Markets, incentives, and health promotion can improve family planning and maternal health practices: a quasi-experimental evaluation of a tech-enabled social franchising and social marketing platform in India.

BACKGROUND: Improving family planning and maternal health outcomes are critical to achieving the Sustainable Development Goals. While evidence on the effectiveness of government-driven public health programs is extensive, more research is needed on effectiveness of private-sector interventions, especially in low- and middle-income countries. We evaluated the impacts of a commercial social-franchising and social-marketing program - Tiko Platform - which created a local ecosystem of health promoters, healthcare providers, pharmacies, stockists/wholesalers, and lifestyle shops. It provided economic incentives through discounts and reward points to nudge health-seeking behaviors from enrolled women consumers/beneficiaries. METHODS: An ex-post facto evaluation was commissioned, and we employed a quasi-experimental design to compare outcomes related to the use of family planning, and antenatal and postnatal services between users and non-users who had registered for Tiko in three North Indian cities. Between March and April 2021, 1514 married women were surveyed, and outcome indicators were constructed based on recall. Despite statistical approaches to control for confounding, the effect of COVID-19 lockdown on Tiko operations and methodological limitations preclude inferring causality or arguing generalizability. RESULTS: We found a strong association between the use of the Tiko platform and the current use of temporary modern contraceptives [non-users: 9.5%, effect: +9.4 percentage points (pp), p-value < 0.001], consumption of 100 or more iron-folic-acid tablets during pregnancy [non-users: 25.5%, effect: +14 pp, p-value < 0.001], receiving four or more antenatal check-ups [non-users: 18.3%, effect: +11.3 pp, p-value 0.007], and receiving postnatal check-up within six weeks of birth [non-users: 50.9%, effect: +7.5 pp, p-value 0.091]. No associations were found between the use of the Tiko platform and the current use of any type of contraceptive (temporary, permanent, or rudimentary). Effects were pronounced when a community health worker of the National Health Mission also worked as a health promoter for the Tiko Platform. CONCLUSION: Commercial interventions that harness market-driven approaches of incentives, social marketing, and social franchising improved family planning and maternal health practices through higher utilization of private market providers while maintaining access to government health services. Findings support a unifying approach to public health without separating government versus private services, but more rigorous and generalizable research is needed. TRIAL REGISTRATION: NCT05725278 at clinicaltrials.gov (retrospective); 13/02/2023.

Is respectful care provided by community health workers associated with infant feeding practices? A cross sectional analysis from India.

OBJECTIVES: Breastfeeding and complementary feeding practices in India do not meet recommendations. Community health care workers (CHWs) are often the primary source of information for pregnant and postpartum women about Infant and Young Child Feeding (IYCF) practices. While existing research has evaluated the effectiveness of content and delivery of information through CHWs, little is known about the quality of the interpersonal communication (respectful care). We analyzed the effect of respectful interactions on recommended IYCF practices. METHODS: We use data from evaluation of an at-scale mHealth intervention in India that serves as a job aid to the CHWs (n = 3266 mothers of children < 12 m from 841 villages in 2 Indian states). The binary indicator variable for respectful care is constructed using a set of 7 questions related to trust, respect, friendliness during these interactions. The binary outcomes variables are exclusive breastfeeding, timely introduction of complimentary feeding, and minimum diet diversity for infants. We also explore if most of the pathway from respectful care to improved behaviors is through better recall of messages (mediation analysis). All models controlled for socio-economic-demographic characteristics and number of interactions with the CHW. RESULTS: About half of women reported positive, respectful interactions with CHWs. Interactions that are more respectful were associated with better recall of appropriate health messages. Interactions that are more respectful were associated with a greater likelihood of adopting all child-feeding behaviors except timely initiation of breastfeeding. After including recall in the model, the effect of respectful interactions alone reduced. CONCLUSIONS: Respectful care from CHWs appears to be significantly associated with some behaviors around infant feeding, with the primary pathway being through better recall of messages. Focusing on improving social and soft skills of CHWs that can translate into better CHW-beneficiary interactions can pay rich dividends. FUNDING: This study is funded by Grant No. OPP1158231 from Bill and Melinda Gates Foundation. TRIAL REGISTRATION NUMBER: https://doi.org/10.1186/ISRCTN83902145.

