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Nutrition‐sensitive agriculture (NSA) interventions offer a means to improve the dietary quality of rural, undernourished populations. Their effectiveness could be further increased by understanding how household dynamics enable or inhibit the uptake of NSA behaviours. We used a convergent parallel mixed‐methods design to describe the links between household dynamics—specifically intrahousehold power inequalities and intrahousehold cooperation—and dietary quality and to explore whether household dynamics mediated or modified the effects of NSA interventions tested in a cluster‐randomized trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN). We use quantitative data from cross‐sectional surveys in 148 village clusters at UPAVAN's baseline and 32 months afterwards (endline), and qualitative data from family case studies and focus group discussions with intervention participants and facilitators. We found that households cooperated to grow and buy nutritious foods, and gendered power inequalities were associated with women's dietary quality, but cooperation and women's use of power was inhibited by several interlinked factors. UPAVAN interventions were more successful in more supportive, cooperative households, and in some cases, the interventions increased women's decision‐making power. However, women's decisions to enter into negotiations with family members depended on whether women deemed the practices promoted by UPAVAN interventions to be feasible, as well as women's confidence and previous cultivation success. We conclude that interventions may be more effective if they can elicit cooperation from the whole household. This will require a move towards more family‐centric intervention models that empower women while involving other family members and accounting for the varied ways that families cooperate and negotiate. Key messages: Household cooperation and intrahousehold power inequalities may influence children's and mothers' dietary diversity in rural OdishaThese factors partly determine the effects of nutrition‐sensitive agriculture (NSA) interventions tested in Upscaling Participatory Action and Videos for Agriculture and Nutrition, indicating that NSA interventions may be more effective if they include multiple family members.There is wide heterogeneity in household dynamics and the constraints that families face. Further research is needed to identify how interventions can respond to this heterogeneity so that NSA interventions are effective in an inclusive and empowering way. [ABSTRACT FROM AUTHOR]

Background: Economic evaluations of nutrition-sensitive agriculture (NSA) interventions are scarce, limiting assessment of their potential affordability and scalability.Objectives: We conducted cost-consequence analyses of 3 participatory video-based interventions of fortnightly women's group meetings using the following platforms: 1) NSA videos; 2) NSA and nutrition-specific videos; or 3) NSA videos with a nutrition-specific participatory learning and action (PLA) cycle.Methods: Interventions were tested in a 32-mo, 4-arm cluster-randomized controlled trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) in the Keonjhar district, Odisha, India. Impacts were evaluated in children aged 0-23 mo and their mothers. We estimated program costs using data collected prospectively from expenditure records of implementing and technical partners and societal costs using expenditure assessment data collected from households with a child aged 0-23 mo and key informant interviews. Costs were adjusted for inflation, discounted, and converted to 2019 US$.Results: Total program costs of each intervention ranged from US$272,121 to US$386,907. Program costs per pregnant woman or mother of a child aged 0-23 mo were US$62 for NSA videos, US$84 for NSA and nutrition-specific videos, and US$78 for NSA videos with PLA (societal costs: US$125, US$143, and US$122, respectively). Substantial shares of total costs were attributable to development and delivery of the videos and PLA (52-69%) and quality assurance (25-41%). Relative to control, minimum dietary diversity was higher in the children who underwent the interventions incorporating nutrition-specific videos and PLA (adjusted RRs: 1.19 and 1.27; 95% CIs: 1.03-1.37 and 1.11, 1.46, respectively). Relative to control, minimum dietary diversity in mothers was higher in those who underwent NSA video (1.21 [1.01, 1.45]) and NSA with PLA (1.30 [1.10, 1.53]) interventions.Conclusion: NSA videos with PLA can increase both maternal and child dietary diversity and have the lowest cost per unit increase in diet diversity. Building on investments made in developing UPAVAN, cost-efficiency at scale could be increased with less intensive monitoring, reduced startup costs, and integration within existing government programs. This trial was registered at clinicaltrials.gov as ISRCTN65922679. [ABSTRACT FROM AUTHOR]

A trial of three nutrition‐sensitive agriculture interventions with participatory videos and women's group meetings in rural Odisha, India, found improvements in maternal and child dietary diversity, limited effects on agricultural production, and no effects on women and children's nutritional status. Our process evaluation explored fidelity, reach, and mechanisms behind interventions' effects. We also examined how context affected implementation, mechanisms, and outcomes. We 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). We found that interventions were implemented with high fidelity. 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. Families responded in diverse ways. Many adopted or improved rainfed homestead garden cultivation for consumption, which could explain gains in maternal and child dietary diversity seen in the impact evaluation. Cultivation for income was less common. This was often 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. Future nutrition‐sensitive agriculture interventions could include additional flexibility to address families' land, water, labour and time constraints, as well as actively engage with spouses and in‐laws. Key messages: In rural eastern India, participatory videos and women's group meetings on agriculture and maternal and child nutrition increased women's knowledge, motivation and confidence to improve their and their children's diets.Given strong constraints linked to small landholdings, poor access to water and gender norms which meant that in‐laws' and husbands' assent or support were often required for cultivation decisions, many women responded to interventions by increasing rainfed homestead garden cultivation for consumption rather than cultivating for income.Women's and children's diets may have improved because of discussions about nutrition and an increase in homestead garden cultivation. These dietary changes alone were likely insufficient to improve women's and children's nutritional status.The 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. [ABSTRACT FROM AUTHOR]

