Effectiveness of “SAFAL MATRUTV GATS” (Stunting alleviation by facilitation of antenatal-postnatal-interventions for low birth weight reduction) – A peer-led self-empowerment group at rural villages in Eastern Maharashtra: Protocol for a pragmatic cluster randomized controlled trial

ABSTRACT

Background:

Stunting or chronic malnutrition has been one of the major challenges to mankind for ages. The trends from the National Family Health surveys are more or less stagnant with a huge failure of the public health systems to tackle the problem of malnutrition. Innovative approaches are needed to tackle malnutrition.

Objective:

This pragmatic cluster randomized controlled trial (CTRI registration no. Trial REF/2023/08/071521) is planned to assess the effectiveness of a multifaceted antenatal and postnatal health educational intervention package implemented from the first trimester of pregnancy up to one year of infant age in reducing the rates of Low Birth Weight and improving the maternal-infant growth and developmental indicators in a cohort of rural pregnant women as compared to existing standards of care. Implication - The study emphasizes the importance of an ongoing continuum of care during the first 1000 days for effective birth weight, preventing malnutrition, and fostering infant growth and development as its programmatic pathway to impact.

Results:

We anticipate that the intervention will complement the existing health programs and will be implemented through the grassroot-level workers along with a community peer named “Safalta Tai” enabling community ownership of the intervention.

Discussion:

It also has a robust inbuilt monitoring and evaluation system through participatory action research for making it scalable and sustainable beyond the implementation period.

Conclusion:

The program leverages on the existing goverment programs like the poshan abhiyaan and the digital health mission. It has the potential to be incorporated in the exsiting health infrastructure without any additional resources and scaled up if found effective in reduction of low birth weight which is an important determinant of stunting in under five children.

Introduction

Malnutrition is among India’s most serious public health and development challenges. It contributes significantly to the country’s disease burden.[1] In the Global Burden of Disease Report 2020, child and maternal malnutrition has evolved as the second leading risk factor for attributable DALYs globally in 2019. This largely affects health in the youngest age groups and perpetuates a vicious transgenerational cycle of malnutrition, that is, a malnourished young mother giving birth to a malnourished child that accounted for 295 million (253–350) DALYs (11.6% [95% Confidence Intervals 10.3 - 13.1] of all global DALYs) in 2019. The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0–9 years, the three leading detailed risk factors for attributable DALYs and under five mortality, namely, low birth weight, infections, and poor indoor air quality, were all related to and enhanced by malnutrition.[1]

Stunting and undernutrition continue to be the big challenges. The National Family Health Survey (NFHS) 5 has revealed some more insights into the problem of malnutrition.[2] The NFHS is a large-scale, multi-round survey conducted in a representative sample of households throughout India. It is second only to the Census. Although Bihar has the highest number of underweight children (41%), followed by Gujarat (39.7%), and Jharkhand at (39.4%), Maharashtra is among the other few states (Assam, Dadra, and Nagar Haveli, Karnataka, Madhya Pradesh, and Uttar Pradesh) that has a higher percentage of underweight children than the national average of 32.1%.[2]

According to the statistics of National Family Health Survey 5 (NFHS -5) conducted during 2019-2020, stunting has only marginally reduced from 38.4% to 35.5% from NFHS 4 (2015-2016), and wasting has reduced from 21.0% to 19.3%, whereas the prevalence of underweight has reduced from 35.8% to 32.1%, respectively.[2,3] The risk factors that contribute to stunting begin in the foetal period itself, which is described as the fetal programming of malnutrition in utero that leads to the birth of a low birth weight baby which needs further care and nutrition for achieving the catch-up growth which if not achieved leads to faltering of not only physical but also mental growth. According to Barker’s hypothesis for “Foetal programming,” which states that insufficient nutrition during embryonic and foetal development during a critical period in which tissues and organs are created, results in permanent alterations to certain structural and physiological metabolic functions of the foetus. This leads to long-term consequences on maternal as well as neonatal and infant health and development.[4]

In a study on preterm birth and low birth weight[5] conducted by the author, the prevalence of preterm birth and LBW in the villages of Eastern Maharashtra was reported to be 21.8% and 9.8%, respectively. The occurrence of LBW is fraught with consequences like increased risk of neonatal complications, infections, growth faltering, developmental delays, and infant mortality.[6,7,8] LBW babies are at the highest risk of adverse neonatal outcomes and long-term effects, such as stunting and developmental delays.[9,10]

Behaviour change communication (BCC) interventions are commonly used to improve health outcomes[11] and also show a positive impact on maternal and child health practices including nutrition.[12,13] BCC interventions can be effectively deployed, and adaptive to the community and family needs using community-centred interventions by the community members and health care workers.[14] The health sector has over the years invested heavily in training and empowering ASHA workers who help in the implementation of community-based health programs. However, additionally, peer facilitators like local women from the community can be trained as peer educators to implement health and nutrition-based interventions.

