Rasmi Avula

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.

Predictors of Essential Health and Nutrition Service Delivery in Bihar, India: Results From Household and Frontline Worker Surveys

Only about 35% of sample households reported receiving immunization, food supplements, pregnancy care information, or nutrition information. Monetary incentives for such product-oriented services as immunization improved performance and may have spillover effects for information-oriented services. Immunization day events and good frontline worker recordkeeping also improved service delivery. Only about 35% of sample households reported receiving immunization, food supplements, pregnancy care information, or nutrition information. Monetary incentives for such product-oriented services as immunization improved performance and may have spillover effects for information-oriented services. Immunization day events and good frontline worker recordkeeping also improved service delivery. Background: In Bihar, India, coverage of essential health and nutrition interventions is low. These interventions are provided by 2 national programs—the Integrated Child Development Services (ICDS) and Health/National Rural Health Mission (NRHM)—through Anganwadi workers (AWWs) and Accredited Social Health Activists (ASHAs), respectively. Little is known, however, about factors that predict effective service delivery by these frontline workers (FLWs) or receipt of services by households. This study examined the predictors of use of 4 services: (1) immunization information and services, (2) food supplements, (3) pregnancy care information, and (4) general nutrition information. Methods: Data are from a 2012 cross-sectional survey of 6,002 households in 400 randomly selected villages in 1 district of Bihar state, as well as an integrated survey of 377 AWWs and 382 ASHAs from the same villages. For each of the 4 service delivery outcomes, logistic regression models were specified using a combination of variables hypothesized to be supply- and demand-side drivers of service utilization. Results: About 35% of households reported receiving any of the 4 services. Monetary immunization incentives for AWWs (OR = 1.55, CI = 1.02–2.36) and above-median household head education (OR = 1.39, CI = 1.05–1.82) were statistically significant predictors of household receipt of immunization services. Higher household socioeconomic status was associated with significantly lower odds of receiving food supplements (OR = 0.87, CI = 0.79–0.96). ASHAs receiving incentives for institutional delivery (OR = 1.52, CI = 0.99–2.33) was marginally associated with higher odds of receiving pregnancy care information, and ASHAs who maintained records of pregnant women was significantly associated with households receiving such information (OR = 2.25, CI = 1.07–4.74). AWWs receiving immunization incentives was associated with significantly higher odds of households receiving general nutrition information (OR = 1.92, CI = 1.08–3.41), suggesting a large spillover effect of incentives from product- to information-oriented services. Conclusion: Product-oriented incentives affect delivery of both product- and information-oriented services, although household factors are also important. In India, existing government programs can mitigate supply- and demand-side constraints to receiving essential interventions by optimizing existing incentives for FLWs in national programs, helping FLWs better organize their work, and raising awareness among groups who are less likely to access services.

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

BackgroundExperience-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.ResultsOut 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.ConclusionsAn 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.

Reducing stunting in India: what investments are needed?

India has among the highest rates of child malnutrition rates in the world, but these rates have been declining rapidly during the past decade. Between 2006 and 2014, stunting rates for children under five in India have declined from 48 to 38% (Global Nutrition Report, 2014). Despite this progress, child undernutrition rates in India are among the highest in the world, with nearly one-half of all children under 3 years of age being either underweight or stunted. India is still home to over 40 million stunted children and 17 million wasted children (Global Nutrition Report, 2014). In addition, the rates of decline have been highly variable across India’s states. Some states, including Arunachal Pradesh, Mizoram and Delhi, had large rates of reduction in stunting, but overall levels of undernutrition remained high because of high baseline rates. Meanwhile, in Uttar Pradesh, Jammu and Kashmir, Manipur and Jharkhand the situation has not changed significantly (Raykar et al., 2015). Similar variability is observed in the prevalence of anaemia rates as well, which range from 38% in Goa to 78% in Bihar (IIPS & Macro International, International Institute for Population Sciences (IIPS) and Macro International, 2007). Global evidence shows that childmalnutrition is only weakly correlated with income. In fact, a quarter of Indian children from the top income quintile were stunted in 2006. Stunting is a marker for poor environmental, maternal and child factors, including poor sanitation, intrauterine growth restriction, micronutrient deficiencies, and sub-optimal infant and young child feeding practices. Current global recommendations for achieving 20% reduction in stunting and 61% reduction in severe wasting include delivery of a set of nutrition-specific interventions at 90% coverage level (Bhutta et al., 2013). These interventions span the continuum of care and include food and micronutrient supplements before and during pregnancy, counselling for initiation of breastfeeding and food and micronutrient supplementation formothers in the newborn period and breastfeeding counselling, food and micronutrient supplementation along with routine immunization for the under five children (Fig. 1). Available data indicate that less than 50% of mothers and children in India are exposed to a majority of these interventions. The shortfall is greater for iron folic acid supplementation, food supplementation and minimum diet diversity, whereas exclusive breastfeeding and immunization have improved in recent years (Fig. 2).

