Purnima Menon

Socio-economic differentials in child stunting are consistently larger in urban than rural areas

Iron deficiency is the world’s most common nutritional disorder and is predominantly responsible for anaemia in human populations. Its management and control involve iron supplementation and fortification of foods and, in developing countries, the control of parasitic infections as well. It is also important to formulate foodbased strategies to improve the bioavailability of dietary iron, for example, by promoting culturally acceptable changes in food choices, processing, and preservation. These require sound scientific data from nutritional research and the participation of women scientists who are familiar with the local and sociocultural preferences of the target communities. Research has shown that the major effects of processing on iron availability are associated with the separation, dehulling, and cooking procedures. The magnitude of losses varies with the food type and processing technique. Blanching and homogenization of vegetables may account for up to 28% and 40% of soluble iron loss, respectively. Moreover, the traditional practice of adding kanwa (an alkaline salt) to soften beans and to impart a green colour to vegetables during cooking results in reduced iron availability. In contrast, germination and fermentation have been shown to enhance the availability of iron from foods. Thus, traditional-food processing methods, such as fermentation, should be encouraged, actively promoted, and preserved.Urban-rural comparisons of childhood undernutrition suggest that urban populations are better-off than rural populations. However, these comparisons could mask the large differentials that exist among socioeconomic groups in urban areas. Data from the Demographic and Health Surveys (DHS) for 11 countries from three regions were used to test the hypothesis that intra-urban differentials in child stunting were greater than intra-rural differentials, and that the prevalence of stunting among the urban and the rural poor was equally high. A socioeconomic status (SES) index based on household assets, housing quality, and availability of services was created separately for rural and urban areas of each country, using principal components analysis. In most countries, stunting in the poorest urban quintile was almost on par with that of poor rural dwellers. Thus, malnutrition in urban areas continues to be of concern, and effective targeting of nutrition programs to the poorest segments of the urban population will be critical to their success and cost-effectiveness.

The politics of reducing malnutrition: building commitment and accelerating progress

In the past 5 years, political discourse about the challenge of undernutrition has increased substantially at national and international levels and has led to stated commitments from many national governments, international organisations, and donors. The Scaling Up Nutrition movement has both driven, and been driven by, this developing momentum. Harmonisation has increased among stakeholders, with regard to their understanding of the main causes of malnutrition and to the various options for addressing it. The main challenges are to enhance and expand the quality and coverage of nutrition-specific interventions, and to maximise the nutrition sensitivity of more distal interventions, such as agriculture, social protection, and water and sanitation. But a crucial third level of action exists, which relates to the environments and processes that underpin and shape political and policy processes. We focus on this neglected level. We address several fundamental questions: how can enabling environments and processes be cultivated, sustained, and ultimately translated into results on the ground? How has high-level political momentum been generated? What needs to happen to turn this momentum into results? How can we ensure that high-quality, well-resourced interventions for nutrition are available to those who need them, and that agriculture, social protection, and water and sanitation systems and programmes are proactively reoriented to support nutrition goals? We use a six-cell framework to discuss the ways in which three domains (knowledge and evidence, politics and governance, and capacity and resources) are pivotal to create and sustain political momentum, and to translate momentum into results in high-burden countries.

