If Only I Knew: Nutrition Behavior Change Delivered by Women’s Groups Has Impacts on Diet Quality That Are Mediated by Knowledge in Rural Bihar, India

Abstract

Abstract Objectives Poor diets are a major challenge in India. Barriers to improving diets include limited knowledge, access to resources and availability of affordable nutritious foods. Bihar, a poor state in India, has scaled up women's savings and credit self-help group (SHG) programs state-wide to improve livelihoods and access to resources. SHGs are now being leveraged to integrate health and nutrition discussions into their activities but rigorous evidence on the impact of integration is limited. Methods Cluster-randomized impact evaluation comparing 12 treatment and 12 comparison villages. Treatment area SHGs engaged in facilitated bi-monthly health/nutrition discussions, and increased coordination efforts between SHGs and their federations and health/nutrition service providers. Control SHGs conducted routine savings & credit activities. We surveyed 2000 households (1000 treatment; 1000 control) in April 2016 and again in Oct 2018. We assessed impact on diet diversity of women and their children and body mass index (BMI) of women using analysis of covariance, adjusting for sample clustering, baseline levels of outcomes & other characteristics. We did a mid-term mixed-methods process evaluation to assess implementation and uptake and a retrospective costing study to estimate implementation costs. Results Sample characteristics were generally balanced across arms at baseline. The intervention led to a 7–8% increase (P < 0.05) in the number of food groups consumed by women and children but had no impact on women's BMI. Consumption of pulses, fruits, vegetables and dairy increased significantly, but not eggs or flesh foods, suggesting resource constraints and social norms were barriers. A pathway analysis showed that the intervention worked primarily by improving awareness about diets. Process evaluation identified various implementation challenges that affected intervention exposure. The implementation cost $6/SHG member/year, comparable to other similar interventions. Conclusions SHG platforms have potential to influence awareness about nutrition and dietary practices but impact can be constrained by exposure to interventions and household-level economic and social constraints. Funding Sources World Bank Strategic Impact Evaluation Fund; Bill & Melinda Gates through WINGS, managed by IFPRI.