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Fivian E, Parida M, Harris-Fry H, Mohanty S, Padhan S, Pradhan R, Das P, Odhiambo G, Prost A, Roopnaraine T, Behera S, James P, Mishra NK, Rath S, Nair N, Rath S, Koniz-Booher P, Danton H, Allen E, Kadiyala S. Feasibility, acceptability and equity of a mobile intervention for Upscaling Participatory Action and Videos for Agriculture and Nutrition (m-UPAVAN) in rural Odisha, India. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003206. [PMID: 38743726 DOI: 10.1371/journal.pgph.0003206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 04/14/2024] [Indexed: 05/16/2024]
Abstract
Addressing undernutrition requires strategies that remove barriers to health for all. We adapted an intervention from the 'UPAVAN' trial to a mobile intervention (m-UPAVAN) during the COVID-19 pandemic in rural Odisha, India. In UPAVAN, women's groups viewed and discussed participatory videos on nutrition-specific and nutrition-sensitive agricultural (NSA) topics. In m-UPAVAN, weekly videos and audios on the same topics were disseminated via WhatsApp and an interactive voice response system. We assessed feasibility, acceptability, and equity of m-UPAVAN using a convergent parallel mixed-methods design. m-UPAVAN ran from Mar-Sept 2021 in 133 UPAVAN villages. In Feb-Mar 2021, we invited 1000 mothers of children aged 0-23 months to participate in a sociodemographic phone survey. Of those, we randomly sampled 200 mothers each month for five months for phone surveys to monitor progress against targets. Feasibility targets were met if >70% received videos/audios and >50% watched/listened at least once. Acceptability targets were met if >75% of those watching/listening liked the videos/audios and <20% opted out of the intervention. We investigated mothers' experiences of the intervention, including preferences for m-UPAVAN versus UPAVAN, using in-person, semi-structured interviews (n = 38). Of the 810 mothers we reached, 666 provided monitoring data at least once. Among these mothers, feasibility and acceptability targets were achieved. m-UPAVAN engaged whole families, which facilitated family-level discussions around promoted practices. Women valued the ability to access m-UPAVAN content on demand. This advantage did not apply to many mothers with limited phone access. Mothers highlighted that the UPAVAN interventions' in-person participatory approaches and longer videos were more conducive to learning and inclusive, and that mobile approaches provide important complementarity. We conclude that mobile NSA interventions are feasible and acceptable, can engage families, and reinforce learning. However, in-person participatory approaches remain essential for improving equity of NSA interventions. Investments are needed in developing and testing hybrid NSA interventions.
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Affiliation(s)
- Emily Fivian
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Helen Harris-Fry
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Shibanath Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapara, India
| | | | - Pranay Das
- DCOR Consulting Pvt. Ltd., Bhubaneswar, India
| | - Gladys Odhiambo
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Audrey Prost
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Philip James
- Emergency Nutrition Network (ENN), Oxford, United Kingdom
| | - Naba Kishor Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapara, India
| | | | | | | | - Peggy Koniz-Booher
- JSI Research & Training Institute, Inc. Arlington, Virginia, United States of America
| | - Heather Danton
- JSI Research & Training Institute, Inc. Arlington, Virginia, United States of America
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Suneetha Kadiyala
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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2
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Cooper GS, Davies-Kershaw H, Dominguez-Salas P, Fahmida U, Faye B, Ferguson E, Grace D, Häsler BN, Kadiyala S, Konapur A, Kulkarni B, Chengat Prakashbabu B, Pramesthi IL, Rowland D, Selvaraj K, Sudibya ARP, Tine RC, Yadav DMD, Zahra NL, Shankar B, Heffernan C. Investigating market-based opportunities for the provision of nutritious and safe diets to prevent childhood stunting: a UKRI-GCRF action against stunting hub protocol paper. BMJ Paediatr Open 2024; 8:e001671. [PMID: 38417923 PMCID: PMC10900371 DOI: 10.1136/bmjpo-2022-001671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/13/2022] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Inadequate access to affordable, safe, desirable and convenient nutrient-dense food is one of the underlying causes of child stunting. While targeted nutrition-sensitive interventions (eg, backyard 'nutri-gardens') may increase dietary diversity within farming households, such interventions have limited scalability across the wider food system where markets remain underdeveloped. This research aims to develop and assess market-based interventions for key nutrient-dense foods to help improve the diets of women and children in the first 1000 days of life. METHODS Data collection uses four parallel approaches in each of the three study countries (India, Indonesia and Senegal). (1) A novel food environment tool will be developed to characterise the accessibility and affordability of nutrient-dense foods in the study countries. The tool will be validated through pretesting using cognitive interviewing and piloting in purposively sampled households, 10 (cognitive interviewing) and 30 (piloting) households in each country; (2) stakeholder interviews (eg, with producers, intermediaries and retailers) will be conducted to map out nutrition-sensitive entry points of key value chains (eg, animal-sourced foods), before hotspots of potential food safety hazards will be identified from food samples collected along the chains; (3) the Optifood and Agrifood tools will be used to identify foods that can address food system nutrient gaps and engage key stakeholders to prioritise market interventions to improve nutrition outcomes. Optifood and Agrifood parameters will be informed by publicly available data, plus interviews and focus groups with value chain stakeholders; (4) informed by the previous three approaches and a campaign of participatory 'group model building', a novel system dynamics model will evaluate the impact of alternative market-based solutions on the availability and affordability of nutrient-dense foods over time. ETHICS AND DISSEMINATION The study has received ethical approval in the United Kingdom, Senegal, Indonesia and India. Dissemination comprises peer-reviewed journals, international disciplinary conferences and multistakeholder dissemination workshops.
