Feasibility, Acceptability and Equity of a Mobile Intervention for Upscaling Participatory Action and Videos for Agriculture and Nutrition (m-UPAVAN) in Rural Odisha, India

"...found that the interpersonal communication provided by the well-trained and trusted local intervention facilitators was integral for community mobilisation and engaging women and their families with the intervention."

Addressing undernutrition requires strategies that remove barriers to health for all. Alongside potential challenges, mobile strategies (mHealth) may present opportunities to overcome barriers that arise from face-to-face approaches. One type of intervention that may be conducive to mHealth adaptation are the nutrition-sensitive agriculture (NSA) interventions tested in the 4-arm cluster-randomised controlled trial (cRCT) UPAVAN. Given community demand for the continuation of UPAVAN in rural Odisha, India, and based on restrictions imposed during the COVID-19 pandemic, the researchers designed a behaviour change intervention retaining the core UPAVAN model with locally made NSA and nutrition-specific videos but adapted for mobile delivery (m-UPAVAN). The study reported in this paper assesses the feasibility, acceptability, and equity of the m-UPAVAN intervention.

As detailed at Related Summaries, below, in UPAVAN, women's groups viewed and discussed participatory videos on nutrition-specific and NSA topics. The interventions ran for 32 months between 2016 and 2019. In m-UPAVAN, weekly videos and audios on the same topics were disseminated via WhatsApp and an interactive voice response (IVR) system. Specifically, the key components of m-UPAVAN were as follows:
 

1. Recruitment and training of facilitators at the village level: Facilitators were responsible for community sensitisation, encouraging participation, and managing WhatsApp groups for video dissemination.
2. Dissemination of re-purposed UPAVAN videos through WhatsApp: Topics were sequenced based on season and community preference, as informed by experience from the UPAVAN trial. On average, videos were 4 minutes long, with critical messages ("knowledge recall points") written in the local language (Odiya) at key points in videos, and 49 seconds of COVID-19 guidelines were included at the end of each video. Facilitators formed village-level WhatsApp groups for disseminating videos and WhatsApp viewers' groups, where women who owned a smartphone were grouped with women who did not own a smartphone to watch videos together. Facilitators shared one video per week over 6 months.
3. IVR: For those owning a feature phone only, the same content as in the weekly videos was scripted as audio and disseminated through a toll-free IVR system. Users could respond to the audio or ask questions by submitting a voice recording.
4. Promotional activities and interactive learning: Facilitators shared short video advertisements through WhatsApp before each video dissemination that highlighted the constraints that each topic addressed. Village-wise posters advertised the toll-free IVR system, and text messages were sent each Sunday to remind registered users to listen to the audio messages. Facilitators encouraged participants to watch or listen to m-UPAVAN messages and to watch with their families via WhatsApp group chat or in-person, depending on COVID-19 restrictions. Facilitators helped community members with queries and encouraged them to adopt new practices. After each video dissemination, a quiz with multiple-choice questions took place in WhatsApp groups. Participants who selected the correct answers received an appreciation message; facilitators encouraged those who got the wrong answer to re-watch the video. Facilitators also encouraged women to share photos of families watching or listening together and of them implementing the recommended practices.

m-UPAVAN ran from Mar-Sept 2021 in 133 UPAVAN villages. All 37 UPAVAN control clusters were included, and intervention clusters with a higher proportion of Scheduled Tribe households were prioritised. In February-March 2021, the researchers invited 1,000 mothers of children aged 0-23 months to participate in a sociodemographic phone survey. Of those, they randomly sampled 200 mothers each month for 5 months for phone surveys to monitor progress against feasibility and acceptability targets. They also investigated mothers' experiences of the intervention, including preferences for m-UPAVAN versus UPAVAN, using in-person, semi-structured interviews (n = 38). 

The study used a convergent parallel mixed-methods design. In the 133 villages enrolled in m-UPAVAN, facilitators formed one WhatsApp group per village. All women in the villages owning a smartphone (n = 3,099) formed video viewing groups with 7-8 women without a smartphone (n = 18,679). 5,667 households were registered to receive IVR audio services. Intervention activities were delivered as planned.

