Tackling Malnutrition through Community Nutrition Educators
May 23, 2013
Michael Matheke-Fischer & Pratik Phadkule
To reduce the prevalence of underweight children under 5 years old and to reduce child mortality from malnutrition by strengthening communities and village level government facilities’ capacity to identify, treat, and prevent malnutrition. This project aims to prove that a holistic, decentralized, community-based approach to malnutrition eradication will have better health outcomes, be more inclusive for children under 5 and will be more cost-effective in the long-run than centralized approaches, especially for rural, marginalized tribal communities.
Photo: RMF's Malnutrition Education Booth at the International Women’s Day Mela
This project empowers communities through health literacy and connects rural communities with the government health and nutrition services available.
In Year Three of this program, RMF does not just act as a catalyst mobilizing communities to the resources available, but also works on a more intimate level with government health and nutrition workers and Village Health and Sanitation Committees to help build their capacity towards social mobilization, referrals, and provision of effective nutrition counseling. Throughout this year RMF will gradually transfer the responsibilities of our CNEs to government supervisors and Anganwadi workers, helping integrate RMF’s work into the government framework to ensure long-term sustainability.
Project Objectives during this reporting period:
- Continue to identify new SAM and MAM cases, refer complicated cases to the NRC and provide home-based counseling for all malnourished children
- Review all program data and make necessary changes in program reporting system
- Refer 1,000 SAM children to government centers for treatment with a 50% success rate
- Conduct 2,500 Community Nutrition Meetings
- Conduct 9,000 Individual Family Counseling Sessions
- Send CNEs to Nutrition Rehabilitation Centers (NRCs) to help counsel families present
- Continue to develop linkages with government health and nutrition services
Results and/or accomplishments achieved during this reporting period:
During the First Quarter of 2013, RMF’s Malnutrition Eradication Program continued to be a strong presence in Madhya Pradesh (MP). The CNEs are continuing their day-to-day activities of counseling, identification and referrals, while RMF staff work to improve the rollout of Madhya Pradesh’s Atal Bal Mission state nutrition mission (ABM). By collecting feedback on the implementation of the ABM in our 5 target districts, and presenting our findings to policymakers in Bhopal, RMF is integrating field level observation with our model to change the landscape of malnutrition treatment in MP.
For instance, under the 2013 implementation plan for the ABM, all Anganwadi workers were scheduled to receive additional training for master trainers trained in Bhopal. In January, four members of RMF’s staff were selected by the state government to be members of the master training cadre, and will bring their three years of practical, on-the-ground experience to the training sessions of Anganwadi workers in our five districts. After working with officials at the state and district levels, RMF was also able to help facilitate the scheduling of trainings for Accredited Social Health Activists and Village Health, Sanitation, and Nutrition Committee Members in 2013, and several of RMF’s staff have been selected by the government to become master trainers and attended training sessions for these trainings.
Photo: RMF CNE's attend a training session with Dimagi, Inc, trainers
This inclusion of RMF staff into the training cadre presents an oppurtunity to integrate RMF practices into Anganwadi services in our target districts. In 2011, with support from the Government of MP and the Madhya Pradesh Technical Assistance Team (MPTAST), RMF designed and finalized a training module for Anganwadi workers. This easy to use module integrates best practices and is divided into separate sub-modules; each section can be completed in one day, allowing for Anganwadi supervisors to provide continual on the job training at monthly sector meetings.
CommCare by Dimagi
In January 2013, RMF and our partner, Dimagi, upgraded our mobile data collection application and conducted trainings with all of our CNEs across 5 districts. The new application provides a more seamless platform for data entry, and also provides a clearer presentation of data of individual cases as well as referrals. Since RMF launched CommCare in May of 2012, we have collected and maintained a database on over 8,000 children.
In parallel, RMF management staff also worked diligently towards securing the permissions required for the upcoming CMAM (Community Based Management of Acute Malnutrition) pilot using Ready to Use Therapeutic Food (RUTF) for community based treatment of malnutrition in our target villages.
