Innovative approaches: C
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Intro animation:

Innovative approaches studies at ANH2020


Session recording:

ANH2020: Innovative approaches C


Speakers and presentations:

  • Session chair: Umi Fahmida, University of Indonesia
    @Umifahmida  @univ_indonesia

  • Gabriella Chiutsi-Phiri, Lilongwe University of Agriculture and Natural Resources
    Intensive sensitisation a key to successful community based research: Lessons from an agriculture-to-nutrition trial in rural Malawi
    Presentation | Slides

  • Laura Trijsburg, Wageningen University and Research
    Development and evaluation of the WISH Diet Index, a globally applicable diet quality index for sustainable food system
    Presentation | Slides

  • Sarah McClung, John Snow International
    @SarahMcclung @JSIhealth
    Not your usual survey: Using unexpected tools to advance understanding of the role of markets to improve young child nutrition through egg consumption in Tigray, Ethiopia
    Presentation | Slides


Intensive Sensitisation a Key to Successful Community Based Research: Lessons from an Agriculture-To-Nutrition Trial in Rural Malawi 

Gabriella Chiutsi-Phiri1

Alexander A. Kalimbira1

Joseph Mfutso-Bengo2

Kate Millar4

Limbanazo Matandika2

Patson C. Nalivata1

Zione Kalumikiza1

Leonard Banda1

Jellita Gondwe5

Jo Sturgess3

Martin R. Broadley4

Edward J.M. Joy3

1Lilongwe University of Agriculture and Natural Resources, Lilongwe, Malawi

2College of Medicine, University of Malawi, Blantyre, Malawi

3Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK

4School of Biosciences, Sutton Bonington Campus, University of Nottingham, Loughborough, LE12 5RD, UK

5Community Health Sciences Unit, Lilongwe, Malawi


Community-based trials provide valuable evidence to assess the effectiveness of agriculture-to-nutrition interventions. The Addressing Hidden Hunger with Agronomy (AHHA) trial was conducted in rural Kasungu District, Malawi from July to September 2019. In this community-based, randomised, controlled trial, participants received selenium biofortified or control maize flour for 12 weeks, with blood samples taken at baseline and endline. This study considers (1) the challenges faced in trial implementation, including gaining the trust of participants and the wider community, and (2) the importance of formative research and the adoption of enhanced community sensitisation approaches for successful completion of the trial.       


Successful implementation of the AHHA trial required the willing support of participants and the wider community. Risks were identified, e.g. that participants might sell or share their assigned flour with other households, or that people might decline to participate due to fear of providing blood samples. Formative research was conducted one year before the baseline survey to gauge these risks and identify mitigating strategies. We conducted a survey with 50 adult women, 6 Focus Group Discussions (FGDs) with adult men and women and 12 Key Informant Interviews (KII) with stakeholders ranging from the District Nutrition Officer to a Village Chief. Descriptive statistics were used to analyse the quantitative survey data, while FGD and KII data were analysed using qualitative methods. The formative research findings guided key implementation decisions, including the adoption of an enhanced community sensitisation approach. Community sensitisation was conducted by the project team and started with awareness creation among key district officers, traditional authority leaders and heads of all villages in the project catchment area. Subsequently, community sensitisation was conducted through village gatherings prior to household listing and baseline survey, and at three timepoints during maize flour distribution.


Survey participants typically ate all their previous days’ meals at home, although 16% reported eating at another household or restaurant. This was consistent with FGD findings, e.g. “It’s rarely that we share with our neighbours”. Thus, it was considered feasible to randomise allocation to treatment at household level provided participants understood that trial flour should be eaten at home. FGD and KII participants raised concerns that the biofortified flour might affect fertility, that blood sampling might be linked to witchcraft (“Maybe blood sampling has to do with Satanism”) and that participants might be subject to social stigma if community members considered them lazy for receiving free flour. However, mitigating strategies were proposed including community dialogue (“…every new thing it’s received with some doubts. People talk because there’s no information. If people have information and have everything, it clears out those misconceptions”) and the involvement of Malawi government partners, especially health extension workers. These suggestions were taken on board with regular village gatherings as part of an enhanced community sensitisation approach. Ministry of Health nurses were employed to collect blood samples, and all Research Assistants in the field were informed on Frequently Asked Questions to ensure the community received consistent information.


The AHHA trial is now complete providing a chance to reflect on its implementation. Nearly all (99.9%) the randomly sampled households agreed to recruitment and provision of blood samples, and 96% of participants completed the trial. These figures suggest that the community sensitisation was successful. From the experience of the AHHA trial, community sensitisation guided by formative research is an essential component of successful delivery of community-based trials, providing an opportunity to hear and answer community members’ fears and concerns, and ensure that participants and the surrounding communities are fully aware of trial activities and their purposes.


Joy EJM, Kalimbira AA, Gashu D, Ferguson EL, Sturgess J, Dangour AD, Banda L, Chiutsi-Phiri G, Bailey EH, Langley-Evans SC, Lark RM. Can selenium deficiency in Malawi be alleviated through consumption of agro-biofortified maize flour? Study protocol for a randomised, double-blind, controlled trial. Trials. 2019 Dec;20(1):1-9.

Development and evaluation of the WISH Diet Index, a globally applicable diet quality index for sustainable food systems 

Laura Trijsburg1

Elise F. Talsma 1

Sandra P. Crispim 2

James Garrett 3

Gina Kennedy 3

Jeanne H.M. de Vries 1

Inge D Brouwer 1

1Wageningen University and Research, Human Nutrition and Health, the Netherlands

2Federal University of Paraná, Department of Nutrition, Brazil

3Bioversity International, Italy


Worldwide, diets of poor quality are the main contributors to all forms of malnutrition. However, emphasis should not only be put on promoting a healthy diet but also the environmental sustainability aspects of production and consumption of foods should be taken into account. To be able to evaluate diets for healthiness and sustainability we developed the WISH (World Index Sustainability and Health) - Diet Index.       


