Effect of social and behavioral change interventions on minimum dietary diversity among pregnant women and associated socio-economic inequality in Rajasthan, India

Abstract

Background

Maternal dietary intake is a critical and modifiable risk factor determining child health outcomes and mortality [1]. India shares a significant burden of neonatal mortality (NM) as it contributes 60% of all neonatal deaths in South Asian countries (0.9 million) in 2017 [2]. Maternal malnourishment leading to inadequate weight gain during gestation results in adverse birth outcomes such as preterm birth, short for gestational ages and contributing significantly to NM [3–5]. Globally, 20 million low birth weight (LBW) children are born, and India shares 40% of the burden. Additionally, one-third of the low birth weight (LBW) babies are short for gestational age, while the rest are preterm [6]. To end all forms of malnourishment, Sustainable Development Goals aim to reduce the prevalence of LBW by 30% by the end of 2030. India has also launched the National Nutrition Mission/ POSHAN Abhiyaan with the aim of a 2-percentage points reduction in the prevalence of LBW annually between 2017 and 2022 [5].

Often, in low- and middle-income countries, women start pregnancy with low BMI, resulting in a high demand for a balanced energy and protein intake during pregnancy [7]. Consumption of 5 out of 10 food groups is required to maintain nutrient adequacy among pregnant women [8]. However, women in India consume fewer food groups than their household members, resulting in low dietary diversity [9, 10]. The dietary practices of pregnant women are determined by a complex nexus of biological, physiological, psychological, and socio-economic factors [11]. Gestational weight gain is highly correlated with the consumption of energy rich food, carbohydrate, monosaccharide and saccharose [12]. In the Asian sub-continent, the dietary consumption of cereals is much higher than other food groups [13, 14]. However, consumption of carbohydrates is often insufficient, which negatively affects the nutritional outcomes. In particular, overall dietary consumption of nutritious foods in the lower socio-economic strata was less diverse than in reference groups [15]. Despite its significance, only a few studies have been conducted in small geographies and communities to measure the effect of maternal dietary intake on birth outcomes in India ( [15–17] .

The fundamental approach identified to improve maternal nutrition comprises three major intervention processes - food fortification/ supplementation, cash transfers or incentives and behavioural change interventions. These follow a pathway to enhance calorie consumption and micronutrient intakes that, in turn, affect maternal health outcomes [18]. Together, nutrition-specific interventions such as counselling – behavioural change interventions and education/ awareness and nutrition-sensitive interventions – cash incentives have compounding effect on the maternal dietary diversity compared to a specific intervention [19]. However, pathways determining the change across population groups have been a contesting topic. Any positive change is observed as a trickledown effect from higher to lower socio-economic groups in each population group [20]. Further, it is found that the impact of the state-sponsored scheme(s) through intervention programs shows a divergent effect among the rich and poor, though the barriers faced by the targeted groups are yet to be determined in this context [21].

Program interventions

Rajasthan, the largest state in India with a high burden of malnourishment, has shown a sluggish decline in neonatal mortality [2]. As per the latest round of National Family Health Survey of India (2019-21), the neonatal mortality rate in Rajasthan was reported as 20.2 per 1000 live births, along with 17% and 18% of children reported as having low birth weight and wasted, respectively. Therefore, it underscores the gravity of malnourishment among children and emphasizes the importance of addressing maternal malnutrition as the proximate determinant for the same.

RajPusht, launched in 2017 and implemented by IPE Global in five selected districts (Banswara, Baran, Dungarpur, Pratapgarh and Udaipur), is a program supported by Children’s Investment Fund Foundation (CIFF) - that works with various departments of Government of Rajasthan to accelerate the reduction in the prevalence of low birth weight and wasting by addressing the intergenerational effect of malnutrition. A multi-level SBCC strategy was deployed under the program, focusing on establishing a conducive environment by emphasizing the importance of maternal and child nutrition at the household and community level. As part of the intervention design, pregnant women were registered and given nutrition-specific interpersonal counselling by community volunteers (Poshan Champions) (see Table 1). Further, the capacity of frontline workers to deliver nutrition-sensitive counselling during pregnancy and early childhood at the household and community level was also developed by providing continuous mentoring and handholding support. An array of mid-media interventions was deployed to reiterate the essential messages at various forums so that there is a strong recall of such messages being delivered via interpersonal counselling (see Table 1). The SBCC strategy also targeted men and other family members, such as mothers-in-law, who were the prime decision-makers at the household level. Besides providing regular monitoring, the program conducted concurrent assessments of program quality biannually on several demographic, socio-economic, program intervention indicators and knowledge, attitude, and practice indicators. The program also supported the design and implementation of conditional cash transfer schemes in the intervention area. The primary objective of such cash transfer schemes was to supplement the households with additional resources to act on the dietary advice delivered through the SBCC interventions. In addition, the conditionalities of the schemes also act as a solid nudge to influence health-seeking behaviour within the target communities.