Strengthening Nutrition Interventions in Antenatal Care Services Affects Dietary Intake, Micronutrient Intake, Gestational Weight Gain, and Breastfeeding in Uttar Pradesh, India: Results of a Cluster-Randomized Program Evaluation.

BACKGROUND: Maternal nutrition interventions are inadequately integrated into antenatal care (ANC). Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization through government ANC services. OBJECTIVES: We compared nutrition-intensified ANC (I-ANC) with standard ANC (S-ANC) on coverage of nutrition interventions and maternal nutrition practices. METHODS: We used a cluster-randomized design with cross-sectional baseline (2017) and endline (2019) surveys (n ∼660 pregnant and 1800 recently delivered women per survey) and a repeated-measures longitudinal study in 2018-2019 (n = 400). We derived difference-in-difference effect estimates (DIDs) for diet diversity, consumption of micronutrient supplements, weight monitoring, and early breastfeeding practices. RESULTS: Despite substantial secular improvements in service coverage from India's national nutrition program, women in the I-ANC arm received more home visits [DID: 7-14 percentage points (pp)] and counseling on core nutrition messages (DID: 10-23 pp) than in the S-ANC arm. One-third of women got ≥3 home visits and one-fourth received ≥4 ANC check-ups in the I-ANC arm. Improvements were greater in the I-ANC arm than in the S-ANC arm for any receipt and consumption of iron-folic acid (DID: 7.5 pp and 9.5 pp, respectively) and calcium supplements (DID: 14.1 pp and 11.5 pp, respectively). Exclusive breastfeeding improved (DID: 7.5 pp) but early initiation of breastfeeding did not. Maternal food group consumption (∼4 food groups) and probability of adequacy of micronutrients (∼20%) remained low in both arms. Repeated-measures longitudinal analyses showed similar results, with additional impact on consumption of vitamin A-rich foods (10 pp, 11 g/d), other vegetables and fruits (22-29 g/d), and gestational weight gain (0.4 kg). CONCLUSIONS: Intensifying nutrition in government ANC services improved maternal nutrition practices even with strong secular trends in service coverage. Dietary diversity, supplement consumption, and breastfeeding practices remained suboptimal. Achieving greater behavior changes will require strengthening the delivery and use of maternal nutrition services integrated into ANC services in the health system. This trial was registered at clinicaltrials.gov as NCT03378141.

Association between supportive supervision and performance of community health workers in India: a longitudinal multi-level analysis.

INTRODUCTION: Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services. OBJECTIVES: We examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge. METHODS: We used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong. RESULTS: Among 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge. CONCLUSION: Higher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes. TRIAL REGISTRATION: Trial registration number:  https://doi.org/10.1186/ISRCTN83902145.

Anganwadi worker time use in Madhya Pradesh, India: a cross-sectional study.

BACKGROUND: Anganwadi Workers (AWWs) are a group of 1.4 million community health workers that operate throughout rural India as a part of the Integrated Child Development Services program. AWWs are responsible for disseminating key health information regarding nutrition, family planning, and immunizations to the women and children in their catchment area, while maintaining detailed registers that track key beneficiary data, updates on health status, and supply inventory beneficiaries. There is a need to understand how AWWs spend their time on all of these activities given all of their responsibilities, and the factors that are associated with their time use. METHODS: This cross-sectional study conducted in Madhya Pradesh, collected time use data from AWWs using a standard approach in which we asked participants how much time they spent on various activities. Additionally, we estimated a logistic regression model to elucidate what AWW characteristics are associated with time use. RESULTS: We found that AWWs spend substantial amounts of time on administrative tasks, such as filling out their paper registers. Additionally, we explored the associations between various AWW characteristics and their likelihood of spending the expected amount of time on preschool work, filling out their registers, feeding children, and conducting home visits. We found a positive significant association between AWW education and their likelihood of filling out their registers. CONCLUSIONS: AWWs spend substantial amounts of time on administrative tasks, which could take away from their ability to spend time on providing direct care. Additionally, future research should explore why AWW characteristics matter and how such factors can be addressed to improve AWWs' performance and should explore the associations between Anganwadi Center characteristics and AWW time use.

Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors.

Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self-efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization-recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change.

The effect of India's total sanitation campaign on defecation behaviors and child health in rural Madhya Pradesh: a cluster randomized controlled trial.

BACKGROUND: Poor sanitation is thought to be a major cause of enteric infections among young children. However, there are no previously published randomized trials to measure the health impacts of large-scale sanitation programs. India's Total Sanitation Campaign (TSC) is one such program that seeks to end the practice of open defecation by changing social norms and behaviors, and providing technical support and financial subsidies. The objective of this study was to measure the effect of the TSC implemented with capacity building support from the World Bank's Water and Sanitation Program in Madhya Pradesh on availability of individual household latrines (IHLs), defecation behaviors, and child health (diarrhea, highly credible gastrointestinal illness [HCGI], parasitic infections, anemia, growth). METHODS AND FINDINGS: We conducted a cluster-randomized, controlled trial in 80 rural villages. Field staff collected baseline measures of sanitation conditions, behaviors, and child health (May-July 2009), and revisited households 21 months later (February-April 2011) after the program was delivered. The study enrolled a random sample of 5,209 children <5 years old from 3,039 households that had at least one child <24 months at the beginning of the study. A random subsample of 1,150 children <24 months at enrollment were tested for soil transmitted helminth and protozoan infections in stool. The randomization successfully balanced intervention and control groups, and we estimated differences between groups in an intention to treat analysis. The intervention increased percentage of households in a village with improved sanitation facilities as defined by the WHO/UNICEF Joint Monitoring Programme by an average of 19% (95% CI for difference: 12%-26%; group means: 22% control versus 41% intervention), decreased open defecation among adults by an average of 10% (95% CI for difference: 4%-15%; group means: 73% intervention versus 84% control). However, the intervention did not improve child health measured in terms of multiple health outcomes (diarrhea, HCGI, helminth infections, anemia, growth). Limitations of the study included a relatively short follow-up period following implementation, evidence for contamination in ten of the 40 control villages, and bias possible in self-reported outcomes for diarrhea, HCGI, and open defecation behaviors. CONCLUSIONS: The intervention led to modest increases in availability of IHLs and even more modest reductions in open defecation. These improvements were insufficient to improve child health outcomes (diarrhea, HCGI, parasite infection, anemia, growth). The results underscore the difficulty of achieving adequately large improvements in sanitation levels to deliver expected health benefits within large-scale rural sanitation programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT01465204. Please see later in the article for the Editors' Summary.

Life skills and reproductive health empowerment intervention for newly married women and their families to reduce unintended pregnancy in India: protocol for the TARANG cluster randomised controlled trial.

INTRODUCTION: In South Asia, younger women have high rates of unmet need for family planning and low empowerment. Life skills interventions can equip young women with agency, but the effectiveness of these interventions in reproductive and sexual autonomy and contraception has not been examined. METHODS AND ANALYSIS: A two-arm, parallel, cluster randomised controlled trial will evaluate the impact of TARANG (Transforming Actions for Reaching and Nurturing Gender Equity and Empowerment), a life skills and reproductive health empowerment group-based intervention for newly married women, compared with usual services in the community in rural and tribal Rajasthan, India. TARANG will also provide light-touch sessions to husbands and mothers-in-law of newly married women. We will test the impact of TARANG in 80 village clusters among 800 eligible households comprising newly married women aged 18-25 years who are at risk of pregnancy but do not want a pregnancy within 1 year at the time of enrolment, their husbands and mothers-in-law who consent to participate. Women in the intervention villages will receive 14 sessions over a 6-month period, while husbands and mothers-in-law will receive 1 and 4 sessions (respectively) each. Three rounds of surveys will be collected over 18 months. Control villages will receive the intervention after the endline surveys. Primary outcomes include rate of unintended pregnancy and modern contraceptive use. We plan to start recruitment of participants and data collection in April 2024. We will estimate unadjusted and adjusted intention-to-treat effects using survival analysis and mixed models. ETHICS AND DISSEMINATION: Study protocols have been reviewed and approved by the human subjects review boards at the University of California, San Francisco, and the Centre for Media Studies, India (IRB00006230) and ACE Independent Ethics Committee, Bangalore (NET0062022). Results will be disseminated in international peer-reviewed journals and conferences, to stakeholders including local government and non-governmental organisations, and directly to the communities and individuals that participated in the intervention. TRIAL REGISTRATION NUMBER: NCT06024616.

