FEX Special Series on Complementary Feeding: A Conversation with UNICEF Bangladesh Nutrition team

Speaker 1: 

Hello and welcome to the ENN Podcast. In this episode, the second part of our podcast series on Complementary Feeding in Emergencies, Eilise Brennan talks to Karanveer Singh and Zahid Manir of UNICEF Bangladesh. They'll be talking about their program in Cox's Bazar. 

Eilise Brennan: 

Hi, everyone. My name is Eilise Brennan and I'm one of the nutritionists at the Emergency Nutrition Network. Today I am really excited to be joined by Dr. Karanveer Singh and Zahid Manir; a warm welcome to you both. Today they are joining us to talk to us all about the Complementary Feeding program they've been implementing in the Rohingya refugee camp in Cox's Bazar, Bangladesh. So thank you both for joining us. I know you've had very busy days, so really appreciate you taking the time. So to start us off, would you just be able to introduce yourself to our listeners? 

Dr. Karanveer Singh: 

Hello, I'm Dr. Karanveer, I'm the nutrition manager with UNICEF in Cox's Bazar and I've been working here for the last three and a half years. It's a pleasure talking to you, Eilise. 

Mohammad Zahidul Manir: 

Hi, this is Mohammad Zahidul Manir. I'm working as a nutrition officer at UNICEF in Bangladesh. I'm working in Cox's Bazar Field Office focusing on the emergency response for Rohingya. 

Eilise Brennan: 

Delighted to have you both here today. And I have to start off by saying that I thoroughly enjoyed reading the article that you wrote in the Complementary Feeding in Emergency Special Series, which is in Field Exchange 68. So for you listeners who haven't had a chance to go and read it yet, I would really encourage you to go do so. And just to start us off as well, for those of you who might not know, though I'm sure many of you already do, complementary feeding is the period between six to 23 months when a child's energy and nutrient needs begin to exceed what is provided by breast milk alone. So ensuring continued breastfeeding as well as access to safe and diverse and nutritious diet is really vital during this period as it's essential for proper growth and development. So it really is such a crucial period of time and it's fantastic that we're talking about complementary feeding today. 

In your article you describe how in response to poor infant and young child feeding practices among Rohingya children, you've been using cooking demonstrations as well as leveraging traditional ceremonies called Mukhe Bhaat to build a capacity and confidence in mothers and complementary feeding. And we know that context is so important and context specific interventions are really important, something we actually discussed on a previous podcast that I would also encourage listeners to go have a listen to. So to start us off, would you be able to give us a bit of background and a bit of context in the Rohingya refugee camps? 

Dr. Karanveer Singh: 

Sure, thank you. So we have around 1 million Rohingya refugees living in 33 camps since 2017. These Rohingyas are completely dependent on humanitarian aid. So the food that they get is basically what World Food Programme provides to general food assistance. They have no regular source of income. Employment opportunities are very less. Food is available in the market but is extremely expensive, so they cannot really go and buy food in the market. Again, making them dependent on the aid or the food that they're getting. And even the knowledge on feeding and caring practices amongst the mothers and caregivers is poor. 

So we have a huge population living in crowded camps completely dependent on humanitarian aid and services. So that is the context that we are working in. And to improve the feeding and caring practices, we came up with this idea of using cooking demonstration and Mukhe Bhaat ceremonies that have been used as well also in the world. But we thought that it would be good to use this over here as well in this context. 

Eilise Brennan: 

It's such a huge Rohingya population you have in Cox's Bazar, Bangladesh. I actually didn't realize how large this population was. And it sounds like there's a lot of challenges in the context that you're working in. Thinking about the context and context-specific interventions, what were the specific challenges that you identified as the barriers to good complementary feeding practices in these camps? And then how did you adapt and design the intervention so that it addresses these specific barriers? 

Mohammad Zahidul Manir: 

Thank you, Eilise. So it's very important to understand the barriers to design an intervention that actually respond to the needs and context. So in the Rohingya camp, the breastfeeding practice is very good. More than 85% mother initiating breastfeeding within the past hour of birth, 62% mother exclusively breastfeeding in first six month of age, and more than 78% mother continuing breastfeeding over 12 months. So there is no issue actually regarding the breastfeeding, but we observe that complementary feeding, there is a gap. Around 28% of mother actually ensured the diversified food for their children, and 22% mother actually ensured the minimum acceptable diet. 