The developed index intends to assess the adherence to an existing global set of technical recommendations for a healthy and sustainable diet in the general population, globally applicable across multiple settings and populations. The 13 food groups (including whole grains, vegetables, fruits, dairy foods, red meat, fish, eggs, chicken and other poultry, legumes, nuts, unsaturated oils, saturated fat and all sweeteners) are scored between 0 and 10, based on their association with disease and impact on selected environmental indicators (greenhouse gas emission, land use, eutrophication, acidification, and scarcity weighted water). The scoring system was evaluated for association with energy and nutrient intake using a dataset of duplicate 24h recalls from 396 Vietnamese men and women.  


Out of a maximum of 130, the mean total WISH score was 51 (standard deviation ±11.3). Individual food group scores were high for vegetables (8.7±3), saturated fat (10±0.5) and all sweeteners (9.9±0.9), whereas low scores were observed for whole grains (0.0±0.01), dairy foods(0.2±1.4), nuts(0.6±1.8) and unsaturated oils(0.5±1.5) due to high percentages of non-consumers, and red meat(0.4±1.8) as the intake of red meat was often above the recommended maximum intake level of 28 g/day. The total WISH score is mainly influenced by the following component scores: legumes (r=0.48), poultry (r=0.42), eggs (r=0.37), fish (r=0.36), fruits (r=0.36) and vegetables (r=0.34) and correlations between the selected nutrients and the total WISH index score show low, but mostly significant correlation coefficients.  


This sustainable diet quality index seeks to measure two complex multidimensional concepts; diet quality and environmental sustainability. Although both concepts are closely related, healthy diets show a strong correlations with environmental sustainably diets and a diluting effect of capturing the dimensions is expected. it is therefore not surprising that the findings from this study show an average reliability and construct validity of the WISH index in this Vietnamese population. Further evaluation of the sustainable diet quality index is planned whereby datasets from other countries containing dietary intake data and life cycle assessment data will be included.


Willett W, Rockström J, Loken B, et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. The Lancet. 2019;393(10170):447-492.

Not your usual survey: Using unexpected tools to advance understanding of the role of markets to improve young child nutrition through egg consumption in Tigray, Ethiopia 

Alyssa Klein1

Sarah McClung1

Sarah Hogan1

Karin Christianson1

Ashley Aakesson2

Kaleab Baye3


2The Manoff Group

3OSSREA, Ethiopia


Animal sourced foods (ASFs) have a demonstrated ability to improve child health. Yet, they are underutilized by communities with high burdens of malnutrition. Recognizing that improving knowledge about the benefits of consuming ASFs alone is not adequate to change behavior, the Studying Animal Food Markets in Rural Areas (SAFIRA) project is testing an innovative market-focused approach to increasing the intake of nutrient-dense ASFs by children 6-23 months in rural Tigray, Ethiopia. By mid 2020, SAFIRA will have conducted three rounds of formative research to inform a future cluster randomized control trial (cRCT). 


Our process of designing in-market behavior change strategies involved identifying the project’s target ASF, co-creating and testing marketing prototypes, and understanding motivations of key market actors’ behaviors. To better understand parents’ motivations, we analyzed fathers’ and mothers’ perceptions of foods relative to four domains: affordability, availability, desirability (child acceptance), and healthiness. Through analyzing parent’s perceptions of 98 local foods across these domains, we determined our target ASF, eggs. We then applied a traditional concept testing technique involving three marketing prototypes. Through analyzing fathers’ and mothers’ discussions, we uncovered parents’ mental models around caregiving, young child feeding practices, and aspirations. These mental models provided key insights into parents’ capabilities, motivations, and opportunities related to our project’s target behavior, parents feeding eggs to their young children. To more deeply understand egg sellers’ practices, we conducted Trials of Improved Practice (TIPs) in which egg traders were presented with (and selected at least one of four different practices to either preserve nutrients/egg quality, increase sales and/or improve transportation as well as conducted mapping of the egg value chain. The latter involved participatory mapping with actors along the entire value chain to clarify understanding of the flow of both eggs and financial resources.


The concepts tested focused on love (love your child, give her/them eggs to help them grow), convenience (boiled eggs are a convenient, tasty treat) and acceptability during fasting seasons (message was delivered by religious leader – children under seven are exempt from fasting customarily). All three concepts were well received though many had not considered convenience as a priority. The TIPs yielded unexpected information – it is rare for community members to purchase eggs from traders as most supply is aggregated for sale to commercial entities. Additionally, it uncovered important cultural norms around offering discounts (can create suspicion about quality of eggs), food consumption outside of the home (hard boiled eggs are often sold as a hangover cure), and supply turnover (if oiling to preserve eggs may wait for better prices). As a result of this finding (little purchasing of eggs by community members), we anticipate a third round of formative research in early 2020 which will include the value chain mapping. Based on the outcome of that, and a quantitative household survey of both egg-producing and non-producing households, we will reflect and refine our intervention and conduct the cluster randomized control trial beginning in mid-late 2020.


What has made this project unique is the utilization of methods considered outside the scope of traditional nutrition, agriculture, and economic toolboxes. Conducting the trials of improved practices (TIPs) with traders offered a unique opportunity for insight into habits and willingness to adopt new practices around selling, and unexpectedly, shifted the scope of the project by revealing a value chain which doesn’t promote household consumption. Similarly, the concept testing utilized the tenets of market research in a nutrition context. We expect that the value chain mapping will further contribute to formulating our final intervention to be tested in the cRCT.



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