Introduction

Notwithstanding rapid economic growth since the 1990s, the developmental performance of India is weighed down by a worrisome state-of-affairs in the field of child health and nutrition. The National Family Health Survey (NFHS 2019–21) of India finds that 35.5%, 32.1% and 19.3% of the children (below five years) continue to suffer from stunting, underweight and wasting, respectively [1]. While these indicators have shown reductions since early 2000s but these improvements are offset by recent deteriorations in certain other nutrition-related indicators for children. The increase in the prevalence of anemia (58.6% in NFHS 2015–16 to 67.1% in NFHS 2019–21) as well as severe acute malnutrition (7.5% in NFHS 2015–16 to 7.7% in NFHS 2019–21) among children under-five is rather disturbing [1,2]. Such burden has a detrimental impact on the income and productivity levels of the concerned individuals as well as on the overall economic growth and welfare potential of the countries [3]. The stagnancy (and worsening) of some of these indicators also undermines the programmatic efforts to improve maternal and child nutrition in India and unequivocally calls for devising alternative strategies to address this long-standing problem in public health [4–7].

This paper contributes in this direction and aims to analyze the impact of Behavior Change and Communication (BCC) module roll out in SHG meetings on complementary feeding practices in rural Bihar. The findings add to the evidence base on the role of health and nutrition layering interventions in community settings (such as SHGs) with special reference to complementary feeding practices. It is hypothesized that exposure of SHG members to BCC modules should lead to improvements in complementary feeding practices and should have a spillover on the community (those unexposed to BCC module). Based on a cross-sectional pre- and post-intervention exposure design, the three specific objectives of the analysis are listed as follows: First, to examine the change in knowledge levels of mothers regarding complementary feeding and dietary diversity in the pre- and post-intervention setting. Second, to estimate the impact of the intervention on the level of dietary diversity and minimum acceptable diet among children 6–23 months. And finally, to understand the direct effect of exposure to the intervention among participants of SHG events vis-à-vis the indirect effect among the non-participants. The findings are expected to inform policymaking on BCC strategies for improving complementary feeding practices in rural geographies that impose severe time and resource constraints.

As such, since the advent of the Demographic and Health Surveys (DHS) in 1980s, a large number of studies have examined the drivers and determinants of child undernutrition among low- and middle-income countries including India [8–11]. Most of this evidence on social and biological determinants is translated into action by the national and international organizations including the union and the state governments in India through various flagship programmes that seek to accelerate reductions in child undernutrition globally. However, sub-optimal achievements of some of the nutrition-related programmes, such as the Integrated Child Development Services (ICDS), calls for a scrutiny and re-calibration of the policy matrix [12,13]. In this regard, particular interest has emerged in directly addressing—what is presumably—the most important determinant of nutrition i.e., complementary feeding practices. Several studies and policy guidelines now lay a clear emphasis on influencing dietary intake and dietary diversity among children in the age group of 6–23 months [14–18]. It is worth noting that adequate dietary intake among children (6–23 months) is among the slowest improving indicators in India [1]. For instance, the proportion of children (6–23 months) receiving an adequate diet in India was estimated to be 9.6% in NFHS 2015–16 and 11.3% in NFHS 2019–21. Therefore, attaining rapid improvements in complementary feeding practices is an important area for policymaking. In particular, greater focus is desired on the first 1000 days, including the 6–23 months window, with dietary counseling and behavior change being accorded highest priority for improving nutrition [19].

It is argued that a pro-active community outreach model can be an effective means to overcome the limitations of the health centre or ICDS centre based delivery approach to improve complementary feeding practices [20]. Some studies also recommend such outreach via community health workers but their effectiveness, acceptance, coverage and workload imbalances are fundamental constraints in leveraging their role toward improving complementary feeding practices [21–24]. Hence, development and testing of alternate strategies to address the problem of inter-personal counseling for nutrition assumes huge relevance in vastly rural and populous environments with overwhelming physical and financial barriers [25–28]. In this context, layering of health and nutrition interventions on rapidly expanding platform of women self-help group (SHG) networks across low-income geographies is viewed as a unique opportunity to influence complementary feeding norms and practices [29,30]. This is largely attributable to the attractiveness of the SHG model as a cost-effective option for governments and donors to quickly transmit behavior change messages and use the social capital of the groups to reinforce these norms through peer-support as well as sanctioning of any deviant practices [31–33].

