How do programs work to improve child nutrition?: Program impact pathways of three nongovernmental organization intervention projects in the Peruvian highlands

This paper examines the program logic of three nongovernmental, community-based programs with different intervention models to reduce childhood stunting. Two programs, Child Nutrition Program (PNI) and Good Start, focused directly on education and behavior change among caregivers, or the short routes to achieve impact, while one program, Sustainable Networks for Food Security (REDESA), focused on upstream factors, such as improving local governance and coordination, improving water and sanitation, and increasing family incomes, or the long routes to achieve impact. We compared the logic of each program as it was explicitly documented to the logic as perceived by the implementers. We elucidated the program impact pathways (PIPs) of key activities by actors at different operational levels in each program to identify congruencies and gaps in the perceptions of causal mechanisms between program activities and their intended outcomes, and analyzed them with the simple program models and logical frameworks to highlight the methodology and utility of PIPs. In a desire to move beyond static input-out models of the three programs, we designed and conducted data collection activities (document review, semi-structured interviews, and observations) with the intention of gaining insights about those aspects of the program that brought causal mechanisms of a given program into clearer focus. We propose that different methods for eliciting PIPs may be necessary at different operational levels. The interview method elicited more complete responses among those who are familiar with programmatic concepts, whereas actors at the local operational level provided sparse and fragmentary responses, even when simple, common language was used during the interviews. Group participatory processes, using visual aids, may be more effective for mapping the perceptions of those who are not accustomed to articulating information about programs. To reduce the length and frequency of interviews with program actors, initial PIPs could also be constructed from program documents, then discussed and revised iteratively with program actors. Although program logic models and the logical frameworks provide a succinct overview of the program (for communication, strategic planning, and management), we found that PIPs provide a better representation of the causal connections between program activities and results, particularly when both upstream and direct intervention activities were part of the same program. PIPs provide a visual tool for tracking how activities were perceived to work and make an impact, bringing into focus the different pathways of the activities and influences along the way. Beyond the logical sequence of program inputs, outputs, and outcomes, the conceptualization of impact pathways is a useful approach for understanding the causal connections required for impact and for identifying where attention and reinforcements may be required within program operation. The utility of this tool warrants its use not only during final evaluation but also during mid-program monitoring and relevant assessments. National- and regional-level program actors had good understanding of the overarching frameworks and principles of their respective programs as well as the program components and activities. They demonstrated a strong coherence to the program documents, provided similar cohesive responses, and were able to articulate the impact pathways. However, program actors at the national level identified fewer facilitators and barriers along the impact pathways than did the local actors, revealing that the practical dimensions of the impact pathways were not as evident to planners and managers farther from the communities. Although program actors at the local level were more apt to provide practical examples of influencing factors or incidents that occur during implementation, they had difficulty fully articulating their perceived PIPs and provided fragmented views of how the activities linked to their outcomes. Similar patterns were found across the three programs. This finding raises the question of desirability of a common understanding of the goals and pathways by which these outcomes are achieved or the acceptability of diversity of perspectives. It is still unclear whether program effectiveness may be improved through greater congruency in the PIPs. Future research should elucidate how congruency of PIPs among program actors across operational levels could be increased, and whether greater congruency would improve program implementation and effectiveness.program impact pathway, program logic model, logical framework, childhood stunting, child nutrition programs,

Iron Deficiency and the Well-being of Older Adults: Early Results From a Randomized Nutrition Intervention

Iron deficiency is widespread throughout the developing world. We provide new evidence on the effect of iron deficiency on economic and social prosperity of older adults drawing on data from a random assignment treatment-control design intervention. The Work and Iron Status Evaluation is an on-going study following over 17,000 individuals in Central Java, Indonesia. Half the respondents receive a treatment of 120 mg of iron every week for a year; the controls receive a placebo. Compliance is monitored carefully. Results from the first six months of the intervention are presented for adults age 30 through 70 years. Males who were iron deficient prior to the intervention and who are assigned to the treatment are better off in terms of physical health, psycho-social health and economic success. These men are more likely to be working, sleep less, lose less work time to illness, are more energetic, more able to conduct physically arduous activities and their psycho-social health is better. There is evidence that economic productivity of these males also increased. Among iron-deficient males assigned to the treatment who were also self-employed prior to the baseline, hourly earnings rose substantially and so they earned more on a monthly basis. Benefits for women are in the same direction but the effects are more muted. The results provide unambiguous evidence in support of the hypothesis that health has a causal effect on economic prosperity of males during middle and older ages

Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial.