Temporary childbirth migration and maternal health care in India.

BACKGROUND: Women in South Asia often return to their natal home during pregnancy, for childbirth, and stay through the postpartum period-potentially impacting access to health care and health outcomes in this important period. However, this phenomenon is understudied (and not even named) in the demographic or health literature, nor do we know how it impacts health. OBJECTIVE: The aim of this study is to measure the magnitude, timing, duration, risk factors and impact on care of this phenomenon, which we name Temporary Childbirth Migration. METHODS: Using data from 9,033 pregnant and postpartum women collected in 2019 in two large states of India (Madhya Pradesh and Bihar) we achieve these aims using descriptive statistics and logistic regression models, combined with qualitative data from community health workers about this practice. RESULTS: We find that about one third of women return to their natal home at some point in pregnancy or postpartum, mostly clustered close to the time of delivery. Younger, primiparous, and non-Hindu women were more likely to return to their natal home. Women reported that they went to their natal home because they believed that they would receive better care; this was born out by our analysis in Bihar, but not Madhya Pradesh, for prenatal care. CONCLUSIONS: Temporary childbirth migration is common, and, contrary to expectations, did not lead to disruptions in care, but rather led to more access to care. CONTRIBUTION: We describe a hitherto un-named, underexplored yet common phenomenon that has implications for health care use and potentially health outcomes.

Can digitally enabling community health and nutrition workers improve services delivery to pregnant women and mothers of infants? Quasi-experimental evidence from a national-scale nutrition programme in India.

BACKGROUND: India's 1.4 million community health and nutrition workers (CHNWs) serve 158 million beneficiaries under the Integrated Child Development Services (ICDS) programme. We assessed the impact of a data capture, decision support, and job-aid mobile app for the CHNWs on two primary outcomes-(1) timeliness of home visits and (2) appropriate counselling specific to the needs of pregnant women and mothers of children <12 months. METHODS: We used a quasi-experimental pair-matched controlled trial using repeated cross-sectional surveys to evaluate the intervention in Bihar and Madhya Pradesh (MP) separately using an intention-to-treat analysis. The study was powered to detect difference of 5-9 percentage points (pp) with type I error of 0.05 and type II error of 0.20 with endline sample of 6635 mothers of children <12 months and 2398 pregnant women from a panel of 841 villages. RESULTS: Among pregnant women and mothers of children <12 months, recall of counselling specific to the trimester of pregnancy or age of the child as per ICDS guidelines was higher in both MP (11.5pp (95% CI 7.0pp to 16.0pp)) and Bihar (8.0pp (95% CI 5.3pp to 10.7pp)). Significant differences were observed in the proportion of mothers of children <12 months receiving adequate number of home visits as per ICDS guidelines (MP 8.3pp (95% CI 4.1pp to 12.5pp), Bihar: 7.9pp (95% CI 4.1pp to 11.6pp)). Coverage of children receiving growth monitoring increased in Bihar (22pp (95% CI 0.18 to 0.25)), but not in MP. No effects were observed on infant and young child feeding practices. CONCLUSION: The at-scale app integrated with ICDS improved provision of services under the purview of CHNWs but not those that depended on systemic factors, and was relatively more effective when baseline levels of services were low. Overall, digitally enabling CHNWs can complement but not substitute efforts for strengthening health systems and addressing structural barriers. TRIAL REGISTRATION NUMBER: ISRCTN83902145.

Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study.

BACKGROUND: Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020. METHODS: We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August-October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2. RESULTS: In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges. CONCLUSIONS: Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.

How valuable are environmental health interventions? Evaluation of water and sanitation programmes in India.

OBJECTIVE: To evaluate and quantify the economic benefits attributable to improvements in water supply and sanitation in rural India. METHODS: We combined propensity-score "pre-matching" and rich pre-post panel data on 9500 households in 242 villages located in four geographically different districts to estimate the economic benefits of a large-scale community demand-driven water supply programme in Maharashtra, India. We calculated coping costs and cost of illness by adding across several elements of coping and illness and then estimated causal impacts using a difference-in-difference strategy on the pre-matched sample. The pre-post design allowed us to use a difference-in-difference estimator to measure "treatment effect" by comparing treatment and control villages during both periods. We compared average household costs with respect to out-of-pocket medical expenses, patients' lost income, caregiving costs, time spent on collecting water, time spent on sanitation, and water treatment costs due to filtration, boiling, chemical use and storage. FINDINGS: Three years after programme initiation, the number of households using piped water and private pit latrines had increased by 10% on average, but no changes in hygiene-related behaviour had occurred. The behavioural changes observed suggest that the average household in a programme community could save as much as 7 United States dollars per month (or 5% of monthly household cash expenditures) in coping costs, but would not reduce illness costs. Poorer, socially marginalized households benefited more, in alignment with programme objectives. CONCLUSION: Given the renewed interest in water, sanitation and hygiene outcomes, evaluating the economic benefits of environmental interventions by means of causal research is important for understanding the true value of such interventions.

Shame or subsidy revisited: social mobilization for sanitation in Orissa, India.

OBJECTIVE: To determine the effectiveness of a sanitation campaign that combines 'shaming' (i.e. emotional motivators) with subsidies for poor households in rural Orissa, an Indian state with a disproportionately high share of India's child mortality. METHODS: Using a cluster-randomized design, we selected 20 treatment and 20 control villages in the coastal district of Bhadrak, rural Orissa, for a total sample of 1050 households. We collected sanitation and health data before and after a community-led sanitation project, and we used a difference-in-difference estimator to determine the extent to which the campaign influenced the number of households building and using a latrine. FINDINGS: Latrine ownership did not increase in control villages, but in treatment villages it rose from 6% to 32% in the overall sample, from 5% to 36% in households below the poverty line (eligible for a government subsidy) and from 7% to 26% in households above the poverty line (not eligible for a government subsidy). CONCLUSION: Subsidies can overcome serious budget constraints but are not necessary to spur action, for shaming can be very effective by harnessing the power of social pressure and peer monitoring. Through a combination of shaming and subsidies, social marketing can improve sanitation worldwide.

Of taps and toilets: quasi-experimental protocol for evaluating community-demand-driven projects.

Sustainable and equitable access to safe water and adequate sanitation are widely acknowledged as vital, yet neglected, development goals. Water supply and sanitation (WSS) policies are justified because of the usual efficiency criteria, but also major equity concerns. Yet, to date there are few scientific impact evaluations showing that WSS policies are effective in delivering social welfare outcomes. This lack of an evaluation culture is partly because WSS policies are characterized by diverse mechanisms, broad goals and the increasing importance of decentralized delivery, and partly because programme administrators are unaware of appropriate methods. We describe a protocol for a quasi-experimental evaluation of a community-demand-driven programme for water and sanitation in rural India, which addresses several evaluation challenges. After briefly reviewing policy and implementation issues in the sector, we describe key features of our protocol, including control group identification, pre-post measurement, programme theory, sample sufficiency and robust indicators. At its core, our protocol proposes to combine propensity score matching and difference-in-difference estimation. We conclude by briefly summarizing how quasi-experimental impact evaluations can address key issues in WSS policy design and when such evaluations are needed.

