urban nutrition program: may 2012 update
DESCRIPTION
Final process journal from DI Fellow Anisha Shankar.TRANSCRIPT
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.
The time-and-activity line.
December January February March April May
IMMERSION
December spent in full
learning mode. Observe-
talk-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.
RESEARCH
Extremely productive
contact with pediatric
nutrition research
group at Jehangir
Hospital. Read-read-
read and refine
outcomes and
measures of progress.
DGS signs off on
project plan.
DESIGN-IN-ACTION
Alternate between
kitchen and sampling
table. Experiment with
(1) cheap, (2) tasty, (3)
healthy, and (4) easy-
to-make (5) finger
foods. Then ask DGS
staff which ones they
liked best.
PRE-IMPLEMENTATION
MEASUREMENT
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.
DESIGN-IN-ACTION &
LOOKING AHEAD
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!
REACHING OUT AND
REFLECTIONS
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?
Observe-Shadow-Talk-Repeat.
So I spent the next few weeks
learning about current nutrition-
related 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.
The Sit Down with the Director
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 locally-
made 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 Plan
Test snacks. Sample for
DGS staff. Select
favorites. Have nutritional
analysis performed.
Feed to crèche
children for at
least 6 months.
Train
community-
based SHGs in
snack–making,
quality control.
Identify markets.
Help with
marketing.
Children in
the community
Measure children’s heights,
weights, and hemoglobin counts
Regular nutrition education for care-
givers? 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
Doing the research
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
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.
Claire Malseed and Jennifer Isautier arrived to volunteer at DGS just
as I was starting to research recipes. Such luck!
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
Did you like it?
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 naïve!
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.
Ok, now it’s your turn.
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.
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.
raw
materials
funds
labor
Professional
cooks
Women’s self
help groups
DGS staff
& friends
Snack Program
Track nutritional
standing, height, weight,
and hemoglobin count,
then compare to the
World Health
Organization standards.
The brainstorming output: three solutions.
3 potential models
outcome
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
Measuring heights and weights is trickier than you think.
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.
You never know what you’ll get if you ask.
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.
Measuring heights and weights…the right way.
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 weights…the 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.
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.
Comparing DGS children to the WHO standard (weight-for-age).
Many of the severely malnourished
children are likely already part of
DGS’s special nutrition program, but
this effort acts as a prompt to re-
examine and refer these children as
needed. Changes to the nutrition
status, post-supplementation, of
these children will be of particular
note.
Measuring heights and weights…the right way.
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).
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.
The stalwarts of DGS
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.
Asking for leadership
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.
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
Design Impact
Thank you for your time! If you have questions, please don’t hesitate to contact me.
Anisha Shankar, Fellow
anisha.shankar@d-
impact.org
www.d-impact.org