Urban Nutrition Program: May 2012 Update

Improving Urban Nutrition with Deep Griha Society Tracing the project’s arc Date: June 15, 2012 Anisha Shankar, DI Fellow

 Since 1975, Deep Griha Society has served Pune’s impoverished communities and neighboring villages through childcare services, women’s empowerment programs, education, and awareness raising.  Children in these communities begin suffering from the effects of poverty and lack of knowledge early, often in the womb - malnourishment is rampant.  Deep Griha and Design Impact believe that the solution – better nutrition for children – can have also a positive impact on local women. What if a nutritious snack program implemented over a 6-

month period shows higher weights, heights, and hemoglobin counts for the 270 children at Deep Griha’s daycare centers? These positive health impacts could catalyze a new livelihood option – manufacture and sale of these snacks - for local women’s self-help groups while children in the community would have increased access to nutritious foods.

The organization, the project.

IMMERSION

DESIGN-IN-ACTION

PRE-IMPLEMENTATION

December spent in full learning mode. Observetalk-shadow-repeat. Do children in crèches eat enough? Aadhar Kendra children seem to eat well.

Mind boggled by array of programs on offer. Several ideas to approach outcome goals.

Alternate between kitchen and sampling table. Experiment with (1) cheap, (2) tasty, (3) healthy, and (4) easyto-make (5) finger foods. Then ask DGS staff which ones they liked best.

MEASUREMENT

December

January

RESEARCH

Extremely productive contact with pediatric nutrition research group at Jehangir Hospital. Read-readread and refine outcomes and measures of progress.

DGS signs off on project plan.

The time-and-activity line.

February

Height, weight and hemoglobin counts demonstrated measures of nutritional impact. Weigh, measure, then repeat, and again, but get it right! Botched blood draws heart breaking.

March

DESIGN-IN-ACTION

April

&

May

REACHING OUT AND

LOOKING AHEAD

REFLECTIONS

Food testing is hard!

Soliciting feedback in culturally relevant way harder still! What if program successful?

Need funding plan in place, if so.

Brainstorm with DGS staff to get best ideas!

Can’t do it alone, can’t do it alone, can’t do it alone! Reach out to DGS staff and ask for help. Other times, just do it and get it done, and “jugaad” isn't a bad word.

THE IMMERSION In my first two weeks at DGS, I was startled to find myself mostly dismayed. How could I possibly be useful or effective in this programmatically-sprawling and hierarchy ordered organization? And then helped with intake for a volunteer-led health camp for the crèches.

With the sharpness and clarity that only belongs to a few moments in life, I knew that everything else was mostly irrelevant.

Grinning, skinny, crying, scared, naughty, and snotty, these children were the reason I was here and dang it I was going to do this job to the best of my ability.

What motivates you?

So I spent the next few weeks learning about current nutritionrelated practices, menus, and donations. I found out that Venkateshwara Hatcheries donates daily vats of rice and dal to DGS that makes it possible to feed the approximately 270 children that come to DGS’ crèches.

But I couldn’t help notice that the rice is white and the dal could be thicker. I found DGS was supplementing these as best it can within its limited budget. But plainly there were opportunities to make any new nutritional efforts count for these children.

Observe-Shadow-Talk-Repeat.

Talks with Dr. Prakash and with medical volunteers revealed that the children in the crèches tend to be underweight and anemic, a daily DGS meal and snack notwithstanding. So children in these impoverished communities without access to this food likely have a much tougher go of it. Research papers indicated the same thing.

Observe-Shadow-Talk-Repeat.

I also wanted to see if children in other programs fared better. I found that some did. The Aadhar Kendra program, which connects a donor to each child identified as coming from a difficult home life, is better resourced. Children eat one meal that seems power-packed. They get some combination of dark leafy green vegetables, eggs, sprouted lentils, whole grains, and dal.

Observe-Shadow-Talk-Repeat.

THE DIRECTOR Then I sat down with the Director, Dr. Neela Onawale, to truly understand what DGS wanted.

In collaboration with DI, DGS’ is gazing out at the community – let’s make available a substitute locallymade healthy snack for the many packaged ones that community children are known to consume.

Local women’s self-help groups could produce these snacks and sell it in the community.

Maybe we could do this and simultaneously add value to the crèche meal program. The project plan was coming together…

The Sit Down with the Director

Test snacks. Sample for DGS staff. Select favorites. Have nutritional analysis performed.

Feed to crèche children for at least 6 months.

Measure children’s heights, weights, and hemoglobin counts

The Plan

Train communitybased SHGs in snack–making, quality control.

Identify markets.

Help with marketing.

Children in the community

Regular nutrition education for caregivers? Can trainee nurses deliver?

THE RESEARCH DGS’ long life and consistent service to its target population makes it a natural partner for many organizations.

