Community Mobilisation: A foundation for better health and nutrition outcomes.

1. Community Mobilisation: A foundation for better health and nutrition outcomes. A concept for Action. Dr Prasanta Tripathy, Rajkumar Gope, Swati Sarbani Roy, Ekjut Dr Audrey Prost, University College London

2. THIS TALK • UNDERNUTRITION • COMMUNITY MOBILISATION THROUGH WOMEN’S GROUPS WITH PARTICIPATORY LEARNING AND ACTION • DISCUSSION

3. UNDERNUTRITION Underlying cause for an estimated 35% of child deaths worldwide Disproportionately affects the poorest Black et al. Lancet 2008; World Bank, 2009

4. TODAY’S FOCUS STATES % of children under-3 who are underweight NFHS-3 (2005-6)

5. INEQUALITIES IN UNDERNUTRITION % children under-3 who are underweight (too thin for their age) ORISSA (LWQ) 54.0 % ORISSA 41.0 % INDIA 43.0 % 57.0 % ORISSA (LWQ) % stunted (too short for their age) ORISSA 45.0 % INDIA 45.5 % ORISSA NOP: REDUCE STUNTING FROM 45% TO 35% BY 2013 NFHS-3 (2005-6) ORISSA NOP (2009)

6. DATA FROM UNDERSERVED AREAS OF ORISSA(KEONJHAR DISTRICT = 1258 children aged 6-35 months)

7. CAUSES OF MATERNAL AND CHILD UNDERNUTRITION MATERNAL AND CHILD UNDERNUTRITION INADEQUATE DIETARY INTAKE DISEASE IMMEDIATE CAUSES Household food insecurity Unhealthy household environment & lack of health services Inadequate care UNDERLYING CAUSES Income poverty Lack of capital BASIC CAUSES Social, economic and political context Black et al. 2008, adapted from UNICEF, 1998

8. STRATEGIES TO ADDRESS UNDERNUTRITION • Direct interventions: • Improved dietary intake for adolescent girls & mothers • Iron and calcium sup. for pregnant women • Timely and exclusive breastfeeding • Timely, age-appropriate, hygienic complementary feeding • Illness prevention for children through: • handwashing; immunisations.; Vitamin A; Iron; de-worming • Appropriate care during illness for children • Therapeutic feeding for children with SAM • Family planning Immediatecauses Immediatecauses Underlyingcauses • Indirect interventions: • Support women’s education and empowerment • Increase access to safe water and sanitation • Support food security & sustainable livelihoods • Advocate for good nutrition governance Basic causes Black et al. Lancet 2008 India’s Expert Taskforce on Infant & Young Child Nutrition, 2009 DFID: The neglected crisis of undernutrition, 2009

9. ARE CURRENT INTERVENTIONS DELIVERING ?% OF CHILDREN WHO RECEIVE SERVICES FROM AWCs Percent of age-eligible children in areas with an AWC NFHS-3 (2005-6)

10. ARE CURRENT INTERVENTIONS DELIVERING ?% WOMEN WHO RECEIVE SERVICES FROM AWCs NFHS-3 (2005-6)

11. High participation Low community participation Community mobilisation e.g. Participatory learning and action with women’s groups & Village Health Committees Health education BCC Individual (message-giving) Collective (e.g. mass media)

12. THIS TALK • UNDERNUTRITION • COMMUNITY MOBILISATION THROUGH WOMEN’S GROUPS WITH PARTICIPATORY LEARNING AND ACTION • DISCUSSION

13. WHAT IS COMMUNITY MOBILISATION ? A capacity building process through which community members, groups or organizations plan, carry out, and evaluate activities in a participatory and sustained basis to improve their health and other conditions, either on their own initiative or stimulated by others. Howard-Grabman et al. 2006

14. OFTEN USES A PARTICIPATORY LEARNING & ACTIONCYCLE EVALUATE TOGETHER IDENTIFY PROBLEMS PLAN STRATEGIES ACT TOGETHER

15. IMPACT ON NEONATAL MORTALITY 45% reduction in NMR OR 0.55 (95% CI 0.46-0.66) Tripathy et al. Lancet 2010

16. THE IMPORTANCE OF TARGETING Tribal , Marginalized & Underserved communities Families living in hamlets, remote regions Where health services are inaccessible Married women of WRA Men, Adolescents & Elderly women TARGET POPULATION

17. IMPACT ON MOST MARGINALISED Unpublished data, forthcoming 2011

18. GROUPS ATTRACT THE POOREST IN MADHYA PRADESH A to D: Economic status of households as categorised by Madhya Pradesh Rural Livelihood Programme. A = wealthiest households; D= poorest households.

