Delivering for Nutrition in India: Insights from Implementation Research - 24 September 2019

1. 1
List of Abstracts
Delivering for Nutrition in India
Insights from Implementation Research
Sept 24, 2019; India International Centre, New Delhi, INDIA
Why implementation research matters for scaling up nutrition programs with
equity and quality
Co-chairs: Alok Kumar, NITI Aayog and R. Hemalatha, NIN
KEYNOTE ADDRESS: History and relevance of implementation research in nutrition
Marie Ruel, IFPRI
The presentation “The History and Relevance of Implementation Research in Nutrition” will
provide a broad overview of: what implementation research in nutrition is; why it is critically
important to invest in this type of research; what types of research questions it can answer;
and what are the tools and methods available in the implementation research toolkit. The
presentation will also introduce the Society for Implementation Science in Nutrition (SISN)
launched in 2016, which is “constituted as a society of researchers and implementers who
share a common vision, values and goals and who collaborate in various ways to achieve
these.” IFPRI’s work on implementation research globally will be briefly highlighted. The
main key take-aways of the presentation is that implementation constraints are a key
obstacle to achieving impact on nutrition at scale and that we need to invest more on
delivery- and implementation-focused research to accelerate progress in improving nutrition
globally.
An evidence gap map for implementation research in nutrition in India
Stuti Tripathi, 3ie
3ie is developing an implementation research evidence map for nutrition specific
interventions in collaboration with IFPRI to gather evidence on the implementation of
nutrition programmes in India and identify where gaps in literature exist. Evidence maps are
a useful tool to visualise the state of evidence in a sector. To address the challenges to
maternal and child health, it is essential to understand the barriers and facilitators to
implementing nutrition interventions effectively. Implementation research is a systematic
approach to recognise implementation bottlenecks, identify optimal options for a given
setting and promote the uptake of research findings into policy and practice. Evidence
mapping will yield important insights for various stakeholders, especially those involved in
funding large-scale nutrition programmes and commissioning research.
M-Health interventions and their role in service delivery: Learnings from the
field
Co-chairs: Sajjan Singh Yadav, MWCD and Rahul Mullick, BMGF

2. 2
List of Abstracts
Overview and current reach of ICDS-CAS under POSHAN Abhiyaan
Sajjan Singh Yadav, MWCD
This presentation shares an overview and current rollout status of ICDS-CAS. It also explains
how ICDS-CAS takes a multi-pronged approach for tackling malnutrition. ICDS-CAS focuses
on the key touch-points across the crucial ‘First 1000 Days Lifecycle’, monitors the growth
status on a monthly basis, ensures effective beneficiary and stakeholder engagement and
provides effective services like hot cooked meals at AWC and Take-Home Ration (THR) to
beneficiaries including pregnant women, lactating mother and children.
Insights on technology integration from the ICDS-CAS process evaluation
Rasmi Avula, IFPRI
Objectives: A mobile-phone based common application software (CAS) intended to digitize
beneficiary enrollment, enable beneficiary tracking, and support delivery of Integrated Child
Development Services (ICDS) services, is being integrated into the ICDS program in India. In
the context of an ongoing impact evaluation of ICDS-CAS, we conducted a process
evaluation (PE) in Madhya Pradesh and Bihar to identify facilitators and barriers to
implementation and help explain ICDS-CAS impact.
Methods: In collaboration with multiple partners and implementers, we developed the
program impact pathways (PIPs). All research questions and methods were informed by the
PIPs. Data collection was temporally sequenced and aligned with program roll-out and
included training observations, semi-structured interviews with national and state-level
stakeholders, field surveys of AWWs, supervisory staff at the sector, block, and district
levels, and phone surveys with AWWs.
Results: There was an enabling environment for the roll-out of ICDS-CAS including vision,
leadership, multiple external partner support, and champions for technology integration.
Nearly all AWWs and Lady Supervisors (LS) reported being satisfied with the training. The
app is well used by the AWWs in both states, but nearly all AWWs and LS reported facing
challenges related to the hardware, app, or network.
Conclusions: Further scale-up requires investments in strengthening network infrastructure
and institutional mechanisms to support implementation needs. In addition, it is imperative
to begin examining data quality and use of data in the ICDS to fully realize the potential of
CAS.
Learnings from a technology-based nutrition surveillance system – a six state study
Kakani Sreerama Krishna, NIN
The Government of India formulated National Nutrition Policy (NNP) in 1993 and National
Plan of Action on Nutrition (NPAN) to prevent and control of undernutrition in the country.
As per the directives of NNP and five-year plans of Government of India, there is a need to
establish ‘Nutrition Surveillance System (NSS)’ to provide early warning signs of nutritional
problems for initiating prompt action and also for effective monitoring of existing national
nutrition intervention programmes in the country.
The ICDS has the infrastructure and manpower with a built-in management information
system (MIS) right from the village level through state and national level. Majority of the
nutrition goals set by the ‘NNP/SDGs/WHO Nutrition frame work’ are mostly related to the

