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Barnett I, Meeker J, Roelen K, Nisbett N. Behaviour change communication for child feeding in social assistance: A scoping review and expert consultation. MATERNAL & CHILD NUTRITION 2022; 18:e13361. [PMID: 35502622 PMCID: PMC9218306 DOI: 10.1111/mcn.13361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/29/2022]
Abstract
To increase the effectiveness of social assistance on child nutrition, programmes are increasingly combined with behaviour change communication for improved infant and young child feeding (BCC for IYCF). Unfortunately, there is limited knowledge about which BCC strategies are most effective when combined with social assistance. A systematic scoping review and an expert consultation was conducted to (1) describe the landscape of BCC for IYCF strategies used in social assistance within low‐ and middle‐income countries and (2) to examine the effects of these BCC strategies on IYCF practices and child nutrition. Ten quantitative, three qualitative and four mixed methods studies were reviewed and complemented by 12 expert consultations carried out between August and October 2020. In most of the studies attendance in BCC for IYCF was conditional for receiving social assistance, although experts agreed that this conditionality may be counterproductive. A variety of BCC strategies were used with two being most common—group sessions with pre‐determined topics and individual counselling. Context‐specific adaptation, interactive delivery and building on existing IYCF knowledge emerged as crucial but was perceived as economically infeasible in social assistance programmes. Given the variety of BCC strategies and inconsistency in outcomes, it is impossible to draw conclusions regarding effectiveness. Nevertheless, tentative evidence suggests that the promotion of existing nutrition services, educational group sessions and individual counselling may be effective in improving IYCF. BCC for IYCF can make social assistance more beneficial, but may increase costs, demands on beneficiaries, and deviate from the original focus of the programmes. Findings suggest that integrating BCC for IYCF in social assistance programmes can be beneficial for young children, however, it may increase the costs of the programme, create additional demands on beneficiaries and may deviate the original focus of the programme. Most BCC for IYCF in social assistance programmes used two different behaviour change strategies (with group session with pre‐determined topics and individual nutrition counselling being most common). However, there is limited evidence on what BCC strategies (as part of social assistance) change behaviours most effectively. Formative research is important for the design and implementation of context‐specific BCC that builds on existing IYCF knowledge but can be time‐and resource‐consuming to develop and may thus be economically infeasible within social assistance programmes.
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Affiliation(s)
- Inka Barnett
- Institute of Development Studies (IDS) University of Sussex Brighton UK
| | - Jessica Meeker
- Institute of Development Studies (IDS) University of Sussex Brighton UK
| | - Keetie Roelen
- Institute of Development Studies (IDS) University of Sussex Brighton UK
| | - Nick Nisbett
- Institute of Development Studies (IDS) University of Sussex Brighton UK
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Unar-Munguía M, Lozada-Tequeanes AL, González-Castell D, Cervantes-Armenta MA, Bonvecchio A. Breastfeeding practices in Mexico: Results from the National Demographic Dynamic Survey 2006-2018. MATERNAL AND CHILD NUTRITION 2020; 17:e13119. [PMID: 33325133 PMCID: PMC7988861 DOI: 10.1111/mcn.13119] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/06/2020] [Accepted: 11/18/2020] [Indexed: 12/19/2022]
Abstract
Although actions have been taken to improve breastfeeding in Mexico, trends over the last decade and their associated factors have not been analysed. We estimated trends in breastfeeding practices at the national, rural/urban, and regional level indigenous ethnicity and socio-economic level, and their associated factors using the National Demographic Dynamics Survey (2006, 2009, 2014 and 2018). We assessed breastfeeding indicators of women with children <24 months according to The World Health Organization recommendations. Logistic regressions models of pooled data were used to estimate trends and associations with biological and sociodemographic characteristics. Between 2006 and 2018, the prevalence of ever breastfed increased from 91.8% to 94.2% (p < 0.001), whereas early initiation of breastfeeding increased from 40.8% to 59.7% (p < 0.001), with similar increments by urban/rural level. Between 2009 and 2018, the prevalence of exclusive breastfeeding in children <6 months increased from 13.0% to 20.7% (p < 0.001). The largest increase was seen in Mexico City, in nonindigenous women and those with a high socio-economic status, whereas indigenous women and those from the South had the lowest or no improvements. Breastfeeding education during pregnancy [odds ratio (OR) 1.3; 95% confidence interval (CI) 1.1-1.5] was positively associated with exclusive breastfeeding, whereas being employed (OR 0.8; 95% CI 0.6-0.9) was negatively associated. Breastfeeding practices improved but are still far from recommendations. Implementing strategies like breastfeeding counselling and programmes and policies that promote and support breastfeeding for poor, indigenous, single and working mothers should be a priority for the government to ensure that all children have the best start in life.