The proposed intervention complements and strengthens the vision of “Poshan Abhiyaan”, which strives to improve maternal-neonatal nutrition and health outcomes. The platforms provided to the health workers through the recently launched digital health mission by the government of India, like tablets and mobiles for ASHA workers for data collection will be effectively utilized as tools of change by using them as a medium for BCC through this study. The Health and Family Welfare Department, Government of India also uses mobile-based digital system (maternal and child tracking system) for tracking data on pregnant women and children for fertility rates, and maternal and infant mortality.[15]

The IEC materials in the form of informative photo cards and informative videos from the public domains of the IEC materials developed and utilized by MOHFW focussing on maternal, and infant nutrition, growth, and development will be uploaded on the ASHA phones and tablets and will be shown to the antenatal women during the “safal matrutva gat” meetings for creating nutritional and health awareness for improving their outcomes. In the process, the integrated nutrition and health education intervention will also be conducive to the capacity building of the health workers implementing the study.[16]

WHO has reported the prevalence of LBW as 15.5% globally, 96.5% of whom are born in developing countries.[17] Globally, LBW contributes to 40–60% of newborn mortality with a prevalence of 30.0% in India.[18] India ranks first in neonatal deaths in the world, with 700,000 newborns dying each year with a neonatal mortality rate of 29 per 1,000 births.[19,20] Lack of health education and awareness, poverty, and poor access to healthcare are persistent barriers to achieving a reduction in LBW.[21] The babies born as LBW tend to remain poorly developed and are a major vulnerable group that may suffer from stunted growth in the future.[21]

Stunting remains a major public health concern with very minimal reduction in rates from NFHS 4 to NFHS 5. Although Child stunting (low height for age) has declined from 38.7% to 35.5% between 2014 and 2022, it still is an area that needs further improvement to allow children to grow and develop to their full potential.[2] Reduction in LBW and stunting in infancy is dependent mainly on nourishment during the pre-conceptional period as well as during pregnancy. Although many interventions are in place, there is a paucity of a unified approach for providing nutrition and health education that would improve maternal health and thereby improve neonatal and infant health.[22] Also, the existing programs are fragmented and do not provide an ongoing continuum of care that can help continuous monitoring of maternal and infant health, nutrition, growth, and development, to take early action, if any deviation is present.[23]

The present intervention, “Safal Matrutv” strengthens and complements the POSHAN Abhiyaan to support nutrition interventions for children, adolescents, and mothers. It also builds the capacity of the frontline workers (Anganwadi workers or AWWs, Accredited Social Health Activists or ASHAs) on nutrition through an incremental learning approach while implementing the intervention itself.[24] The IEC materials shared with the beneficiaries for enhancing their awareness resounds with the mission of Digital health interventions and help in its reinforcement for improved maternal and infant outcomes.[25]

Aim and Objectives

Aim

To study the effectiveness of a multifaceted antenatal and postnatal educational intervention package implemented from the first trimester of pregnancy up to one year of infant age in reducing the rates of LBW and improving the maternal-infant growth and developmental indicators in a cohort of rural pregnant women as compared to existing standards of care.

Objectives

Primary objective

To assess the effectiveness of the multi-faceted behaviour change intervention package on the LBW rates, infant growth, and development, and maternal and neonatal complications during the antenatal and postnatal period as compared to the existing standards of care.

Secondary objectives

To assess the impact of this integrated “Safal Matrutv package”, on a range of health and nutrition indicators of the infant and mother like maternal complications during pregnancy, infant feeding indicators, infant growth and development as assessed by the Ages and Stages Questionnaire and, to assess its effect on knowledge and skill indicators of the participating rural women (safalta tais or didis), ASHAs and AWWs, as provided in Table 1.

Table 1.