Scaling-up interventions to improve infant and young child feeding in India: What will it take?

Abstract We assessed Indias readiness to deliver infant and young child feeding (IYCF) interventions by examining elements related to policy, implementation, financing, and evidence. We based our analysis on review of (a) nutrition policy guidance and program platforms, (b) published literature on interventions to improve IYCF in India, and (c) IYCF program models implemented between 2007 and 2012. We find that Indian policies are well aligned with global technical guidance on counselling interventions. However, guidelines for complementary food supplements (CFS) need to be reexamined. Two national programs with the operational infrastructure to deliver IYCF interventions offer great potential for scale, but more operational guidance, capacity, and monitoring are needed to actively support delivery of IYCF counselling at scale by available frontline workers. Many IYCF implementation efforts to date have experimented with approaches to improve breastfeeding and initiation of complementary feeding but not with improving diet diversity or the quality of food supplements. Financing is currently inadequate to deliver CFS at scale, and governance issues affect the quality and reach of CFS. Available evidence from Indian studies supports the use of counselling strategies to improve breastfeeding practices and initiation of complementary feeding, but limited evidence exists on improving full spectrum of IYCF practices and the impact and operational aspects of CFS in India. We conclude that India is well positioned to support the full spectrum of IYCF using existing policies and delivery platforms, but capacity, financing, and evidence gaps on critical areas of programming can limit impact at scale.

Understanding the geographical burden of stunting in India: A regression-decomposition analysis of district-level data from 2015-16

Abstract India accounts for approximately one third of the worlds total population of stunted preschoolers. Addressing global undernutrition, therefore, requires an understanding of the determinants of stunting across Indias diverse states and districts. We created a district‐level aggregate data set from the recently released 2015–2016 National and Family Health Survey, which covered 601,509 households in 640 districts. We used mapping and descriptive analyses to understand spatial differences in distribution of stunting. We then used population‐weighted regressions to identify stunting determinants and regression‐based decompositions to explain differences between high‐ and low‐stunting districts across India. Stunting prevalence is high (38.4%) and varies considerably across districts (range: 12.4% to 65.1%), with 239 of the 640 districts have stunting levels above 40% and 202 have prevalence of 30–40%. High‐stunting districts are heavily clustered in the north and centre of the country. Differences in stunting prevalence between low and high burden districts were explained by differences in womens low body mass index (19% of the difference), education (12%), childrens adequate diet (9%), assets (7%), open defecation (7%), age at marriage (7%), antenatal care (6%), and household size (5%). The decomposition models explained 71% of the observed difference in stunting prevalence. Our findings emphasize the variability in stunting across India, reinforce the multifactorial determinants of stunting, and highlight that interdistrict differences in stunting are strongly explained by a multitude of economic, health, hygiene, and demographic factors. A nationwide focus for stunting prevention is required, while addressing critical determinants district‐by‐district to reduce inequalities and prevalence of childhood stunting.

Trends and drivers of change in the prevalence of anaemia among 1 million women and children in India, 2006 to 2016

Introduction India carries the largest burden of anaemia globally. Progress to reduce anaemia has been slow despite substantial economic growth and 50 years of programmatic efforts. Identification of the factors that contribute to anaemia reductions is needed to accelerate progress. We examined changes in haemoglobin (Hb) and anaemia among women and children in India from 2006 to 2016 and identified drivers of changes in these outcomes over time. Methods We used two rounds of National Family Health Survey data collected in 2005–2006 and 2015–2016 (n=245 346 children 6–59 months; 37 165 pregnant women (PW) 15–49 years; 760 460 non-pregnant women (NPW) 15–49 years). We first examined trends in Hb and anaemia, and changes in 30 selected variables (including immediate and underlying determinants, and nutrition and health interventions (NHIs)). We identified drivers of Hb and anaemia using multivariate regression and estimated their contribution to changes in these outcomes over time using regression-based decomposition. Results Hb and anaemia improved significantly between 2006 and 2016 in children (4.5  g/L and 11 percentage points (pp), respectively) and PW (3.2  g/L and 7.6 pp), but not in NPW. Despite these changes, anaemia is still very high (>50%) and progress varied considerably by state (−33 pp to +16 pp). Most immediate and underlying determinants, and NHIs improved significantly over time. Changes among a set of drivers common to children and PW accounted for the changes in Hb; these included maternal schooling (children, 10%; PW, 24%), coverage of NHIs (children, 18%; PW, 7%), socioeconomic status (children, 7%; PW, 17%), sanitation (children, 3%; PW, 9%), and meat and fish consumption (children, 3%; PW, 1%). The decomposition models moderately explained Hb changes over time (children, 49%; PW, 66%). Conclusions Multiple common drivers have contributed to the anaemia changes among children and pregnant women in India. Further improvements in these drivers can have population-level effects by simultaneously influencing both maternal and child anaemia.

