Advocacy coalitions and the transfer of nutrition policy to Zambia

Malnutrition, protein energy wasting and sarcopenia in patients attending a haemodialysis centre in sub-Saharan Africa

BACKGROUND

Haemodialysis (HD) patients are reported to be at greater risk of malnourishment, and at risk of increased morbidity and mortality. However, most studies report from economically advanced countries. We therefore assessed the nutritional status and diet among HD patients attending a public university hospital in a sub-Saharan African country.

SUBJECTS

We performed nutritional assessments in HD patients attending the largest dialysis centre, in the country, collecting demographic and clinical data, dietary intake, along with anthropometric and bioimpedance body composition measurements in May 2022. Malnutrition was classified according to subjective global assessment score (SGA). Additional assessments of protein energy wasting (PEW), clinical frailty, and sarcopenia were made.

RESULTS

All 97 HD patients were recruited, mean age 44.7 ± 12.2 years, with 55 (56.7%) males. Malnutrition was present in 43.8%, PEW 20.6%, frailty 17.6% and sarcopenia 4.1%. On multivariable logistic regression higher serum albumin (adjusted odds ratio (AOR) 0.89, 95% confidence intervals (CI) 0.85-0.95, p < 0.001), creatinine (AOR 0.99, 95%CI 0.98-0.99, p < 0.001), greater mid upper arm circumference (AOR 0.89, 95%CI 0.83-0.95, p = 0.001), body cell mass (BCM) (AOR 0.79, 95%CI 0.67-0.95, p = 0.013) and employment (AOR 0.45, 95%CI 0.23-0.87, p = 0.017), were are all protective against malnourishment. Almost 75% had reduced dietary protein intake.

CONCLUSIONS

Despite a younger, less co-morbid patient population, malnutrition is common in this resource poor setting. The staple diet is based on maize, a low protein foodstuff. Employment improved finances and potentially allows better nutrition. Further studies are required to determine whether additional dietary protein can reduce the prevalence of malnutrition in this population.

Divergent beliefs about food safety and affordability in Nigeria

Access to safe, affordable diets is paramount for improved nutritional outcomes. Yet, how do stakeholders perceive the binding constraints and requisite policy actions to increase food safety and affordability? Focusing on Nigeria, this paper uses best-worst scaling techniques applied to a survey of 200 government and agrifood system stakeholders to examine their policy beliefs on safety and affordability vis-à-vis the vegetable and fish value chains. We find that divergence among stakeholders is greater for food safety than affordability. While antibiotics overuse and toxin exposure, lack of knowledge, and weak legislation were identified by different stakeholders as the binding constraints for food safety, high costs of inputs and infrastructure, as well as security threats, were seen as common challenges for affordability across most, though not all, stakeholders for both value chains. Overall, the paper highlights the importance of beliefs in the agrifood system policymaking process and emphasizes the need to explore not only the existence but also the source of divergent beliefs among policy actors in greater depth.

Voice, access, and ownership: enabling environments for nutrition advocacy in India and Nigeria

What constitutes an enabling environment for nutrition advocacy in low- and middle-income countries? While a sizeable body of scholarship considers the enabling environment for nutrition policy, we focus specifically on the necessary conditions for advocacy. We argue that three factors-voice, access, and ownership-provide a useful lens into the advocacy enabling environment. These are operationalized, respectively, as the space to articulate and frame policy positions, entry points to interact with policy decision makers, and the existence of committed decision makers rather than those responding to pressures from external actors. These three factors are explored vis-à-vis a comparative analysis of two federal democracies-India and Nigeria-that each have vibrant advocacy communities confronting persistent malnutrition. Drawing on more than 100 structured interviews with nutrition advocates, government actors, donors, and researchers in the two countries, we highlight the ways in which voice, access, and ownership interactively shape advocacy efforts. In doing so, we find that Nigeria has a less ideological approach to certain nutrition issues than in India but also perceived to be more beholden to external actors in defining its nutrition actions. Recent restrictions on freedom of speech and association shrunk the civic space in India but these were less problematic in Nigeria. In both countries, the multi-tiered, multi-party system offers many different points of access into the policy arena, with sometimes negative implications for coordination. Overall, the paper contributes more broadly to the literature on enabling environments by highlighting potential indicators to guide nutrition advocates in other settings.

