAC for half of the children under observation
School Level – Impact Highlights
Average awareness levels –
 Importance of Balanced Diet – 100% of the class
 Hygiene (personal, food and environment) – 98% of the class
 Waste management (94%), child marriage (74%), Anaemia (75%) and importance of micronutrients,
specifically Iodine (96%) and Vitamin A (74%) in the diet
 General awareness levels about malnutrition shot up to 89% (post-intervention) from 48% (pre-
intervention)
The project interventions and post-intervention impact achieved is in line with the scholarly research and
also extensive supporting evidence available for such interventions carried out in the past.
In summary, it is noted that a combination of nutrition-specific and nutrition-sensitive strategies is an
effective approach to prevent undernutrition. Post-evaluation of the project interventions concluded that
nutrition-sensitive programmes can help scale up nutrition-specific interventions and create a stimulating
environment in which young children can grow and develop to their full potential.

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Furthermore, post-evaluation of the interventions and project objectives and aims shows that the project
was successful in providing health awareness to the tribal village residents. The project was successful in
both mitigating the extent and severity of malnutrition among mothers, pregnant and lactating women
and children under the age of 5 via behaviour change communication and community mobilisation; and
ensuring health information and knowledge dissemination, improving health and hygiene literacy and
increasing the awareness levels about malnutrition and malnutrition prevention among adolescent
children via interpersonal communication, among others.

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CHAPTER 1: Introduction
1.1 Project Location
The project location is Jawhar, situated in the Sahayadri mountain range. Jawhar is a block in Palghar
district of Maharashtra comprising of approximately a hundred villages. Established in the year 1918,
Jawhar is one of the oldest municipal councils in the state of Maharashtra. The majority of the population
are tribes belonging to communities like Konkana, Koli, Varali, Dharkoli, Katkari and Thakar. It is spread
across an area of c. 62,000 hectares of which around 6,800 ha is reserved forest. The average rainfall is
between 2,200-2,500 mm and the climate is hot and humid. The main occupation of the tribal community
in Jawhar is agriculture.
Figure 1.1: Map of Jawhar block, Palghar district, Maharashtra
The target village chosen for project intervention is Walwanda village. Walwanda village is located in
Jawhar block of Palghar district in the state of Maharashtra. This village is relatively densely populated
with respect to some other villages in Jawhar. According to the village census data, as corroborated by the
Gram Panchayat Samiti office, there are around 200 family households residing in the village. The village
has 6 hamlets. The latest census suggests that there are approximately 322 females and 295 males in the
village. The village has c.80 children (0-5 years old). There is one Anganwadi centre, catering to
approximately 55 children.1
1
Refer Appendix I

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1.2 Project Background
Walwanda village in Jawhar block is a tribal dominated village in the newly formed Palghar district in the
state of Maharashtra. Jawhar is infamous for having a high rate of maternal and child malnutrition and
Walwanda village is no exception.
Malnutrition – Definition
According to WHO, malnutrition refers to deficiencies, excesses or imbalances in a person‘s intake of
energy and/or nutrients. The term malnutrition covers 2 broad groups of conditions. One is
‗undernutrition‘ – which includes stunting (low height for age), wasting (low weight for height),
underweight (low weight for age) and micronutrient deficiencies or insufficiencies (lack of important
vitamins and minerals). The other is overweight, obesity and diet-related non-communicable diseases
(such as heart disease, stroke, diabetes and cancer).1
Figure 1.2: UNICEF‘s Conceptual Framework for Malnutrition
UNICEF defines malnutrition as a broad term commonly used as an alternative to undernutrition but
technically it also refers to overnutrition – to the current epidemic of obesity and related diseases, such as
diabetes, in both the industrialized and developing worlds. People are malnourished if their diet does not

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provide adequate calories and protein for growth and maintenance or they are unable to fully utilize the
food they eat due to illness (undernutrition). They are also malnourished if they consume too many
calories (overnutrition).2
According to UNICEF when individuals are undernourished, they can no longer maintain natural bodily
capacities, such as growth, resisting infections and recovering from disease, learning and physical work,
and pregnancy and lactation in women. Poor feeding of infants and young children, especially the lack of
optimal breastfeeding and responsive complementary feeding, along with such illnesses as diarrhoea,
pneumonia, malaria and HIV/AIDS, often exacerbated by helminths, are major causes of undernutrition.3
Alternatively, malnutrition indicates that children are either too short for their age or too thin.4 Children
whose height is below the average for their age are considered to be stunted. Similarly, children whose
weight is below the average for their age are considered thin for their height or wasted. Together, the
stunted and wasted children are considered to be underweight – indicating a lack of proper nutritional
intake and inadequate care post childbirth.
Malnutrition – A Global Issue
Stunting refers to a child who is too short for his or her age. Stunting is the failure to grow both physically
and cognitively and is the result of chronic or recurrent malnutrition. The devastating effects of stunting
can last a lifetime. Stunting is the devastating result of poor nutrition in early childhood. Children
suffering from stunting may never grow to their full height and their brains may never develop to their
full cognitive potential.
Wasting refers to a child who is too thin for his or her height. Wasting, or acute malnutrition, is the result
of recent rapid weight loss or the failure to gain weight. A child who is moderately or severely wasted has
an increased risk of death, but treatment is possible. Wasting in children is the life-threatening result of
hunger and/or disease. Children suffering from wasting have weakened immunity, are susceptible to long
term developmental delays, and face an increased risk of death: they require urgent treatment and care to
survive.
Global malnutrition estimates published jointly by UNICEF, WHO and the World Bank Group suggest
that in 2016, there were 155 million stunted children (or approximately 23% children under the age of 5