Nevertheless, there is limited yet mixed evidence on the effectiveness and impact of such SHG centric interventions on complementary feeding practices [34–36]. For instance, Kushwaha et al (2014) finds that peer counselling by the mother support groups had a favorable impact on infant and young child feeding practices in Lalitpur district of Uttar Pradesh. Similarly, in the context of Ethiopia, Kang et al (2018) suggest that maternal social capital via group memberships is associated with better dietary diversity among children. Whereas, a couple of studies [30,37] find that the effects of health layering on SHGs were relatively weaker on complementary feeding and nutrition. However, much of this evidence is context specific and given the increasing governmental attention on SHGs for women empowerment and livelihoods promotion, it is critical to further the understanding on effectiveness and impact of health layering initiatives on child diets and nutrition.

Data and methods

Results

The study sample comprises of information on dietary diversity of 297 children in the pre-intervention phase and 300 children in the post-intervention phase. The representation of male children in the pre-intervention sample was higher (59%) whereas it was more or less equal in the post-intervention sample (Table 1). To a great extent the background characteristics of the sample respondents and households is homogenous between pre and post intervention. In the pre-intervention sample most of the respondent mothers (61%) and their partners (41%) do not have any formal education or schooling.

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Table 1. Background characteristics of sample respondents in pre and post-intervention survey, Rural Bihar, 2017.

https://doi.org/10.1371/journal.pone.0279724.t001

The sample comprises of mostly Hindu households (93% in pre-intervention and 92% in post-intervention sample). Scheduled caste and scheduled tribe (SC/ST) households comprised 30% of the sample in both the survey rounds. Most of the households reported a family size of more than 5 members and the households on average have 3–4 children which indicates high fertility rates. The use of LPG for cooking was low across both the control and intervention areas. Almost one-half of the sample respondents reported knowledge of kitchen garden and reported growing some fruits and vegetables at home or plain land nearby home.

More than two-third (72%) of the sample respondents had attended BCC module session on complementary feeding during the SHG meetings. The remaining 28% are thus unexposed to the BCC intervention in the post-intervention sample. During the pre-intervention phase 48% of the respondents reported higher knowledge levels on complementary feeding practices and this increased to 81% in the post-intervention phase with bulk of this attributable to the exposed group of respondents (91%). Similar pattern in level and changes in diet preference score is also noted whereby low score in dietary preference patterns for children is almost negligible among the exposed group (S2 and S3 Tables).

Fig 1 presents the consumption patterns of children 6–23 months from the various food groups (S4 Table). A high proportion of children consume grains, roots, tubers and plantains (83% and 95% in pre- and post-intervention sample, respectively) followed by pulses, beans, nuts and seeds (63% and 83% in pre- and post-intervention sample, respectively). Consumption of eggs among children was 3% in the pre-intervention sample but it increased to 18% among the exposed group in the post-intervention phase (S4 Table). The increase is much higher among SC/ST households than other social groups (Fig 1). Consumption of vitamin A rich fruits and vegetables also improved after the intervention (from 9% to 29%). The child dietary diversity improvements are much higher among the respondents who were exposed to the BCC modules whereas the effect was lower among those who were not directly exposed to these sessions. This indicates that there are likely to be positive but limited spill-over effects of the BCC intervention. Interestingly, no significant changes are noted in the consumption of milk products in the pre- and post-intervention phases. The overall child dietary diversity scores are computed using both the old as well as the new definition of the indicator. As regards the old definition, during the pre-intervention phase, 19% of the children had adequate dietary diversity (eating from at least 4 out of 7 different food groups) and this increased to 49% among the exposed group and to 28% among the non-exposed group in the post-intervention phase. As per the new definition of (consuming from at least 5 out of 8 different food groups including breastfeeding), the estimates of child dietary diversity levels are more or less similar (S4 Table). This is attributable to near universal prevalence of breastfeeding for the 6–23 months old children as revealed through the data from rural Bihar.

