Rasmi Avula

• PhD
• PostDoc Position at International Food Policy Research Institute

Anaemia among mothers and their children is a widespread public health challenge with profound consequences for individuals and societies. While anaemia has been studied separately in women and children, there remains a literature gap examining anaemia in mother-child dyads, limiting insights on interventions that may simultaneously address anaemia...

Growth monitoring and promotion (GMP), the process of periodic anthropometric measurements to assess the adequacy of individual child growth, is implemented across low-income and middle-income countries. The epidemiologic foundations of GMP (i.e., that GMP can accurately diagnose or screen for inadequate growth) have never been critically reviewed....

Assessing behaviors related to food choice at individual- and household-levels is essential for improving household diets, but assessment tools are limited. We conducted a systematic review to identify gaps in existing assessment tools for food acquisition, preparation, and household consumption practices in South Asia, wherein diets are rapidly ch...

Background High coverage of nutrition-specific interventions is critical to meet global nutrition targets, and it is imperative to understand how to attain it. We examined trends and inequalities in the coverage of interventions in India and the role of the National Nutrition Mission (NNM) in achieving improvements. Methods We conducted trends and...

Background Limited evidence exists on determinants of maternal and child diet quality. Objectives This study examined the role of social and behavior change communication (SBCC) and nutrition-sensitive social protection (NSSP) programs on maternal and child diet quality. Methods Data were from cross-sectional phone survey on 6627 Indian mothers t...

Optimal child growth requires a combination of nutrition‐specific and sensitive interventions in the first 1,000 days. There is limited guidance on how to measure the population‐level coverage of nutrition‐sensitive social protection (NSSP), which is designed with explicit nutrition goals and often provides food or cash transfers and co‐coverage wi...

The Integrated Child Development Services (ICDS) programme has been the central focus of the POSHAN Abhiyaan to combat maternal and child malnutrition under the national nutrition mission in India. This paper examined the linkages between utilization of ICDS and underweight among children aged 6–59 months. The study utilized data from two recent ro...

This brief identifies important constructs for assessing drivers of food choice behaviors and describes progress on the development of a repository of instruments and measures for assessing these constructs. OBJECTIVES 1. List constructs that can be assessed to understand drivers of household and individual food choice behaviors. 2. Identify inst...

Background: Counseling on infant and young child feeding (IYCF) to support optimal breastfeeding and complementary feeding practices is an essential intervention, and accurate coverage data is needed to identify gaps and monitor progress. However, coverage information captured during household surveys have not yet been validated. Objectives: We...

How does nutrition improve? We need to understand better what drives both positive and negative change in different contexts, and what more can be done to reduce malnutrition. Since 2015, the Stories of Change in Nutrition studies have analysed and documented experiences in many different African and Asian countries, to foster empirically-grounded...

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...

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 cou...

Objectives Scarce data exists on coverage of infant and young child feeding (IYCF) counseling, which includes counseling about breastfeeding and complementary feeding, because few large-scale surveys have included questions to capture the coverage of these essential nutrition interventions. Consequently, maternal report of this information during h...

The National Nutrition Services of Bangladesh aims to deliver nutrition services through the primary health care system. Little is known about the feasibility of reshaping service delivery to close gaps in nutrition intervention coverage and utilization. We used a scenario-based feasibility testing approach to assess potential implementation improv...

Global success case analyses have identified factors supporting reductions in stunting across countries; less is known about successes at the subnational levels. We studied four states in India, assessing contributors to reductions in stunting between 2006 and 2016. Using public datasets, literature review, policy analyses and stakeholder interview...

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 ex...

Background To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive (I-ANC) to standard (S-ANC) areas and found modest im...

Designing survey questions that clearly and precisely communicate the question's intent and elicit responses based on the intended interpretation is critical but often undervalued. We used cognitive interviewing to qualitatively assess respondents' interpretation of and responses to questions pertaining to maternal and child nutrition intervention...