Can conditional cash transfers improve the uptake of nutrition interventions and household food security? Evidence from Odisha’s Mamata scheme

There is considerable global evidence on the effectiveness of cash transfers in improving health and nutrition outcomes; however, the evidence from South Asia, particularly India, is limited. In the context of India where more than a third of children are undernourished, and where there is considerable under-utilization of health and nutrition interventions, it is opportune to investigate the impact of cash transfer programs on the use of interventions. We study one conditional cash transfer program, Mamata scheme, implemented in the state of Odisha, in India that targeted pregnant and lactating women. Using survey data on 1161 households from three districts in the state of Odisha, we examine the effect of the scheme on eight outcomes: 1) pregnancy registration; 2) receipt of antenatal services; 3) receipt of iron and folic acid (IFA) tablets; 4) exposure to counseling during pregnancy; 5) exposure to postnatal counseling; 6) exclusive breastfeeding; 7) full immunization; and 8) household food security. We conduct regression analyses and correct for endogeneity using nearest-neighbor matching and inverse-probability weighting models. We find that the receipt of payments from the Mamata scheme is associated with a 5 percentage point (pp) increase in the likelihood of receiving antenatal services, a 10 pp increase in the likelihood of receiving IFA tablets, and a decline of 0.84 on the Household Food Insecurity Access Scale. These results provide the first quantitative estimates of effects associated with the Mamata scheme, which can inform the design of government policies related to conditional cash transfers.

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

BackgroundConvergence 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.MethodsSemi-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.ResultsClose 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.ConclusionsCongruent 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.

Education and work incentives for frontline workers and household socioeconomic status influence delivery of health and nutrition interventions in Bihar, India (624.5)

GABA and its synthesising enzyme, glutamate decarboxylase, have been detected in the rat kidney [1–2]. GABA has also been found in human plasma and urine [3–4] and most recently, a renoprotective role for GABA has been suggested [5]. We are systematically investigating functional roles for GABA and glutamate in the mammalian kidney. Contractile pericytes regulate vasa recta diameter in response to a number of endogenous vasoactive agents and in doing so regulate medullary blood flow (MBF) [6]. We have utilised the live kidney slice model [6] to demonstrate GABA-mediated constriction of vasa recta that was significantly greater at pericyte sites than at non-pericyte sites (p< 0.01). Conversely, the GABA substrate glutamate (100 ?M) caused a significantly greater vasodilation of vasa recta at pericyte sites compared to non-pericyte sites (p< 0.05). Data presented here identifies a novel role for GABA and glutamate in pericyte-mediated regulation of vasa recta diameter and thus MBF.Obesity frequently associates with chronic inflammatory diseases, including type 2 diabetes. In this study, a combination of a protein hydrolysate, LCPUFAs and a probiotic strain was investigated on the development of high fat diet -induced diabetic risk factors and complications in LDLr-/-.Leiden mice. Male LDLr-/-.Leiden mice at 12 wks of age received a high fat diet (HFD) for 21 wks with or without a combination of an extensive casein hydrolysate, docosahexaenoic acid (DHA), arachidonic acid (ARA), and Lactobacillus Rhamnosus GG (LGG). Both HFD and intervention diet were isocaloric and casein from HFD was replaced with casein hydrolysate in the test diets. The addition of DHA/ARA in the test diets was controlled for in the HFD. Moreover, a PBS gavage control group was included to control for potential effects of LGG gavage. There were significant beneficial effects of the hydrolysate/ARA/DHA/LGG composition versus the HFD control group including reduced body weight gain, lower plasma levels of insulin, cholesterol and triglycerides, lower systemic inflammation, improved adipose tissue quality and mass, and improved kidney and liver function. In a follow up study, evaluating the individual components of the test formulation, some of the outcomes were attributable to the hydrolysate or LGG. A combination of an extensive casein hydrolysate, ARA, DHA and LGG reduces the detrimental effects of HFD on the development of obesity and its metabolic complications. Main risk factors for the metabolic syndrome such as adipose tissue and chronic inflammation were markedly reduced which could provide a rationale for the beneficial effects observed.OBJECTIVETo evaluate the impact of a mobile phone SMS text message intervention on the exclusiveness of breastfeeding (EBF) in infants 0–6 months. METHODSA two-arm parallel randomized controlled tr...