A Process Evaluation Revealed That Flexibility Was Key to Delivering Nutrition Education to Vulnerable Tribal Groups in India

Abstract

Background

This study is a process evaluation of a nutrition education intervention that is part of a large-scale development program targeting vulnerable tribal groups in Odisha, India.

Objective

The objectives are to examine whether the intervention is operating as planned (implementation fidelity), investigate potential pathways to achieve greater impact, and provide recommendations on how to design nutrition education interventions in similar contexts.

Methods

A program impact pathway forms the basis of this process evaluation, tracing inputs, processes, outputs, outcomes, and impacts. The study's mixed-methods approach includes semistructured interviews, focus group discussions, and Process Net-Mapping. Narrative analysis was applied to examine the transcripts. Data were analyzed in the context of the program impact pathway.

Results

The intervention was not delivered as intended (low implementation fidelity). Flexibility was key in providing nutrition education to beneficiaries despite challenges, such as the inability to utilize behavior change communication, inadequate funding, and language and cultural barriers. Despite low fidelity, the qualitative results show that the intervention improved awareness of nutrition and health among beneficiaries.

Conclusions

Providing adequate resources for training frontline workers and beneficiaries is required for nutrition education programs to achieve their desired effectiveness and impact. Utilizing existing organizations, integration into production-based interventions, and incorporating easy-to-understand nutrition models, practical demonstrations, and videos would increase frontline worker and beneficiary engagement and understanding, leading to improved maternal and child nutritional and health outcomes.

Plain language title

A process evaluation revealed that flexibility in program implementation was key to delivering nutrition education to vulnerable tribal groups in India

Plain language summary

This study is a process evaluation that examines how the design and implementation of a nutrition education intervention are able to influence health and nutrition. The nutrition education intervention is part of a large-scale development program among vulnerable tribal groups in Odisha, India. The objectives are to examine whether the intervention is operating as planned, investigate potential pathways to achieve greater impact, and provide recommendations to help design nutrition education interventions in similar contexts. The results can assist future nutrition education interventions and nutrition-sensitive programs by providing insights into how their design and implementation could be improved to achieve greater impact. This study utilizes both qualitative and quantitative methods, which is recommended for process evaluations. We conducted semistructured interviews and focus group discussions with project management staff, frontline workers, and beneficiaries, as well as a participatory exercise with project management staff called Process Net-Mapping. The results show that nutrition education was not provided to beneficiaries in the same way that it was designed. Flexibility in implementation was critical for the program to deliver nutrition education and improve awareness of nutrition and health, despite many challenges, such as inadequate resources and language barriers. Future nutrition education programs should ensure that there are adequate resources, such as funding and audio/visual equipment. In addition, training of both frontline workers and beneficiaries should include lessons that are easy to understand and remember, such as those utilizing simple messages and shown by practical demonstrations. Nutrition education interventions should be integrated into production-based interventions, such as home gardens. We also recommend engaging existing organizations and groups to help educate and motivate people to participate in nutrition education programs.

Keywords

process evaluation nutrition education program impact pathway process net-mapping implementation fidelity India

Introduction

Although India has made significant progress, food insecurity and chronic malnutrition are still a problem, especially among vulnerable population groups. Odisha is one of the poorest states in India and has a population of roughly 42 million people of which 23% are Scheduled Tribes and 17% are Scheduled Castes.¹ Significant improvements in the production of food grains have been achieved, but access to food and malnutrition among poor and vulnerable households remain a problem.² In Odisha, 20.5% of children suffer from wasting, 34.1% suffer from stunting, 34.4% are underweight, and only 22% consume a diverse diet.² Malnutrition among adults is also common: 26% of women and 20% of men aged 18 to 49 years have a body mass index lower than 18.5 kg/m² and 51% of women suffer from anemia (<12 g/dL).² Given that knowledge about maternal nutrition is associated with improved dietary diversity, nutrition, and health outcomes,^3–11 this study assesses a nutrition education intervention that targeted mothers of young children in Odisha. Our main research question is: How does the design and implementation of a nutrition education intervention influence its ability to lead to positive health and nutritional outcomes?