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globally); 52 million wasted children (or approximately 8% children under the age of 5 globally) and 41
million overweight children (or estimated 6.0% children under the age of 5 around the world).5
Asia was the worst performing with respect to the child malnutrition levels. The global average prevalence
for stunting in children under the age of 5 was ~23% (that is, percentage of wasted children under the age
of 5). Southern Asia has stunting prevalence rate at 34.1%, better than only Eastern Africa. The global
average prevalence for wasting in children under the age of 5 was 7.7%. Southern Asia has wasting
prevalence rate at 15.4% (highest in the world). To put things in perspective, 2 out of every 5 stunted
children in the world live in Southern Asia. Asia is home to the majority of children under the age of 5
suffering from wasting and severe wasting. 87 million children under the age of 5 were stunted; 36 million
children under the age of 5 were wasted and 20 million children under the age of 5 were over-weight.
Particularly in Southern Asia, wasting is acute with the number of wasted children under the age of 5
years being 27.6 million. Thus, wasting in Southern Asia constitutes a critical public health emergency.
While malnutrition can manifest in multiple ways, the path to prevention is virtually identical: adequate
maternal nutrition before and during pregnancy and lactation; optimal breastfeeding in the first two years
of life; nutritious and safe foods in early childhood; and a healthy environment including access to basic
services and opportunities for physical activity. These key ingredients can deliver a world where children
are free from all forms of malnutrition.
Despite this opportunity, global and regional child malnutrition estimates from 1990 to 2017 reveal that
we are still far from a world without malnutrition. The joint estimates, published in May 2017, cover
indicators of stunting, wasting, severe wasting and overweight among children under the age of 5, and
reveal insufficient progress to reach the World Health Assembly targets set for 2025 and the Sustainable
Development Goals set for 2030. Improving children‘s nutrition requires effective and sustained multi-
sectoral nutrition programming over the long term.
Combating malnutrition in all its forms is one of the greatest global health challenges. Influenced by
economic and income growth, urbanization and globalization, a significant shift in the quality and
quantity of human diets and nutrition-related epidemiology has occurred in the past few decades6,7.
Nutrition and associated epidemiological and demographic transitions were once accepted as near-linear,

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gradual processes. Instead, countries are now experiencing a fast-evolving and more complex nutrition
paradigm.
Today, nearly one in three persons globally suffers from at least one form of malnutrition: wasting,
stunting, vitamin and mineral deficiency, overweight or obesity and diet-related NCDs. In 2014,
approximately 462 million adults worldwide were underweight, while 1.9 billion were either overweight or
obese8. In 2016, an estimated 41 million children under the age of 5 years were overweight or obese, while
155 million were chronically undernourished9. Nutrition-related factors contribute to approximately 45%
of deaths in children under the age of 5 (mainly due to undernutrition), while low and middle-income
countries are now witnessing a simultaneous rise in childhood overweight and obesity.10,11
The developmental, economic, social and medical impacts of this global burden of malnutrition are
serious and lasting, for individuals and their families, for communities and for countries.
Malnutrition in India
In the recent past, there has been a renewed discussion around nutrition in India. A few months ago, the
Ministry of Health and Family Welfare had released the National Health Policy, 2017 (NHP-2017). It
highlighted the negative impact of malnutrition on the population‘s productivity, and its contribution to
mortality rates in the country. Apart from poverty, factors like dietary issues, poor sanitation and low
social status of women are the likely reasons for high child malnutrition in India. With one of the highest
rates of child malnutrition in the world, India has won notoriety as one of the nutritional basket cases of
the world over the past few years. Although India has witnessed significant progress in its battle against
child malnutrition over the past decade, the progress has been quite uneven, and child malnutrition rates
still remain high in many parts of the country.
The survey of over 6 lakh households conducted in 2015-16 shows that over the past decade, the
proportion of underweight children fell nearly 7 percentage points to 36%, while the proportion of
stunted children declined nearly 10 percentage points to 38%. Despite the progress, these rates are still
higher than those of many poorer countries in sub-Saharan Africa. And in some of the worst affected

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districts such as Purulia in West Bengal and Nandurbar in Maharashtra, every second child is
undernourished.12
India‘s performance on key malnutrition indicators is poor according to both national and international
studies. According to UNICEF, India was at the 10th spot among countries with the highest number of
underweight children, and at the 17th spot for the highest number of stunted children in the world.13
The 2016 Global Hunger Index (GHI) Report ranked India 97th among 118 developing countries for
which the GHI was calculated. The 2016 GHI score for India is 28.5 (‗serious‘ level). The GHI report
also reported that prevalence of stunting in children under the age of 5 was 38.7%; wasting stood at
15.1% and undernourished level stood at 15.2%.14
Figure 1.3: Comparative analysis of malnutrition status of children under 5 in India
Malnutrition in Palghar and Maharashtra
The National Family Health Survey (NFHS-4) 2015-16 has revealed that 83,000 children, below the age
of six years, were found to be severely underweight in the Maharashtra. Recently, the National Human
Rights Commission had sent a notice to the Maharashtra government over 600 malnutrition deaths that
were reported from the tribal belt of Palghar in a year.15

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Maharashtra was the first state in India to launch its mission in the form of an autonomous technical and
advisory body, in 2005 under the Department of Women and Child Development. Subsequently, five
other states have launched their respective missions based on the Maharashtra model: Madhya Pradesh,
Uttar Pradesh, Odisha, Gujarat, and Karnataka. All six state nutrition missions focus on the 1,000-day
post-conception period and commit to improving inter-sectoral coordination in order to improve child
nutrition.
Table 1.1: Maharashtra State Nutrition Mission Targets
Malnutrition is a multi-dimensional and an inter-generational phenomenon. The vicious cycle of
malnutrition leads to health crisis and is no less than an epidemic. The fellowship project is focussed
towards health interventions to tackle malnutrition in Walwanda village, Jawhar block, Palghar district in
Maharashtra, India. The worse-affected areas in Palghar are Jawhar and Mokhada blocks, where the
number of infant and child deaths increased historically in comparison to the last two years. Thus, there is
an urgent and persistent requirement to address the critical health issue of malnutrition plaguing the tribal
population in Jawhar.
1.3 Project Rationale
The preliminary stakeholder meetings held with including, inter alia, the primary health centre and village
health sub-centre officials, Anganwadi workers, Accredited Social Health Activists, Auxiliary Midwives,
Self-help Groups, Community Resource Personnel, the village community, school children, adolescent
girls and boys, the Gram Panchayat Samiti officials and Gram Sewaks, Gram Panchayat leader (sarpanch),
the Panchayat members and the local NGOs, all pointed towards the major health concern of
malnutrition in Jawhar. Malnutrition, by far, has been the primary cause of deaths among children aged 0-
5 years. Lack of proper nutrition, early marriages, frequent births, high fertility rate and a lack of proper
birth spacing has led to widespread anaemia, related diseases and worsening health conditions among the
pregnant and lactating women. This has further resulted in exacerbation of the maternal mortality and
child mortality rates in Jawhar.

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Factors such as early marriage, seasonal migration and meal intake were some of the factors that featured
high above, amongst rest of the factors that also contributed to poor nutrition among children, adolescent
girls and mothers. Other factors that has led to abysmal health profile of people in the tribal villages is
lack of awareness of institutional deliveries (home deliveries carried out by the inexperienced traditional
birth attendants due to un-affordability and inaccessibility to health care facilities), lack of both antenatal
and postnatal care, cultural barriers and superstitions, among others.
Though, the conventional belief is that malnutrition is caused due to lack of nutrition or nutritional
deficiencies of macronutrients and micronutrients. However, my understanding is that other non-
conventional factors (in addition to the factors listed above) such as poor sanitation, hygiene, health,
poverty, unemployment, poor environmental health conditions are equally vital and critical factors
contributing to the menace of malnutrition in Jawhar, Palghar.
Figure 1.4: The Cycle of Undernutrition (Source: http://iap.healthphone.org/the-cycle-of-undernutrition .html)
Thus, the project intervention strategies focus on nutrition-sensitive interventions rather than only
nutrition-specific interventions.

