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

"Earlier I used to make breakfast for my child, but I used to skip it....In the evening I cooked snacks for the child but I was not eating that. The Accredited Social Health Activists told me to prepare more snacks in the morning and evening so that both I and my child can eat properly. So I followed that. The same thing was shown in the video."

Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) was a 4-arm cluster-randomised controlled trial (RCT) testing three nutrition-sensitive agriculture interventions with participatory videos and women's group meetings to improve maternal and child nutrition in rural villages of Odisha, India. The trial found improvements in maternal and child dietary diversity, limited effects on agricultural production, and no effects on women and children's nutritional status. This article shares the process evaluation of UPAVAN, exploring fidelity, reach, and mechanisms behind interventions' effects. The evaluation also examined how context affected implementation, mechanisms, and outcomes.

As detailed at Related Summaries, below, all UPAVAN interventions used a participatory video approach designed by Digital Green, an international non-governmental organisation. Interventions delivered in the three UPAVAN arms built on the participatory video approach. In brief, in the first of the UPAVAN intervention arms (AGRI), local salaried facilitators called Community Service Providers disseminated videos on nutrition-sensitive agriculture and facilitated related discussions with women's groups. In the second intervention arm (AGRI-NUT), women's groups viewed and discussed nutrition-sensitive agriculture videos and videos promoting nutrition-specific maternal, infant and young child nutrition (AGRI-NUT) designed using formative research, again under the guidance of Community Service Providers. Videos also described ways to overcome social and economic barriers to adopting these changes. In the third intervention arm (AGRI-NUT-PLA), women's groups viewed and discussed nutrition-sensitive agriculture videos, but also took part in a Participatory Learning and Action cycle of meetings in which they identified, prioritised and addressed problems related to maternal and child nutrition in four phases.

The cluster RCT (see below) found an increase in the proportion of children achieving minimum dietary diversity in both arms where groups discussed maternal and child nutrition (AGRI vs. control: 1.06 [0.91, 1.23]; AGRI-NUT vs. control: 1.19 [1.03, 1·37]; AGRI-NUT-PLA vs. control: 1.27 [1.11, 1.46]), but no effect on maternal body mass index (BMI). There were significant or borderline effects on the secondary outcome of maternal minimum dietary diversity in all three intervention arms (AGRI vs. control: 1.21 [1.01, 1.45]; AGRI-NUT vs. control: 1.16 [0.98, 1.38]; AGRI-NUT-PLA vs. control: 1.30 [1.10, 1.53]), but no effect on child wasting in any arm (AGRI: 0.95 [0.73, 1.24]; AGRI-NUT: 0.96 [0.72, 1.29]; AGRI-NUT-PLA: 0.96 [0.73, 1.26]). The AGRI intervention increased women's decision-making power and the total and net annual value of agricultural production compared to the control arm. The trial found no consistent effects on agricultural production diversity, gender parity in decision-making for agriculture and health, household expenditure, or women's work in any arm.

The process evaluation 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). Data reveal that interventions were implemented with high fidelity. Training and supervision increased Community Service Providers' knowledge of nutrition-sensitive agriculture, maternal and child nutrition, and their confidence in discussing these matters with community members. 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. In the AGRI-NUT-PLA arm, Community Service Providers asked each woman in the group to speak. According to Community Service Providers, the practice of speaking and listening to others in the group also made some women more confident to speak at home.

In UPAVAN's theory of change, participatory videos and women's group meetings were conceptualised as giving group members relevant knowledge, enabling peer support and, especially in the AGRI-NUT-PLA arm, engaging in collective learning and problem-solving and action with support from the wider community. The evaluation found that these objectives were largely met.

In the Participatory Learning and Action meetings held as part of the AGRI-NUT-PLA arm, group members identified strategies to address their prioritised problems and took collective and individual responsibility for implementation. For example, group members in one village decided to practise handwashing with soap before feeding children, counsel mothers-in-law and other family members not to impose food restrictions on pregnant women and mothers of children under 2, and give diverse foods to children after 6 months and develop homestead food production. At every meeting, the Community Service Provider discussed the implementation of these strategies and tried to resolve challenges. Some groups also took collective action by organising rallies for the wider community. Overall, enablers specific to Participatory Learning and Action included engaging active learning techniques, using in-built mechanisms to enable problem-solving, and involving more community members than self-help groups alone.

As a result of UPAVAN, many families adopted or improved rainfed homestead garden cultivation for consumption, which could explain gains in maternal and child dietary diversity seen in the impact evaluation. Thus, women's and children's diets may have improved because of discussions about nutrition and an increase in homestead garden cultivation. However, these dietary changes alone were likely insufficient to improve women's and children's nutritional status. Cultivation for income was less common 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. In sum, women's ability to take agricultural decisions varied considerably both prior to and after UPAVAN interventions.

The researchers suggest that 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.

Full list of authors, with institutional affiliations: Audrey Prost, University College London; Helen Harris‐Fry, London School of Hygiene & Tropical Medicine (LSHTM); Satyanarayan Mohanty, D‐COR Consulting Pvt. Ltd.; Manoj Parida, D‐COR Consulting Pvt. Ltd.; Sneha Krishnan, Jindal Global University; Emily Fivian, LSHTM; Suchitra Rath, Ekjut; Nirmala Nair, Ekjut; Naba K. Mishra, Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT); Shibanath Padhan, VARRAT; Ronali Pradhan, Digital Green; Satyapriya Sahu, Digital Green; Jolene Skordis, University College London; Heather Danton, JSI Research & Training Institute, Inc.; Peggy Koniz‐Booher, JSI Research & Training Institute, Inc.; Emma Beaumont, LSHTM; Philip James, LSHTM; Elizabeth Allen, LSHTM; Diana Elbourne, LSHTM; Suneetha Kadiyala, LSHTM