Child Development: Vulnerability and Resilience

Many of the challenges facing children now are a function of changing times, including increase in urbanization, political violence, changing family forms, and in some areas decreased supplies of adequate food. This review focuses particularly on those changes in which children are the victims and which induce new threats for them, rather than on problems such as child disability or mental illness. The outcome variables of interest in this paper are dimensions of childrens psychosocial development, including cognitive development, psychological adjustment and aggression, whereas the companion paper in this issue (Caldwell P., Child survival: vulnerability and resilience in adversity in the European past and the contemporary Third World, Soc. Sci. Med.) [1] focuses on physical aspects of childrens development. The risks that are hurdles in the process of development of a young child begin from conception and carry on into later life. To address them all would be impossible; thus, in order to do justice to the issues at hand, we have chosen those risks that, in our view, are important in a childs psychosocial development in developing countries. This paper will thus provide a discussion of the concepts of risk and resilience, then apply these concepts to the analysis of three examples of risk faced by children today: nutritional threats (e.g. malnutrition due to decline in breastfeeding); family dynamics and types of family forms (e.g. child fostering and non-traditional families); and experiences of violence (domestic or political). In each case, the same four questions will be addressed: what are the consequences of the risk factor for children, what are the etiologies and conditions of risk, are there any children who seem to cope with the risk factor successfully and what are some of the protective factors, and what interventions or programs would help support these children?

Age-based preventive targeting of food assistance and behaviour change and communication for reduction of childhood undernutrition in Haiti: a cluster randomised trial.

BACKGROUND Food-assisted maternal and child health and nutrition programmes usually target underweight children younger than 5 years of age. Previous evidence suggests that targeting nutrition interventions earlier in life, before children become undernourished, might be more effective for reduction of childhood undernutrition. METHODS We used a cluster randomised trial to compare two World Vision programmes for maternal and child health and nutrition, which included a behaviour change and communication component: a preventive model, targeting all children aged 6-23 months; and a recuperative model, targeting underweight (weight-for-age Z score <-2) children aged 6-60 months. Both models also targeted pregnant and lactating women. Clusters of communities (n=20) were paired on access to services and other factors and were randomly assigned to each model. Using two cross-sectional surveys (at baseline and 3 years later), we tested differences in undernutrition in children aged 12-41 months (roughly 1500 children per survey). Analyses were by intention to treat, both by pair-wise community-level comparisons and by child-level analyses adjusting for the clustering effect and child age and sex. This study is registered with ClinicalTrials.gov, number NCT00210418. FINDINGS There were no differences between programme groups at baseline. At follow-up, stunting, underweight, and wasting (using WHO 2006 reference data) were 4-6 percentage points lower in preventive than in recuperative communities; and mean anthropometric indicators were higher by +0.14 Z scores (height for age; p=0.07), and +0.24 Z scores (weight for age and weight for height; p<0.0001). The effect was greater in children exposed to the preventive programme for the full span between 6 and 23 months of age than in children exposed for shorter durations during this period. The quality of implementation did not differ between the two programmes; nor did use of services for maternal and child health and nutrition. INTERPRETATION The preventive programme was more effective for the reduction of childhood undernutrition than the traditional recuperative model.

Nutrition agenda setting, policy formulation and implementation: lessons from the Mainstreaming Nutrition Initiative

Undernutrition is the single largest contributor to the global burden of disease and can be addressed through a number of highly efficacious interventions. Undernutrition generally has not received commensurate attention in policy agendas at global and national levels, however, and implementing these efficacious interventions at a national scale has proven difficult. This paper reports on the findings from studies in Bangladesh, Bolivia, Guatemala, Peru and Vietnam which sought to identify the challenges in the policy process and ways to overcome them, notably with respect to commitment, agenda setting, policy formulation and implementation. Data were collected through participant observation, documents and interviews. Data collection, analysis and synthesis were guided by published conceptual frameworks for understanding malnutrition, commitment, agenda setting and implementation capacities. The experiences in these countries provide several insights for future efforts: (a) high-level political attention to nutrition can be generated in a number of ways, but the generation of political commitment and system commitment requires sustained efforts from policy entrepreneurs and champions; (b) mid-level actors from ministries and external partners had great difficulty translating political windows of opportunity for nutrition into concrete operational plans, due to capacity constraints, differing professional views of undernutrition and disagreements over interventions, ownership, roles and responsibilities; and (c) the pace and quality of implementation was severely constrained in most cases by weaknesses in human and organizational capacities from national to frontline levels. These findings deepen our understanding of the factors that can influence commitment, agenda setting, policy formulation and implementation. They also confirm and extend upon the growing recognition that the heavy investment to identify efficacious nutrition interventions is unlikely to reduce the burden of undernutrition unless or until these systemic capacity constraints are addressed, with an emphasis initially on strategic and management capacities.

