Take-Home Rations

A route to nutrition security

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On August 28, 2020, Times of India published “Take-Home Rations: A route to nutrition security” by Dr. Rajan Sankar of TINI Tata Trusts (read the more about Dr Rajan Sankar here) and Kalpana Beesabathuni, Sight and Life’s Global Lead for Technology and Entrepreneurship. The full article can be read  here.

Abstract

The disruption of food systems by Covid-19 and its impact on the availability of nutritious food in large parts of the country has brought to light the importance of the Take-Home Rations (THR) programme and its potential to deliver fortified food to the last mile in the country. The THR programme is unique in its reach and scale; it is also well resourced with a budget of Rs. 13,500 crore and hundreds of millions of beneficiaries. The current crisis presents a window of opportunity for THR to fully realise its promise and transform India’s nutrition security scenario.

India is home to one-third of the world’s stunted children (4.7 crore) and half of the world’s wasted children (2.6 crore). Nearly 41% of children less than five years old are anaemic. To combat malnutrition, the Government of India launched the Integrated Child Development Services (ICDS) programme in 1975; it offers a variety of nutrition and health services for the first 1,000 days of life. This time span is vital for preventing long-term consequences associated with malnutrition, particularly during pregnancy and also when infants transition out of breastfeeding.

Read the full article on the Times on India website here. We also invite you to take a look at the Take-Home Rations Compendium, a recent analysis of the THR program here.  

Exchange in Behavior Change

Making consumers feel, instead of do

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One of the most often expressed grievances related to the COVID-19 pandemic has been around wearing face masks. Everyone is made aware of its importance when stepping out. We can thank the hundreds of videos, posters (digital and offline), social media content, and articles on the subject. Not wearing a face mask outside today could mean instant scrutiny, even mockery or humiliation. Sometimes I wonder how many wear face masks to protect their health and that of others, and how many wear face masks because ‘everybody else is doing it’ or it is ‘cool’ or ‘popular’ or ‘this one is branded and oh so pretty’. Of course, this is not to say there is only one motivation at play here, or that one is better than the other. It just is an excellent example of how simple awareness-raising of the health benefits is not enough – motivation comes from a combination of individual and social factors as well as knowledge.  

Social marketing’s impact

In the context of social marketing, we briefly discussed the idea of ‘exchange’ in our blog post by social marketing expert Rowena Merritt, “It Makes Me Smile,” posted a fortnight back. We explained how, if the goal is to change a behavior, offer something in return. While most of us might think of cash incentives or gift vouchers as rewards, the exchange is often non-monetary, such as making someone feel unique, or creating a sense of control or ownership. At Sight and Life, we think about whom we are serving and what could be a compelling exchange for our target audience. 

Research is important

Let us look at the Eat More, Eat Better campaign* launched in Rajasthan – a state in Northern India – in 2018. The project aimed to improve food access and food choices for pregnant and lactating women (PLW), whose calorie intake was 40% below doctors’ recommendations. However, we quickly realized that we needed to do more than raise awareness; we needed to offer an exchange that our audience valued. To help us do this, we used social marketing techniques and tools and conducted in-depth formative research. 

The findings helped identify critical insights to develop a behavior change strategy, the most notable being:
  A. The kitchen was generally the mother-in-law’s domain, and she associated eating more with being indulgent, greedy or lazy. This perception was not relaxed even for her pregnant or lactating daughter-in-law!
  B. The husband tried to balance patriarchal norms with being more emotionally available to his wife. For instance, he would occasionally smuggle in goodies or fruits for his wife to eat.
  C. Snacking, rather than the three meals, carried greater permission for the PLW as it did not lead to territorial clashes in the kitchen and was also something that was not frowned upon by the mother-in-law.

Based on these findings, the social marketing project focused on introducing a new behavior – nutritive snacking for PLW. The habit of snacking was accepted and already practiced, making it a more natural behavior to change. PLW were provided a specially designed snack box that she could use when away from the kitchen and a small treat pouch that she could use to carry snacks in her sari.  The baby was dubbed a ‘Champion’ that would fill both the mother and father with pride and parents were encouraged to do what is best for their ‘Champion’. Fathers were also asked to sign a pledge to support the nutritional needs of their wives and babies actively. And the exchange? The PLW felt special and cared for by her husband and empowered when it came to looking after herself and her baby. 