India has been on a steady march to address malnutrition in the last decade. The nutrition community has worked on building consensus on key actions, implementation platforms were put in place and financing for nutrition slowly increased. Under the strong leadership of the Prime Minister, a revolutionary program to address malnutrition was launched...

Objectives Modeling studies have estimated impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes, but little is known about actual delivery status. We studied disruptions and restorations of health and nutrition services by frontline workers (FLWs) in India during COVID-19. Methods We c...

Objectives The Coronavirus (COVID-19) pandemic has profound negative impacts on people's lives, but little is known on the effect of COVID-19 on household food insecurity (HFI) in poor setting resources. This study aimed to assess the changes in HFI during the pandemic and examine the interlinkages between HFI with child feeding practices and copin...

Objectives The COVID-19 pandemic has significant potential implications for health systems, but little primary evidence is available on effects on health and nutrition services. We aimed to examine changes in service provision and utilization during the pandemic in Uttar Pradesh, India and identify positive adaptations to service delivery. Methods...

Objectives Addressing the double burden of malnutrition in many low- and middle-income countries through double duty strategies requires understanding of how stakeholder framing influences nutrition agenda-setting at the subnational level where policies are translated to address local context. We aimed to identify differences in frames of undernutr...

Objectives Designing survey questions that clearly and precisely communicate the question's intent and elicit responses based on the intended interpretation is critical but often undervalued. We used cognitive interviewing to qualitatively assess respondents’ interpretation and responses to questions pertaining to maternal and child nutrition inter...

Background The coronavirus (COVID-19) pandemic may substantially affect health systems, but little primary evidence is available on disruption of health and nutrition services. Objectives This study aimed to 1) determine the extent of disruption in provision and utilization of health and nutrition services induced by the pandemic in Uttar Pradesh,...

Background In response to the high levels of maternal nutrition in Uttar Pradesh, Alive & Thrive (A&T) aimed to strengthen the delivery of nutrition interventions through the government antenatal care platform, including leveraging ongoing data collection to improve program delivery and reach (clinicaltrials.gov NCT03378141). However, we have a lim...

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-...

Objectives The COVID-19 pandemic has profound negative impacts on people’s lives, but little is known on its effect on household food insecurity (HFI) in poor setting resources. This study assessed changes in HFI during the pandemic and examined the interlinkages between HFI with child feeding practices and coping strategies. Design A longitudinal...

Objectives Existing health and community nutrition systems have the potential to deliver many nutrition interventions. However, the coverage of nutrition interventions across the delivery platforms of these systems has not been uniform. We (1) examined the opportunity gaps between delivery platforms and corresponding nutrition interventions through...

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...

Globally, there remain significant knowledge and evidence gaps around how to support Community Health Worker (CHW) programmes to achieve high coverage and quality of interventions. India’s Integrated Child Development Services scheme employs the largest CHW cadre in the world—Anganwadi Workers (AWWs). However, factors influencing the performance of...

Background Healthy diets can help reduce undernutrition, morbidity, and mortality. However, evidence on the accessibility and affordability of recommended diets is limited, particularly in poor-resource settings including India. Objectives This study examined: 1) the minimum cost of different types of household diets; 2) how economic constraints m...

Introduction Childhood stunting has declined in India between 2006 and 2016, but not uniformly across all states. Little is known about what helped some states accelerate progress while others did not. Insights on subnational drivers of progress are useful not just for India but for other decentralised policy contexts. Thus, we aimed to identify th...

Objectives Maternal undernutrition remains high in India and is associated with maternal mortality and adverse birth outcomes. To address this challenge, Alive & Thrive (A&T) aimed to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in UP. The nu...

Objectives Growth monitoring (GM) and promotion is a routine part of primary healthcare for children in >80% of countries. In India, 57.5 million children are measured every month by frontline workers to assess their growth and to trigger preventive or curative services. Standard guidance for anthropometry suggests that quality can be compromised b...

Objectives Global attention to reducing childhood stunting has increased the demand for guidance on translating policies into impact. Evidence from national-level success cases is emerging but little is known about how subnational entities can accelerate change. In India, despite a common national framework of programs/policies targeting many deter...