Objective: On average, boys grow faster than girls in early life but appear more susceptible to undernutrition. We investigated sex differences in early child growth, and whether maternal nutritional status and diet differed by offspring sex during and after pregnancy in an undernourished population. Methods: We analyzed longitudinal data from a cluster‐randomized trial from plains Nepal, stratifying results by child or gestational age. Children's outcomes (0–20 months) were weight, length, and head circumference and their z‐scores relative to WHO reference data in 2‐monthly intervals (n range: 24837 to 25 946). Maternal outcomes were mid‐upper arm circumference (MUAC), and body mass index (BMI) during pregnancy (12–40 weeks) (n = 5550 and n = 5519) and postpartum (n = 15 710 and n = 15 356), and diet in pregnancy. We fitted unadjusted and adjusted mixed‐effects linear and logistic regression models comparing boys with girls. Results: Boys were larger than girls, however relative to their sex‐specific reference they had lower length and head circumference z‐scores from birth to 12 months, but higher weight‐for‐length z‐scores from 0 to 6 months. Mothers of sons had higher MUAC and BMI around 36 weeks gestation but no other differences in pregnancy diets or pregnancy/postpartum maternal anthropometry were detected. Larger sex differences in children's size in the food supplementation study arm suggest that food restriction in pregnancy may limit fetal growth of boys more than girls. Conclusions: Generally, mothers' anthropometry and dietary intake do not differ according to offspring sex. As boys are consistently larger, we expect that poor maternal nutritional status may compromise their growth more than girls. Copyright © 2021 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Optimising child feeding behaviours could improve child health in Guatemala, Honduras and El Salvador, where undernutrition rates remain high. However, the design of interventions to improve child feeding behaviours is limited by piecemeal, theoretically underdeveloped evidence on factors that may influence these behaviours. Between July 2018 and January 2020, we systematically searched Cochrane, Medline, EMBASE, Global Health and LILACS databases, grey literature websites and reference lists, for evidence of region‐specific causes of child feeding behaviours and the effectiveness of related interventions and policies. The Behaviour Change Wheel was used as a framework to synthesise and map the resulting literature. We identified 2,905 records and included 68 relevant studies of mixed quality, published between 1964 and 2019. Most (n = 50) were quantitative, 15 were qualitative and three used mixed methods. A total of 39 studies described causes of child feeding behaviour; 29 evaluated interventions or policies. Frequently cited barriers to breastfeeding included mothers' beliefs and perceptions of colostrum and breast milk sufficiency; fears around child illness; and familial and societal pressures, particularly from paternal grandmothers. Child diets were influenced by similar beliefs and mothers' lack of money, time and control over household finances and decisions. Interventions (n = 22) primarily provided foods or supplements with education, resulting in mixed effects on breastfeeding and child diets. Policy evaluations (n = 7) showed positive and null effects on child feeding practices. We conclude that interventions should address context‐specific barriers to optimal feeding behaviours, use behaviour change theory to apply appropriate techniques and evaluate impact using robust research methods. [ABSTRACT FROM AUTHOR]

Land size is an important equity concern for the design of 'nutrition‐sensitive' agricultural interventions. We unpack some of the pathways between land and nutrition using a cross‐sectional baseline survey data set of 4,480 women from 148 clusters from the 'Upscaling Participatory Action and Videos for Agriculture and Nutrition' trial in Keonjhar district in Odisha, India. Variables used are household ln‐land size owned (exposure) and maternal dietary diversity score out of 10 food groups and body mass index (BMI; kg/m2) (outcomes); and mediators investigated are production diversity score, value of agricultural production, and indicators for women's empowerment (decision‐making in agriculture, group participation, work‐free time and land ownership). We assessed mediation using a non‐parametric potential outcomes framework method. Land size positively affects maternal dietary diversity scores [β 0.047; 95% confidence interval (CI) (0.011, 0.082)] but not BMI. Production diversity, but not value of production, accounts for 17.6% of total effect mediated. We observe suppression of the effect of land size on BMI, with no evidence of a direct effect for either of the agricultural mediators but indirect effects of β −0.031 [95% CI (−0.048, −0.017)] through production diversity and β −0.047 [95% CI (−0.075, −0.021)] through value of production. An increase in land size positively affects women's decision‐making, which in turn negatively affects maternal BMI. The positive effect of work‐free time on maternal BMI is suppressed by the negative effect of household land size on work‐free time. Agriculture interventions must consider land quality, women's decision‐making and implications for women's workload in their design. [ABSTRACT FROM AUTHOR]

Background: There is scarce evidence on the impacts of food transfers, cash transfers, or women's groups on food sharing, dietary intakes, or nutrition during pregnancy, when nutritional needs are elevated.Objective: This study measured the effects of 3 pregnancy-focused nutrition interventions on intrahousehold food allocation, dietary adequacy, and maternal nutritional status in Nepal.Methods: Interventions tested in a cluster-randomized controlled trial (ISRCTN 75964374) were "Participatory Learning and Action" (PLA) monthly women's groups, PLA with transfers of 10 kg fortified flour ("Super Cereal"), and PLA plus transfers of 750 Nepalese rupees (∼US$7.5) to pregnant women. Control clusters received usual government services. Primary outcomes were Relative Dietary Energy Adequacy Ratios (RDEARs) between pregnant women and male household heads and pregnant women and their mothers-in-law. Diets were measured by repeated 24-h dietary recalls.Results: Relative to control, RDEARs between pregnant women and their mothers-in-law were 12% higher in the PLA plus food arm (log-RDEAR coefficient = 0.12; 95% CI: 0.02, 0.21; P = 0.014), but 10% lower in the PLA-only arm between pregnant women and male household heads (-0.11; 95% CI: -0.19, -0.02; P = 0.020). In all interventions, pregnant women's energy intakes did not improve, but odds of pregnant women consuming iron-folate supplements were 2.5-4.6 times higher, odds of pregnant women consuming more animal-source foods than the household head were 1.7-2.4 times higher, and midupper arm circumference was higher relative to control. Dietary diversity was 0.4 food groups higher in the PLA plus cash arm than in the control arm.Conclusions: All interventions improved maternal diets and nutritional status in pregnancy. PLA women's groups with food transfers increased equity in energy allocation, whereas PLA with cash improved dietary diversity. PLA alone improved diets, but effects were mixed. Scale-up of these interventions in marginalized populations is a policy option, but researchers should find ways to increase adherence to interventions. This trial was registered at www.controlled-trials.com as ISRCTN 75964374. [ABSTRACT FROM AUTHOR]