BACKGROUND: Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS: We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS: Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION: Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING: Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.The SHINE trial is funded by the Bill & Melinda Gates Foundation (OPP1021542 and OPP113707); UK Department for International Development; Wellcome Trust, UK (093768/Z/10/Z, 108065/Z/15/Z and 203905/Z/16/Z); Swiss Agency for Development and Cooperation; US National Institutes of Health (2R01HD060338-06); and UNICEF (PCA-2017-0002)

Concepts about infant health, growth, and weaning: A comparison between nutritional scientists and madurese mothers

Nutrition education is a critical component of programs designed to improve nutritional status, yet it often fails because of differences in the concepts underlying the educational message and those motivating mothers' behavior. To illustrate this discrepancy in the context of infant feeding we compare the views of nutritional scientists' and mothers in Madura, Indonesia on (a) health and disease and (b) the relationship of foods to the concepts of state-of-health, infancy and growth. The relationship of these concepts to mothers' practices and nutritional scientists' recommendations are also explored. Views of the nutritional scientist were drawn from the published literature and those for the Madurese mothers' from ethnographic and survey data gathered between February 1983 and June 1984. While mothers and nutritional scientists both seek to give a diet appropriate for a stage of infancy, their definitions of key concepts differed. Nutritional scientists recommend feeding infants high quality clean foods in amounts sufficient for maintenance, activity and growth. Underlying these recommendations are the concepts of disease as a deviation from the norm, food as a source of pathogens as well as nutrients, infancy as a period of physiological growth, and poor growth as an indicator of disease. All infants have the same type of nutrient requirements. Madurese mothers perceive health and its components as a process of balance. Balance is partly attained either by feeding rice soon after birth or by withholding rice until after one year of age. This concepts results in two distinct but coexisting types of requirement and weaning patterns for infants. The important development during an infant's first year of life is 'growth' from a vulnerable state in the 'neonatal' period (40 days) to a state of independence and reason (akal) in late infancy (> 7 months). To foster 'growth' in rice-fed infants, mothers force-feed increasing amounts of quality foods. Once akal is achieved, mothers no longer feed quality foods or increase amounts of food, and the infant, not the mother, initiates feeding. These comparisons suggest how nutritional scientists can help improve the process of communication in nutrition programs. First they can describe and analyze the mother's as well as their own conceptual framework to arrive at approaches and messages that blend together points of views. Second, by studying the consequence on infants of mother's behavior, nutritional scientists may gain further insight into the biological processes leading to good nutrition and refine messages and interventions accordingly.infant feeding Indonesia nutrition interventions folk beliefs

The Multi-Country Evaluation of the Integrated Management of Childhood Illness Strategy: Lessons for the Evaluation of Public Health Interventions

The Multi-Country Evaluation of the Integrated Management of Childhood Illness (IMCI) includes studies of the effectiveness, cost, and impact of the IMCI strategy in Bangladesh, Brazil, Peru, Tanzania, and Uganda. Seven questions were addressed when the evaluation was designed: who would be in charge, through what mechanisms IMCI could affect child health, whether the focus would be efficacy or effectiveness, what indicators would be measured, what types of inference would be made, how costs would be incorporated, and what elements would constitute the plan of analysis. We describe how these questions were answered, the challenges encountered in implementing the evaluation, and the 5 study designs. The methodological insights gained can improve future evaluations of public health programs

Effects of Maternal Nutritional Status and Maternal Energy Supplementation on Length of Postpartum Amenorrhea Among Guatemalan Women

This issue was undated. The date given is an estimate.28 pages, 1 article*Effects of Maternal Nutritional Status and Maternal Energy Supplementation on Length of Postpartum Amenorrhea Among Guatemalan Women* (Kurz, Kathleen M.; Habicht, Jean-Pierre; Rasmussen, Kathleen M.; Schwager, Steven J.) 28 page