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The motive is to address the issue of malnutrition with the following approaches viz. social behaviour change
communication; information, education and communication; interpersonal communication; and community mobilisation.
The project entails both qualitative and quantitative analyses of the multiple conventional and non-
conventional factors that directly or indirectly result in maternal, newborn and child malnutrition.
1.4 Project Objectives
The project was conceptualised on three hypotheses –
1. As the foundation of nutrition programme and primary healthcare of the country‘s health ecosystem,
especially rural areas, the Anganwadi centres provided an effective mechanism for improving health
outcomes through community-based and participatory behaviour change communication.
2. Anganwadi workers and Accredited Social Health Activists could effectively mobilise members of the
village community and interface with various actors and institutions to activate the public health
system and respond to the needs of the most vulnerable sections of the society, that is, mothers,
PLW and children under the age of 5.
3. Schools, specifically tribal residential schools (ashram shalas) could effectively form the base for health
information, education and communication and preventive and promotive healthcare interventions
targeting adolescent children.
The project objectives were formulated taking into account the most vulnerable sections of the tribal
village, that is, mothers, pregnant and lactating women and children (age 0-5 years). The target group was
a) village community and households (with severe acute malnourished children) and b) Tribal residential
school (adolescent school children studying in standard 8th and 9th).
The project broadly aimed at developing community-based malnutrition awareness interventions. The
specific objectives included the following:
 To provide health promotion and health literacy at the tribal school targeting adolescent girls and
boys

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 To provide health awareness via conducting sessions and campaigns focussing on mothers, pregnant
and lactating women and children (0-5 years old) at the village and household level
 To provide health awareness to the tribal village residents – nutrition-sensitive awareness, community
mobilisation and food and nutritional security
The main aim of the project is to address the issue of malnutrition at the grass-root level, focusing on the
most vulnerable sections of the tribal community in the village. In essence, the aim of the project
intervention is to address the following –
(a) To mitigate the extent and severity of malnutrition among mothers, pregnant and lactating women
and children under the age of 5 via behavior change communication and community mobilisation
(b) To ensure information and knowledge dissemination, improve health and hygiene literacy and
increase the awareness levels about malnutrition and malnutrition prevention among adolescent
children via interpersonal communication, among others
1.5 Project Scope
Broadly, the project scope and design of the interventions and deliverables (at the village, household and
school level) for the purpose of the fellowship project is mentioned below:
Table 1.2: Project Design and Scope
Project Stage Activities/Interventions Deliverables
Stakeholder
mapping;
baseline
surveys; and
community
needs
assessment
- Visit PHCs, health sub-centres and
AWCs and conduct interviews with the
concerned stakeholders (PHC-MO,
ASHA, ANM, AWWs), Self Help
Groups (SHGs), Gram Panchayat (GP)
and community resource personnel
(CRP) to understand the malnutrition
issue
- Prepare discussion surveys for focus
groups (i.e. SHG, GP, etc.)
- Conduct discussions with the focus
groups (SHGs, etc.)
- Prepare baseline survey questionnaires
for household and village
- Institutional and shareholder
mapping
- Prepare stakeholder report with
focus on prospective interventions
to address malnutrition
- Summary report of the views,
opinions and feedback of the
concerned medical officers and other
health personnel
- Conduct a socio-demographic
survey/questionnaire with an
anthropometric design at the village
level and the household level,
respectively
- Data collection – compilation of survey
data
- Data interpretation and analysis
- Analysis of discussion surveys
- Preparation of health awareness
material for the purpose of
implementing project interventions

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Project
Scoping –
Village and
Household
- Follow-up with the AWCs and AWWs
to identify malnutrition cases (SAM and
MAM cases)
- Awareness sessions targeting children
under the age of 5, mothers and
pregnant and lactating women
- Prepare awareness material and
formulate the proposed interventions
via interpersonal communication (IPC),
awareness camps and community
mobilisation (CM)
- Introduction and setting up of
nutritional gardens in the village and
households to provide food and
nutritional security
- Household level interventions viz.
providing awareness on nutrition-
sensitive issues including, inter alia,
girl education, child marriage,
immunisation, water chlorination
and improved sanitation and hygiene
and other nutrition-specific factors
resulting in malnutrition
Project
Scoping –
School
- Formulate strategies to improve health
literacy and conduct medical camps and
awareness sessions
- Mobilise school students and conduct
health, hygiene and nutrition awareness
camps at tribal schools and ashram shalas
(residential schools), directed towards
adolescent girls and boys
- Design pamphlets on health and
hygiene practices
- Encourage youth to disseminate the
knowledge gained in the process
- Interventions at school level
providing awareness via creative
learning techniques
- Awareness on the planned modules
via classroom based creative learning
such as essay writing, drawing
competition, board game, health
education cards, comics, animations
and illustrative health education
material, among others
- Partner with local doctors, medical
officers, public health practitioners
and NGOs for conducting medical
camps
- Partner with schools and school
teachers for conducting classes on
adolescent health, health and hygiene
awareness and health literacy, etc.
Sustainability
– School;
Households
and Village
Household Level –
- Health promotion and health education
via health sub-centre and AWCs
- Kitchen Garden activities – promotion
and maintenance of nutritional gardens
School Level –
- Knowledge sharing with school teachers
– ‘Train the Trainer’
- ‘Student Health Ambassador’ (based on
student elections)
- Sustainable and creative learning
techniques (mentioned above)
Village Level –
- Kitchen Garden initiative: Food &
nutritional security via perennial food
crops
- Community participation,
empowerment and ownership

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1.6 Project Methodology
The methodology devised to conduct planned interventions and impact assessment of the project is as
follows –
1. Institutional and stakeholder mapping
2. Community needs assessment
3. Conduct baseline surveys (pre-intervention surveys at the a) village; b) households and c)
school)*
4. Design project structure at the school and village and household level.
5. Implement project interventions based on the project structure.
6. Impact assessment of project interventions at the village, household and school.
*Baseline surveys formed the basis for designing project structure and interventions at the school, household and village level
The parameters utilised to study the impact of the project interventions is as follows –
Village and Household Level –
Post-intervention survey will be conducted to assess the impact of the project pertaining to mitigation of
the extent and severity of malnutrition among mothers, pregnant and lactating women and children under
the age of 5, via behavior change communication and community mobilisation. For this purpose, the data
points studied to ascertain the extent of malnourishment was based on a) Height; b) Weight and c) Mid-
Upper Arm Circumference. Further, linkages shall be drawn based on nutrition-sensitive factor analysis.
In addition to the above, project status and impact assessment of nutrition-specific interventions
(nutrition garden initiatives) will also be evaluated.
For the village and household level interventions, the target group was a) mothers; b) pregnant and
lactating women (PLW); and c) children (0-5 years old).
School Level –
Post-intervention survey will be conducted to assess the impact of the project pertaining to information
and knowledge dissemination, health and hygiene literacy and awareness for malnutrition and
malnutrition prevention among adolescent children via interpersonal communication, among others.
For the school level interventions, the target group was students studying in the 8th and 9th standard.
However, for the purpose of project impact assessment, only 8th standard students were evaluated.