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Affiliation(s)
- Mishel Unar-Munguía
- Center for Research on Health and Nutrition, National Institute of Public Health, Cuernavaca, Mexico
| | | | - Dinorah González-Castell
- Center for Research on Health and Nutrition, National Institute of Public Health, Cuernavaca, Mexico
| | | | - Anabelle Bonvecchio
- Center for Research on Health and Nutrition, National Institute of Public Health, Cuernavaca, Mexico
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Robert RC, Bartolini RM, Creed-Kanashiro HM, Verney Sward A. Using formative research to design context-specific animal source food and multiple micronutrient powder interventions to improve the consumption of micronutrients by infants and young children in Tanzania, Kenya, Bangladesh and Pakistan. MATERNAL AND CHILD NUTRITION 2020; 17:e13084. [PMID: 33064374 PMCID: PMC7988862 DOI: 10.1111/mcn.13084] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 07/31/2020] [Accepted: 09/01/2020] [Indexed: 01/26/2023]
Abstract
Optimal complementary feeding practices including consumption of multiple micronutrient powders (MNP) are recommended to improve micronutrient intake by infants and young children (IYC) 6-23 months. Formative research was used to design the behaviour change strategy to improve IYC micronutrient intake for the multicountry ENRICH project in rural impoverished areas of Tanzania, Kenya, Bangladesh and Pakistan. Employing a qualitative approach with multiple methods and guided by a social ecological framework, the study was conducted in several phases: data collection in the community, household and health facilities, initial analysis and household trials (HHT). Results found limited use of animal source foods (ASF) for feeding IYC and MNP largely unavailable. Although cost constrained access to ASF, potential more affordable context-specific ASF options were identified in each setting. Caregivers associated ASF with many positive attributes for IYC, but barriers to feeding them included lack of caregiver time and knowledge of specific preparation techniques, and limited advice from health workers. Feeding practices were identified that used time-efficient, specific preparations for eggs and other ASF, and demonstrated good initial acceptability and feasibility during HHT. Testing MNP in HHT found good initial feasibility and acceptability and provided an understanding of the facilitators and constraints for preparing, feeding and promoting MNP. In conclusion, formative research led to the design of context-specific ASF and MNP complementary feeding promotion strategies to improve IYC consumption of micronutrients by identifying the practices, benefits, motivations and alternative actions to overcome the barriers in each setting.