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Fig 1. Mean consumption of various food groups by SC-ST and Others during pre- and post-intervention survey, Rural Bihar 2017.

https://doi.org/10.1371/journal.pone.0279724.g001

Child dietary diversity among children (6–23 months) estimated as consumption of five out of eight food groups is found to be much lower at 19% during the pre-intervention period (Table 2). The levels among respondents exposed (54%) to the BCC module are much better as compared to those who were not exposed (24%) to the module on complementary feeding practices (S4 Table). The dietary diversity levels thus show an over two-fold increase among the exposed group during the post-intervention phase (54%). However, there is only a small increment among the unexposed sample (24%). Both girls (20%) and boys (18%) have similar dietary diversity levels in the pre-intervention sample as well as among the exposed sample in the pre-intervention phase. Nevertheless, in the unexposed sample male child shows a relatively higher level of dietary diversity. Across both control and intervention area, dietary diversity among children is lower in households with more than 4 children. During baseline survey the dietary diversity level among households with and without kitchen garden was more or less similar at 20%.

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Table 2. Child dietary diversity (5 out of 8 groups) levels in pre and post-intervention survey, Rural Bihar, 2017.

https://doi.org/10.1371/journal.pone.0279724.t002

However, in the post-intervention phase the levels of child dietary diversity is found to be higher among households that have a kitchen garden (57%) than those without kitchen garden (40%). Besides, children belonging to SC/ST category also have higher dietary diversity than those who are other social groups. Dietary diversity is higher among children of mothers in the younger age group of less than 25 years and those who have more than 5 years of education and belong to economically better-off households.

Estimates from the logistic regression analysis confirm a statistically significant association between child dietary diversity and exposure to BCC module during SHG session (S5 and S6 Tables). The odds ratio (OR) in S5 Table shows that exposure to BCC module is associated with 2.90 times (95% confidence interval (CI): 1.46, 5.74) higher chances of child dietary diversity. However, these estimates are adjusted for the complementary feeding knowledge levels as well as household preferences for child diets which itself are influenced because of exposure to the BCC module. This is validated through the increased odds ratio in child dietary diversity among the exposed group when these two variables are removed from the equation (Table 3). The odds ratio increases to 3.81 (95% CI: 2.03, 7.15) when the old definition of 4 out of 7 groups is considered and 4.12 (95% CI: 2.17, 7.81) when new definition of 5 out of 8 groups is considered. The econometric analysis also shows that maternal education has a significant association with child dietary diversity. Children of mothers with 5 or more years of education are twice more likely to consume a diversified diet. Children belonging to SC/ST households have 70% higher chances (OR 1.74, 95% CI: 1.08, 2.79) of consuming a diversified diet. Those who are using LPG are also twice as likely to report a diversified diet (Model-2 OR 2.14, 95% CI: 1.32, 3.46). This indicator presumably captures the wealth effect even though the causation may be difficult as there is a widespread policy effort to ensure universal access to clean cooking fuel implying that some of the poor households may also have LPG cylinders at home through government initiatives such as Ujjwala.

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Table 3. Logistic regression based odds ratio (OR) for child dietary diversity (CDD) for pooled sample, Rural Bihar 2017.

https://doi.org/10.1371/journal.pone.0279724.t003

Finally, the impact of the BCC module exposure is assessed using the propensity score matching technique. The ATE and ATT values are estimated for the both old and new definitions of child dietary diversity. The robustness checks for covariate balancing as well as common support for the propensity scores of the matched sample is also performed (S1–S3 Figs and S8 Table). The mean and standard deviation for the propensity score is estimated to 0.422 and 0.111, respectively. The region of common support for the propensity scores ranges from 0.182 to 0.706. For the old definition of child dietary diversity (CDD of 4 out of 7 food groups), the PSM based ATE and ATT estimates of exposure to BCC module during SHG sessions are estimated to be 0.336 [95% CI: 0.246; 0.427] and 0.294 [95% CI: 0.184; 0.404], respectively (Table 4). For the new definition of child dietary diversity (5 out of 8 food groups), the PSM based ATE and ATT estimates are 0.331 [95% CI: 0.240; 0.421] and 0.281 [95% CI: 0.173; 0.389], respectively. The estimates for both CDD definition are also confirmed using the alternative strategy of nearest neighbor matching (Table 4). As sensitivity check for the estimation approach, we present the ATT estimates for both the definitions in S9 Table. The ATT estimates across the various approaches are found to be consistent. The ATT estimate indicates that after matching those children whose mother were exposed to the BCC module have a much higher chance of receiving a diversified diet. If we consider diversity based on 5 out of 8 groups, we observe similar ATT effects.