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1.7 Project Limitations
1. Only one village in Jawhar, that is, Walwanda village was chosen as the target village for the purpose
of the fellowship project. The limitation related to the choice of target village was the result of
following parameters that went into the selection of location –
 Presence of a tribal school (residential)
 There must be at least 10 severe acute malnutrition cases
 Accessibility – the village must be easily accessible by road and be within 10-20 kilometer radius.
2. Other critical areas and villages (where malnutrition is high) could not be selected as focus villages for
the project, due to the following reasons –
 Time constraint (the project intervention spanned less than a year and thus there was not
sufficient time to scale-up to other locations, taking into account the depth of project
interventions conducted for the target groups at the target village).
 Inaccessibility – there was no mode of public transport that was available to reach other villages.
 Distance – the other villages were quite far-off from the base location. The distance was on
average ~50 kilometers or more.
 Political risks – some of the villages were politically very active and thus working on a community
centric and socially sensitive topic such as malnutrition, child marriage, among others was neither
viable nor feasible.
3. Only SAM/MAM cases were treated as the focus group as far as the household interventions were
concerned. Due to factors such as fellowship time constraints, project design and scope and impact-
oriented interventions, only such cases were considered to bring about a tangible impact among the
target group.
4. Only one tribal (residential) school was adopted as the target school. That is, only one school met the
requirements for the project intervention and activities to be carried out. The parameters for
choosing the school were –
 Availability of resource room with an audio-visual facility
 Availability of electricity for at least a few hours in the day

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 The school must be a residential school (that is, an ashram shala)
Since, other schools in other villages did not meet the above basic requirements; no other school was
adopted for the purpose of this project.
5. The main activity of the tribal village residents is farming. Since, migration is rampant during off-
season (post harvest), not all households‘ members were available at all times. This impacted the
regularity and frequency of the planned interventions and activities. However, best efforts were made
to design and time the critical interventions accordingly, taking various impediments into account.
6. Project interventions were based on social behavior change communication, community mobilisation,
information, education and communication and inter-personal communication. Thus, language
barrier (Marathi being the native language) limited the communication mediums and language used
for the purpose of health promotion and education.
7. Occasional student and teacher absenteeism – impacted comprehensive and effective training on
health literacy and awareness. Further, summer vacations, school exams, incessant monsoon rains and
days with no electricity also led to no-show day.
8. Certain activities and interventions that was dependent on timely monsoon rains such as ‗perennial
nutritional gardens‘ (i.e. kitchen garden initiative) got adversely affected. This resulted in intervention
delays and led to challenges related to implementation, timely monitoring and evaluation, impact
assessment, among others.
9. Inherent superstitions and cultural barriers and practices such as early marriage, erratic meal timings
and meal intake, seasonal migration, women being fed the last, among others negatively impacted the
progress of the project. Further, reluctance and resistance from the community to change social
behavior made it difficult to overcome certain critical blockers and implementation challenges.
10. Based on research and observations, other critical factors leading directly or indirectly to malnutrition
among the tribals in Palghar was tribal landlessness, seasonal migration, lack of alternate livelihood,
gaps in public distribution system (PDS), among others. These issues could not be addressed as these
were beyond the scope of this project.
11. Lastly, only one village, one school and c.12 households were considered as targets for the purpose of
the fellowship project. This was due to limitations related to the project design, scope and

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interventions. Further, systemic, logistical and infrastructural bottlenecks at various levels viz. rural
governance systems, rural health systems, among others, led to various inadvertent and unforeseen
limitations that could not be mitigated in its entirety.

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CHAPTER 2: Literature Review
2.1 Health Promotion and Behaviour Change
The best known definition of health is that given in the WHO Constitution: Health is a state of complete
physical, mental and social well-being and not merely the absence of disease or infirmity. Describing
health as a general value, this definition was perhaps intended neither to serve as a framework for
formulating goals of health policy nor for deriving operational definitions of health. However, health is a
holistic concept. Furthermore, these definitions indicate that health is a complex, multi-dimensional
concept. The common themes referring to several such dimensions are: health as the absence of
symptoms, illness or disability; health as a positively valued psychological experience; health as balance or
equilibrium within oneself and with the environment; health as a capacity or potential to pursue personal
goals and to cope with environmental and social demands; or health as the process of goal-directed action
or as the process of effective coping.
On the basis of these considerations, two key dimensions of health can be defined: health balance and
health potential. Both dimensions seem to integrate much previous thinking as well as important
conclusions drawn from research and practical experience, and they are relevant to the level of both the
individual and the community.
At the level of the individual, health balance is a process or an internal state that is customarily taken as a
dynamic equilibrium. Normally, lay people will experience such a state either as the absence of physical
and psychosocial needs, symptoms, illness or disability, or in a positive sense as physical, psychological or
social wellbeing, depending on their socio-cultural background and personal health related experiences.
Health professionals, on the other hand, will define health balance in terms of physiological and/or
psychological and behavioural parameters that usually vary between certain accepted norms and form
particular patterns over time. Thus, subjective or professional judgements of negative or positive health
and of its established biological parameters can serve as indicators of health balance of individuals. More
complex indices can be developed, for example by combining subjective and medical parameters as
suggested by Antonovsky for the ease/disease indicator.16

