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Tumilowicz A, McClafferty B, Neufeld LM, Hotz C, Pelto GH. Using implementation research for evidence-based programme development: a case study from Kenya. MATERNAL AND CHILD NUTRITION 2016; 11 Suppl 3:1-5. [PMID: 26778798 PMCID: PMC5066633 DOI: 10.1111/mcn.12242] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 09/28/2015] [Accepted: 09/30/2015] [Indexed: 01/22/2023]
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. © 2015 Blackwell Publishing Ltd
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Affiliation(s)
| | | | | | - Christine Hotz
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Gretel H Pelto
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
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Mbuya MNN, Jones AD, Ntozini R, Humphrey JH, Moulton LH, Stoltzfus RJ, Maluccio JA. Theory-Driven Process Evaluation of the SHINE Trial Using a Program Impact Pathway Approach. Clin Infect Dis 2016; 61 Suppl 7:S752-8. [PMID: 26602304 PMCID: PMC4657588 DOI: 10.1093/cid/civ716] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Two reasons for the lack of success of programs or interventions are poor alignment of interventions with the causes of the problem targeted by the intervention, leading to poor efficacy (theory failure), and failure to implement interventions as designed (program failure). These failures are important for both public health programs and randomized trials. In the Sanitation Hygiene and Infant Nutrition Efficacy (SHINE) Trial, we utilize the program impact pathway (PIP) approach to track intervention implementation and behavior uptake. In this article, we present the SHINE PIP including definitions and measurements of key mediating domains, and discuss the implications of this approach for randomized trials. Operationally, the PIP can be used for monitoring and strengthening intervention delivery, facilitating course-correction at various stages of implementation. Analytically, the PIP can facilitate a richer understanding of the mediating and modifying determinants of intervention impact than would be possible from an intention-to-treat analysis alone.
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Affiliation(s)
- Mduduzi N N Mbuya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe Division of Nutritional Sciences, Cornell University, Ithaca, New York Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andrew D Jones
- School of Public Health, University of Michigan, Ann Arbor
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jean H Humphrey
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lawrence H Moulton
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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De-Regil LM, Harding KB, Roche ML. Preconceptional Nutrition Interventions for Adolescent Girls and Adult Women: Global Guidelines and Gaps in Evidence and Policy with Emphasis on Micronutrients. J Nutr 2016; 146:1461S-70S. [PMID: 27281812 DOI: 10.3945/jn.115.223487] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 04/19/2016] [Indexed: 12/15/2022] Open
Abstract
Much of the global nutrition efforts in recent years have been focused on improving the nutritional status of children during the window of the first 1000 d of life, from conception to 2 y of age. However, as the world transitions from the Millennium Development Goals to the Sustainable Development Goals, women's and adolescent girls' overall health and well-being are being placed at the center of the global agenda. It is also increasingly recognized that a woman's nutritional status before pregnancy affects maternal and child outcomes and thus needs to be improved to ensure optimal outcomes. This article reviews the global picture of preconception nutrition in women and girls, including some of the key factors that influence women's outcomes, as well as their children's outcomes, if they do become pregnant. This article describes the current global guidelines on preconceptional nutrition interventions for girls and women; highlights related gaps in evidence, guidelines, and policy; and discusses research to forward the agenda of improving women's and girls' preconceptional nutrition.
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Affiliation(s)
- Luz M De-Regil
- Research and Evaluation, Micronutrient Initiative, Ottawa, Canada
| | | | - Marion L Roche
- Research and Evaluation, Micronutrient Initiative, Ottawa, Canada
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Tumilowicz A, Neufeld LM, Pelto GH. Using ethnography in implementation research to improve nutrition interventions in populations. MATERNAL & CHILD NUTRITION 2015; 11 Suppl 3:55-72. [PMID: 26778802 PMCID: PMC5019237 DOI: 10.1111/mcn.12246] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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 insider's 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' (insider's) 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.
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Affiliation(s)
| | | | - Gretel H. Pelto
- Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
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Abstract
Despite consensus on actions to improve nutrition globally, less is known about how to operationalize the right mix of actions-nutrition-specific and nutrition-sensitive-equitably, at scale, in different contexts. This review draws on a large scaling-up literature search and 4 case studies of large-scale nutrition programs with proven impact to synthesize critical elements for impact at scale. Nine elements emerged as central: 1) having a clear vision or goal for impact; 2) intervention characteristics; 3) an enabling organizational context for scaling up; 4) establishing drivers such as catalysts, champions, systemwide ownership, and incentives; 5) choosing contextually relevant strategies and pathways for scaling up, 6) building operational and strategic capacities; 7) ensuring adequacy, stability, and flexibility of financing; 8) ensuring adequate governance structures and systems; and 9) embedding mechanisms for monitoring, learning, and accountability. Translating current political commitment to large-scale impact on nutrition will require robust attention to these elements.