Among nutrition education interventions, behavioral change communication (BCC) has become popular among development practitioners in low- and middle-income countries.¹² Behavioral change communication promotes the skills and knowledge that are needed to change behaviors related to nutrition by using different communication strategies.¹³ Several studies show that BCC interventions improve nutrition knowledge, nutrition practices, dietary intake and/or diversity, and growth.^14–17 Compared to more health-based nutrition interventions which can be thought of as sets of flows delivering nutrients from a source to a beneficiary,¹⁸ interventions that involve flows of knowledge and uptake of behaviors are less systematically monitored and are part of the “black box” of unknown causal mechanisms.^19,20

Process evaluations can provide unique insights, such as exploring reasons behind the effectiveness or failures of a program's implementation¹⁸ and improving the development and utilization of limited resources,²¹ by tracing intervention's inputs, processes, outputs, outcomes, and impacts in a program impact pathway (PIP).²⁰ Indeed, process evaluations are the principal approach to identify discrepancies between the program as intended and the program as implemented,²² that is, program or implementation fidelity.^23–25 By helping identify bottlenecks early on, process evaluations can enable a project to modify its activities to be able to meet targets, as well as identify successes so that they can be maintained and replicated.²⁶

This study is a midterm process evaluation of a nutrition education intervention designed to include BCC to create awareness and encourage behavior change related to food, nutrition, and health among vulnerable tribal groups in Odisha, India. The intervention is part of a large-scale, nutrition-sensitive program, the Odisha Particularly Vulnerable Tribal Groups Empowerment and Livelihoods Improvement Program (OPELIP). The OPELIP's goal is to enhance the livelihood and food and nutrition security of particularly vulnerable tribal groups (PVTGs) and other surrounding tribal and nontribal communities through over 3 dozen interventions—one of which is nutrition education. The program aims to reach 62 356 households in 1125 villages located in 17 administrative areas called Micro Project Areas (MPAs) from 2017 to 2024.²⁷ The objectives of this study are to examine whether the nutrition education intervention is operating as planned (fidelity), investigate potential pathways to achieve greater impact, and provide recommendations on how to design nutrition education interventions in similar contexts.

This study provides several contributions to the literature. This study contributes to the sparse literature on process evaluations of nutrition education interventions in developing countries.^{16,20,21,28–33} Among this literature, this is the first to include an underutilized participatory qualitative research method called Process Net-Mapping and the first to examine a nutrition education intervention targeting vulnerable tribal groups. The results can help in the design and implementation of future nutrition education interventions in other low- and middle-income countries.

The remainder of this paper is organized as follows. “Methods” section explains the mixed-methods methodology. “Results” section contains the results, which are presented according to the steps in the PIP: inputs (design, funding, implementation), processes, outputs, outcomes, and impacts. “Discussion” section discusses the results and provides recommendations for researchers and policymakers.

Methods

This process evaluation is theory-driven and relies on mixed methods combining quantitative and qualitative data, as well as an extensive document review. Our methodological approach is based on the following 4 key principles of a process evaluation (20: S212):

Developing detailed PIP models;

Linking data collection to PIPs and using mixed methods and multiple data sources;

Linking evaluation activities within program implementation timelines; and

Engaging with program implementation and management teams.

Below, we discuss how we applied these 4 principles.

Through the aid of PIPs, process evaluations identify how impacts emerge from program inputs, processes, outputs, and outcomes³⁴ to illuminate barriers and facilitators of participation and uptake. Program impact pathways are a tool that: conceptualize flows and identify inefficiencies; assist program planning, management, evaluation; guide the design of survey instruments; and shed light on the generalizability of implementing similar programs.¹⁸ The PIP model has been used in other theory-driven process evaluations to track implementation and behavior.^20,30 The PIP for OPELIP's nutrition education intervention (shown in Figure 1) visualizes how nutrition education was expected to achieve impact through flows of knowledge. The pathways show how increased knowledge leads to the adoption of optimal health and nutritional practices through inputs, processes, outputs, outcomes, and impacts. The outcomes and impacts examined in this study are qualitative only since we were unable to collect quantitative data.

Figure 1.

Program impact pathway for the nutrition education intervention. Source: Authors’ illustration.

As the second principle states, we used a mixed methods approach and multiple data sources (see Table 1). Qualitative methods relied on 3 tools: Process Net-Mapping, semistructured interviews (SSIs), and focus group discussions (FGDs). Quantitative data were collected in the frontline worker SSI.

Table 1.

Methods for Data Collection.^a

Method	Respondents/Source	Study sites	Steps in program impact pathway covered
Quantitative data
Frontline worker knowledge-based questionnaire	Frontline workers (N = 60: 28 men, 32 women).	6 Micro Project Areas (Chatikona, Lanjigarh, Mudulipada, Belghar, Sunabeda, and Serango)	Processes
Qualitative data
Process Net-Mapping	1 exercise with Program Management Unit (PMU) staff (N = 7)	Bhubaneswar, Odisha	Inputs, processes, and outputs
Semistructured interviews	PMU staff (N = 4) Micro Project Area-level staff (N = 1) Frontline workers (N = 60) (the same frontline workers who completed the quantitative knowledge-based questionnaire)	Bhubaneswar, Odisha and 6 Micro Project Areas (Chatikona, Lanjigarh, Mudulipada, Belghar, Sunabeda, and Serango)	All steps in program impact pathway
Focus group discussions (FGDs)	1 FGD with 7 (6 men, 1 woman) PMU staff 4 FGDs with 23 (13 men, 10 women) frontline workers (average N = 6) 4 FGDs with 26 women beneficiaries of nutrition education (average N = 6)	Bhubaneswar, Odisha and 6 Micro Project Areas (same as above)	All steps in program impact pathway
Secondary data
Document review	Project design report^27,40 Implementation and guideline reports^41,42 Supervision and monitoring and evaluation reports^43–46 Impact assessment plan³⁴ Baseline report³⁴ Internal training materials	NA	All steps in program impact pathway

Abbreviations: MPA, micro project area; PMU, program management unit.