Protecting children from unhealthy food marketing: a comparative policy analysis in Australia, Fiji and Thailand

Restrictions on marketing of unhealthy foods and beverages to children is a globally recommended policy measure to improve diets and health. The aim of the analysis was to identify opportunities to enable policy learning and shift beliefs of relevant actors, to engender policy progress on restrictions on marketing of unhealthy foods to children. We drew on the Advocacy Coalition Framework to thematically analyse data from qualitative policy interviews conducted Australia (n = 24), Fiji (n = 10) and Thailand (n = 20). In all three countries two clear and opposing advocacy coalitions were evident within the policy subsystem related to regulation of unhealthy food marketing, which we termed the 'strengthen regulation' and 'minimal/self regulation' coalitions. Contributors to policy stasis on this issue were identified as tensions between public health and economic objectives of government, and limited formal and informal spaces for productive dialogue. The analysis also identified opportunities for policy learning that could enable policy progress on restrictions on marketing of unhealthy foods to children as: taking an incremental approach to policy change, defining permitted (rather than restricted) foods, investing in new public health expertise related to emerging marketing approaches and scaling up of monitoring of impacts. The insights from this study are likely to be relevant to many countries seeking to strengthen regulation of marketing to children, in response to recent global recommendations.

The politics of agricultural policy and nutrition: A case study of Malawi's Farm Input Subsidy Programme (FISP)

The concept of food and nutrition policy has broadened from simply being an aspect of health policy, to policy interventions from across a wide range of sectors, but still with potentially important impact on nutritional outcomes. This wider and more complex conceptualisation involves policy with multiple objectives and stakeholder influences. Thus, it becomes particularly important to understand the dynamics of these policy processes, including policy design and implementation. To add to this literature, we apply the Kaleidoscope Model for understanding policy change in developing country contexts to the case-study of an agricultural input subsidy (AIS) programme in Malawi, the Farm Input Subsidy Programme (FISP), exploring the dynamics of the FISP policy process including nutritional impact. Over a three-month period between 2017 and 2019 we conducted in-depth interviews with key stakeholders at national and district levels, and focus groups with people from rural districts in Malawi. We also undertook a review of literature relating to the political economy of the FISP. We analysed the data thematically, as per the domains of the Kaleidoscope Model. The analysis across the FISP policy process including policy design and implementation highlights how stakeholders' ideas, interests and influence have shaped the evolution of FISP policy including constraints to policy improvement-and the nutritional impacts of this. This approach extends the literature on the tensions, contradictions and challenges in food and nutrition policy by examining the reasons that these occur in Malawi with the FISP. We also add to the political science and policy analysis literature on policy implementation, extending the concept of veto players to include those targeted by the policy. The findings are important for consideration by policymakers and other stakeholders seeking to address malnutrition in rural, food-insecure populations in Malawi and other low-income settings.

Mapping of food environment policies in Zambia: a qualitative document analysis

BACKGROUND

The food environment in which people exercise food choices significantly impacts their dietary patterns. Policies that limit the availability, affordability, and access to unhealthy food while increasing that of healthier alternatives help build healthy food environments, which are required to address the double burden of malnutrition. This study aimed to assess the availability of food environment policies in Zambia.

METHOD

We applied a two-step qualitative document analysis to identify policy content relating to healthy food environments from global and Zambia-specific nutrition-related policy documents. In the first step, global policy documents were analyzed to develop a reference point for globally recommended policies for healthy food environments. In the second step, Zambia's nutrition-related policies were analyzed to identify content relating to healthy food environments. The identified policy content was then mapped against the global reference point to identify food environment policy gaps.

RESULTS

Our analysis of global policy recommendations identified five broad categories of policy provisions: information and education based; regulatory and legislative tools; strategies to promote production and access to healthy food production; social protection-based strategies and guiding principles for governments relating to multisectoral collaboration and governance. Our analysis found that Zambian Government policy documents in the health, agriculture, education, and national planning and development sectors have policy provisions for healthy food environments. While these policy provisions generally covered all five reference categories, we found policy gaps in the regulatory and legislative tools category relative to global recommendations.

