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Packard-Winkler M, Golding L, Tewodros T, Faerber E, Webb Girard A. Core Principles and Practices for the Design, Implementation, and Evaluation of Social and Behavior Change for Nutrition in Low- and Middle-Income Contexts with Special Applications for Nutrition-Sensitive Agriculture. Curr Dev Nutr 2024; 8:104414. [PMID: 39224137 PMCID: PMC11367532 DOI: 10.1016/j.cdnut.2024.104414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 07/05/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024] Open
Abstract
Background There is currently no cogent set of standards to guide the design, implementation and evaluation of nutrition social and behavior change (SBC), including for nutrition-sensitive agriculture (NSA). Objectives We aimed to capture, consolidate, and describe SBC core principles and practices (CPPs), reflecting professional consensus, and to offer programmatic examples that illustrate their application for NSA projects in low- and middle-income countries. Methods We conducted a narrative review following a 4-step iterative process to identify and describe SBC CPPs. We first reviewed general SBC frameworks and technical documents and developed a preliminary list of CPPs and their definitions. Following review and feedback from 8 content experts, we revised the CPPs, incorporating the panel's feedback, and conducted a more specific search of the peer-reviewed and gray literature. We presented a revised draft of the CPPs to 26 NSA researchers, practitioners, and implementers at the 2022 Agriculture, Nutrition and Health Academy annual conference. We then conducted a focused review of each CPP, and 3 content experts rereviewed the final draft. Results We reviewed ∼475 documents and resources resulting in a set of 4 core principles: 1) following a systematic, strategic method in designing, implementing, and evaluating SBC activities; 2) ensuring design and implementation are evidence-based; 3) grounding design and implementation in theory; and 4) authentically engaging communities. Additionally, we identified 11 core practices and mapped these to the different stages in the SBC design, implementation, and evaluation cycle. Detailed descriptions, illustrative examples and resources for implementation are provided for each CPP. Conclusions An explicit set of CPPs for SBC can serve as a guide for design, research, implementation, and evaluation of nutrition and NSA programs; help standardize knowledge sharing and production; and contribute to improved quality of implementation. Broader consultation with SBC practitioners and researchers will further consensus on this work.
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Affiliation(s)
| | - Lenette Golding
- Save the Children U.S., Department of Global Health, Washington, DC, United States
| | - Tsedenia Tewodros
- Hubert Department of Global Health, Rollins School of Public Health at Emory University, Atlanta, GA, United States
| | - Emily Faerber
- Dietetics and Nutrition Department, College of Health, University of Alaska Anchorage, Anchorage, AK, United States
| | - Amy Webb Girard
- Hubert Department of Global Health, Rollins School of Public Health at Emory University, Atlanta, GA, United States
- Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, United States
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Watson D, Mushamiri P, Beeri P, Rouamba T, Jenner S, Proebstl S, Kehoe SH, Ward KA, Barker M, Lawrence W. Behaviour change interventions improve maternal and child nutrition in sub-Saharan Africa: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000401. [PMID: 36996036 PMCID: PMC10062616 DOI: 10.1371/journal.pgph.0000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 02/28/2023] [Indexed: 03/31/2023]
Abstract
Evidence that nutrition-specific and nutrition-sensitive interventions can improve maternal and child nutrition status in sub-Saharan Africa is inconclusive. Using behaviour change theory and techniques in intervention design may increase effectiveness and make outcomes more predictable. This systematic review aimed to determine whether interventions that included behaviour change functions were effective. Six databases were searched systematically, using MeSH and free-text terms, for articles describing nutrition-specific and nutrition-sensitive behaviour change interventions published in English until January 2022. Titles, abstracts and full-text papers were double-screened. Data extraction and quality assessments followed Centre for Reviews and Dissemination guidelines. Behaviour change functions of interventions were mapped onto the COM-B model and Behaviour Change Wheel. PROSPERO registered (135054). The search yielded 1193 articles: 79 articles met inclusion criteria, ranging from low (n = 30) to high (n = 11) risk of bias. Many that applied behaviour change theory, communication or counselling resulted in significant improvements in infant stunting and wasting, household dietary intake and maternal psychosocial measures. Interventions with >2 behaviour change functions (including persuasion, incentivisation, environmental restructuring) were the most effective. We recommend incorporating behaviour change functions in nutrition interventions to improve maternal and child outcomes, specifically drawing on the Behaviour Change Wheel, COM-B model (SORT B recommendation). To enhance the designs of these interventions, and ultimately improve the nutritional and psychosocial outcomes for mothers and infants in sub-Saharan Africa, collaborations are recommended between behaviour change and nutrition experts, intervention designers, policy makers and commissioners to fund and roll-out multicomponent behaviour change interventions.
