How to design a complex behaviour change intervention: experiences from a nutrition-sensitive agriculture trial in rural India

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

How to design a complex behaviour change intervention: experiences from a nutrition-sensitive agriculture trial in rural India.

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

A compendium of Technologies, Practices, Services and Policies for Scaling Climate Smart Agriculture in Odisha (India)

Stakeholders engaged in agricultural research for development (AR4D) are increasingly tackling risks associated with climate change in smallholder systems. Accordingly, development and scaling of climate-smart agriculture (CSA) are one of the priorities for all the organizations, departments and ministries associated with the farm sector. Having a ‘one-stop-shop’ compiled in the format of a compendium for CSA technologies, practices and services would therefore serve a guide for all the stakeholders for scaling CSA in smallholder systems. Bringing out a Compendium on Climate-Smart Agriculture (CSA) for Odisha, India was therefore thought of during the workshop on ‘Scaling Climate-Smart Agriculture in Odisha’ organized at Bhubaneswar on 18-19 July 2018 by International Rice Research Institute (IRRI) in collaboration with Department of Agriculture (DoA) & Farmers’ Empowerment, Indian Council of Agricultural Research-National Rice Research Institute (ICAR-NRRI), Orissa University of Agriculture and Technology (OUAT) & International Maize and Wheat Improvement Center (CIMMYT) under the aegis of CGIAR Research program on Climate Change, Agriculture and Food Security (CCAFS). The main objectives to bring forth this compendium are: to argue the case for agriculture policies and practices that are climate-smart; to raise awareness of what can be done to make agriculture policies and practices climatesmart; and to provide practical guidance and recommendations that are well referenced and, wherever possible, based on lessons learned from practical action. CSA programmes are unlikely to be effective unless their implementation is supported by sound policies and institutions. It is therefore important to enhance institutional capacities in order to implement and replicate CSA strategies. Institutions are vital to agricultural development as well as the realisation of resilient livelihoods.They are not only a tool for farmers and decision-makers, but are also the main conduit through which CSA practices can be scaled up and sustained. The focus in this compendium is on CSA and it’s relevant aspects, i.e., (i) technologies and practices, (ii) services, (iii) technology targeting, (iv) business models, (v) capacity building, and (vi) policies. The approaches and tools available in the compendium span from face-to-face technicianfarmer dialogues to more structured exchanges of online and offline e-learning. In every scenario it is clear that tailoring to local expectations and needs is key. In particular, the voice of farmers is essential to be captured as they are the key actors to promote sustainable agriculture, and their issues need to be prioritized. CSA practices are expected to sustainably increase productivity and resilience (adaptation), reduce Greenhouse Gases (mitigation), and enhance achievement of national food security along with sustainable development goals. CSA is widely expected to contribute towards achieving these objectives and enhance climate change adaptation. CSA practices have to be included in State’s Climate Policy as a priority intervention as the state steps up efforts to tackle climate change. Furthermore, emphasis shoud be laid on CSA training for a sustainable mode to enhance CSA adoption in the state hence the relevance of developing this document. The adaption of climate related knowledge, technologies and practices to local conditions, promoting joint learning by farmers, researchers, rural advisor and widely disseminating CSA practices, is critical. This compendium brings together a collection of experiences from different stakeholders with background of agricultural extension and rural advisory services in supporting CSA. The contributions are not intended to be state-of-the art academic articles but thought and discussion pieces of work in progress. The compendium itself is a ‘living‘ document which is intended to be revised periodically

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)

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

Rule of Thumb: Mobiles for governance in India

Between 1996 and 2012, India's standing dropped on five of the six indicators of governance developed by the World Bank. Today, with over 900 million mobile phone subscriptions, India's mobile revolution presents an unprecedented opportunity to address this deficit and bring good governance to the farthest corners of the country. Adding 10 mobile phones per 100 people in a developing country can lead to half a point of additional GDP growth per person. Rule of Thumb makes a case for m-governance, and for reimagining the ways in which governments and citizens function, transact and interact with each other. It also explores how, in India and the world over, non-profits and social businesses are marrying the ubiquity of mobile technology with governance systems and processes to produce great benefits for citizens and governments alike. Dasra mapped over 130 organizations and profiled the work of 11 organizations with the most impactful and scalable programs

Lifeline: Tech innovations for maternal and child health - Part 2

At 16% and 27%, India contributes the highest global share of maternal and new-born deaths. Most of these are preventable through simple, proven and low-cost solutions. With close to a billion mobile phones and over a million broadband connections, Information and Communication Technologies (ICTs) can address the key informational and process challenges to RMNCH+A in India.Dasra's report, Life Line, lays out the key challenges and solutions, alongside the work of scalable and impactful social organizations for funders' consideration

Body of Knowledge: Improving sexual and reproductive health for India's adolescents

Comprising one-fifth of India's population, adolescents are a significant demographic transitioning into adulthood. Adolescents making this transition experience rapid change and heightened vulnerability. The onset of puberty is a period wrought with challenges that impact an adolescent's sexual and reproductive health and rights (SRHR). Dasra's report, Body of Knowledge, highlights the challenges that adolescents face, the efforts of key stakeholders and the specific steps implementing organizations are taking on the ground to improve outcomes for adolescents. During this research, Dasra mapped 192 organizations working to improve sexual and reproductive health outcomes in India. This report profiles 22 organizations, whose work effectively represents the scope and breadth of the adolescent SRHR sector in India

Disposal of child faeces: practices, determinants and health effects.

An estimated 2.4 billion people worldwide lack access to improved sanitation. This includes nearly 1 billion people practicing open defecation, of which around 60% reside in India. Even among households with access to improved sanitation, children’s faeces—a potentially important source of disease transmission—are not always disposed of safely (disposal of faeces or defecation into latrine). In India only 20% of child faeces were reportedly disposed of safely in the latest National Family Health Survey (2006). This research has two overall aims. The first is to summarize existing knowledge of the health impact of safely disposing child faeces. The second is to advance our understanding of the scope and possible reasons for unsafe disposal of child faeces among a population in Eastern India. To achieve these aims a systematic review and cross-sectional study were conducted. The systematic review summarized the evidence on the effectiveness of interventions to improve child faeces disposal for preventing diarrhoea and soiltransmitted helminth (STH) infections from 46 studies. The evidence suggested that safe child faeces disposal may reduce diarrhoea. However, the evidence was limited and of low quality. Only 2 studies measured effects on STH, neither found a protective effect. Findings from the cross-sectional study in slums in Odisha, India, were divided into two papers. The first described child faeces management practices and identified potential sources of faecal exposure, highlighting the importance of considering other steps of child faeces management rather than just the place of disposal. The second paper investigated factors associated with being a safe disposal household, where the faeces of all children <5 ended up in a latrine. Significant risk factors were: education and religion of the primary caregiver, number and mobility of children <5 in the household, wealth, type and location of latrine, and defecation behaviours of household members >5

Promoting Handwashing and Sanitation Behaviour Change in Low- and Middle-Income Countries: A Mixed-Method Systematic Review

This systematic review shows which promotional approaches are effective in changing handwashing and sanitation behaviour and which implementation factors affect the success or failure of such interventions. The authors find that promotional approaches can be effective in terms of handwashing with soap, latrine use, safe faeces disposal and open defecation. No one specific approach is most effective. However, several promotional elements do induce behaviour change. Different barriers and facilitators that influence implementing promotional approaches should be carefully considered when developing new policy, programming, practice, or research in this area