CONCLUSION

Zambia's food environment policy landscape must include globally recommended regulatory and legislative policy measures like restricting the marketing of unhealthy foods and non-alcoholic beverages to children. Nutrition policy reforms are required to facilitate the introduction of regulatory and legislative policy measures that effectively address the double burden of malnutrition in Zambia.

Nutrition policy reforms to address the double burden of malnutrition in Zambia: a prospective policy analysis

The evolution of nutrition patterns in Zambia has resulted in the coexistence of undernutrition and overnutrition in the same population, the double burden of malnutrition. While Zambia has strong policies addressing undernutrition and stunting, these do not adequately address food environment drivers of the double burden of malnutrition and the adolescent age group and hence the need for nutrition policy reforms. We conducted a theory-based qualitative prospective policy analysis involving in-depth interviews with nutrition policy stakeholders and policy document review to examine the feasibility of introducing nutrition policy options that address the double burden of malnutrition among adolescents to identify barriers and facilitators to such policy reforms. Using the multiple streams theory, we categorized the barriers and facilitators to prospective policy reforms into those related to the problem, policy solutions and politics stream. The use of a life-course approach in nutrition programming could facilitate policy reforms, as adolescence is one of the critical invention points in a person's lifecycle. Another key facilitator of policy reform was the availability of institutional infrastructure that could be leveraged to deliver adolescent-focused policies. However, the lack of evidence on the burden and long-term impacts of adolescent nutrition problems, the food industry's strong influence over governments' policy agenda setting and the lack of public awareness to demand better nutrition were perceived as critical barriers to policy reforms. In addition, the use of the individual responsibility framing for nutrition problems was dominant among stakeholders. As a result, stakeholders did not perceive legislative nutrition policy options that effectively address food environment drivers of the double burden of malnutrition to be feasible for the Zambian context. Policy entrepreneurs are required to broker policy reforms that will get legislative policy options on the government's agenda as they can help raise public support and re-engineer the framing of nutrition problems and their solutions in Zambia.

Emergence of National Nutrition Policy in the Lao People's Democratic Republic: an analysis of collaborations between governmental and external actors

BACKGROUND

In most developing countries, addressing malnutrition involves a coalition of stakeholders that includes the government and international development partners. This study explores the evolution of the malnutrition actor coalition landscape before and after the emergence of the National Nutrition Policy in the Lao People's Democratic Republic (Lao PDR) in 2008.

METHODS

A qualitative study was conducted based on the theory of coalition structuring. Twenty semi-structured interviews were performed with representatives of national and international organisations involved in addressing malnutrition in Lao PDR. The information obtained from the interviews was complemented by an analysis of relevant documents dating back to 1990. Interviews were recorded and transcribed verbatim. A thematic analysis was performed using NVivo 11 software and the diagrams of collaboration drawn by the participants were turned into a visual collaboration map using SocNetV software. We relied on various types of triangulation to increase the analysis's credibility, reliability, and confirmability.

RESULTS

The results showed that before the emergence of the National Nutrition Policy, three coalitions representing the health, agriculture, and education sectors coexisted. These colalitions worked largely in silos, although with some interactions when deemed necessary mainly by United Nations agencies. The emergence of the National Nutrition Policy provided the government with an effective political tool for coalescing the three coalitions into a unique coalition involving all major stakeholders in the nutrition field. All three forces that incite actors to collaborate inside a coalition according to the theory of coalition structuring (transactions, control, intangible factors) were mobilised in the creation of the single coalition.

CONCLUSIONS

Combating malnutrition is a government priority in the Lao PDR. The current study showed that the National Nutrition Policy in Lao PDR has led to a significant evolution in the malnutrition coalition landscape, resulting in improved collaboration among stakeholders. This finding highlights the effectiveness of public policies in facilitating intersectoral activities to tackle complex problems, such as malnutrition.