So it's very clear that there is a gap. Complementary feeding is far from being satisfactory. So as a program we have decided to work very hard to improve the complementary feeding practices. In Bangladesh, there is almost 1 million Rohingya people totally dependent on the food aid. They don't have any income source and unable to procure food from the market due to high cost. Their poor knowledge on feeding and caring practice of young children, and the chronic malnutrition rate is also high here. 

So the options for us is actually very limited. We have to work with the various food item that are part of the general food assistant provided by WFP, and the food they actually prepared should be also culturally acceptable, doable and sustainable, also reaching energy, safe, age appropriate, and also diverse. 

Dr. Karanveer Singh: 

As Zahid has just mentioned, the breastfeeding practices are extremely good and complementary feeding practices are where we really need to focus much more on. We have a very good program in the camps for the treatment of acute malnutrition, both severe acute malnutrition and moderate acute malnutrition, but it is a prevention of malnutrition where we thought that we really need to focus on. And amongst the activities for preventing malnutrition, we thought because of the poor complementary feeding practices, that we need to do something more to improve the complementary feeding practices amongst the mothers and caregivers in the camp. 

Eilise Brennan: 

It's fantastic to hear about the good breastfeeding practices within the camp and it sounds like there is quite a few challenges to do with complementary feeding, but I'm really encouraged to hear about the lengths of prevention being taken and I think thinking about prevention is so important. 

Something that you mentioned earlier was around the Mukhe Bhaat ceremonies and I thought these were particularly interesting, and I just wanted to learn a bit more about these ceremonies and how they were leveraged to improve complementary feeding practices. 

Dr. Karanveer Singh: 

Sure. So Mukhe Bhaat is a traditional ceremony in this part of the world where rice, that is bhaat, is touched to the mouth of the child, the mukhe, for the first time. So, Mukhe Bhaat, touching rice to the mouth of the child for the first time. This is something that is done culturally in this part of the world and this also ensures the timely introduction of complementary feeding. 

So we thought why not make this ceremony the center to begin with, so that timely introduction of complementary foods are begun. So what we do is when a child attains the age of six months, these children with their mothers are called to the center. It's a small ceremony that we have for the children where rice, and especially what we do is make rice pudding, rice and milk with sugar, so that is fed to the child for the first time. And it's a small ceremony and then we give a bowl, a spoon, a plate to the child and the mother so that they can take it home. And that also helps them, is a small incentive, but also a measure of how much to feed the child and have a separate feeling plate and a bowl for the child. So it is a small ceremony that we have but that ensures that the complementary feeding gets started on time. 

Eilise Brennan: 

It's great to hear about these ceremonies, and you paint a really nice picture about what's what's involved in them and I'd love to be able to see one of these ceremonies one day. It sounds really great and it's fantastic as well that you've managed to leverage something that was already going on in the community and kind of built on from that. 

And something else that really stuck out to me in this article was how you've used a learning-by-doing approach, and I just thought this was a more innovative approach and I was just wondering, could you explain to me why this approach was chosen and why you thought this would have the most impact? 

Dr. Karanveer Singh: 

We have been counseling the mothers and caregivers on infant and young child feeding and caring practices, so counseling is something that's ongoing and we are continuing with it and we are trying to improve it even further. But really to make a dent, we felt that we need to go beyond counseling a step further, and one of the ways of doing it was using the old adult learning methodology of discussion, of practicing, of teaching others. So if a mother does this, this helps her retain this information much more, and the likelihood of the mother practicing at home what she learns at the centers is much more. So this whole thing of learning-by-doing adds on to the counseling that we have at the centers, which is a formal counseling on infant/young child feeding and caring practices, but making it even stronger by practicing and by learning, by doing. 

So here the mothers are taught of different recipes that they can make by themselves, but then even the small things of how a vegetable needs to be washed before cutting, what is the size, how much of water should we put before cooking, not too much of water. So those small little things are also taught to the mother, which helps maintain the nutrients within the food, and making the food soft so that the child can eat, more diverse, more energy rich so that the food that is being prepared at these centers, and of course later on fed to these children, is something that these mothers learn to prepare and do it something similar at home as well. So that is the approach we took over here. 