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At the community level, health balance also reflects dynamic balance, but as related to the characteristics
of a particular population, such as the experiences and activities of people and the interactions among
them. The health balance of a community may be assessed, for example, through household surveys by
subjective ratings of the level of wellbeing and health related activities.
The meaning of health promotion overlaps considerably with the meaning of prevention. Customarily,
three levels of prevention are distinguished. Primary prevention can be defined as the promotion of
health by personal and community-wide efforts, e.g., improving nutritional status, physical fitness, and
emotional well-being, immunizing against infectious diseases, and making the environment safe.
Secondary prevention can be defined as the measures available to individuals and populations for the
early detection and prompt and effective intervention to correct departures from good health. Tertiary
prevention consists of the measures available to reduce impairments and disabilities, minimize suffering
caused by existing departures from good health, and to promote the patient's adjustment to irremediable
conditions. This extends the concept of prevention into the field of rehabilitation.
Two major types of health promotion are distinguished here: the individual health approach and the
community health approach.
The individual health approach aims directly at improving an individual person's health potential. As a
consequence, he or she is expected to change his or her health behaviour and lifestyle and to help
improve health related aspects of the social, cultural, economic, natural and technical environments. Thus,
the personal health approach lies in the tradition of clinical intervention, counselling and face-to-face
education.17
The community health approach, on the other hand, is primarily directed towards improving the socio-
ecological health potential: the health resources of the economic, social, cultural, natural and technical
environments. It is assumed that this will have a positive impact on people's physical conditions, health
risks and lifestyles and consequently on their individual health potential. The community health approach
thus follows very much the tradition of social medicine and public health.18

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Figure 2.1: Health Promotion Emblem (logo used by WHO since the First International Conference on Health
Promotion held in Ottawa, Canada, in 1986)
2.2 Community Engagement, Participation and Mobilisation
Primary health care was ratified as the health policy of WHO member states in 1978. Participation in
health care was a key principle in the Alma-Ata Declaration. This principle reflected the underlying value
of social justice, confirming the view that all people have the right to be involved in decisions that affect
their lives. It also reflected the value of participation in improving health, often among the poor,
particularly in rural areas, based on health programmes mainly in the non-governmental organization
sector. Community participation became a defining characteristic of the primary healthcare approach to
health.
In developing countries, ante-natal, delivery, and post-natal experiences for women usually take place in
communities rather than health facilities. Strategies to improve maternal and child health should therefore
involve the community as a complement to any facility-based component. The fourth article of the
Declaration stated that, ―people have the right and duty to participate individually and collectively in the
planning and implementation of their health care‖, and the seventh article stated that primary health care
―requires and promotes maximum community and individual self-reliance and participation in the
planning, organization, operation and control of primary health care‖.

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Rosato et al. (2008)19 also noted the benefits of community participation in maternal, newborn and child
health (MNCH). According to Susan B. Rifkin (2009)20, evidence has been forthcoming to show that
community participation has made significant contributions to health improvements, particularly among
the poorer members of the population. Further, Susan noted that community participation as a critical
factor in health improvements identified 30 years ago in the Alma-Ata declaration has continued to be
relevant over this period and is, once again, being highlighted as an essential element for improving
health, particularly among the poor, in all countries.
N Gray et al. (2014) noted the benefits of community engagement for management of acute malnutrition.
Engagement with the community should be participatory, inclusive, equitable, reciprocal, creative,
continuous, accountable and transparent. It must be adapted to a local context in a way that inspires
ownership, empowerment and shared responsibility. At the same time, strong commitment at local, sub-
national, national and international levels needs to be structured through relevant policy and broader
community health system strengthening strategies that are informed by health systems analysis, including
root cause analysis. These measures combined with ongoing analysis and sharing of promising practices
will help to ensure the feasibility and sustainability of CMAM.21
Further, Prasad and Sinha (2015) published a paper on community based programme to address
malnutrition in tribal India. The paper demonstrates the effect of an innovative community-based
management programme on acute malnutrition among children (0-3 years old), through an
observational longitudinal cohort study in tribal blocks in central-eastern India. The key components of
the programme included child care through crèches, community mobilisation and systems strengthening
to ensure better child feeding and caring practices and delivery of public health and nutrition services.
The study suggests that this medium term strategy using a rights-based participatory approach for
community based management of malnutrition may be comparatively effective by current WHO
guidelines and other known community based interventions in terms of mortality, cost, degree and pace
of improvements.22

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2.3 Nutrition-specific factors
India, with a population of more than 1 billion people, has many challenges in improving the health and
nutrition of its citizens. Steady declines have been noted in fertility, maternal, infant and child mortalities,
and the prevalence of severe manifestations of nutritional deficiencies, but the pace has been slow and
falls short of national and SDG targets. The likely explanations include social inequities, disparities in
health systems between and within states, and consequences of urbanisation and demographic transition.
In 2005, India embarked on the National Rural Health Mission, an extraordinary effort to strengthen the
health systems. However, coverage of priority interventions remains insufficient, and the content and
quality of existing interventions are sub-optimum. A need for transformation of health systems through
effective stewardship, decentralised planning in districts, a reasoned approach to financing that affects
demand for health care, a campaign to create awareness and change health and nutrition behaviour, and
revision of programmes for child nutrition was studied by Paul, V.K et al.23
Stone-Jimenez, M. (2014) found some evidence for preventing MAM through nutrition-specific
interventions. The paper concluded that although providing a food supplement, usually in the form of a
specialised food product, has demonstrated limited effectiveness in preventing MAM in some contexts –
the combination of product and delivery strategy can vary significantly so finding consistent results has
not been straightforward.24
Trehan, Indi, et al.25 concluded in the study paper that extending supplementary feeding for children
under the age of five with MAM leads to lower relapse rates.
Lack of diet diversity causing micronutrient deficiency is common in developing countries and is gaining
attention due to the hidden consequences of impaired physical and cognitive development. Birdi and
Shah (2015) describe the propagation of a sustainable perennial kitchen garden (KG) model to address
household diet diversity in Melghat, Maharashtra. The paper concluded that a well designed perennial KG
along with imparting adequate knowledge can be a sustainable practice to increase diet diversity and green
leafy vegetable intake which would help address micronutrient deficiencies in the community.26

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2.4 Nutrition-sensitive factors
According to de Pee, Saskia, et al., acute malnutrition is associated with increased morbidity and mortality
risk. When episodes are prolonged or frequent, acute malnutrition is also associated with poor growth and
development, which contributes to stunting. Nutrition-specific and nutrition-sensitive strategies to
prevent undernutrition during the first 1,000 days from conception to 24 months of age can reduce the
risks of wasting, stunting, and micronutrient deficiencies. Under circumstances that exacerbate the
underlying causes of undernutrition and increase the incidence of wasting, such as food insecurity related
to lean seasons or emergencies, or increased incidence of illness, such as diarrhoea or measles, additional
efforts are required to prevent and treat wasting. Special nutritious foods directly meet the increased
nutrient requirements of children at risk for wasting; assistance to vulnerable households, in the form of
cash or food, enables households to better meet the food, health, and other needs of household members
and may increase resilience; water, sanitation, and hygiene (WASH) and health interventions help prevent
and address illness and hence reduce wasting risk.27
Ruel, Marie T. And Harold Alderman (2013) found that acceleration of progress in nutrition will require
effective, large-scale nutrition-sensitive programmes that address key underlying determinants of nutrition
and enhance the coverage and effectiveness of nutrition-specific interventions. The study paper reported
that combined early child development and nutrition interventions show promising additive or synergistic
effects on child development and in some cases could lead to substantial gains. Furthermore, the paper
concluded ways to enhance nutrition-sensitivity by improving targeting; using conditions to stimulate
participation; strengthening nutrition goals and actions; and optimising women's nutrition, time, physical
and mental health, and empowerment. Nutrition-sensitive programmes can help scale up nutrition-
specific interventions and create a stimulating environment in which young children can grow and
develop to their full potential.28