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Table 4. Estimated treatment effects of exposure to BCC module for child dietary diversity (CDD) based on propensity score and nearest neighbor matching, Rural Bihar 2017.

https://doi.org/10.1371/journal.pone.0279724.t004

Discussion and conclusion

The study analyzed the role of BCC module roll out in SHG sessions for improving child dietary diversity in rural Bihar. The five salient findings of the study are as follows: First, compared to the baseline status, the dietary diversity among children 6–23 months showed more than two-fold increase among beneficiaries who were directly exposed to the BCC module roll out at SHG meetings. This effect was robust even after adjusting for socioeconomic factors as well as information on knowledge and dietary preference levels. Further, we find that there was a small increment in dietary diversity scores among the unexposed group but the effect was statistically insignificant. Second, the knowledge about complementary feeding practices and dietary preferences for children are identified as important factors influencing child dietary diversity scores. This effect persisted even after adjusting for the socioeconomic background of the respondents suggesting that behavioral factors can be improved with improving knowledge and awareness on complementary feeding. Third, maternal education level as well as household income status also have independent effects on increasing the chances of providing a more diverse diet to children (6–23 months). This reinforces the association of socioeconomic status with child health and nutrition. Fourth, availability of kitchen gardens, although reveals a favorable effect on child dietary diversity, but the effects were muted when adjusted for various factors in the econometric analysis. It perhaps implies that the pathways to link kitchen gardens with nutritional diversity may have to be viewed on a case-to-case basis during intervention roll out as there is considerable scope of household level variations for nature, type, seasonality and production focus of the kitchen gardens. Finally, the dietary diversity was weaker in terms of provisioning of meat, eggs and green leafy vegetables to children. These preferences can be partly associated with availability concerns and in part because of household preferences and can be verified through further assessments. Provisioning of milk products or fruits was also low. In the post-intervention phase consumption levels of eggs and fruits improved among the exposed group. Similar to other studies, it is noted that demographic factors such as age of child and mother, sex of child and birth order were unrelated with dietary diversity patterns [43]. However, SC/ST households were more likely to have dietary diversity when the recent definition of 5 out of 8 groups was considered. This is found to be associated with improved uptake of eggs as well as higher breastfeeding practices in the SCST community (Table 3).

The study, however, is not devoid of certain limitations. In particular, the study design is based on a pre-post assessment framework with an effort to understand the impact among the exposed and unexposed in the post intervention phase. For this purpose, the sampling of the respondent clusters for both pre-intervention and post-intervention survey was done prior to the launch of the intervention. Although this does not necessarily allow a robust randomized control design but nevertheless a priori random allocation of VOs in two groups makes them comparable with no or limited risk of any self-selection bias. Moreover, the length of intervention being short, about a month, it is least expected that other exogenous factors would affect the outcomes observed between pre- and post-intervention phases. This ‘single’ difference in this design arguably captures the essence of the ‘double’ difference usually adopted in quasi-experimental evaluation designs. Although, the analysis finds that the association of exposure to BCC module on child dietary diversity is significant but given the limitations of the study design it cannot be claimed to be strictly causal association. Furthermore, the post-intervention survey was conducted soon after the BCC module roll out and hence the recall abilities and adopted practices were discerned to be high. It will be important to understand whether such levels are sustained in subsequent months. Also, information on diet quantity is unavailable to understand improvements in actual dietary intake. Finally, it is also important to acknowledge that the BCC effort undertaken by JEEViKA was complementary to the ICDS driven activities like POSHAN Maah (month) celebration and monthly community-based events called Annaprashan Diwas. However, information on these components were not included in the survey or the analysis. We, however, expect none or minimal influence of the role of ICDS even as it aims at improving dietary diversity with certain basic provisioning of supplementary nutrition services to the beneficiaries (children, pregnant women and lactating mothers). This is mainly because of limited dietary diversity in the supplementary nutrition products distributed by the ICDS.