Eilise Brennan: 

I think needing to be able to implement what you're taught in order for it to be able to be a practice that sinks in and that you continue is something I think we can all relate to even in our everyday life, that sometimes you need to do in order to be able to learn and to be able to put these things into practice. 

I really love this learning-by-doing approach and something that's very relatable to us all. One thing that strikes me is an approach like this might require more resources, more capacity, more finance and just more time in general. So I'm wondering is this something that you experienced? Did you find this initiative more resource-intensive? And generally what were the challenges that you faced? 

Mohammad Zahidul Manir: 

So we faced small challenges while we were planning and designing the intervention. So number one is the space to contact this session, especially the overcrowded capacities. And this is number one, overcrowded, and other problem was like it was hilly area, totally hilly area where they're living. So that's one. 

Then ensuring mother's participation regularly in the program as we are dealing with a conservative community, number two. And then the recipe actually we are proposing that should be culturally acceptable, that one also another challenge for us. And at the same time the recipe we are proposing, mother should also practice it at the home level. And there is several other present demand from the family side as well. 

So while we design our program, so we actually wanted to model some approach that wouldn't be much resource-intensive and also something switchable and scalable. So what we did, we actually organized this session at our integrated nutrition facility. It's the nutrition facility from where actually we are providing all the nutrition services like curative and preventive program. 

So we actually organized this session at our integrated nutrition facility and we actually trained one of our existing worker. So she conduct this session and we actually developed those recipes using the various food ingredients that is provided by WFP as a general food assistance. So it's nothing they need to procure or buy from outside is the food they actually receive as a general food assistance. So that's actually helps us to organize this session as well. 

And actually when we design this intervention, we actually involve mother and also community leaders. We organize several session with mother-to-mother support group member and community leader and also husband, mother-in-laws. And from them, those session, actually we take their opinion and suggestion how to actually design this session and not like how much time they will be involved and what kind of recipe and what kind of traditional food actually they use at house level for their children. So we actually consider every aspect when we design, and this is the way actually we overcome all those challenges. 

Dr. Karanveer Singh: 

And if I can add to Zahid, actually we had a very limited canvas to work in. In the camps, we can't really prepare recipes, as Zahid just mentioned, with any food ingredient. It has to be something which is a part of the general food assistance. Plus we also needed to ensure that we come up with a program where the mothers come to us regularly. It's just not that they come once or twice and then they drop out; it's not of interest to them anymore. 

And of course, as Zahid just mentioned, we wanted it to be sustainable and scalable. So we didn't want it to be very expensive so that is very difficult to maintain and after a few months we had to do away with it. So the way we have planned it using the existing resources and minimum resources from the top, that is I think what will really help us carry on with this intervention and that benefit the population as well. 

Eilise Brennan: 

It's interesting to hear you chat about the general food assistance as well and how the recipes can be prepared using the general food assistance and what's in that basket. I think it's a unique context, the fact that you're in a camp setting, and this is a unique constraint. So it's interesting to hear how you've adapted the intervention to that. 

And something as well that made me quite excited and that made my ears prick up when you said it was about scalability and that you've mentioned you were thinking about this from the very beginning. So I wanted to ask you, have you scaled up or are you planning to scale up in the near future? 

Dr. Karanveer Singh: 

So we have already scaled up in all the nutrition facilities that UNICEF and WFP are supporting in the camps here in Cox's Bazar. But beyond the camps, we have now scaled this up across all the eight upazila. Upazilas are the sub-districts of a district where we are, the Cox's Bazar. So we have scaled it up in the host community as well now. So in all the community clinic areas that we have in the host community, we do have such sessions, both Mukhe Bhaat and cooking demonstrations, happening for the host community and covering the mothers and children in the host community as well. So we have already scaled it up across the district. 

Mohammad Zahidul Manir: 

So just adding with Karanveer, that's why initially we started with only four sessions in a month. Now actually from there, but when we observed that okay, their knowledge and practice are increasing with the number of sessions they attended, so now we actually organize every day there is one session in each facility. 