Study data source.

Process Net-Mapping is an underutilized participatory method developed by Birner et al³⁵ that is a modification of the Net-Map method.³⁶ The Process Net-Map technique was developed to analyze challenges, especially governance ones such as absenteeism and procurement of subpar materials, arising from the implementation of publicly funded programs^35,37,38 and is recommended to address problems of high complexity.³⁹ Process Net-Mapping involves mapping out consecutive steps of a program's implementation process to understand the actors involved, how an activity was implemented, the flows of inputs and resources, power dynamics (called influence levels), and hurdles. Participants are asked to create a map of the different actors involved in the program, and to show how funds, technical inputs, monitoring, and materials flow between these actors. A discussion centered around this map is a focal point of the Process Net-Mapping activity, during which influence levels are assigned to each actor which range from 0 (no influence) to 8 (maximum influence). We undertook a Process Net-Mapping exercise with OPELIP's Program Management Unit (PMU) staff with extensive knowledge and experience in OPELIP's nutrition education activity. The Supplementary Files contain the guide used.

As shown in Table 1, SSIs and FGDs were conducted with a variety of respondent types. Program Management Unit staff at the state level that had knowledge about OPELIP's nutrition education activity participated in the FGDs (N = 7) and 4 PMU-level staff who were available participated in SSIs, 3 of whom were the same respondents from the PMU-level FGD. SSIs and FGDs were also held with frontline workers and beneficiaries in 6 MPAs. All frontline workers involved in nutrition education in the selected MPAs were asked to participate in an SSI or FGD based on their availability. Frontline workers who participated in the SSIs differed from those in the FGDs. A random selection of beneficiaries with exposure to nutrition education in the program was asked to participate in the FGDs. Focus group discussions with frontline workers and beneficiaries each had an average of 6 participants. Focus group discussions with frontline workers had both men and women, but those with beneficiaries were with women since women were the primary target of nutrition education. These MPAs were selected based on feedback from PMU staff on 3 MPAs that had successful implementation and 3 that had less successful implementation of nutrition education. Major topics covered in the SSIs and FGDs include the design, training of frontline workers and beneficiaries, communication channels between the actors involved in the program (program staff, frontline workers, and beneficiaries), variations in implementation across the program area and over time, challenges, successes, and recommendations for improvements in program design, training, adoption, continued use, and impact (see the Supplementary files for these guides).

Focus group discussions and SSIs were audio recorded with informed consent (both verbal and written) and transcribed. The method of narrative analysis^47–49 was used to examine the transcripts. Major themes and quotes were extracted from each transcript by 2 researchers. Data were analyzed in the context of the PIP from inputs to impact. To ensure anonymity, interviewees are not identified by their job title.

For quantitative data, a knowledge-based questionnaire was administered verbally to frontline workers at the end of the SSI. Frontline workers were asked 7 questions covering hygiene, water treatment, breastfeeding, and foods rich in Vitamin A. Multiple-choice questions from the SSIs were tabulated in Excel by the leader of the enumerator and transcription team who is fluent in both the local language (Odia) and English. A researcher read the transcripts to confirm that data entered into Excel from the transcripts were valid. We had planned to collect quantitative data on the utilization, outcomes, and impacts of nutrition education from program staff; however, such data did not exist. For example, there were no data on how many beneficiaries received nutrition education. As a result, we are unable to present quantitative findings on these important facets of the process evaluation.

Regarding the last 2 principles, this process evaluation was purposefully conducted halfway through OPELIP's implementation, so that findings and insights can be used to improve the program's second half. The process evaluation team engaged with PMU staff throughout the study. After preliminary results were available, they were presented to PMU staff and follow-up SSIs were conducted with them. A member of the process evaluation team visited program areas to witness implementation first-hand and to follow-up with frontline workers on preliminary findings. The process evaluation team thus engaged with program implementation and management teams before, during, and after data collection and analysis.

To reduce bias, interviews were conducted by trained field staff with the exception of follow-up SSIs conducted with a PMU-level staff. Therefore, for the vast majority of the interviews, the individuals conducting the interviews and analyzing the data differed. Lastly, all field staff and individuals conducting interviews and analyzing the data were independent from the intervention.