Objective: To outline the development of a smartphone-based tool to collect thrice-repeated 24 h dietary recall data in rural Nepal, and to describe energy intakes, common errors and researchers' experiences using the tool.Design: We designed a novel tool to collect multi-pass 24 h dietary recalls in rural Nepal by combining the use of a CommCare questionnaire on smartphones, a paper form, a QR (quick response)-coded list of foods and a photographic atlas of portion sizes. Twenty interviewers collected dietary data on three non-consecutive days per respondent, with three respondents per household. Intakes were converted into nutrients using databases on nutritional composition of foods, recipes and portion sizes.Setting: Dhanusha and Mahottari districts, Nepal.Subjects: Pregnant women, their mothers-in-law and male household heads. Energy intakes assessed in 150 households; data corrections and our experiences reported from 805 households and 6765 individual recalls.Results: Dietary intake estimates gave plausible values, with male household heads appearing to have higher energy intakes (median (25th-75th centile): 12 079 (9293-14 108) kJ/d) than female members (8979 (7234-11 042) kJ/d for pregnant women). Manual editing of data was required when interviewers mistook portions for food codes and for coding items not on the food list. Smartphones enabled quick monitoring of data and interviewer performance, but we initially faced technical challenges with CommCare forms crashing.Conclusions: With sufficient time dedicated to development and pre-testing, this novel smartphone-based tool provides a useful method to collect data. Future work is needed to further validate this tool and adapt it for other contexts. [ABSTRACT FROM AUTHOR]

Background: Nutrition interventions, often delivered at the household level, could increase their efficiency by channelling resources towards pregnant or lactating women, instead of leaving resources to be disproportionately allocated to traditionally favoured men. However, understanding of how to design targeted nutrition programs is limited by a lack of understanding of the factors affecting the intra-household allocation of food. Methods: We systematically reviewed literature on the factors affecting the allocation of food to adults in South Asian households (in Afghanistan, Bangladesh, Bhutan, India, Islamic Republic of Iran, Maldives, Nepal, Pakistan, Sri Lanka) and developed a framework of food allocation determinants. Two reviewers independently searched and filtered results from PubMed, Web of Knowledge and Scopus databases by using pre-defined search terms and hand-searching the references from selected papers. Determinants were extracted, categorised into a framework, and narratively described. We used adapted Downs and Black and Critical Appraisal Skills Programme checklists to assess the quality of evidence. Results: Out of 6928 retrieved studies we found 60 relevant results. Recent, high quality evidence was limited and mainly from Bangladesh, India and Nepal. There were no results from Iran, Afghanistan, Maldives, or Bhutan. At the intra-household level, food allocation was determined by relative differences in household members' income, bargaining power, food behaviours, social status, tastes and preferences, and interpersonal relationships. Household-level determinants included wealth, food security, occupation, land ownership, household size, religion / ethnicity / caste, education, and nutrition knowledge. In general, the highest inequity occurred in households experiencing severe or unexpected food insecurity, and also in better-off, high caste households, whereas poorer, low caste but not severely food insecure households were more equitable. Food allocation also varied regionally and seasonally. Conclusion: Program benefits may be differentially distributed within households of different socioeconomic status, and targeting of nutrition programs might be improved by influencing determinants that are amenable to change, such as food security, women's employment, or nutrition knowledge. Longitudinal studies in different settings could unravel causal effects. Conclusions are not generalizable to the whole South Asian region, and research is needed in many countries. [ABSTRACT FROM AUTHOR]

ObjectiveTo develop and validate a photographic food atlas of common foods for dietary assessment in southern Nepal.DesignWe created a life-sized photographic atlas of forty locally prepared foods. Between March and June 2014, data collectors weighed portion sizes that respondents consumed during one mealtime and then a different data collector revisited the household the next day to record respondents’ estimations of their previous day’s intakes using the atlas. Validity was assessed by percentage error, Cohen’s weighted kappa (κw) and Bland–Altman limits of agreement.SettingDhanusha and Mahottari districts in southern Nepal.SubjectsA random sample of ninety-five adults in forty-eight rural households with a pregnant woman.ResultsOverall, respondents underestimated their intakes (mean error =−4·5 %). Rice and dal (spiced lentil soup) intakes were underestimated (−14·1 % and −34·5 %, respectively), but vegetable curry intake was overestimated (+20·8 %). Rice and vegetable curry portion size images were significantly reliably selected (Cohen’s κw (se): rice=0·391 (0·105); vegetable curry=0·430 (0·139)), whereas dal images were not. Energy intake over one mealtime was under-reported by an average of 569 kJ (136 kcal; 4·5 % error) using recall compared with the weighing method.ConclusionsThe photographic atlas is a useful tool for field estimation of dietary intake. Average errors were low, and there was ‘modest’ agreement between weighed and recalled portion size image selection of rice and vegetable curry food items. Error in energy estimation was low but with wide limits of agreement, suggesting that there is scope for future work to reduce error further. [ABSTRACT FROM PUBLISHER]