SAFAL MATRUTV GAT - Outcome Indicators

PRIMARY OBJECTIVE- Reduce stunting in children at 12 months of age by 5% in the intervention clusters as compared to clusters with existing maternal and infant care practices and improve Early childhood development
Indicators		Description	How and when it is measured, and by whom?
Stunting		Number of stunted (height-for-age < −2 Z) children at 12 months of age	Trained and standardized anthropometry data collectors will collect Weight and height measurements of mothers and infants, using appropriate scales respectively antenatally, at birth, 6 and 12 months of infant age
Early childhood development outcomes at 12 months		Gross and fine motor,	Ages and Stages Questionnaire (ASQ 3)
		Expressive and repetitive
		Language Socio-emotional development
		Mother-child interactions
		Home environment
SECONDARY OBJECTIVES
A. Improvement in maternal health outcomes
Indicators		Description of indicators	How and when it is measured, by whom?
Antenatal and		Number of antenatal and post- natal visits at health facility	Project trained data collectors -safalta taais will collect data from beneficiaries
postnatal visits			using Standardized questionnaires, starting at enrolment, once at second and third trimester, at delivery, then biannually at 6 months and 12
Iron An folic acid		Total number of IFA tablets
IFA		consumed during pregnancy
Place of delivery		Number of facility and home deliveries
Mode of delivery		Number of vaginal deliveries /c-section deliveries
Maternal immunizati on		Number of tetanus immunization completed during pregnancy
Maternal nutrient intake		Ranking of women’s intake of macronutrient and selected micronutrients assessed by food frequency questionnaire	Project trained data collectors safalta taais will collect data from beneficiaries using standard methods of Food Frequency Questionnaires (FFQ)
Maternal dietary diversity		Consumption of >4 food groups as assessed by 24hr recall
B. Improvement in Maternal/Foetal/Neonatal/Infant Outcomes
Indicators		Description of indicators	How and when it is measured, by whom?
Foetal loss		Number of miscarriages and abortion	Project trained data collectors safalta taais will collect data from beneficiaries at enrolment, once at second and third trimester and at delivery
		Number of stillbirths
Preterm deliveries		Number of preterm births (based on LMP and EDD <37 weeks)
ow birth weight (LBW)		Number of low birth weight (<2.5kg) infants
Neonatal complications		Episodes of birth asphyxia, sepsis, jaundice, pneumonia and diarrhoea and other conditions requiring hospitalizations	Project trained data collectors safalta taais will collect data from beneficiaries at delivery, biannually at 6 and 12 months of infant age
Infant immunizati -ons		Number of immunizations completed till 12 months of age
Infant morbidity		Number of days ill with diarrhoea, fever, or cough
Infant hospitalizati -ons		Number of days neonate/infant hospitalized for any complications
Rates of neonatal/infant mortality (NMR/ IMR)		Number of neonatal and infant deaths
Exclusive breastfeedin g		Proportion of infants 0–5 months of age who are fed exclusively with breast milk	Project trained data collectors safalta taais will collect data from beneficiaries at delivery, biannually at 6 and 12 months of infant age based on WHO 24 hour recall method.
Early initiation of breastfeedin g		Proportion of children born in the last 24 months who were put to the breast within one hour of birth
Timely Introduction of solid, semi-solid or soft foods		Proportion of infants 6–8 Months receiving solid, semi-solid or soft foods
Minimum dietary diversity		Proportion of children 6– 12 months who receive foods from 4 or more food groups
Minimum meal frequency		Proportion of breastfed and non- breastfed children 6–12 months, who receive solid, semi-solid, or soft foods (but also milk feeds for non-breastfed children) the minimum number of times or more.
Stunting or low length- for-age and wasting or low weight for length		The proportion of children at 2,4, 6, 8, 10, 12, 15 and 18 months with low length-for-age or weight-for- height Z score (< -2 Z calculated from the 2006 WHO growth standard).	Project trained data collectors safalta taais will collect data for anthropometry at birth, 6 and 12 months of infant age.
Infant development assessed by Ages and Stages Questionnai re 3rd Edition – ASQ - 3		ASQ scores to assess the motor (fine and gross), language (receptive and expressive), and cognitive development of infant	Project trained data collectors safalta taais will collect data using ASQ – 3, scoring paper forms, once at 12 months
C. ASHA/AWW/Safalta taai outcomes
Indicators		Description of indicators	How and when it is measured, by whom?
Knowledge and performanc e assessment of ASHA		Number of safalta taais, ASHAs and AWWs with adequate grades in pre- and post- training knowledge tests. Proportion of ASHAs receiving with good Participant visit targets	These scores will be obtained by CI in pre- and post-test and their performance as assessed by Project CI and study co-ordinator.
D. Impact evaluation outcomes
Indicators	Description of indicators			How and when it is measured, by whom?
Fidelity	Extent to which an intervention has been implemented as planned			From monitoring data and qualitative interviews conducted by separate trained project staff
Dose delivered (completen ess)	Amount of activities/ deliverables			From monitoring data
Dose received (exposure)	Extent to which beneficiaries actively engage with, interact with and/or use program materials and activities.			From monitoring and evaluation data and qualitative interviews
Dose received (satisfaction)	Beneficiaries` satisfaction with program, interactions with staff			From qualitative interviews and observations
Reach (participatio n rate)	Proportion of target group that participates in program (attendance and barriers to participation)			From evaluation data and qualitative interviews
Contextual Factors	Methods of communicating with and recruiting participants, and maintaining participation Elements of the physical, social, cultural and political environment that influenced implementation or outcomes.			All qualitative interviews and observations