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Affiliation(s)
- Gregory S Cooper
- Institute of Sustainable Food, Department of Geography, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Hilary Davies-Kershaw
- Department of Population Health, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Public Health, London, UK
| | - Paula Dominguez-Salas
- Animal and Human Health Program, International Livestock Research Institute, Nairobi, Nairobi, Kenya
- Food and Markets Department, Natural Resources Institute, University of Greenwich, London, UK
| | - Umi Fahmida
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition, Jakarta, DKI Jakarta, Indonesia
- Department of Nutrition, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Babacar Faye
- Department of Parasitology-Mycology, Cheikh Anta Diop University of Dakar, Dakar, Senegal
| | - Elaine Ferguson
- Department of Population Health, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Public Health, London, UK
| | - Delia Grace
- Animal and Human Health Program, International Livestock Research Institute, Nairobi, Nairobi, Kenya
- Food and Markets Department, Natural Resources Institute, University of Greenwich, London, UK
| | - Barbara N Häsler
- Department of Pathobiology and Population Sciences, The Royal Veterinary College, Hatfield, Hertfordshire, UK
| | - Suneetha Kadiyala
- Department of Population Health, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Public Health, London, UK
| | - Archana Konapur
- Department of Population Health, London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | - Bharati Kulkarni
- Department of Population Health, London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | | | - Indriya L Pramesthi
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition, Jakarta, DKI Jakarta, Indonesia
| | - Dominic Rowland
- Center for International Forestry Research, Bogor Barat, Indonesia
- Centre for Environment, Development and Policy (CeDEP), SOAS, London, UK
| | | | - Arienta R P Sudibya
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition, Jakarta, DKI Jakarta, Indonesia
| | - Roger C Tine
- Department of Parasitology-Mycology, Cheikh Anta Diop University of Dakar, Dakar, Senegal
| | - D M Dinesh Yadav
- Department of Population Health, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Public Health, London, UK
| | - Nur L Zahra
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition, Jakarta, DKI Jakarta, Indonesia
| | - Bhavani Shankar
- Institute of Sustainable Food, Department of Geography, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Claire Heffernan
- Department of Pathobiology and Population Sciences, The Royal Veterinary College, Hatfield, Hertfordshire, UK
- London International Development Centre, London, UK
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3
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Harris-Fry H, Prost A, Beaumont E, Fivian E, Mohanty S, Parida M, Pradhan R, Sahu S, Padhan S, Mishra NK, Rath S, Rath S, Koniz-Booher P, Allen E, Kadiyala S. Intrahousehold power inequalities and cooperation: Unpacking household responses to nutrition-sensitive agriculture interventions in rural India. MATERNAL & CHILD NUTRITION 2023:e13503. [PMID: 36939121 DOI: 10.1111/mcn.13503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/27/2023] [Accepted: 03/01/2023] [Indexed: 03/21/2023]
Abstract
Nutrition-sensitive agriculture (NSA) interventions offer a means to improve the dietary quality of rural, undernourished populations. Their effectiveness could be further increased by understanding how household dynamics enable or inhibit the uptake of NSA behaviours. We used a convergent parallel mixed-methods design to describe the links between household dynamics-specifically intrahousehold power inequalities and intrahousehold cooperation-and dietary quality and to explore whether household dynamics mediated or modified the effects of NSA interventions tested in a cluster-randomized trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN). We use quantitative data from cross-sectional surveys in 148 village clusters at UPAVAN's baseline and 32 months afterwards (endline), and qualitative data from family case studies and focus group discussions with intervention participants and facilitators. We found that households cooperated to grow and buy nutritious foods, and gendered power inequalities were associated with women's dietary quality, but cooperation and women's use of power was inhibited by several interlinked factors. UPAVAN interventions were more successful in more supportive, cooperative households, and in some cases, the interventions increased women's decision-making power. However, women's decisions to enter into negotiations with family members depended on whether women deemed the practices promoted by UPAVAN interventions to be feasible, as well as women's confidence and previous cultivation success. We conclude that interventions may be more effective if they can elicit cooperation from the whole household. This will require a move towards more family-centric intervention models that empower women while involving other family members and accounting for the varied ways that families cooperate and negotiate.
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Affiliation(s)
- Helen Harris-Fry
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Audrey Prost
- Institute for Global Health, University College London, London, UK
| | - Emma Beaumont
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Manoj Parida
- DCOR (Development Corner) Consulting Pvt. Ltd., Bhubaneswar, India
| | | | | | - Shibanath Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology, Kendrapara, India
| | - Naba K Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology, Kendrapara, India
| | | | | | | | - Elizabeth Allen
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Suneetha Kadiyala
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Hoft G, Forseth B, Trofimoff A, Bangash M, Davis AM. Barriers to Participation in a Telemedicine-based, Family-based Behavioral Group Treatment Program for Pediatric Obesity: Qualitative findings from Rural Caregivers. CHILDRENS HEALTH CARE 2023; 53:60-75. [PMID: 38239336 PMCID: PMC10794019 DOI: 10.1080/02739615.2023.2189116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
This study examined factors influencing rural caregivers' decision to decline participation in a healthy lifestyle intervention. Eligible caregivers of rural children who declined participation in a healthy lifestyle intervention were interviewed regarding reasons for declining. Inductive thematic analyses were conducted for responses. Caregiver interviews (n=16) resulted in 5 saturated themes: (1) rural families' household schedules prohibit participation, (2) preference for diverse treatment approaches, (3) desire for information across multimedia platforms, and more communication with a point-of-contact, (4) support for an inclusive approach integrated with existing school practices, and (5) caregivers had an understanding of behaviors that promote health.