Objectives Most nutrition interventions can be delivered through health systems. However, the progress to scale up effective nutrition interventions and achieve universal health coverage has not been uniform. We aimed to 1) examine the opportunity gaps (OGs) between delivery platforms and corresponding nutrition interventions through the continuum...

Objectives An mHealth job aid and real time monitoring tool currently targets over 1 million community health workers in India (Anganwadi workers – AWWs). Previous studies have shown that mHealth interventions can be effective at a small scale. In this study, we evaluate whether this at-scale mHealth intervention improved the quantity and quality o...

Objectives Bangladesh's National Nutrition Services aims to deliver nutrition services to pregnant women and children through the primary health care system. Previous research highlighted gaps in coverage of preventive nutrition intervention delivery through this system but little is known about feasibility of reshaping service delivery to close th...

Objectives Interventions to improve maternal nutrition are poorly integrated into antenatal care (ANC) services in India. Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization implemented through government ANC services. We evaluated the impact of nutrition-intensi...

Objectives Administrative Data (AD) are a key component of nutrition data systems, but little is known about how AD are used or can be reshaped for accountability and action. We studied factors influencing AD use in India's Integrated Child Development Services (ICDS), in two Indian states; and assessed how an m-Health intervention (Common Applicat...

Objectives India has a nutrition policy framework that includes several evidence-based interventions. However, the availability of data to analyze coverage, assess equity and track progress on scaling up interventions is not known. We assessed data availability for nutrition interventions by reviewing multiple data systems in India. Methods Using...

Objectives Implementation research can support iterative program improvement, yet limited examples of such dynamic experiences exist. We conducted a multi-stage and multi-method process evaluation (PE) of a large-scale m-Health intervention in India that currently reaches 581,282 frontline workers (FLWs). The intervention (Common Application Softwa...

Objectives Frontline workers (FLWs) deliver essential nutrition services to reduce maternal undernutrition in India, but coverage and quality remain sub-optimal. Alive & Thrive aimed to strengthen delivery of interpersonal counselling, community mobilization and micronutrient supplements through the government antenatal care (ANC) platform in UP. W...

Evidence on strategies to improve infant and young child feeding in India, a country that carries the world's largest burden of undernutrition, is limited. In the context of a programme evaluation in two districts in Uttar Pradesh, we sought to understand the multiple influences on breastfeeding practices and to model potential programme influence...

Background: India is facing a dual burden of undernutrition and overweight/obesity, and there are gaps in our understanding of the driving factors over time. Objective: This study examined the national and state trends for BMI and identified the determinants of underweight and overweight/obesity among adolescent girls and women. Methods: We us...

Objectives: Low BMI among women and girls has implications for their health and that of the next generation. Yet, little is known about the determinants of low BMI despite the known high burden of undernutrition in India. We aimed to use nationally representative data to examine national and state trends for BMI and to identify the determinants of...

Objectives: Evidence on strategies to improve infant and young child feeding in India, a country that carries the world's largest burden of undernutrition, is limited. In the context of a program evaluation in two districts in Uttar Pradesh, we sought to understand the multiple influences on breastfeeding practices and to model potential program i...

Objectives: Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examines multi-factorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Methods: Data were from a househ...

Objectives: Uttar Pradesh (UP) is the most populous state with the highest burden of undernutrition in India. Alive & Thrive is working to strengthen behavior change communication (BCC) on diet diversity and quantity, using health systems platforms to deliver maternal nutrition intervention. However, evidence on the accessibility and affordability...

Objectives: Globally, it is recognized that multiple forms of undernutrition exist. Yet, little evidence exists on co-existence of multiple forms of undernutrition or on the potential shared determinants of these manifestations. Therefore, using data from India, we aimed to: 1) estimate the co-occurrence of undernutrition among children (stunting...