In February 2013, the Government of Madhya Pradesh held a stakeholder consultation on CMAM to introduce the CMAM pilots in the state and receive inputs from various agencies on their roles in the production of RUTF, the inpatient treatment of SAM under CMAM, and the designs and geographic coverage of the pilots. RMF’s pilot program will cover three districts specifically identified as high-burden for SAM: Jhabua, Alirajpur, and Barwani. Production of the RUTF for this pilot will be undertaken by MPAGRO, a government run corporation currently producing Take Home Rations for the Integrated Child Development Scheme (ICDS). During the stakeholder consultation on February 5th, representatives from RMF were officially named to join the MP State Technical Steering Committee on CMAM along with representatives from UNICEF, DFID, Valid International, the Department of Women and Child Development, and the MP Department of Health and Family welfare.
On February 6th, the steering committee held its first meeting, and:
- Determined its mandate to draft the MP state protocols for Community Management of SAM.
- Reviewed the methodologies of two pilots: RMF and Vikas Samwad.
- Set a schedule and agenda for further meetings.
A second meeting was held on March 26th, and the steering committee:
- Reviewed the progress of production of RUTF by MPAGRO.
- Finalized the formula, testing, and quality assurance protocols for locally produced RUTF.
- Revised the current protocols for facility-based management of SAM in line with WHO guidelines for CMAM programs, reducing the required stay for children with complications to 5-7 days.
While there continues to be delays in the beginning of production of RUTF by MPAGRO, the product is slated to be available in Q3 of 2013.
After a successful demonstration of CMAM with RUTF, RMF hopes to change the landscape of SAM treatment in India. Previous programs using RUTF in Africa and other Asian countries have shown that, with proper counseling and monitoring, the use of RUTF in CMAM programs has a success rate as high as 80%.
RMF Celebrates International Women’s Day in Barwani
Friday, March 8th marked International Women’s Day. Across the world, women stood up and celebrated their right to equality, freedom from fear and domestic inequality and violence, and their own dreams of self-determination and economic security.
Photo: Information on Nutritious Foods at RMF's Booth
In Barwani, Madhya Pradesh, International Women’s Day was celebrated with a “Mela” (fair) to celebrate the remarkable women of the area, and to highlight the enormous challenges many of them face in their daily live. RMF’s Barwani team was invited to participate in the event and the march that preceded it.
RMF’s CNEs planned three major events for this mela, which lasted three days. On the first day, in addition to the march, 6 of RMF’s Community Nutrition Educators (CNEs) wrote and sang a song about malnutrition to help inaugurate the event and spread RMF’s nutrition message. RMF also set up a booth with information on our program, the services that every woman in every village is entitled to from the Government of Madhya Pradesh, locally available nutritious foods, the importance of breastfeeding, and sanitation and hygiene. Over four days, from March 8th to 11th, this booth was continuously staffed with RMF CNEs to provide more information, individual counseling, and cooking demonstrations on how to prepare most nutritious local foods.
The core of RMF’s eradicate malnutrition program is women’s empowerment. Our staff of 66, all women, consistently and tenaciously works to fight malnutrition by bringing the basics of health literacy to individual women and families in the 600 villages that we work in. Without this foundation, and without individual women understanding that they have the right to control their own destinies, including decisions about proper feeding and family planning, malnutrition will continue to be a problem in Madhya Pradesh. Furthermore, although the government reserves seats on various committees in the village government, such as in the Panchayats (the local elected councils) and the Village Health, Sanitation, and Nutrition Committees, many women are not aware that these bodies exist, much less their rights to sit on them. Our CNE’s work to improve that knowledge and hope to help communities take control of their outcomes in a sustainable way.