The Hirabai Cowasji Jehangir Medical Research Institute has based many of its pediatric nutrition research studies at DGS. It was a relationship that I got on board with and quick. Research head Dr. Anuradha Khadilkar and nutritionist Veena Ekbote were a fount of perspectives, tips, research papers, and good advice and I am deeply grateful to them.

They’ll show up later in this story as well, so stay tuned…

Know what’s known

DGS identified protein and iron as the two nutrients of greatest need for the children in the community. The research supported this and I planned in pre- and post-program measurements after six months of snack supplementation.

Doing the research

The Nutritive Value of Indian Foods was my bible during this period. I identified foods that were high is protein and iron and then searched online for recipes that combined such foods or where substitutions allowed the content of these two nutrients to be boosted.

Doing the research

Claire Malseed and Jennifer Isautier arrived to volunteer at DGS just as I was starting to research recipes. Such luck!

Both recent Master’s graduates in nutrition, their help and enthusiasm made this work so much easier. I know – I did much recipe testing after they left and doing it alone was hard! We researched ingredients, calculated the nutritional content of recipes, and made careful notes during testing.

Doing the research

DESIGN IN ACTION They might have been nutritious but not all the snacks I made went down easily! My goal was to select two sweet and two savory snacks and I was surprised by how much work, at every stage, that was. So, it wasn’t just the toil in the kitchen, finding a way for DGS staff to provide honest feedback was also a real challenge. It took three rounds and the simplest, most obvious methodology to get it right (I think).

Cook-Sample-Survey-Repeat

Weigh, soak, wash, grind, mix, shape, cook...whew

It is hard to cook up a bunch of cheap, nutritious, tasty, and easy-to-make finger foods, but it was nothing compared to the difficulty of designing a good survey. My first attempt was naĂŻve!

I used a range of sad to happy faces and found myself explaining what the faces represented to every person who sampled the snacks. No, I wasn’t going to use this format again.

Did you like it?

In my second attempt, I replaced the faces with nine short “yes/no” statement s such as “It looks very good to eat” (appearance), and “It tastes very bad” (taste). I think it was still confusing. Staff turnout was low at the tasting table and all that effort was worth it only because a group of women from the community were at the Tadiwala Road office attending a meeting.

Did you like it?

In my last attempt, I either was exhausted or had finally wised up. I just put two questions to each sampler – “which snack did you like best?”, and “which one was your second choice?”. There was no confusion now – everyone easily compared between the three and picked their favorites. I also got very good turnout. Many wanted the recipes, which I took to be a very good sign.

Did you like it?

I now had two sweets (ladoos) – wheat and peanut, and millet, flax, and coconut, and two savories – chickpea burgers, and soy burgers. It was time for recipe sharing. Ranjana Bhosale, the team lead for the crèches assigned four staff members to this training.

Ok, now it’s your turn.

Ok, now it’s your turn.

At the end of the day’s training, I also had 400 gram samples for each snack ready to take to the laboratory for a protein and iron analysis.

Ok, now it’s your turn.

LOOKING AHEAD

Although the snack supplementation program was technically supposed to run for six months, I wanted to make sure DGS had a plan to make it permanent if they liked the results. I turned to staff at all levels of the organization to brainstorm responses to this question.

Three sessions and 45 participants later, we had three possible routes to take. I left this plan with the team leaders, encouraging them to select the best one (or variations thereof).

Realistically, I don’t expect this plan to progress past six months in its current form.

But, I believe that this exercise is in an opportunity for staff to learn about brainstorming.

Let’s brainstorm.

3 potential models

Professional cooks

outcome

Snack Program raw materials labor

Women’s self help groups

funds

DGS staff & friends

The brainstorming output: three solutions.

Track nutritional standing, height, weight, and hemoglobin count, then compare to the World Health Organization standards.

THE PRE-IMPLEMENTATION MEASUREMENTS I wanted to share a powerful story with the self-help groups so they would be excited about the production of ladoos. I wanted them to know that these snacks are tasty and (we expect) have a measureable positive impact if consumed everyday.

Researcher Veena is confident that the six month snack implementation program will show results. So I scheduled height and weight measurements sessions. It took three tries to get it right—but we’ve been able to establish base-line measurements for the children.

We are also doing basic blood tests on the children. We had a minor set back with a less than expert phlebotomist, but these measurements are now underway, with the direct oversight of Dr. Prakash.

Taking baseline measurements for the study

In the first round of height weight measures, we used a simple analog weighing scale and a tape measure. This was the equipment at hand, but I worried that the measurements were not fine enough to note small changes that might be attributable to the snack program. The equipment definitely had to change.

Measuring heights and weights is trickier than you think.

In the next round, we upgraded our equipment – a digital bathroom scale and a wall-mounted stadiometer, partly funded by DGS volunteers and friends. But although we didn’t know it, we weren’t quite there yet. We measured over 200 children in this second round as well.

Measuring heights and weights is trickier than you think.