Effects of an mHealth intervention for community health workers on maternal and child nutrition and health service delivery in India: protocol for a quasi-experimental mixed-methods evaluation.

INTRODUCTION: Millions of children in India still suffer from poor health and under-nutrition, despite substantial improvement over decades of public health programmes. The Anganwadi centres under the Integrated Child Development Scheme (ICDS) provide a range of health and nutrition services to pregnant women, children <6 years and their mothers. However, major gaps exist in ICDS service delivery. The government is currently strengthening ICDS through an mHealth intervention called Common Application Software (ICDS-CAS) installed on smart phones, with accompanying multilevel data dashboards. This system is intended to be a job aid for frontline workers, supervisors and managers, aims to ensure better service delivery and supervision, and enable real-time monitoring and data-based decision-making. However, there is little to no evidence on the effectiveness of such large-scale mHealth interventions integrated with public health programmes in resource-constrained settings on the service delivery and subsequent health and nutrition outcomes. METHODS AND ANALYSIS: This study uses a village-matched controlled design with repeated cross-sectional surveys to evaluate whether ICDS-CAS can enable more timely and appropriate services to pregnant women, children <12 months and their mothers, compared with the standard ICDS programme. The study will recruit approximately 1500 Anganwadi workers and 6000+ mother-child dyads from 400+ matched-pair villages in Bihar and Madhya Pradesh. The primary outcomes are the proportion of beneficiaries receiving (a) adequate number of home visits and (b) appropriate level of counselling by the Anganwadi workers. Secondary outcomes are related to improvements in other ICDS services, and knowledge and practices of the Anganwadi workers and beneficiaries. ETHICS AND DISSEMINATION: Ethical oversight is provided by the Committee for the Protection of Human Subjects at the University of California at Berkeley, and the Suraksha Independent Ethics Committee in India. The results will be published in peer-reviewed journals and analysis data will be made public. TRIAL REGISTRATION NUMBER: ISRCTN83902145.

Consumer food safety knowledge, practices, and demographic differences: findings from a meta-analysis.

Risk communication and consumer education to promote safer handling of food can be the best way of managing the risk of foodborne illness at the consumer end of the food chain. Thus, an understanding of the overall status of food handling knowledge and practices is needed. Although traditional qualitative reviews can be used for combining information from several studies on specific food handling behaviors, a structured approach of meta-analysis can be more advantageous in a holistic assessment. We combined findings from 20 studies using meta-analysis methods to estimate percentages of consumers engaging in risky behaviors, such as consumption of raw food, poor hygiene, and cross-contamination, separated by various demographic categories. We estimated standard errors to reflect sampling error and between-study random variation. Then we evaluated the statistical significance of differences in behaviors across demographic categories and across behavioral measures. There were considerable differences in behaviors across demographic categories, possibly because of socioeconomic and cultural differences. For example, compared with women, men reported greater consumption of raw or undercooked foods, poorer hygiene, poorer practices to prevent cross-contamination, and less safe defrosting practices. Mid-age adults consumed more raw food (except milk) than did young adults and seniors. High-income individuals reported greater consumption of raw foods, less knowledge of hygiene, and poorer cross-contamination practices. The highest raw ground beef and egg consumption and the poorest hygiene and cross-contamination practices were found in the U.S. Mountain region. Meta-analysis was useful for identifying important data gaps and demographic groups with risky behaviors, and this information can be used to prioritize further research.

An application of meta-analysis in food safety consumer research to evaluate consumer behaviors and practices.