During this quarter the Malnutrition Eradication program:
- Identified 402 children suffering from SAM and gave counseling to the caregivers of each of these children
- Saw an improvement from SAM to MAM in 388 children
- Identified 920 newchildren with MAM and provided one-on-one counseling to the caregivers of these children
- Saw an improvement from MAM to normal in 1,064 children
- Successfully ensured the 14 day treatment of 90of the most serious cases at local Nutrition Rehabilitation Centers
- Conducted 297 village nutrition training sessions, with over 4,831 people in attendance
- Conducted 12,154 family counseling sessions
Impact this project has on the community (who is benefiting and how):
Since our program began in 2010 this program directly impacted:
2,247 children who have received lifesaving treatment
- 26,274 children who have improved directly through our intervention
- 362,377 individuals from rural villages who have received training on malnutrition awareness and prevention in their villages
The families of the 66 women RMF employs as part of this initiative, many of whom are from the intervention villages themselves and use their salary from RMF to support their children’s education and to improve the lives of their families.
RMF CNE Savitri Kajle first diagnosed Shivani in Maidarai village with Severe Acute Malnutrition (SAM) 15 months ago in Khandwa district, presenting with a MUAC (Measurement of Upper Arm Circumference) of 9. As a one year old, Shivani’s nutrition is particularly important because children suffering from SAM in the first two years of their lives face developmental difficulties, stunting and delayed growth, and other future health complications. Savitri counseled the family extensively, and Shivani was admitted to the Khandwa NRC for 14 days of treatment with therapeutic feeding. However, the burden of such a long hospital stay is often too much for the families, and Shivani’s mother left the NRC before her treatment was complete.
However, Shivani’s story did not end there. One of the cornerstones of RMF’s program is continuous follow up with children, even after they have been admitted for treatment. On her visits to Maidarani, Savitri continually observed that Shivani had not fully recovered and had recurrent bouts of diarrhea and fever.
Children suffering from SAM have weakened immune systems and even minor infections can be fatal. Recognizing this, Savitri continued to refer her to the NRC and Anganwadi worker. She was admitted to the Khandwa NRC twice more for treatment, spending over 30 days in NRCs, and has now recovered. As her visits continue, Savitri will ensure that Shivani does not relapse, and counsel her parents on best feeding practices and nutritious foods to help her grow.
Pinki was initially identified by RMF 17 months ago as a 7 month old. One of the contributing causes to Madhya Pradesh’s high malnutrition burden is poor diet in pregnant women; up to 70% of pregnant women in MP suffer from iron and protein deficiencies, leading to low birth weight infants. Pinki and his mother were victims of this; he was born underweight, only 1.2 kilos (2.65 pounds) at birth.
Again, the assistance of RMF’s CNEs helped Pinki recover from this disadvantage at the start of his life. Initially diagnosed with a MUAC of 8.5 17 months ago when he was 7 months old, Pinki was immediately referred to the nearest NRC in Khandwa. Although he completed his initial treatment, he was still classified as SAM at dischargeand referred to the Anganwadi Centre in his village for enrollment in the Supplemental Nutrition Program. Under this scheme, his family received regular take home rations to help him grow and gain weight. However, over the course of the next few months, he still did not recover.
With close follow up by RMF’s CNEs, Pinki was admitted to the NRC twice more. After many rounds of treatment and continual counseling, Pinki has finally recovered and is gaining weight at home, eating nutritious foods under the guidance of a CNE.
Naitik was first diagnosed 5 months ago as an 8 month old with a MUAC of 11.5 and severe recurrent diarrhea. Children are often exposed to unsanitary conditions in and around their homes, which leads to diarrhea and malnutrition. RMF’s CNEs counsel families on both sanitation and hygiene practices to prevent diarrhea, and the availability of ORS at Anganwadi Centres free of cost for the treatment of diarrhea.
However, despite this, Naitik still slipped into malnutrition, and, with the help of one of RMF’s CNEs, was admitted to the NRC. In the NRC, he received treatment for both his diarrhea and malnutrition, and after 14 days was discharged. He is now a healthy child with a MUAC of 12.8, and both he and his family are followed up with every two weeks by an RMF CNE.