Results

The results are presented in terms of the 5 components of the PIP—inputs, processes, outputs, outcomes, and impacts. To understand the structure of the program and actors involved, we first provide an overview of the organizational structure (see Figure 2) as revealed by the PMU in the FGD, SSIs, and Process Net-Mapping exercise as well as secondary data. Starting at the state level, the PMU is responsible for day-to-day program management and providing guidance and oversight. The MPA level is responsible for implementation and each of the 17 MPAs includes a Facilitating Non-Governmental Organization. The Department of Women and Child Development have staff to work under the MPA's Special Officer and are responsible for coordinating and implementing nutrition-related activities in OPELIP together with Nutrition Coordinators and Social Mobilizers. At the village level, Village Development Committees identify potential beneficiaries with MPA-level and village-level staff. Community Resource Persons (CRPs) are responsible for ensuring program implementation in 2 to 3 villages each and live in the same communities where they work. They are supported by Gram Panchayat (village-level) Nutrition Assistants who provide training to self-help groups who are then supposed to pass nutrition education to beneficiaries.

Figure 2.

Organizational structure. Study data source: Semistructured interviews and the Design Completion Report.²⁷

Inputs

To examine fidelity, the design of the program needs to be compared to realities on the ground. According to secondary data, OPELIP was designed to provide training on the availability, preparation, and consumption of nutrition-rich local foods, as well as the causes, impacts, and remedies of child malnutrition. The intervention was designed to teach beneficiaries through a BCC methodology called Learning by Conversation, which was supposed to be implemented early on in OPELIP's timeline.²⁷ Nutrition education was planned to be provided at Farmer Field Schools, Nutrition Resource Centers (NRCs), creches (daycares), and home visits by self-help groups, mother groups, Gram Panchayat Level Federation members, Village Development Committee members, CRPs, and Department of Women and Child Development staff. Project documents state that 89 NRCs were supposed to be built and linked to Anganwadi Centers (daycare centers for children aged 3-6 years). Project documents had inadequate information on the design and implementation of nutrition education. For example, the 197-page Design Report only mentions nutrition education 6 times.²⁷ One has to comb through hundreds of pages of program documents to piece together how nutrition education was intended to be implemented. Even then, a clear picture does not arise.

Nutrition education went through several major changes during the first half of the program due to several setbacks. According to the FGD and SSIs with PMU-level staff, a setback early on was that the PMU twice tried to hire an agency to undertake BCC training using a specific methodology, Learning-by-Conversation, mentioned in design documents, but both times the same agency placed a very high bid, so the PMU was unable to hire an agency to conduct the training. Another setback was the delay in hiring and training of nutrition-related staff. According to an SSI with a PMU staff member, training of MPA-level staff was conducted in 2017 and training for frontline workers began in 2019. It was not until 2021 that Nutrition Coordinators (at the MPA level) and Gram Panchayat Nutrition Assistants (at the village level) were hired. An SSI with a PMU-level staff member revealed that staff are spread thin: At the PMU-level, there is just 1 person responsible for nutrition in addition to 3 other major components of OPELIP (capacity building, gender, and procurement.) According to the document review, nutrition education was designed to be provided at NRCs linked to Anganwadi Centers. However, NRCs were not linked to Anganwadi Centers and just 14 out of 89 were built in 2019 to 2020 and none in 2020 to 2021.⁴⁴ Based on field observations in 2022, existing NRCs do not have basic facilities, such as a toilet and very few NRCs were functional or open. Therefore, the intended locations where nutrition education was designed to take place were largely unavailable.

Despite these setbacks, SSIs with PMU-level staff and FLWs showed that OPELIP staff continued to work to make sure that nutrition activities were part of OPELIP's program. For example, the PMU made changes in the approach of providing nutrition education. Instead of providing nutrition education as a separate intervention, the Process Net-Mapping exercise revealed that the PMU decided to include nutrition education in existing meetings, other interventions in OPELIP, and even in non-OPELIP programs. Community Resource Persons were given the instruction to disseminate nutrition education at “any platforms wherever they get an opportunity” according to a PMU staff member in a FGD. Because of the inability to hire an agency to train staff in BCC, according to an SSI with a PMU staff member, the PMU decided that CRPs should provide nutrition education by teaching 1 nutrition-related topic at a time to attendees of already existing meetings and trainings, such as self-help group and Gram Panchayat Level Federation meetings, schools, and home garden training which is another intervention in OPELIP.