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Affiliation(s)
- Daniella Watson
- Global Health Research Institute, Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Department of Global Health and Social Medicine, King's College London, London, United Kingdom
- SAMRC Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Patience Mushamiri
- SAMRC Centre for Health Economics and Decision Science, PRICELESS, University of the Witwatersrand, School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa
| | - Paula Beeri
- Navrongo Health Research Centre, Ghana Health Service, Accra, Ghana
| | - Toussaint Rouamba
- Clinical Research Unit of Nanoro, Institute for Research in Health Sciences, National Center for Scientific and Technological Research, Ouagadougou, Burkina Faso
| | - Sarah Jenner
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
| | - Simone Proebstl
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
- Institute for Medical Information Processing, Biometry, and Epidemiology-IBE, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Sarah H Kehoe
- Global Health Research Institute, Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
| | - Kate A Ward
- Global Health Research Institute, Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mary Barker
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Cambridge, United Kingdom
- School of Health Sciences, Faculty of Life and Environmental Sciences, University of Southampton, Southampton, United Kingdom
| | - Wendy Lawrence
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Cambridge, United Kingdom
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Huey SL, Krisher JT, Bhargava A, Friesen VM, Konieczynski EM, Mbuya MNN, Mehta NH, Monterrosa E, Nyangaresi AM, Mehta S. Review of the Impact Pathways of Biofortified Foods and Food Products. Nutrients 2022; 14:1200. [PMID: 35334857 PMCID: PMC8952206 DOI: 10.3390/nu14061200] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/07/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022] Open
Abstract
Biofortification is the process of increasing the concentrations and/or bioavailability of micronutrients in staple crops and has the potential to mitigate micronutrient deficiencies globally. Efficacy trials have demonstrated benefits of consuming biofortified crops (BFCs); and in this paper, we report on the results of a systematic review of biofortified crops effectiveness in real-world settings. We synthesized the evidence on biofortified crops consumption through four Impact Pathways: (1) purchased directly; (2) in informal settings; (3) in formal settings; or (4) in farmer households, from their own production. Twenty-five studies, covering Impact Pathway 1 (five studies), Impact Pathway 2 (three), Impact Pathway 3 (three), Impact Pathway 4 (21) were included. The review found evidence of an improvement in micronutrient status via Impact Pathway 4 (mainly in terms of vitamin A from orange sweet potato) in controlled interventions that involved the creation of demand, the extension of agriculture and promotion of marketing. In summary, evidence supports that biofortified crops can be part of food systems interventions to reduce micronutrient deficiencies in farmer households; ongoing and future research will help fully inform their potential along the other three Impact Pathways for scaling up.
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Affiliation(s)
- Samantha L. Huey
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (S.L.H.); (J.T.K.); (A.B.); (E.M.K.); (N.H.M.)
- Program in International Nutrition, Cornell University, Ithaca, NY 14853, USA
| | - Jesse T. Krisher
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (S.L.H.); (J.T.K.); (A.B.); (E.M.K.); (N.H.M.)
| | - Arini Bhargava
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (S.L.H.); (J.T.K.); (A.B.); (E.M.K.); (N.H.M.)
| | - Valerie M. Friesen
- Global Alliance for Improved Nutrition, 1202 Geneva, Switzerland; (V.M.F.); (E.M.)
| | - Elsa M. Konieczynski
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (S.L.H.); (J.T.K.); (A.B.); (E.M.K.); (N.H.M.)
| | | | - Neel H. Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (S.L.H.); (J.T.K.); (A.B.); (E.M.K.); (N.H.M.)
| | - Eva Monterrosa
- Global Alliance for Improved Nutrition, 1202 Geneva, Switzerland; (V.M.F.); (E.M.)
| | | | - Saurabh Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA; (S.L.H.); (J.T.K.); (A.B.); (E.M.K.); (N.H.M.)