This is a graphic for the Eat More, Eat Better campaign paying a tribute to the region’s unique Rajput painting style. It shows a husband urging his wife to eat more and calling her the mother of the ‘Champion’.

Another good example is our work in the 2017 Karnataka WASH (Water, Sanitation and Hygiene) behavior change project. As part of the larger objective to improve nutritional status among school-going children, Sight and Life worked with PATH and Karuna Trust on a strategy to prevent loss of nutrients among children by aiming to influence motivations regarding several behaviors:
  A. Washing hands with soap at key times, including before meals, after using the toilet, after play, and after handling garbage
  B. Drinking water from safe sources only
  C. Rejecting open defecation or urination
  D. Flushing the toilet with water after use
  E. Keeping their school tidy and free of garbage
  F. Eating vegetables and healthy snacks

The formative research delved into the physical, social-normative, and biological factors that drove eating and hygiene practices in school. The team conducted a combination of ethnographic interviews and focus group discussions exploring codes related to hygiene, sanitation, and social influence. Based on this information, the team designed a phased strategy where they tried to make the behavior changes as fun, easy, and as popular (the social norm) as they could by deploying the following:
  A. Physical cues – for example, rhymes and short messages, relevant signboards, installing a tippy tap, soap for handwashing and buckets and jugs made available in toilets (making it easy)
  B. Games – specially crafted games and someone entrusted with the responsibility of owning these games (making it fun)
  C. Role modeling – each class elected a role model, who would then encourage his/her classmates to adopt health behaviors (making it popular) 
  D. Helper crews – specifically created to ensure all tasks were fulfilled (making it fun, easy and popular!) 

In 2017 Sight and Life’s intern, Shannon King, worked in India to research the implementation of these school-based nutrition and WASH intervention strategies to develop healthy eating habits while improving hygiene and sanitation behaviors.

It is interesting to see how the ‘fun’ element was given great importance, and rightly so since the target audience was young children. The rhymes and games helped children identify ideal WASH behaviors; watching role models encourage the same outside of playtime helped build good habits. Rhymes and games acted as an essential feel-good factor and led to a higher recall for a topic that runs the risk of being regarded as boring and irrelevant by many children. 

Knowledge is key

Figuring out the exchange is an engaging journey, one which requires exploring the individual and society, the motivations at play, and the broader environment they are all delicately balanced within. This summer, Sight and Life is holding a three-day online course with the SSPH Lugano Summer School, “Generating Demand for better public health goods and services: A systems and consumer-centered approach”. The course will look at how to create demand for healthy products and healthy behaviors (and we will also talk about exchange). Further details regarding enrollment can be found here. We look forward to (virtually) meeting you there!

* The formative research for the Eat More, Eat Better campaign was completed by Eva Monterrosa, former Sight and Life Senior Research Manager.

Feeding Families in Need During COVID-19 Pandemic

 

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There are many hungry bellies to feed around the world and we are merely scratching the surface to nourish the vulnerable populations of the world. Due to the current COVID-19 pandemic triggering lockdowns around the world, issues in nutrition such as food systems and malnutrition have been heightened and are now more of a global urgency than ever before. Here at Sight and Life, we are working on initiatives in Rwanda, South Africa and India to help improve the lives of those in need during this crisis.

“The only silver lining during this grave crisis has been how quickly and effectively we’ve been able to work together as a team and with our partner organizations to identify food insecurity hotspots and mobilize resources for emergency hunger relief. The guiding principle behind our efforts has been to look beyond just filling bellies but make sure adequate and critical nutritional needs are met,” expresses Sight and Life team members.

In India, we have partnered with grassroots NGOs across India, such as Aahawaan Foundation, based in Bangalore, and Kutumb, working in Uttar Pradesh, to donate grocery kits and nutritious food to the affected communities.

Kutumb is an organization attending to abandoned and slum children by giving them a sense of family. They are also dedicated to strengthening all units of marginalized and underprivileged families, realizing that children can be nurtured best in a family setting. Together with Kutumb, we provided nutritious food to over 1500 children with moderate acute malnutrition in 75 villages located in Uttar Pradesh. 