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Affiliation(s)
- Rebecca C Robert
- Conway School of Nursing, The Catholic University of America, Washington, D.C., USA.,Instituto de Investigación Nutricional, Lima, Peru
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Vilar-Compte M, Pérez-Escamilla R, Moncada M, Flores D. How much can Mexican healthcare providers learn about breastfeeding through a semi-virtual training? A propensity score matching analysis. Int Breastfeed J 2020; 15:59. [PMID: 32600367 PMCID: PMC7322928 DOI: 10.1186/s13006-020-00297-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 06/02/2020] [Indexed: 02/01/2023] Open
Abstract
Background Mexico has shown a worrisome decrease in breastfeeding indicators, especially in the lowest socioeconomic level. Improving breastfeeding protection, promotion, and support services through workforce development is a key area of intervention. The objective of this study is to assess the influence on breastfeeding knowledge and abilities of a semi-virtual training for primary healthcare providers assisting beneficiaries of PROSPERA in Mexico, which is one of the largest conditional cash-transfer programs in the world. Methods Two independent cross-sectional samples of healthcare providers were drawn at baseline and post-intervention in three states of Mexico. Baseline data were collected among primary physicians, registered nurses and nurse technicians (i.e. unit of analysis) on July 2016 (n = 529) and post-training between March and April 2017 (n = 211). A 19-item telephone questionnaire assessed providers’ general knowledge about breastfeeding, breastfeeding benefits and clinical aspects of breastfeeding, clinical ability to solve problems and abilities to overcome breastfeeding challenges. The effects of the training were assessed through a propensity score matching (PSM) stratified by types of providers (i.e. physicians, registered nurses, nurse technicians). Results The PSM analysis showed significant improvements among all providers in the general knowledge about breastfeeding (around 20 percentage points [pp]) and knowledge about breastfeeding benefits (approximately 50 pp). In addition, physicians improved their knowledge about clinical aspects of breastfeeding (7 pp), while registered nurses improved in their ability to solve breastfeeding problems (14 pp) and in helping mothers overcome breastfeeding challenges (12 pp). Conclusions Promoting a breastfeeding enabling environment in Mexico to improve breastfeeding rates will require improving the knowledge and skills of healthcare providers. While a semi-virtual training showed large improvements in knowledge, developing skills among providers may require a more intensive approach.
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Affiliation(s)
- Mireya Vilar-Compte
- Research Institute for Equitable Development EQUIDE, Universidad Iberoamericana, Mexico City, Mexico.
| | - Rafael Pérez-Escamilla
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Meztli Moncada
- Research Institute for Equitable Development EQUIDE, Universidad Iberoamericana, Mexico City, Mexico
| | - Diana Flores
- Research Institute for Equitable Development EQUIDE, Universidad Iberoamericana, Mexico City, Mexico
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Bonvecchio Arenas A, González W, Théodore FL, Lozada-Tequeanes AL, Garcia-Guerra A, Alvarado R, Fernández-Gaxiola AC, Rawlinson CJ, de la Vega AV, Neufeld LM. Translating Evidence-Based Program Recommendations into Action: The Design, Testing, and Scaling Up of the Behavior Change Strategy EsIAN in Mexico. J Nutr 2019; 149:2310S-2322S. [PMID: 31793647 DOI: 10.1093/jn/nxz229] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/24/2019] [Accepted: 08/29/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The Integrated Strategy for Attention to Nutrition (EsIAN in Spanish) is a national strategy within Mexico's conditional cash transfer program (initially Progresa, then Oportunidades, then Prospera, CCT-POP) designed to strengthen the health and nutrition component, address the nutrition transition, and improve the health and nutritional status of its beneficiaries, through 3 main components: 1) procurement of functioning equipment to primary health care (PHC) units; 2) providing free micronutrient supplements to beneficiary women and children; 3) implementing a behavior change communication (BCC) strategy and a training system for PHC providers (PHCPs). OBJECTIVE We aim to describe the iterative process and evidence-based approach used to design and roll-out the EsIAN at scale, by focusing on the BCC component. METHODS The BCC strategy was developed by following an iterative process through the following phases: situational analysis, formative research and design of the BCC strategy (using the socioecological framework and the social marketing approach), large-scale feasibility study, redesign, and national scale-up. RESULTS The review and formative research revealed several barriers and issues that limited program coverage, utilization, and acceptance. These included misconceptions about pregnancy and infant feeding, nonalignment of practices with international recommendations, and lack of knowledge on nutrition and related topics, among others. These results were used to identify priority behaviors and elaborate key messages for mothers/caregivers and providers to develop the BCC strategy. The feasibility study resulted in significant improvements in PHCPs' knowledge, counseling (breastfeeding, and supplement use and consumption), and caregivers' complementary feeding behaviors, and highlighted several design and delivery aspects that needed strengthening. Based on these findings, the BCC strategy was adapted prior to a national scale-up. CONCLUSIONS The theory-based iterative approach resulted in the identification of specific actions to target, and approaches to do so, as part of the design and roll-out of the BCC strategy at scale.
