Engaging men can help transform nutrition and family planning in rural India - Hindustan Times
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Engaging men can help transform household nutrition and family planning in rural India

Sep 02, 2023 10:58 AM IST

In India, men and women receive health information in isolation. A six-month learning pilot in Bihar challenged this, with promising outcomes

Everything that Santosh* knows about contraceptives, he has learnt from his mobile phone and friends. After the birth of his first child, it was him, in consultation with his parents, who decided that his 21-year-old wife should start using a copper IUD as a form of birth control.

Household health programmes delivered by couples to couples signal that achieving a family’s health goal is a shared responsibility(Representative Image - Pratham Gokhale / HT Photo)
Household health programmes delivered by couples to couples signal that achieving a family’s health goal is a shared responsibility(Representative Image - Pratham Gokhale / HT Photo)

His wife, Deepa, on the other hand, gets her information from more credible sources: Frontline workers called accredited social health activists (ASHAs) and nurses. She started visiting the nearby health and wellness centre as part of her antenatal care visits, and now uses it to get information on what to feed her child and family. Thanks to these routine trips, Deepa knew that her child had to be given the BCG vaccine within two days of birth and that once he completed six months, he had to be fed at least five of seven essential food groups every day.

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Santosh, a truck driver, has never accompanied her on these visits because he is at work at this time. On days when he is home and the ASHA worker visits, he stays aloof. “It is embarrassing to talk about contraceptives with female health workers,” he tells us. The couple lives in a village in Samastipur district, Bihar’s sixth-largest in terms of population, with their two-year-old son and Santosh’s parents.

This gap between awareness and action — between who receives information and who drives decisions — is a running theme across rural Bihar. This is especially true when it comes to family planning and care, or other work viewed as belonging to a “female-only” domain.

Munira, 19, is among the women who pay regular visits to the health and wellness centre in her village, located about 85 km away from Patna. Here, anganwadi workers advise her on what to feed her nine-month-old daughter and how to prepare the food. Back home, she takes on the majority of the child-rearing work. She is also responsible for cooking and feeding the entire household. But the relevant information she receives at the centre does not effectively pass on to her husband Nadeem, who purchases the pulses and vegetables, or to her father-in-law, who allocates the household budget for these expenses.

The chain of communication, somewhere, is broken.

This is in part because women are not taken seriously when they share information received from female community health workers. Men either shy away from engaging with health workers or outright question their credibility. According to Reena, an anganwadi worker from a neighbouring village, when women pass on nutrition habits and related information, their families do not believe them. “Some have told me that their husbands call them liars,” she says.

How the onus of healthcare delivery came to be placed on women

In India, the National Rural Health Mission (NRHM) has shaped how we give and receive healthcare information. In 2005, the scheme instituted ASHA, the frontline worker cadre responsible for addressing issues related to reproduction and child health. Policymakers at the time determined that it was women volunteers, drawn from the community, who were best placed to address these needs. The policy significantly strengthened last-mile access to the rural population. ASHAs — alongside anganwadi workers, who run rural childcare centres and provide basic nutritional information, and auxiliary nurse midwives (ANMs), state-certified midwives who assist with childbirth and work closely with the health centres — together make up the healthcare information ecosystem in Indian villages. Women, thus, comprise the backbone of household healthcare interventions.

In the years since, policies and programmes have continued to contribute to a system where the onus of healthcare delivery continues to be placed squarely on women. At the receiving end too, women are seen as the sole audience for programmes relating to child nutrition, household health, and contraceptive use. Men continue to be left out of the conversation.

Societal norms that restrict interaction between men and women, and the historical undervaluing of women’s work, have created a barrier between men and female community health workers. Sabhya, a 23-year-old from Samastipur, leads a self-help group (SHG) that promotes livelihood-generating activity for women as well as functions as a space for resource sharing. She says that men tend to regard her opinions as coming from someone less than an expert. “When a male doctor tells them [about children’s nutrition], husbands will pay attention,” she says.

The lines have been drawn, and the roles fixed. Men take the onus of being breadwinners and handling the finances, but do not feel responsible for creating meal plans or helping with food preparation. The same goes for family planning: even as men predominantly drive the decisions, they themselves do not feel they are responsible for using contraception. According to the latest round of the National Family Health Survey (NFHS-5), half of men aged 15-49 in Bihar felt that contraceptive use was a woman’s business and a man should not have to worry about it. The time burden of paid work hardens the divide.