The present research argues for the effectiveness of nutrition-specific programs on the dietary diversity of pregnant women in the intervention districts. The study’s objective is to examine the effectiveness of various SBCC interventions deployed under RajPusht Program and measure the other socio-economic factors associated with the minimum dietary diversity of pregnant women. Secondly, to measure the rich and poor gaps in the behaviour of consuming diverse diets by pregnant women.

Methods

Statistical analysis

Descriptive statistics, including frequency distribution and cross-tabulations of each predictor and outcome variable, were used to describe variables for the study. Categorical variables were presented in percentages and frequency, whereas continuous variables were presented in mean and standard deviation. Pearson’s X2 test verified the association of the outcome variable with the predictors. Binary logistic regression was used to estimate odds ratios and 95% Confidence Intervals (CIs). Results were presented as crude odds ratio (cOR) and adjusted odds ratio (aOR) to assess the strength and presence of association, with a threshold of p < .05 used for determination of statistical significance.

Multivariate decomposition analysis was used to quantify the contribution of selected predictors in explaining the rich-poor gap in the prevalence of maternal dietary diversity. Multivariate decomposition technique uses the output from regression models to partition the components of a group difference in a statistic, such as a mean or proportion, into a component attributable to compositional differences between groups, i.e., differences in characteristics or endowments, and a component attributable to differences in the effects of characteristics, i.e., differences in the returns, coefficients or behavioural responses. The mean difference in Y between groups A and B can be decomposed as,

where Y denotes the N × 1 dependent variable vector, X is an N × K matrix of independent variables, and β is a K × 1 vector of the coefficient. The component labelled E refers to the part of the differential attributable to differences in endowments or characteristics, usually called the explained component or characteristics effects. C refers to the part of the differential attributable to differences in coefficients or effects usually known as the unexplained component or coefficient effects, where A is the pregnant woman from the richest household (comparison group), and B is the pregnant woman from the poorest household (reference group). Therefore, E reflects a counterfactual comparison of the difference in outcomes from the women from the richest household perspective, and C reflects a counterfactual comparison of outcomes from women from the poorest household perspective. STATA 18.0 software was used for data analysis.

Results

Discussion

The current study contributes to a limited but growing literature on maternal dietary diversity, associated socio-economic factors, impact of social behaviour change interventions and factors contributing to socio-economic inequality. The findings indicate that more than half (55.2%) of the pregnant women in the selected five districts of Rajasthan had met a minimum dietary diversity. Further, the mean dietary diversity score in the study was reported as 4.8 +/- 1.5. To our knowledge, this is the first study in the selected study sites. A study conducted in Haryana by [22] reported more than three-fourth of the lactating mothers consuming a minimum diversified diet. Compared to this study, the high prevalence of dietary diversity can be attributed to the fact that the state of Haryana is predominantly an agricultural state, resulting in relatively better dietary diversity [23].

Further, the difference in the prevalence of minimum dietary diversity can be attributed to the seasonal differential, i.e., period when data was collected, socio-cultural factors and overall profile of the study population. According to the Rajasthan state-specific Sustainable Development Goal (SDG) index, all five selected districts for this study were among the bottom-ranked 10 districts of Rajasthan [24]. It can also be associated with a higher prevalence of tribal population in the region, leading to protracted socio-economic inequality in the region.