Footnotes & abbreviations: ASHAs - Accredited Social Health Activists; * - all data collection will be collected for both intervention and Control groups, except the knowledge and performance of ASHAs which will be conducted only in the intervention group

Material and Methods

Study Design: The study is designed as a pragmatic cluster randomized controlled trial which will include an in-built action implementation research and impact evaluation component using participatory action research for assessing the impact and effectiveness of the proposed intervention.

Study setting: The study will be conducted in the selected villages from Nagpur district with poor maternal and infant nutrition indicators like high rates of maternal anaemia and LBW. The selected villages will be randomly allocated to the intervention or the “SAFAL matrutv gat” arm and the “standard of care”, that is, the control arm that will implement the existing care package, and the information about all the maternal and infant indicators as well as the health workers’ indicators [Table 1] will be recorded from the villages or clusters from both the arms. The study has been approved by the institutional ethics committee and written informed consent will be obtained from each participant before their recruitment in the study. The study is registered with the clinical trials registry of India with registration number Trial REF/2023/08/071521.

Study population: The primary beneficiaries will include the pregnant mothers enrolled in the study during the first trimester of their pregnancy and followed up till one year of infant age. The secondary beneficiaries will be the peer facilitators or the “safalta taais”, ASHAs and AWWs who will be benefitted by the training and capacity building in the maternal and infant nutrition, health, growth, and infant development domains.

Sampling Technique: The villages near Nagpur district with high rates of maternal anaemia and LBW will be listed and included for final selection in either of the study arms. The listed villages will be randomly allocated to the intervention and control arms using computer-generated random blocks. Baseline similarity of the villages of both arms will be measured by including the villages with similar baseline maternal and infant health indicators (maternal anaemia and LBW rate and propensity score matching will be done for villages of both arms will be done to eliminate significant differences in clusters).

Sample size: The sample size was calculated based on a proposed reduction in stunting of 5% in the intervention arm as compared to the control arm from 32.8% (NFHS 5)[2] to 27.44% at 95% confidence interval and at 80% power to detect the minimal stated difference or the effect size. The sample size obtained was 304 pregnant women. On applying a design effect of 1.5 for cRCT, the sample obtained was 456, and after adding a 20% loss to follow-up accounting for 10% early pregnancy losses and 10% loss to follow-up, the final sample size was 546 with 273 pregnant women in each arm. The present crude birth rate CBR of 21, and the anticipated number of villages will be 26-30 villages with a minimum population of about 1000, with 13-15 villages in the intervention arm and 13-15 villages in the control arm.