Household Food Insecurity Is Associated with Higher Child Undernutrition in Bangladesh, Ethiopia, and Vietnam, but the Effect Is Not Mediated by Child Dietary Diversity

Household food insecurity (HFI) is a recognized underlying determinant of child undernutrition, but evidence of associations between HFI and child undernutrition is mixed. The purpose of this study was to investigate if HFI is associated with undernutrition in children aged 6-59.9 mo in Bangladesh (n = 2356), Ethiopia (n = 3422), and Vietnam (n = 3075) and if child dietary diversity (DD) mediated this effect. We used baseline survey data from the Alive & Thrive project. Logistic regression, adjusting for potential confounding factors, was used to determine the magnitude and significance of the association of HFI with stunting, underweight, and wasting. The mediating effect of child DD was tested by using a Sobel-Goodman mediation test. The prevalences of HFI were 66%, 40%, and 32% in Ethiopia, Vietnam, and Bangladesh, respectively. The prevalences of stunting, underweight, and wasting were higher in Bangladesh (47.1%, 43.7%, and 19.1%, respectively) and Ethiopia (50.7%, 27.5%, and 5.9%, respectively) than in Vietnam (20.7%, 15.8%, and 5%, respectively). In the adjusted models, the odds of being stunted or underweight were significantly higher for children in severely food-insecure households in Bangladesh (stunting OR: 1.36; 95% CI: 1.05, 1.76; underweight OR: 1.28; 95% CI: 0.99, 1.65) and Ethiopia (stunting OR: 1.48; 95% CI: 1.09, 2.00; underweight OR: 1.68; 95% CI: 1.22, 2.30) and in moderately food-insecure households in Vietnam (stunting OR: 1.39; 95% CI: 1.16, 1.65; underweight OR: 1.69; 95% CI: 1.28, 2.23). HFI was significantly associated with wasting in Bangladesh where close to 1 in 5 children demonstrated wasting. Child DD did not mediate the relation between HFI and undernutrition in any of the countries. Further research is recommended to investigate potential mediators in this pathway.

From research to program design: Use of formative research in Haiti to develop a behavior change communication program to prevent malnutrition: International Food Policy Research Institute (IFPRI) Discussion Paper 170 (December 2003).

For children to grow normally there are many parental caregiving behaviors related to food that are essential to ensuring adequate nutritional intake: obtaining and selecting foods that meet nutritional requirements preparing them safely and in a form that is appropriate for the childs age and feeding them in a manner that encourages adequate intake. To engage in these critical caregiving behaviors parents need access to the foods their children require; fuel water and other materials to prepare and preserve these foods; and the time and energy to carry out the activities. They also need knowledge. These are essential underpinnings of nutrition and health-giving behaviors and the prerequisites for child health and well-being. Because caregiving behaviors are the links between resources knowledge and child health programs that seek to improve child health and nutrition must by definition change caregiving behaviors. Programs that aim to improve child outcomes by improving childcare behaviors are collectively referred to as behavior change communication (BCC) programs. (excerpt)

The Nutrition Policy Process: The Role of Strategic Capacity in Advancing National Nutrition Agendas:

