Are the Nutrition Rehabilitation Centres serving the ‘purpose’? A study in Palghar district of Maharashtra Authors: Vidula Purohit, Prashant Kulkarni, Dr Shilpa Karvande, Rajendra Kale and Dr Nerges Mistry Background In India 4.7 million tribal children are suffering from under-nutrition (UNICEF India 2019) and Nutrition Rehabilitation Centres (NRCs) have been established to provide therapeutic nourishment and care to the under-nourished children for minimizing the severe impacts of under-nutrition on their survival, growth and development. NRCs provide in-patient care to the admitted children till they meet the defined discharge criteria such as 15% weight gain, monitor their progress for three months through four follow-up visits to NRC and conduct activities for improving skills of family caregivers regarding proper caring and feeding practices. Hence NRCs are considered as a bridge between hospital care and home care of under-nourished children. Palghar district of Maharashtra has around three million population of which 37.4% is scheduled tribe population (Census 2011). The predominantly tribal areas of Palghar have high prevalence of under-nutrition in the children aged 1-6 years (Ghosh et al 2019). The district has five NRCs across eight blocks. As a part of the larger study “Capacity building of healthcare providers from eight blocks of Palghar District, Maharashtra in maternal and newborn health care and nutrition” an exploratory study was undertaken in Palghar to understand the role of NRCs in providing services to under-nourished children. Overall aim of this study was to understand the functioning of NRCs from the tribal dominant district by-a) evaluating the outcome indicators of management of children admitted in the NRCs and b) learning about the perspectives of caregivers. Methods Monthly performance reports of the five NRCs from Palghar district for the period of April 2019 to March 2020 were reviewed and analysed. Additionally, family caregivers (n=25) of the children who availed services of NRCs were interviewed to learn about their understanding of NRC functioning and interaction with the providers at NRCs using a semi structured interview tool. Interviews’ participants recruited through convenience sampling. Results Profile of malnourished children admitted to NRCs in Palghar Children admitted in NRCs during April 2019 to March 2020 (n=948) Age group Age-Below six months of age 32 (3.4%) Age- six months to 2 years 586 (61.8%) Age-2 years to 5 years 200 (32.7%) Sex Male 486 (51.3%) Female 462 (48.7%) Caste Scheduled tribe 948 (100%) Duration of stay Less than 7 days 125 (13.2%) 7 days to 15 days 801 (84.5%) More than 15 days 22 (2.32%) Expected weight gain 15% weight gain at the time of discharge 485 (54.4%) 15% weight gain during follow-up visits 273 (30.6%) Did not gain 15% weight either at the time of discharge or during follow-up visits 134 (15.0%) Follow-up visit Completed first follow-up 761 (85.3%) Completed fourth follow-up 478 (53.6%) Family care givers (n=25) of children - who were they and what did they say? We interviewed 14 family care givers of children admitted in the NRCs and 11 family care givers who were at the NRCs for a follow-up visit of their children. A typical family care giver was a married mother with a mean age 28.43 years. She was an agricultural labour and had at least two living children. Family care givers of admitted children- Most of the family care givers (12/14) were aware that their child had to stay at the NRC for 14 days, and their stay and food arrangements would be borne by the NRC and they would get INR 100 per day towards loss of wages during the stay at NRC. Ten family care givers reported that they had received information about how to feed their child, of which only six were reportedly involved in preparing food for their children during NRC stay. They learned to prepare nutritious recipes in the form of kheer (porridge), rajgeera laddus (mixture of amaranth, sugar and ghee shaped into ball) and sprouts and were counselled to continue feeding these food items to their children after discharge. Out of 14, only two were aware that after the discharge they need to bring their child to the NRC for four follow-up visits in the span of three months. Family care givers of follow-up children- None of them (0/11) was aware that they had to bring their child to NRC for four follow-up visits in the span of three months from the NRC discharge, however most of them (10/11) knew that they should take their child to the health facility if child gets fever, cold or cough, stomach pain, diarrhoea/dysentery. Discussion and conclusion All the five NRCs from the Palghar district catered about 1000 children from April 2019 to March 2020. All the admitted children belonged to scheduled tribe with equal number of girls and boys and 61.8% of children were in the age group of six months to 2 years. It confirms that transition from breastfeeding to complementary feeding is a weak area in Palghar and calls for urgent intervention. Of the total, 85% children reported to have gained the expected 15% of weight (as per the NRC programme) either during their stay or during the follow-up visits within the span of three months from NRC discharge. However, 15% could not gain their weight which is a point of concern. Only about half of them completed all the four follow-up visits, and very few family care givers were aware of its importance. However the available data don’t provide answers to the questions such as ‘Why these 15% children couldn’t achieve expected weight gain?’ ‘What happened to the children who didn’t complete four follow-up visits?’ Hence detailed analysis is essential about these parameters of performance of NRCs and expected follow-up to keep-up the gains achieved during the stay at NRC and prevent relapse. Improving communication between NRC providers and family care givers of admitted children is vital in boosting up the facility based follow-up and home-based care to sustain improved nutritional status of children discharged from NRCs.