It sometimes pays to be that pesky question-asker. I sent so many emails to Veena over the last six months that when they announced the workshop on measurements to assess pediatric nutritional status, I naturally got invited. It was a Sunday excellently spent. I learned good measurement protocols.

You never know what you’ll get if you ask.

The first order of business: purchase 1, 2, and, 5 Kg weights to calibrate the digital scale before every weighing session to ensure that the reading it provided matched the known weight of the object. The second order of business was to (a) position the child correctly on the scale, and (b) take two successive readings (three if the first two weren't exactly the same).

Measuring heights and weights‌the right way.

It helped that we had secured the crèche team lead’s presence because it would have been difficult to explain to the crèche teachers why we were back to disrupt normal proceedings! We were in the summer by this time, so measured only 156 of the 270 children enrolled.

Nonetheless, we got a good baseline sample of weights that I have confidence in.

Measuring heights and weights…the right way.

This little stadiometer presented a few frustrating moments which I’ll cover in the “reflections” section but I was glad we had it. We quickly got the hang of mounting it, correctly positioning the children gently but firmly, and taking two (if the first two were exactly the same) or three (if the first two didn’t match) successive measurements. If we took three, we recorded the median height for the child. All measurements were also entered in the children’s health cards.

Measuring heights and weights…the right way.

The weight-for-age measure provides an indication of nutritional status. Low weight-for-age indicates moderate to severe malnutrition. We plotted the final round of measurements using WHO’s AnthroPlus program which compares the population to the median. This plot appears on the following page.

The red line curve shows that about 1/8th of the 156 children (19) are severely malnourished, that is, more than three negative standard deviations from the median (http://www.who.int/nutrition/topics/severe_malnutrition/en/index.html).

Almost 1/4th (43 of 156) are moderately malnourished, i.e., between 2 and 3 negative standard deviations from the median (http://www.who.int/nutrition/topics/moderate_malnutrition/en/index.html ).

Comparing DGS children to the WHO standard.

Many of the severely malnourished children are likely already part of DGS’s special nutrition program, but this effort acts as a prompt to reexamine and refer these children as needed. Changes to the nutrition status, post-supplementation, of these children will be of particular note.

Comparing DGS children to the WHO standard (weight-for-age).

I also visited a few of the local Tadiwala Road women’s self-help groups to gauge their reaction to the project idea…with a bowl of ladoos. One group already supplies meals to the local school under government contract. They’re interested but savvy enough to ask what support DGS will provide in getting them started. This work will occur in the second phase of this project (starting August 2012).

Measuring heights and weights…the right way.

REACHING OUT AND REFLECTIONS Despite all that got done, by the end of April, I was quite disheartened. Some of it due to the debacle of the blood draws, some of it because the project didn’t seem to have an in-house champion, but a lot from the realization that I just couldn’t drive all the tasks myself.

Then I followed some very sage advice–ask for help. What an idea! And I did – I went to a weekly team lead meeting, refreshed their understanding of my role at DGS as DI Fellow, elaborated on the project plan, and laid out the specific asks to keep the work going. Suddenly, a lot got done in a relatively short amount of time.

On the other hand, I also learned that sometimes, it is a lot easier to just do the work. I also did some “jugaad” or work arounds to keep on going.

Sometimes, you just have to do it yourself.

Bismilla (lefy), Poonam (right), and Amrapali (not pictured) answered my biggest request. Team leads identified them for the day-to-day oversight of the snack supplementation program and to support the upcoming collaboration with select SHGs. They are committed, efficient, and smart, and I believe represent the next line of middle managers at DGS. This progression is not the norm at DGS but with a combination of mentorship and the independence to act, they could be the start of a very successful policy for DGS.

The stalwarts of DGS

My second request was to have team leads take responsibility for specific aspects of the project. I handed off the hemoglobin measurement task to Dr. Prakash, and Ranjana stepped up to offer reassuring leadership in both completing the height-weight measurements, and in overseeing the recipe training session.

Asking for leadership

These later conversations with team leaders gave me good insight into how to get work done. In the absence of better structure, many DGS volunteers simply take the initiative to start projects designed to meet perceived needs. Often, staff treat these as temporary projects that aren’t officially sanctioned.

The nutrition project was likely viewed in the same light and so it was very hard to get lower level staff to provide help. As far as they were concerned my requests were for yet another non-significant or short term project. This meant I often spent much time planning, managing, and implementing tasks (largest to the slightest).

This is where, however, team leads come into their own. They are perfectly accustomed to issuing task orders to lower level staff and lower level staff is equally accustomed to getting it done. When I finally realized this, I began to funnel requests for help through the appropriate team leader. Life got much less stressful after that!

Getting someone else to issue orders

Thank you for your time! If you have questions, please don’t hesitate to contact me.

Anisha Shankar, Fellow anisha.shankar@dimpact.org www.d-impact.org

Design Impact