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

Abstract

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.

Effect of nutrition-sensitive agriculture interventions with participatory videos and women's group meetings on maternal and child nutritional outcomes in rural Odisha, India (UPAVAN trial): a four-arm, observer-blind, cluster-randomised controlled trial

“…Strong feedback loops ensured the interventions remained demand-driven and relevant. 20 Our intervention packages were derived from prevailing policy interventions and are amenable to scale up.…”

“…We adapted this participatory video approach to make it nutrition sensitive and enhance participation, described in depth elsewhere. 18 , 20 Local, trained, salaried facilitators worked with self-help groups—an existing platform of women's groups involved in savings and lending activities (usually 20–25 members each).…”

Qualitative evidence for improved caring, feeding and food production practices after nutrition-sensitive agriculture interventions in rural Vietnam

“…There is a need to identify best practices in the design and implementation of effective and affordable behaviour change strategies, learning how to increase their value for beneficiaries without excessive increases in workload [ 24 ]. Furthermore, since the level of complexity increases in multi-sectoral NSA programs, selecting which behaviours to prioritise and which mechanisms to apply is a challenge, as nutrition outcomes are the cumulative effect of interlinked changes on multiple dimensions (production, food purchasing, consumption, caring and feeding, among others) [ 28 ]. As Green and Kreuter stated, “people learn continuously from their environmental and social surroundings and can develop, individually or collectively, the knowledge and skills to modify them” [ 29 ].…”

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

“…Video content was selected using social and agronomic information gathered during formative research, and by responding to requests or barriers faced by group participants, including land or water scarcity (Aakesson et al, 2017 ; Harris‐Fry et al, 2020 ). For example, some videos focused on cultivating Indian spinach with wastewater.…”

“…In the final phase, groups evaluated activities and discussed strategies which they thought were impactful or While creating all intervention videos, we used the transtheoretical model of behaviour change's stages of change to reinforce uptake and maintenance of core practices (Prochaska & DiClemente, 1982). Specifically, we mapped whether a proposed behaviour was new to a community ('precontemplation'); being passively considered ('contemplation'); actively considered ('preparation'); first adopted ('action'); continued ('maintenance') or modelled for others in the community ('termination') (Harris-Fry et al, 2020;Prochaska & DiClemente, 1982).…”