Internal validity and reliability of experience-based household food insecurity scales in Indian settings

Background: Experience-based household food insecurity (HFI) scales are not included in large-scale Indian surveys. There is limited evidence on which experience-based HFI scale or questions within a scale are most relevant for India. Between 01 June and 31 August 2015, we reviewed 19 published and unpublished studies, conducted in India between January 2000 and June 2015, which used experience-based HFI scales. As part of this exercise, internal validity and reliability of the scale used in these studies was examined, field experiences of 31 researchers who used experience-based HFI scales in India were gathered and psychometric tests were conducted where raw data were available. Results: Out of the 19 studies reviewed, HFI prevalence varied depending on the type of experience-based HFI scale used. Internal reliability across scales ranged between 0.75 and 0.94; however certain items ('balanced meal', 'preferred food', 'worried food would run out') had poor in-fit and out-fit statistics. To improve this, the following is suggested, based on review and experience of researchers: (1) cognitive testing of quality of diet items; (2) avoiding child-referenced items; (3) rigorous training of enumerators; (4) addition of 'how often' to avoid overestimation of food-insecure conditions; (5) splitting the cut and skip meal item and (6) using a standardized set of questions for aiding comparison of construct validity across scales. Conclusions: An evidence-based policy dialogue is needed in India for contextualizing and harmonizing the experience-based HFI scales across multiple surveys to aid comparability over time, and support policy decision making

Cash transfer is positively associated with better dietary outcomes – Evidence from a phone survey among women with children less than two years in six states of India

This poster was presented virtually at the Delivering for Nutrition (D4N) conference https://poshan.ifpri.info/delivering-for-nutrition-in-south-asia-transforming-diets/) and can be found online here: https://vimeo.com/showcase/9959813/video/768260329Introduction • Women’s diet is one of the immediate determinants of maternal and child nutrition Objectives • Examine dietary intake of women with children <2 years of age • Examine inequity in dietary intake by wealth status • Assess the role of food or cash transfers in maternal diet diversity Methods • Data came from a phone survey of 6,227 women in six states of India. • Dietary intake was assessed using the diet quality questionnaire which was then recategorized to calculate score for food diversity, consumption of healthy and unhealthy foods, and minimum diet diversity (MDD) for women. • Inequity in dietary intake was examined using wealth quintiles • Association between food and cash transfer on maternal diet was examined using multivariate regression analysis controlling for maternal, child, households' factors and state fixed effects

Understanding the role of intersectoral convergence in the delivery of essential maternal and child nutrition interventions in Odisha, India: a qualitative study.

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

Effects of an mHealth intervention for community health workers on maternal and child nutrition and health service delivery in India: protocol for a quasi-experimental mixed-methods evaluation.

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 &lt;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 &lt;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. ETHICS AND DISSEMINATION:Ethical oversight is provided by the Committee for the Protection of Human Subjects at the University of California at Berkeley, and the Suraksha Independent Ethics Committee in India. The results will be published in peer-reviewed journals and analysis data will be made public. TRIAL REGISTRATION NUMBER:ISRCTN83902145

Development of a methods repository for food choice behaviors and drivers at the household and individual levels

This brief identifies important constructs for assessing drivers of food choice behaviors and describes progress on the development of a repository of instruments and measures for assessing these constructs. OBJECTIVES 1. List constructs that can be assessed to understand drivers of household and individual food choice behaviors. 2. Identify instruments and measures to assess each food choice construct and organize these into a searchable repository. 3. Illustrate the use of the Food Choice Repository

Coverage of nutrition and health interventions in India: Insights from the National Family Health Surveys

