Ag-nutrition implementation science studies: A
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Animation: Ag-nutrition implementation science studies at ANH2020


Session recording:

ANH2020: Ag-nutrition implementation science studies A


Speakers and presentations:

  • Session chair: Nilofer Fatimi, Dow University of Health Sciences
  • Deborah Aluh, University of Nigeria Nsukka
    @debbilici0uss  @unn_tweets
    Evaluation of Health-related Quality of life of small-scale farmers in Enugu State, Nigeria
    Presentation | Slides
  • Afkera Daniel, Johns Hopkins University School of Medicine
    Land Tenure, Empowerment, and Health Outcomes among Communities of the Shamba Maisha Intervention in Western Kenya 
    Presentation | Slides

  • John Frederick Hoddinott, Cornell University
    @CornellNutri @Cornell_PIN @CornellGlobal
    Testing the effectiveness of combinations of trainings to improve agricultural production diversity, dietary diversity, and women’s empowerment in Bangladesh: The Agriculture, Nutrition, and Gender Linkages (ANGeL) Project
    Presentation | Slides

  • Nadine Bader, GIZ

    What enables and prevents women from following good nutrition practices in Madhya Pradesh, India? – Results from a multi-sectoral nutrition project
    Presentation | Slides

  • Victoria Chi, University of California, San Francisco
    Effects of Shamba Maisha Multisectoral Food Security Intervention on Community Empowerment in Kenya: A Qualitative Study
    Presentation | Slides


Evaluation of Health-related Quality of life of small-scale farmers in Enugu State, Nigeria 

Deborah Oyine Aluh1, Michael Ejime Ikehi2

1 Department of Clinical Pharmacy and Pharmacy Management, University of Nigeria Nsukka
2 Department of Agricultural Education, University of Nigeria Nsukka


Agriculture has been acknowledged as one of the most hazardous occupations worldwide. Health Related Quality of life (HRQOL) is a multidimensional concept, which measures the patient’s health status in the domains related to physical, mental, emotional, and social functioning. Many studies have cited occupation as one of the demographic factors related to HRQOL. With agriculture being acclaimed as the largest employer of labour and a prominent workplace for a majority especially in Nigeria, evaluating the HRQOL of its employees becomes essential for policy advice. This will be the first attempt to assess the HRQOL of farmers in Nigeria.         


The study employed a cross-sectional design. All Small-scale farmers from five communities in two local government areas in Enugu State who were willing to participate were included in the study.  Both the EQ-5D-5L and EQ-VAS were used to evaluate the HRQOL of respondent farmers. English language, version 3.0 (Van Reenen et al., n.d.). Because there is no reference value set for Nigeria, the health state values of Zimbabwe was adopted (Jelsma, Hansen, de Weerdt, de Cock, & Kind, 2003). The Visual Analog Scale (EQ-VAS) is a vertical visual analog scale 20 cm in length, with a scale ranging from 0 (worst imaginable health state) to 100 (best imaginable health state. Each EQ-5D-5L health state were coded using a five-digit (1-5) numbering system to indicate the functional levels of the 5 dimensions of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression in the state. The scores were converted into an index using the shiny app (  Pearson’s correlations were used to examine the nature of associations between socio-demographic factors and the EQ-5D index scores and the EQ-VAS scores. All statistical tests were considered significant at p<0.05. Data analyses were performed using SPSS version 24 (IBM Corporation, Armonk, NY, USA).   


Of the 280 participants, 50% were female. Most of the respondents were between 41 and 45 years old (37.5%, n = 105) and had at least secondary school education (75%, n = 210). The mean EQ5D index score was 0.838±0.091. The mean EQVAS score was 81.88±27.38. The most prevalent problems reported were Pain/Discomfort and Anxiety/Depression. EQ5D scores were significantly strongly correlated with the Education level among the farmers surveyed (r=0.789, 0.020). EQ5D was also moderately negatively associated with the presence of an ailment (r=-0.550, p = 0.158). The most common ailment reported by the farmers was Malaria. The strong correlation between the EQ5D index score and education is consistent with previous studies (Adibe et al., 2014; Liu et al., 2017) and underscores the importance of education among the populace.  The presence of an ailment was associated with a lower quality of life, thus farmers in malaria-endemic regions need to be educated on Malaria prevention and management.  While Pain/Discomfort reflects problems with physiology, Anxiety/Depression reflects problems in the areas of psychology and social adaptation. Greater than one-third of the farmers reported having anxiety and depression pointing to the need to improve mental health awareness and help-seeking behaviors among this population.   