Intervention: The intervention package will comprise monthly group counselling sessions at Anganwadi centres conducted by a local woman member or entrepreneur “safalta tai or didi” as the agent of change for reducing stunting through bringing down the low-birth-weight rates. She will be facilitated by the AWW and ASHA workers and will form village self-help groups of pregnant women that will be addressed as “safal matrutv gats” or safe motherhood groups which will be peer-led maternal empowerment groups that will conduct the following activities during their monthly group meetings for educating the antenatal cases about

1. adequate nutrition during pregnancy with respect to macro and micronutrient compositions, appropriate maternal weight gain, and monitoring of mother’s nutrition during pregnancy;

2. ensuring compliance to maternal iron folic acid and calcium for reduction of maternal anaemia;

3. early identification of maternal antenatal complications for providing necessary referrals;

4. sharing IEC materials like reminder messages for IFA tablets, videos, and informative content regarding nutrition, IYCN, and preventing antenatal and postnatal problems on the phone of the beneficiaries by ASHA;

5. counselling for and monitoring postnatal maternal nutrition and infant growth indicators like age-appropriate weight gain, breastfeeding, immunizations, and appropriate complementary feeding using responsive parenting techniques for facilitating early infant growth and development.

Implementation plan

This will be achieved through the strategic implementation plan described below:

• i)Ethical approvals and Permissions − The study was approved by the Institutional Ethics Committee and consent, questionnaires were reviewed and approved. The study will be registered at ClinicalTrials.gov and a Data Safety Monitoring Committee will also be formed that will review the data on an annual basis.
• ii)The selection of villages in both arms – This has been described in the sampling technique section.
• iii)Intervention – The “SAFAL package” will be provided through the monthly group meetings in the following manner:

• a)Recruitment of pregnant women by the safalta taai and formation of safal matrutv gat in each village;
• b)The safalta taais will create WhatsApp groups at each village to provide information to the members and also to share informative materials regarding their nutrition and care during pregnancy;
• c)Conducting monthly group meetings to educate the women on antenatal nutrition, early recognition of danger signs, the importance of regular antenatal visits, iron folic acid and calcium supplements, infant feeding and care using the IEC materials uploaded on their phones or tablets provided by the government through the MOHFW;
• d)Data collection of each woman using the baseline and monthly follow-up forms for the mother and infant.

Intervention package: The “SAFAL mata shishu package” will centrally comprise IEC materials in the form of informative photo cards and informative videos from the public domains of the IEC materials developed and utilized by MOHFW focussing on maternal, infant nutrition, growth, and development will be uploaded on the ASHA phones and tablets and will be shown to the antenatal women during the “safal matrutva gat” meetings for creating nutritional and health awareness for improving their outcomes. The monthly meeting will be focussing on the major maternal and neonatal problems in the village that are identified through group discussions with the community stakeholders and health providers.

In addition to the health education component, the meeting will also serve as the data collection point when the antenatal, delivery, and postnatal forms for both the mother and the infant will be obtained. In the process, the integrated nutrition and health education intervention will also be conducive to the capacity building of the health workers implementing the study (16).

Project outcomes

Among pregnant and lactating women

• i)Improved levels of haemoglobin (reduction in anaemia) as compared to the baseline
• ii)Improved nutritional status as assessed by dietary assessment and anthropometry
• iii)Early identification of danger signs in mother and baby
• iv)Early identification of common mental health disorders
• v)Improved healthcare utilization
• vi)Improved sanitation and hygiene practices
• vii)Improved rates of immunization

Outcomes among neonates and children (below 12 months of age)

• i)Reduction in low birth weight
• ii)Reduction in underweight/undernutrition
• iii)Improved infant development
• iv)Improved rates for initiation of breastfeeding, exclusive breastfeeding, appropriate initiation of solid foods, and meal diversity for women and children.
• v)Reduced episodes of childhood illnesses (pneumonia and diarrhoea)
• vi)Improved childhood development indicators

Impact Evaluation Indicators

• Number of timely SAFAL MATRITV GAT meetings

• Number of community sensitization meetings conducted

• Number of text messages, videos, and informative content sent

• Number of referrals made

The proposed program impact pathway is depicted in Figure 1. It is postulated that well-informed mothers are empowered to take better care of their own and their infants’ nourishment and health, which in turn will give outputs in terms of a healthy newborn and a healthy infant through improved health-seeking behaviours, hygiene, and sanitation as well as prevention of illnesses.

Figure 1.

Proposed program impact pathway

Comparison group: The primary outcome indicators will be assessed for the control villages that will be receiving the existing standard of care.

Data collection: The methods for respective variables, with respect to what indicators will be measured, how, when and by whom is, described in the Table 1.

Timeline: The detailed gnat chart for the project activities, their timelines and the responsible persons along with the critical milestones are described in Table 2.

