Cornell University, 2020

Abstract: Background and Objectives Despite global progress on reducing malnutrition, micronutrient-inadequate diets still contribute to a large public health burden in many underdeveloped regions. These deficiencies are a product of both lack of sufficient affordable diverse foods in local food systems, as well as lack of demand for such foods by consumers. A dual approach may thus be taken in addressing micronutrient inadequacy of diet: supply-based agriculture interventions to increase the availability of micronutrient-rich foods, and demand-based nutrition education interventions to increase demand for those foods. Introduction of vitamin-A rich orange-flesh sweet potato (OFSP) to East African food system using both supply- and demand-based strategies has been shown to improve multiple markers of vitamin A (VA) status in women and children. These improvements have been seen even when the OFSP has been introduced without intensive nutrition education components. VA deficiency particularly in women and children remains a major problem in North India, however the potential of OFSP to improve VA intake in this context has never been examined. This study tests the effectiveness of an integrated agriculture-nutrition intervention on cultivation and consumption of OFSP and proper feeding for young children. Specifically, this study aims to: 1) Understand whether and how the integration of nutrition-specific and nutrition-sensitive interventions can work in synergy to improve the magnitude and sustainability of nutrition outcomes; 2) Demonstrate the extent to which OFSP promotion can overcome the challenges and seize opportunities for introducing new crops into rural value chains with the objective of improving diets; 3) Better explain the demand and supply constraints and opportunities for orange-flesh sweet potato in the Indian context to inform future interventions. Methods/ Approach Ten villages in northeast Uttar Pradesh with agroclimates suitable for OFSP production were provided with OFSP vines and 6 monthly field trainings on cultivation methods and simple messages on the health benefits of consuming OFSP (Ag-Only model). Five of these villages were randomly selected to also receive intensive monthly nutrition education programs targeted at caretakers of young children with messages designed based on previous observations of child feeding patterns (Ag+Nutr model). Five other villages were randomly selected to serve as control villages and received no intervention. Outcomes and indicators were assessed a survey on knowledge, attitudes, and practices that were delivered to every household in intervention (n=1120) and control (n=246) villages at baseline t, midline t+6 months, and endline t+12 months. From each village, 25 mother-child pairs were randomly selected and surveyed at the same three timepoints with 24-hour quantitative dietary recalls for both mother and child, and 7-day vitamin-A focused food frequency questionnaires for children. Outcomes were assessed at endline using difference in difference. Outcomes assessed were nutrition knowledge, persistence of OFSP cultivation, and maternal and child consumption of vitamin A. Findings and Interpretations We find both interventions groups to have significantly increased knowledge of OFSP, vitamin A, and infant and young child feeding practices as compared to control villages. Nearly all (94%) of households in the intervention villages were aware of OFSP, compared to 34.6% of control households. There was no significant difference between Ag-Only and Ag+Nutr village households in knowledge at any time point nor in change over time. In the first season 25.8% and 16.8% of households in Ag-Only and Ag+Nutr villages respectively cultivated OFSP versus zero baseline cultivation. In the second season one year later, cultivation declined to 8.6% and 5.1% of households. There was no significant difference in persistence of cultivation into the endline period between Ag-Only and Ag+Nutr village groups. The main predictors of persistent cultivation were having a kitchen garden, cultivation of other vegetables in the season previous to the study commencement, and greater ownership of durable household goods. There was no clear pattern in gendered responsibility for OFSP cultivation or decision-making, but a positive and significant relationship of both OFSP and VA knowledge with likelihood of persistence in cultivation of OFSP. Finally, no significant change over time relative to control villages was observed for either maternal or child 24-hour vitamin A intake. In all groups at all timepoints, vitamin A consumption was very low, and the vast majority of women failed to meet the recommended levels of vitamin A intake. Dietary survey timing limited capture of OFSP intake, which did not significantly vary by treatment group, with 39.5% and 38.0% of households reporting home consumption of OFSP in the past year at endline (3% in control villages). A significant limitation to our interpretation of the effectiveness of the nutrition-specific intervention component is low levels of intervention event attendance in the Ag+Nutr villages. In Ag+Nutr villages, 58.5% of households did not attend any nutrition event and were therefore not directly exposed to the intervention messages. With this low exposure, it is difficult to ascertain whether the lack of observed effect is due to inefficacy of the intervention program despite careful design of nutrition messages and delivery strategy, or due to lack of dissemination of the messages among study households. Further, timing of dietary surveys did not overlap with the OFSP harvest period, masking the true potential effect on diet. Conclusions Our findings indicate both the potential of OFSP to improve the vitamin A quality of diets in North India as well as the power of nutrition-oriented agriculture interventions to improve nutrition knowledge among both direct and indirect beneficiaries. Future work is needed to develop more sustainable intervention delivery strategies, that can both harness the power of social networks through group-based intervention programs while also ensuring that a sufficient number of households are directly exposed to intervention activities. Faltering OFSP cultivation was largely a factor of agricultural challenges that may be addressed with improved varieties of OFSP more suited to the land constraints and pest pressures of the region. This work highlights the specific breeding priorities for OFSP in North India, and the need for consumer education around methods of OFSP consumption for adults and children. Despite the decrease in cultivation, demand for both OFSP tubers and leaves for consumption remained high, indicating an opportunity for future market development interventions. With these considerations, OFSP has the potential to improve vitamin A adequacy of diets in North India.

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