• Household Consumption Expenditure Surveys (HCES) can overestimate household intakes. • The use of Adult Male Equivalents (AME) underestimates of women's shares of foods. • Large errors in potential impact of fortification for foods eaten in small amounts. • Low agreement of HCES and diet recall driven by quantification error more than AME. • Correction factors from small samples of diet recalls can reduce HCES biases. Household Consumption Expenditure Survey (HCES) data are increasingly used to inform nutrition policy around the world, most prominently for food fortification programs. However, they risk providing incorrect and gender-biased estimates of dietary intakes. We use both 7-day HCES and 24-hour dietary recall (24HR) data on all members of 5604 households in rural Bangladesh to disentangle the two main sources of error: 1) mismeasurement of household consumption, and 2) intra-household allocation assumptions used to individualize household consumption. We show that, relative to 24HR, HCES overestimate household-level quantities and underestimate women's share of household foods. Errors from modeling the potential benefits and risks of fortification depend on the food – better measurement is needed for foods consumed episodically (e.g. wheat flour or sugar) or in small quantities (e.g. salt and oil). Beyond mean bias, we find poor and heteroskedastic agreement between HCES and 24HR methods, which is more driven by mismeasurement of food quantities than the application of flawed assumptions about food allocation – at least in the Bangladeshi context. We demonstrate a novel generalizable method for improving HCES intake estimates by drawing on the advantages of both HCES and 24HR data. Using a small sample of 24HR data to generate context- and food-specific quantity and allocation corrections, we can almost eliminate mean bias. With further validation, we hope our proposed method can be used to ensure that HCES estimates account for locally-specific measurement error and gender norms, and that nutrition policy based on these data will be safer and more gender-sensitive. [ABSTRACT FROM AUTHOR]

Background: The Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) indicator was validated as a proxy of micronutrient adequacy among nonpregnant women in low- and middle-income countries (LMICs). At that time, indeed, there was insufficient data to validate the indicator among pregnant women, who face higher micronutrient requirements. Objective: This study aimed to validate a minimum food group consumption threshold, out of the 10 food groups used to construct MDD-W, to be used as a population-level indicator of higher micronutrient adequacy among pregnant women aged 15-49 y in LMICs. Methods: We used secondary quantitative 24-h recall data from 6 surveys in 4 LMICs (Bangladesh, Burkina Faso, India, and Nepal, total n = 4909). We computed the 10-food group Women's Dietary Diversity Score (WDDS-10) and calculated the mean probability of adequacy (MPA) of 11 micronutrients. Linear regression models were fitted to assess the associations between WDDS-10 and MPA. Sensitivity, specificity, and proportion of individuals correctly classified were used to assess the performance of MDD-W in predicting an MPA of >0.60. Results: In the pooled sample, median values (interquartile range) of WDDS-10 and MPA were 3 (1) and 0.20 (0.34), respectively, whereas the proportion of pregnant women with an MPA of >0.60 was 9.6%. The WDDS-10 was significantly positively associated with MPA in each survey. Although the acceptable food group consumption threshold varied between 4 and 6 food groups across surveys, the threshold of 5 showed the highest performance in the pooled sample with good sensitivity (62%), very good specificity (81%), and percentage of correctly classified individuals (79%). Conclusions: The WDDS-10 is a good predictor of dietary micronutrient adequacy among pregnant women aged 15-49 y in LMICs. Moreover, the threshold of 5 or more food groups for the MDD-W indicator may be extended to all women of reproductive age, regardless of their physiologic status. [ABSTRACT FROM AUTHOR]

Introduction: Micronutrient deficiencies are prevalent in Nepal where starchy foods constitute a large proportion of diets and consumption of micronutrient-rich foods is inadequate. We conducted a study to determine whether rice would be an appropriate vehicle for micronutrient fortification in Nepal. Materials and methods: In Bajura in remote rural Nepal, we conducted a household survey to characterize rice intakes in 195 households, and a double-blinded acceptability test with 177 social safety net rice consumers ≥18 years of age. Of these, 168 tasted fortified and unfortified rice to assess whether respondents could differentiate between fortified and non-fortified rice and their sensory properties. Rice was fortified by blending hot extruded kernels containing 6 micronutrients together with non-fortified rice at a 1:99 ratio. We used binomial tests to assess whether participants could correctly differentiate fortified rice, from non-fortified rice and paired t-tests to compare scores for sensory qualities of cooked fortified and non-fortified rice. We used multiple regression to test associations between per capita consumption and age, gender, wealth and food security. Results: Per capita consumption of rice (median 216g/day, IQR 144.0, 288.0) did not vary by wealth but was +52.08g, (95% CI 10.43, 93.72) higher amongst moderately to severely food insecure households compared with food secure / mildly food insecure. Most respondents could not differentiate fortified rice from non-fortified rice: 37.5% identified uncooked fortified rice and 39.3% cooked rice, which was not different from the 33% expected by chance (p = 0.22 and p = 0.09 respectively). The sensory qualities of fortified rice were acceptable (scoring 3.9 out of 5) and did not differ from non-fortified rice (p>0.05). Conclusion: A rice fortification programme implemented through the Nepal Food Corporation’s social safety nets has potential because purchase and consumption of rice is high and fortified rice is acceptable among consumers in remote food insecure areas of Nepal. [ABSTRACT FROM AUTHOR]