Overall, the majority of the farmers and workers reported no health problems. Although some associations between specific sociodemographic factors and HRQOL were identified in this study, the cross-sectional nature of the study limits the validity of the findings. Further studies, preferably longitudinal, are needed to confirm these associations. Future studies should also focus on understanding the reasons behind the associations between specific sociodemographic factors and HRQOL.         "Adibe, M. O., Ubaka, C. M., Udeogaranya, P. O., Igboeli, N. U., & Abraham-Igwe, K. A. 2014. Effect of Occupational Factors on the Quality of Life of Workers in Governmental and Non-Governmental Sectors in Southeastern Nigeria. Tropical Journal of Pharmaceutical Research, 13(2), 287–293.


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Jelsma, J., Hansen, K. S., de Weerdt, W., de Cock, P., & Kind, P. 2003. How do Zimbabweans value health states? Population Health Metrics.

Kim, B., Kim, W., Choi, H., Won, C., & Kim, Y. 2012. Health-related quality of life and related factors in full-time and part-time workers. Korean Journal of Family Medicine.

Liu, X., Gu, S., Duan, S., Wu, Y., Ye, C., Wang, J., & Dong, H. 2017. Comparative Study on Health-Related Quality of Life of Farmers and Workers. Value in Health Regional Issues, 12, 123–129.

Olowogbon, T. S., Yoder, A. M., Fakayode, S. B., & Falola, A. O. 2019. Agricultural stressors: identification, causes and perceived effects among Nigerian crop farmers. Journal of Agromedicine.

Omonona B.T., E. O. A. and O. M. A. (2012). Farmers’ Health and Labour Productivity in Osun State, Nigeria. Greener Journal of Agricultural Sciences, 2(4), 001–009. Retrieved from Omonona et al.htm

Van Reenen, M., Janssen, B., Stolk, E., Boye, K. S., Herdman, M., Kennedy-Martin, M., … Slaap, B. (n.d.). CHANGES INCLUDED in this update of the EQ-5D-5L User Guide Table of contents. Retrieved from

Wu, S. F., Tong, H. Y., kan, Y. Y., Su, S. H., Lee, M. C., Kao, C. C., & Lin, Y. H. 2017. The Exploration of Health-Related Quality of Life: Factors Influencing Quality of Life in Gynecologic Cancer Patients. Clinical Nursing Research, 26(1), 114–131."

Land Tenure, Empowerment, and Health Outcomes among Communities of the Shamba Maisha Intervention in Western Kenya

Afkera Daniel1, Annie McDonough2, Abagail Hatcher2, Rachel Burger2, Elly Weke3, Pauline Wekesa3, Monica Getahun2, Elizabeth A. Bukusi3, Sheri D Weiser2, Craig R. Cohen2

1Johns Hopkins University School of Medicine

2University of California San Francisco School of Medicine

3Kenya Medical Research Institute


Women’s lack of land tenure (defined as the common law systems by which land is owned) has been linked to poor health, a higher probability of experiencing physical and sexual violence, and increased risk of HIV, poverty, and poor access to medical care. Few studies have explored the relationship between land access and women’s health and empowerment. This study sought to qualitatively explore how land access and property rights impact women’s empowerment in the context of the Shamba Maisha study -- a multisectoral agricultural and finance intervention – and whether land tenure affected how participants benefited from the intervention.         


This qualitative study was embedded within the Shamba Maisha study (NCT02815579), a randomized controlled trial examining the impact of a multi-sectorial agricultural and finance intervention among HIV-infected farmers in western Kenya. The intervention consisted of a commodity loan and a human-powered water pump, agricultural commodities, and farming and financial management training. At enrollment, all participants were on ART, and had moderate to severe food insecurity and/or low body mass index. Thirty in-depth interviews (IDIs) were conducted within six months of intervention implementation with a purposively sampled cohort of male and female participants, balanced for age, gender, and region. We used a semi-structured interview guide to explore the effect of land tenure on experiences with the Shamba Maisha study. Interviews explored perceived and recent changes in self-confidence, empowerment, agricultural knowledge, household decision-making, and the role of women in the family/community. Interviews were conducted in the local language, audio recorded and transcribed in English. A collaboratively coded framework, developed deductively on the basis of theory, and inductively following the review of transcripts, was applied to segments of texts using Dedoose software. All interviews were double-coded by two investigators using the thematic framework. Codes were then queried and discussed by the study team.


