Two-year-old Aparna eats a nutritious meal while her mother looks on at a government supported 'Anganwadi' childcare centre in West Bengal.
DUMURDI, India, 18 November 2009 – Bharati Mandi walks to her local Anganwadi centre each day with her 4-month-old son, Biswajit, and her three-year-old daughter, Shampa, in tow. Together with other mothers, she prepares the mid-day meal of dal, rice and vegetables, which will help feed herself and her young children.
“I come here to learn about child feeding, to learn how to take care of my child,” she says. “If I consume this food, I will be able to breastfeed my son, because I’ll have more milk. By eating this food, (my children) are healthier.”
Bharati and her children are part of a positive deviance program mobilizing community resources to tackle malnutrition in this poor village of 565 inhabitants. The idea behind positive deviance is to understand the feeding and caring patterns of families who are equally deprived but whose children are well-nourished. These are the positive deviants within the community.
'Why can't we do it?'
In West Bengal the positive deviance program is popularly known as “Keno Parbo Na” meaning “Why can’t we do it?” The initiative works to bring about sustained behavioral change among parents to improve feeding practices for children 3-years-old and under.
“When positive deviance was developed, the mothers began to realize the importance of addressing malnutrition,” said Monjary Chakraborty, The Government’s Integrated Child Development Services (ICDS) supervisor in Purulia. “The mothers are empowered and now are able to take decisions that are accepted by the family. Their husbands listen.”
The District of Purulia, where Durmudi is located, faces many challenges regarding health and nutrition standards. Early marriage and motherhood have contributed to high levels of malnutrition and anaemia among adolescent girls and expectant mothers, leading to low-birth weight babies. With district-wide programs for vitamin A supplementation, anaemia control and universal salt iodization, indicators are slowly improving but more community involvement is needed to successfully address the issue.
At the core of positive deviance is the belief that there is significant wisdom and untapped resources inherent in communities, enabling villagers to use existing solutions to address complex problems. The approach uses collective learning to identify positive nutrition practices by individual families which can be adapted by the larger community.
“Community engagement is key to addressing malnutrition,” said Lori Calvo, UNICEF’s Chief of Field Office in West Bengal. “By promoting self-reliance, communities understand the magnitude of the problem and can easily replicate solutions using local resources.”
In Phase I of the program, the community is mobilized using simple tools to make malnutrition visible, including community growth charts, mother and child protection cards and a social map identifying homes where children are malnourished. Homes are color-coded, ranging from green for normal to red for severely malnourished , so parents know at a glance how their children fare nutritionally.
“We are always keeping in mind that literacy levels are very low,” says Monjary Chakraborty. “Pictorials help them to understand much better.”
To identify positive deviant practices, focus group discussions with caregivers in three households each of normal and moderately malnourished children are held. The results are then shared at a community meeting.
In Phase II, good practices are identified and are advocated through nutrition counseling and child care sessions. During these 12-day monthly sessions, good practices are learned by care givers of moderate and severely malnourished children through a process of “learning by doing.”
At the beginning of each session, each mother is asked to draw one feature of her child – ears, eyes, mouth etc, -- until the child’s figure/body is complete. This linking the entire body mapping exercise with 12 days of sessions. “No mother wants to skip a session otherwise the figure/body will be incomplete,” explains Sanjoy Dey, nutrition consultant. “It’s healthy competition between the mothers so they attend the sessions.”
Women updating a child's growth chart' at the Durmurdi Angawadi Centre in West Bengal.
Teaching children about nutrition
The classes are held at the local Angawandi Centers, where older children are occupied with games, songs and other activities which teach them in a fun way about good health, nutrition and hygiene practices.
“I find it very interesting to deal with children. They are the future generation,” says Monica Rajwar, who runs the Dumurdi Angawadi centre, decorated with colorful posters detailing proper handwashing techniques and good nutrition practices. “If they grow up healthy, they will help lead society. There are so many children malnourished, and their parents need some support.”
Community members contribute eggs and vegetables, like okra, pumpkin and peas. Mothers learn how to cook more nutritious meals, which in turn creates community ownership in the management of child malnutrition.
As part of the Government’s ICDS scheme, each eligible child receives 50 grams rice, 18 grams dal and half an egg. Severely Malnourished children receive 70 grams rice, 25 grams dal and a whole egg. Nursing mothers receive 70 grams rice, 30 grams dal and an egg.
Other sessions include how to care for newborns, early and exclusive breastfeeding including colostrum within half an hour of giving birth, timely and appropriate complementary feeding, immunization, diarrhoea management, including zinc and Oral Rehydration Salts (ORS), and micronutrients. Proper hygiene practices like hand-washing with soap and cleaning utensils before feeding a child are also emphasized.
Gender discrimination can also be a factor in malnutrition rates. For instance, a girl twin may not get as much breast milk as her twin brother, says Rajwar. These sessions empower mothers and help build their confidence in rehabilitating their children.
Many mistaken community nutrition practices can lead to malnutrition. Some families may introduce honey rather than exclusively breastfeed. “If you give honey as a baby, your child will talk sweetly,” explains Chakraborty. Goat milk is considered “more nutritious,” and colostrum “is considered a sacred milk that should be offered to the gods.”
Caregivers are encouraged to continue the good practices at home for the remaining 18 days of the month. Every child is weighed each month to gauge progress. At the end of six months, most moderate and Severely Malnourished children usually experience a significant weight gain, says Tuktuki Kundu, a positive deviance facilitator for Purulia.
“Once the child gains weight, the mothers are happy, and that helps the child maintain weight,” she explains. “It’s an inspiration for them.”