Background: There has been limited decline in undernutrition rates in South Asia compared with the rest of Asia and one reason for this may be low levels of household food security. However, the evidence base on the determinants of household food security is limited. To develop policies intended to improve household food security, improved knowledge of the determinants of household food security is required. Methods: Household data were collected in 2011 from a randomly selected sample of 2,809 women of reproductive age. The sample was drawn from nine unions in three districts of rural Bangladesh. Multinomial logistic regression was conducted to measure the relationship between selected determinants of household food security and months of adequate household food provisioning, and a linear regression to measure the association between the same determinants and women's dietary diversity score. Results: The analyses found that land ownership, adjusted relative risk ratio (RRR) 0.28 (CI 0.18, 0.42); relative wealth (middle tertile 0.49 (0.29, 0.84) and top tertile 0.18 (0.10, 0.33)); women's literacy 0.64 (0.46, 0.90); access to media 0.49 (0.33, 0.72); and women's freedom to access the market 0.56 (0.36, 0.85) all significantly reduced the risk of food insecurity. Larger households increased the risk of food insecurity, adjusted RRR 1.46 (CI 1.02, 2.09). Households with vegetable gardens 0.20 (0.11, 0.31), rich households 0.46 (0.24, 0.68) and literate women 0.37 (0.20, 0.54) were significantly more likely to have better dietary diversity scores. Conclusion: Household food insecurity remains a key public health problem in Bangladesh, with households suffering food shortages for an average of one quarter of the year. Simple survey and analytical methods are able to identify numerous interlinked factors associated with household food security, but wealth and literacy were the only two determinants associated with both improved food security and dietary diversity. We cannot conclude whether improvements in all determinants are necessarily needed to improve household food security, but new and existing policies that relate to these determinants should be designed and monitored with the knowledge that they could substantially influence the food security and nutritional status of the population. [ABSTRACT FROM AUTHOR]

Objective: To explore the factors affecting intra-household food allocation practices to inform the development of interventions to prevent low birth weight in rural plains of Nepal.Design: Qualitative methodology using purposive sampling to explore the barriers and facilitating factors to improved maternal nutrition.Setting: Rural Dhanusha District, Nepal.Subjects: We purposively sampled twenty-five young daughters-in-law from marginalised groups living in extended families and conducted semi-structured interviews with them. We also conducted one focus group discussion with men and one with female community health volunteers who were mothers-in-law.Results: Gender and age hierarchies were important in household decision making. The mother-in-law was responsible for ensuring that a meal was provided to productive household members. The youngest daughter-in-law usually cooked last and ate less than other family members, and showed respect for other family members by cooking only when permitted and deferring to others' choice of food. There were limited opportunities for these women to snack between main meals. Daughters-in-law' movement outside the household was restricted and therefore family members perceived that their nutritional need was less. Poverty affected food choice and families considered cost before nutritional value.Conclusions: It is important to work with the whole household, particularly mothers-in-law, to improve maternal nutrition. We present five barriers to behaviour change: poverty; lack of knowledge about cheap nutritional food, the value of snacking, and cheap nutritional food that does not require cooking; sharing food; lack of self-confidence; and deference to household guardians. We discuss how we have targeted our interventions to develop knowledge, discuss strategies to overcome barriers, engage mothers-in-law, and build the confidence and social support networks of pregnant women. [ABSTRACT FROM AUTHOR]

Background: Anemia is estimated to cause 115,000 maternal deaths each year. In Nepal, 46% of pregnant women have anemia. As part of an integrated anemia-prevention strategy, family engagement and counseling of pregnant women can increase compliance to iron folic acid tablets, but marginalized women often have lower access to these interventions. We implemented the VALID (Virtual antenatal intervention for improved diet and iron intake) randomized controlled trial to test a family-focused virtual counseling mHealth intervention designed to inclusively increase iron folic acid compliance in rural Nepal; here we report findings from our process evaluation research. Methods: We conducted semi structured interviews with 20 pregnant women who had received the intervention, eight husbands, seven mothers-in-laws and four health workers. We did four focus groups discussions with intervention implementers, 39 observations of counseling, and used routine monitoring data in our evaluation. We used inductive and deductive analysis of qualitative data, and descriptive statistics of monitoring data. Results: We were able to implement the intervention largely as planned and all participants liked the dialogical counseling approach and use of story-telling to trigger conversation. However, an unreliable and inaccessible mobile network impeded training families about how to use the mobile device, arrange the counseling time, and conduct the counseling. Women were not equally confident using mobile devices, and the need to frequently visit households to troubleshoot negated the virtual nature of the intervention for some. Women's lack of agency restricted both their ability to speak freely and their mobility, which meant that some women were unable to move to areas with better mobile reception. It was difficult for some women to schedule the counseling, as there were competing demands on their time. Family members were difficult to engage because they were often working outside the home; the small screen made it difficult to interact, and some women were uncomfortable speaking in front of family members. Conclusions: It is important to understand gender norms, mobile access, and mobile literacy before implementing an mHealth intervention. The contextual barriers to implementation meant that we were not able to engage family members as much as we had hoped, and we were not able to minimize in-person contact with families. We recommend a flexible approach to mHealth interventions which can be responsive to local context and the situation of participants. Home visits may be more effective for those women who are most marginalized, lack confidence in using a mobile device, and where internet access is poor. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic affected access to antenatal care in low and middle-income countries where anaemia in pregnancy is prevalent. We analyse how health workers provided antenatal care and the factors affecting access to antenatal care during the COVID-19 pandemic in Kapilvastu district in the western plains of Nepal. We used qualitative and quantitative methodologies, conducting eight semi-structured interviews with health workers who provided antenatal care during the pandemic, and a questionnaire containing open and closed questions with 52 female community health volunteers. Antenatal care was severely disrupted during the pandemic. Health workers had to find ways to provide care with insufficient personal protective equipment and guidance whilst facing extreme levels of stigmatisation which prevented them from providing outreach services. Pregnant women were fearful or unable to visit health institutions during the pandemic because of COVID-19 control measures. Pre-pandemic and during the pandemic health workers tried to contact pregnant and postpartum women and families over the phone, but this was challenging because of limited access to phones, and required pregnant women to make at least one antenatal care visit to give their phone number. The pandemic prevented new pregnancies from being registered, and therefore the possibilities to provide services over the phone for these pregnancies were limited. To reach the most marginalised during a pandemic or other health emergency, health volunteers and households need to exchange phone numbers, enabling proactive monitoring and care-seeking. Strengthening procurement and coordination between the municipal, provincial, and federal levels of government is needed to ensure adequacy of antenatal supplies, such as iron folic acid tablets, in health emergencies. Community engagement is important to ensure women and families are aware of the need to access antenatal care and iron folic acid, and to address stigmatisation of health workers. [ABSTRACT FROM AUTHOR]