Eilise Brennan: 

That's so encouraging to hear. And I would imagine now that the camp context and the context in the host community can be quite different. So I'm wondering were there any adaptations you made to the program when you transferred it over to the host community? 

Dr. Karanveer Singh: 

Yes, definitely. Yes. The structure that we have in the camps is much more stronger. We have more staff that works in the nutrition facilities. It's a dedicated facility which provides a nutrition services. But in the host community is a very different volume altogether. So there we are dependent on the government structure, infrastructure, number one, and the community structures that we have. 

So in the host community, when we started practicing these interventions, we started using more and more of the community structures that we have, the mother-to-mother support groups, the community support groups, we build their capacity. And here we had the liberty to experiment a bit more with the ingredients because we are also encouraging the mother, especially in the host community, to bring food from their home. So a mother can come with eggs, someone could come with potatoes, someone could come with a carrot or a eggplant, something of that sort, so that they are bringing different [inaudible 00:17:32] of food items so they get cooked together and feed it to the children. So we had to make a lot of adaptations when we had to bring it to the host community. The approach was very different. 

Eilise Brennan: 

Fantastic though that the program could still be adapted to that very different context, and I'm sure it's very encouraging for listeners as well to know that this can be implemented in a variety of different contexts. It's just about knowing what you have in your context and really thinking through how to design that program or any program really to what you have available to you. And I think it's a very encouraging message. 

And thinking about I suppose the encouraging message, when I was reading the article, it was great to just see the amount of impact that this has already had. So the fact that you're seeing caregivers who attended cooking demonstrations having increased knowledge on infant and young child feeding practices, the children were more likely to achieve minimum dietary diversity post intervention. 

And something that I found particularly interesting was the fact that you also captured caregivers' experiences, of mother's experiences. I think it's something that's so important and that we don't always invest enough time into capturing and listening to. And so I was wondering would you be able to expand a little bit more on what the caregivers thought and what the mothers thought of the intervention and how you've really taken what they have told you on board? 

Dr. Karanveer Singh: 

So whether it was while planning in the camps or in the host community, one thing that we did was involve the mothers and caregivers right from the planning stage, because listening to them, seeing what they really needed, seeing how they would accept it, I think that was extremely important. So bringing the mothers and the key stakeholders, even some grandmothers, into the discussions in the early phase of the planning really helped. And we also included fathers. So listening to different stakeholders and their perspective in the planning stage really helped. 

So there were a lot of feedbacks, like in the camp they told us that if you hold the sessions late in the day, we will not be able to attend. So it has to be around this at this and this time cause that's the time when the mothers are slightly free so they can come and they can attend these sessions. 

They were also very keen on that we don't want a very large crowd because then we don't really learn and we don't really get to practice ourselves. So one thing very good about the mothers, both, whether it's in the camps or the hosts, they're very vocal; they know what they like or what they don't like and they express it very clearly. And I think listening to that and adapting to that really helped us come up with this intervention. 

And one thing I can say is, it's been almost a year now we are implementing it both in the host and the camps, don't worry about the context, don't worry about the challenges, don't worry about the problems. We have to go beyond this, see what the context is, see what the need is. We have to take a step extra. We have to go beyond what you're doing normally to really make a difference. So we have to take that extra step. And to take that extra step, involve the stakeholders, listen to them, design a program, implement it. Don't worry about resources; it's not very resource intensive. That's what we can say from our experience. 

Eilise Brennan: 

I think it's great that the mothers as well are just telling you how it is. I just have this image in my mind of them feeding into the process and it's just fantastic. And I know as well that since the FEX article came out, you've actually had more assessments and evaluations take place, which shows some more findings. And so would you be able to share some more of them with us as well? 

Dr. Karanveer Singh: 

Sure. So as Zahid has earlier mentioned, the breastfeeding rates, the early initiation of breastfeeding, exclusive breastfeeding rates are pretty good. And we have just finished conducting a detailed IYCF assessment in the camp, and we have the initial findings and I'll just share that with you, but also would like to tell you that we are having a similar assessment in the host community. The data collection is ongoing at the moment and in a few weeks' time we will have the prelim data from the host community as well. 