Participants described several livelihood benefits resulting from their involvement in the Shamba Maisha study, including increased income and enhanced farming and cultivation practices. Through the sustenance provided from their Shamba Maisha farms, participants were able to reliably provide food for their families and reported feeling stronger and making fewer visits to the hospital due to opportunistic infections. Increased income, which helped to alleviate financial stress among families, was reported to increase self-confidence, ability to speak out in groups, and decision-making capacity – especially for women.
However, participants indicated that farming practices and participation in Shamba Maisha was heavily dependent on land tenure and the strength of their claim over their land. Findings revealed that land security (or lack thereof) dictated decision-making critical for intervention participation and success. Male and female participants who felt secure about their access to land reported increased investment in longer-term crops, farm equipment, and improvements to protect farm-land from domestic and wild animals. Women conveyed insecurity about their access to land and reported challenges with lack of legal documentation showing ownership or right to land. Land tenure security posed unique challenges for women, with important implications for their continued participation and success in the intervention.


Targeted livelihood interventions, like Shamba Maisha, have great potential for improving health among vulnerable populations. However, our data show that livelihood interventions may be more effective among those who have land tenure security and this should be a target for future interventions, especially among women.


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Nagata JM, Magerenge RO, Young SL, Oguta JO, Weiser SD, Cohen CR (2012) Social determinants, lived experiences, and consequences of household food insecurity among persons living with HIV/AIDS on the shore of Lake Victoria, Kenya. AIDS Care 24(6):728–736

National AIDS Control Council (NACC). (2016). Kenya HIV County Profiles 2016. Nairobi: Kenya Ministry of Health. Retrieved from

Oluoko-Odingo, Alice Atieno (2011) Vulnerability and Adaptation to Food Insecurity and Poverty in Kenya, Annals of the Association of American Geographers, 101:1, 1-20, DOI: 10.1080/00045608.2010.532739

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Testing the effectiveness of combinations of trainings to improve agricultural production diversity, dietary diversity, and women’s empowerment in Bangladesh: The Agriculture, Nutrition, and Gender Linkages (ANGeL) Project

Akhter U. Ahmed1, Julie Ghostlaw1John Hoddinott2, Purnima Menon3, Aklima Parvin1, Audrey Pereira4 , Agnes Quisumbing4, Shalini Roy4, Masuma Younus5

1International Food Policy Research Institute, Bangladesh
2Cornell University, USA
3International Food Policy Research Institute, India
4International Food Policy Research Institute, USA
5Ministry of Agriculture, Bangladesh


Previous IFPRI research in Bangladesh using a nationally-representative household survey has demonstrated positive associations across agricultural diversity, household and child dietary diversity, and women’s empowerment. For policy, it is useful to understand whether these linkages imply that combined interventions across these areas will be more effective than single-dimension interventions in improving outcomes across agriculture, nutrition, and gender. The Agriculture, Nutrition, and Gender Linkages (ANGeL) project was a collaboration between the Ministry of Agriculture and IFPRI that aimed to test the effectiveness of combinations of trainings to improve agricultural production diversity, dietary diversity, and women’s empowerment in Bangladesh.        


ANGeL used a randomized controlled trial (RCT) to evaluate the impacts of combinations of agriculture production, nutrition, and gender trainings. Using simple cluster randomization, 160 blocks from 16 upazilas were randomly assigned to five treatments or a control arm, without stratification. The five treatment arms included trainings on: (T1) nutrition by government agricultural extension agents (AEAs); (T2) nutrition by community nutrition workers; (T3) agriculture, on production of nutrient-rich foods by AEAs; (T4) agriculture and nutrition by AEAs; and (T5) agriculture and nutrition by AEAs, and gender sensitization training by project facilitators hired by Helen Keller International. All trainings targeted men and women. Because agriculture production and child diets were outcomes of interest, ANGeL targeted farm households with at least one child under 24 months. 4,000 farm households were included; 3,125 farm households from 125 blocks were assigned to five treatment arms, while 875 farm households from 35 blocks were assigned to the control group. We measured women’s empowerment using the Abbreviated Women’s Empowerment in Agriculture Index and its project-level counterpart, pro-WEAI, and household dietary diversity via WFP’s Food Consumption Score. We used endline data for impact estimates, adjusting for baseline characteristics using analysis of covariance (ANCOVA) estimators.