Suitability of maize crop residue fermented by Pleurotus ostreatus as feed for edible crickets: growth performance, micronutrient content, and iron bioavailability

Small-scale farming of edible insects could help combat public health challenges such as protein energy malnutrition and anemia, but reliable low-cost feeds for insects are needed. In resource-limited contexts, where grains such as maize are prohibitively costly for use as insect feed, the feasibility of insect farming may depend on finding alternatives. Here, we explore the potential to modify plentiful maize crop residue with edible mushroom mycelium to generate a low-cost feed adjunct for the farmed two-spotted cricket, Gryllus bimaculatus. Mushroom farming, like insect agriculture, is versatile; it can yield nutritious food while increasing system circularity by utilizing lignocellulosic residues from row crops as inputs. Pleurotus ostreatus, is an edible basidiomycete capable of being cultivated on corn stover (Zea mays). Mushroom harvest results in abundant "spent" substrate, which we investigated as a candidate feed ingredient. We created six cricket feeds containing fermented Pleurotus substrate plus an unfermented control, measuring cricket mass, mortality, and maturation weekly to evaluate cricket growth performance impacts of both fungal fermentation duration and mushroom formation. Pasteurized corn stover was inoculated with P. ostreatus mycelium and fermented for 0, 2, 3, 4, or 8 weeks. Some 4 and 8-week substrates were induced to produce mushrooms through manipulations of temperature, humidity, and light conditions. Dried fermented stover (40%) was added to a 1:1 corn/soy grain mix and fed to crickets ad libitum for 44 days. The unfermented control group showed higher survivorship compared to several fermented diets. Control group mass yield was higher for 2 out of 6 fermented diets. Little variation in cricket iron content was observed via ICP-spectrometry across feeds, averaging 2.46 mg/100 g. To determine bioavailability, we conducted in vitro Caco-2 human colon epithelial cell absorption assays, showing that iron in crickets fed fruiting-induced substrates was more bioavailable than in unfruited groups. Despite more bioavailable iron in crickets reared on post-fruiting substrates, we conclude that Pleurotus-fermented stover is an unsuitable feed ingredient for G. bimaculatus due to high mortality, variability in growth responses within treatments, and low mass yield.

Integrating Nutrition Actions in Service Delivery: The Practices of Frontline Workers in Uganda

BACKGROUND

Integrating nutrition actions into service delivery in different policy sectors is an increasing concern. Nutrition literature recognizes the discrepancies existing between policies as adopted and actual service delivery. This study applies a street-level bureaucracy (SLB) perspective to understand frontline workers' practices that enact or impede nutrition integration in services and the conditions galvanizing them.

METHODS

This qualitative exploratory study assesses the contextual conditions and practices of 45 frontline workers employed by the agriculture, health and community development departments in two Ugandan districts.

RESULTS

Frontline workers incur different demands and resources arising at societal, organizational, and individual level. Hence, they adopt nine co-existing practices that ultimately shape nutrition service delivery. Nutrition integration is accomplished through: (1) ritualizing task performance; (2) bundling with established services; (3) scheduling services on a specific day; and (4) piggybacking on services in other domains. Disintegration results from (5) non-involvement and (6) shifting blame to other entities. Other practices display both integrative and disintegrative effects: (7) creaming off citizens; (8) down prioritization by fixating on a few nutrition actions; and (9) following the bureaucratic 'jobs worth'. Integrative practices are driven mostly by donors.

CONCLUSION

Understanding frontline workers' practices is crucial for identifying policy solutions to sustain nutrition improvements. Sustaining services beyond timebound projects necessitates institutionalizing demands and resources within government systems. Interventions to facilitate effective nutrition service delivery should strengthen the integrative capacities of actors across different government levels. This includes investing in integrative leadership, facilitating frontline workers across sectors to provide nutrition services, and adjusting the nutrition monitoring systems to capture cross-sector data and support policy learning.

What Opportunities Exist for Making the Food Supply Nutrition Friendly? A Policy Space Analysis in Mexico

BACKGROUND

As part of a global policy response for addressing malnutrition, food system actions have been proposed. Within food system interventions, policies directed to supply chains have the potential to increase the availability and affordability of a healthy diet. This qualitative study aimed to identify opportunities to integrate nutrition as a priority into the food supply policy space in Mexico.

METHODS

Data were collected through analysis of 19 policy documents and 20 semi-structured stakeholder interviews. As an analytical framework, we used policy space analysis and embedded the Advocacy Coalition Framework (ACF) and the steps of the food chain of the conceptual framework of food systems for diets and nutrition.