According to the FGD with PMU-level staff, they sought other learning methodologies that could be included in nutrition education, and in the end drew on the experience of 2 easy-to-understand nutrition models, Tiringa Thali and 7-din 7-ghar, which were successful in an IFAD-funded project in Madhya Pradesh.⁵⁰ These models were introduced into the program in 2019 to 2020 through the home garden intervention, information sessions at the village level, and nutritional knowledge competitions at schools. In the Tiringa Thali model, households are encouraged to prepare meals that include the 3 colors of the Indian flag (white, green, and saffron), whereas in the 7-din 7-ghar model, households are supposed to grow 7 types of vegetables in 7 different garden beds that are harvested on different days of the week. Both models target increasing dietary diversity and increasing micronutrients in diets. Lastly, according to the Process Net-Mapping exercise and SSIs with PMU-level staff, OPELIP decided to support nutrition education in non-OPELIP programs in a further effort to reach beneficiaries. In 2021, OPELIP began acting as implementers of 3 other nutrition-related programs: the 3-year United Nations International Children's Emergency Fund's (UNICEF) Jiban Sampark program; the government-funded Orissa PVTG Nutrition Improvement Program (OPNIP) which provides daycare to young children and spot feeding centers for young children and pregnant and lactating women—both of which include displays of nutrition education materials; and the Azim Premji Foundation which began work in 2021 in southwestern Odisha to improve nutrition and hygiene, targeting creches.

A Process Net-Mapping exercise conducted in November 2021 examined the flows of information, funds, technical support, and monitoring and evaluation, as well as the level of influence of actors involved in nutrition education based on the updated design. Influence levels were assigned by participants in the exercise and range from 0 (no influence) to 8 (the highest level of influence). The PMU focused on their role as an implementor of the Jiban Sampark program in addition to OPELIP providing nutrition education through existing meetings and other interventions in OPELIP (discussed above). A digitalized version of the map is shown in Figure 3. A total of 12 actors were mentioned by participants. United Nations International Children’s Emergency Fund was assigned an influence level of 4 (indicating a medium level of influence) for designing the Jiban Sampark program, providing funding, and conducting nutrition training at the MPA level. The All India Institute of Medical Sciences was also assigned an influence level of 4 for designing the training modules in the UNICEF program. The International Fund for Agricultural Development was assigned a very high influence level of 7 because of their overall guidance and financial support of OPELIP. MPA-level staff and fieldworkers were assigned high influence levels, with the exception of the Women and Child Development Department. Beneficiaries were assigned an influence level of zero indicating no influence. This is surprising given that project documents state that beneficiaries should have an active role in the program. The PMU-level participants assigned the PMU an influence level of 8, which was the maximum level of influence, due to their overall management of the program. Self-help groups were the only other actor to receive the maximum influence level, which stems from their influence in the implementation of the program.

Figure 3.

Process net-map. Study data source: Digitized version of the process net-map created during the Process Net-Mapping exercise. Note: Influence levels were assigned by participants in the Process Net-Mapping exercise.

According to the SSIs with PMU-level staff, nutrition education needs more focus in the program since it is spread throughout several other interventions and programs instead of being its own separate activity. The PMU said that one major hurdle to providing nutrition education is the fact that OPELIP has over 36 interventions, which means that sufficient attention cannot be provided to how nutrition is incorporated in each intervention.

Processes

This step in the PIP includes training frontline workers and beneficiaries. According to the SSIs and FGDs with PMU-level staff and frontline workers, training of MPA-level staff was organized, yet training of frontline workers was much less so. Instead of organized training for frontline workers, MPA-level staff communicated with frontline workers about nutritional topics at already-existing MPA-level, village-level, and frontline worker meetings. Based on the SSIs with frontline workers, topics covered during frontline worker training, as well as frontline workers’ responsibilities and knowledge on health and nutrition topics are shown in Table 2. On average, frontline workers were trained on nutritional topics for 17.8 h. In addition, the majority of frontline workers (75.6%) received refresher training. According to PMU-level staff in the FGD and SSIs, while training MPA- and state-level officials was more straightforward since they could understand Hindi and English, training frontline workers was more difficult since not everyone could understand the reading materials. Trainers of the trainers often did not speak the local language, so they needed to find a translator. The PMU said that they are unable to confirm if the correct information was passed to frontline workers and beneficiaries due to language barriers.

Table 2.

Frontline Worker Training, Service Delivery, and Knowledge.^a

Received training on…
Infant and young child feeding practices (N = 58)	93.1%
Water, sanitation and hygiene (N = 59)	98.3%
Tiringa Thali model (N = 59)	72.9%
7-din 7-ghar model (N = 60)	28.3%
Quality of training
Average length of training in hours (N = 53)	17.8 h
Received refresher training (N = 45)	75.6%
Knowledge on…
When to wash hands (N = 55)	96.4%
How to treat water (N = 46)	80.4%
Initiation of breastfeeding (N = 52)	88.5%
Exclusive breastfeeding (N = 52)	82.7%
Breastfeed at least 24 months (N = 49)	34.7%
When to introduce complementary foods (N = 41)	80.5%
Foods rich in Vitamin A (N = 54)	81.5%
Total knowledge score (range 0-7) (N = 29)	5.3
Quality of service delivery to beneficiaries
Did not receive funds to train beneficiaries (N = 58)	81.0%
Did not receive any materials for training (N = 55)	29.0%
Received a poster (N = 55)	27.3%
Received a video (N = 55)	10.9%
Received pictures/mother and child protection cards (N = 55)	27.3%
Received a book/booklet/handout (N = 55)	7.3%
Reporting process/documentation (N = 45)	86.5%
Repeat contact with beneficiaries (N = 52)	82.7%

Study data source: Frontline worker knowledge-based questionnaire.