In Bangalore, we teamed up with the Aahawaan Foundation who is committed to providing basic requirements and facilitate the development of the overall potential of people and their communities. Together, we delivered 15-day grocery kits with staples and fortified kernels as top-up was delivered to migrant workers and their families ensuring that the nutritional needs are met, beyond just filling stomachs.

 “I was unsure of how I would provide for my own children and was hence, worried about feeding my neighbor’s children as well. This ration will help me cope with this crisis for some more time,” explains Sita Ben, one of the many women workers our partner reached with an essential food kit. She spoke about her difficulties during this pandemic as she is responsible for her children and neighbor’s children as they are unable to return due to the lockdown in India. Now she can sleep a little bit knowing she has the ability to feed her and her neighbor’s children.

Meanwhile, in Delhi, monthly ration kits made it to 200 daily-wage households. The kits contain additional essential supplies such as oil for cooking, grains, lentils, and an egg for a family of four in order to help ease the pain of many in unfortunate situations.

 “A great number of my fellow countrymen are forced to walk a thousand miles, often hungry, just to reach the safety and comfort of their families. We are grateful for the opportunity to raise funds on their behalf and support them with nutritious meals,” explains the Sight and Life team. 

We are committed to doing more however, we need support. Please donate to via our Milaap or GoFundMe crowdfunding page to further our efforts. We are also interested in partnering with organizations that have similar initiatives and are located in Rwanda, South Africa, or India.

Five-step plan to prevent an impending nutrition famine during COVID-19 in India

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India’s isolation measures in response to COVID-19 are having a far-reaching impact and is among one of the largest initiatives globally to impose strict limitations on its 1.3 billion citizens. People with pre-existing vulnerabilities, marginalized communities, pregnant and lactating women (PLW), daily wage earners, migrant workers, and the elderly have been the hardest hit as the protective measures disrupt the economy.

To ease the effects of the pandemic, the national and state governments have announced extensive stimulus packages and policy measures. The national government on 12th May announced a $265 billion relief package aimed at injecting liquidity into the economy. The first tranche of $ 22.6 billion included several social protection measures such as payment of ex gratia amount to marginalized populations, increased wages for workers under the National Rural Employment Guarantee Act, doubling rations for three months, collateral-free loans to women’s Self Help Groups (SHGs), the inclusion of support to COVID-19 under Corporate Social Responsibility (CSR), and financial assistance to villagers through farmer cooperatives. These aid benefits are aimed to help more than 810 million Indians and are a step in the right direction.

In addition, integrating nutrition in the current policies will be fundamental to improving nutritional status and building immunity of the population, especially high need groups like PLW and children under 5 years of age. The WHO guidance on diet during the COVID-19 pandemic states that “good nutrition is crucial for health, particularly in times when the immune system might need to fight back”. India is already battling a high prevalence of malnutrition (Table 1). As India, in unison with the rest of the world, battles an evolving pandemic of unprecedented proportions, policymakers must be vigilant, agile, and innovative to halt our population from sliding into hunger and acute malnutrition due to the COVID-19 outbreak.

Table 1:

Source: Comprehensive National Nutrition Survey 2016-2018, Ministry of Health and Family Welfare Govt. of India.

We propose a five-point plan to put nutrition-sensitive policy measures in place to combat the adverse effects of COVID-19:

1. Increase budget and coverage for essentials

Many state and national governments have gone beyond the entitlement provisions under the National Food Security Act – 2013 to announce a stimulus package, the key elements of which are grain and pulses, and cash transfers to lower-income households. While this is a necessary and commendable step, a much stronger nutrition-sensitive hunger mitigation and food programming scheme is crucial. A basic, nutritious diet, recommended by the EAT-Lancet Commission, would cost at least INR 33.69 per day. Accounting for a family of 4, cash transfer of INR 500 per month would only satisfy a family’s requirement for approximately four days a month! Most states’ announcement of transferring an additional INR 1,000 only satisfies their requirement for an additional eight days. India has surplus food grains to weather the current crisis. Universal access and 3x more rations, irrespective of possession of ration cards, will be effective in addressing hunger including the 70 million poor households who lack an identification document.

