Lead institution

London School of Hygiene & Tropical Medicine

Collaborating institutions

VARRAT
Ekjut
Digital Green 
Development Corner (D-COR)
JSI-SPRING
UCL Institute for Global Health 

Value: $2,989,696
Principal Investigator: Dr. Suneetha Kadiyala  

Project summary

We will not achieve global nutrition targets unless we can find ways to address the underlying causes of undernutrition. To do this, we must embrace the complexity of factors that influence people’s nutrition by working across sectors, connecting with other disciplines, and thinking creatively. Agriculture is an obvious sector to link with, because it is so directly linked to the foods that people grow, sell, and eat. The development of effective, affordable interventions that ‘make agriculture work for nutrition’ is a top policy priority.

The UPAVAN project aimed to do this by building on an intervention that has proven successful in the agriculture world.¹  Digital Green (www.digitalgreen.org), an international NGO, has developed a novel and successful method to improve agricultural practices in rural communities. By working with local partners, communities co-produce videos that demonstrate and discuss important agricultural techniques, starring local farmers who can show off their success stories and share their personal experiences. Local, trained facilitators then show the videos in women’s groups, pausing the videos at key points to recap, discuss, and problem-solve. This method has been effective at improving agricultural practices and increasing crop yields. But can we make it work to improve nutrition?
Between Nov 2016 and October 2019, we tested the effect of three ‘nutrition-sensitive’ variants of this Digital Green intervention, in a four-arm cluster randomised control trial in 148 villages in rural Odisha, India. 

The interventions we tested were:

• Women’s groups meeting fortnightly to view and discuss locally made videos on nutrition-sensitive agriculture. Nutrition-sensitive video topics included mushroom cultivation, Sustainable Rice Intensification, techniques to increase Indian spinach yields, methods to reduce chicken mortality, budget and kitchen garden planning, and more.
• Women’s groups meeting fortnightly to view and discuss videos on nutrition-sensitive agriculture AND nutrition specific topics. In place of half of the agricultural videos, groups watched nutrition-specific videos about topics such as key food groups, nutrient-rich recipes, rest-taking in pregnancy, and advice on breastfeeding.  
• Women’s groups meeting fortnightly to view and discuss nutrition-sensitive agriculture videos, combined with a Participatory Learning and Action (PLA) approach. Recognising the need for community engagement and interactive, participatory methods, we partnered with Ekjut, an Indian non-profit organisation who specialise in Participatory Learning and Action approaches. In a PLA cycle of meetings, groups identify and prioritise health problems, identify feasible strategies, implement these strategies with help from the wider community, and informally evaluate the process. Previous work has shown dramatic improvements in birth outcomes, and nutrition outcomes when combined with creches.^2,3

In all interventions, group facilitators followed up with home visits to pregnant women and mothers of young children, to reinforce the video messages, and facilitate discussions at home. The interventions were compared to a control arm, that received usual government services. In all arms – including as a benefit to the control villages – we gave basic training to government frontline workers on maternal, infant and young child nutrition. 

Study objectives

1. Our main objective was to estimate the impact of these interventions, each compared to the control, on maternal nutritional status (body mass index), maternal dietary diversity, child dietary diversity, and child wasting (low weight-for-height). We assessed this through cross-sectional studies at baseline and endline.
2. Intermediate outcomes: We also estimated the effects on key hypothesised impact pathways: improved agricultural diversity, increased household income, increased women’s decision-making, and reduced women’s workload. 
3. Our cost effectiveness evaluation: will quantify the intervention costs and equity of the interventions
4. A detailed process evaluation: Will unpack processes of change, describe the essential ingredients, and identify contextual enablers or barriers.

Results

Women in the intervention arms substantially improved their diets, and the diets of their children. This indicates that the interventions resulted in important improvements in micronutrient adequacy. It is also a great achievement because access to a healthy diet is an important human right. These effects were observed on top of large, very promising secular nutritional improvements across Odisha. 

On the other hand, we did not improve women’s or children’s nutritional status (body mass index or the proportion of wasted children). More work is needed to find ways to increase energy intakes, reduce energy expenditure, and reduce infection.

How did the intervention work? Impacts on our intermediate indicators reveal some small improvements in agricultural production and women’s decision-making, but this was not consistent across all interventions so it doesn’t seem to be the whole story. Our detailed process evaluation will reveal more about what happened.

We conclude that enhancing nutrition-sensitivity and participatory components of agricultural intervention can improve diet quality! But, continued investment in, and coordination of multi-sectoral programmes are required to improve child and maternal nutrition status. 

Resources

• Publications:

  • Prost, A., Harris-Fry, H., Mohanty, S., Parida, M., Krishnan, S., Fivian, E., Rath, S., Nair, N., Mishra, N. K., Padhan, S., Pradhan, R., Sahu, S., Skordis, J., Danton, H., Koniz-Booher, P., Beaumont, E., James, P., Allen, E., Elbourne, D., & Kadiyala, S. (2022). 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, e13398. https://doi.org/10.1111/mcn.13398

  • Trial results: Kadiyala, S., Harris-Fry, H., Pradhan, R., Mohanty, S., Padhan, S., Rath, S., et al. (2021). Effect of nutrition-sensitive agricultural interventions with participatory videos and women’s group meetings on maternal and child nutritional outcomes (UPAVAN trial): a four-arm cluster-randomised controlled trial in rural Odisha, India. Lancet Planetary Health. https://doi.org/10.1016/S2542-5196(21)00001-2

  • Intervention design: Harris-Fry H, O’Hearn M, Pradhan R, et al. How to design a complex behaviour change intervention: experiences from a nutrition-sensitive agriculture trial in rural India. BMJ Glob Heathl 2020; 5: e002384.

  • Baseline data on landownership and maternal nutrition outcomes: Harris‐Fry, H, Krishnan, S, Beaumont, E, et al. Agricultural and empowerment pathways from land ownership to women's nutrition in India. Matern Child Nutr. 2020; 16:e12995. https://doi.org/10.1111/mcn.12995

  • Trial protocol: Kadiyala S et al. Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) trial comparing three variants of a nutrition-sensitive agricultural extension intervention to improve maternal and child nutritional outcomes in rural Odisha, India: study protocol for a cluster randomised controlled trial. Trials 2018; 19:176 https://doi.org/10.1186/s13063-018-2521-y

• UPAVAN presentation at ANH Academy Week 2020
• Examples of Digital Green videos:
  • Growing Indian spinach for nutrition
  • Benefits of chicken farming
  • Benefits of summer ploughing

Contact information

London School of Hygiene and Tropical Medicine - Dr. Suneetha Kadiyala: [email protected]

References

All photos on this page are kindly provided by the UPAVAN project team.

1. Toyama K. Digital Green RCT: final report with preliminary analysis. Jameel Poverty Action Lab South Asia, Cambridge, 2017. 

2. Tripathy, Prasanta, et al. "Effect of participatory women's groups facilitated by Accredited Social Health Activists on birth outcomes in rural eastern India: a cluster-randomised controlled trial." The Lancet Global Health 4.2 (2016): e119-e128.

3. Gope, Raj Kumar, et al. "Effects of participatory learning and action with women’s groups, counselling through home visits and crèches on undernutrition among children under three years in eastern India: a quasi-experimental study." BMC public health 19.1 (2019): 1-15.