The proportion of frontline workers trained on different topics varied by topic. According to the SSIs with frontline workers, nearly all frontline workers received training on infant and young child feeding practices and on water, sanitation, and hygiene. Less than three-quarters received training on the Tiringa Thali model and just over a quarter received training on the 7-din 7-ghar model. This was surprising given the emphasis that midterm project documents placed on these models. Training was conducted mainly through lectures. A frontline worker in a FGD emphasized, “We were provided with lectures with no practical demonstration or video.” Frontline workers in FGDs said they would like more training on topics such as child and maternal care, how income affects nutrition, hygiene, responsibilities of self-help groups, how to work in remote villages, and administrative issues. This training would help beneficiary understanding. A frontline worker in a FGD said, “We need more training so that our talents and skills can be developed such that we can answer all the questions of the people.”

To understand how well frontline workers were trained and to provide insight into the quality of the messaging they delivered to beneficiaries, knowledge on nutritional and hygiene topics were assessed at the end of the SSI (Table 2). Overall, frontline workers had fairly good knowledge on the topics covered in the knowledge-based questionnaire (namely, hygiene, water treatment, breastfeeding, and foods rich in Vitamin A), answering an average of just over 5 out of the 7 questions correctly. Nearly all frontline workers knew at least 1 appropriate handwashing time. The majority knew that breastfeeding should be initiated within 1 hour after birth (88.5%) and that exclusive breastfeeding should last 6 months (82.7%), while a minority (34.7%) knew that breastfeeding should continue for 24 months. Most were able to name at least 1 food rich in Vitamin A.

According to SSIs with frontline workers and PMU-level staff, beneficiary training took place at a variety of settings, such as at daycares, homes, self-help group meetings, village-level meetings, home garden training, and, in some cases, at NRCs. A setback to providing nutrition education at daycares and NRCs according to FGDs with frontline workers is that mothers prefer to drop their children off and come back later to pick them up, rather than stay to receive nutrition-related materials. Frontline workers in the FGDs indicated that beneficiaries understood the training on the Tiringa Thali model. For example, a frontline worker said, “The mothers have understood this (Tiringa Thali model) very well and started implementing the practice in their homes.” Frontline workers recommended the Tiringa Thali model since it was easy for them and beneficiaries to understand.

The quality of frontline worker training was low due to inadequate materials (see Table 2). According to the SSIs with frontline workers, the vast majority of frontline workers (81.0%) did not receive any funds to train beneficiaries. According to frontline workers in the SSIs, funds would have made organizing and holding training sessions easier. In addition, nearly one-third (29%) of frontline workers did not receive any materials to train beneficiaries. For those that did, the most common materials were posters and pictures. Given the setbacks in the inputs stage, according to frontline workers in the FGDs, self-help groups did not provide formal training on nutrition education, but instead displayed communication materials at NRCs, daycare centers, and spot feeding centers. In addition, frontline workers had to incorporate nutrition education into already existing meetings and interventions rather than provide nutrition education training on its own. This led to haphazard implementation and less focus on nutrition education than designed. In addition, due to nutrition education being implemented within other interventions and not systematically, the program did not have data on the number of beneficiaries utilizing nutrition education.

Outputs

Outputs cover whether beneficiaries understood the training. Nutrition education in the program faced several challenges which affected the understanding of topics among beneficiaries. As with frontline worker training, lack of technology was a recurring theme among beneficiaries that emerged from FGDs with beneficiaries and SSIs with frontline workers. For example, although there are many types of videos on nutrition that could have been shown to beneficiaries, there was no way to display them. SSIs with frontline workers revealed that innovative frontline workers showed videos on their mobile phones to small groups of beneficiaries to try to increase the likelihood of beneficiaries understanding the topics, but this occurred only infrequently and was not practical since beneficiaries had to huddle around a mobile phone screen. Language barriers and low literacy levels were another impediment mentioned by frontline workers in the FGDs, making it difficult to ascertain whether the right information was delivered. According to the PMU in the FGD, the low level of literacy requires that PVTG beneficiaries have more participatory methods and “rigorous training and handholding.” However, according to the PMU, the program was unable to provide nutrition education through participatory methods due to the inability to hire an organization to provide BCC nutrition education training. Other challenges, such as cultural barriers, beneficiaries lacking time, remoteness of villages, and poor mobile connectivity were cited in the SSIs and FGDs with frontline workers and FGDs with beneficiaries. With regard to cultural barriers, a frontline worker in a FGD explained, “They were not ready to compromise on their cultural practices like restriction on consumption of eggs, consumption of food cooked by women outside their families…We provided them with eggs, but they refused to take eggs, so we have to provide a substitute for egg.” Examining the outputs step in the PIP shows that nutrition education programs need to provide higher quality training to ensure beneficiaries understand the material. In addition, incorporating beneficiaries more into the program design would help ensure that culturally acceptable practices are promoted.