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Affiliation(s)
- Anabelle Bonvecchio Arenas
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Wendy González
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Florence L Théodore
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Ana Lilia Lozada-Tequeanes
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Armando Garcia-Guerra
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Rocio Alvarado
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Ana C Fernández-Gaxiola
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
| | - Cloe J Rawlinson
- Centro de Investigación en Nutrición y Salud (CINyS), Instituto Nacional de Salud Pública, Cuernavaca, Mor., México
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Neufeld LM, García-Guerra A, Quezada AD, Théodore F, Bonvecchio Arenas A, Islas CD, Garcia-Feregrino R, Hernandez A, Colchero A, Habicht JP. A Fortified Food Can Be Replaced by Micronutrient Supplements for Distribution in a Mexican Social Protection Program Based on Results of a Cluster-Randomized Trial and Costing Analysis. J Nutr 2019; 149:2302S-2309S. [PMID: 31793645 PMCID: PMC6888020 DOI: 10.1093/jn/nxz176] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/28/2019] [Accepted: 07/03/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Despite positive nutrition impacts, the prevalence of malnutrition among beneficiaries of Mexico's conditional cash transfer (CCT) program remains high. Greater nutrition impact may have been constrained by the type of nutritional supplements provided. OBJECTIVE The objective of this study was to inform a potential modification to the supplements distributed to pregnant and lactating women and children. METHODS Impact was assessed using 2 cluster-randomized trials (pregnant women, children) run simultaneously. Communities (n = 54) were randomly assigned to the fortified foods provided by the program (Nutrivida women, Nutrisano children) or alternatives: tablets (women), syrup (children), or micronutrient powders for women (MNP-W) and children (MNP-C). Each supplement for women/children contained the same micronutrients based on the formulations of Nutrivida and Nutrisano, respectively. Pregnant women (aged >18 y) were recruited before 25 weeks of gestation and followed to 3 mo postpartum. Children aged 6-12 mo were recruited and followed to age 24 mo. Primary outcomes were anemia for women and length growth for children. Statistical analyses appropriate for cluster-randomized designs were used, and structural equation modeling to estimate dose-response effects. Supplement costs per beneficiary (daily dose for 18 mo) were estimated for production and distribution. RESULTS There was no significant difference in change of anemia prevalence between supplement groups in women, or in length growth between groups in children. One daily dose of any supplement was associated with 0.8 cm greater length growth. From baseline to age 24 mo, the prevalence of anemia in the Nutrisano, syrup, and MNP-C groups decreased by 36.7, 40.8, and 37.9 percentage points, respectively (within-group, P < 0.05; between groups, P > 0.05). Costs per beneficiary ranged from $12.1 (MNP-C) to $94.8 (Nutrivida). CONCLUSIONS The CCT program could distribute alternative supplements at lower cost per beneficiary without compromising potential for impact. Acceptance among beneficiaries should also be considered in choice of alternatives. This trial was registered at www.clinicaltrials.gov as NCT00531674.
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Affiliation(s)
| | - Armando García-Guerra
- Center for Research in Nutrition and Health, National Institute of Public Health, Santa María Ahuacatitlán, Cuernavaca, Morelos, Mexico
| | - Amado D Quezada
- Center for Research in Nutrition and Health, National Institute of Public Health, Santa María Ahuacatitlán, Cuernavaca, Morelos, Mexico
| | - Florence Théodore
- Center for Research in Nutrition and Health, National Institute of Public Health, Santa María Ahuacatitlán, Cuernavaca, Morelos, Mexico
| | - Anabelle Bonvecchio Arenas
- Center for Research in Nutrition and Health, National Institute of Public Health, Santa María Ahuacatitlán, Cuernavaca, Morelos, Mexico
| | - Clara Domínguez Islas
- Fred Hutchinson Cancer Research Center, Vaccine and Infectious Disease Division, Seattle, WA, USA
| | - Raquel Garcia-Feregrino
- Center for Research in Nutrition and Health, National Institute of Public Health, Santa María Ahuacatitlán, Cuernavaca, Morelos, Mexico
| | - Amira Hernandez
- Center for Research in Nutrition and Health, National Institute of Public Health, Santa María Ahuacatitlán, Cuernavaca, Morelos, Mexico
| | - Arantxa Colchero
- Center for Research in Nutrition and Health, National Institute of Public Health, Santa María Ahuacatitlán, Cuernavaca, Morelos, Mexico
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Théodore FL, Bonvecchio Arenas A, García-Guerra A, García IB, Alvarado R, Rawlinson CJ, Neufeld LM, Pelto GH. Sociocultural Influences on Poor Nutrition and Program Utilization of Mexico's Conditional Cash Transfer Program. J Nutr 2019; 149:2290S-2301S. [PMID: 31793644 DOI: 10.1093/jn/nxz181] [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: 05/07/2019] [Revised: 06/17/2019] [Accepted: 07/11/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze. OBJECTIVES We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program. METHODS We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions. RESULTS Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions. CONCLUSIONS Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented.