3. 3
List of Abstracts
ICDS services. The ICDS integrates with different stakeholder departments, which are
working for optimal health and nutrition status of vulnerable population groups in India.
Therefore, ‘Nutritional Surveillance System (NSS) was established in September 2017 with
the funding support of ICMR in Kerala, Madhya Pradesh, Maharashtra, Meghalaya, Orissa
and Telangana on pilot basis by existing utilizing ICDS infrastructure and funding. The
information collected under NSS at various (village/sector/sub-district/district/state) levels
will also be useful in decentralization for micro planning and development of various
intervention strategies at the lowest levels and to facilitate a targeted approach to prevent
and control undernutrition.
The important objectives of the NSS are; i) to develop a digital based reporting system from
AWC through CDPO, PO/State and NIN Central server to make the data into a real time one
by collecting the data using computer-assisted personal interviewing (CAPI) by gross root
level workers (AWWs/Lady supervisors/CDPO) with a provision of internet for instant data
transfer, to track nutritionally high individuals by GPS for continuous monitoring for its
prognosis and treatment and validation of data collected by the Anganwadi Teachers (AWTs)
and capacity building of the functionaries of all the stakeholder departments. The
implementation of project has been completed 2 years. The NSS has helped in improvement
of weighing efficiency, tracking of SAM and MAM children and also improved the quality of
anthropometric measurements of AWTs and regular submission of monthly monitoring
report through online.
Data use in the ICDS: Implications for ICDS-CAS
Divya Nair, IDinsight
Given the large amounts of data available, and the effort that goes into collecting these, it is
imperative to understand and to improve the use of these data to enable more efficient and
effective decision-making. In collaboration with IFPRI, EPoD, and Alive & Thrive, IDinsight has
been working to understand the culture of data use in nutrition, in CAS and non-CAS
districts. We have also conducted workshops among district and sub-district officials to build
excitement around data use, understand ways to address data quality, and improve data
visualization. The findings we present are preliminary and part of this implementation
research.
Maternal nutrition implementation research update
Chair: Purnima Menon, IFPRI
Overview of ongoing maternal nutrition implementation research
Purnima Menon, IFPRI
Maternal malnutrition – both undernutrition and overweight/obesity – are significant
challenges for India. Poor nutrition among mothers is not only an intrinsic challenge for
maternal health; it also contributes to poor birth outcomes among children. Despite a
strong scientific base, a policy framework that recognizes the importance of maternal
nutrition and the existence of at-scale platforms for delivery of maternal health and
nutrition interventions, the coverage and quality of nutritional care during pregnancy is
variable across India. The Ministry of Health and Family Welfare in India aims to strengthen

4. 4
List of Abstracts
the quality of nutritional care for pregnant women as part of antenatal care, as do programs
like the Integrated Child Development Services. A range of programmatic efforts are
currently being tested to improve the quality of this nutritional care. An accompanying
implementation research agenda is also underway to generate lessons on these efforts.
Studies include qualitative research documenting program efforts, empirical analyses of
existing datasets, primary surveys and impact evaluations. Robust evidence synthesis efforts
will be needed to examine the implications of all the available evidence for strategy
refinement and program improvement.
Pathways from program inputs to service delivery: Experience from maternal nutrition
interventions in Uttar Pradesh, India
Shivani Kachwaha, IFPRI
Process evaluations are critical to opening the “black box” of programs and illuminating the
processes through which programs achieve their impact, or not. Despite global recognition
of their importance, examples of rigorous process evaluations in the field of nutrition are
few. In this study, we examine the pathways through which the Alive & Thrive program is
intended to improve maternal nutrition services and practices in two districts of Uttar
Pradesh. We conceptualized six domains of the program impact pathway: capacity building,
data and supply chain, service delivery, community mobilization, exposure and utilization,
and behaviour change. In addition, we conducted mixed-methods surveys with pregnant
women, frontline workers, and supervisors. We present survey results for each domain of
the program impact pathway, finding marginal improvements in intervention areas, and
highlighting the need to intensify coverage and service quality in specific areas of program
implementation.
Evidence based and actionable dietary advice for pregnant and lactating women in
Rajasthan
Goutam Sadhu, IIHMR and Namita Wadhwa, IPE Global
The study was conducted among 2160 lactating and pregnant women of different categories
in three agroclimatic districts of Rajasthan, which shows that dietary intake among pregnant
and lactating women was not different from their non-pregnant counterparts in terms of
food group, the number of meals and nutrition intake. The median intake of fruits, meat,
and poultry products was found negligible in both the groups. The other food groups like
cereals, millet, sugar, fats, and oil were the main source of energy intake.
The respondents consumed 114 different food items, out of which 35 were the source of
one or more nutrient only. Dietary pattern data shows inadequate dietary intake, especially
hunger pangs during pregnancy and lactation period among women.
The lactating mother was reported to have maximum deficiencies of vitamin A vitamin C, fat,
and calcium consumption in reference to RDA recommendations. Among pregnant women,
maximum dietary deficiencies were reported for fat, vitamin, calcium, and vitamin C as
suggested by RDA. Among the non-pregnant and non-lactating women, the fat and vitamin A
deficiency were found the maximum.
Across all category’s fat, calcium, vitamin A, and vitamin C were the maximum deficient
nutrients (Gap> 70% of RDA) where micronutrients like Iron and zinc intake was almost zero.