- Program in International Nutrition, Cornell University, Ithaca, NY 14853, USA
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Okello JJ, Just DR, Jogo W, Kwikiriza N, Tesfaye H. Do Behavioral Interventions Increase the Intake of Biofortified Foods in School Lunch Meals? Evidence from a Field Experiment with Elementary School Children in Ethiopia. Curr Dev Nutr 2022; 6:nzac008. [PMID: 35224419 PMCID: PMC8866104 DOI: 10.1093/cdn/nzac008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/06/2021] [Accepted: 01/20/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Many African countries are seeking to improve nutrition by introducing biofortified foods in school feeding programs. These programs are generally designed to create demand for biofortified foods both in and outside of school. Finding ways to encourage child acceptance of novel biofortified foods is key to the success of this strategy. OBJECTIVES The aim was to assess effects of 2 behavioral interventions in promoting the consumption of biofortified foods as part of school lunch meals. METHODS The study is based on a field experiment involving 360 school-going children of in the third, fourth, and sixth grades. We tested if structured provision of information about the nutritional benefits of a biofortified food and its association with an aspirational figure influence its consumption when served alongside a favorite local food as part of school lunch meal. Six schools in Tigray, Ethiopia, were randomly selected to participate, with 4 participating in the Orange-Fleshed Sweetpotato (OFSP) Program. Of the 4 participating in the program, 2 were assigned to provide educational information about sweetpotato, whereas 2 presented the same information plus depictions of an aspirational figure (a famous local athlete) associated with the sweetpotato. RESULTS Provision of information on the nutritional benefits of biofortified food combined with an aspirational figure resulted in increased consumption of biofortified food by children. However, provision of the information alone did not detectably increase consumption. An analysis of trends over the course of the study revealed no discernable decay effect. CONCLUSIONS Our results highlight the potential for relatively inexpensive behavioral interventions to increase acceptance of novel biofortified foods among children in a developing-country context. Larger studies with more varied interventions and larger numbers of participating schools could address several of the weaknesses in this study and establish more robust findings.
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Affiliation(s)
| | - David R Just
- The Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, NY, USA
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Brouwer R. Marketing Healthy Food in an African City: Consumer Motivations for Adopting Orange-Fleshed Sweet Potato in Maputo, Mozambique. Food Nutr Bull 2021; 42:361-377. [PMID: 34142599 DOI: 10.1177/03795721211021266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Since the late 1990s, the International Potato Center has promoted orange-fleshed sweet potato (OFSP) cultivars in Mozambique as a healthy food, emphasizing its capacity to reduce the prevalence of vitamin A deficiency among mothers and young children. This article seeks to reveal why consumers in Maputo, the capital city of Mozambique, adopt or reject OFSP looking at the role of food systems and consumer characteristics in access and acceptance of healthy food and at the positioning OFSP on the market in terms of lifestyle and need satisfaction.The results of 255 street interviews confirm that OFSP is widely known. Information reaches people mainly via informal channels (relatives and retailers). Nonadoption is the result of the positioning of OFSP as food for young children and sick people. The OFSP appeals most to the hedonistic and conservative lifestyle segments. Adoption is associated with the perception of OFSP as a source of vitamins that builds up muscles and improves physical appearance and self-fulfillment. While women are typically responsible for domestic tasks, male adopters emphasize the role of OFSP in family health and well-being more than female adopters. This first attempt to understand the marketing of healthy food in Mozambique exposes many similarities between the urban consumers in Maputo and those in developed countries. The results indicate that future marketing should exploit informal channels such as vendors and emphasize its nutritious value for all consumers instead of focusing on mothers and young children.
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Effectiveness of school-based nutrition interventions in sub-Saharan Africa: a systematic review. Public Health Nutr 2020; 23:2626-2636. [PMID: 32646534 DOI: 10.1017/s1368980020000506] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the effect of school-based nutrition interventions (SBNI) involving schoolchildren and adolescents in sub-Saharan Africa (SSA) on child nutrition status and nutrition-related knowledge, attitudes and behaviour. DESIGN A systematic review on published school nutrition intervention studies of randomised controlled trials, controlled clinical trials, controlled before-and-after studies or quasi-experimental designs with control. Nine electronic bibliographic databases were searched. To be included, interventions had to involve changes to the school's physical and social environments, to the school's nutrition policies, to teaching curriculum to incorporate nutrition education and/or to partnership with parents/community. SETTING Schools in SSA. PARTICIPANTS School-aged children and adolescents, aged 5-19 years. RESULTS Fourteen studies met our inclusion criteria. While there are few existing studies of SBNI in SSA, the evidence shows that food supplementation/fortification is very effective in reducing micronutrient deficiencies and can improve nutrition status. Secondly, school nutrition education can improve nutrition knowledge, but this may not necessarily translate into healthy nutrition behaviour, indicating that nutrition knowledge may have little impact without a facilitating environment. Results regarding anthropometry were inconclusive; however, there is evidence for the effectiveness of SBNI in improving cognitive abilities. CONCLUSIONS There is enough evidence to warrant further trials of SBNI in SSA. Future research should consider investigating the impact of SBNI on anthropometry and nutrition behaviour, focusing on the role of programme intensity and/or duration. To address the high incidence of micronutrient deficiencies in low- and middle-income countries, food supplementation strategies currently available to schoolchildren should be expanded.