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CHAPTER 3: Methodology
3.1 Community Needs Assessment
For the purpose of formulation of project methodology and structure, it was imperative to understand
the local community needs. Thus, various stakeholder meetings were conducted at the start of the project.
Following is the summary of the community needs assessment –
Table 3.1: Stakeholder Mapping and Community Needs Assessment
Stakeholder Details Issues Reported Way Forward Potential Scope
Dr. Anita Patil -
Siddhivinayak Hospital
Gynaecologist &
Obstetrician
 Early Marriage
 Alcoholism
 Erratic meal
frequency among
the children
 Malnutrition
(Stunting, Wasting,
Under-
nourishment)
 Lack of awareness
of Institutional
deliveries
 Various cultural
barriers and
superstitions
pertaining to food
intake during
pregnancy
 Lack of ante-natal
care and post-natal
care
 Health Literacy
 Awareness about
girl child education
and health
 Curb early marriage
practices
 Preventive and
promotive health
interventions to
counter
malnutrition among
adolescent girls and
boys
 Enhanced focus on
residential schools
and tribal children
and households
 Preventive and
promotive health
care initiatives to
tackle the
malnutrition issue
in the tribal villages
 Design health
interventions to
address the issue at
the school level as
well as the
household level
 Enhanced focus on
child health during
the first 1000 days
of birth
 Address maternal
health via social
behaviour change
communication
Dr. Satpal Pratap Singh
Rajput -
PHC MO-in charge
(Sakur)
 Children and
mothers suffering
from Anorexia
 Ear discharge
 Maternal issues viz.
Anaemia
 Revamp of the
meals provided at
the Anganwadi
centres
 Ensure
consumption of
balanced diets at the
household level
 Awareness about
the dietary issues
impacting the
malnutrition issues
 Work with the
Anganwadi workers
to tackle
malnutrition issue
Ms. Pallavi Tamedkar -
Tehsildhar
 Unemployment
 Alcoholism
 Malnutrition (i.e.
undernutrition )
 Enhance the reach
of various
government
schemes
 Awareness
programs on
government/social
schemes
Dr. Kiran T. Patil -
PHC MO-in charge
(Jamsar)
 High infant
mortality among the
tribal population
 Malnutrition
 Early marriage
 Lack of regular
health-checkups
 High total fertility
 Infant and newborn
child care
 Address the multi-
dimensional issue of
malnutrition
 Preventive health
care
 Reduce
 Special focus on the
most vulnerable
sections of the
society i.e. children
below the age of 5,
adolescent girls,
pregnant and
lactating women

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rate
 Poverty and
illiteracy
unemployment,
income inequality,
poverty and
illiteracy
 Provide general
awareness about
health and hygiene
 Focus on
environmental
health and
sanitation
Ms. Bharti Subhash
Gavi
Anganwadi Worker,
Jawhar
 Food wastage due
to bad taste
 Introduction of
better meal plans
and timing
 Advocacy at the
household level on
the importance of
consuming
balanced diets
 Provide meals at
regular and
consistent times
every day
 Increase awareness
of child health for
child growth and
development
Mr. Vilas Gole
School Principal –
Walwanda Tribal High
School
 Skewed gender ratio
 Erratic meal timings
as per government
policies
 Early marriage
 High school
dropout rate
especially among
girl students
 Health awareness
sessions in
collaboration with
school teachers
 Emphasis on girl
education
 Addressing
malnutrition, early
marriage, girl
education, teacher
training, among
others
SHGs  Financial literacy
amongst women
 Women health
issues
 Child health
 Community
mobilisation
 Financial literacy
awareness programs
and camps
 Awareness
programs on
Maternal and Child
Health (MCH)
 Alternative
livelihood
 Addressing
Maternal and Child
health (MCH)
issues
Date of Survey: Oct. 18, 2016 – Oct. 31, 2016
Preliminary meetings and interviews with various stakeholders suggested that malnutrition issue is a multi-
dimensional issue and not caused solely due to nutritional deficiencies. Understanding the profundity of
this enormous issue seemed an uphill task in itself, let alone tackling the issue.
Post stakeholder meetings, it was concluded that malnutrition is definitely a multi-dimensional issue and
all these contributing critical issues need to be tackled from all the fronts simultaneously and not

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separately. Various factors contribute in one form or the other bringing Jawhar block and Palghar district
to the brink of a health crisis.
Thus, the strategy devised to address the issue of maternal and child malnutrition in the target village was
based on two cornerstones, that is, social behaviour change communication and community mobilisation.
3.2 Behaviour Change Communication
3.2.1 BCC – Strategy
Behaviour change communication was a multi-level tool for promoting and sustaining risk-reducing
behaviours in individuals and communities by distributing tailored messages through a variety of
communication channels. It was of immense importance to make the individuals and communities have a
comprehensive understanding about malnutrition and its implications.
As malnutrition is related to cultural elements and belief systems, this required larger level discussion
about behaviours.
 BCC was part of an integrated, multilevel, interactive process with communities aimed at developing
tailored messages and approaches using a variety of communication channels
 BCC aimed to foster positive behaviour; promote and sustain individual, community, and societal
behaviour change; and maintain appropriate behaviour
 BCC was a process of working with individuals, communities and societies to develop
communication strategies to promote positive behaviours, which were appropriate to their settings;
and provide a supportive environment which would enable people to initiate and sustain positive
behaviours
 BCC was unique in that it used local language expressions, traditions and practices to convey health
promoting messages
3.2.2 BCC – Approaches
The following are the approaches to communication adopted in BCC:
1. Behaviour change was the ultimate task in BCC process to sustain the initiatives and practice of
individuals.