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Affiliation(s)
- Galen Hoft
- Center for Children’s Healthy Lifestyles & Nutrition – Department of Pediatrics - University of Kansas Medical Center - Kansas City, Kansas
- Kansas City University of Medicine and Biosciences – Kansas City, Missouri
| | - Bethany Forseth
- Center for Children’s Healthy Lifestyles & Nutrition – Department of Pediatrics - University of Kansas Medical Center - Kansas City, Kansas
| | - Anna Trofimoff
- Center for Children’s Healthy Lifestyles & Nutrition – Department of Pediatrics - University of Kansas Medical Center - Kansas City, Kansas
| | - Maheen Bangash
- Center for Children’s Healthy Lifestyles & Nutrition – Department of Pediatrics - University of Kansas Medical Center - Kansas City, Kansas
| | - Ann M. Davis
- Center for Children’s Healthy Lifestyles & Nutrition – Department of Pediatrics - University of Kansas Medical Center - Kansas City, Kansas
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Prost A, Harris‐Fry H, Mohanty S, Parida M, Krishnan S, Fivian E, Rath S, Nair N, Mishra NK, Padhan S, Pradhan R, Sahu S, Skordis J, Danton H, Koniz‐Booher P, Beaumont E, James P, Allen E, Elbourne D, Kadiyala S. Understanding the effects of nutrition‐sensitive agriculture interventions with participatory videos and women's group meetings on maternal and child nutrition in rural Odisha, India: A mixed‐methods process evaluation. MATERNAL & CHILD NUTRITION 2022; 18:e13398. [PMID: 35851750 PMCID: PMC9480959 DOI: 10.1111/mcn.13398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 05/14/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022]
Abstract
A trial of three nutrition‐sensitive agriculture interventions with participatory videos and women's group meetings in rural Odisha, India, found improvements in maternal and child dietary diversity, limited effects on agricultural production, and no effects on women and children's nutritional status. Our process evaluation explored fidelity, reach, and mechanisms behind interventions' effects. We also examined how context affected implementation, mechanisms, and outcomes. We used data from intervention monitoring systems, review notes, trial surveys, 32 case studies with families (n = 91 family members), and 20 group discussions with women's group members and intervention workers (n = 181 and 32, respectively). We found that interventions were implemented with high fidelity. Groups reached around half of the mothers of children under 2 years. Videos and meetings increased women's knowledge, motivation and confidence to suggest or make changes to their diets and agricultural production. Families responded in diverse ways. Many adopted or improved rainfed homestead garden cultivation for consumption, which could explain gains in maternal and child dietary diversity seen in the impact evaluation. Cultivation for income was less common. This was often due to small landholdings, poor access to irrigation and decision‐making dominated by men. Interventions helped change norms about heavy work during pregnancy, but young women with little family support still did considerable work. Women's ability to shape cultivation, income and workload decisions was strongly influenced by support from male relatives. Future nutrition‐sensitive agriculture interventions could include additional flexibility to address families’ land, water, labour and time constraints, as well as actively engage with spouses and in‐laws. In rural eastern India, participatory videos and women's group meetings on agriculture and maternal and child nutrition increased women's knowledge, motivation and confidence to improve their and their children's diets. Given strong constraints linked to small landholdings, poor access to water and gender norms which meant that in‐laws' and husbands' assent or support were often required for cultivation decisions, many women responded to interventions by increasing rainfed homestead garden cultivation for consumption rather than cultivating for income. Women's and children's diets may have improved because of discussions about nutrition and an increase in homestead garden cultivation. These dietary changes alone were likely insufficient to improve women's and children's nutritional status. The interventions’ ability to influence the adoption of nutrition‐sensitive agriculture practices could be improved by being family‐centric: understanding women's decision‐making power in a family context, using tailored problem‐solving to address households' individual constraints to cultivation, and including women's husbands and in‐laws.
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Affiliation(s)
- Audrey Prost
- Institute for Global Health University College London London UK
| | - Helen Harris‐Fry
- Department of Population Health London School of Hygiene & Tropical Medicine London UK
| | | | | | - Sneha Krishnan
- Jindal School of Environment and Sustainability Jindal Global University Haryana India
| | - Emily Fivian
- Department of Population Health London School of Hygiene & Tropical Medicine London UK
| | | | | | - Naba K. Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT) Kendrapara India
| | - Shibanath Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT) Kendrapara India
| | | | | | - Jolene Skordis
- Institute for Global Health University College London London UK
| | - Heather Danton
- JSI Research & Training Institute, Inc. Arlington Virginia USA
| | | | - Emma Beaumont
- Department of Medical Statistics London School of Hygiene & Tropical Medicine London UK
| | - Philip James
- Department of Population Health London School of Hygiene & Tropical Medicine London UK
| | - Elizabeth Allen
- Department of Medical Statistics London School of Hygiene & Tropical Medicine London UK
| | - Diana Elbourne
- Department of Medical Statistics London School of Hygiene & Tropical Medicine London UK
| | - Suneetha Kadiyala
- Department of Population Health London School of Hygiene & Tropical Medicine London UK
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6
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Haghparast-Bidgoli H, Harris-Fry H, Kumar A, Pradhan R, Mishra NK, Padhan S, Ojha AK, Mishra SN, Fivian E, James P, Ferguson S, Krishnan S, O'Hearn M, Palmer T, Koniz-Booher P, Danton H, Minovi S, Mohanty S, Rath S, Rath S, Nair N, Tripathy P, Prost A, Allen E, Skordis J, Kadiyala S. Economic Evaluation of Nutrition-Sensitive Agricultural Interventions to Increase Maternal and Child Dietary Diversity and Nutritional Status in Rural Odisha, India. J Nutr 2022; 152:2255-2268. [PMID: 35687367 PMCID: PMC9535442 DOI: 10.1093/jn/nxac132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/01/2021] [Accepted: 06/04/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Economic evaluations of nutrition-sensitive agriculture (NSA) interventions are scarce, limiting assessment of their potential affordability and scalability. OBJECTIVES We conducted cost-consequence analyses of 3 participatory video-based interventions of fortnightly women's group meetings using the following platforms: 1) NSA videos; 2) NSA and nutrition-specific videos; or 3) NSA videos with a nutrition-specific participatory learning and action (PLA) cycle. METHODS Interventions were tested in a 32-mo, 4-arm cluster-randomized controlled trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) in the Keonjhar district, Odisha, India. Impacts were evaluated in children aged 0-23 mo and their mothers. We estimated program costs using data collected prospectively from expenditure records of implementing and technical partners and societal costs using expenditure assessment data collected from households with a child aged 0-23 mo and key informant interviews. Costs were adjusted for inflation, discounted, and converted to 2019 US$. RESULTS Total program costs of each intervention ranged from US$272,121 to US$386,907. Program costs per pregnant woman or mother of a child aged 0-23 mo were US$62 for NSA videos, US$84 for NSA and nutrition-specific videos, and US$78 for NSA videos with PLA (societal costs: US$125, US$143, and US$122, respectively). Substantial shares of total costs were attributable to development and delivery of the videos and PLA (52-69%) and quality assurance (25-41%). Relative to control, minimum dietary diversity was higher in the children who underwent the interventions incorporating nutrition-specific videos and PLA (adjusted RRs: 1.19 and 1.27; 95% CIs: 1.03-1.37 and 1.11, 1.46, respectively). Relative to control, minimum dietary diversity in mothers was higher in those who underwent NSA video (1.21 [1.01, 1.45]) and NSA with PLA (1.30 [1.10, 1.53]) interventions. CONCLUSION NSA videos with PLA can increase both maternal and child dietary diversity and have the lowest cost per unit increase in diet diversity. Building on investments made in developing UPAVAN, cost-efficiency at scale could be increased with less intensive monitoring, reduced startup costs, and integration within existing government programs. This trial was registered at clinicaltrials.gov as ISRCTN65922679.
