Alison Tumilowicz

Using ethnography in implementation research to improve nutrition interventions in populations.

Abstract ‘Implementation research in nutrition’ is an emerging area of study aimed at building evidence‐based knowledge and sound theory to design and implement programs that will effectively deliver nutrition interventions. This paper describes some of the basic features of ethnography and illustrates its applications in components of the implementation process. We review the central purpose of ethnography, which is to obtain the emic view – the insiders perspective – and how ethnography has historically interfaced with nutrition. We present examples of ethnographic studies in relation to an analytic framework of the implementation process, situating them with respect to landscape analysis, formative research, process evaluation and impact evaluation. These examples, conducted in various parts of the world by different investigators, demonstrate how ethnography provided important, often essential, insights that influenced programming decisions or explained programme outcomes. Key messages Designing, implementing and evaluating interventions requires knowledge about the populations and communities in which interventions are situated, including knowledge from the ‘emic’ (insiders) perspective. Obtaining emic perspectives and analysing them in relation to cultural, economic and structural features of social organisation in societies is a central purpose of ethnography. Ethnography is an essential aspect of implementation research in nutrition, as it provides important insights for making decisions about appropriate interventions and delivery platforms; determining how best to fit aspects of programme design and implementation into different environmental and cultural contexts; opening the ‘black box’ in interventions to understand how delivery and utilisation processes affect programme outcomes or impacts; and understanding how programme impacts were achieved, or not.

Gender perceptions predict sex differences in growth patterns of indigenous Guatemalan infants and young children.

ABSTRACT Background: Nearly one-half of Guatemalan children experience growth faltering, more so in indigenous than in nonindigenous children. Objectives: On the basis of ethnographic interviews in Totonicapán, Guatemala, which revealed differences in maternal perceptions about food needs in infant girls and boys, we predicted a cumulative sex difference in favor of girls that occurred at ∼6 mo of age and diminished markedly thereafter. We examined whether the predicted differences in age-sex patterns were observed in the village, replicated the examination nationally for indigenous children, and examined whether the pattern in nonindigenous children was different. Design: Ethnographic interviews (n = 24) in an indigenous village were conducted. Anthropometric measurements of the village children aged 0–35 mo (n = 119) were obtained. National-level growth patterns were analyzed for indigenous (n = 969) and nonindigenous (n = 1374) children aged 0–35 mo with the use of Demographic and Health Survey (DHS) data. Results: Mothers reported that, compared with female infants, male infants were hungrier, were not as satisfied with breastfeeding alone, and required earlier complementary feeding. An anthropometric analysis confirmed the prediction of healthier growth in indigenous girls than in indigenous boys throughout the first year of life, which resulted in a 2.98-cm height-for-age difference (HAD) between sexes in the village and a 1.61-cm HAD (P < 0.001) in the DHS data between 6 and 17 mo of age in favor of girls. In both data sets, the growth sex differences diminished in the second year of life (P < 0.05). No such pattern was seen in nonindigenous children. Conclusions: We propose that the differences in the HAD that first favor girls and then favor boys in the indigenous growth patterns are due to feeding patterns on the basis of gendered cultural perceptions. Circumstances that result in differential sex growth patterns need to be elucidated, in particular the favorable growth in girls in the first year of life.

Context-specific complementary feeding recommendations developed using Optifood could improve the diets of breast-fed infants and young children from diverse livelihood groups in northern Kenya

OBJECTIVE To formulate age- and context-specific complementary feeding recommendations (CFR) for infants and young children (IYC) and to compare the potential of filling population-level nutrient gaps using common sets of CFR across age groups. DESIGN Linear programming was used to develop CFR using locally available and acceptable foods based on livelihood- and age-group-specific dietary patterns observed through 24 h dietary recalls. Within each livelihood group, the nutrient potential of age-group-specific v. consolidated CFR across the three age groups was tested. SETTING Three food-insecure counties in northern Kenya; namely, settled communities from Isiolo (n 300), pastoralist communities from Marsabit (n 283) and agro-pastoralist communities from Turkana (n 299). SUBJECTS Breast-fed IYC aged 6-23 months (n 882). RESULTS Age-specific CFR could achieve adequacy for seven to nine of eleven modelled micronutrients, except among 12-23-month-old children in agro-pastoralist communities. Contribution of Fe, Zn and niacin remained low for most groups, and thiamin, vitamin B6 and folate for some groups. Age-group-consolidated CFR could not reach the same level of nutrient adequacy as age-specific sets among the settled and pastoralist communities. CONCLUSIONS Context- and age-specific CFR could ensure adequate levels of more modelled nutrients among settled and pastoralist IYC than among agro-pastoralist communities where use of nutrient-dense foods was limited. Adequacy of all eleven modelled micronutrients was not achievable and additional approaches to ensure adequate diets are required. Consolidated messages should be easier to implement as part of a behaviour change strategy; however, they would likely not achieve the same improvements in population-level dietary adequacy as age-specific CFR.