RESULTS

Policy issues relevant to nutrition were viewed differently in the economic and agricultural sectors versus the health sector. Overall, the main policy objective related to nutrition within the economic and agricultural sectors was to contribute to food security in terms of food quantity. Nutrition was an objective in itself only in the health sector, with a focus on food quality. Our policy space analysis reveals an opportunity to promote a new integrated vision with the recent creation of an intersectoral group working on the public agenda for a food system transformation. This newer integrative narrative on food systems presents an opportunity to shift the existing food security narrative from quantity towards considerations of diet quality.

CONCLUSION

The political context and public agenda are favorable to pursue a food system transformation to deliver sustainable healthy diets. Mexico can provide a case study for other low- and middle-income countries (LMICs) for putting nutrition at the center of food policy, despite the ongoing constraints on achieving this.

Toward good governance for the prosthetics and orthotics sector in Iran: Evidence from a qualitative study

BACKGROUND

Prosthetics and orthotics (P&O) services are essential health services whose desired provision is considered as prerequisite to achieving universal health coverage. However, the P&O sector is sometimes not audited and governed, leading to groups that receive and offer the services to face challenges for benefits in Iran.

OBJECTIVES

To identify common challenges of governance for the P&O sector and provide some potential policy recommendations to strengthen it.

STUDY DESIGN

Qualitative study.

METHODS

This study was conducted using semistructured in-depth interviews with prosthetists and orthotists (n = 13), P&O academicians (n = 6), and healthcare policy-makers (n = 8). The interview guide was also established based on 10 dimensions of the Framework for Governance of Healthcare System.

RESULTS

Challenges identified included no legislation on P&O services, insufficient government support, uninformed policy-makers, and lack of interest by powerful stakeholders. In addition, nontransparent policy-making, inadequate distribution of workforce across the country, and lack of insurance coverage for P&O services were also raised as other challenges. The respondents identified the need for clear legislation to inform policy-makers and to seek advocacy from the government.

CONCLUSIONS

The governance of the P&O sector in Iran has faced with a number of challenges that have made it unable to respond to existing demands desirably. Hence, it is important and necessary to adopt effective and comprehensive policies to reduce current challenges and barriers and improve the governance for P&O services.

The complex challenge of governing food systems: The case of South African food policy

International experience reveals that food policy development often occurs in silos and offers few tangible mechanisms to address the interlinked, systemic issues underpinning food and nutrition insecurity. This paper investigated what South African government policies cover in terms of different aspects of the food system, who is responsible for them, and how coordinated they are. Policy objectives were categorized into seven policy domains relevant to food systems: agriculture, environment, social protection, health, land, education, economic development, and rural development. Of the ninety-one policies reviewed from 1947-2017, six were identified as being "overarching" with goals across all the domains. About half of the policies focused on agriculture and the environment, reflecting an emphasis on agricultural production. Policies were formulated and implemented in silos. As a result, learning from implementation, and adjusting to improve impact has been limited. Particularly important is that coordination during implementation, across these complex domains, has been partial. In order to achieve its stated food and nutrition outcomes, including Sustainable Development Goal (SDG) 2, South Africa needs to translate its policies into tangible, practical plans and processes guided by effective coordination and alignment. Key recommendations are practically to align policies to a higher-level "food goal", establish better coordination mechanisms, consolidate an effective monitoring and evaluation approach to address data gaps and encourage learning for adaptive implementation. Actively engaging the existing commitments to the SDGs would draw stated international commitments together to meet the constitutional commitment to food rights into an overarching food and nutrition security law.

Framing and the formation of global health priorities

Health issues vary in the amount of attention and resources they receive from global health organisations and national governments. How issues are framed could shape differences in levels of priority. We reviewed scholarship on global health policy making to examine the role of framing in shaping global health priorities. The review provides evidence of the influence of three framing processes-securitisation, moralisation, and technification. Securitisation refers to an issue's framing as an existential threat, moralisation as an ethical imperative, and technification as a wise investment that science can solve. These framing processes concern more than how issues are portrayed publicly. They are socio-political processes, characterised by contestation among actors in civil society, government, international organisations, foundations, and research institutions. These actors deploy various forms of power to advance particular frames as a means of securing attention and resources for the issues that concern them. The ascription of an issue as a security concern, an ethical imperative, or a wise investment is historically contingent: it is not inevitable that any given issue will be framed in one or more of these ways. A health issue's inherent characteristics-such as the lethality of a pathogen that causes it-also shape these ascriptions, but do not fully determine them. Although commonly facing resistance, global health elites often determine which frames prevail, raising questions about the legitimacy of priority-setting processes. We draw on the review to offer ideas on how to make these processes fairer than they are at present, including a call for democratic representation even as necessary space is preserved for elite expertise.