5. 5
List of Abstracts
This presentation is on the study based on Opti-food analysis and suggest an intake of food
among different categories of women based on accessibility, availability, and affordability.
Scaling up social and behavioral change communication through multiple
platforms: What does the evidence tell us?
Co-Chairs: Sebanti Ghosh, A&T and Rachana Sharma, UNICEF
Global evidence: Summary of findings from multiple evaluations of SBCC programs
Phuong Nguyen, IFPRI
Nutrition social behavior change communication (SBCC) is a set of interventions that
combines elements of interpersonal communication, social change and community
mobilization activities, mass media, and advocacy to support individuals, families,
communities, institutions, and countries to adopt and maintain high-impact nutrition-
related practices. SBCC interventions are a crucial component of most nutrition-focused
interventions/ programs, but lessons on effectiveness at large-scale are limited. We present
global evidence regarding the effectiveness of SBCC approaches to improve three key
nutrition behaviors: 1) Breastfeeding practices; 2) Complementary feeding practices; and 3)
Maternal nutrition practices during pregnancy. We also highlight opportunities and
challenges for Indian policy and programs in improving maternal and child nutrition.
Women’s group platforms for health and nutrition SBCC: What does the evidence say?
What more is needed?
Madhavi Misra, Population Council
Population Council is presenting interim findings of a mixed methods systematic review that
focuses on understanding how women’s groups achieve change for women’s and children’s
health in India. It aims to answer two research questions, 1) what is the impact? 2) what
barriers and enablers related to content, mechanisms and outcomes that explain these
effects. Mid-range theories are being developed to explain how groups work, for who and in
what context. The systematic review found 36 experimental studies, plus 59 observational
and qualitative studies. Groups have been categorized using Kok et al’s taxonomy of
behavior change methods into a simplified typology. The results of this presentation are
specifically on nutrition and MNCH behaviours, specifically ANC, IFA and breastfeeding.
The review found that groups which employed a community mobilization approach, several
of them reported effects on NMR and nutrition outcomes at the population level. Among
the groups that aimed to mobilise women and communities (including through SHG
federations): one had effect on some behaviours related to nutrition, but not on NMR. SHG
(layered) interventions reported effects on breastfeeding though these were only amongst
group members, not population-level outcomes. Some important policy takeaways are that
investing in groups has promise to mobilise communities. Group-based interventions must
be inclusive and focused and supply side integration is important.

6. 6
List of Abstracts
Organizing and attendance of community-based events – Learnings from organizing of
Annaprashan Diwas
Sai Mala, CARE India
Annaprashan divas continues to be a critical community-based event to bring awareness to
mothers and initiation of the child to right nutrition practices. There has been a drastic
improvement in conducting the event after the launch of National nutrition Mission.
However, the attendance of mothers belonging to children who have to be initiated to
complementary feeding is low. It was observed that FLW’s visits and interaction with
mothers had significant association in improving IYCF practices. To further improve the
outcomes, there is a need to plan measures which would bring more mothers to participate
in the event and improve the quality of interaction between mothers and the Anganwadi
worker.
Reaching families, reaching mothers, shaping behaviors: Insights from the national SBCC
survey
Pulkit Agarwal, IDinsight
Social and behaviour change communication is central to POSHAN Abhiyaan. The current
scale of national SBCC programming means that a number of messages are being
disseminated through a variety of platforms. This presents an opportunity to refine the SBCC
strategy through the collection of evidence on platform/message reach and quality.
IDinsight has generated evidence for the Ministry of Women and Child Development on
SBCC in November 2018 (‘Phase I’) and in July 2019 (referred to as ‘Phase II’). Phase I was
conducted across 27 Aspirational Districts across eight states. The objective was to inform
programing post Poshan Maah last year. Phase II was conducted in four states with the
objective to inform the second Poshan Maah in September 2019, as well as inform long-term
programming. Overall, the results have highlighted that patterns are similar across
geographies, but also that there are varying levels of key SBCC indicators across states. Our
presentation will focus on Phase II findings, and where useful, draw comparisons to Phase I.
Frontline worker capacity, financing and governance
Co-chairs: Gayatri Singh, UNICEF and Suneeta Krishnan, BMGF
Factors affecting implementation of ICDS services - governance, human resource capacity,
and other barriers
William Joe, Institute for Economic Growth
We present preliminary findings based on a NITI Aayog sponsored multi-state research study
on evaluation of ICDS scheme with specific focus on governance, processes and
implementation. We describe state-specific variations in approaches toward ICDS
governance and process implementation. It is observed that ICDS frontline workers are
almost exclusively focused on delivery of supplementary nutrition and to some extent on
early childhood education. The efficiency and quality of service delivery is, however, affected
by shortage of human resources and physical / digital infrastructure bottlenecks.
Importantly, ICDS continues to be of high relevance for realizing the POSHAN Abhiyaan