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Affiliation(s)
| | - Helen Harris-Fry
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Naba Kishore Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapada, Odisha, India
| | - Shibananth Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapada, Odisha, India
| | | | - Sailendra Narayan Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapada, Odisha, India
| | - Emily Fivian
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Philip James
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Sneha Krishnan
- Jindal School of Environment and Sustainability, OP Jindal Global University and ETCH Consultancy Services, Mumbai, Maharashtra, India
| | - Meghan O'Hearn
- Tufts University Friedman School of Nutrition Science and Policy, Boston, MA, USA
| | - Tom Palmer
- University College London, Institute for Global Health, London, United Kingdom
| | | | - Heather Danton
- SI Research & Training Institute, Inc. Arlington, VA, USA
| | - Sandee Minovi
- SI Research & Training Institute, Inc. Arlington, VA, USA
| | | | | | | | | | | | - Audrey Prost
- University College London, Institute for Global Health, London, United Kingdom
| | - Elizabeth Allen
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jolene Skordis
- University College London, Institute for Global Health, London, United Kingdom
| | - Suneetha Kadiyala
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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7
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Saville NM, Kharel C, Morrison J, Harris-Fry H, James P, Copas A, Giri S, Arjyal A, Beard BJ, Haghparast-Bidgoli H, Skordis J, Richter A, Baral S, Hillman S. Comprehensive Anaemia Programme and Personalized Therapies (CAPPT): protocol for a cluster-randomised controlled trial testing the effect women's groups, home counselling and iron supplementation on haemoglobin in pregnancy in southern Nepal. Trials 2022; 23:183. [PMID: 35232469 PMCID: PMC8886560 DOI: 10.1186/s13063-022-06043-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 01/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anaemia in pregnancy remains prevalent in Nepal and causes severe adverse health outcomes. METHODS This non-blinded cluster-randomised controlled trial in the plains of Nepal has two study arms: (1) Control: routine antenatal care (ANC); (2) Home visiting, iron supplementation, Participatory Learning and Action (PLA) groups, plus routine ANC. Participants, including women in 54 non-contiguous clusters (mean 2582; range 1299-4865 population) in Southern Kapilbastu district, are eligible if they consent to menstrual monitoring, are resident, married, aged 13-49 years and able to respond to questions. After 1-2 missed menses and a positive pregnancy test, consenting women < 20 weeks' gestation, who plan to reside locally for most of the pregnancy, enrol into trial follow-up. Interventions comprise two home-counselling visits (at 12-21 and 22-26 weeks' gestation) with iron folic acid (IFA) supplement dosage tailored to women's haemoglobin concentration, plus monthly PLA women's group meetings using a dialogical problem-solving approach to engage pregnant women and their families. Home visits and PLA meetings will be facilitated by auxiliary nurse midwives. The hypothesis is as follows: Haemoglobin of women at 30 ± 2 weeks' gestation is ≥ 0.4 g/dL higher in the intervention arm than in the control. A sample of 842 women (421 per arm, average 15.6 per cluster) will provide 88% power, assuming SD 1.2, ICC 0.09 and CV of cluster size 0.27. Outcomes are captured at 30 ± 2 weeks gestation. Primary outcome is haemoglobin concentration (g/dL). Secondary outcomes are as follows: anaemia prevalence (%), mid-upper arm circumference (cm), mean probability of micronutrient adequacy (MPA) and number of ANC visits at a health facility. Indicators to assess pathways to impact include number of IFA tablets consumed during pregnancy, intake of energy (kcal/day) and dietary iron (mg/day), a score of bioavailability-enhancing behaviours and recall of one nutrition knowledge indicator. Costs and cost-effectiveness of the intervention will be estimated from a provider perspective. Using constrained randomisation, we allocated clusters to study arms, ensuring similarity with respect to cluster size, ethnicity, religion and distance to a health facility. Analysis is by intention-to-treat at the individual level, using mixed-effects regression. DISCUSSION Findings will inform Nepal government policy on approaches to increase adherence to IFA, improve diets and reduce anaemia in pregnancy. TRIAL REGISTRATION ISRCTN 12272130 .
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Affiliation(s)
- Naomi M Saville
- Institute for Global Health, University College London (UCL), London, UK.