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2. Curriculum approach – seeding depth of knowledge with technical content.
3. Multimedia approach – using multiple ways of communication for improved knowledge and
behaviour (including clear cut messages for dissemination on malnutrition awareness).
4. Peer pressure process – developing pressure through peers and neighbours while operating in groups
or village as a unit.
5. Cascading model – spill-over effect to be created from one to another.
6. Comprehensive approach – All in one and interlinked with one another.
7. Community ownership – ownership for sustainability and follow-up
3.2.3 BCC – Processes
The main objective of BCC was to make the target group understand about malnutrition and its serious
implications. The processes changing the behaviours through BCC are mentioned below.
a. Unaware/Aware – Initially the target group was only partially aware that a particular behaviour may
be incorrect. The first step was to create awareness via a comprehensive BCC approach.
b. Concerned – Awareness about an issue need not necessarily generate concern about it. The given
information must be appealing to the target audience, enabling them to develop concern about the
extent to which the person gets motivated to evaluate one‘s own behaviour. Hence, targeted
communication and inter-personal approaches remained critical, which was attempted in the BCC
process.
c. Knowledgeable – In this stage, out of concern, the individual starts interacting with other members in
the community to gain more knowledge about malnutrition and methods of prevention. In this stage,
the role of IEC, CM and IPC, especially training programmes on health promotion and awareness to
build knowledge and skills about the issue and negotiate on desired behaviour was made.
d. Motivated – At this stage, the target group was motivated and ready to change present health
behaviours after assessing past health behaviours.
e. Persistent change in behaviour – The target group realise benefits to imbibe new behaviours in their
day to day life. Bringing about a behavioural change is not an easy process. It is pertinent to design a

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comprehensive approach to facilitate target group‘s movement along the continuum of behavioural
change.
3.2.4 BCC – Preparation of Materials
Planning and preparation of health promotion, education and awareness for BCC was vital for
malnutrition control. A timeline was set for each and every work as part of the planning process. The
BCC materials were prepared on the basis of the following aspects experienced during the project period.
 The preparation was done based on experience and evidence.
 Kinds of communication support and resources the healthcare facilitators (ASHA, AWW, etc.) would
need was taken into consideration.
 Recognition of the socio-cultural milieu of the people and the community were considered.
 The heterogeneity of the target group (based on socio-economic factors, socio-cultural factors, and
demographic factors, among others) was also considered to ensure reinforcement of positive social
and cultural values in the community.
 Monitoring and evaluation were the two key factors needed for effective outcome of the behaviour
change.
3.3 Baseline survey data
A comprehensive approach was devised to address the issue of malnutrition among the target group that
ensures community ownership.
Baseline surveys were conducted at the target village (Walwanda village), village households and the
school (Walwanda Tribal High School, a tribal residential school or ashram shala). These surveys formed
the basis for designing project interventions and activities at the school, household and village level.

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Village Level – Baseline Survey2
Baseline survey conducted at the Walwanda village suggested that there are approximately 200
households. The population comprises of c.320 males and c.300 females. The total number of children
(0-5 years old) was c.80. Out of this, approximately 55 children were enrolled at the village Anganwadi
centre. The SAM children (0-5 years old) in the village were 12 in number, with 3 male SAM cases, 7
female SAM cases and 2 female MAM cases (per baseline survey conducted on 30 December 2016).
Household Level - Baseline Survey3,4
Baseline survey at the household level was conducted for a population size of 117 households. The
sample size was 12 households (that is, the target group for the project intervention). The aim of the
project was to focus only on the target group of 12 households. This is due to the fact that baseline
survey data suggested these 12 households had children (under the age of 5) that were severe acute
malnourished or moderate acute malnourished (as per factors such as body weight, height, mid-upper arm
circumference and body mass index calculation prescribed by the World Health Organisation). On an
average, each household had 6 members with at least 1 and at most 3 children severely malnourished. The
baseline survey conducted was based on nutrition-sensitive factor analysis. The factor analysis pertained
to the following factors viz. a) biological factors; b) socio-cultural factors; c) socio-demographic factors; d)
socio-economic factors; e) environmental factors; and f) behavioural factors.
Following are some critical facts and findings of the factor analysis –
 There were 10 children that were severe acute malnourished and 2 children that were moderate acute
malnourished. That is, 12 children were stunted (low height for age), wasted (low weight for height)
or undernourished (low weight for age) and thus categorised as SAM/MAM cases accordingly.
 Further, the data points studied to ascertain the extent of malnourishment was based on weight,
height, Body Mass Index (BMI) and mid-upper arm circumference.
 As far as mothers were concerned, 3 mothers were underweight, 3 were overweight and 6 had normal
weight (per BMI definition prescribed by the WHO).
2
Refer Appendix I
3
Refer Appendix II.A
4
Refer Appendix II.B

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 Birth-spacing was found to be normal. That is, on average 2 years.
 Out of the 12 households surveyed, 5 households were landless. The remaining households had
farming land anywhere between 1 – 2 acres in area.
 Half of the village households did not have a toilet constructed at home.
Tribal Residential School - Baseline Survey5
A baseline survey was conducted at the Walwanda Tribal High School in Walwanda village, Jawhar. For
the purpose of analysing the outcomes and impact of the proposed project interventions on health
literacy, health promotion and awareness, two surveys were conducted – pre-intervention and post-
intervention.
The target group for the school project intervention was students of the school studying in the 8th and 9th
standard.
Pre-intervention survey statistics: students having awareness about balanced diet (21%), hygiene
(personal, food and environment) stood at 47% students, waste management (50%), child marriage
(44%), Anaemia (15%) and importance of micronutrients, specifically Vitamin A (15%).
Based on the baseline surveys, the project structure and interventions were designed for the village,
household and school, respectively.
Project Structure – Village
 Nutrition-sensitive awareness
 Social behaviour change communication
 Community mobilisation
 Health awareness sessions via Anganwadi centres and village health sub-centre
 Knowledge sharing on nutritious recipes with the village Anganwadi workers
5
Refer Appendix III

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 Health and hygiene awareness campaigns (with a focus on environmental health, immunisation, etc.)
via posters, banners and other health promotion material
Project Structure – Household
 Targeted health awareness and promotional activities
 Health promotion via Anganwadi centres and health sub-centre
 Health and hygiene awareness campaigns via posters, banners, among others
 Kitchen Garden initiative – ‘perennial nutrition garden’ via growing perennial food crops
 Knowledge dissemination on nutritious recipes and traditional healing practices with the households
Project Structure – School
 Nutrition-sensitive awareness
 Health information, education and communication
 Health literacy and malnutrition awareness training sessions covering topics such as Food &
Nutrition, Water, Sanitation and Hygiene (WASH), Child marriage, Immunisation, Drinking water,
Girl education, among others
 Creative learning techniques (essay writing, drawing competition, board game, health education cards,
comics, animations and illustrative health education material, etc.)
 Health and hygiene awareness campaigns (with a focus on environmental health, sanitation, etc.)

