Suchergebnisse

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 impacts on micronutrient supplementation, dietary diversity, and weight gain monitoring. Objectives: This study examined intervention-specific program impact pathways (PIP) and identified reasons for limited impacts of the A&T maternal nutrition intervention package. Methods: We used mixed methods: frontline workers surveys (FLWs, n∼500); counseling observations (n = 407); and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed seven PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling. Results: Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC versus S-ANC (90 vs.70%), but gaps remained for training content and refresher trainings. FLW's knowledge improvement was higher in I-ANC than S-ANC (22–36 percentage points), but knowledge on micronutrient supplement benefits and recommended foods was insufficient (90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30–50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52 vs. 36%), but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight gain monitoring were low (30–40%). Conclusions: Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact. ; PR ; IFPRI3; ISI; Alive and Thrive; 2 Promoting Healthy Diets and Nutrition for all; CRP4; IFPRIOA ; PHND; A4NH ; CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)

OBJECTIVES: Routine antenatal care (ANC) offers opportunities to receive a broad range of services including support for adequate nutritional care for pregnant women and their newborns. Alive & Thrive (A&T) aimed to strengthen provision of iron-folic acid (IFA) supplementation and interpersonal counseling on maternal nutrition and breastfeeding through government ANC services and community-based contacts in two regions in Burkina Faso. We assessed the impacts of intensified nutrition interventions during ANC (A&T) and standard ANC services (control) on intervention coverage and maternal nutrition practices. METHODS: A cluster-randomized design compared 40 health center catchment areas in A&T areas to 40 in control areas. Repeated cross-sectional surveys in 2019 and 2021 (960 pregnant women and 1920 women with children 0–5 months of age per survey round) provided data on impact indicators and intervention exposure. We derived difference-in-difference effect estimates (DID), adjusted for geographical clustering, for maternal dietary diversity, IFA consumption, and early breastfeeding practices. RESULTS: More women in A&T areas had 4 + ANC visits (DID: 8.5 percentage points [pp]) and 4 + community-based contacts during their last pregnancy (DID: 14.7 pp) and started ANC during the first trimester (DID: 11.3 pp), compared to control areas. A larger improvement in exposure to nutrition counseling during ANC was achieved in A&T areas than in control areas (DID: 39.5 pp). Women in A&T areas consumed more IFA supplements during pregnancy than in control areas (DID: 21 tablets). Both early initiation of breastfeeding and exclusive breastfeeding also improved (DID: 17.1 pp and 8.3 pp, respectively). However, dietary diversity (4 out of 10 food groups) and mean probability of adequacy of micronutrients intake (14%) among pregnant women remained low in both areas. CONCLUSIONS: Strengthening maternal nutrition interventions delivered through government ANC services was feasible and effective in ...

OBJECTIVES: Secondary data analysis in Bangladesh has found associations across agricultural production, women's empowerment, and nutrition outcomes. Less is known, though, about whether combining interventions across these areas is more effective than isolated interventions to improve agricultural diversity, diet diversity, and women's empowerment in Bangladesh. METHODS: The Agriculture, Nutrition, and Gender Linkages study used a cluster randomized controlled trial to evaluate impacts of agriculture, nutrition, and/or gender interventions on food production, diets, and empowerment. 160 blocks were randomized to control and 5 training models: (T1) nutrition by government agriculture extension agents (AEAs); (T2) nutrition by community nutrition workers; (T3) agriculture on production of nutrient-rich foods by AEAs; (T4) agriculture and nutrition by AEAs; and (T5) agriculture and nutrition by AEAs, and gender sensitization. Trainings targeted men and women together. 4000 farm households with a child under age 2 at baseline were surveyed 2 years apart. Impact estimates used endline data, adjusting for baseline characteristics using analysis of covariance. RESULTS: All treatments significantly improved agriculture production knowledge and adoption of improved production practices, more so in arms with agriculture training (T3, T4, T5), and for women than men. All treatments significantly improved nutrition knowledge, more so in arms with nutrition training, and for women than men. Household diet quality and child diet diversity significantly improved only in T2 and T4. Women's empowerment significantly improved in all treatments, and men's gender attitudes improved in T1, T4, T5, more so in the gender arm (T5). No impacts were expected or found on child anthropometry. CONCLUSIONS: Joint interventions had larger impacts than isolated ones, suggesting synergies across agriculture, nutrition, and gender. Impact on food and nutrition outcomes (food production or nutrition practices) required agriculture and/or ...