In terms of agriculture impacts, all treatments significantly increased agriculture production knowledge, but magnitudes were larger from arms including agriculture training (T3, T4, T5) than those with nutrition training only, and knowledge impacts were larger for women than men. All treatments increased adoption of improved agriculture production practices, but magnitudes were larger from arms with agriculture training (T3, T4, and T5) and larger among women than men. Nutrition knowledge significantly improved from all treatment arms, but magnitudes were larger from arms including nutrition training, and impacts were larger for women than men. Household diet quality and child diet diversity significantly increased only from the treatment that provided nutrition training from community women and from the treatments that combined nutrition and agriculture training from AEAs. Women’s empowerment significantly improved across all treatments, but improvement was significantly larger with added gender sensitization (T5). Results suggest several treatment arms improved men’s attitudes around gender roles (T1, T4, T5), with larger improvements from the arm with gender sensitization. There were no significant increases in men’s empowerment, but also no significant decreases, suggesting that gains for women were not achieved at the expense of men in this context.


ANGeL demonstrated important linkages between nutrition, agriculture, and gender interventions. Isolated trainings in nutrition, targeted to men and women, improved nutrition, but also had small impacts on agriculture and women’s empowerment; isolated trainings in agriculture, targeted to men and women, improved agriculture, but also nutrition and women’s empowerment. These impacts tended to be smaller than impacts of interventions combining agriculture, nutrition, and gender trainings, suggesting synergies across these. Combined interventions were also more successful in giving women access to the benefits of these interventions, without disadvantaging men. The Bangladesh Ministry of Agriculture is scaling up the most effective interventions nationally.


Ahmed, A.U., J. Ghostlaw, L. Haque, N. Hossain, A. Parvin, F. Sufian, and S. Tauseef. 2017. Agriculture, Nutrition, and Gender Linkages (ANGeL) Baseline Study. Project report. Dhaka: International Food Policy Research Institute (IFPRI).

Ahmed, A.U., J. Hoddinott, P. Menon, A. Quisumbing, S. Roy and M. Younus. 2018. Agriculture, Nutrition, and Gender Linkages (ANGeL) Evaluation Results. Dhaka: International Food Policy Research Institute (IFPRI).

Alkire, S., Meinzen-Dick, R. S. S., Peterman, A., Quisumbing, A., Seymour, G., and Vaz., A. (2013). The Women’s Empowerment in Agriculture Index. World Development 52: 71-91.

Helen Keller International, Bangladesh. 2017. Nurturing Connections - Adapted for Homestead Food Production and Nutrition.

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Malapit, H., Quisumbing, A., Meinzen-Dick, R., Seymour, G., Martinez, E.M., Heckert, J., Rubin, D., Vaz, A., Yount, K.M., Phase, G.A.A.P. and Team, S., 2019. Development of the project-level Women’s Empowerment in Agriculture Index (pro-WEAI). World Development, 122, pp.675-692.

Malapit, H.J.L., Sraboni, E., Quisumbing, A.R. and Ahmed, A.U., 2019. Intrahousehold empowerment gaps in agriculture and children's well‐being in Bangladesh. Development Policy Review, 37(2), pp.176-203.

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What enables and prevents women from following good nutrition practices in Madhya Pradesh, India? – Results from a multi-sectoral nutrition project

Nadine Bader1 ,Archana Sarkar1,Neha Khara1,Gerrit Qualitz1 ,Petr Schmied2 ,Tina Koch3, Annette Roth3

Food and Nutrition Security, Enhanced Resilience project, GIZ India
Independent Consultant M&E and Behaviour Change
3 Sector Programme Agriculture Policy and Food Security, GIZ Germany


India is affected by high stunting rates of children under 5 years, especially Madhya Pradesh (39.5%). The Food and Nutrition Security, Enhanced Resilience project, initiated by Deutsche Gesellschaft fuer Internationale Zusammenarbeit (GIZ) in 2015, aims to improve the food and nutrition situation of 30,000 children (6-23 months) and 144,000 women of reproductive age in Madhya Pradesh. The project´s focus is on improving dietary diversity through participatory nutrition trainings, facilitated by trained frontline workers, and support to homestead gardening. However, results of a midline survey showed a gap between women’s knowledge of promoted nutrition practices and the extent they follow them.  


