New Delhi: The prevalence of malnutrition is extremely high in Rajasthan. As per the Comprehensive National Nutrition Survey (CNNS) report, Rajasthan ranked 22 among 30 states in prevalence of underweight children in the under-5 year category. The report stated that in Jaipur, despite efforts to tackle malnutrition, 40.9 percent children under five years are underweight and 44.4 percent are anaemic.To address this, in 2018, the focus of the State through its POSHAN Abhiyaan has been on the Community based Management of Acute Malnutrition (CMAM) model. It is a model that enables community volunteers to identify and initiate treatment for children with acute malnutrition before they become seriously ill.
But the problem is that gaps persist in service delivery framework and its reach. According to National Family Health Survey-4 to National Family Health Survey-5, there has been a 8.5 per cent increase in anaemia in children (aged between 6 to 59 months) in the state. Moreover, still less than 55 per cent mothers and children have access to health and nutrition programmes set by Centre and State.
As a part of Reckitt’s Reach Each Child Programme, an Ethnographic study was conducted in Rajsamand and Kumbhalgarh villages of Rajasthan in bid to understand the challenges being faced by the community and what is the need of the hour.
Here are top highlights:
1. Frontline Health Workers Not Trained Enough For Identifying Malnutrition In Community Members
Front-line health workers ability to identify symptoms of malnutrition among the community members is not upto the mark and is one of the factors that impacts communities’ ability to timely seek care. During Reckitt’s onground study it was highlighted that the last training that took place for the same in Kumbhalgarh village was pre-pandemic.
The study also highlighted the fact that there is a lack of training specific to SAM/MAM and is reflected in the inability to timely identify SAM/MAM cases, unless the symptoms are too severe. This is the reason behind community members’ inability to correlate visible symptoms such as ‘pet phoolna’ and stunting with occurrence/possibility of malnutrition.
2. Intake Of Supplementation and Fortified Foods, A Missing Chain In Rajasthan
Reckitt study noted that there is low adherence to supplements and fortified food across families in Rajasthan due to varied reasons such as palatability, preference and culturally mismatched provision of food. Families and frontline health workers enhance the taste of Poshahar received at AWC (Anganwadi Centre) to increase palatability by adding spices, washing away the present flavour (and therefore washing the nutrients).
The study also stated that IFA and Iron tablet uptake is low due to the perceived negative impact on body such as nausea and lack of counselling around the same by frontline health workers. Mothers discontinue children’s consumption of iron syrup for the impact it has on the colour of the stool.
3. Colour My Plate, Not A Favourable Concept
There are n-number of factors that are affecting the food choices in Rajasthan, which is directly having an impact on nutrition of children and mothers in the state thereby impacting the nutritional numbers. According to Reckitt’s onground study, following are the issues that affect food choices in the state:
- Procuring food from the market is challenging due to financial constraints. Families rely on subsistence farming and foraging and consequently prioritize food items that are readily accessible to them
- Lack of male member, familial caregiving and mobilisation support has a negative impact on food procurement leading to less variability in food consumption
- Cultural norms surrounding food consumption during pregnancy such as prohibition of dairy consumption of the mother lead to a lack of nutritional diversity
- Mothers’ knowledge of complementary feeding is low. Usually complementary feeding starts at 6 months and biscuits with milk are fed to the child
- Families with deeply ingrained religious and traditional beliefs do not consume non-vegetarian food
- There is limited knowledge base of frontline workers (variety of healthy food items, kitchen gardening) limits the variability of diet
4. Traditional Breastfeeding Practices Overpowers Recommended Breastfeeding Practices in Rajasthan
The report highlights that in Rajasthan mother stops lactating in case of pregnancy within 3-6 months of delivery. This happens due to in-exclusive and insufficient breastfeeding to the child dependent on breast feed till 6 months rendering the Lactational Amenorrhea Method (LAM) ineffective. As a result, there is an early introduction of complementary foods like cow or goat’s milk which further leads to early onset malnutrition and illnesses for the child.
In case of home delivery, it is common for the newborn to be given gudla or jam gutti, jaggery wrapped in a cloth and dipped in ghee or water for the first few days. This is because the Dai advises against breastfeeding during this time, claiming that it can cause acid reflux in the baby.
5. Belief In Local Traditional Healers and Practices Is More
Traditional practices such as faith healing are thriving and trust in local practitioners – maharaj, baba ji, bhopa ji is very strong in the community of Rajasthan. Practices such as dhoomni and daam lagana are sometimes followed as the sole method and at other times mixed with visits to government and private health facilities.
Dhoomni is a traditional fumigation process using ingredients such as dog excreta and hair strands of a family member. The sick person is made to inhale the fumes repeatedly until there is full recovery. Daam lagana is an age old, self healing practice used to treat various illnesses. A hot iron rod is applied to a specific area of the body corresponding to the organ where the illness has spread. Fluid from a rubber or mango tree is then applied to the wound. Discharge or pus from the wound is considered to be the initiation of the healing process.
What Are The Learnings From The Field?
According to the Reckitt’s onground report, following are the learnings from Rajasthan, which are hampering the nutritional growth of the state:
- Caregiving and household work burden is a major reason why mothers are unable to prioritise the care pathway of the child with malnutrition
- Financial burden and seasonal-cropping activities lead to de-prioritisation of care pathway for the child with malnutrition
- Unaffordability of transportation cost – In many cases where travel cost is high, families are unable to prioritise follow-ups and do not complete treatment cycle.
- No Follow-ups – In some cases, families do not come back for follow-ups due to lack of counselling. It takes sustained counselling and frequent interactions with family members to build their trust in the course of action since there are chances of families not continuing the course of action
- Mothers are pressurised by families (fathers and mother in laws) to leave the facility in order to prioritise household responsibilities over the treatment journey of the child
- Inadequate number of staff at the Nutrition Rehabilitation Centers facility affects the treatment given to each child
- Lack of female staff affects the counselling process which leads to lower retention rates at the Nutrition Rehabilitation Centers
About the Author: Ravi Bhatnagar, Director-External Affairs and Partnerships, Reckitt – South Asia
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