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 nutrition-intensified ANC (I-ANC) intervention facilitated regular use of data to enable corrective actions. We aimed to understand how maternal health data was used for improving the delivery of maternal nutrition services and to identify factors associated with data use. METHODS: In-depth interviews (N = 35) were conducted among sub-district government staff, frontline worker (FLW) supervisors and A&T staff in two districts in UP. Systematic coding of verbatim transcripts and detailed summaries was undertaken to elucidate themes and patterns related to data use and facilitators and barriers. RESULTS: Sub-district government staff reported using government data (i.e., HMIS) to estimate demand for prenatal supplements. Sub-district government staff, FLW supervisors and A&T staff used government and intervention monitoring data to understand the impact and reach of services delivered to women. Key indicators on the attendance of pregnant women at community health events and number of women receiving adequate supplements was discussed with FLWs in monthly review meetings. Data review guided identification of areas of low FLW performance (i.e., monitoring weight gain) and prompted refresher trainings. Facilitators of data use included collaboration between sub-district health department officials on data analysis and monthly review meetings to provide feedback on improving performance (including counseling topics and stock of supplements). Barriers to data use included staff vacancies, education level of FLWs and conflicts between FLWs and supervisors. CONCLUSIONS: Use of data for decision making is critical for supporting intervention planning and ...

OBJECTIVES: High coverage of any antenatal care (ANC) and near-universal coverage of iron-folic acid (IFA) supplementation is reported by nationally representative surveys in Burkina Faso. We examined the coverage of maternal nutrition interventions during ANC to assess gaps and missed opportunities in achieving global and national recommendations. METHODS: We used household survey data among 1920 mothers with children <6 months of age in 2 regions in Burkina Faso, collected in November-December 2019. Descriptive statistics were used to examine exposure to nutrition interventions during antenatal care throughout pregnancy and equity analyses were conducted to assess differences in exposure by maternal age (adolescents 15–19 y of age and older mothers) and education (none vs. any schooling). RESULTS: All mothers reported having attended at least one ANC visit at a health facility (mostly government health centers) during last pregnancy, but only 66.6% reported attending at least 4 visits. All consumed IFA tablets, but reported consuming 109 tablets on average during pregnancy, which was short of the recommended 180 tablets over 6 months. Only 42.7% reported receiving any nutrition counseling during ANC, with the most common messages reported on consuming one IFA tablet daily (93.4%) and eating a variety of foods (68.8%). While nearly all mothers were weighed during ANC, very few reported receiving information about weight gain. Among mothers, 14% were adolescents below 20 y, and 66.1% never attended school. For all indicators related to exposure to ANC or maternal nutrition intervention, we observed no differences by maternal age, education or other subgroups such as religion, parity or household composition. CONCLUSIONS: The government health system in Burkina Faso with its widespread and uniform reach provides an opportunity for improving the low coverage of maternal nutrition interventions during ANC. Doing so will require efforts both to improve the coverage of 4 or more ANC visits and the effective ...

AbstractDigital health solutions offer tremendous potential to enhance the reach and quality of health services and population‐level outcomes in low‐ and middle‐income countries (LMICs). While the number of programs reaching scale increases yearly, the long‐term sustainability for most remains uncertain. In this article, as researchers and implementors, we draw on experiences of designing, implementing and evaluating digital health solutions at scale in Africa and Asia, and provide examples from India and South Africa to illustrate ten considerations to support scale and sustainability of digital health solutions in LMICs. Given the investments being made in digital health solutions and the urgent concurrent needs to strengthen health systems to ensure their responsiveness to marginalized populations in LMICs, we cannot afford to go down roads that 'lead to nowhere'. These ten considerations focus on drivers of equity and innovation, the foundations for a digital health ecosystem, and the elements for systems integration. We urge technology enthusiasts to consider these issues before and during the roll‐out of large‐scale digital health initiatives to navigate the complexities of achieving scale and enabling sustainability.

Women's self-help groups (SHGs) have increasingly been used as a vehicle for social, political, and economic empowerment as well as a platform for service delivery. Although a growing body of literature shows evidence of positive impacts of SHGs on various measures of empowerment, our understanding of ways in which SHGs improve awareness and use of public services is limited. To fill this knowledge gap, this paper first examines how SHG membership is associated with political participation, awareness, and use of government entitlement schemes. It further examines the effect of SHG membership on various measures of social networks and mobility. Using data collected in 2015 across five Indian states and matching methods to correct for endogeneity of SHG membership, we find that SHG members are more politically engaged. We also find that SHG members are not only more likely to know of certain public entitlements than non-members, they are significantly more likely to avail of a greater number of public entitlement schemes. Additionally, SHG members have wider social networks and greater mobility as compared to non-members. Our results suggest that SHGs have the potential to increase their members' ability to hold public entities accountable and demand what is rightfully theirs. An important insight, however, is that the SHGs themselves cannot be expected to increase knowledge of public entitlement schemes in absence of a deliberate effort to do so by an external agency. ; PR ; IFPRI3; ISI; CRP4; Women Improving Nutrition through Group-based Strategies (WINGS); G Cross-cutting gender theme; 5 Strengthening Institutions and Governance; 2 Promoting Healthy Diets and Nutrition for all ; A4NH; PHND ; CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)