| | | | - Joanna Morrison
- Institute for Global Health, University College London (UCL), London, UK
| | - Helen Harris-Fry
- Department of Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Philip James
- Department of Population Health, London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Andrew Copas
- Institute for Global Health, University College London (UCL), London, UK
| | - Santosh Giri
- HERD International, Thapathali, Kathmandu, Nepal
| | | | | | | | - Jolene Skordis
- Institute for Global Health, University College London (UCL), London, UK
| | - Adam Richter
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Sushil Baral
- HERD International, Thapathali, Kathmandu, Nepal.,Health Research and Social Development Forum (HERD), Kathmandu, Nepal
| | - Sara Hillman
- Institute for Women's Health, University College London (UCL), London, UK
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8
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Cooper GS, Shankar B, Rich KM, Ratna NN, Alam MJ, Singh N, Kadiyala S. Can fruit and vegetable aggregation systems better balance improved producer livelihoods with more equitable distribution? WORLD DEVELOPMENT 2021; 148:105678. [PMID: 34866757 PMCID: PMC8520944 DOI: 10.1016/j.worlddev.2021.105678] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 05/03/2023]
Abstract
The need for food systems to generate sustainable and equitable benefits for all is a global imperative. However, whilst ample evidence exists linking smallholder farmer coordination and aggregation (i.e. the collective transport and marketing of produce on behalf of multiple farmers) to improved market participation and farmer incomes, the extent to which interventions that aim to improve farmer market engagement may co-develop equitable consumer benefits remains uncertain. This challenge is pertinent to the horticultural systems of South Asia, where the increasing purchasing power of urban consumers, lengthening urban catchments, underdeveloped rural infrastructures and inadequate local demands combine to undermine the delivery of fresh fruits and vegetables to smaller, often rural or semi-rural markets serving nutritionally insecure populations. To this end, we investigate the potential for aggregation to be developed to increase fruit and vegetable delivery to these neglected smaller markets, whilst simultaneously improving farmer returns. Using an innovative system dynamics modelling approach based on an aggregation scheme in Bihar, India, we identify potential trade-offs between outcomes relating to farmers and consumers in smaller local markets. We find that changes to aggregation alone (i.e. scaling-up participation; subsidising small market transportation; mandating quotas for smaller markets) are unable to achieve significant improvements in smaller market delivery without risking reduced farmer participation in aggregation. Contrastingly, combining aggregation with the introduction of market-based cold storage and measures that boost demand improves fruit and vegetable availability significantly in smaller markets, whilst avoiding farmer-facing trade-offs. Critically, our study emphasises the benefits that may be attained from combining multiple nutrition-sensitive market interventions, and stresses the need for policies that narrow the fruit and vegetable cold storage deficits that exist away from more lucrative markets in developing countries. The future pathways and policy options discovered work towards making win-win futures for farmers and disadvantaged consumers a reality.
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Affiliation(s)
- G S Cooper
- Institute for Sustainable Food and Department of Geography, University of Sheffield, Sheffield, United Kingdom
| | - B Shankar
- Institute for Sustainable Food and Department of Geography, University of Sheffield, Sheffield, United Kingdom
| | - K M Rich
- Ferguson College of Agriculture, Oklahoma State University, Stillwater, OK, USA
- International Livestock Research Institute (ILRI), West Africa Regional Office, Dakar, Senegal
| | - N N Ratna
- Department of Global Value Chain & Trade, Faculty of Agribusiness and Commerce, Lincoln University, Christchurch, New Zealand
| | - M J Alam
- Department of Agribusiness and Marketing, Bangladesh Agricultural University (BAU), Mymensingh, Bangladesh
| | - N Singh
- Digital Green, North India Office, New Delhi, India
| | - S Kadiyala
- Department for Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
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9
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O'Donovan J, Thompson A, Stiles C, Opintan JA, Kabali K, Willis I, Mutimba ME, Nalweyiso E, Mugabi H, Kateete DP, Ameniko M, Govina G, Weberman R, O'Neil E, Winters N, Mutreja A. Participatory approaches, local stakeholders and cultural relevance facilitate an impactful community-based project in Uganda. Health Promot Int 2021; 35:1353-1368. [PMID: 32068865 PMCID: PMC7785315 DOI: 10.1093/heapro/daz127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Sanitation is a major global challenge that is often addressed at national and international levels, while community opinions and beliefs are neglected. To promote water, sanitation and hygiene (WASH) we organized a cross-cultural knowledge exchange workshop to assess participatory methods for engaging local stakeholders. The workshop included 22 participants from all sectors of society. Practical solutions to sanitation challenges were identified and later shared with a local community. Qualitative and quantitative analyses were used to assess impact and showed participatory methods were highly valued to encourage information sharing among widely varied stakeholders, and that video was a particularly successful approach when engaging with local communities. An 8-month follow-up survey of village members revealed excellent information recall, positive behaviour changes and a desire for future visits. Our evidence suggests that community-based participation helped identify solutions to WASH issues affecting rural communities in resource-poor settings. Engaging in a multicultural knowledge-share was particularly valuable as it enabled participants to recognize they have common challenges and allowed them to share low-cost solutions from their different communities. Our use of video was widely viewed as an ideal means of circulating findings, as it communicated information to people with a wide variety of community roles and to all age groups. Its relevance was increased by adopting a culturally appropriate context by involving local communities in workshop activities. We recommend that research in low- and middle-income countries should be mindful of the environmental context in which WASH is implemented, and encourage acceptance by engaging with communities through the use of varied participatory methods.
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Affiliation(s)
- James O'Donovan
- Department of Education, University of Oxford, Oxford, UK.,Division of Research & Global Health Equity, Omni Med, Mukono, Mukono District, Uganda
| | - Andrew Thompson
- Department of Medicine, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | - Christina Stiles
- Division of Research & Global Health Equity, Omni Med, Mukono, Mukono District, Uganda.,Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Japheth A Opintan
- Department of Medical Microbiology, University of Ghana, Korle-Bu, Ghana
| | - Ken Kabali
- Division of Research & Global Health Equity, Omni Med, Mukono, Mukono District, Uganda
| | - Ian Willis
- Department of Medicine, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | | | | | - Henry Mugabi
- Division of Community Services, Omni Med, Mukono, Mukono District, Uganda
| | - David P Kateete
- Makerere University School of Health Sciences, Makerere University, Kampala, Uganda
| | | | - George Govina
- Community Health Water and Sanitation Agency, Accra, Ghana
| | - Rachel Weberman
- University of Illinois College of Medicine-Peoria, Peoria, IL, USA
| | - Edward O'Neil
- Division of Research & Global Health Equity, Omni Med, Mukono, Mukono District, Uganda.,Department of Emergency Medicine, St. Elizabeth's Medical Center, Boston, MA, USA
| | - Niall Winters
- Department of Education, University of Oxford, Oxford, UK
| | - Ankur Mutreja
- Department of Medicine, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
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10
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Harris-Fry H, O'Hearn M, Pradhan R, Krishnan S, Nair N, Rath S, Rath S, Koniz-Booher P, Danton H, Aakesson A, Pradhan S, Mishra NK, Kumar A, Upadhay A, Prost A, Kadiyala S. How to design a complex behaviour change intervention: experiences from a nutrition-sensitive agriculture trial in rural India. BMJ Glob Health 2021; 5:bmjgh-2020-002384. [PMID: 32513863 PMCID: PMC7282327 DOI: 10.1136/bmjgh-2020-002384] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 11/06/2022] Open
Abstract
Many public health interventions aim to promote healthful behaviours, with varying degrees of success. With a lack of existing empirical evidence on the optimal number or combination of behaviours to promote to achieve a given health outcome, a key challenge in intervention design lies in deciding what behaviours to prioritise, and how best to promote them. We describe how key behaviours were selected and promoted within a multisectoral nutrition-sensitive agriculture intervention that aimed to address maternal and child undernutrition in rural India. First, we formulated a Theory of Change, which outlined our hypothesised impact pathways. To do this, we used the following inputs: existing conceptual frameworks, published empirical evidence, a feasibility study, formative research and the intervention team’s local knowledge. Then, we selected specific behaviours to address within each impact pathway, based on our formative research, behaviour change models, local knowledge and community feedback. As the intervention progressed, we mapped each of the behaviours against our impact pathways and the transtheoretical model of behaviour change, to monitor the balance of behaviours across pathways and along stages of behaviour change. By collectively agreeing on definitions of complex concepts and hypothesised impact pathways, implementing partners were able to communicate clearly between each other and with intervention participants. Our intervention was iteratively informed by continuous review, by monitoring implementation against targets and by integrating community feedback. Impact and process evaluations will reveal whether these approaches are effective for improving maternal and child nutrition, and what the effects are on each hypothesised impact pathway.
