Nutrition-sensitive value chains from a smallholder perspective: A framework for project design

"The Alliance of Bioversity International and the International Center for Tropical Agriculture (CIAT) gratefully acknowledges permission from IFAD to re-publish that work as an Alliance Working Paper, with updated acknowledgements, author information and information on additional resources.

Hunger and learning : evidence on the costs and effectiveness of providing food through schools in food-insecure areas

Globally, over the last decade primary school access has improved significantly. Yet challenges remain: 67 million primary school-aged children are not in school. Poor nutrition and health among schoolchildren are important barriers in achieving education-for-all goals. School feeding is a popular intervention supporting the education, health and nutrition of children in food-insecure settings. However, school feeding programmes are complex, involving a broad range of stakeholders across different sectors and implementation levels. This thesis is aimed at providing evidence to support policy-makers in managing trade-offs among alternative targeting approaches, feeding modalities, and costs. This work is also aimed at building an evidence-based framework to guide Governments in managing the inherent complexity of school feeding interventions. The thesis includes an analysis of a natural experiment involving survey data from 32 countries across sub-Saharan Africa that suggested that school feeding increased enrolment by 10 percent. Enrolment changes varied by modality and gender, with onsite meals having stronger effects in the first year of treatment in lower grades, and onsite combined with take-home rations being effective post-year 1, particularly for girls. Expenditures across 62 countries indicated considerable differences in costs across modalities, ranging from $23 USD for fortified biscuits to$75 USD for take-home rations. This raises important questions of cost-effectiveness and sustainability, also in terms of school-level costs not normally captured in programme expenditures. Findings also suggest that school level costs are substantive, and are a considerable overhead, considering that these costs are generally borne by food-insecure communities. The thesis also highlights that scaling-up school feeding requires significant financing, on average equal to 40 percent of primary education costs. Despite these opportunity costs there is strong buy-in on school feeding from governments in sub-Saharan Africa. The implications of this thesis also suggest that the complexity of school feeding as an intervention has perhaps been underestimated by policymakers. Strengthening the evidence linking outcomes to the design of school feeding and to the quality of the service delivery, including the trade-offs between implementation modalities, remains a critical area of future research. This thesis provides both a foundation and a step towards answering these complex questions in a comparable and meaningful way

Improving community development by linking agriculture, nutrition and education: design of a randomised trial of "home-grown" school feeding in Mali.

BACKGROUND: Providing food through schools has well documented effects in terms of the education, health and nutrition of school children. However, there is limited evidence in terms of the benefits of providing a reliable market for small-holder farmers through "home-grown" school feeding approaches. This study aims to evaluate the impact of school feeding programmes sourced from small-holder farmers on small-holder food security, as well as on school children's education, health and nutrition in Mali. In addition, this study will examine the links between social accountability and programme performance. DESIGN: This is a field experiment planned around the scale-up of the national school feeding programme, involving 116 primary schools in 58 communities in food insecure areas of Mali. The randomly assigned interventions are: 1) a school feeding programme group, including schools and villages where the standard government programme is implemented; 2) a "home-grown" school feeding and social accountability group, including schools and villages where the programme is implemented in addition to training of community based organisations and local government; and 3) the control group, including schools and household from villages where the intervention will be delayed by at least two years, preferably without informing schools and households. Primary outcomes include small-holder farmer income, school participation and learning, and community involvement in the programme. Other outcomes include nutritional status and diet-diversity. The evaluation will follow a mixed method approach, including household, school and village level surveys as well as focus group discussions with small-holder farmers, school children, parents and community members. The impact evaluation will be incorporated within the national monitoring and evaluation (M&E) system strengthening activities that are currently underway in Mali. Baselines surveys are planned for 2012. A monthly process monitoring visits, spot checks and quarterly reporting will be undertaken as part of the regular programme monitoring activities. Evaluation surveys are planned for 2014. DISCUSSION: National governments in sub-Saharan Africa have demonstrated strong leadership in the response to the recent food and financial crises by scaling-up school feeding programmes. "Home-grown" school feeding programmes have the potential to link the increased demand for school feeding goods and services to community-based stakeholders, including small-holder farmers and women's groups. Alongside assessing the more traditional benefits to school children, this evaluation will be the first to examine the impact of linking school food service provision to small-holder farmer income, as well as the link between community level engagement and programme performance. TRIAL REGISTRATION: ISRCTN76705891