Advocacy Organizations and Nutrition Policy in Nigeria: Identifying Metrics for Enhanced Efficacy

Advocacy organizations have played a significant role in the field of nutrition in recent years. However, why are some advocates viewed as more effective than others? This paper derives metrics for assessing advocacy efficacy by first drawing on key insights from the nutrition and public policy scholarship. A set of metrics is proposed to capture the constitutive elements of three concepts that often emerge as critical from that literature: organizational capacity, strong networks, and external outreach. Based on a survey of 66 nutrition stakeholders in Nigeria, including at the federal level and within the states of Kaduna and Kano, the metrics are then applied to a set of advocacy organizations within the country. We show that the metrics can provide insights into why some advocacy organizations are perceived as more effective than others by policymakers. Specifically, we find that geographical reach, share of budget allocated to advocacy, action plans with clear objectives, large networks that include government and non-governmental policy champions, multiple media and dissemination outputs, and numerous training events collectively increase nutrition advocates' visibility to, and influence on, policymakers. Although the metrics are subject to further testing in other country settings and need to be interpreted based on a country's underlying policy system, they offer a useful starting point for more systematic, comparative advocacy analysis and learning within the nutrition field and beyond.

Tensions and coalitions: A new trade agreement affects the policy space for nutrition in Vietnam

Global trade has shaped food systems over centuries, but modern trade agreements are hastening these changes and making them more complex, with implications for public health and nutrition transition. This study aimed to understand the impact of the 2018 Comprehensive and Progressive Agreement for Trans-Pacific Partnership (CPTPP) on the policy space for public health nutrition in Vietnam. We conducted comparative document review and key informant interviews, and our analysis drew on a framework of policy space and the theory of advocacy coalitions. We identified 10 CPTPP sections with potential public health nutrition implications; and 50 Vietnamese policies relevant to nutrition having one or more tensions with one or more CPTPP sections. A majority of policy tensions were in sections of the CPTPP relating to technical barriers to trade and government procurement; most tensions related to protecting policy-making from vested interests. Different groups of policy actors hold different beliefs and interests on these issues, and therefore promote different framings and policy approaches. We identified two advocacy coalitions working very separately on issues affecting nutrition policy space: a trade coalition holding the policy position that free trade improves nutrition by default; and a nutrition coalition holding the policy position that nutrition should be explicitly considered in trade policy. The policy space for nutrition in Vietnam has important potential constraints through written policy, and the trade and nutrition coalitions will need to interact more regularly and constructively in order to foresee where these tensions will arise in practice, and create plans for their mitigation. This study adds to global evidence of free trade agreement impacts on nutrition policy space, and we extend previous work by explaining these actor groupings in the policy space through the theory of advocacy coalitions.

How are global health policies transferred to sub-Saharan Africa countries? A systematic critical review of literature

Background

Most sub-Saharan Africa countries adopt global health policies. However, mechanisms with which policy transfers occur have largely been studied amongst developed countries and much less in low- and middle- income countries. The current review sought to contribute to literature in this area by exploring how health policy agendas have been transferred from global to national level in sub-Saharan Africa. This is particularly important in the Sustainable Development Goals (SDGs) era as there are many policy prepositions by global actors to be transferred to national level for example the World Health Organization (WHO) policy principles of health financing reforms that advance Universal Health Coverage (UHC).

Methods

We conducted a critical review of literature following Arksey and O’Malley framework for conducting reviews. We searched EBSCOhost, ProQuest, PubMed, Scopus, Web of Science and Google scholar for articles. We combined the concepts and synonyms of “policy transfer” with those of “sub-Saharan Africa” using Boolean operators in searching databases. Data were analyzed thematically, and results presented narratively.