Delivering healthcare to couples, by couples

As part of an action research project called Engage Men, we spent six months in rural Bihar, running two learning pilots to test what happens when this established norm is reimagined. About 40 couples delivered nutrition and family planning programmes – otherwise typically by women, to women – to 2,000 households in two blocks, Samastipur and Patna. Couples were given edutainment modules on financial, family, and nutritional planning, followed by weekly checkins. Community resource persons would track children’s nutritional intake through the week and conduct refresher training sessions via household visits and digital channels.

What we found seems intuitive, but is worth highlighting: Engaging men in a meaningful manner to contribute to household decisions is central to breaking the silos through which men and women receive health information. It dismantles archaic notions about what constitutes “women’s work” and helps shift the disproportionate burden of healthcare. At the same time, it is not enough for the information to simply reach men. For an actual mindset shift, it needs to happen through trusted channels and sustained dialogue. In Sabhya’s words, “Men will listen at that moment, but then when they go home, I don’t know if their behaviour will actually change.”

Household health programmes delivered by couples to couples signal that achieving a family’s health goal is a shared responsibility. It creates deeper engagement, establishes a trusted platform for dialogue, and allows joint decision-making. In the villages where we ran the action research, couples reported an increase in instances of children meeting the Minimum Dietary Diversity; the percentage of women consuming more diverse food groups also increased by 14 percentage points. Far more women from intervention villages, compared to the control group, reported greater support from their husbands on contraceptive use and choice.

Additionally, couple frontline workers are seen as more relatable – figures that newly-wed couples can instantly connect to and comfortably converse with. Men who were part of the programme said that earlier, they used to feel alienated from female healthcare workers. Now, they were able to imagine themselves in the situation and overcome the hesitation of engaging with the subject. Such “role model” couples are also able to engage older household members who play a significant role, either through guidance or persuasion, in influencing couples’ choices.

Working as a pair also comes with benefits for the frontline workers themselves. Because they travel together, women can reach participants at distances and times of the day that would have otherwise not been possible. Additionally, couple facilitators are also able to deploy strategies – such as splitting the couple up when curious in-laws encroach on their privacy – to navigate difficult household dynamics.

Involving men helps reimagine the future of families

While the model shows promise, our interactions shone a light on some of the roadblocks to its success. For one, healthcare workers continue to be inadequately compensated for the disproportionate amount of time and energy they expend on the services. There has been considerable academic as well as media focus, especially post the pandemic, on the lack of formal recognition, safety gear, and fair pay, leaving workers in a precarious situation. This is heightened in cases of couple program delivery, where both husband and wife rely on the same work to support their family.

Additionally, healthcare workers that challenge traditional norms – such as advocating for the involvement of men in preparing feed for the child – may face backlash and reputational damage within the community. Nandini, 22, a healthcare worker who had come on board as part of the learning pilot, quit the programme after criticism from a participating couple’s family members. Even after the family members were eventually convinced, Nandini refused to rejoin. “We are doing this in service of our own community, yet there is no value for our efforts. It is discouraging that our own people don’t support us,” she said.

Supportive policies and grassroots initiatives can address these challenges to some extent. For longer-lasting results, interventions need to go deeper and weed out ingrained ideas about gender norms. And while this is an uphill task, the payoff is rewarding.

Our research findings and interactions give a glimpse of what a more gender-transformative rural India could look like, if the model is replicated in other villages. Padma, 22, reflects on the changes since program implementation. “Earlier, my husband Kamlesh used to get irritated if he had to look after our two children. After the program, when we started tracking the children’s nutrition together, he is more present. He plays with our children, shows them affection and feeds them if they have not eaten.”

Engaging men in household health conversations has shown to make spousal communication transparent and deeper. Among the couples exposed to the programme, communication about child nutrition increased by 24% points, compared to non-participating couples. Women reported a net increase of 18% points in discussing delaying or spacing pregnancies with their husbands. Several women even reported increased support from their in-laws, affording them greater agency within the marriage.

Ultimately, this can pave the way to positive household well-being and healthier relationships. Padma continues: “After my husband’s increased involvement in our children’s lives, we spend more time together. We talk about our family’s health, but also our dreams and aspirations, every night now.”

*All names have been changed to maintain anonymity and adhere to confidentiality guidelines of our research methodology.

Prerak Mehta is a partner and Zarah Udwadia is a former creative lead at Dalberg Design. They were part of the team that led the action research project Engage Men, in collaboration with Project Concern International India and with support from Bill and Melinda Gates Foundation. The views expressed are personal

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