Successful integration of nutrition interventions into large-scale development programmes from nutrition-relevant sectors, such as agriculture, can address critical underlying determinants of undernutrition and enhance the coverage and effectiveness of on-going nutrition-specific activities. However, evidence on how this can be done is limited. This study examines the feasibility of delivering maternal, infant, and young child nutrition behaviour change communication through an innovative agricultural extension programme serving nutritionally vulnerable groups in rural India. The existing agriculture programme involves participatory production of low-cost videos promoting best practices and broad dissemination through village-level women’s self-help groups. For the nutrition intervention, 10 videos promoting specific maternal, infant, and young child nutrition practices were produced and disseminated in 30 villages. A range of methods was used to collect data, including in-depth interviews with project staff, frontline health workers, and self-help group members and their families; structured observations of mediated video dissemination sessions; nutrition knowledge tests with project staff and self-help group members; and a social network questionnaire to assess diffusion of promoted nutrition messages. We found the nutrition intervention to be well-received by rural communities and viewed as complementary to existing frontline health services. However, compared to agriculture, nutrition content required more time, creativity, and technical support to develop and deliver. Experimentation with promoted nutrition behaviours was high, but sharing of information from the videos with non-viewers was limited. Key lessons learned include the benefits of and need for collaboration with existing health services; continued technical support for implementing partners; engagement with local cultural norms and beliefs; empowerment of women’s group members to champion nutrition; and enhancement of message diffusion mechanisms to reach pregnant women and mothers of young children at scale. Understanding the experience of developing and delivering this intervention will benefit the design of new nutrition interventions which seek to leverage agriculture platforms.

Background Healthy diets can help reduce undernutrition, morbidity, and mortality. However, evidence on the accessibility and affordability of recommended diets is limited, particularly in poor-resource settings including India. Objectives This study examined: 1) the minimum cost of different types of household diets; 2) how economic constraints may prevent households from accessing a nutritious diet; and 3) how home production and social protection may improve access to nutritious diets. Methods We conducted 24 market and 125 household surveys in Uttar Pradesh, India to obtain food prices and consumption patterns. Cost of Diet, a linear programming software, was used to assess the minimum cost of different diets, estimate affordability of nutritious diets, and model scenarios of home production and social protection interventions to improve affordability. Results The minimum cost nutritious diet that met all recommended nutrient requirements (US${\$}$904/year) was over twice as expensive compared to the diet which only met energy requirements (US${\$}$393/year). The nutritious diet was unaffordable for 75% of households given current income levels, consumption patterns, and food prices. Household income and dietary preferences were the key barriers to obtain nutritious diets rather than food availability. Home production had potential to reduce cost of nutritious diets by 35%, subsidized grains by 19%, and supplementary food by 10%. The poorest households could only afford recommended nutritious diets with access to multiple interventions. Conclusions Practical, habitual diet-related behavior change communication to middle and high-income households and additional social protection for poorer households could enable individuals to achieve optimal nutrient intakes.

Background Anemia, iron deficiency, and iodine deficiency are problems of important public health concern in many parts of the world, with consequences for the health, development, and work capacity of populations. Several countries are beginning to implement double fortified salt (DFS) programs to simultaneously address iodine and iron deficiencies. Objective Our objective was to summarize the evidence for efficacy and effectiveness of DFS on the full range of status and functional outcomes and across different implementation and evaluation designs essential to successful interventions. Methods We conducted a systematic review and meta-analysis of published and gray literature examining the effects of DFS on nutritional status, cognition, work productivity, development, and morbidity of all population groups. We searched for articles in Medline, Embase, CINAHL, Cochrane Central Register, and ProQuest for randomized trials, quasi-randomized trials, and program effectiveness evaluations. Results A total of 22 studies (N individuals = 52,758) were included. Efficacy studies indicated a significant overall positive effect on hemoglobin concentration [standardized mean difference (95% CI): 0.33 (0.18, 0.48)], ferritin [0.42 (0.08, 0.76)], anemia [risk ratio (95% CI): 0.80 (0.70, 0.92)], and iron deficiency anemia [0.36 (0.24, 0.55)]. Effects on urinary iodine concentration were not significantly different between DFS and iodized salt. The impact on functional outcomes was mixed. Only 2 effectiveness studies were identified. They reported programmatic challenges including low coverage, suboptimal DFS quality, and storage constraints. Conclusions Given the biological benefits of DFS across several populations in efficacy research, additional evaluations of robust DFS programs delivered at scale, which consider effective implementation and measure appropriate biomarkers, are needed.

Background Double Fortified Salt (DFS) is efficacious in addressing iron deficiency, but evidence of its effectiveness is limited. The few published evaluations do not include details on program implementation, limiting their utility for programmatic decisions. Objective We sought to characterize the coverage of a DFS program implemented through the Public Distribution System (PDS) in Uttar Pradesh (UP), India, and understand the drivers of DFS adherence. Methods After eight months of implementation, we surveyed 1202 households in five districts and collected data on sociodemographic characteristics, asset ownership, food security and regular PDS utilization. We defined ‘DFS program coverage’ as the proportion of PDS beneficiaries who had heard of and purchased DFS, and ‘DFS adherence’ as DFS use reported by households. We used principal components analysis to create an asset-based index of relative wealth, and categorized households into higher/lower relative wealth quintiles. We conducted path analyses to examine the drivers of DFS adherence, particularly the mediated influence of household wealth on DFS adherence. The evaluation is registered at RIDIE-STUDY-ID-58f6eeb45c050. Results The DFS program had good coverage – 83% respondents had heard of DFS, 74% had purchased it at least once and yet, only 23% exclusively used DFS. Respondents had low awareness about DFS benefits and considered DFS quality as poor. Being in a lower household wealth quintile and being food insecure were significant drivers of DFS adherence and regular PDS utilization acted as a mediator. Adherence was lower in urban areas. Conclusions We observed significant heterogeneity in DFS implementation as reflected by high coverage and low adherence. Learnings from this process evaluation informed the design of an adaptive impact evaluation, and provided generalizable insights for ensuring the potential for impact is realized. Efforts are needed to increase awareness, improve product quality as well as mitigate against the sensory challenges identified. Evaluation Registration: RIDIE-STUDY-ID-58f6eeb45c050.