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Affiliation(s)
- Helen Harris-Fry
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Meghan O'Hearn
- Friedman School of Nutrition Science and Policy, Tufts University, Medford, Massachusetts, USA
| | | | - Sneha Krishnan
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | | | | | | | | | | | - Audrey Prost
- University College London Institute of Child Health, London, UK
| | - Suneetha Kadiyala
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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11
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Kadiyala S, Harris-Fry H, Pradhan R, Mohanty S, Padhan S, Rath S, James P, Fivian E, Koniz-Booher P, Nair N, Haghparast-Bidgoli H, Mishra NK, Rath S, Beaumont E, Danton H, Krishnan S, Parida M, O'Hearn M, Kumar A, Upadhyay A, Tripathy P, Skordis J, Sturgess J, Elbourne D, Prost A, Allen E. Effect of nutrition-sensitive agriculture interventions with participatory videos and women's group meetings on maternal and child nutritional outcomes in rural Odisha, India (UPAVAN trial): a four-arm, observer-blind, cluster-randomised controlled trial. Lancet Planet Health 2021; 5:e263-e276. [PMID: 33811818 PMCID: PMC8099729 DOI: 10.1016/s2542-5196(21)00001-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 05/04/2023]
Abstract
BACKGROUND Almost a quarter of the world's undernourished people live in India. We tested the effects of three nutrition-sensitive agriculture (NSA) interventions on maternal and child nutrition in India. METHODS We did a parallel, four-arm, observer-blind, cluster-randomised trial in Keonjhar district, Odisha, India. A cluster was one or more villages with a combined minimum population of 800 residents. The clusters were allocated 1:1:1:1 to a control group or an intervention group of fortnightly women's groups meetings and household visits over 32 months using: NSA videos (AGRI group); NSA and nutrition-specific videos (AGRI-NUT group); or NSA videos and a nutrition-specific participatory learning and action (PLA) cycle meetings and videos (AGRI-NUT+PLA group). Primary outcomes were the proportion of children aged 6-23 months consuming at least four of seven food groups the previous day and mean maternal body-mass index (BMI). Secondary outcomes were proportion of mothers consuming at least five of ten food groups and child wasting (proportion of children with weight-for-height Z score SD <-2). Outcomes were assessed in children and mothers through cross-sectional surveys at baseline and at endline, 36 months later. Analyses were by intention to treat. Participants and intervention facilitators were not blinded to allocation; the research team were. This trial is registered at ISRCTN, ISRCTN65922679. FINDINGS 148 of 162 clusters assessed for eligibility were enrolled and randomly allocated to trial groups (37 clusters per group). Baseline surveys took place from Nov 24, 2016, to Jan 24, 2017; clusters were randomised from December, 2016, to January, 2017; and interventions were implemented from March 20, 2017, to Oct 31, 2019, and endline surveys done from Nov 19, 2019, to Jan 12, 2020, in an average of 32 households per cluster. All clusters were included in the analyses. There was an increase in the proportion of children consuming at least four of seven food groups in the AGRI-NUT (adjusted relative risk [RR] 1·19, 95% CI 1·03 to 1·37, p=0·02) and AGRI-NUT+PLA (1·27, 1·11 to 1·46, p=0·001) groups, but not AGRI (1·06, 0·91 to 1·23, p=0·44), compared with the control group. We found no effects on mean maternal BMI (adjusted mean differences vs control, AGRI -0·05, -0·34 to 0·24; AGRI-NUT 0·04, -0·26 to 0·33; AGRI-NUT+PLA -0·03, -0·3 to 0·23). An increase in the proportion of mothers consuming at least five of ten food groups was seen in the AGRI (adjusted RR 1·21, 1·01 to 1·45) and AGRI-NUT+PLA (1·30, 1·10 to 1·53) groups compared with the control group, but not in AGRI-NUT (1·16, 0·98 to 1·38). We found no effects on child wasting (adjusted RR vs control, AGRI 0·95, 0·73 to 1·24; AGRI-NUT 0·96, 0·72 to 1·29; AGRI-NUT+PLA 0·96, 0·73 to 1·26). INTERPRETATION Women's groups using combinations of NSA videos, nutrition-specific videos, and PLA cycle meetings improved maternal and child diet quality in rural Odisha, India. These components have been implemented separately in several low-income settings; effects could be increased by scaling up together. FUNDING Bill & Melinda Gates Foundation, UK AID from the UK Government, and US Agency for International Development.