7. 7
List of Abstracts
targets and child development needs. Greater resolve and intent is, however, necessary for
streamlining policies and to implement certain best practices.
Financial factors, human resources, and bottlenecks: Delivery of services through
Integrated Child Development Services
Avani Kapur, Accountability Initiative
A critical yet often overlooked component of successful, scalable and equitable nutrition
interventions are the manner in which governance processes are designed and
implemented. Since 2018, Accountability Initiative has been undertaking a multi-state
process-tracking survey to study planning, fund flows, and governance structures which
impact implementation of key nutrition-specific interventions specifically ICDS and Vitamin A
and IFA supplementation. The aim is to determine bottlenecks and better practices across
states or even across districts to determine mechanisms to make the system more efficient
and effective. This presentation focuses on some of the preliminary findings and lessons
learnt from our primary surveys and focus group discussions– both from the perspective of
the citizen, as well as, the service provider. This work is supported by the Gates Foundation.
Take-home rations, cash or hot meals? What’s the scoop?
Co-chairs: Roli Singh, GoR, HPS Sachdev, Sitaram Bharti Hospital and Medical Research Centre and
Sudharsanam M. Balasubramaniam, CIFF
Update of evidence on India’s ICDS Supplementary Nutrition Program
Saachi Bhalla, BMGF
The supplementary nutrition program is one of the six services provided under the
Integrated Child Development Services (ICDS). Within this, the Take Home Rations (THR),
provided to pregnant and lactating mothers and children (7 months - 3 years) is a crucial
component of the supplementary nutrition program and a substantial proportion of the ICDS
budget is allocated towards it. Recent research efforts and program experiences, several
challenges remain in ensuring that the ICDS THR is effective in reach and impact. These
challenges range from composition to production to distribution and finally, to consumption
by client populations. This presentation will focus on the evidence around THR uptake and
consumption collating insights from various organizations.
Global evidence on relative impacts of cash and food on child nutrition outcomes
Harold Alderman, IFPRI
This study looks at the global evidence on relative impacts of cash and food on child
nutrition outcomes. It looks at various studies and finds that on average, impacts of cash and
food are similar. There is extensive evidence that both forms of transfers have favorable
impacts on household budget priorities. But, the path from increased resources to improved
nutritional status is not assured. There are some advantages of in-kind transfers. One role
that cash transfers cannot fill directly is micronutrient fortification.
Implications of the global evidence for India’s cash transfer programs
Urvashi Wattal, J-PAL South Asia