Background: Anaemia in pregnancy remains prevalent in Nepal and causes severe adverse health outcomes.Methods: This non-blinded cluster-randomised controlled trial in the plains of Nepal has two study arms: (1) Control: routine antenatal care (ANC); (2) Home visiting, iron supplementation, Participatory Learning and Action (PLA) groups, plus routine ANC. Participants, including women in 54 non-contiguous clusters (mean 2582; range 1299-4865 population) in Southern Kapilbastu district, are eligible if they consent to menstrual monitoring, are resident, married, aged 13-49 years and able to respond to questions. After 1-2 missed menses and a positive pregnancy test, consenting women < 20 weeks' gestation, who plan to reside locally for most of the pregnancy, enrol into trial follow-up. Interventions comprise two home-counselling visits (at 12-21 and 22-26 weeks' gestation) with iron folic acid (IFA) supplement dosage tailored to women's haemoglobin concentration, plus monthly PLA women's group meetings using a dialogical problem-solving approach to engage pregnant women and their families. Home visits and PLA meetings will be facilitated by auxiliary nurse midwives. The hypothesis is as follows: Haemoglobin of women at 30 ± 2 weeks' gestation is ≥ 0.4 g/dL higher in the intervention arm than in the control. A sample of 842 women (421 per arm, average 15.6 per cluster) will provide 88% power, assuming SD 1.2, ICC 0.09 and CV of cluster size 0.27. Outcomes are captured at 30 ± 2 weeks gestation. Primary outcome is haemoglobin concentration (g/dL). Secondary outcomes are as follows: anaemia prevalence (%), mid-upper arm circumference (cm), mean probability of micronutrient adequacy (MPA) and number of ANC visits at a health facility. Indicators to assess pathways to impact include number of IFA tablets consumed during pregnancy, intake of energy (kcal/day) and dietary iron (mg/day), a score of bioavailability-enhancing behaviours and recall of one nutrition knowledge indicator. Costs and cost-effectiveness of the intervention will be estimated from a provider perspective. Using constrained randomisation, we allocated clusters to study arms, ensuring similarity with respect to cluster size, ethnicity, religion and distance to a health facility. Analysis is by intention-to-treat at the individual level, using mixed-effects regression.Discussion: Findings will inform Nepal government policy on approaches to increase adherence to IFA, improve diets and reduce anaemia in pregnancy.Trial Registration: ISRCTN 12272130 . [ABSTRACT FROM AUTHOR]

Maternal anaemia prevalence in low‐income countries is unacceptably high. Our research explored the individual‐, family‐ and community‐level factors affecting antenatal care uptake, iron folic acid (IFA) intake and consumption of micronutrient‐rich diets among pregnant women in the plains of Nepal. We discuss how these findings informed the development of a home visit and community mobilisation intervention to reduce anaemia in pregnancy. We used a qualitative methodology informed by the socio‐ecological framework, conducting semi‐structured interviews with recently pregnant women and key informants, and focus group discussions with mothers‐in‐law and fathers. We found that harmful gender norms restricted women's access to nutrient‐rich food, restricted their mobility and access to antenatal care. These norms also restricted fathers' role to that of the provider, as opposed to the caregiver. Pregnant women, mothers‐in‐law and fathers lacked awareness about iron‐rich foods and how to manage the side effects of IFA. Fathers lacked trust in government health facilities affecting access to care and trust in the efficacy of IFA. Our research informed interventions by (1) informing the development of intervention tools and training; (2) informing the intervention focus to engaging mothers‐in‐law and men to enable behaviour change; and (3) demonstrating the need to work in synergy across individual, family and community levels to address power and positionality, gender norms, trust in health services and harmful norms. Participatory groups and home visits will enable the development and implementation of feasible and acceptable strategies to address family and contextual issues generating knowledge and an enabling environment for behaviour change. [ABSTRACT FROM AUTHOR]