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CHAPTER 4: Project Interventions
Two-tiered project interventions were conducted, that is, one at the village and household level and the
second at the school level. Broadly, the project interventions were categorised as nutrition-specific and
nutrition-sensitive.
4.1 Village and Household – Interventions
4.1.1 ‘Swasthya Samwad’
This intervention was based on providing health promotion and education with a specific focus on
spreading awareness about malnutrition and its implications. This was done through community
engagement, participation and mobilisation via Anganwadi centre in the village. The target group, that is,
the SAM households was the primary focus of this intervention.
A comprehensive BCC approach (utilising all communication channels such as posters, banners, hand
bills and leaflets, pamphlets, among others) was devised to disseminate vital knowledge among the
households, specifically and the village community, in general.
Figure 4.1: ‗Swasthya Samwad’ session at the village AWC

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Figure 4.2: Use of poster for depicting nutritious food items
The main purpose of this intervention was to achieve higher awareness and health literacy levels among
the target group, that is, ‗at-risk‘ SAM households. Weekly health communication sessions (Swasthya
Samwad) were carried out at the village AWC with the help of AWWs.
4.1.2 Nutritious Food Recipes
This intervention was based on providing knowledge about micronutrients and also introducing new
recipes (with locally grown and available ingredients). The ingredients included green leafy items: taro leaf,
curry leaf, drumstick leaf; locally available nagli (finger millet) flour, puffed rice, tomatoes, lemon and so
on.

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Activities related to demonstration and preparation of the nutritious recipes for the children (under the
age of 5) enrolled at the AWC was also carried out. For this intervention, it was taken into consideration
that the recipes were both cost and time effective.
Rawa Ladoo Nagli Ladoo Nagli Parantha
Figure 4.3: Nutritious Food Recipes
The main purpose of this intervention was to ensure knowledge dissemination about nutritious recipes to
the vulnerable target group comprising of mothers and PLW. Further, this activity was proposed to
improve intake of nutritious food to control undernutrition among children under the age of 5.
4.1.3 Perennial Nutrition Garden
This intervention was carried out in collaboration with the partner NGO BAIF and the village CRP. The
nutrition garden concept involved procurement and distribution of seeds of perennial food
crops/vegetables such as lady finger, spinach, among others.6
Following activities were undertaken with respect to this intervention –
• Procurement of seed packets from NGO BAIF7
• Distribution of vegetable seed packets8 among:
a) SAM households; and
b) AWC
6
Refer Appendix IV
7
Refer Appendix IV
8
Refer Appendix V

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Figure 4.4: Distribution of seed packets
• Demonstrations provided on the following parameters:
- Vegetable seed planting techniques
- Seed planting times
- Sowing distance (distance between plants)
- Distance between planting rows, etc.
Figure 4.5: Demonstrations provided by the CRP and the AWW

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Furthermore, the SAM households were mobilised to set up nutrition gardens at their
household/farmland.
Figure 4.6: Community members planting seeds in the kitchen garden
4.1.4 Health Awareness Campaigns
Various health awareness campaigns were conducted at regular intervals in collaboration with the village
health sub-centre and the AWC. The health campaigns comprised of conducting general health check-up
camps, immunisation camps, awareness about mobile medical units and medicine centres and awareness
on environmental health (open defecation, sanitation and general hygiene practices).
In this intervention, the primary focus was to provide the target group essential knowledge about overall
good health practices to address the malnutrition issue.
Figure 4.7: General health check-up camp

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Figure 4.8: Immunisation camp conducted at the health sub-centre
Figure 4.9: Health clinic and mobile medical unit (in collaboration with Savali Charitable Trust, Walwanda village)
4.1.5 Traditional Healthcare Awareness
Traditional medicine is critical and has contributed tremendously to the healthcare of both the mother
and the child in tribal regions. Jawhar block in Palghar district is a tribal block having rich biodiversity,
especially rice varieties having specific characteristics and uses. But during the last two decades or so there

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47
has been a gradual loss of practical knowledge about traditional medicine and healing practices in the
tribal regions, during the past couple of decades. This has resulted in poor health status of the most
vulnerable sections of the tribal population.
In this intervention, the tribal farmers were encouraged to cultivate diverse rice varieties for purposes
such as food security, instant energy provision during peak workload and medicinal use. Further, various
ongoing studies conducted by the NGOs such as BAIF Development Research Foundation in different tribal
belts across Maharashtra found a number of rice varieties having specific medicinal properties and uses.
For instance, one rice variety called ‘Mahadi’ has multiple health benefits; one of them is to cure weakness
in women post pregnancy. Other rice varieties include ‗Rajghudya’ and ‗Kali Kudai’ (used to increase breast
milk in lactating women); ‗Kali Khadsi’ (for child‘s growth and nutrition); ‗Kasbai’ (used for nebulisation,
which gives instant relief from cough) and ‗Dangi’ (used for instant energy boost), among others.9
The main purpose of this intervention was to utilise the wonderful diversity of rice and form the basis of
a nutritious and secure diet for the vulnerable groups of the tribal population, that is, mothers, pregnant
and lactating women and children (under the age of 5) via knowledge dissemination through face-to-face
interactions with the tribal farmers.
4.2 School – Interventions
At the school level, focussed health literacy and health promotion sessions were undertaken at the
Walwanda Tribal High School. The details of the project interventions and activities (nutrition-sensitive)
are mentioned below.
4.2.1 Food, Nutrition and Balanced Diet
The main objective of this health training module was to impart knowledge about the food types, food
uses (i.e. strength, growth and immunity), importance of micronutrients (i.e. Vitamin A, Iodine, Iron,
etc.), food hygiene (i.e. washing raw vegetables and eating properly cooked food), importance of exclusive
breastfeeding for six months and balanced diet.
9
https://ankurchhabrablog.wordpress.com/2017/08/17/traditional-healing-practices-implications-for-healthcare/

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Specific focus was given to awareness on micronutrient deficiency and balanced diet. These two factors
are critical from the stand point of malnutrition.
A balanced diet contains foods that provide adequate amounts of carbohydrates, fat, protein, minerals
and vitamins, which help the body to grow, develop and stay healthy.
Figure 4.10: Balanced Diet – Pyramid Chart
Students were encouraged to adopt a balanced diet and healthy eating practices. For this purpose, various
activities and creative learning techniques were devised to spread awareness about food and nutrition.
Figure 4.11: Food and Indian Flag

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Here, the children were educated about the importance of food and nutritious food items and inter-linked
with colours of the Indian national flag (i.e. saffron, white and green).
Figure 4.12: Use of audio-visual aids for awareness on food and nutrition
Figure 4.13: Balanced Diet Activity

SBI Youth for India Fellowship 2016-17 - Final Report

SBI Youth for India Fellowship 2016-17 - Final Report

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