8. 8
List of Abstracts
As part of the Cash Transfer for Child Health initiative, funded by the Bill and Melinda Gates
Foundation, J-PAL South Asia conducted a review of global evidence on the effectiveness of
cash transfers on child health outcomes, including nutrition in 2017. This study shares key
highlights from the findings on the effectiveness of cash transfers (along with other
modalities) on nutrition globally, and the implications for implementation of cash transfer
programmes in India.
Overview of “one full meal” programs for maternal nutrition and evidence needs
Rasmi Avula, IFPRI
The One-Full Meal (OFM) program is a spot-feeding initiative, which began in a few states in
2013, and is being implemented through the Integrated Child Development Services (ICDS)
to improve diets of pregnant and lactating women. To understand the design,
implementation, and evidence base for the OFM program, we conducted a desk review of
the OFM program implemented in Andhra Pradesh, Chhattisgarh, Karnataka, Madhya
Pradesh, Maharashtra, Telangana, and Uttar Pradesh. We used government orders,
government reports, UNICEF state reports, and findings from studies or assessments
conducted relating to OFM. Our findings show that the program objectives vary from
targeting outcomes to activities. Some states piloted prior to scaling-up and some did not.
Except in Maharashtra, the program is universal i.e., accessible to all pregnant women.
There is variability in the cost norms among the states. Limited rigorous research exists on
the program. There is a need for mapping pathways to impact and identifying evidence gaps
prior to introducing the program into other places or investing in scaling-up in the existing
areas.
Delivering cash to mothers: Insights from implementation research on the Pradhan
Mantri Matrutva Vandana Program (PMMVY)
Manoj Mohanan and Mantasha Husain, Duke University
The Pradhan Mantri Matru Vandana Yojana (PMMVY) is a conditional cash transfer program
to provide cash payments to eligible mothers during their pregnancy and after immunization
of the newborn child, with the objective of improving childhood nutrition and maternal
health outcomes. Our project, implemented in Madhya Pradesh in partnership with the
state government’s DoWCD, NITI-Aayog, the World Bank, and JPAL, aimed to study the
implementation of the program in MP and identify bottlenecks in delivering program
benefits. Using administrative data, qualitative and quantitative data that we collected in the
field, we study utilization of program benefits, delays in payments and barriers faced by
households.
Design overview: Plans for a cash versus take-home ration pilot study
G.S. Toteja, ICMR and HPS Sachdev, Sitaram Bharti Hospital and Medical Research Centre
The objective of this study is to determine the effect of cash transfer to pregnant women
and mothers with children between birth and 36 months on health and nutrition indicators
in pregnant and lactating women and under-3 children in comparison to the ongoing
program of Take-Home Ration (THR). The primary outcomes look at children’s length/height
for age z score at the end of intervention period (24 months), and secondary outcomes look
at children’s weight for age z score, weight for length/height z score, proportion stunted,

9. 9
List of Abstracts
underweight, and wasted. The qualitative outcomes look at perceptions of the ICDS
functionaries and beneficiaries on the alternative modes of subsidy will be captured through
qualitative research (in-depth interviews and focus group discussion).
Poster presentations
Understanding the processes of growth monitoring in ICDS - a multi-state study
Sumati Bajaj, IFPRI
Routine growth monitoring (GM) is a globally recommended practice to assess children’s
nutritional status and is a key monitoring indicator under the National Nutrition Mission.
Under ICDS, GM is conducted monthly for children up to 5 years old. However, almost no
assessments of GM processes exist, particularly in India. We examined the processes of
growth monitoring in 105 anganwadi centers (AWC) across four states in India and
compared them to the global standards of measurement. We used observational checklist to
record the measurement process of 5-7 children per AWC, and analysed data along the
potential faltering points including use and placement of correct instrument and correct
child positioning. We found that the measurement processes were quite deviant from the
global standards. Processes of height measurement were more flawed than weighing due to
use of incorrect instruments and inaccurate positioning of children.
Understanding the use of ICDS-CAS Dashboard and features of dashboard
Sarvesh Tewari, Dimagi
POSHAN Abhiyaan in its fight against malnutrition uses ICDS-CAS as the ICT system to
leverage Technology for Social Good. The ICDS-CAS displays 100+ program indicators for
officers to effectively monitor the implementation of POSHAN Abhiyaan. The dashboard has
been live for more than 2 years and processes, on an average, 3.2 million forms every day
filled by Community Health Workers across 24 states in India. The user research was aimed
to understand, using human-centered design principles, the dashboard users, their
motivations, behaviors, needs, expectations and usage patterns of data. The findings of the
research will be used to improve dashboard UI/UX to help users in leveraging data for
decision making.
India’s Integrated Child Development Services programme: equity and extent of coverage
in 2006 and 2016
Purnima Menon, IFPRI
Objective: To investigate coverage and equity of India’s Integrated Child Development
Services programme across the continuum of care from pregnancy to early childhood,
before and after the programme was expanded to provide universal access.
Methods: The programme offers nutrition and health services to pregnant and lactating
mothers and young children. We used data from nationally representative surveys in 2005–
2006 and 2015–2016, including 36 850 mother‒child pairs in 2006 and 190 804 in 2016. We
assessed changes in the equity of use of programme services by socioeconomic quintile,
caste, education and rural or urban residence. We used regression models to investigate the
determinants of programme use.