But from the camps what we are seeing is something very encouraging and something a bit disappointing as well; it's a mixed bag. And what we are seeing is like the timely introduction of complementary food, probably because of the Mukhe Bhaat we are starting, is 75%. So 75% of children within six to eight months have initiated the complementary food on time. I think that is a good beginning. 

What we are also seeing is that almost 62% of the children in this IYCF assessment, they are meeting the minimum meal frequency; so the frequency is depleted there. But what is really lacking is diversity. Only 28% of the children reported using that, which is diverse, using more than five different type of food items in a day. 

So this is one area where I think we really need to work more on. But where I think the timely introduction of complementary food is concerned, the minimum meal frequency is concerned, we are doing well, but I think we need to again get back to our WFP colleagues, they're already doing a lot, and see how more we could work together and make this food more diverse for the child. 

Eilise Brennan: 

Why do you think dietary diversity continues to be such a challenge? Do you have any insights into that? 

Dr. Karanveer Singh: 

Yes. The food that they are getting is basically based on the e-voucher system. And here I can tell you they can choose from a vast variety of foods. We have fresh vegetables, we have eggs, we have fish, chicken, beef, rice, lentil, oil. So the variety is huge. But the issue is sometimes the families mainly focus on buying rice, lentil and oil, and the focus is more on adult food so that they can have ample quantity so that it fills their stomach. 

So the issue of dietary diversity, the changing in the behavior I think will take some time. It is not something that is going to be impossible, but it'll need more time, it'll need more intense ... I think we will even change our approach so that we are stressing more now on how to make the food more diverse. And also tell the families and the mothers to buy the different type of food items which are already available through the e-voucher outlets that is supported by the WFP. 

Eilise Brennan: 

I think that's something that's important to remember, that change is possible, but change also takes time and to change practices definitely takes time and takes investment of time. And I'm sure after listening to you both chatting today about the program you've been implementing, that many people are going to be inspired and going to want to do something similar, or hopefully will want to do something similar. So would you be able to share with us some key learnings that we should take away from us today and that programmers and researchers who are listening to this podcast should take away from this and from you? 

Dr. Karanveer Singh: 

Sure. So for us, as you know, implementers, what we would like to say is sometimes doing more of the same doesn't really help. We have to think out of the box. We have to row a step further and try to improve, try to understand where the constraints are. For us, the breastfeeding practices were good. It is complementary feeding practices that were needing improvement. And the stunting levels that Zahid just mentioned, almost 30% of our children are stunted. So we have to come out with some interventions which are again context based, number one. 

Number two, you have to involve the stakeholders right from the planning stage. Once they're involved right from the initial stage, they own the program. It is their program, it's not our program. And even in the camps, we are seeing many mothers bringing some food items from their own ... Whatever food that they are getting through the food rations, they bring it to these sessions so that we can add it to the food that is being cooked. 

So involving the stakeholders, the mothers, right from the beginning is very important. And then having a constant dialogue with them. It's just not you started something and you leave it there; you have to engage with the mothers constantly. Learn, ask them, "What is happening well? What is the area that you want us to change? What is it that you want us more to improve on? Or is this thing that you can prepare at home or do you think that you know what we are telling you, this particular recipe that we've talked about today, is something that's difficult for you to prepare?" 

And many times mothers do tell us that, "Okay, we do know how important it is to prepare this different type of diverse food, but then there's so many things that I need to do at the home that is I have very little time to prepare this type of food for my child. So many times I just feed what we have prepared. But sometimes, or many times, I also prepare this more diverse type of food for my child and I feed this to my child." 

Eilise Brennan: 

I think those lessons are great and really applicable to any program that someone's thinking of implementing for complementary feeding and beyond. Thank you both so much for taking the time to chat with me today and for sharing your insights and learnings. For all you listeners who would like to learn more about the work going on in Cox's Bazar, please do check out the article. It's improving the quality of complementary feeding in Rohingya refugee camps in Bangladesh, and it can be found in the Complementary Feeding in Emergencies Special Series in Field Exchange 68 on ENN's website. 

Dr. Karanveer Singh: 

Thank you. It was a pleasure talking. 

Mohammad Zahidul Manir: 

Thank you, Eilise. 

Speaker 1: 

Thanks for listening to the ENN podcast. You can find out more about our special effects supplement on Complementary Feeding in Emergencies on ennonline/fex.