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Lagerkvist CJ, Mutiso JM, Okello JJ, Muoki P, Oluoch-Kosura W, Heck S. Predictors of Intention to Integrate Biofortified Orange-fleshed Sweetpotato in Child Feeding: A Field Information Experiment in Rural Kenya. Ecol Food Nutr 2020; 59:615-638. [PMID: 32406767 DOI: 10.1080/03670244.2020.1759576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The study assesses the psychosocial predictors of intention to integrate biofortified pro-vitamin A orange-fleshed sweet potato (OFSP) in proper complementary feeding (PCF) among women who received either verbal or verbal and visual demonstrations on OFSP-based foods. A total of 764 randomly selected women grouped into four categories, namely pregnant women, women with infants, women with young children, and potential mothers, participated in this study. Using a structural equation model of predicted intentions based on an extended Theory of Planned Behavior (TPB) the study found goal-setting, perceived behavior control, subjective norms, and attitudes had a significant influence on intention to integrate OFSP in PCF. Unexpectedly, knowledge of the various health benefits of OFSP did not positively influence intention. Probabilistic recursive regression was then used to estimate the relationship between the intention to provide PCF practices and its potential antecedents. The results then showed that the model structure and explanatory power was information-specific and also revealing outcome differences by category of women. These results have implications on how interventions targeting the improvement of PCF should be organized and delivered. They underscore the need to segment the audience during nutrition education.
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Affiliation(s)
- Carl Johan Lagerkvist
- Department of Economics, Swedish University of Agricultural Sciences , Uppsala, Sweden
| | - Janet Mwende Mutiso
- Department of Agricultural Economics, University of Nairobi , Nairobi, Kenya
| | - Julius Juma Okello
- Social & Nutrition Sciences Division, International Potato Centre , Kampala, Uganda
| | | | | | - Simon Heck
- International Potato Centre , Nairobi, Kenya
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Mau G, Schramm-Klein H, Schuhen M, Steinmann S. What helps children resist distracting marketing stimuli? Implementation intentions and restrictions alter food choice. Appetite 2019; 140:159-168. [PMID: 31103444 DOI: 10.1016/j.appet.2019.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 04/08/2019] [Accepted: 05/13/2019] [Indexed: 11/27/2022]
Abstract
This study analyzes the impact of implementation intentions as well as restrictions on the delay of gratification in children. We assume that both strategies impact the decision process of children in different ways: While implementation intentions activate the mental representation of specified cues that help pursuing a goal, restrictions support goal attainment because of the threatened consequence. The results of two studies support these assumptions. A correlation between the physiological arousal and the success in the delay task indicates that for children that follow implementation intentions arousal provides motivation to wait for a greater gratification. These results provide possible explanations for the heterogeneous outcomes of existing studies about the effects of parenting practices.
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Affiliation(s)
- Gunnar Mau
- Department of Business Psychology, Schloss Seeburg University, Seeburgstraße 8, 5201, Seekirchen am Wallersee, Salzburg, Austria.
| | - Hanna Schramm-Klein
- Department of Marketing, University of Siegen, Unteres Schloß 3, 57072, Siegen, Germany
| | - Michael Schuhen
- Department of Marketing, University of Siegen, Unteres Schloß 3, 57072, Siegen, Germany
| | - Sascha Steinmann
- Department of Marketing, University of Siegen, Unteres Schloß 3, 57072, Siegen, Germany
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Mohr B, Dolgopolova I, Roosen J. The influence of sex and self-control on the efficacy of nudges in lowering the energy content of food during a fast food order. Appetite 2019; 141:104314. [PMID: 31181248 DOI: 10.1016/j.appet.2019.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/05/2019] [Accepted: 06/05/2019] [Indexed: 11/15/2022]
Abstract
An experiment aimed at reducing calorie content of a food order was performed by introducing interventions at the fast food ordering screen on a tablet computer. Modifications included a virtual order assistant, a color-coded system and highlighting low-calorie choices. Participants of the study were 401 university students. Before starting an order, participants were asked to indicate their calorie goal. Our results show that the order assistant is the only intervention that leads to significantly fewer calories in the fast food order. The effect is due to women ordering fewer high-calorie dishes. Men, in contrast, are unresponsive to changes in the choice context regarding calories ordered. Results indicate that the level of self-control moderates the impact of the feature highlighting choices so that higher levels of self-control lead to lower calorie intake for both sexes. This research highlights the importance of gender and self-control for designing choice environments aimed at decreasing calorie intake.
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Affiliation(s)
- Bernhard Mohr
- Chair of Marketing and Consumer Research, TUM School of Management, Technical University of Munich, Germany
| | - Irina Dolgopolova
- Chair of Marketing and Consumer Research, TUM School of Management, Technical University of Munich, Germany.
| | - Jutta Roosen
- Chair of Marketing and Consumer Research, TUM School of Management, Technical University of Munich, Germany
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