2. Address malnutrition through dietary diversity, supplementation, and fortification:

Current food supplies through the Targeted Public Distribution Systems (TPDS) are predominantly comprised of grain and pulses. In the current situation where farm supply chains are expected to take at least four months to be restored, essentials such as vegetables, milk, and eggs, could be sourced directly from the farmers and made available in the open markets, supplied through public distribution systems and provided as weekly take home supplies to children and PLW. A few state governments such as the Telangana government have directed Anganwadi workers to provide eggs to mothers and children. Scaling such initiatives to a national level will help improve nutrition outcomes during the pandemic.
 
The honorable Prime Minister of India, in his address to the nation, ‘Mann ki baat’ on 25th August 2019, announced fortification of rice that is distributed to India’s poor through the public distribution systems, Integrated Child Development Services (ICDS) and mid-day meals. This would be the right time to implement the policy and improve access to fortified products including salt, edible oil, flour, rice, and milk. The aforesaid initiative is critical in the current scenario when nutrient consumption is bound to be erratic due to cash and food shortages.

3. Create awareness about nutrition practices:

Increasing evidence suggests that malnutrition increases susceptibility to infections including COVID-19. We, therefore, need to create awareness about better nutrition practices. The National Nutrition Mission (POSHAN Abhiyaan)’s Jan Andolan movement is a platform to engage in civil society and engage people to be committed to better nutrition. The Jan Andolan initiative can be utilized to implement a social behavior change campaign addressing food safety and feeding practices at the household level. Second, front-line workers can be empowered to halt the rise of malnutrition. They can be trained and equipped with behavior change communication equipment on nutrition care during pandemics. Empowering them with the right information and communication technology (ICT) equipment will enable them to spread information through digital platforms while following social distancing norms.

4. Incentivize farmers and small enterprises to produce nutrition-rich crops and food:

The following initiatives can improve the livelihoods of small-scale farmers and enterprises while improving access to nutrition. Incentivize smallholder farmers to produce nutrition-rich crops and staple foods and thus improving access to safe and nutritious diets across the value chain. Micro small and medium enterprises (MSMEs) can be motivated to produce and process nutritious and culturally appropriate foods using millets and legumes such as lentils, chickpea, groundnut, ragi which contain many nutrients and can store for long periods. They can also be prepared by women self-help groups authorized to prepare take-home rations and then the ICDS channel can distribute these foods to PLW and young children.


5. Harness technology for better nutrition:

India has a successful history of using technology to improve socio-economic and public health outcomes. For example, the Arogya Setu app, recently developed by the National Informatics Centre, uses technology to track coronavirus infections, thus providing a valuable tool in the fight against the pandemic. The government can similarly engage entrepreneurs to develop technologies to forecast the trend and pattern of disease burden in future months, rectify supply chain management of key food and nutrition supplies, revitalize already introduced software in public distribution systems to monitor food supplies.
 
Nutrition is a great equalizer. It can create the right environment to stimulate growth, economic development, and progress of an entire generation, thus propelling India on a path towards excellence. India has demonstrated early successes in managing the pandemic through strict isolation measures, innovative use of technology, and public health services. As we fight a pandemic of epic proportions, accounting for the nutritional needs of the world’s most vulnerable will not only give us the strength and immunity to fight COVID-19 but also save lives and give more babies the healthy start they deserve, irrespective of their socio-economic status.
 

Spotlight: Gratitude to frontline workers at the time of coronavirus

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At nearly six months pregnant, Vidyarani learned that her neighborhood anganwadi center was closing due to the coronavirus (COVID-19) control measures. She depends on the anganwadi for a daily hot cooked meal to feed herself and her two-year-old daughter. Adding to her growing concerns, the lockdown caused her husband to lose his job. 

Anganwadis, or courtyard shelters, are primary childcare centers providing basic health care activities and nutritious meals for families while also serving as a pre-school for young children. Across all states in India, anganwadis serve either hot cooked meals or provide monthly rations that can be cooked at home. The Telangana state government, for instance, serves approximately half a million hot cooked nutritious meals daily to pregnant and lactating women through the anganwadis. As a part of this program, all beneficiaries also receive one egg every day. Here at Sight and Life, we know the importance of including eggs in a diet.