In this study, about (96%) of pregnant women consumed grain, white roots, tubers, and plantation food groups. The findings corroborate the study done in Pune, Maharashtra [25] reporting high starchy staple food group consumption. Less than (3%) of pregnant women reported consumption of food groups such as meat, poultry, fish, and eggs. This is in alignment with the study on dietary intake among pregnant women in India [26] and the fact that most of the population in Rajasthan prefers vegetarian diets [27] Two-third of the respondents reported consumption of dairy products. High consumption of dairy products may be attributed to the increased purchasing power of pregnant women from the cash incentive received during pregnancy. Supplementary Table 1 shows the distribution of food groups across those with a diverse and non-diverse dietary diet among the poorest and richest wealth quintile groups. The findings state that pregnant women from both the wealth quintiles consume dairy products, which are cost intensive. The study conducted among pregnant women in Nepal reported higher proportions of cash incentives for purchasing and consuming milk [28]. These findings align with the current study, indicating that cash availability improves the purchasing power for expensive micronutrient rich food with lesser calorie value across socio-economic groups [29]. Vitamin A rich fruits and vegetables and dark green vegetables were consumed by (39%) and (47%) of pregnant women, viz. The relatively high consumption of dark green vegetables, vitamin A-rich fruits and vegetables, and starchy staple food groups is a distinct pattern and does not concur with previous studies. This may be attributed to increased knowledge and awareness of maternal nutrition and diet diversification due to specific messaging from the frontline workers and Poshan champions who delivered targeted, tailored messages highlighting the importance of same.

Factors associated with consumption of specific food groups to achieve a minimum dietary diversity are multi-dimensional. The study findings indicate that pregnant women from wealthier households were more likely to consume a diverse diet than women from poorer households. The findings were corroborated by prior studies done in the domain [17, 30, 31]. These findings support Bennett’s law, which states that with greater resources, there is relocation among food groups constituting diverse diet and consumption of improved and nutritious diets [32]. This is also supported by our study that shows that despite a lesser share in the consumption of pulses, dark and green leafy vegetables, Vit A rich fruits and other fruits among dietary diversified women in the richest wealth quintile, they are more likely to consume diversified food items than women in poorest wealth quintile.

Besides the association of dietary diversity with economic factors, dietary diversity was positively associated with educational status, where pregnant women with higher education had a more diverse diet. This finding aligns with previous studies conducted in Uttar Pradesh [17] and a multi-state study done in Bihar, Chhattisgarh, and Odisha [33]. One of the possible explanations could be that women with higher education levels have better exposure and, therefore, are more likely to receive appropriate information related to diet diversity and comprehend the importance of maternal nutrition [34, 35]. Additionally, education can be seen as a proximate determinant of women’s empowerment, allowing women to exercise their rights related to household and individual level decisions, particularly on the financial allocation for the purchase of nutrient-dense food [36, 37]. Further, socio-cultural factors such as the caste of the pregnant women was found to be associated with their diet diversity. Women belonging to the Scheduled caste and Scheduled tribe have lower dietary variety than those belonging to general and other backward classes. These findings are consistent with the past study [38] explaining the role of economic and social status on women’s nutritional status in India. Women from socially disadvantaged castes face multifaceted challenges such as lack of knowledge, social taboos, limited individual agency and decision-making power [39–43]. This leads to poor diet diversification and micronutrient deficiency during pregnancy, which has acute and chronic repercussions on women and their offspring’s health [44].

Food-related myths and perceived restrictions during pregnancy were not significantly associated with maternal dietary diversity. This contrasts with previous studies’ findings [45, 46], where, food-related taboos were associated with dietary restrictions. Several food items were believed to be heat-producing, deforming the fetus’s growth, and therefore, should be restricted during pregnancy. The difference in findings of our study can be related to targeted messaging on the importance of diet diversification and busting the myths and taboos related to several food items within the communication package of the program delivered by the Poshan Champions and frontline workers at every stage of pregnancy. In addition, this can also be attributed to the fact that women find alternative food items to replace the restricted food items. Future research to understand the role of family members, particularly understanding Mother-in-law’s perspective on the food-related myths during pregnancy, will be informative.