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Affiliation(s)
- Suneetha Kadiyala
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
| | - Helen Harris-Fry
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Shibanath Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology, Kendrapara, India
| | | | - Philip James
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emily Fivian
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Naba Kishor Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology, Kendrapara, India
| | | | - Emma Beaumont
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Sneha Krishnan
- Environment, Technology and Community Health Consultancy Service, Mumbai, India; Jindal School of Environment and Sustainability, Jindal Global University, Haryana, India
| | | | - Meghan O'Hearn
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | | | | | | | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Joanna Sturgess
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Diana Elbourne
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Audrey Prost
- Institute for Global Health, University College London, London, UK
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
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12
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Mehta KM, Irani L, Chaudhuri I, Mahapatra T, Schooley J, Srikantiah S, Abdalla S, Ward V, Carmichael SL, Bentley J, Creanga A, Wilhelm J, Tarigopula UK, Bhattacharya D, Atmavilas Y, Nanda P, Weng Y, Pepper KT, Darmstadt GL. Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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13
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Mehta KM, Irani L, Chaudhuri I, Mahapatra T, Schooley J, Srikantiah S, Abdalla S, Ward VC, Carmichael SL, Bentley J, Creanga A, Wilhelm J, Tarigopula UK, Bhattacharya D, Atmavilas Y, Nanda P, Weng Y, Pepper KT, Darmstadt GL. Health impact of self-help groups scaled-up statewide in Bihar, India. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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14
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Mehta KM, Irani L, Chaudhuri I, Mahapatra T, Schooley J, Srikantiah S, Abdalla S, Ward VC, Carmichael SL, Bentley J, Creanga A, Wilhelm J, Tarigopula UK, Bhattacharya D, Atmavilas Y, Nanda P, Weng Y, Pepper KT, Darmstadt GL. Health impact of self-help groups scaled-up statewide in Bihar, India. J Glob Health 2020; 10:021006. [PMID: 33425330 PMCID: PMC7761401 DOI: 10.7189/jogh.10.021006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The objective of this study was to assess the impact of self-help groups (SHGs) and subsequent scale-up on reproductive, maternal, newborn, child health, and nutrition (RMNCHN) and sanitation outcomes among marginalised women in Bihar, India from 2014-2017. METHODS We examined RMNCHN and sanitation behaviors in women who were members of any SHGs compared to non-members, without differentiating between types of SHGs. We analysed annual surveys across 38 districts of Bihar covering 62 690 women who had a live birth in the past 12 months. All analyses utilised data from Community-based Household Surveys (CHS) rounds 6-9 collected in 2014-2017 by CARE India as part of the Bihar Technical Support Program funded by the Bill & Melinda Gates Foundation. We examined 66 RMNCHN and sanitation indicators using survey logistic regression; the comparison group in all cases was age-comparable women from the geographic contexts of the SHG members but who did not belong to SHGs. We also examined links between discussion topics in SHGs and changes in relevant behaviours, and stratification of effects by parity and mother's age. RESULTS SHG members had higher odds compared to non-SHG members for 60% of antenatal care indicators, 22% of delivery indicators, 70% of postnatal care indicators, 50% of nutrition indicators, 100% of family planning and sanitation indicators and no immunisation indicators measured. According to delivery platform, most FLW performance indicators (80%) had increased odds, followed by maternal behaviours (57%) and facility care and outreach service delivery (22%) compared to non-SHG members. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours. Younger SHG members (<25 years) had attenuated health indicators compared to older group members (≥25 years), and women with more children had more positive indicators compared to women with fewer children. CONCLUSIONS SHG membership was associated with improved RMNCHN and sanitation indicators at scale in Bihar, India. Further work is needed to understand the specific impacts of health layering upon SHGs. Working through SHGs is a promising vehicle for improving primary health care. STUDY REGISTRATION ClinicalTrials.gov number NCT02726230.
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Affiliation(s)
- Kala M Mehta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | | | - Indrajit Chaudhuri
- Project Concern International, Delhi, India and San Diego, California, USA
| | | | - Janine Schooley
- Project Concern International, Delhi, India and San Diego, California, USA
| | | | - Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Victoria C Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jason Bentley
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andreea Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jess Wilhelm
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | - Priya Nanda
- Bill and Melinda Gates Foundation, Delhi, India
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
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15
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Mehta KM, Irani L, Chaudhuri I, Mahapatra T, Schooley J, Srikantiah S, Abdalla S, Ward V, Carmichael SL, Bentley J, Creanga A, Wilhelm J, Tarigopula UK, Bhattacharya D, Atmavilas Y, Nanda P, Weng Y, Pepper KT, Darmstadt GL. Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India. J Glob Health 2020; 10:021007. [PMID: 33425331 PMCID: PMC7759023 DOI: 10.7189/jogh.10.021007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs. METHODS A model for health layering of SHGs - Parivartan - was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKA+HL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering (Pavivartan SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression. RESULTS In 2014, 64% of indicators were significantly higher in Parivartan members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members (Parivartan or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks. CONCLUSIONS Health layering of SHGs was demonstrated by an NGO-led model (Parivartan), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change. STUDY REGISTRATION ClinicalTrials.gov number NCT02726230.
