A little healthy parental competition can lead to healthier kids

A nudge as simple and elegant as posting individual health statistics for a village’s children on a health clinic door can go a long way toward eliminating the three leading causes of infant mortality in a developing world village: chronic starvation, diarrhea and respiratory infections. To the surprise of many, this doesn’t always require highly trained doctors or drugs.

By tapping the natural competitive instincts of fathers, Drs. Raj and Mabelle Arole designed a nudge that persuades both parents from families representing every caste background in a village to get actively involved in measures that ensure the healthy development of their children. Traditional scourges—childhood diarrhea, pneumonia, neonatal deaths, malaria, leprosy, maternal tetanus, tuberculosis—have nearly vanished from the villages where the Aroles have established their Comprehensive Rural Health Project (CRHP).

The Aroles started the program in 1970 in Jamkhed, a small city in India’s Maharashtra state. They figured that the best way to help the poor in local villages was to encourage preventative medicine, and to do this by engaging the villagers themselves.

They estimate a trained village health worker can take care of 80 percent of a village’s health issues because most problems are related to nutrition and to the environment. So they recruit a single health worker in each village who is typically an illiterate woman from the Dalit or Untouchable caste.

These health workers receive two weeks of training on CRHP’s campus in Jamkhed before beginning their duties. When they return to their villages, they are supported by a mobile team—a nurse, paramedic, social worker, and sometimes a doctor—who visit each village, initially once a week, and then tapering off as the workers gain confidence.

To track the success of the program, as well as the healthy development of children, the Aroles have the health workers weigh and assess the villager’s nutritional status and create a composite “picture” of each child’s health. Soon, villagers become accustomed to interpreting a child’s healthy growth line made on his or her own individual card.

Child rearing in India is typically a woman’s business, but because men are usually more literate, they are needed to help make regular records of each child’s growth. This becomes a regular activity that brings families together.

In the Aroles’ program, literate husbands helped illiterate wives mark cards. Together they write down the weights, heights, pulse rates, blood pressure and other details of their infants and young children. This requirement begins to involve fathers, who at first are often reluctant to get involved in child rearing, in thinking about the healthy development of their children.

One day, an enterprising health worker listed an entire village’s statistics on a poster and attached it to the front door of the village clinic—and something magical happened. Fathers from every caste began stopping by just to see how their kids were doing.

A natural competitiveness kicked in and fathers became interested in how they could elevate their child to the top of the list. The health of the village’s children went from being a private affair that fathers engaged in reluctantly to a public discussion where fathers whole-heartedly took an interest.

The health worker took this simple poster idea to a monthly network meeting in Jamkhed and the idea spread to other villages in the program, and in sister programs around the world. Thirty-eight years after its founding, the CRHP program is now run by the Aroles’ children, Shobha and Ravi, and has achieved dramatic successes.

It works in 120 villages and has trained health workers in more than 300 villages. In addition to nearly eliminating childhood diarrhoea, pneumonia, neonatal deaths, malaria, leprosy, maternal tetanus, tuberculosis, villages with a CRHP health worker have much higher rates of vaccination, and an infant mortality rate of less than half the average for rural Maharashtra.

Today, all across India almost half of all Indian children under age three are malnourished. But in villages in the CRHP program, there are not enough cases to register. A key to all these changes: a nudge that ensures fathers take a daily interest in the healthy development of their children.

The rest of the post, which contains an analysis of why this qualifies as a nudge, is here.