Objectives: We examined trends and inequities in the double burden of malnutrition among girls, boys, women and men by residence and wealth between 2006 and 2016 in India where 590 million individuals are expected to live in cities by 2030. Methods: Two rounds of National Family Health Survey data collected in 2006 and 2016 (n = 276,000 children...

Objectives: Behavior change communication (BCC) effectiveness depends on the knowledge of frontline workers (FLWs) who counsel clients. Most studies assess content-based knowledge of FLWs but do not examine their ability to apply this content. We tested the use of situational vignettes to assess 'application knowledge' and examined gaps between co...

Objectives: In low- and middle-income countries, non-communicable disease (NCD) prevalence is increasing while undernutrition persists, resulting in a double-burden of malnutrition. How policy actors frame malnutrition may shape policy, programming, and investment. In India, where NCDs are rising rapidly and undernutrition persists throughout the...

Objectives: India rolled out ambitious program efforts for health and nutrition (H&N) in 2005-06, scaling up community H&N services through the National Rural Health Mission and the Integrated Child Development Services (ICDS). Evidence on the combined reach and impact of these programs on closing equity gaps is limited. We aimed to assess how cov...

Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multi‐factorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (...

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. Ho...

Limited evidence exists on socio‐economic status (SES) inequalities in infant and young child feeding (IYCF) in India. We examine trends and changes in inequalities for IYCF practices over 2006–2016 and identify factors that may explain differences in IYCF across SES groups. We use data from the 2015–2016 and 2005–2006 National Family Health Survey...

Introduction India carries the largest burden of anaemia globally. Progress to reduce anaemia has been slow despite substantial economic growth and 50 years of programmatic efforts. Identification of the factors that contribute to anaemia reductions is needed to accelerate progress. We examined changes in haemoglobin (Hb) and anaemia among women an...

Nearly 80% of children under 5 are anemic in Bihar, India. Pediatric iron/folic‐acid syrup (IFAS) and multiple micronutrient powders (MMPs) are two of the evidence‐based interventions to prevent anemia. India's current policy solution includes IFAS for children, but there are limited data on the use and effectiveness of MMPs. We examined the accept...

India accounts for approximately one third of the world's total population of stunted preschoolers. Addressing global undernutrition, therefore, requires an understanding of the determinants of stunting across India's diverse states and districts. We created a district‐level aggregate data set from the recently released 2015–2016 National and Famil...

Figure A1. Participant flow chart

There is considerable global evidence on the effectiveness of cash transfers in improving health and nutrition outcomes; however, the evidence from South Asia, particularly India, is limited. In the context of India where more than a third of children are undernourished, and where there is considerable under-utilization of health and nutrition inte...

OLS regressions on household food insecurity (full results). (DOCX)

Nearest-neighbor and IPW estimates of the ATE for household food security (full results). (DOCX)

List of assets used in the construction of household socio-economic status. (DOCX)

Kernel densities of the receipt of Mamata money by the propensity score. Source: Author’s calculations. (DOCX)

Nearly two thirds of young children are anaemic in Bihar, India. Paediatric iron and folic acid syrup (IFAS) and multiple micronutrient powders (MNPs) are two evidence-based interventions to prevent anaemia. Using a randomized crossover design, we examined the acceptability of IFAS versus MNPs for children 6–23 months. In a catchment area of 2 heal...

We assessed India's readiness to deliver infant and young child feeding (IYCF) interventions by examining elements related to policy, implementation, financing, and evidence. We based our analysis on review of (a) nutrition policy guidance and program platforms, (b) published literature on interventions to improve IYCF in India, and (c) IYCF progra...

Background and Objectives India has a decentralized governance setting but there is limited data on how decentralization impacts nutrition policy. Policy actors and their networks are central to the process of decision‐making for policy but little is known about the spread and connectedness of diverse actors in the nutrition landscape in India and...

The Indian state of Odisha has made significant strides to address health and nutrition in the last 25 years. We used public data, policy and program documents, published literature, and interviews with program and policy decision-makers, development partners, civil society members (n=29) and community members (n=45) to analyze these changes. Facto...