10. 10
List of Abstracts
Findings: The mean proportion of respondents using programme services increased between
2006 and 2016, from 9.6% to 37.9% for supplementary food, 3.2% to 21.0% for health and
nutrition education, 4.5% to 28% for health check-ups and 10.4% to 24.2% for child-specific
services (e.g. immunization, growth monitoring). Wealth, maternal education and caste
showed the largest positive associations with use of services. However, expansion in service
use varied at the sub-national level. Although overall use had improved and reached
marginalized groups such as disadvantaged castes and tribes, the poorest quintiles of the
population were still left behind, especially in the largest states that carry the highest
burden of undernutrition.
Conclusion: India’s policy reforms have increased coverage of the programme at national
level, including for marginalized groups. With further scaling-up, the programme needs to
focus on reaching households from the lowest socioeconomic strata and women with low
education.
Goal setting and identification of priority interventions for stunting reduction in Odisha: A
Lives Saved Tool (LiST) based approach
Santanu Bhaumik, APPI
Although nutrition-specific interventions are designed based on maternal, household and
community level correlates, no attempt has been made to project stunting and wasting and
identify intervention priorities in India. The objective of this paper/poster is to model the
stunting and wasting in the state of Odisha, India by scaling up maternal and child health
interventions under alternative scenarios. This study primarily used data from National
Family Health Survey 4, 2015–2016. Measures The LiST (Lives Saved Tool) software is used to
model the nutritional outcomes and prioritise interventions. The projections were carried
out under four alternative scenarios.
Appropriate complementary feeding would avert about half of the total stunting cases under
all four scenarios, followed by zinc supplementation. Water connection at home, washing
hands with soap and improved sanitation are other effective interventions. Sustaining the
maternal and child health interventions, promoting evidence-based stunting and wasting
reduction interventions, and a multi sectoral approach can help the state in achieving
WHA,2025/SDGs,2030.
Maternal spot feeding evaluation in Chhattisgarh and strengthening its quality in southern
states
William Joe, IEG
In 2016, the Government of Chhattisgarh launched an integrated maternal spot-feeding
program - Mahatari Jatan Yojana (MJY) - to improve maternal nutrition and promote
utilization of ICDS services. Using a mixed-methods approach (household survey and
qualitative insights), we find 65% coverage rate for regular meal (4-6 meals per week) intake.
We find higher coverage of ST and BPL population suggesting equity enhancing effects.
Further, we discern significant improvements in gestational weight gain and reduction in low
birthweight outcomes. IFA consumption has also increased among regular beneficiaries.
Overall, MJY has emerged as an efficient platform to deliver combined nutrition and non-
nutrition interventions. In concluding, we list critical areas for improvements and program
strengthening.

11. 11
List of Abstracts
'Effect Of ‘Anna Amrutha Hastham (Full meal programme)’ On Nutritional Status of
pregnant women and lactating mothers in Andhra Pradesh'
Kakani Sreerama Krishna, NIN
Assessed the effect of “Anna Amrutha Hastam” by covering 578 pregnant women, 956
lactating mothers, who were the beneficiaries AAH and findings were compared in 538
pregnant women, and 1034 lactating mothers who were receiving only ‘take home ration’.
About 80% of pregnant women and lactating mothers were consuming full meals at AWCs
only. It was observed that the full meal was providing stipulated food and nutrients
supplemented through AAH. Gestational weight monitoring was irregular; however, the
mean gestational mean weight gain between two successive weight recordings (1-2 months)
was 1.9kgs. The prevalence of low birth weight was decreased from 13.7% to 11.9%.
In spite some logistic problems, the program had contributed in positive way in meeting the
nutritional requirements of pregnant and lactating mothers.
Use of the Jeevika SHG platform for the delivery of BCC messages: Impact and factors
influencing impact (If only I knew: experimental evidence of the impact of nutrition
information on behavior in rural Bihar)
Kalyani Raghunathan, IFPRI
We use a randomized controlled trial and primary survey data on more than 2000
households from Bihar, India, to examine the impact on diet quality and anthropometry of a
health and nutrition pilot delivered through woman’s groups. We find that the pilot had
small but significant impacts on women’s and children’s dietary diversity but no impact on
women’s BMI. We identify and investigate several potential pathways to impact. Our
analysis suggests that the main channel through which the intervention worked was
improving awareness of quality of diets, however, conditional on exposure, resource
constraints and social norms around child diets remain significant barriers to further
progress.
Integrated multisectoral strategy to improve girls’ and women’s nutrition before
conception, during pregnancy and after birth in India (Swabhimaan): A prospective, non-
randomized controlled evaluation 2016-2021
Vani Sethi, UNICEF
We describe the swabhimaan demonstration programme being by State Rural Livelihood
Mission in four districts of Indian states- Bihar, Chhattisgarh and Odisha. The programme
aims to improve nutrition status of women – before, during and after pregnancy by
improving the delivery of 18 nutrition-specific and nutrition-sensitive interventions through
a mix of systems strengthening and Community activities. Swabhimaan has a nested
prospective, non-randomized controlled evaluation. Intervention sites receive community
activities, which include - POSHAN microplanning, receipt of nutrition cash grants to village
organizations implement the plans, newly-wed, women farmers and adolescent groups
inclusion and men engagement. Both intervention and control sites receive systems
strengthening interventions to improve the coverage of food security entitlements, health,
nutrition, water and sanitation services.