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 there is limited understanding of the nature and extent of coordination in place and needed at the various administrative levels. Our study examined how intersectoral convergence in nutrition programming is operationalized between ICDS and NRHM from the state to village levels in Odisha, and the factors influencing convergence in policy implementation and service delivery. METHODS: Semi-structured interviews were conducted with state-level stakeholders (n = 12), district (n = 19) and block officials (n = 66), and frontline workers (FLWs, n = 48). Systematic coding and content analysis of transcripts were undertaken to elucidate themes and patterns related to the degree and mechanisms of convergence, types of actions/services, and facilitators and barriers. RESULTS: Close collaboration at state level was observed in developing guidelines, planning, and reviewing programs, facilitated by a shared motivation and recognized leadership for coordination. However, the health department was perceived to drive the agenda, and different priorities and little data sharing presented challenges. At the district level, there were joint planning and review meetings, trainings, and data sharing, but poor participation in the intersectoral meetings and limited supervision. While the block level is the hub for planning and supervision, cooperation is limited by the lack of guidelines for coordination, heavy workload, inadequate resources, and poor communication. Strong collaboration among FLWs was facilitated by close interpersonal communication and mutual understanding of roles and responsibilities. CONCLUSIONS: Congruent or shared priorities and regularity of actions between sectors across all levels will likely improve the quality of coordination, and clear roles and leadership and accountability are imperative. As convergence is a means to achieving effective coverage and delivery of services for improved maternal and child health and nutrition, focus should be on delivering all the essential services to the mother-child dyads through mechanisms that facilitate a continuum of care approach, rather than sectorally-driven, service-specific delivery processes.

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 of AWW home visits and counseling. We also examined whether these improvements led to better infant and young child feeding (IYCF) practices among beneficiaries. METHODS: The mHealth intervention (Common Application Software – CAS) is currently being used by 581,282 AWWs across India. We conducted a village-matched, quasi-experimental design to examine program effectiveness across 428 villages in Madhya Pradesh (MP) and Bihar (BH). Repeated cross-sectional surveys were completed 17–24 months apart with AWWs (n = 1344) and mothers of children < 12 m (n = 6635). We compared post-intervention outcomes between matched groups, controlling for average baseline outcome levels and other covariates to correct for imbalances and improve precision. Program effects were assessed separately within each state. RESULTS: In both states, mothers in the intervention group were more likely to receive adequate number of home visits (MP: control = 42%; ß = 9.1%; P < 0.05; BH: control = 24%; ß = 7.7%; P < 0.05). A larger proportion of mothers in the intervention group could recall at least half the life-stage appropriate counseling messages (MP: control = 28.1%; ß = 11.8%. BH: control = 9.5%; ß = 7.7%). However, no improvements in IYCF practices were associated with the intervention. CONCLUSIONS: mHealth interventions like CAS can support gains in immediate term service delivery outcomes by enabling more age-appropriate home-visits and counseling. However, impacts on nutrition and health behaviors will require a longer-term evaluation and parallel efforts to improve a range of other outcomes, including structural poverty, gender norms, and larger socio-economic and political ...

As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda—now amplified by the COVID-19 crisis. ; PR ; IFPRI3; ISI; CRP4; 2 Promoting Healthy Diets and Nutrition for all; POSHAN; Transform Nutrition West Africa ; PHND; SAR; A4NH ; CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)

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. We studied pathways through which the nutrition-intensified ANC (I-ANC) was intended to impact FLWs capacity, knowledge, and service delivery, compared to standard ANC (S-ANC). METHODS: We used a cluster-randomized design with cross-sectional surveys at baseline (2017) and endline (2019), ∼500 FLWs per survey. Differences between I-ANC and S-ANC were compared along six impact pathway components (training, availability of materials, supportive supervision, knowledge, service delivery, and counselling content) using mixed-effects regression adjusted for clustering. RESULTS: Training exposure was higher in I-ANC than S-ANC (9 percentage points, pp). Nutrition training topics were low-moderate (30–60%) in both arms. Job aids were more available in I-ANC (70–80%) than S-ANC (30–40%). Supply of iron-folate and calcium supplements were low in both arms, with 10–50% having stock-outs. FLWs in I-ANC were more likely to receive supervision visits (7 pp), but gaps remained in both arms. Compared to S-ANC, FLWs in I-ANC had higher knowledge on diet diversity (6 pp), adequate intake (10 pp), iron-folate (10 pp) and calcium supplements (30 pp), pregnancy weight gain (20–30 pp), and early breastfeeding (5 pp), but similarly low knowledge of exclusive breastfeeding. ANC check-ups by FLWs were 20 pp higher in I-ANC. FLWs in I-ANC did more counselling on adequate diet, supplements, and weight gain (10–20 pp). Counselling on diet diversity and breastfeeding were low in both arms. CONCLUSIONS: Health systems strengthening efforts helped improve the delivery of maternal nutrition interventions in antenatal care in this context, but gaps remain. Several health system elements along the ...