Overall, the findings suggests that the behavioral change communication in a group setting and through community mobilizers of SHGs can be an important intervention to improve child dietary diversity in rural communities. Along with this, maternal knowledge on complementary feeding practices, maternal education as well as household income are discerned are critical influencing factors in complementary feeding. The theory of change underlying the initiative emphasizes that community group mobilization with focus on community mobilization processes can improve self-efficacy, confidence, collectivization and change in norms and beliefs in accordance with the recommended practices for dietary diversity. In particular, the community mobilization activities were strengthened with both individual level interventions (such as messages and services to the marginalized women) and structural level interventions (such as resources and activities for the community or the group). These in turn were helpful in strengthening program activities such as the coverage of the program and also encouraged participation for trainings, meetings and social advocacy. The increased coverage also led to increase collective agency and action with improvements expected in knowledge levels and behaviors among marginalized women. The collection action also created an enabling environment that supported and reinforced the practices around dietary diversity and nutrition.

The proliferation of community institutions in the form of women collectives or SHGs in rural Bihar and also in other states has paved the way for mobilizing the community and layer health, nutrition, WASH interventions using the SHG cadre such as Community Mobilizers (CMs) and variety of Community Resource Persons (CRPs). While the SHG network is primarily a livelihood platform for rural women, it has complemented the efforts of the frontline health workers e.g., ASHAs, AWWs and ANMs to improve community demand for health, nutrition and WASH services offered by the government. The community institutions have a three tier upwardly federated system. SHGs are at the grassroots level where 10–12 married women form a group and the leaders of 10–12 SHGs form a Village Organization (VO) and the representatives of VOs in a cluster (sub-block unit) form a Cluster Level Federation (CLF). The network is run and managed by the State Rural Livelihood Mission having an office in each block with dedicated staff for overseeing the work of various verticals of the livelihood platform. Interestingly, there are more than 1 million SHG groups in Bihar alone. Nearly 10–12 million rural households have a member in the SHG fold. Hence, any intervention rolled out through the SHG network reaches easily to a large section of the rural community in no time. These SHG members meet once every week. The VO and CLF members meet once a month. Every SHG meeting is usually attended by over 60% of its members. Besides the meeting, the SHG, VO and CLM members and leaders participate in various community level activities and contribute to the local health and development agenda. Thus, it is a promising platform. As part of the organizations, the BCC intervention used multiple community level activities to improve the community engagement besides the module roll out during the weekly SHG meeting (please refer to our description of the intervention for more).

Even in similar other contexts (such as Maharashtra), engagement with BCC modules to improve counseling is found to be effective medium for improving dietary diversity among children from rural and marginalized communities. For instance, a positive change was observed in maternal and child dietary diversity after implementation of ICDS systems strengthening activities including behavior change communication among frontline workers [44]. A few other studies also discern a positive impact on the level of health and nutrition knowledge and feeding practices when BCC module applied through participatory leaning action (PLA) or community groups such as SHGs are introduced [45–49]. Since food and diets are the key determinants of nutritional status, there can be further impacts of such changes in the form of improved anthropometric outcomes among children. For instance, a latest quasi-experimental study in India showed that after the delivery of a knowledge and awareness package to the pregnant mothers, their infants showed significant improvements in mean weight-for-age z-scores [50]. Such evidences support the argument that providing culturally-appropriate nutrition educational intervention to individuals via trained community health workers can effectively improve complementary feeding practices [51].

The analysis also indicated that BCC interventions can augment the knowledge levels on complementary feeding and dietary preferences. However, translation of such knowledge into intent and action i.e., improved dietary diversity can be influenced presumably by socioeconomic status, cultural factors and behavioral norms. This gap between knowledge of complementary feeding and actual practice of child dietary diversity is also observed in this study. This finding is usually common in low-income settings [52]. Sometimes difficulties experienced in child feeding such as refusal by the child despite repeated feeding is a major obstacle for mothers. In fact, studies have noted that forcible feeding sometimes leads to undesirable health consequences such as vomiting which dissuades households to repeat such actions in future [53].

Notwithstanding the role of knowledge, awareness and behaviors, the level of household incomes are perhaps a critical determinant of food availability for women and children [54]. A number of studies from low-income settings confirm the positive association between household incomes and maternal and child dietary diversity [24,37,55,56]. For instance, in West Africa, poverty is seen as a main determinant of cereal-centric diets whereas consumption of meat, fruits and vegetables improve with household socioeconomic status [57]. India, including rural Bihar, is no exception to this basic tenet as noted in this study. A recent study [58] reaffirm that the significant modifiable factors associated with complementary feeding practices includes higher household wealth status and higher maternal education. But heterogeneity of impact across region is also apparent that reinforces the role of locally and culturally-sensitive dietary counseling through community health interventions. Paternal education is a relevant but often neglected aspect in child health and nutrition and should be emphasized as these can lead to improvements in dietary diversity as well as nutrition outcomes among children [36,59]. This also provides programmatic insights for BCC centric interventions for inclusion of men (husbands and fathers) in such SHG session roll outs through alternate participatory mechanisms.