12. 12
List of Abstracts
Testing the impact of layered health & nutrition interventions in Rajasthan
Neha Raykar, OPM
The Children’s Investment Fund Foundation (CIFF) in partnership with the Government of
Rajasthan seeks to reduce the prevalence of low birthweight and wasting in children through
multi-faceted interventions to strengthen the existing delivery of services during pregnancy
continuing into early childhood. As a part of the overarching impact evaluation of these
interventions, we conducted a retrospective survey of mothers with children under three
years to assess baseline prevalence of low birthweight and wasting in matched treatment
and control areas. Matching facility birthweight records of children born to mothers in the
sample confirmed heaping of data well-documented in the literature on birthweight records
from administrative or secondary data sources in developing countries across the world. This
evidence has prompted innovations to improve birthweight measurement in Rajasthan,
whereby all selected public delivery facilities in treatment and control areas will now receive
digitised weighing scales, along with training and mentoring of labour room staff based on a
standardised protocol developed by partners.
Understanding of factors influencing pregnant and lactating women’s decisions on food
intake: Findings from a formative research in Rajasthan
Subir Kole, IPE Global
Introduction: Rajasthan has one of the highest burdens of maternal undernutrition in India
with nearly one-third women having low-BMI (<18.5 Kg/m2) and 47% women suffering from
anemia. Maternal nutrition is significantly associated with weight gain during pregnancy and
is a strong predictor of low birth weight (Kramer 1987; Metgud et.al. 2012). Studies suggest
that pregnant women in Rajasthan consumed nearly 35% less calories (500-700 Kcal) during
pregnancy than what is recommended by ICMR (Sadhu, et.al. 2017). Strategies to improve
maternal nutrition through behaviour change, must explore the factors that foster or hinder
food consumption during pregnancy and lactation. This formative research aims to
understand the barriers and enablers of food intake for designing appropriate behaviour
change communication to improve maternal nutrition.
Objectives: The objectives of this study are primarily two:
1. To identify the key factors influencing pregnant and lactating women’s (PLW)
decisions on what to eat, when, and how much? and
2. To suggest actionable strategies for communication to promote healthy eating
practices among PLW.
Methods: This study adopts a qualitative research design. Quantitative data from secondary
sources were only used to corroborate the findings. The study was conducted in four
districts of Rajasthan representing distinct agro-climatic regions – Pali, Tonk, Baran, and
Udaipur. Pregnant and lactating women were recruited in the study using a convenience
sampling methodology representing women from low income communities, married with at
least one child, from nuclear/ extended families and varied literacy levels. In-depth-
interviews, concept testing, storytelling, evaluation of images, ethnographic observations,
and focus group discussions were used to collect data from PLWs, mothers-in-law, husbands,
and front-line workers. Data were analysed using Atlas.Ti through open coding by identifying
emerging themes that influence maternal food choice and consumption.

13. 13
List of Abstracts
Results: The study identified four maternal factors influencing food intake during pregnancy
and lactation. These were grouped under: 1) physiological factors such as appetite and were
influenced by social customs and traditions; 2) access to food, consisting of order of eating,
quantity and quality of food, and household norms such as food sharing; 3) women’s
autonomy reflecting household level decision-making, mobility, and workload; and 4)
cognitive factors such as maternal knowledge, motivation to change diet, and aspirations for
the unborn child. These factors were interlinked through complex pathways and reinforced
each other affecting women’s food choices. The study finds that adopting dietary advice to
modify main-meal is difficult. Thus, non-meal occasions for dietary intervention provides an
opportunity. The study came out with socially acceptable and doable dietary advice tapping
non-meal occasions that preserves dietary diversity:
• One glass of milk, or lassi;
• One glass of raab (corn or millet cooked in buttermilk);
• A handful of channa (Bengal gram) – roasted or boiled, with jaggery;
• One Fresh fruit;
• A handful of ground nuts (moongphali), and
• Biscuits, rusk or roti with tea.
Lessons learnt:
• Improving food intake for PLW is feasible through non-main-meal occasions. Advice
with higher action-efficacy should include foods that do not require cooking, can
deliver calories and nutrients in a small portion, and are readily available at home.
• Women need permission to eat more during pregnancy and lactation. Since family’s
influence outweigh PLW’s autonomy in the household, dietary advice to be given to
mother-in-law and husband by a key influencer (doctor) to promote healthy eating.
• Emotions are important pathways for motivating for dietary changes.
Communication message to promote maternal nutrition should leverage on the
emotional trigger such as maternal aspiration and future of the child. Logo, slogan,
visual, and narrative emphasizing on the emotional hook is important for behaviour
change (example, Champion ri ma logo).
Mapping Foods for Community Based Management of Children with Severe Acute
Malnutrition (CMAM) in India
Shivani Rohatgi, Kalawati Saran Children’s Hospital
For CMAM, availability of therapeutic foods is one of the treatment components. WHO
recommends the use of ready-to-use therapeutic food (RUTF) for the management of SAM
children without complications. In India, there is currently no food supplement specifically
formulated for SAM children. Therefore, Kalawati Saran Children’s Hospital in collaboration
with National Institute of Nutrition, Hyderabad and UNICEF reviewed the literature to
identify and map the profile energy and nutrient dense food items that have been used to
manage different forms of undernutrition in community settings in India with objective to
select most suitable and potential food items. This exercise will help State Governments to
explore alternative foods for the use to treat SAM children at community level.

