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

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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