Outcomes

Outcomes cover whether feeding and hygiene practices as well as the diets of children and women improved. Although we did not have quantitative data, the qualitative data collected in this study found that most frontline workers in the FGDs and SSIs as well as beneficiaries in the FGDs reported improvements from nutrition education. For example, a frontline worker in a FGD said, “If we take the practice of handwashing, we saw that they (beneficiaries) keep soap and handwash at their home and wash regularly.” In terms of adopting what was taught related to nutrition, another frontline worker in a FGD said, “When a mother goes to the market or anyone from the family, they understand that they should buy the right food items to get proper diet rather than buying unnecessary items in the market as they previously did.” Similar to encouraging participation in training, family members were instrumental in the adoption of recommended practices. For example, a frontline worker in a FGD stated, “Support from their household members helped with the adoption of the (nutrition education) intervention.” In FGDs, beneficiaries also emphasized the importance of training as typified in the statement, “As you see, we are maintaining hygiene, cleaning our hands whenever is required.” An officer at the MPA-level in an SSI also added, “previously some mothers could not prepare and eat good food but now they are making good food and having good nutrition regularly… Also, in the creche, the children are fed a balanced diet throughout the day.” The above statements demonstrate that although nutrition education was not provided as its own separate intervention within OPELIP, qualitative data support the finding that it was able to have positive outcomes on beneficiaries, especially related to hygiene and nutritious diets. Utilizing existing meetings, such as self-help group meetings and other village-level meetings, as platforms for providing nutrition education may have been a way for the program to tap into already-existing social institutions that are trusted in the community.

Impacts

The last step in the PIP examines whether maternal and child nutritional and health outcomes improved as a result of nutrition education. Although frontline workers did not collect quantitative data on beneficiaries’ nutritional and health outcomes, there were qualitative reports of improved health outcomes for mothers and children. For example, frontline workers noticed weight gain among beneficiaries, a reduction in malnutrition cases, improved hygiene, and an anecdotal decrease in referral cases to NRCs and anemia in pregnant women and lactating mothers. For example, a frontline worker in a FGD stated, “We found positive changes in their food consumption habit and physical growth.” Another frontline worker further indicated, “We can see changes in the health of the mothers and children… they have gained weight and are eating good food at home.” This is collaborated by another frontline worker in a FGD, “We have seen some changes like weight gain and changes in looking, and health conditions.” An MPA official in an SSI stated, “A lot of changes have happened due to nutrition education. These include a drop in malnutrition cases, drop in referral case numbers to NRCs, drop in anemia cases of pregnant and lactating mothers, and development in the hemoglobin percentage. Additionally, health conditions of babies (7-36 months) have improved.” However, caution is needed in interpreting these findings since we were unable to confirm them with quantitative data as such data did not exist. Examining the impacts from nutrition education in OPELIP highlights that combining nutrition education with other OPELIP interventions, such as the home garden intervention, and through non-OPELIP programs, such as the Jiban Sampark program and OPNIP, helped OPELIP have positive impacts on nutritional and health outcomes.

Discussion

By examining the 5 steps in the PIP, this process evaluation was able to examine how the design and implementation of a nutrition education intervention influenced its ability to lead to anecdotal evidence of positive health and nutritional outcomes. Despite low implementation fidelity, that is, a low extent of the intervention being implemented as planned,^23,25 stemming from setbacks early on, due to the flexibility and creativity of the PMU staff, nutrition education was able to be provided to beneficiaries. The initial inability to hire an organization to provide BCC training meant that OPELIP was not able to implement the design of nutrition education as originally envisioned, leading to low fidelity. However, staff adjusted. Instead of relying on certain, predetermined methodology, nutrition education was provided through already existing village-level meetings, self-help group meetings, other OPELIP interventions, and other programs. As such, we interpret the data to show low implementation fidelity, rather than implementation failure. Nevertheless, evidence of positive outcomes and impacts relied on interviews and FGDs with frontline workers and beneficiaries, rather than quantitative data. We recommend that future research collect quantitative data in addition to solely qualitative data on outcomes and impacts.

