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 the factors that contributed to declines in childhood stunting (from 52.9% to 37.6%) between 2006 and 2016 in the state of Chhattisgarh, a subnational success story in stunting reduction in India. ; PR ; IFPRI3; 2 Promoting Healthy Diets and Nutrition for all; CRP4; POSHAN; Stories of Change in Nutrition ; PHND; A4NH ; CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)
Data systems and their usage are of great significance in the process of tracking malnutrition and improving programs. The key elements of a data system for nutrition include (1) data sources such as survey and administrative data and implementation research, (2) systems and processes for data use, and (3) data stewardship across a data value chain. The nutrition data value chain includes the prioritization of indicators, data collection, curation, analysis, and translation to policy and program recommendations and evidence based decisions. Finding the right fit for nutrition information systems is important and must include neither too little nor too much data; finding the data system that is the right fit for multiple decision makers is a big challenge. Developed together with NITI Aayog, this document covers issues that need to be considered in the strengthening of efforts to improve the availability and use of data generated through the work of POSHAN Abhiyaan, India's National Nutrition Mission. The paper provides guidance for national-, state-, and district-level government officials and stakeholders regarding the use of data to track progress on nutrition interventions, immediate and underlying determinants, and outcomes. It examines the availability of data across a range of interventions in the POSHAN Abhiyaan framework, including population-based surveys and administrative data systems; it then makes recommendations for the improvement of data availability and use. To improve monitoring and data use, this document focuses on three questions: what types of indicators should be used; what types of data sources can be used; and with what frequency should progress on different indicator domains be assessed. ; Non-PR ; IFPRI1; DCA; POSHAN; 2 Promoting Healthy Diets and Nutrition for all ; PHND; SAR
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 country, much of food and health policy is decentralized, but little is known of how the double burden of malnutrition is understood at the state level. This study aimed to identify and compare frames and priorities for nutrition used by relevant policy actors to help understand the narrative emerging around policy solutions for the double burden of malnutrition. ; IFPRI5; POSHAN; CRP4 ; PHND; A4NH ; Non-PR ; CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)
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)
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. However, major gaps exist in ICDS service delivery. The government is currently strengthening ICDS through an mHealth intervention called Common Application Software (ICDS-CAS) installed on smart phones, with accompanying multilevel data dashboards. This system is intended to be a job aid for frontline workers, supervisors and managers, aims to ensure better service delivery and supervision, and enable real-time monitoring and data-based decision-making. However, there is little to no evidence on the effectiveness of such large-scale mHealth interventions integrated with public health programmes in resource-constrained settings on the service delivery and subsequent health and nutrition outcomes. Methods and analysis -- This study uses a village-matched controlled design with repeated cross-sectional surveys to evaluate whether ICDS-CAS can enable more timely and appropriate services to pregnant women, children <12 months and their mothers, compared with the standard ICDS programme. The study will recruit approximately 1500 Anganwadi workers and 6000+ mother-child dyads from 400+ matched-pair villages in Bihar and Madhya Pradesh. The primary outcomes are the proportion of beneficiaries receiving (a) adequate number of home visits and (b) appropriate level of counselling by the Anganwadi workers. Secondary outcomes are related to improvements in other ICDS services, and knowledge and practices of the Anganwadi workers and beneficiaries. ; IFPRI3; ISI; CRP4; DCA; 2 Promoting Healthy Diets and Nutrition for all ; PHND; A4NH ; PR ; CGIAR Research Programs on Agriculture for Nutrition and Health (A4NH)
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 interviews, we interpreted changes in the context of policies, programs and enabling environment. Primary contributors to stunting reduction were improvements in coverage of health and nutrition interventions (ranged between 11 to 23% among different states), household conditions (22–47%), and maternal factors (15–30%). Political and bureaucratic leadership engaged civil society and development partners facilitated change. Policy and program actions to address the multidimensional determinants of stunting reduction occur in sectors addressing poverty, food security, education, health services and nutrition programs. Therefore, for stunting reduction, focus should be on implementing multisectoral actions with equity, quality, and intensity with assured convergence on the same geographies and households. ; PR ; IFPRI3; POSHAN; 2 Promoting Healthy Diets and Nutrition for all; 5 Strengthening Institutions and Governance; DCA; ISI ; PHND; SAR
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 limited understanding of providers' experiences and challenges of collecting and using data for decision making. Objective: To identify barriers and facilitators to the 1) collection of data and 2) use of data for decision-making. Methods: In-depth interviews (N = 35) were conducted among block-level government staff, frontline worker (FLW) supervisors and A&T staff in two districts in Uttar Pradesh. Systematic coding of verbatim transcripts and detailed summaries were undertaken to elucidate themes related to data collection and use. FLW supervisors (N = 103) were surveyed to assess data use experiences. Results: Data were used to understand the reach of maternal nutrition services, estimate the demand for supplements and guide identification of areas of low FLW performance. About half of supervisors reported using data to identify areas of improvement; however, only 23% reported using data to inform decision-making. Facilitators of data collection and use included collaboration between health department officials, perceived importance of block ranking and monthly review meetings with staff and supervisors to review and discuss data. Barriers to data collection and use included human resource gaps, inadequate technology infrastructure, FLW education level, political structure and lack of cooperation between FLWs and supervisors. Conclusions: Use of data for decision-making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Despite intensive data collection efforts, the use of data to inform decision-making remains limited. Collaboration facilitated data collection and use, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions. ; PR ; IFPRI3; 2 Promoting Healthy Diets and Nutrition for all; CRP4; Alive and Thrive ; PHND; A4NH ; CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)
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-ANC) on coverage of nutrition interventions and maternal nutrition practices. Methods: We used a cluster-randomized design with cross-sectional baseline (2017) and endline (2019) surveys (n ∼660 pregnant and 1800 recently delivered women per survey) and a repeated-measures longitudinal study in 2018–2019 (n = 400). We derived difference-in-difference effect estimates (DIDs) for diet diversity, consumption of micronutrient supplements, weight monitoring, and early breastfeeding practices. Results: Despite substantial secular improvements in service coverage from India's national nutrition program, women in the I-ANC arm received more home visits [DID: 7–14 percentage points (pp)] and counseling on core nutrition messages (DID: 10–23 pp) than in the S-ANC arm. One-third of women got ≥3 home visits and one-fourth received ≥4 ANC check-ups in the I-ANC arm. Improvements were greater in the I-ANC arm than in the S-ANC arm for any receipt and consumption of iron–folic acid (DID: 7.5 pp and 9.5 pp, respectively) and calcium supplements (DID: 14.1 pp and 11.5 pp, respectively). Exclusive breastfeeding improved (DID: 7.5 pp) but early initiation of breastfeeding did not. Maternal food group consumption (∼4 food groups) and probability of adequacy of micronutrients (∼20%) remained low in both arms. Repeated-measures longitudinal analyses showed similar results, with additional impact on consumption of vitamin A–rich foods (10 pp, 11 g/d), other vegetables and fruits (22–29 g/d), and gestational weight gain (0.4 kg). Conclusions: Intensifying nutrition in government ANC services improved maternal nutrition practices even with strong secular trends in service coverage. Dietary diversity, supplement consumption, and breastfeeding practices remained suboptimal. Achieving greater behavior changes will require strengthening the delivery and use of maternal nutrition services integrated into ANC services in the health system. This trial was registered at clinicaltrials.gov as NCT03378141. ; PR ; IFPRI3; ISI; 2 Promoting Healthy Diets and Nutrition for all; CRP4; Alive and Thrive; DCA ; PHND; A4NH ; CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)