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Affiliation(s)
- Stuart Gillespie
- International Food Policy Research Institute (IFPRI), Brighton, United Kingdom;
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Haddad L, Achadi E, Bendech MA, Ahuja A, Bhatia K, Bhutta Z, Blössner M, Borghi E, Colecraft E, de Onis M, Eriksen K, Fanzo J, Flores-Ayala R, Fracassi P, Kimani-Murage E, Koukoubou EN, Krasevec J, Newby H, Nugent R, Oenema S, Martin-Prével Y, Randel J, Requejo J, Shyam T, Udomkesmalee E, Reddy KS. The Global Nutrition Report 2014: actions and accountability to accelerate the world's progress on nutrition. J Nutr 2015; 145:663-71. [PMID: 25740908 PMCID: PMC5129664 DOI: 10.3945/jn.114.206078] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/02/2015] [Indexed: 11/14/2022] Open
Abstract
In 2013, the Nutrition for Growth Summit called for a Global Nutrition Report (GNR) to strengthen accountability in nutrition so that progress in reducing malnutrition could be accelerated. This article summarizes the results of the first GNR. By focusing on undernutrition and overweight, the GNR puts malnutrition in a new light. Nearly every country in the world is affected by malnutrition, and multiple malnutrition burdens are the "new normal." Unfortunately, the world is off track to meet the 2025 World Health Assembly (WHA) targets for nutrition. Many countries are, however, making good progress on WHA indicators, providing inspiration and guidance for others. Beyond the WHA goals, nutrition needs to be more strongly represented in the Sustainable Development Goal (SDG) framework. At present, it is only explicitly mentioned in 1 of 169 SDG targets despite the many contributions improved nutritional status will make to their attainment. To achieve improvements in nutrition status, it is vital to scale up nutrition programs. We identify bottlenecks in the scale-up of nutrition-specific and nutrition-sensitive approaches and highlight actions to accelerate coverage and reach. Holding stakeholders to account for delivery on nutrition actions requires a well-functioning accountability infrastructure, which is lacking in nutrition. New accountability mechanisms need piloting and evaluation, financial resource flows to nutrition need to be made explicit, nutrition spending targets should be established, and some key data gaps need to be filled. For example, many UN member states cannot report on their WHA progress and those that can often rely on data >5 y old. The world can accelerate malnutrition reduction substantially, but this will require stronger accountability mechanisms to hold all stakeholders to account.
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Affiliation(s)
- Lawrence Haddad
- International Food Policy Research Institute, Washington, DC;
| | | | | | - Arti Ahuja
- Women and Child Development, Odisha, India
| | - Komal Bhatia
- Institute of Development Studies, Brighton, United Kingdom
| | - Zulfiqar Bhutta
- Center for Global Child Health, Hospital for Sick Children, Toronto, Canada,Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stineke Oenema
- Interchurch Organization for Development Cooperation (ICCO) Alliance, Utrecht, The Netherlands
| | | | | | - Jennifer Requejo
- Partnership for Maternal, Newborn and Child Health, WHO, Geneva, Switzerland
| | - Tara Shyam
- Institute of Development Studies, Brighton, United Kingdom
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Pelletier D, Pelto G. From efficacy research to large-scale impact on undernutrition: the role of organizational cultures. Adv Nutr 2013; 4:687-96. [PMID: 24228200 PMCID: PMC3823517 DOI: 10.3945/an.113.004622] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Undernutrition in low-income countries is receiving unprecedented attention at global and national levels due to the convergence of many forces, including strong evidence concerning its magnitude, consequences, and potential solutions and effective advocacy by many organizations. The translation of this attention into large-scale reductions in undernutrition at the country level requires the alignment and support of many organizations in the development and implementation of a coherent policy agenda for nutrition, including the strengthening of operational and strategic capacities and a supportive research agenda. However, many countries experience difficulties achieving such alignment. This article uses the concept of organizational culture to better understand some of the reasons for these difficulties. This concept is applied to the constellation of organizations that make up the "National Nutrition Network" in a given country and some of the individual organizations within that network, including academic institutions that conduct research on undernutrition. We illustrate this concept through a case study involving a middle-income country. We conclude that efforts to align organizations in support of coherent nutrition agendas should do the following: 1) make intentional and sustained efforts to foster common understanding, shared learning, and socialization of new members and other elements of a shared culture among partners; 2) seek a way to frame problems and solutions in a fashion that enables individual organizations to secure some of their particular interests by joining the effort; and 3) not only advocate on the importance of nutrition but also insist that high-level officials hold organizations accountable for aligning in support of common-interest solutions (through some elements of a common culture) that can be effective and appropriate in the national context. We further conclude that a culture change is needed within academic departments if the discipline of nutrition is to play a central role in translating the findings from efficacy trials into large-scale reductions in undernutrition.
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