Trends and Factors Associated with the Nutritional Status of Adolescent Girls in Ghana:A Secondary Analysis of the 2003-2014 Ghana Demographic and Health Survey (GDHS) Data

Objective: We examined the trends over time and the factors associated with malnutrition among adolescent girls in Ghana. Design: Cross-sectional analysis from 3 nationwide Ghana Demographic and Health Surveys conducted in 2003 (n 983), 2008 (n 955) and 2014 (n 857). We used Cox proportional hazard models with sample weighting to model the prevalence ratio (PR) of malnutrition. Setting: Countrywide, covering rural and urban areas in Ghana. Participants: Non-pregnant adolescent girls aged 15–19 years. Results: Compared with 2003, thinness declined marginally (PR 0·88 (95 % CI 0·45, 1·73)) in 2008 and in 2014 (PR 0·71 (95 % CI 0·38, 1·56)). Stunting declined marginally by 19 % in 2008 (PR 0·81 (95 % CI 0·59, 1·12)), flattening out in 2014 (PR 0·81 (95 % CI 0·57, 1·17)). We found an increasing trend of overweight/obesity with the PR peaking in 2014 (PR 1·39 (95 % CI 1·02, 1·88)) compared to 2003. The anaemia prevalence remained severe without a clear trend. A low level of education of the adolescent girl was positively associated with stunting. Increasing age was positively associated with stunting but inversely associated with thinness and anaemia. Girls who ever bore a child were more likely to be anaemic compared to those who never did. A lower level of household wealth and a unit increase in household size was negatively associated with overweight/obesity. Urban dwelling girls were less likely to be stunted. Conclusions: The stagnant burden of under-nutrition and rising over-nutrition emphasise the need for double-duty actions to tackle malnutrition in all its forms in Ghanaian adolescent girls

Malnutrition, Hypertension Risk, and Correlates:An Analysis of the 2014 Ghana Demographic and Health Survey Data for 15–19 Years Adolescent Boys and Girls

The sex differences in malnutrition and hypertension during adolescence is largely inconclusive. There is also a paucity of data on the sex-specific correlates of malnutrition and hypertension for adolescents. Hence, this study aimed to assess the association between malnutrition, pre-hypertension/hypertension (PHH) and sex among adolescents. The study also aimed to determine and contrast the factors associated with these risks in Ghana. We analysed data of non-pregnant adolescent girls (n = 857) and adolescent boys (n = 870) aged 15–19 years from the 2014 Ghana Demographic and Health Survey (DHS). We modelled the prevalence risk ratio (PRR) of malnutrition and PHH using Cox proportional hazard models. Compared to adolescent girls, boys were more than twice likely to be stunted (PRR = 2.58, 95% C.I (1.77, 3.76)) and underweight (PRR = 2.67, 95% C.I (1.41, 5.09)) but less likely to be overweight/obese (PRR = 0.85, 95% C.I (0.08, 0.29)). Boys were also about twice likely to have PHH (PRR = 1.96, 95% C.I (1.47, 2.59)) compared to their female peers. Girls were more at risk of the detrimental effects of poor education on stunting and PHH. Empowerment index while protective of stunting for girls (PRR = 0.82, 95% C.I (0.67, 0.99)) also increased their risk of overweight/obesity (PRR = 1.31, 95% C.I (1.02, 1.68)). A higher household wealth index (HWI) increased the risk of overweight/obesity for adolescent girls but was protective of stunting and PHH for adolescent boys. Improvement in household water, hygiene, and sanitation (WASH) reduced the risk of stunting by 15% for adolescent boys. Overall, our findings suggest a double-burden of malnutrition with an up-coming non-communicable disease burden for adolescents in Ghana. Our indings may also be highlighting the need to target adolescent boys alongside girls in nutrition and health intervention programmes.</p

A School Meals Program Implemented at Scale in Ghana Increases Height-for-Age during Midchildhood in Girls and in Children from Poor Households: A Cluster Randomized Trial

Attention to nutrition during all phases of child and adolescent development is necessary to ensure healthy physical growth and to protect investments made earlier in life. Leveraging school meals programs as platforms to scale-up nutrition interventions is relevant as programs function in nearly every country in the world. The aim of this study was to evaluate the impact of a large-scale school meals program in Ghana on school-age children's anthropometry indicators