Results

Nine articles satisfied our eligibility criteria. The predominant policy transfer mechanism in the health sector in sub-Saharan Africa is voluntarism. There are cases of coercion, however, even in the face of coercion, there is usually some level of negotiation. Agency, context and nature of the issue are key influencers in policy transfers. The transfer is likely to be smooth if it is mainly technical and changes are within the confines of a given disease programmatic area. Policies with potential implications on bureaucratic and political status quo are more challenging to transfer.

Conclusion

Policy transfer, irrespective of the mechanism, requires local alignment and appreciation of context by the principal agents, availability of financial resources, a coordination platform and good working relations amongst stakeholders. Potential effects of the policy on the bureaucratic structure and political status are also important during the policy transfer process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00821-9.

Who influences nutrition policy space using international trade and investment agreements? A global stakeholder analysis

Background

Regulation of food environments is needed to address the global challenge of poor nutrition, yet policy inertia has been a problem. A common argument against regulation is potential conflict with binding commitments under international trade and investment agreements (TIAs). This study aimed to identify which actors and institutions, in different contexts, influence how TIAs are used to constrain policy space for improving food environments, and to describe their core beliefs, interests, resources and strategies, with the objective of informing strategic global action to preserve nutrition policy space.

Methods

We conducted a global stakeholder analysis applying the Advocacy Coalition Framework, based on existing academic literature and key informant interviews with international experts in trade and investment law and public health nutrition policy.

Results

We identified 12 types of actors who influence policy space in the food environment policy subsystem, relevant to TIAs. These actors hold various beliefs regarding the economic policy paradigm, the nature of obesity and dietary diseases as health problems, the role of government, and the role of industry in solving the health problem. We identified two primary competing coalitions: 1) a ‘public health nutrition’ coalition, which is overall supportive of and actively working to enact comprehensive food environment regulation; and 2) an ‘industry and economic growth’ focussed coalition, which places a higher priority on deregulation and is overall not supportive of comprehensive food environment regulation. The industry and economic growth coalition appears to be dominant, based on its relative power, resources and coordination. However, the public health nutrition coalition maintains influence through individual activism, collective lobbying and government pressure (e.g. by civil society), and expert knowledge generation.

Conclusions

Our analysis suggests that industry and economic growth-focussed coalitions are highly capable of leveraging networks, institutional structures and ideologies to their advantage, and are a formidable source of opposition acting to constrain nutrition policy space globally, including through TIAs. Opportunities for global public health nutrition coalitions to strengthen their influence in the support of nutrition policy space include strategic evidence generation and coalition-building through broader engagement and capacity-building.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00764-7.

Viewpoint: Agri-nutrition research: Revisiting the contribution of maize and wheat to human nutrition and health

Research linking agriculture and nutrition has evolved since the mid-20th century. The current focus is on child-stunting, dietary diversity and 'nutrient-rich' foods in recognition of the growing burdens of malnutrition and non-communicable diseases. This article concerns the global dietary and health contribution of major cereals, specifically maize and wheat, which are often considered not to be 'nutrient-rich' foods. Nevertheless, these cereals are major sources of dietary energy, of essential proteins and micronutrients, and diverse non-nutrient bioactive food components. Research on bioactives, and dietary fibre in particular, is somewhat 'siloed', with little attention paid by the agri-nutrition research community to the role of cereal bioactives in healthy diets, and the adverse health effects often arising through processing and manufacturing of cereals-based food products. We argue that the research agenda should embrace the whole nutritional contribution of the multiple dietary components of cereals towards addressing the triple burden of undernutrition, micronutrient malnutrition, overweight/obesity and non-communicable diseases. Agri-nutrition and development communities need to adopt a multidisciplinary and food systems research approach from farm to metabolism. Agriculture researchers should collaborate with other food systems stakeholders on nutrition-related challenges in cereal production, processing and manufacturing, and food waste and losses. Cereal and food scientists should also collaborate with social scientists to better understand the impacts on diets of the political economy of the food industry, and the diverse factors which influence local and global dietary transitions, consumer behavioural choices, dietary change, and the assessment and acceptance of novel and nutritious cereal-based products.