Executive summary for the Micronutrient Powders Consultation: Lessons Learned for Operational Guidance

Abstract Iron deficiency anaemia is estimated to be the leading cause of years lived with disability among children. Young childrens diets are often inadequate in iron and other micronutrients, and provision of essential vitamin and minerals has long been recommended. With the limited programmatic success of iron drop/syrup interventions, interest in micronutrient powders (MNP) has increased. MNP are a mixture of vitamins and minerals, enclosed in single‐dose sachets, which are stirred into a childs portion of food immediately before consumption. MNP are an efficacious intervention for reducing iron deficiency anaemia and filling important nutrient gaps in children 6–23 months of age. As of 2014, 50 countries have implemented MNP programmes including 9 at a national level. This paper provides an overview of a 3‐paper series, based on findings from the “Micronutrient Powders Consultation: Lessons Learned for Operational Guidance” held by the USAID‐funded Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project. The objectives of the Consultation were to identify and summarize the most recent MNP programme experiences and lessons learned for operationalizing MNP for young children and prioritize an implementation research agenda. The Consultation was composed of 3 working groups that used the following methods: deliberations among 49 MNP programme implementers and experts, a review of published and grey literature, questionnaires, and key informant interviews, described in this overview. The following articles summarize findings in 3 broad programme areas: planning, implementation, and continual programme improvement. The papers also outline priorities for implementation research to inform improved operationalization of MNP.

Using implementation research for evidence-based programme development: a case study from Kenya.

Abstract The few available studies of programme effectiveness in nutrition find that programmes are less effective than would be predicted from the efficacy trials that are the basis for evidence‐based programming. Some of these are due to gaps in utilisation within households. To a greater extent, these gaps can be attributed to problems in programme design and implementation. ‘Implementation research in nutrition’ is an emerging area of study aimed at addressing this problem, by building an evidence base and a sound theory to design and implement programmes that will effectively deliver nutrition interventions. The purpose of this supplement to Maternal & Child Nutrition is to contribute to this growing area of implementation research. The series of papers presented and the reflections for policymaking and programmes, combined with the reflections on the application of ethnography to this area of inquiry, illustrate the value of systematic research undertaken for the purpose of supporting the design of nutrition interventions that are appropriate for the specific populations in which they are undertaken.

Experiences and lessons learned for programme improvement of micronutrient powders interventions

Abstract Continual course correction during implementation of nutrition programmes is critical to address factors that might limit coverage and potential for impact. Programme improvement requires rigorous scientific inquiry to identify and address implementation pathways and the factors that affect them. Under the auspices of “The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance,” 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powder (MNP) interventions for young children. This paper focuses on how MNP interventions undertook key elements of programme improvement, specifically, the use of programme theory, monitoring, process evaluation, and supportive supervision. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that although much has been written and published about the use of monitoring and process evaluation to inform MNP interventions at small scale, there has been little formal documentation of lessons for the transition from pilot to scaled implementation. Supervision processes and experiences are not documented, and to our knowledge, there is no evidence of whether they have been effective to improve implementation. Improving the efficiency and effectiveness of interventions requires identification of critical indicators for detecting implementation challenges and drivers of impact, integration with existing programmes and systems, strengthened technical capacity, and financing for implementation of effective monitoring systems. Our understanding of programme improvement for MNP interventions is still incomplete, especially outside of the pilot stage, and we propose a set of implementation research questions that require further investigation.

Coverage and Consumption of Micronutrient Powders, Fortified Staples, and Iodized Salt Among Children Aged 6 to 23 Months in Selected Neighborhoods of Nairobi County, Kenya

Background: Intake of micronutrient-rich foods among children aged 6 to 23 months in Nairobi is low. Objective: This study aimed to assess existing coverage and utilization of micronutrient powders (MNPs), fortified staples, and iodized salt among children aged 6 to 23 months prior to implementation of an MNP program. Methods: A cross-sectional survey among caregivers of children aged 6 to 23 months (n = 618) was implemented in 7 neighborhoods within Nairobi County, representing the implementation area of the new MNP program. Results: Results for MNP coverage and utilization showed 28.5% of all caregivers were aware of MNP, 18.5% had ever received MNP for their child, and 10.8% had fed MNP to their child in the previous 7 days. Effective coverage (ie, the child had been given the MNP at least 3 times in the previous 7 days) was 5.8%. Effective coverage of infants and young children with poor feeding practices was significantly lower as compared to those with non-poor feeding practices (coverage ratio, 0.34; confidence interval, 0.12-0.70). Most households purchased iodized salt (96.9%), fortified oil (61.0%), and fortified maize flour (93.9%). An estimated 23.9% of vitamin A requirements of children (6-23 months) were provided from fortified oil and 50.7% of iron from fortified maize flour. Most households consumed processed milk (81%). Conclusion: Coverage of MNPs in the surveyed neighborhoods was low. Coverage of fortified salt, oil, and maize flour was high and provided significant amount of micronutrients to children. Processed milk has potential as a vehicle for food fortification.

