Uncommon Solutions to Improve Child Nutrition - an Example From India

What if your neighbor’s child is better nourished, more active and healthier than your own child? How can you tell what they are doing differently? Often it is not expert solutions or the better socio-economic circumstances the other family lives in, but small differences, small shifts in behavior which can successfully change the situation of your child.

Despite improvements over the past decades, data on global child nutrition is still worrying. In 2024, the State of Food Security and Nutrition in the World (SOFI) reports a prevalence of 22.3% (148 Mio.) children under 5 years of age being stunted (chronically malnourished) and 6.8% (45 Mio.) being wasted (acutely malnourished). More than every tenth child (14.7%) is born with low birthweight. This is closely linked to the urgent need to transform our current food systems where one third of the world population (2.8 billion people) cannot afford a healthy diet. This has implications for children’s diet: only 21% globally consume an adequate diet that includes diverse foods such as vegetables, fruits or animal-sourced foods.

Suffering from malnutrition early in life, especially during the first 1’000 days (from conception until the child’s second birthday), determines the child’s physical and mental development. Failures in this phase are often irreversible and impact the nutritional situation later in life. As adults, these children will be more likely to suffer from nutrition-related non-communicable diseases such as diabetes or coronary heart disease. This will have an impact on economies and societies. The costs of malnutrition to the global economy are estimated to be 41 trillion USD a year. At the same time data show that the return on investment in nutrition actions is high: every US dollar invested brings a return of 23 dollars for economies.

While there is evidence of what works well – exclusive breastfeeding for the first six months of life; increased dietary diversity for women and children; responsive feeding practices; fortified complementary foods; micronutrient supplements – we know that implementing and scaling such interventions effectively and with sensitivity to the respective context, embedded and linked to local food and health systems, can be time- and resource-intense. Capacity building of frontline workers, who in most countries work on a voluntary basis and bear a heavy burden of different tasks, has been insufficient to combat child malnutrition to a satisfactory extent.

New behavioral approach

We need to pay additional attention to the underlying causes of child malnutrition and consider factors which might be indirectly linked to nutrition. The following example from India illustrates an approach to the problem of child malnutrition starting with solutions that already exist in the community. It also offers a strong behavioral method to empower communities.

In Vietnam in the 1990s, child malnutrition was successfully overcome within a short span of time through the implementation of the so-called Positive Deviance (PD) approach. A similar PD approach was applied in selected villages of the central Indian state of Madhya Pradesh by the project “Securing Nutrition, Enhancing Resilience (SENU)”, funded by the German Federal Ministry for Economic Cooperation and Development (BMZ) as part of a larger Global Program on Food and Nutrition Security, Enhanced Resilience. The guiding question was ‘Are there any well-nourished children among families living in low socio-economic circumstances?’ – that is, are there families who are better able to feed and take care of their children than others in their community, families that deviate in a positive way from the norm?

The project was implemented by GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit – German  International Cooperation) in partnership with Welthungerhilfe India and collaborated with the state Department of Women and Child Development (DWCD).

Ideally, the community is involved throughout the process to foster ownership and collective motivation to change. The objective was not only research to discover uncommon solutions for good child nutrition, but also to build capacity of local frontline workers that are in day-to-day interaction with families.

The PD approach provides an opportunity for governments and development cooperation organizations to go beyond the common model of Social and Behavioral Change (SBC) which usually starts with external experts training communities in evidence-based practices around infant and young child feeding as well as optimal nutrition for pregnant and lactating mothers. However, in many contexts these practices are not easily adoptable. For instance, in the project villages most families cannot afford or access fruits and vegetables on a daily basis which makes it difficult to achieve the recommended dietary diversity for mothers and children. In general, the two daily meals consist of rice or wheat-based pancakes with lentil soup.

Variety is difficult to achieve

The PD approach offers the chance to complement the promotion of evidence-based practices with practice-based evidence from the local context. In the selected villages, the project team, accompanied by local NGO partners and frontline workers, visited families identified as having a well-nourished child. During the visit, the team aimed at discovering what these families do differently compared to their peers living in similar socio-economic circumstances but struggling with malnourished children.

The approach of SBC is reversed here. It is not about being the nutrition expert and sharing what needs to be done for improved child nutrition, but to put the role of expert aside and try to discover what solutions already exist locally. It is about change that starts from within the community with practices that work in their context and hence have a higher chance of adoption, suitability and sustainability.

The research team discovered a range of uncommon practices in various areas: child nutrition and childcare; family nutrition; hygiene; nutrition gardens; the involvement of fathers in family nutrition and gender roles, as well as family values and related decision-making processes. Uncommon practices were for example: The daughter-in-law eats together with the rest of the family rather than having to be the last, eating leftovers; the father participates in household chores, buys vegetables and fruits when seasonal prices drop or buys an egg for the child instead of a packaged snack which costs the same; the family waters their backyard garden with waste water from the bathroom while other families say they cannot have a garden due to water scarcity.

These are deviations from common practices that can positively contribute to child nutrition. Even subtle practices can make a difference such as bonding with a small child through affection and attention instead of ordering a child to be quiet; and having a supportive neighborhood where the child gets snacks on demand.

In the process of discovering those uncommon practices frontline workers became curious. Their daily job is counselling parents with young children about healthy diets and hygiene practices. Their focus usually lies on families with malnourished children, a problem-centric approach. The fact that the research team asked them about families with a well-nourished child in resource-poor pockets of their villages surprised and inspired them to approach the problem of malnutrition by looking out for existing solutions. During the research visits to PD families, they learnt about innovations they had not been aware of.

For the dissemination of these uncommon practices, the research team engaged adolescent girls from the research villages as drivers of change. After training, they were asked to take photos of uncommon practices in their community. Pictures were then presented in a participatory, traveling photo exhibition which was set up together with frontline workers. This created interest in and triggered reflection on local practices, especially around gender and nutrition gardens. In a further step, the research team is cooperating with local NGO partners and frontline workers so that they are able to disseminate uncommon practices jointly with community members.

There is a great opportunity to scale up the PD approach as a tool which enables local frontline workers and communities to discover context-adequate solutions for improved child nutrition and complement these with globally agreed evidence-based practices. The approach can contribute to and support SBC-efforts to improve child nutrition. Over the past year the GIZ-project designed a tailor-made version of the PD tool that fits into the daily work routine of frontline workers. This pilot-project is ongoing with capacity building and mentoring of 400 frontline workers.

When taking action to transform our food systems, questions of child nutrition should be at the center. Negative consequences of certain actions for child nutrition (e.g. increasing employment for women without taking account of child care or places for breastfeeding) should be avoided. Child nutrition depends on the availability and affordability of healthy food,  and on equitable access to healthy food environments which provide a choice of healthy foods. Counselling services and caring structures are important underlying support factors which have to be taken into consideration as well. In addition, equal rights for women and men are crucial for child well-being. Innovative approaches such as the Positive Deviance method change communication and perception within communities and strengthen efforts to achieve the long-needed food system transformation in a sustainable way.