There are many studies that linked the effectiveness of kitchen garden in enhancing dietary diversity [60]. For instance, kitchen gardens were observed to significantly influence dietary diversity among landless households in Myanmar and enhances food security of households [61]. There is robust evidence from other countries such as Kenya and Burkina Faso that on community participatory approach toward agriculture and nutrition activities have influenced dietary diversity but the impact of kitchen gardens per se have been small or minimal [62,63]. Our analysis in the context of rural Bihar also shows that the success of kitchen gardens in influencing dietary diversity is not necessarily universal and it can be rather context-driven. Such findings are consistent with other studies where lack of significant association between home-gardens and dietary diversity are observed. A potential caveat in such interpretations, however, is the nature of study design and the sample size requirements for estimation of the effects [64]. For instance, dietary diversity levels among children is notably higher during rainy season but such studies are exception as often cropping pattern as well as seasonality are not considered while drawing such conclusions [65].

Our study finds that demographic characteristics of the children do not majorly impact dietary diversity. Low or no disparities across demographic features is a common understanding in the literature where age and sex of the child are often unrelated with dietary diversity score [64]. However, within the age group of 6–23 months, some age-related disadvantages in dietary diversity is apparent for the younger 6–8 months old infants [66]. Gender disparity in dietary intake is also found to be minimal or negligible. In fact, in the South Asian as well as Indian context there is low intra-household variation in food consumption among the marginalized communities [67,68].

Finally, in the Indian context, it is observed that there is a low preference for feeding meat, eggs and green leafy vegetables to children [69]. Provisioning of milk products or fruits was also low. These preferences can be partly associated with availability concerns and in part because of household preferences even as only less than one-third of the Indian population are found to strictly vegetarian [70,71]. However, some of these practices for children can be improved as noted in the post-intervention phase findings of this study where an increase in the consumption of eggs and fruits among the exposed group is apparent. Our findings suggest SC/ST households have small relative advantage in dietary diversity which can be attributable to varied food preferences as well as access to various non-market sources of food such as forests and backyard poultry [72]. Nevertheless, encouraging non-vegetarian diet for children can be a formidable task for behavior change strategies both because of availability concern as well as preference considerations. Recent research has also highlighted the question of affordability of such diets for the low-income households. For instance, Gupta et al (2021) estimate that it would cost $1.00 per person per day more on each of the food groups meat, fish, poultry, dairy foods and fruits to meet the recommendations on dietary intake as put forward by the EAT Lancet Commission. Further work on strengthening dietary diversity patterns and improving availability and affordability is necessary as these often persist as a lifelong practice and can hamper nutrition in later life [73].

In conclusion, it may be reiterated that there is substantial scope to improve child dietary diversity across rural communities in India with the help of BCC modules rolled out in community settings such as the SHGs. The improvements noted in the levels of dietary diversity in a relatively shorter time span suggests that such patterns are often shaped by behavioral practices that can be altered through effective counseling of mothers and community outreach for wider understanding of nutrition concerns. The reductions in childhood stunting and underweight in Bihar between NFHS 2015–16 and 2019–21 is perhaps a testimony that widespread community-based engagements can help initiate the cycle of improvements almost instantaneously. The SHGs also appear to be a pertinent vehicle as there is a greater governmental involvement and support for health and nutrition layering through women empowerment initiatives (such as National Rural Livelihood Mission, NRLM) across several states of India. Such platform simultaneously can also overcome resource constraints through leveraging economic activities for improving food security and incomes at the household level. However, further research attention is warranted on issues related to sustainability of outcomes and impact demonstrated by such initiatives in rural areas. Also, strategies underlying the BCC roll out would need further research attention to inform policymaking and interventions to reduce heterogeneity of impacts observed across contexts.

Supporting information

Acknowledgments

We acknowledge the support received from JEEViKA–the Bihar Rural Livelihood Promotion Society (BRLPS) during the intervention and fieldwork for the study.