The Indian state of Odisha has made significant strides to address health and nutrition in the last 25 years. We used public data, policy and program documents, published literature, and interviews (n=75) with program and policy decision-makers, representatives from development partners, and civil society and community members to analyze these chan...

Background Convergence of sectoral programs is important for scaling up essential maternal and child health and nutrition interventions. In India, these interventions are implemented by two government programs – Integrated Child Development Services (ICDS) and National Rural Health Mission (NRHM). These programs are designed to work together, but t...

We assessed India's readiness to deliver infant and young child feeding (IYCF) interventions by examining elements related to policy, implementation, financing, and evidence. We based our analysis on review of (a) nutrition policy guidance and program platforms, (b) published literature on interventions to improve IYCF in India, and (c) IYCF progra...

Nepal has a cadre of thousands of Female Community Health Volunteers (FCHVs), whose primary responsibility is to deliver health and nutrition services to rural households. Suaahara, a program which integrates family planning, nutrition, water, sanitation and hygiene and homestead food production, aimed to use FCHVs to deliver information to improve...

Background: In Bihar, India, coverage of essential health and nutrition interventions is low. These interventions are provided by 2 national programs--the Integrated Child Development Services (ICDS) and Health/National Rural Health Mission (NRHM)--through Anganwadi workers (AWWs) and Accredited Social Health Activists (ASHAs), respectively. Littl...

Home‐visit based counseling is a proven intervention to improve complementary feeding (CF) practices. In India, CF counseling is to be delivered by FLWs ‐ Anganwadi Workers (AWWs) and Accredited Social Health Activists (ASHAs) but program experience with CF counseling is limited. We surveyed 588 FLWs and 1183 households in Odisha state to assess th...

Evidence suggests that increasing coverage of 14 ENIs from pre‐pregnancy to early childhood can reduce maternal and child undernutrition. In India, less than 55% of women and children receive any of the ENIs. We assessed readiness to achieve at‐scale delivery of ENIs through an analysis of policies, programs, intervention design, implementation, mo...

Objectives: In India, 79% of children less than three years are anemic. Intermittent iron supplementation, home-fortification with multiple micronutrient powders (MMP), and delayed cord clamping are scientifically recommended interventions to prevent pediatric anemia. Little is known about the extent to which these interventions are integrated into...

Background: In India, delivery of interventions to improve child nutrition requires active IC between the Ministries of Health and Family Welfare (MOHFW) and Women and Child Development (MWCD). This in turn requires linked actions in policy formulation, implementation, and monitoring & evaluation (M&E), but little is known about IC or how to optimi...

In Bihar, India, coverage of essential nutrition interventions is low, but little is known about the factors associated with service delivery by FLW and utilization of services by HH. Data: A cross‐sectional survey of 790 FLWs and 6002 HH from 400 villages in 1 district in Bihar. Analysis: Multivariate regression analysis to examine supply‐ and dem...

Mapping pathways of how interventions are implemented and utilized enables contextually grounded interpretation of results, differentiates poor design from poor implementation, and identifies factors that might influence the utilization of interventions. Few studies in nutrition have comprehensively examined the steps of implementation and utilizat...

Dietary diversity (DD) reflects micronutrient adequacy of the diet and is associated with better child growth. Emerging evidence suggests that maternal and child DD are associated. This could have measurement and programmatic implications. Data on mother-child (6-24 mo) dyads in Bangladesh, Vietnam, and Ethiopia were used to examine agreement and a...

Diverse diets are linked to better child growth from 6 mo onwards. Interventions typically focus on educating mothers about the importance and ways of improving child dietary diversity (DD). However, new evidence suggests that maternal and child DD are associated. Data from surveys on mother and child (6–24 mo) dyads in Bangladesh (BD), Vietnam (VN...

Feeding practices are important determinants of growth and development of children. Using infant and young child feeding indicators and complementary feeding guidelines, 7 practices in 28 countries are described, showing substantial variation across countries. Only 25% of 0- to 5-month-olds were exclusively breastfed, and only half of 6- to 8-month...