Undernutrition is the single largest contributor to the burden of disease in developing countries and has documented effects on social and economic development, yet progress in reducing undernutrition remains slow. This paper identifies the range of factors that have influenced the nutrition agenda in developing countries, in order to inform the implementation of three major global initiatives related to undernutrition. Data sources include interviews with nutrition practitioners at the national and international level, written accounts from six African countries, and observations of the policy process in five countries. Data were thematically coded to identify recurrent factors that facilitated or inhibited progress in addressing undernutrition. The data reveal the following: First, societal conditions and catalytic events pose a variety of challenges and opportunities to enlarge and shape the nutrition agenda. Some countries have been successful in using such opportunities, while others have been less successful and there have been some unintended consequences. Second, disagreements over interventions and strategies are an almost universal feature of the nutrition policy process, occur primarily among mid-level actors rather than among politicians or senior administrators, and are primarily the product of structural factors such as organizational mandates, interests, and differences in professional perspectives. Third, many of these structural factors can be molded, aligned, and/or circumvented through strategic action on the part of the mid-level actors to strengthen movement on the nutrition agenda. This evidence that strategic action can redirect and/or overcome the effects of structural factors has important implications for future efforts to advance the nutrition agenda.

Maternal and Child Dietary Diversity Are Associated in Bangladesh, Vietnam, and Ethiopia

Dietary diversity (DD) reflects micronutrient adequacy of the diet and is associated with better child growth. Emerging evidence suggests that maternal and child DD are associated. This could have measurement and programmatic implications. Data on mother-child (6-24 mo) dyads in Bangladesh, Vietnam, and Ethiopia were used to examine agreement and association between maternal and child DD and identify determinants of maternal and child DD. The DD scores were derived from a 24-h recall of intake of foods from 7 groups. Multivariable regression was used to examine for the association, adjusting for covariates at child, maternal, and household levels. There was mother/child agreement for staple foods across the 3 countries but disagreement for flesh foods, dairy, fruits, and vegetables. A strong positive association was seen between maternal and child DD; a difference of one food group in mothers consumption was associated with a difference of 0.29, 033, and 0.24 groups in childs consumption in Bangladesh, Vietnam, and Ethiopia, respectively. The odds of achieving minimum DD (≥4 groups) were higher among children whose mother consumed 4 groups compared with ≤3 food groups [Bangladesh: OR = 2.73 (95% CI: 1.76, 4.25); Vietnam: OR = 2.30 (95% CI: 1.45, 3.43); Ethiopia: OR = 5.11 (95% CI: 2.36, 11.04)]. Maternal education was associated with both maternal and child DD; food security and socioeconomic status were associated only with maternal DD. Given the disagreements in mother/child intake for nutrient-rich foods, both maternal and child DD should be measured in surveys. Behavior change communications should focus on promoting both mother and child DD and encouraging mothers to feed young children all family foods, not just a subset.

Learning How Programs Achieve their Impact: Embedding Theory-Driven Process Evaluation and Other Program Learning Mechanisms in Alive & Thrive:

Background Traditionally, impact evaluations have focused primarily on answering what impact programs or interventions have, with less attention to how or why impacts are achieved, or not achieved. The Alive & Thrive initiative, a 6-year program that aims to improve infant and young child feeding (IYCF) practices and reduce stunting in Bangladesh, Ethiopia, and Vietnam, has a specific objective to generate learning on how to achieve and replicate Alive & Thrives impact. Objective In Alive & Thrive, theory-driven process evaluation methods are the primary mechanism through which data are generated to address this objective. This paper focuses on the different methodological approaches that are being utilized, to answer the critical “how”; questions, and to generate information on the many processes and pathways to program impact. Methods We identify four key principles in our methodological approach that guides all process evaluation activities: 1) developing detailed program impact pathway (PIP) models, 2) linking data collection to PIPs utilizing mixed methods and multiple data sources, 3) linking evaluation activities with program implementation timelines, and 4) engaging with the program implementation and management teams. Results Beginning with the launch of the program, we outline the steps that have been taken in the design and implementation of the process evaluations of Alive & Thrive, and provide examples of how these steps have been operationalized in different country contexts. Conclusions This theory-driven and country- and component-specific approach, centered on careful analysis of PIPs, is intended to generate information on implementation and utilization pathways of Alive & Thrives interventions, thereby answering the questions of how impacts are achieved, or why not. This evaluation approach is not without challenges, and we highlight some of these key challenges.