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Affiliation(s)
- Kala M Mehta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | | | - Indrajit Chaudhuri
- Project Concern International, Delhi, India and San Diego, California, USA
| | | | - Janine Schooley
- Project Concern International, Delhi, India and San Diego, California, USA
| | | | - Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Victoria Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jason Bentley
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andreea Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jess Wilhelm
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | - Priya Nanda
- Bill and Melinda Gates Foundation, Delhi, India
| | - Yingjie Weng
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
- Center for Population Health Sciences, Stanford University School of Medicine, Palo Alto, California, USA
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16
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Harris-Fry H, Krishnan S, Beaumont E, Prost A, Gouda S, Mohanty S, Pradhan R, Rath S, Rath S, Pradhan S, Mishra NK, Allen E, Kadiyala S. Agricultural and empowerment pathways from land ownership to women's nutrition in India. MATERNAL AND CHILD NUTRITION 2020; 16:e12995. [PMID: 32196969 PMCID: PMC7507043 DOI: 10.1111/mcn.12995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/19/2020] [Accepted: 03/05/2020] [Indexed: 11/26/2022]
Abstract
Land size is an important equity concern for the design of ‘nutrition‐sensitive’ agricultural interventions. We unpack some of the pathways between land and nutrition using a cross‐sectional baseline survey data set of 4,480 women from 148 clusters from the ‘Upscaling Participatory Action and Videos for Agriculture and Nutrition’ trial in Keonjhar district in Odisha, India. Variables used are household ln‐land size owned (exposure) and maternal dietary diversity score out of 10 food groups and body mass index (BMI; kg/m2) (outcomes); and mediators investigated are production diversity score, value of agricultural production, and indicators for women's empowerment (decision‐making in agriculture, group participation, work‐free time and land ownership). We assessed mediation using a non‐parametric potential outcomes framework method. Land size positively affects maternal dietary diversity scores [β 0.047; 95% confidence interval (CI) (0.011, 0.082)] but not BMI. Production diversity, but not value of production, accounts for 17.6% of total effect mediated. We observe suppression of the effect of land size on BMI, with no evidence of a direct effect for either of the agricultural mediators but indirect effects of β −0.031 [95% CI (−0.048, −0.017)] through production diversity and β −0.047 [95% CI (−0.075, −0.021)] through value of production. An increase in land size positively affects women's decision‐making, which in turn negatively affects maternal BMI. The positive effect of work‐free time on maternal BMI is suppressed by the negative effect of household land size on work‐free time. Agriculture interventions must consider land quality, women's decision‐making and implications for women's workload in their design.
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Affiliation(s)
- Helen Harris-Fry
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Sneha Krishnan
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Beaumont
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Audrey Prost
- Institute for Global Health, University College London, London, UK
| | | | | | | | | | | | - Shibnath Pradhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology, Keonjhar, India
| | - Naba Kishore Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology, Keonjhar, India
| | - Elizabeth Allen
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Suneetha Kadiyala
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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17
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Haghparast-Bidgoli H, Skordis J, Harris-Fry H, Krishnan S, O'Hearn M, Kumar A, Pradhan R, Mishra NK, Upadhyay A, Pradhan S, Ojha AK, Cunningham S, Rath S, Palmer T, Koniz-Booher P, Kadiyala S. Protocol for the cost-consequence and equity impact analyses of a cluster randomised controlled trial comparing three variants of a nutrition-sensitive agricultural extension intervention to improve maternal and child dietary diversity and nutritional status in rural Odisha, India (UPAVAN trial). Trials 2019; 20:287. [PMID: 31133067 PMCID: PMC6537168 DOI: 10.1186/s13063-019-3388-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 05/02/2019] [Indexed: 11/18/2022] Open
Abstract
Background Undernutrition causes around 3.1 million child deaths annually, around 45% of all child deaths. India has one of the highest proportions of maternal and child undernutrition globally. To accelerate reductions in undernutrition, nutrition-specific interventions need to be coupled with nutrition-sensitive programmes that tackle the underlying causes of undernutrition. This paper describes the planned economic evaluation of the UPAVAN trial, a four-arm, cluster randomised controlled trial that tests the nutritional and agricultural impacts of an innovative agriculture extension platform of women’s groups viewing videos on nutrition-sensitive agriculture practices, coupled with a nutrition-specific behaviour-change intervention of videos on nutrition, and a participatory learning and action approach. Methods The economic evaluation of the UPAVAN interventions will be conducted from a societal perspective, taking into account all costs incurred by the implementing agency (programme costs), community and health care providers, and participants and their households, and all measurable outcomes associated with the interventions. All direct and indirect costs, including time costs and donated goods, will be estimated. The economic evaluation will take the form of a cost-consequence analysis, comparing incremental costs and incremental changes in the outcomes of the interventions, compared with the status quo. Robustness of the results will be assessed through a series of sensitivity analyses. In addition, an analysis of the equity impact of the interventions will be conducted. Discussion Evidence on the cost and cost-effectiveness of nutrition-sensitive agriculture interventions is scarce. This limits understanding of the costs of rolling out or scaling up programs. The findings of this economic evaluation will provide useful information for different multisectoral stakeholders involved in the planning and implementation of nutrition-sensitive agriculture programmes. Trial registration ISRCTN65922679. Registered on 21 December 2016 Electronic supplementary material The online version of this article (10.1186/s13063-019-3388-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Jolene Skordis
- University College London, Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Helen Harris-Fry
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT,, UK
| | - Sneha Krishnan
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT,, UK
| | - Meghan O'Hearn
- Tufts University, Friedman School of Nutrition Science and Policy, 150 Harrison Avenue, Boston, MA, 02111, USA
| | - Abhinav Kumar
- Digital Green, S-26 to 28, 3rd Floor, Green Park Extension Market, New Delhi, 110016, India
| | - Ronali Pradhan
- Digital Green, S-26 to 28, 3rd Floor, Green Park Extension Market, New Delhi, 110016, India
| | - Naba Kishore Mishra
- VARRAT (Voluntary Association for Rural Reconstruction and Appropriate Technology), Boulakani Baradang, Mahakalpara Kendrapad, Odisha, 754224, India
| | - Avinash Upadhyay
- Digital Green, S-26 to 28, 3rd Floor, Green Park Extension Market, New Delhi, 110016, India
| | - Shibananth Pradhan
- VARRAT (Voluntary Association for Rural Reconstruction and Appropriate Technology), Boulakani Baradang, Mahakalpara Kendrapad, Odisha, 754224, India
| | - Amit Kumar Ojha
- Ekjut, 556 B-Ward No 17-Potka, Chakradharpur, Jharkhand, 833102, India
| | - Sarah Cunningham
- Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115,, USA
| | - Shibanand Rath
- Ekjut, 556 B-Ward No 17-Potka, Chakradharpur, Jharkhand, 833102, India
| | - Tom Palmer
- University College London, Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Peggy Koniz-Booher
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, JSI Research and Training Institute, Inc., 1616 Fort Myer Drive 16th Floor, Arlington, VA, 22209, USA
| | - Suneetha Kadiyala
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT,, UK
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