Various strategies and platforms under social and behavioural change communication (SBCC) were adopted under the Rajpusht project to improve knowledge and awareness of maternal nutrition. Regression analysis in Table 5 shows that maternal dietary diversity is more likely to be higher among pregnant women who received interpersonal counselling and attended community-based events through PCs, ANMs, AWWs and MCHN days. While PCs and AWWs provide regular counselling, support, and monitoring of the women during pregnancies, they also promote awareness among women and their families on diets, supplementary nutrition, vaccinations, and breaking common myths in the community. One key message communicated by ANMs and then supported by PCs during IPC concerns the importance of weight gain during pregnancy. ANMs are specifically capacitated under the programme to provide intensive counselling to pregnant women on vital messages and awareness of localised diverse diets via specialised job aids developed as part of the SBCC strategy. It is important to discuss that the RajPusht intervention has been programmed uniquely by incorporating multiple SBCC touch points at regular intervals, ensuring a comprehensive yet high-dose response to the targeted women, their families, and communities. Multiple modes of social and behavioural change interventions aimed at improving maternal and child health have been recognised to generate positive outcomes in multiple settings [47]. Improvement in outcome indicators like maternal dietary diversity can be envisaged by efficient program coverage to identify pregnant women and expose them to behavioural change interventions [48]. Our study substantiates that achieving equity in the health indicators mostly depends on the dose-response and reach of the population. Compliance towards program intervention is better for those with higher socio-economic status due to better access to resources and services. It subsequently diffuses to the lower socio-economic groups; however, diffusion’s intensity can be time-dependent [49].

SBCC interventions and cash incentives can have a long-term impact beyond program due duration than only cash interventions by modifying immediate and underlying factors of malnutrition [50, 51]. Studies have shown that cash incentives play a role in purchasing food items that are perceived as costly or not purchased by households regularly [52]. Our study also aligns with this argument and provides substantial evidence that cash incentives promote a higher purchase power for protein-rich items among our targeted population.

Socio-economic inequality in the consumption of diverse dietary products can be well explained through the multivariate decomposition analysis done in the study. The study findings revealed that 42% of the gap in the prevalence of diversified diets among pregnant women was attributed mainly to the distribution of determinants between rich and poor households. Our model provides evidence for discernible divergence in dietary diversity among the poorest and richest wealth quintiles through caste and educational attainment of the women. Better accessibility of knowledge and addressing the interlinked detrimental aspects of lower socio groups are vital for improved nutritional practices among women. Therefore, the role of social and behavioural change interventions aiming to improve knowledge, awareness and building of an enabling environment in the community are critical to have positive, sustained behavioural change.

The present study findings should be seen under certain limitations. Firstly, dietary diversity was determined based on answers from participants’ recalls, which might have some recall bias. Secondly, the cross-sectional nature of the data limits causal inference between the outcome and predictor variables. Thirdly, as dietary diversity depends on readily and locally available food items, seasonality might have played some role, which may limit the generalizability of findings to other seasons. Lastly, the study is limited to measuring the combinations of food groups consumed by the women and the most prevalent combinations consumed by the women in the study area. Further study can shed light on building such combinations to measure the best dietary combinations for the birth outcomes of pregnant women.

Conclusion

The study finding reveals that there is association between socio-economic characteristics of pregnant women and consumption of minimum dietary diversity (MDD). Improving women’s education level, exposure to SBCC interventions (nutrition specific) contribute to higher dietary diversity during pregnancy. Despite a predominant vegetarian diet consuming population, better maternal dietary diversity was observed among those exposed to higher dose of SBCC intervention package. Educational status and caste of the respondent were significantly associated with minimum dietary diversity and contributed to the socio-economic inequality highlighting the importance of tailored and sustained SBCC interventions.

Acknowledgements

Abbreviations

Author contributions

AP, NW, AS conceptualized the manuscript and AP, SC, AS contributed in writing the manuscript . AS had led the statistical analysis and SC assisted in analysis. AP guided the analysis and interpreted the results. AS led the writing of manuscript with inputs from SC, AP, RR, NW, DS. RR, NW, DS, HS, SA and RM reviewed the manuscript. All the authors read and approved the final manuscript for publication.

Funding

This study was funded by Children’s Investment Fund Foundation (CIFF).

Data availability

Reasonable request for data used in this article may be made to the corresponding author.

Declarations

Footnotes

References