Monitoring and Evaluation: Indicators for monitoring study compliance and implementation success in the intervention arm and for comparing the primary outcomes in the control arm are shown in the table. Impact evaluation will be done by an external agency to assess the intervention’s effectiveness with regards to its dose, duration, reach, fidelity and contextual parameters as shown in the table.

Results

The results of the trial will provide a deeper insight regarding the optimal dose, fidelity and uptake of the intervention to yield the expected outcomes. This will give the scientific evidence for strengthening the existing programs on which the intervention is built upon.

The results would provide evidence-based mechanisms to effectively bridge the gaps in tackling the gigantic malnutrition problem through an a priori established program impact pathway. The unanticipated events facilitating both the success or failures as well as the challenges encountered during implementation will provide further details for strengthening the intervention at scale, making it well sustained beyond the actual implementation phase.

The project will be continuously monitored at periodic intervals as mentioned in Table 1, with the help of a gamut of process indicators related to antenatal, perinatal and postnatal outcomes. There would be monitoring of the growth, illness episodes, nutritional status, health indicators and development of the baby till 12 months of age which will provide an opportunity for midline or ongoing corrective actions as shown in Table 2.

Furthermore, there would be capacity building of the health workers and the community peers involved in the implementation, which will be evaluated and provided in the trial results. This will be helpful in establishing them as change makers and torch bearers for improving the malnutrition problems in their respective communities earning the love and respect of their societies. This will be evaluated at end line as a part of the participatory action research for the impact evaluation and will be included in the results of the trial.

Discussion

Nutrition-sensitive interventions during the first 1,000 days (from conception to two years of age) can have an enormous impact on a child’s ability to grow and develop.[10] The outcome of pregnancy of malnourished mothers is underweight newborns with poor health and poor cognitive outcomes. Women from poor rural communities lack proper nutrition and indoor sanitation facilities along with limited access to health, nutrition and Early Childhood Development (ECD) services and also face social and economic distress. Therefore, providing these underprivileged women with adequate support for nutrition during pregnancy in addition to routine antenatal care and preparing them to nurture their oncoming progeny both nutritionally and cognitively will help to create a stronger and more able next generation that may be of immense help for interrupting the cycle of poverty and malnutrition.

Early Childhood Education and Care (ECEC) provides a critical opportunity for rapid brain development in both compromised and normal babies from underprivileged rural homes. ECEC provides a head start to a child in education, health and subsequent employment that breaks the multigenerational cycle of poverty. The intervention integrates approaches that focus on maternal nutrition and infant growth as well as cognitive development. Through this study, we will evaluate the effectiveness of implementing this “SAFAL martrutva va shishutva abhiyaan”, which literally means “successful maternity and infancy mission” in rural areas of Eastern Maharashtra using a cluster randomized controlled trial (cRCT) and implementation action approach, in the selected villages around Nagpur. If proved successful, the intervention has the potential to be scaled up in a phasic manner to the other regions of Maharashtra and adapted as a “SAFAL mata shishu model” and serve as a maternal and infant nutrition, growth and development resource centre at the village level in the national nutrition mission as it is complementary to and conducive for the core objectives of both the Poshan Abhiyaan and the Digital Health Mission. The integrated innovation has the potential to be adopted by individual primary care physicians in their routine practice to provide a healthy pregnancy experience and at the same time promote the growth and development of the infant, thus providing a continuum of care through the first 1000 days of life for a healthy infant through educating the primary caregivers on essential aspects pertaining to the health and nutrition of mothers and infants in a user-friendly manner.

Conclusion

As the intervention will be a structured program implemented and monitored by the village entrepreneur or empowered “SAFALTA taais” or “SAFAL matrutv didi” along with the grassroot health workers, it will enhance the sustainability and community integration of the proposed intervention. Therefore, this holistic and comprehensive Intervention package beginning in the antenatal period and continuing throughout infancy will help in improving maternal nutrition, will bring about a reduction in LBW, and stunting and will be instrumental in achieving targeted growth and cognitive development of the infants.

At the same time, it will build the skills and capacity of the local women, ASHAs and AWWs establishing them as sustainable rural change makers.

Financial support and sponsorship

The study was funded through the Long term research grant of the Maharashtra University of Health Sciences Nashik for the research and publication of this article.

Conflicts of interest

There are no conflicts of interest.