Improving child nutrition and development through community-based childcare centres in Malawi - The NEEP-IE study: study protocol for a randomised controlled trial

Abstract Background The Nutrition Embedded Evaluation Programme Impact Evaluation (NEEP-IE) study is a cluster randomised controlled trial designed to evaluate the impact of a childcare centre-based integrated nutritional and agricultural intervention on the diets, nutrition and development of young children in Malawi. The intervention includes activities to improve nutritious food production and training/behaviour-change communication to improve food intake, care and hygiene practices. This paper presents the rationale and study design for this randomised control trial. Methods Sixty community-based childcare centres (CBCCs) in rural communities around Zomba district, Malawi, were randomised to either (1) a control group where children were attending CBCCs supported by Save the Children’s Early Childhood Health and Development (ECD) programme, or (2) an intervention group where nutritional and agricultural support activities were provided alongside the routine provision of the Save the Children’s ECD programme. Primary outcomes at child level include dietary intake (measured through 24-h recall), whilst secondary outcomes include child development (Malawi Development Assessment Tool (MDAT)) and nutritional status (anthropometric measurements). At household level, primary outcomes include smallholder farmer production output and crop-mix (recall of last production season). Intermediate outcomes along theorised agricultural and nutritional pathways were measured. During this trial, we will follow a mixed-methods approach and undertake child-, household-, CBCC- and market-level surveys and assessments as well as in-depth interviews and focus group discussions with project stakeholders. Discussion Assessing the simultaneous impact of preschool meals on diets, nutrition, child development and agriculture is a complex undertaking. This study is the first to explicitly examine, from a food systems perspective, the impact of a preschool meals programme on dietary choices, alongside outcomes in the nutritional, child development and agricultural domains. The findings of this evaluation will provide evidence to support policymakers in the scale-up of national programmes. Trial registration ISRCTN registry, ID: ISRCTN96497560 . Registered on 21 September 2016

The Role of Health in Education and Human Capital: Why an Integrated Approach to School Health Could Make a Difference in the Futures of Schoolchildren in Low-Income Countries.

Healthy students learn better, yet most current investments in schoolchildren focus on education and learning while largely neglecting the health of the learner. Some school-based interventions, such as school feeding and deworming, are already successfully targeted at this age-group, but the efficiency and cost-effectiveness of such programs could be greatly enhanced by better integrated delivery alongside other priority health interventions. A symposium at the society's 68th annual meeting launched a process to explore how integrated delivery of school-based interventions can address prevalent health conditions in school-age children

Understanding modifiable caregiver factors contributing to child development among young children in rural Malawi

This study examined modifiable caregiver factors influencing child development in Malawi using baseline data from 1,021 mothers and their children <2 years of age participating in a cluster‐randomized controlled trial implemented in rural Malawi (2022–2025). We fit an evidence‐based theoretical model using structural equation modelling examining four caregiver factors: (1) diet diversity (sum of food groups consumed in the past 24 h), (2) empowerment (assessed using the project‐level Women's Empowerment in Agriculture Index), (3) mental health (assessed using the Self‐Reported Questionnaire, SRQ‐20), and (4) stimulation (number of stimulation activities the mother engaged in the past 3 days). Child development was assessed using the Malawi Development Assessment Tool (norm‐referenced aggregate Z‐score). The model controlled for child, caregiver, and household socioeconomic characteristics. Results showed that caregiver dietary diversity was directly associated with higher child development scores (standardized coefficient 0.091 [95% CI 0.027, 0.153]) and lower SRQ‐20 scores −0.058 (−0.111, −0.006). Empowerment was directly associated with higher child development scores (0.071 [0.007, 0.133]), higher stimulation score (0.074 [0.013, 0.140]), higher dietary diversity (0.085 [0.016, 0.145]), and lower SRQ‐20 scores (−0.068 [−0.137, −0.002]). Further, higher empowerment was indirectly associated with improved child development through enhancement of caregiver dietary diversity, with an indirect effect of 0.008 (0.002, 0.018). These findings highlight the important role that caregiver diet and empowerment play in directly influencing child development and other aspects of caregiver well‐being. Interventions aimed at enhancing child development should consider these factors as potential targets to improve outcomes for children and caregivers