Adapting acute malnutrition treatment protocols in emergency contexts: a qualitative study of national decision-making

Background

Each year, an estimated 17 million children suffer from severe acute malnutrition (SAM) and 33 million from moderate acute malnutrition (MAM), with many of the most severe cases found in extremely food insecure contexts or conflict situations. Current global outpatient treatment protocols for uncomplicated SAM and MAM, adapted by most countries for use at national level, call for SAM and MAM to be managed separately, however global-level stakeholders have recently begun evaluating simplified and/or combined protocols managing acute malnutrition.

Methods

This study analyzes national policy discussions and decision-making around outpatient acute malnutrition treatment for uncomplicated cases in emergency situations in Niger, Nigeria, Somalia, and South Sudan. Data collection (March–July 2018) included semi-structured in-depth interviews with 50 respondents (N = 11–15 per country) from government, funding agencies, and implementing partners, as well as 11 global and regional stakeholders. We also conducted a document analysis (N = 10–15 per country and at global level) to situate debates and evaluate current policy. Data were analyzed iteratively using thematic content analysis.

Results

We find that while combined/simplified protocols for outpatient management of uncomplicated cases of acute malnutrition are being used in emergency situations in all four countries, there is widespread confusion about protocol terminology and content, stemming from a lack of coherence at the global level. As a result, national-level stakeholders express diverse, if overlapping, rationales for modifying current protocols, which vary given the intensity and scope of the emergency. Without specific global-level guidance, combined/simplified protocols are often used on an ad hoc basis, although the processes for triggering them were at least nominally controlled at the national level. Decisions about when and where to enact “exceptional” modifications to country protocols were often based on inconsistent determinations of what constitutes an “emergency.” Respondents said more evidence is needed on both clinical and operational aspects of these protocols, and they awaited clear guidance from global norm-setting agencies.

Conclusions

Based on these findings, global-level stakeholders should urgently improve coordination and communication around existing protocols. Standardized guidance based on the available evidence is required to clarify best practices for combined management of SAM and MAM, particularly in emergency contexts (which should be defined) and in situations of limited resources. Given the complexity of governance arrangements in conflict situations, both guidance and updates on research must be disseminated in a rational, systematic, and digestible way to the multiplicity of field actors.

Food Insecurity in Europe: A Gender Perspective

Food insecurity is the limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire foods in socially acceptable ways. The study presents a comparison of the principal determinants of individual food insecurity in Europe and other Continents, with particular regard to gender, since the literature clearly states the importance of women in the administration of food in the household. The study of gender related differences in food insecurity is particularly important in Europe, since women experience food insecurity at a larger extent than men, but with a variability related to the geographical distribution and with complex relationships with economic and social drivers. Using a large international sample of individual level data, that allows the analysis for developed Countries for the first time, and the first experiential measure of food insecurity comparable at the global level, the paper analyses the principal determinants of gender differences in food insecurity. In order to verify if women's vulnerability in food insecurity is moderated by specific factors, the modelling approach allows gender to vary by education, poverty, place of residence. The results suggest that the driver that could most mitigate women disadvantage is education: people with a university degree present a lower probability of experiencing food insecurity, both for men and for women. On the contrary, familial characteristics, such as the number of children in the household, present a higher impact on women's food insecurity than on men's.

Towards concerted government efforts? Assessing nutrition policy integration in Uganda

To tackle malnutrition more effectively, Sub-Saharan African governments have developed overarching, integrative policy strategies over the past decade. Despite their popularity, little is known about their follow-up and ultimately their success (or failure). Consequently, tracking the progress of such political commitment has gained global importance. Various studies provide insights into changes in nutrition-related policies. Nevertheless, it is generally acknowledged that we have limited understanding of how nutrition concerns are explicitly addressed in policies of different ministries. This study uses a novel policy integration perspective to investigate the extent to which eight ministries in Uganda integrated nutrition concerns across their policy outputs between 2001 and 2017. The approach used assumes nutrition policy integration is a dynamic process occurring in different policy dimensions. We performed a qualitative content analysis to assess 103 policy outputs for changes in subsystems involved, policy goals, and instruments used. Overall, we found a shift towards increased integrated government action on nutrition over time. The 2011–2015 analysis period was a critical juncture where increased integration of nutrition was observed in all policy integration dimensions across all ministries. However, considerable variations in actor networks, goals, and instruments exist across sectors and over time. The sustainability of nutrition integration efforts remains contentious, because of which continuous monitoring will be essential.