14. 14
List of Abstracts
Tracking and influencing budgetary allocations for Anemia Mukt Bharat
Avi Saini and Vani Sethi, UNICEF
Ministry of Health and Family Welfare’s Anemia Mukt Bharat (AMB) 6X6X6 strategy rollout is
in its first year of implementation and set several institutional mechanism systems to deliver
the set ambitious target backed with increased fiscal allocation space. Denominators, unit
costs and financial allocation guidelines in public domain to aid planning. However, were the
state planner’s handheld to plan their AMB budgets in the 1st year? We present the
planning and allocation efficiency analyses for 14 Indian large sized States. Basis this, we
propose an excel-based tracker for incorporation in annual planning trainings, mid-year
review for planners at national and state level. We also present Dos and don’ts and a
theoretical model for strengthening of “financing efficiency” in the ambitious AMB.
Re-thinking effective nutrition convergence in India: A conceptual and empirical
illustration of outcome of intervention co-coverage
Samuel Scott, IFPRI
The National Nutrition Mission has explicitly recognised the multisectoral nature of the
challenge of malnutrition and has made “convergence” one of its key pillars. However, it
does not yet have sharp operational clarity on how stakeholders can ensure that multiple
programmes reach the same mother–child dyad in the fi rst 1,000-day period. The article
illustrates how data on co-coverage of interventions can be used to plan for and assess the
success of efforts to strengthen convergence.
Mapping NIPI implementation in Telangana & understanding facilitators and barriers
Little Flower Augustine, NIN
Implementation of National Iron plus initiative (NIPI) in Telangana is not well studied. We
aimed to understand the implementation on NIPI in 47 villages Medchal, Telangana. A total
of 110 focus group discussions and in-depth interviews were conducted to understand the
stakeholder’s perspectives on IFA programme. Participatory GIS mapping was carried out to
understand the distance from villages to health facilities. NIPI was partially operational at
ground-level. Majority of the frontline workers (64 %) were not involved in IFA tablet
distribution. A Primary Health centre was accessible beyond 10 kms distance for 32% of
villages. To ensure effectiveness of NIPI programme, creating awareness on anemia and IFA
programme, Strengthen ASHA training and point –of-care screening of anemia are required.
Visiting dieticians’ model for Pradhan Mantri Surakshit Matritva Abhiyaan (PMSMA)
Tashi Choedon and Naman Kaur, NCEARD
While all pregnant women require nutrition counselling, among the 13 high-risk conditions
under PMSMA, dietary management is critical for six. There is no mandate for a dietician’s
services under PMSMA and most health facilities lack full-time dieticians. On two
consecutive PMSMA days a model of pre-event training, provision of a resource kit and
travel support for dieticians was tested in June and July 2019. Based on this and through
engagement of dieticians’ association country-wide NCEARD will facilitate mapping, training
and certification of registered dieticians to bridge the nutritional counselling gap during
PMSMA. Service costs will be drawn from budgets at district and state level for stakeholder
sensitization and related activities under #IPledgeFor9.

15. 15
List of Abstracts
Feasibility of layering maternal nutrition services package for pregnant women in routine
antenatal care
Mansi Chopra, NCEARD
In order to inform Government of India’s antenatal nutrition guidelines, a five-action point
service algorithm was developed based on evidence review, government and expert
consultations and field testing across 14 sites in four states (January 2017 to May 2019).
Sites included all tiers of public health facilities. Anchored by the Auxiliary Nurse Midwives
and Medical Officers the service package bridges gaps in nutrition assessment, micronutrient
supplementation, counselling, prevention and treatment of helminthic infections and
specific actions for at-nutrition risk. A cascade training model with training and
communication resources kit is available for rolling-out the package in a phased manner.
NCEARD as the government’s technical support unit convenes multi-stakeholder forums and
is providing technical assistance to selected states for this roll-out.