Sensory Evaluation of Foods with Added Micronutrient Powder (MNP) “Taburia” to Assess Acceptability among Children Aged 6–24 Months and Their Caregivers in Indonesia

Although it is generally accepted that the addition of micronutrient powders (MNPs) to foods causes no or negligible changes to organoleptic properties, there are anecdotal reports of low acceptability of the MNP (locally known as “Taburia”) distributed in Indonesia. We hypothesized that the organoleptic properties of Taburia do not reduce the acceptability of foods if used as recommended. Acceptability of Taburia and a comparison MNP (MixMe™) were evaluated among 232 children aged 6–24 months and their caregivers. Both caregivers’ perceptions of child acceptance, and their own assessments of organoleptic qualities when added to rice porridge or meals commonly consumed by young children, were assessed. Changes to the organoleptic properties of foods mixed with Taburia and comparison MNP were reported by caregivers, even when following preparation instructions. Taburia was found to enhance texture, sweetness, saltiness, and umami taste, but was also perceived as slightly bitter. Ratings for overall appearance and taste did not differ between rice porridge, plain or with Taburia, but the overall taste of Taburia was preferred over comparison MNP (p = 0.012). Meals consumed by children were preferred without the addition of MNP (p < 0.001). We demonstrate that the addition of Taburia to foods, commonly consumed by Indonesian infants and young children, affects organoleptic properties of the foods, even when prepared according to recommendations. However, these changes are unlikely to be the cause of reported adherence problems in Indonesia. This needs to be taken into consideration for product development and communication strategies promoting adherence.

Improved Information and Educational Messages on Outer Packaging of Micronutrient Powders Distributed in Indonesia Increase Caregiver Knowledge and Adherence to Recommended Use

The objective of this study was to examine the influence of improved information and educational messages on outer packaging of a micronutrient powder (MNP), locally known as “Taburia”, on knowledge and adherence to recommended use. A community-based cluster randomized controlled trial was conducted among 1149 caregivers and their children aged 6–36 months. Caregiver–child dyads were randomized by their villages to receive 30 sachets of Taburia with the: (i) original outer packaging; (ii) improved outer packaging; or (iii) improved outer packaging combined with cooking demonstrations. Adherence to Taburia use was assessed through caregiver interviews and observation of unused sachets during home visits; “high” adherence was defined as consuming 13–17 sachets in the previous month. Data collection included surveys and focus groups discussions. The majority of caregivers (>80%) preferred the improved packaging because it was more attractive and contained more comprehensive information. Caregivers who received the improved packaging had better knowledge regarding the recommended use of Taburia (p < 0.001) and higher adherence with the prescribed use of Taburia (43% with “high” adherence) (p < 0.001) than those who received the original packaging (29% with “high” adherence). Caregivers who participated in cooking demonstrations generally had better knowledge regarding the benefits of Taburia and recommended use, but this did not lead to higher adherence to recommended use. “Underconsumption” of Taburia (≤7 sachets) was much less prevalent than “overconsumption” (≥23 sachets), and original packaging users were more likely to consume Taburia daily instead of every two days as recommended. We conclude that the design of the outer packaging and comprehensiveness of information provided are important influencers of recommended MNP use by caregivers.

A review of child stunting determinants in Indonesia

Abstract Child stunting reduction is the first of 6 goals in the Global Nutrition Targets for 2025 and a key indicator in the second Sustainable Development Goal of Zero Hunger. The prevalence of child stunting in Indonesia has remained high over the past decade, and at the national level is approximately 37%. It is unclear whether current approaches to reduce child stunting align with the scientific evidence in Indonesia. We use the World Health Organization conceptual framework on child stunting to review the available literature and identify what has been studied and can be concluded about the determinants of child stunting in Indonesia and where data gaps remain. Consistent evidence suggests nonexclusive breastfeeding for the first 6 months, low household socio‐economic status, premature birth, short birth length, and low maternal height and education are particularly important child stunting determinants in Indonesia. Children from households with both unimproved latrines and untreated drinking water are also at increased risk. Community and societal factors—particularly, poor access to health care and living in rural areas—have been repeatedly associated with child stunting. Published studies are lacking on how education; society and culture; agriculture and food systems; and water, sanitation, and the environment contribute to child stunting. This comprehensive synthesis of the available evidence on child stunting determinants in Indonesia outlines who are the most vulnerable to stunting, which interventions have been most successful, and what new research is needed to fill knowledge gaps.