Of the 810 mothers reached, 666 provided monitoring data at least once. Among these mothers, feasibility and acceptability targets were achieved. Namely:
 

• Feasibility: Over 70% received videos/audios, and over 50% watched/listened at least once. Two qualitative themes emerged to explain the high coverage: trust in facilitators and perceived value of the intervention. Women generally displayed agency in accessing and using phones. Other emerging themes showed that women were motivated to watch or listen due to curiosity about what future information videos or audios may entail, encouragement by facilitators, and eagerness to participate in the quizzes that followed each weekly video or audio dissemination. In contrast, some women expressed being nervous or fearful of participating in quizzes, either due to a lack of confidence using the phone or concern over what others may think if they were to respond.
• Acceptability: All respondents who watched or listened reported liking the m-UPAVAN messages. A favoured aspect was the mobile delivery platform, which enabled women to gain information from the comfort of their homes and at a convenient time. Women highlighted how the ability to re-watch the videos to reinforce their learning was also important to them. However, this benefit was less applicable to the audios, as audios were only available for a week. Respondents had high praise for the content of the m-UPAVAN messages. They felt the knowledge they gained was unique and otherwise inaccessible if they did not watch the videos or listen to the audio messages. Respondents felt empowered with this knowledge.

Furthermore, m-UPAVAN engaged whole families, which facilitated family-level discussions around promoted practices. Of those who watched or listened, 60.8% (95% confidence interval (CI) 56.3, 65.3) reported their spouses or other senior household members also watching or listening. While families engaging with content was higher among women from smartphone-owning households, over 50% of women from households without a smartphone still reported their spouses or senior family members listening. Women expressed how it was important for their families to learn directly from the videos and audios to ensure they received accurate information and could subsequently support women in implementing new behaviours. Around half of the women watching or listening also reported discussing the content with other family members. More active and deliberate engagement with other family members could help further increase the effectiveness of interventions.

Other insights: Women valued the ability to access m-UPAVAN content on demand. This advantage did not apply to many mothers with limited phone access. Overall, most participants highlighted various aspects that they liked about both the mobile and face-to-face intervention. Mothers highlighted that the UPAVAN interventions' in-person participatory approaches and longer videos were more conducive to learning and were inclusive, and that mobile approaches provide complementarity. Collectively, women's reflections pointed towards the necessity of both intervention modalities

The study's findings highlight "the necessity of addressing inequities in phone access and use to optimise mHealth interventions' potential in low- and middle-income settings. Training and capacity building on phone and mobile app usage in rural communities could help increase the uptake of mHealth interventions and alleviate gender-based social norms in phone usage...Future mHealth interventions and policy approaches should work closely with relevant initiatives to increase their uptake and effectiveness. mHealth interventions that incorporate a microcredit component to help certain individuals purchase phones may also be a feasible approach to reducing inequities in mHealth....Future research must explicitly evaluate the effects of digital inequality on the efficacy and equity of future mHealth interventions."

The researchers conclude that mobile NSA interventions are feasible and acceptable, can engage families, and reinforce learning. However, in-person participatory approaches remain essential for improving equity of NSA interventions. There is a need to develop and test the effectiveness of hybrid NSA interventions that incorporate the complementary strengths of both mobile and face-to-face interventions for improving agricultural and nutrition outcomes.

Full list of authors, with institutional affiliations: Emily Fivian, London School of Hygiene & Tropical Medicine (LSHTM); Manoj Parida, DCOR Consulting Pvt. Ltd.; Helen Harris-Fry, LSHTM; Satyanarayan Mohanty, DCOR Consulting Pvt. Ltd.; Shibanath Padhan, Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT); Ronali Pradhan, Digital Green; Pranay Das, DCOR Consulting Pvt. Ltd.; Gladys Odhiambo, LSHTM; Audrey Prost, University College London; Terry Roopnaraine, independent consultant; Satyaranjan Behera, DCOR Consulting Pvt. Ltd.; Philip James, Emergency Nutrition Network (ENN); Naba Kishor Mishra, VARRAT; Suchitra Rath, Ekjut; Nirmala Nair, Ekjut; Shibanand Rath, Ekjut; Peggy Koniz-Booher, JSI Research & Training Institute, Inc.; Heather Danton, JSI Research & Training Institute, Inc.; Elizabeth Allen, LSHTM; Suneetha Kadiyala, LSHTM