Barriers and facilitators to scaling up a preconception-to-early childhood health intervention in rural India: A convergent mixed-methods formative study in Himachal Pradesh

Abstract Background Maternal and child undernutrition remain persistent public health challenges in India despite large-scale nutrition programmes. The WINGS randomized controlled trial demonstrated that a multi-domain intervention delivered from preconception through early childhood improved birth outcomes and maternal health under trial conditions. Translating this efficacious package into routine public health and nutrition systems requires contextual adaptation. This formative study assessed systems readiness and barriers and facilitators to scaling up the WINGS intervention in Amb block, Una district, Himachal Pradesh. Methods A convergent parallel mixed-methods design was used. Quantitative data comprised three rounds of cross-sectional household surveys and facility assessments in the learning block, which were analysed descriptively. Qualitative data included in-depth interviews, focus group discussions and non-formal interviews, analysed using hybrid inductive-deductive thematic analysis and mapped to the Consolidated Framework for Implementation Research (CFIR). Quantitative and qualitative findings were integrated during interpretation through triangulation and joint display matrices. Results Preconception care was neither socially recognised nor institutionally operationalised: 84.3% of preconception women took no nutritional supplements, no structured preconception services existed at any facility level; a double burden of obesity (41.8%) and anaemia (62.4%) was observed. Antenatal care showed fragmentation, with PMSMA clinics substituting for routine antenatal visits. Transportation barriers deterred access for both workers and beneficiaries. Gestational weight gain and mental health status were rarely assessed. Supplementary nutrition reached most beneficiaries (94–97% take-home ration) but varied acceptability and intra-household sharing (44.4% among children) limited effective consumption. Documentation systems were present but functionally weak, compounded by workforce vacancies. Conclusions While the health and ICDS systems in Una district possess substantial structural assets, functional readiness for a preconception-to-early-childhood intervention is uneven across the continuum of care. Scale-up of WINGS will require establishing preconception care as a distinct service category, strengthening ASHA-Anganwadi Worker coordination, tailoring nutrition counselling to local dietary norms and the dual burden of malnutrition, and reinforcing documentation and referral systems. These formative findings provide a baseline against which iterative adaptation and scale-up of the WINGS intervention can be evaluated. Trial registration: CTRI/2023/10/058538, registered on 11/10/2023.