Meta-analysis provides a structured method for combining results from several studies and accounting for and differentiating between study variables. Numerous food safety consumer research studies often focus on specific behaviors among different subpopulations but fail to provide a holistic picture of consumer behavior. Combining information from several studies provides a broader understanding of differences and trends among demographic subpopulations, and thus, helps in developing effective risk communication messages. In the illustrated example, raw/undercooked ground beef consumption and hygienic practices were evaluated according to gender, ethnicity, and age. Percentages of people engaging in each of the above behaviors (referred to as effect sizes) were combined using weighted averages of these percentages. Several measures, including sampling errors, random variance between studies, sample sizes of studies, and homogeneity of findings across studies, were used in the meta-analysis. The statistical significance of differences in behaviors across demographic segments was evaluated using analysis of variance. The meta-analysis identified considerable variability in effect sizes for raw/undercooked ground beef consumption and poor hygienic practices. More males, African Americans, and adults between 30 and 54 years (mid-age) consumed raw/undercooked ground beef than other demographic segments. Males, Caucasians, and Hispanics and young adults between 18 and 29 years were more likely to engage in poor hygienic practices. Compared to traditional qualitative review methods, meta-analysis quantitatively accounts for interstudy differences, allows greater consideration of data from studies with smaller sample sizes, and offers ease of analysis as newer data become available, and thus, merits consideration for its application in food safety consumer research.

The effect of water quality testing on household behavior: evidence from an experiment in rural India.

How does specific information about contamination in a household's drinking water affect water handling behavior? We randomly split a sample of households in rural Andhra Pradesh, India. The treatment group observed a contamination test of the drinking water in their own household storage vessel; while they were waiting for their results, they were also provided with a list of actions that they could take to remedy contamination if they tested positive. The control group received no test or guidance. The drinking water of nearly 90% of tested households showed evidence of contamination by fecal bacteria. They reacted by purchasing more of their water from commercial sources but not by making more time-intensive adjustments. Providing salient evidence of risk increases demand for commercial clean water.

Consumer preferences for household water treatment products in Andhra Pradesh, India.

Over 5 billion people worldwide are exposed to unsafe water. Given the obstacles to ensuring sustainable improvements in water supply infrastructure and the unhygienic handling of water after collection, household water treatment and storage (HWTS) products have been viewed as important mechanisms for increasing access to safe water. Although studies have shown that HWTS technologies can reduce the likelihood of diarrheal illness by about 30%, levels of adoption and continued use remain low. An understanding of household preferences for HWTS products can be used to create demand through effective product positioning and social marketing, and ultimately improve and ensure commercial sustainability and scalability of these products. However, there has been little systematic research on consumer preferences for HWTS products. This paper reports the results of the first state-of-the-art conjoint analysis study of HWTS products. In 2008, we conducted a conjoint analysis survey of a representative sample of households in Andhra Pradesh (AP), India to elicit and quantify household preferences for commercial HWTS products. Controlling for attribute non-attendance in an error components mixed logit model, the study results indicate that the most important features to respondents, in terms of the effect on utility, were the type of product, followed by the extent to which the product removes pathogens, the retail outlet and, the time required to treat 10 L. Holding all other product attributes constant, filters were preferred to combination products and chemical additives. Department stores and weekly markets were the most favorable sales outlets, followed by mobile salespeople. In general, households do not prefer to purchase HWTS products at local shops. Our results can inform the types of products and sales outlets that are likely to be successful in commercial HWTS markets in AP, as well as the influence of different pricing and financing strategies on product demand and uptake.

Identification and review of sensitivity analysis methods.

Identification and qualitative comparison of sensitivity analysis methods that have been used across various disciplines, and that merit consideration for application to food-safety risk assessment models, are presented in this article. Sensitivity analysis can help in identifying critical control points, prioritizing additional data collection or research, and verifying and validating a model. Ten sensitivity analysis methods, including four mathematical methods, five statistical methods, and one graphical method, are identified. The selected methods are compared on the basis of their applicability to different types of models, computational issues such as initial data requirement and complexity of their application, representation of the sensitivity, and the specific uses of these methods. Applications of these methods are illustrated with examples from various fields. No one method is clearly best for food-safety risk models. In general, use of two or more methods, preferably with dissimilar theoretical foundations, may be needed to increase confidence in the ranking of key inputs.