19. SHGs OPEN UP TO NON-MEMBERS JHABUA DISTRICT, MADHYA PRADESH (>80% TRIBAL)

20. REDUCED MATERNAL DEPRESSION MATERNAL DEPRESSION ASSOCIATED WITH Low birth weight Low weight for age at 6 months Increased risk of diarrhoeal episodes 57% REDUCTION IN MODERATE DEPRESSION OR 0.43 (95% CI 0.23-0.80) Tripathy et al. Lancet 2010 Rahman et al. Arch Dis Child 2007

21. INCREASED AGENCY • Care seeking • Visiting a provider unaccompanied • Going to the shops unaccompanied • Expenditure for daily necessities • Less frequent expenditure • Expenditure on expensive items Unpublished data, forthcoming 2011

22. OTHER EXPERIENCES: THE IRINGA STUDY Assess RURAL TANZANIA (1980s) Triple A: Assess problems, analyse then, act together. Used growth monitoring to track undernutrition at village level, reflect on causes, and implement solutions. The prevalence of underweight children declined from 56% to 38% (1984-8). Triple A cycle Analyse Act Pelletier & Shrimpton. Health Policy and Planning 1994

23. OTHER EXPERIENCES: BANGLADESH Group sessions with mothers in rural Bangladesh used problem-solving and demonstrations to promote responsive stimulation and feeding. Children in the intervention group had better developmental and nutritional outcomes. Aboud & Akhter, Pediatrics 2011

24. CAUSES OF MATERNAL AND CHILD UNDERNUTRITION MATERNAL AND CHILD UNDERNUTRITION IMPROVED NUTRITION DISEASE PREVENTION IMMEDIATE CAUSES Healthy household environment & access to health services Household food security Adequate care UNDERLYING CAUSES Income poverty Human & social capital BASIC CAUSES Social, economic and political context Black et al. 2008, adapted from UNICEF, 1998

25. PROMISING CHANGES AFTER COMMUNITY MOBILISATION IN JHARKHAND AND ORISSA

26. But areas of concern remain… • Timely introduction of complementary foods at 6 months (41%) (n= 1299 children) • Children 6-23 months receiving 4+ food groups (5%)

27. LESSONS FROM OUR WORK IN JHARKHAND, ORISSA & MP Interest of groups/communities can be sustained over a long period of time Different cadres can be trained to facilitate meetings: ASHAs, AWWs … men! Timely incentivisation works Communities respond through numerous strategies Meetings can attract the poorest community members Meetings can engage & energize frontline health workers

28. IDENTIFY AND PRIORITISE IMMEDIATE CAUSES OF UNDERNUTRITION FOR MOTHERS AND CHILDREN EVALUATE TOGETHER MONTHLY GROUP MEETINGS FACILITATED JOINTLY BY AWWs AND ASHAs DEVELOP AND PRACTICE VILLAGE LEVEL STRATEGIES (e.g. malaria control, extra-AWW, shaping norms) DEVELOP AND PRACTICE HOUSEHOLD LEVEL STRATEGIES (e.g. develop and test new complementary food recipes) SHARE WITH COMMUNITY IDENTIFY AND PRIORITISE UNDERLYING CAUSES OF UNDERNUTRITION FOR MOTHERS AND CHILDREN

29. THIS TALK • UNDERNUTRITION • A CASE FOR COMMUNITY MOBILISATION • DISCUSSION

30. YOUR FEEDBACK & OUR QUESTIONS • What are the challenges in changing nutritional practices in the community ? (especially weaning practices) • Sensitivity of discussing food security in poor communities • When will we address controversies around CMAM? • How long will it take to streamline supplies of antibiotics and access to contraceptives in underserved areas?

31. SUMMARY • Rates of maternal and child undernutrition are staggeringly high in underserved areas • We need innovative strategies to address this • Community mobilisation can generate locally owned, sustainable changes in practices and create an enabling environment to address the underlying causes of undernutrition. • This is the minimum required to combat malnutrition - more must be done (HSS/entitlements).