Objective: To model the potential impact and equity impact of fortifying rice on nutritional adequacy of different subpopulations in Nepal.Design: Using 24-h dietary recall data and a household consumption survey, we estimated: rice intakes; probability of adequacy (PA) of eight micronutrients commonly fortified in rice (vitamin A, niacin (B3), pyridoxine (B6), cobalamin (B12), thiamin (B1), folate (B9), Fe and Zn) plus riboflavin (B2), vitamin C and Ca and mean probability of adequacy (MPA) of these micronutrients. We modelled: no fortification; fortification of purchased rice, averaged across all households and in rice-buying households only. We compared adequacy increases between population subgroups.Setting: (i) Dhanusha and Mahottari districts of Nepal (24-h recall) and (ii) all agro-ecological zones of Nepal (consumption data).Participants: (i) Pregnant women (n 128), mothers-in-law and male household heads; (ii) households (n 4360).Results: Unfortified diets were especially inadequate in vitamins B12, A, B9, Zn and Fe. Fortification of purchased rice in rice-purchasing households increased PA > 0·9 for thiamin, niacin, B6, folate and Zn, but B12 and Fe remained inadequate even after fortification (PA range 0·3-0·9). Pregnant women's increases exceeded men's for thiamin, niacin, B6, folate and MPA; men had larger gains in vitamin A, B12 and Zn. Adequacy improved more in the hills (coefficient 0·08 (95 % CI 0·05, 0·10)) and mountains (coefficient 0·07 (95 % CI 0·01, 0·14)) but less in rural areas (coefficient -0·05 (95 % CI -0·09, -0·01)).Conclusions: Consumption of purchased fortified rice improves adequacy and gender equity of nutrient intake, especially in non-rice-growing areas. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Maternal and child undernutrition have adverse consequences for pregnancy outcomes and child morbidity and mortality, and they are associated with low educational attainment, economic productivity as an adult, and human wellbeing. 'Nutrition-sensitive' agriculture programs could tackle the underlying causes of undernutrition.Methods/design: This study is a four-arm cluster randomised controlled trial in Odisha, India. Interventions are as follows: (1) an agricultural extension platform of women's groups viewing and discussing videos on nutrition-sensitive agriculture (NSA) practices, and follow-up visits to women at home to encourage the adoption of new practices shown in the videos; (2) women's groups viewing and discussing videos on NSA and nutrition-specific practices, with follow-up visits; and (3) women's groups viewing and discussing videos on NSA and nutrition-specific practices combined with a cycle of Participatory Learning and Action meetings, with follow-up visits. All arms, including the control, receive basic nutrition training from government community frontline workers. Primary outcomes, assessed at baseline and 32 months after the start of the interventions, are (1) percentage of children aged 6-23 months consuming ≥ 4 out of 7 food groups per day and (2) mean body mass index (BMI) (kg/m2) of non-pregnant, non-postpartum (gave birth > 42 days ago) mothers or female primary caregivers of children aged 0-23 months. Secondary outcomes are percentage of mothers consuming ≥ 5 out of 10 food groups per day and percentage of children's weight-for-height z-score < -2 standard deviations (SD). The unit of randomisation is a cluster, defined as one or more villages with a combined minimum population of 800 residents. There are 37 clusters per arm, and outcomes will be assessed in an average of 32 eligible households per cluster. For randomisation, clusters are stratified by distance to nearest town (< 10 km or ≥ 10 km), and low (< 30%), medium (30-70%), or high (> 70%) proportion of Scheduled Tribe or Scheduled Caste (disadvantaged) households. A process evaluation will assess the quality of implementation and mechanisms behind the intervention effects. A cost-consequence analysis will compare incremental costs and outcomes of the interventions.Discussion: This trial will contribute evidence on the impacts of NSA extension through participatory, low-cost, video-based approaches on maternal and child nutrition and on whether integration with nutrition-specific goals and enhanced participatory approaches can increase these impacts.Trial Registration: ISRCTN , ISRCTN65922679 . Registered on 21 December 2016. [ABSTRACT FROM AUTHOR]

Background: Undernutrition during pregnancy leads to low birthweight, poor growth and inter-generational undernutrition. We did a non-blinded cluster-randomised controlled trial in the plains districts of Dhanusha and Mahottari, Nepal to assess the impact on birthweight and weight-for-age z-scores among children aged 0–16 months of community-based participatory learning and action (PLA) women’s groups, with and without food or cash transfers to pregnant women. Methods: We randomly allocated 20 clusters per arm to four arms (average population/cluster = 6150). All consenting married women aged 10–49 years, who had not had tubal ligation and whose husbands had not had vasectomy, were monitored for missed menses. Between 29 Dec 2013 and 28 Feb 2015 we recruited 25,092 pregnant women to surveillance and interventions: PLA alone (n = 5626); PLA plus food (10 kg/month of fortified wheat-soya ‘Super Cereal’, n = 6884); PLA plus cash (NPR750≈US$7.5/month, n = 7272); control (existing government programmes, n = 5310). 539 PLA groups discussed and implemented strategies to improve low birthweight, nutrition in pregnancy and hand washing. Primary outcomes were birthweight within 72 hours of delivery and weight-for-age z-scores at endline (age 0–16 months). Only children born to permanent residents between 4 June 2014 and 20 June 2015 were eligible for intention to treat analyses (n = 10936), while in-migrating women and children born before interventions had been running for 16 weeks were excluded. Trial status: completed. Results: In PLA plus food/cash arms, 94–97% of pregnant women attended groups and received a mean of four transfers over their pregnancies. In the PLA only arm, 49% of pregnant women attended groups. Due to unrest, the response rate for birthweight was low at 22% (n = 2087), but response rate for endline nutritional and dietary measures exceeded 83% (n = 9242). Compared to the control arm (n = 464), mean birthweight was significantly higher in the PLA plus food arm by 78·0 g (95% CI 13·9, 142·0; n = 626) and not significantly higher in PLA only and PLA plus cash arms by 28·9 g (95% CI -37·7, 95·4; n = 488) and 50·5 g (95% CI -15·0, 116·1; n = 509) respectively. Mean weight-for-age z-scores of children aged 0–16 months (average age 9 months) sampled cross-sectionally at endpoint, were not significantly different from those in the control arm (n = 2091). Differences in weight for-age z-score were as follows: PLA only -0·026 (95% CI -0·117, 0·065; n = 2095); PLA plus cash -0·045 (95% CI -0·133, 0·044; n = 2545); PLA plus food -0·033 (95% CI -0·121, 0·056; n = 2507). Amongst many secondary outcomes tested, compared with control, more institutional deliveries (OR: 1.46 95% CI 1.03, 2.06; n = 2651) and less colostrum discarding (OR:0.71 95% CI 0.54, 0.93; n = 2548) were found in the PLA plus food arm but not in PLA alone or in PLA plus cash arms. Interpretation: Food supplements in pregnancy with PLA women’s groups increased birthweight more than PLA plus cash or PLA alone but differences were not sustained. Nutrition interventions throughout the thousand-day period are recommended. Trial registration: . [ABSTRACT FROM AUTHOR]