As COVID-19 quickly spreads around the globe, India has enforced a nation-wide lockdown to contain the disease creating unprecedented challenges for people like Vidyarani and their families. In addition to the closure of primary schools and anganwadi centers, children in rural India are now not attending school and therefore have to do without their guaranteed school meal, potentially worsening an already “severe” malnutrition problem in India. Even though the government has ordered state authorities to ensure provision of take-home rations and cash allowance during the lockdown, efforts to tackle acute malnutrition could still take a hit. It is in times like these that India’s frontline workers are making sure that no one in their communities goes hungry. Many anganwadi teachers are going door-to-door to deliver their weekly rations of rice, lentils, oil and eggs to beneficiaries.

COVID-19 Essentials Delivery

In this photo, tweeted by the Women and Child Development Ministry of Telangana, an anganwadi teacher delivers take-home rations including eggs to the homes of lactating mothers in the tribal region of Mulugu district via her scooter. Women like Vidyarani and their families are grateful for these workers delivering essential food items.
 

An Eye-Opening Research Experience through India

Learning Along the Way

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Hello, my name is Shannon King and I am working with Sight and Life as an intern while completing my Masters of Science in Public Health with a focus in human nutrition at Johns Hopkins Bloomberg School of Public Health.

The Assignment in India

During the late summer of 2017, I spent 2 months in India where I was working with our local partner, Karuna Trust, to conduct research on the implementation of the PATH “Feeding the Future through Fortified Rice Program”. Within this intervention Sight and Life has designed three school-based nutrition and WASH strategies to develop healthy eating habits while improving hygiene and sanitation behaviours. The intervention uses peer role modeling and cues to action; games and helper crews; and problem-based learning within the school environment to promote behaviour and attitude change.

The study required visiting 50 schools in four different areas of Karnataka in order to understand how the program is being implemented. Our observations allowed for us to examine to what extent each school had executed program activities- such as having soap available for the students, and how the program materials are being used around the school. Further, in-depth discussions with the implementing teachers provided detailed descriptions of how the program is being used and their experiences thus far.

Impact of my Experience

Overall, it was an incredible experience allowing me to engage first-hand in the entire research process from protocol design, to ethics review, data collection, and data analysis. As a graduate student, I have had the opportunity to work on studies in the past; however, this was the first time I have been given ownership of a study and the ability to work on it from initiation to conclusion. It has been very rewarding to work through each step of the process and overcome all the associated challenges and roadblocks.

During my time in the field, I found it fascinating to see a wide range of implementation processes used in the schools despite the fact that each school was provided with the same program materials and instructions. As researchers, a better understanding of the factors influencing implementation allows us to develop programs in a manner that will optimize delivery.

While the research did not involve any formal data collection from the school children, I will always cherish the moments I was able to engage and play with them. The opportunities were few and far between, however, at one school we arrived early and the teachers were having lunch so the facilitators and myself played one of the nutrition and WASH games with the children. Despite needing a translator to help facilitate the process, it was an hour filled with laughter and joy. It was also an incredible opportunity to see the program in action and how much the children were enjoying to learn.

Working through Barriers

The biggest challenge, and the most eye-opening experience of the trip, was working as a young female researcher. In several different contexts and settings, comments and suggestions made by females were treated less seriously than those put forward by males. Or sometimes women’s opinions were simply ignored, and it was eye-opening and aggravating to experience. Witnessing an individual’s esteem being judged primarily on their gender and seniority is quite the contrast to a working environment where your capabilities are judged primarily on your education, experiences and work ethic. It provided me with an even stronger appreciation of the efforts made to promote gender equality. India has an incredible, young female population with the potential to be strong leaders and change-makers, if given the opportunity.  

Lastly, this experience highlighted the need for implementation research to better understand how the nutrition community can optimize the delivery of nutrition interventions rather than purely conducting before-and-after data collection to assess the success of a program. I look forward to sharing the results with both project partners, in the hopes of allowing for mid-course corrections to improve program implementation, and sharing the findings with the greater research community to help build the literature base of implementation research in nutrition.

Enjoy this gallery of pictures showcasing my visit to Indian schools.

Photo credits: Prachi Katre

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