A qualitative research study was carried out to assess enablers and barriers to follow good nutrition and hygiene practices and providing implementation recommendations to overcome the main barriers and to take advantage of the enablers. Data collection was carried out in September 2019 in eight randomly selected villages in the project area using a combination of qualitative methods: Focus Group Discussions (n=15) with women, men, frontline workers and partner organisation´s field staff, semi-structured interviews (n=8) with relevant authorities and positive deviants, and observations (n=14) of child feeding practices, food preparation, homestead gardens and participatory nutrition sessions. Transcripts of audio-recorded interviews were coded and aggregated in themes before being validated. The main findings and recommendations were presented and validated in two workshops involving project and partner organisation staff.


The research has identified six main types of barriers that prevent women from practicing the desired nutrition practices: poor access to nutritious foods due to low income, limited land or seasonal migration; lack of time that is required to follow practices as complementary feeding; limited engagement of men in ensuring good nutrition; harmful beliefs/traditions such as avoid eating green leafy vegetables during lactation; unsupportive social norms such as women should work hard during pregnancy; and limited knowledge. Few women reported that migration hinders them from attending nutrition training sessions. Enabling factors include help provided by household members; know-how provided by frontline workers in participatory nutrition trainings through games, stories, cooking demonstrations and visual materials; women´s decision-making power within the households regarding food choices; and the presence of positive role models in the communities.


Besides further strengthening capacities of frontline workers, nutrition programmes benefit from assessing barriers and enablers towards good nutrition practices. Engaging men in nutrition-related activities, changing the focus of nutrition interventions from ‘women’ to ‘women and their husbands and mothers-in-law’, using the approach of positive deviants as motivators and dispelling harmful beliefs are key besides access to nutritious foods and further support to homestead gardening.


Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF and Population Council. 2019. Comprehensive National Nutrition Survey (CNNS) 2016-2018. National Report. New Delhi.

Effects of Shamba Maisha multisectoral food security intervention on community empowerment in Kenya: A qualitative study

Victoria Chi1, Rachel Burger1, Pauline Wekesa2, Elly Weke2, Elizabeth Bukusi2, Sheri Weiser1, Craig R Cohen1
1University of California, San Francisco, USA
2Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Kenya


Food insecurity is closely linked to morbidity and mortality, particularly among people living with HIV. Beyond the individual, food security and HIV have effects on entire communities: households are less able to provide for their children and societies bear the increased burden of sickness and hunger among their constituents. The Shamba Maisha cluster randomized controlled trial (NCT02815579) tested the effects of an integrated agriculture microfinance intervention on improving food security and health outcomes for people living with HIV in rural Kenya. This qualitative study embedded within Shamba Maisha examined how and why a food security intervention may provide community-level benefits.      


This qualitative study was conducted at the end of the 2-year follow-up of participants enrolled in Shamba Maisha, an intervention consisting of 1) microfinance loans for farm commodities, 2) trainings in sustainable farming and financial management, and 3) implementation of a human-powered water pump to irrigate land for farming. Forty in-depth interviews were conducted with intervention participants using a semi-structured interview guide. Interviews were conducted in the local languages of D’Luo or KiSwahili, recorded, transcribed, and translated to English. Qualitative data from these interviews were managed and analyzed using the software program Dedoose. First, a thematic coding framework was developed, and then an inductive approach was used to draw out emerging themes and codes derived from the data. Analytic reports were created for each key theme. Representative quotes and divergent opinions for each fine code were aggregated, compared, and analyzed.


Participants who improved their food security and income from selling crops grown as part of the intervention reported contributing to and strengthening their communities, with gender differences identified in the mechanisms. Both men and women described caring for the most vulnerable people within their villages. Participants gave what little excess resources they had to those who were impoverished or hungry. Participants also prioritized paying school fees for their children and the children of others. According to a female participant, “I can now show support to others…I have been paying high school fees for my nephew.” Some men reported becoming village leaders, while many men and women described teaching farming practices to others. One female participant said, “So many people usually admire my crops and ask me about the techniques…I invite them over to my farm to show them best practices.” Once participants achieved food security and a financial means, they contributed to the local economy in ways that differed by gender. Male participants described providing employment on their farms to other community members. Male and female participants provided crops to schools and local buyers. Female participants invested money earned from selling crops into women’s economic empowerment and table banking groups.


Participants who improved their food security and income from selling crops as part of Shamba Maisha reported becoming better able to contribute to their communities. Men took on formal roles as leaders and employers, women participated in gender-specific economic empowerment groups, and both men and women gained informal roles teaching, sharing resources, and selling crops to locals. Through a diversity of mechanisms, improving food security for individuals may have larger ripple effects on entire communities. Livelihood interventions such as Shamba Maisha may be able to strengthen regions weakened by a high burden of HIV and food insecurity.


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