The increasing availability and capabilities of mobile phones make them a feasible means of data collection. Electronic Data Capture (EDC) systems have been used widely for public health monitoring and surveillance activities, but documentation of their use in complicated research studies requiring multiple systems is limited. This paper shares our experiences of designing and implementing a complex multi-component EDC system for a community-based four-armed cluster-Randomised Controlled Trial in the rural plains of Nepal, to help other researchers planning to use EDC for complex studies in low-income settings. We designed and implemented three interrelated mobile phone data collection systems to enrol and follow-up pregnant women (trial participants), and to support the implementation of trial interventions (women’s groups, food and cash transfers). 720 field staff used basic phones to send simple coded text messages, 539 women’s group facilitators used Android smartphones with Open Data Kit Collect, and 112 Interviewers, Coordinators and Supervisors used smartphones with CommCare. Barcoded photo ID cards encoded with participant information were generated for each enrolled woman. Automated systems were developed to download, recode and merge data for nearly real-time access by researchers. The systems were successfully rolled out and used by 1371 staff. A total of 25,089 pregnant women were enrolled, and 17,839 follow-up forms completed. Women’s group facilitators recorded 5717 women’s groups and the distribution of 14,647 food and 13,482 cash transfers. Using EDC sped up data collection and processing, although time needed for programming and set-up delayed the study inception. EDC using three interlinked mobile data management systems (FrontlineSMS, ODK and CommCare) was a feasible and effective method of data capture in a complex large-scale trial in the plains of Nepal. Despite challenges including prolonged set-up times, the systems met multiple data collection needs for users with varying levels of literacy and experience. [ABSTRACT FROM PUBLISHER]

Low birth weight (LBW, < 2500 g) affects one third of newborn infants in rural south Asia and compromises child survival, infant growth, educational performance and economic prospects. We aimed to assess the impact on birth weight and weight-for-age Z-score in children aged 0-16 months of a nutrition Participatory Learning and Action behaviour change strategy (PLA) for pregnant women through women's groups, with or without unconditional transfers of food or cash to pregnant women in two districts of southern Nepal. Methods: The study is a cluster randomised controlled trial (non-blinded). PLA comprises women's groups that discuss, and form strategies about, nutrition in pregnancy, low birth weight and hygiene. Women receive up to 7 monthly transfers per pregnancy: cash is NPR 750 (~US$7) and food is 10 kg of fortified sweetened wheat-soya Super Cereal per month. The unit of randomisation is a rural village development committee (VDC) cluster (population 4000-9200, mean 6150) in southern Dhanusha or Mahottari districts. 80 VDCs are randomised to four arms using a participatory 'tombola' method. Twenty clusters each receive: PLA; PLA plus food; PLA plus cash; and standard care (control). Participants are (mostly Maithili-speaking) pregnant women identified from 8 weeks' gestation onwards, and their infants (target sample size 8880 birth weights). After pregnancy verification, mothers may be followed up in early and late pregnancy, within 72 h, after 42 days and within 22 months of birth. Outcomes pertain to the individual level. Primary outcomes include birth weight within 72 h of birth and infant weight-for-age Z-score measured cross-sectionally on children born of the study. Secondary outcomes include prevalence of LBW, eating behaviour and weight during pregnancy, maternal and newborn illness, preterm delivery, miscarriage, stillbirth or neonatal mortality, infant Z-scores for length-for-age and weight-for-length, head circumference, and postnatal maternal BMI and mid-upper arm circumference. Exposure to women's groups, food or cash transfers, home visits, and group interventions are measured. Discussion: Determining the relative importance to birth weight and early childhood nutrition of adding food or cash transfers to PLA women's groups will inform design of nutrition interventions in pregnancy. [ABSTRACT FROM AUTHOR]

Background: Low birth weight (LBW, < 2500 g) affects one third of newborn infants in rural south Asia and compromises child survival, infant growth, educational performance and economic prospects. We aimed to assess the impact on birth weight and weight-for-age Z-score in children aged 0-16 months of a nutrition Participatory Learning and Action behaviour change strategy (PLA) for pregnant women through women's groups, with or without unconditional transfers of food or cash to pregnant women in two districts of southern Nepal.Methods: The study is a cluster randomised controlled trial (non-blinded). PLA comprises women's groups that discuss, and form strategies about, nutrition in pregnancy, low birth weight and hygiene. Women receive up to 7 monthly transfers per pregnancy: cash is NPR 750 (~US$7) and food is 10 kg of fortified sweetened wheat-soya Super Cereal per month. The unit of randomisation is a rural village development committee (VDC) cluster (population 4000-9200, mean 6150) in southern Dhanusha or Mahottari districts. 80 VDCs are randomised to four arms using a participatory 'tombola' method. Twenty clusters each receive: PLA; PLA plus food; PLA plus cash; and standard care (control). Participants are (mostly Maithili-speaking) pregnant women identified from 8 weeks' gestation onwards, and their infants (target sample size 8880 birth weights). After pregnancy verification, mothers may be followed up in early and late pregnancy, within 72 h, after 42 days and within 22 months of birth. Outcomes pertain to the individual level. Primary outcomes include birth weight within 72 h of birth and infant weight-for-age Z-score measured cross-sectionally on children born of the study. Secondary outcomes include prevalence of LBW, eating behaviour and weight during pregnancy, maternal and newborn illness, preterm delivery, miscarriage, stillbirth or neonatal mortality, infant Z-scores for length-for-age and weight-for-length, head circumference, and postnatal maternal BMI and mid-upper arm circumference. Exposure to women's groups, food or cash transfers, home visits, and group interventions are measured.Discussion: Determining the relative importance to birth weight and early childhood nutrition of adding food or cash transfers to PLA women's groups will inform design of nutrition interventions in pregnancy.Trial Registration: ISRCTN75964374 , 12 Jul 2013. [ABSTRACT FROM AUTHOR]