Nutrition-specific interventions are aimed at improving the food, health, and care environment for women and children during the first 1000 days. These interventions span pregnancy, postnatal, and early childhood periods and include food and micronutrient supplementation, nutrition education and/or counselling, growth monitoring and promotion, as well as routine immunization, deworming, and care during illness. At 90% coverage, these interventions can contribute to 20% reduction in stunting and 61% reduction in severe wasting. India’s policy framework for health and nutrition is robust and includes most evidence-based nutrition and health interventions. Two large-scale national program platforms – the Integrated Child Development Services and the National Health Mission – together deliver these interventions across the country. India’s efforts at scaling up nutrition interventions are now also bolstered by the National Nutrition Mission. This Data Note describes the coverage of key nutrition and health interventions for which data are available in the National Family Health Surveys for 2015-2016 and 2019-2021. To examine coverage of interventions, indicators were created based on global definitions and making adaptations to Indian policy context where necessary. Data on women of reproductive age (15-49 years) with a child below five years of age from the most recent birth was used to compute these indicators. Indicator definitions are provided in Annex 1 of this Note

COVID-19 Disrupted Provision and Utilization of Health and Nutrition Services in Uttar Pradesh, India: Insights From Service Providers, Household Phone Surveys, and Administrative Data

BACKGROUND: The coronavirus (COVID-19) pandemic may substantially affect health systems, but little primary evidence is available on disruption of health and nutrition services. OBJECTIVES: This study aimed to 1) determine the extent of disruption in provision and utilization of health and nutrition services induced by the pandemic in Uttar Pradesh, India; and 2) identify how adaptations were made to restore service provision in response to the pandemic. METHODS: We conducted longitudinal surveys with frontline workers (FLWs, n = 313) and mothers of children \u3c 2 y old (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests. RESULTS: Compared with prepandemic, service provision reduced substantially during lockdown (83-98 percentage points, pp), except for home visits and take-home rations (∼ 30%). Most FLWs (68%-90%) restored service provision in July 2020, except for immunization and hot cooked meals (\u3c 10%). Administrative data showed similar patterns of disruption and restoration. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service provision. Key adaptations made to provide services were delivering services to beneficiary homes (∼ 40%-90%), social distancing (80%), and using PPE (40%-50%) and telephones for communication (∼ 20%). On the demand side, service utilization reduced substantially (40-80 pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing the challenges of limited travel (30%), nonavailability of services (26%), and fear of catching the virus when leaving the house (22%) or meeting service providers (14%). CONCLUSIONS: COVID-19 disrupted the provision and use of health and nutrition services in Uttar Pradesh, India, despite adaptations to restore services. Strengthening logistical support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19

Specificity Matters: Unpacking Impact Pathways of Individual Interventions Within Bundled Packages Helps Interpret the Limited Impacts of a Maternal Nutrition Intervention in India

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 ANC (I-ANC) with standard ANC (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 (PIPs) and identified reasons for limited impacts of the A&T maternal nutrition intervention package. METHODS: We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 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 compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs\u27 knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of 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% compared with 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 was 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

Stories of Change in Nutrition: Lessons from a New Generation of Studies from Africa, Asia and Europe

How does nutrition improve? We need to understand better what drives both positive and negative change in different contexts, and what more can be done to reduce malnutrition. Since 2015, the Stories of Change in Nutrition studies have analysed and documented experiences in many different African and Asian countries, to foster empirically-grounded experiential learning across contexts. This article provides an overview of findings from 14 studies undertaken in nine countries in South Asia, sub-Saharan Africa, and Europe between 2017 and 2021. The studies used a combination of methods, including regression-decomposition analyses of national datasets to assess determinants of nutritional change; policy process and food environment analyses; and community-level research assessing attitudes to change. This article takes a narrative synthesis approach to identify key themes across the studies, paying particular attention to multisectoral determinants, changes in the food environment, the role of structural factors (including longstanding social inequities), and changes in political commitment, cross-sectoral coherence and capacity. Given the inherent multisectoral nature of nutrition, many countries are experimenting with different models of ensuring coherence across sectors that are captured in this body of work. The relative immaturity of the policy sector in dealing with issues such as obesity and overweight, and associated influences in the wider food environment, adds a further challenge. To address these interrelated issues, policy must simultaneously tackle nutrition’s upstream (social/economic/equity) and downstream (health and dietary) determinants. Studies synthesised here provide empirically-driven inspiration for action.Bill and Melinda Gates Foundation (BMGF) Grant No. OPP1170621