The findings from this study have important practical implications for designing and implementing nutrition education interventions. Our first set of recommendations pertains to improving the training of frontline workers and beneficiaries. The short duration of frontline worker training, lack of resources for training (such as projectors to show videos and funds to hold practical demonstrations), and language barriers prevented frontline workers from being adequately equipped. These challenges made it difficult for beneficiaries to fully understand the content of the training. Kavle et al⁵¹ also found language as a barrier for implementing nutrition interventions. Conducting training in the local language using locally trained experts would help increase beneficiary understanding. We also recommend that more training be given on easier-to-understand nutrition models, such as the Tiringa Thali and 7-din 7-ghar nutrition models, which were successful in another program⁵² and can be taught to beneficiaries with limited formal education by using simple posters, videos, live cooking demonstrations, and visiting model gardens or plots. These models could be easily adapted to other contexts, such as by taking the concept of colors in the Tiringa Thali model and applying it to the concept of eating the colors of the rainbow. Of course, more training requires more funds. A common theme cited by PMU staff was limited funds for nutrition education. Limited funding has been found to be a major constraint to the more comprehensive and intensive implementation of nutrition interventions.^53,54

There are a few strategies nutrition education interventions can adopt in their design and implementation that will not break the bank. We found that incorporating nutrition education into other interventions that focus on agriculture is an effective method to provide nutrition education within larger programs or other already existing interventions. The convergence of the nutrition education intervention with home gardens provided positive benefits for beneficiaries as they were able to have access to vegetables for consumption. We recommend that nutrition education interventions be scaled up in production-based interventions. This follows recommendations that scaling up the integration of nutrition education into agricultural interventions is vital to improving household and young children's diets.⁵² In addition, we found that family support, community support, and the use of existing social structures were integral to implementing nutrition education. The existing structure of self-help groups played a crucial role in facilitating the dissemination of nutrition education activities, helping compensate for the planned and failed BCC strategies. Involving community members as active partners is critical for ensuring the sustainability of interventions.⁵⁵ This finding coincides with experiences from other programs that using existing structures and community mobilization for the roll-out of interventions are vital for improving program implementation and achieving impact.^51,56,57 We also recommend that process net-mapping exercises should be undertaken midway in more programs to reveal unique insights that other methods may not uncover. For example, if an actor is assigned a low influence level (such as beneficiaries in this case), corrective action could be taken to give these actors more voice in the program. Lastly, the interviews revealed that project management staff felt that they were spread thin and unable to provide enough attention to nutrition education since the program had over 3 dozen interventions. We encourage that future programs have fewer interventions so that each can be provided the attention it requires.

Given the unique insights this process evaluation revealed by following the design and intervention through a PIP, we recommend that future programs and researchers use PIPs in their design, implementation, and evaluation of nutrition education programs as well as process net-mapping to help shed light on the black box of nutrition education interventions.

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Footnotes

Acknowledgments

The authors acknowledge staff from the Research and Impact Assessment Division at International Fund for Agricultural Development (IFAD), Frew Behabtu from the IFAD India Country Office, the OPELIP Programme's Management Unit (particularly Dipti Gantayat), and International Crops Research Institute for the Semi-Arid Tropics (ICRISAT) staff for their research cooperation. The authors are thankful for the support received from Nedumaran Swamikannu from ICRISAT and Ravi Nandi in coordinating the midline data collection during his work at ICRISAT-India. The authors also thank the survey firm HDI for leading the midline data collection efforts and Diego Alvarez for supporting data management and analysis. The authors especially would like to thank Braja Swain and his team of transcribers for diligently transcribing the transcripts. Many thanks to Kashi Kafle and Rui Benfica for leading the efforts to collect the baseline data when they were IFAD staff members. The process evaluation was conducted by this research team and financially supported by IFAD as part of the project “Linking Research to Impact: Increasing the effectiveness of Agriculture and Food Systems in Improving Nutrition,” the CGIAR initiative on National Policies and Strategies (NPS), which is grateful for the support of CGIAR Trust Fund contributors. This research was also supported by the CGIAR Research Program on Agriculture for Nutrition and Health (A4NH). The views and opinions expressed in this paper are those of the authors and should not be attributed to IFAD, its Member States, or their representatives to its Executive Board. The following is the statement of the author's contributions to the manuscript: Jonathan Mockshell designed the research, wrote the manuscript, was engaged in project management and funding acquisition, and had primary responsibility for final content; Thea Ritter designed the research, conducted research, analyzed data, and wrote the manuscript; and James Garrett was responsible for the overall design and management of the “Linking Research to Impact” project and assisted with analysis and revising the manuscript. Qualitative data described in the manuscript will not be made available because of the inability to anonymize the qualitative data. Quantitative data (shown in ) will be made available upon request pending application and approval.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Consortium of International Agricultural Research Centers.

ORCID iDs

Thea Ritter

Jonathan Mockshell

James Garrett

Supplemental Material

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