India is committed to achieving the UN Sustainable Development Goals (SDGs) by 2030 and launched the Poshan Abhiyaan campaign to work towards SDG 2, of zero hunger’. Several proactive steps are being taken by the Union and state governments in partnership with other sectors, notably, the Corporate Sector. Government advisories are directing CSR funding towards districts that are weakest in human indicators, designated ‘Aspirational’ districts by the NITI Aayog. Given the push from the government, several corporates have volunteered their support towards the upliftment of these districts.
Barpeta town in lower Assam is notable as a temple town or the Satra Nagari. The Barpeta district, which goes by the same name, covers an area of 2,600 sq. km and houses 1.6 lakh people. Almost half the women of the district are illiterate and more than 40% get married before the age of 18 years. One in every five adolescent girls have low body mass index (BMI) while one in every three are anaemic.
Madhya Pradesh is the fourth poorest state of the country and despite its illustrious history, Vidisha is amongst the poorer districts of the state. Due to poverty and collateral factors, the overall health and nutrition indicators of the district are weak. One in every three adolescents has a low BMI and are anaemic. Many of these adolescents are chronically deprived of good nutrition from childhood and therefore, will never be able to attain their full mental and physical potential. Weak adolescent girls will further produce low birth weight children, continuing the vicious cycle of malnutrition in society.
Due to these poor human indicators, Barpeta and Vidisha have been identified as aspirational districts. Focussed work in these districts will accelerate India’s journey towards achieving the SDGs.
Nutrition depends in part on the diet. Diet evolves over time, influenced by many social and economic factors that interact in a complex manner to shape individual dietary patterns. These factors include income, food prices (which will affect the availability and affordability of healthy foods), individual preferences and beliefs, cultural traditions, and geographical and environmental aspects (including climate change). In rural India, lack of affordability of healthy foods plays an important role in malnutrition. However, good nutrition depends not only on the quantity but also on the quality of the food consumed. A diverse diet including plenty of locally available fresh foods plays a significant role in improving the overall well-being of an individual.
In September 2019, under the Adolescent Nutrition, Sanitation and Health (ANSH) Project, surveys were carried out in Barpeta and Vidisha towns and peri-urban areas to understand the knowledge and behaviours amongst adolescents towards food and hygiene. Teams visited houses of 50 randomly selected adolescents per district, most of whom attended school regularly. Data was collected on a questionnaire by interviewing adolescents and their parents on three indices: index for food habit, index for hand washing and index for parents’ knowledge on nutrition and water, sanitation and hygiene.
The knowledge and practices regarding food and hygiene among the interviewees was found to be quite poor. Almost all (94-96%) of adolescents consumed only two meals a day with 20-30% consuming food prepared the day before. A large proportion (82-84%) of children missed meals regularly in favour of junk foods, consumed in the form of locally made, highly coloured puffs, deep fried snacks, potato chips, noodles, momos, tea, etc. Consumption of junk foods was considered a status symbol.
As diet is heavily dependant on culture, we found a stark difference between meat and milk products consumption of the families of Assam (98%) versus Madhya Pradesh (16%). Majority of families in both regions were not aware that raw foods are to be washed properly before eating or that green leafy vegetables were sources of iron. About 90-94% parents had not heard of the weekly iron tablets being provided to children in school under the Government of India’s Weekly Iron Folic Acid Supplementation programme. Only 20-30% adolescents drank up to 1.5 litre of water a day while the rest drank less. Almost half the adolescents and their families did not wash hands at the times recommended by the WHO.
Based on the findings of the survey, awareness messages in local languages were developed, aimed at filling the gaps identified in knowledge and practices. To ensure effective understanding of the messages, pictorial counselling tools were prepared. Instead of recommending general food related messages, locally available nutrient rich food items were recommended to improve the diversity of diet. The health workers of the area were sensitised on nutrition and hygiene. Frequent home visits were made to counsel adolescents and their families and there were regular interactions with the people of the village during community gatherings. The messages were reiterated through school-based interactive activities held with the support of school authorities.
After six months, in February 2020, the same survey questionnaire was re-administered to the families and individual data from baseline was compared to the data at six months. A significant improvement was found in all three indices. A significantly higher proportion 58-78% adolescents were now eating more than two meals a day. Regular junk food consumption reduced significantly to 6% in Barpeta and 58% in Vidisha and double the number of children of Vidisha (30%) were consuming milk and milk products. About 74-96% children were consuming more quantity of water and hygiene standards also improved significantly with more families washing thier hands with soap and water, especilly before cooking, serving and eating food. Many more adolescents reported to be consuming the Iron supplementation being provided in school.
Through this experience, one can conclude that by adopting a 360-degree approach for communicating and connecting with adolescents at various levels – through parents, health workers and school – the food consumption pattern and/or diversification of diet and hygiene practices of adolescents can change. Additionally, such interventions require a network of partners and support from corporates who have the expertise. The transformation of these areas of Barpeta and Vidisha districts was made possible with the technical know-how from JSI R&T India Foundation, implemented by NGO SHARP and as a part of ANSH.
(Editor’s note: The authors were supported in their work by the JSI R&T India Foundation.)
Such transformation can happen in areas that have wide-spread poverty as several unhealthy food practices are the result of ignorance rather than lack of resources. This reinforces the need to engage anganwadi workers, ASHA and other field level workers and school teachers for focussed nutrition counselling of all age groups.
Amrita Misra is a public health specialist and a medical doctor with 20 years of technical and programmatic experience in nutrition, maternal, newborns and child health and tuberculosis. Ranajit Sengupta has 15 years of experience in designing and implementing monitoring and evaluating activities in the field of RMNCH+A, nutrition, family planning, HIV/AIDS and education. Tapas Mohanty has 15 years of experience in the development sector, including with the UN. Salman Ali has worked for 20 years in various states of the country mobilising communities. Juhi Arora has 10 years of experience in nutrition, policy advocacy, system building and developing public health for the advancement of the society in the field.