Integrated Health, education and environmental (HEE) intervention to optimise infant feeding practices through schools and Anganwadi networks in India

Early infancy and childhood poses a crucial period of sensitivity to the environment and nutritional intake, when growth, development and health are patterned throughout the life-course and across generations. Malnutrition in this period can predict risk of infection stunting and poor cognitive development in early life and NCDs yet 27% of children globally under 5 are undernourished and childhood obesity is rising (4.2%-1990; 6.7%-2010; estimated 9.1%-2020).

India faces a triple burden of childhood malnutrition: 48% (61 million) under-five's are stunted (one-third of the world's total; highest among all nations), childhood obesity is on the rise (15% of all under-five children), and most have a micronutrient deficiency (70% of the under-fives are anaemic). The World Bank identified under-prioritisation of nutrition and health education as a barrier to progress while the 2016-2030 global strategy emphasises the need to integrate multisector enablers that address education, gender, sanitation, water, agriculture and nutrition (every woman, every child). The Government of India has been implementing key nutrition and behaviour change interventions through three cadres of frontline workers but barriers include outreach, variable levels of sanitation, social-inequity (by gender and Caste) and the feasibility and effectiveness of localised integration. From a socio-ecological viewpoint, these multiple enablers operate at the individual, household, community and environmental level. Nutrition in the first 1000 days (our focus infant and young child (IFYC) 6-24 months) can be shaped by access to adequate dietary diversity, clean water, sanitation and cooking fuels, and also the cultural norms and education of all household members.

This study proposes a Five-Phase participatory and inter-disciplinary study to explore the Health-Education-Environment (HEE) factors influencing IFYC feeding practices and nutrition. The aim is to develop a socio-culturally appropriate, tailored, integrated and interdisciplinary HEE package aimed at the IFYC (6- 24 months) in rural India and test the acceptability of the intervention. Our collaborative approach includes an interdisciplinary team from UCL (across the Institute of Child Health, Institute of Education and Faculty of Engineering Sciences) and expertise from; Save the Children- India, The Indian Institute of Technology, New Delhi (IIT-Delhi) and Jawaharlal Nehru University, New Delhi (JNU). Additionally, we have identified four NGO partner institutions to provide contextual and programmatic advice along with members from the British Indian diaspora.

This collaboration prioritises the integration of existing and individual government programmes at a local level in the design of this HEE package. To achieve this goal, we will engage with selected villages in the Banswara region and with stakeholders across all levels of the socio-ecological framework. Our local partnership will identify, train and support local 'community champions' from a network of Anganwadi Centres and schools and later establish 'community education and innovation hubs' with participating schools but linked into existing systems. Community champions and the British-Indian PPI panel will be invited to contribute at each phase of the 24 month research process, from study design to dissemination. The India-based research team and community champion partnership will collect qualitative data about IFYC feeding practices, education, sanitation and access to energy and water in the local context. During data analysis, all partners will meet to actively draw together the interdisciplinary findings in a linked mapping exercise that will ultimately shape the design of an innovative HEE package. The HEE package will be tailored to the requirements of existing government initiatives and future funding applications will explore how the HEE package can be scaled up to additional India state

India faces a triple burden of childhood malnutrition; 48% under-five's are stunted, 70% anaemic and 15% obese. Malnutrition affects physical growth, and brain development and contributes to India's burden of communicable and NCD's. The Government of India has been implementing key nutritional interventions via three cadres of frontline workers; yet multi-sectoral approaches that address broader determinants of nutrition, education, water, sanitation and hygiene, and social inequities remain crucial.

This inter-disciplinary study explores the Health-Education-Environment (HEE) factors that influence young children's (6-24 months) feeding practices, across priority areas identified by local panchayats, NGOs and government stakeholders. Our collaboration includes an interdisciplinary UCL team from Institute of Child Health, Institute of Education and Faculty of Engineering Sciences and expertise from Save the Children- India, The Indian Institute of Technology (Delhi) and Jawaharlal Nehru University, New Delhi.

A socio-ecological framework will structure mixed-methods data collection at individual, household and community levels during an iterative participatory process. Our participatory methodology includes partnerships with local 'Community Champions', Anganwadi Centres and establishing 'community education and innovation hubs' with participating schools.

The British India diaspora, being an important source of knowledge, will make up the UK PPI panel and participate from study design to dissemination. In the final phase all partners including the community will come together to develop a tailored socio-culturally appropriate HEE package that actively integrates existing government initiatives and test acceptability of the intervention for future scalability. Results will be disseminated via workshops and through 'community hubs' to government representatives, technical experts, program managers, and NGO, civil society and community representatives.

This project aims to address 2030 agenda for Sustainable Development and pertains to goals 3 and 5 (Good health and well-being; Gender Equality). In India, 48% of children under 5 are stunted, 70% anaemic, and 15% obese. Childhood malnutrition has a negative impact on disease, disability, cognitive development, educational attainment and therefore an economic impact. It is more evident in rural India due to intergenerational poverty, gender inequity, educational and societal disadvantages. This is aggravated by inadequate access to basic services and poor environmental conditions.Health Education, Environment (HEE) project will directly benefit residents in the 9 rural communities in Banswara district in Rajasthan. This project will enhance optimal feeding practices for children aged 6-24 months, support mothers in this endeavor improve living conditions and lifestyle in the community at large, and enhance capabilities of local schools and Anganwadis to operate as community education and innovation hubs. HEE will build capacity of local communities in the 9 villages through the training of community champions selected through participatory processes. Community champions will be equipped with skills on participatory techniques, an improved understanding of integrated health, environment and education approaches for enhancing well-being of communities with focus on optimising infant and young children's (IFYC) feeding practices. The community champions will be able to apply their skills to other communities within Banswara district thereby benefiting wider community.

Through future scale up this project has the potential of improving well-being of children in rural parts of Rajasthan comprising 5.7% of the states population and 6.2% of India's population based in rural communities. There is potential to impact rural communities in other LMICS where stunting is prevalent and needs an integrated approach thereby benefiting 27% of children under the age of 5 who suffer from stunting.

Currently, there are varying levels of integration of HEE interventions in academia, NGO's, governmental and civil society organisations. The HEE project will develop an integrated intervention package, linking into existing systems to support long term sustainability. It will test acceptability with local communities in Rajasthan and disseminate to academic bodies, policy makers, practitioners, civil society organisations and NGOs resulting in a more streamlined approach for improving health and well-being of IFYC. The British Indian diaspora network has close linkages with India and will support scale up and impact through providing PPI expertise and dissemination.

IIT-Delhi will incorporate HEE findings into sustainable technologies design at their Centre for Rural Development and Technology and influence policy makers through their convening role for the Unnat Bharat Mission. UCL and JNU will embed HEE into their curriculum thereby influencing the future generation of engineers, health and education practitioners. The project partners will disseminate the methodology to development practitioners, academics and policy makers through their networks in order to influence policy making for 833 million residents in rural communities in India.

This project directly supports the Goverment of India (GOI) flagship programmes such as Sarva Shiksha Abhiyan, Swachh Bharat Abhiyan, Unnat Bharat Abhiyan and the Integrated Child Development Services. By hosting a high level workshop, the project team will engage jointly with state and national level ministers from the Ministry of Human Resources and Development, Ministry of Health and Family Welfare and the Ministry of Environment, Forests and Climate Change, GOI, NGOs, academic bodies, community champions and other implementing bodies. HEE will therefore influence policy making by introducing an integrated and streamlined approach for multi-sectoral ministries and agencies engaged in child health.