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Affiliation(s)
- Florence L Théodore
- Center for Research in Nutrition and Health, National Institute of Public Health, Mexico, Cuernavaca, Mexico
| | - Anabelle Bonvecchio Arenas
- Center for Research in Nutrition and Health, National Institute of Public Health, Mexico, Cuernavaca, Mexico
| | - Armando García-Guerra
- Center for Research in Nutrition and Health, National Institute of Public Health, Mexico, Cuernavaca, Mexico
| | - Ilian Blanco García
- Center for Research in Nutrition and Health, National Institute of Public Health, Mexico, Cuernavaca, Mexico
| | - Rocío Alvarado
- Center for Research in Nutrition and Health, National Institute of Public Health, Mexico, Cuernavaca, Mexico
| | - Cloe J Rawlinson
- Center for Research in Nutrition and Health, National Institute of Public Health, Mexico, Cuernavaca, Mexico
| | | | - Gretel H Pelto
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
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Habicht JP, Pelto GH. Program Impact Pathways and Contexts: A Commentary on Theoretical Issues and Research Applications to Support the EsIAN Component of Mexico's Conditional Cash Transfer Program. J Nutr 2019; 149:2332S-2340S. [PMID: 31793643 PMCID: PMC6887728 DOI: 10.1093/jn/nxz221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/11/2019] [Accepted: 08/21/2019] [Indexed: 11/16/2022] Open
Abstract
This commentary on the Integrated Strategy for Attention to Nutrition (EsIAN) journal supplement begins with a discussion about the challenges that implementation researchers confront with respect to analyzing complex impact pathways. We note that the research on the implementation of the EsIAN component of Mexico's conditional cash transfer program was based implicitly or explicitly on a program impact pathway approach, which used both quantitative and qualitative methods to examine bottlenecks in program implementation. We then identify 5 categories of contexts that affect the impact, implementation, and survival of intervention programs: 1) biological, 2) social-cultural, 3) delivery modalities and platforms, 4) bureaucratic, and 5) political. Each of these contexts presents theoretical and methodological challenges for investigators. In this commentary, we focus primarily on biological and social-cultural contexts, discussing the theoretical and methodological challenges the investigators faced and the research strategies they used to address them, which have produced a unique compilation of "learning by doing" studies. We also touch briefly on the political context in which the Prospera program research was conducted. We conclude with statements that highlight the exceptional value of the journal supplement, not only with respect to the analysis of the interventions the studies cover and the sustained examination of a long-term program but also as a major contribution to the literature in implementation science in nutrition.
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Affiliation(s)
| | - Gretel H Pelto
- Division Nutritional Sciences, Cornell University, Ithaca, NY, USA
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Neufeld LM, Grados R, Villa de la Vega A, Steta C, Regalia F, Rivera-Dommarco JA. A Brief History of Evidence-Informed Decision Making for Nutrition in Mexico. J Nutr 2019; 149:2277S-2280S. [PMID: 31793646 PMCID: PMC6887934 DOI: 10.1093/jn/nxz188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 06/20/2019] [Accepted: 07/18/2019] [Indexed: 11/18/2022] Open
Abstract
The Progresa Conditional Cash Transfer program in Mexico began in 1997, with a strong evidence-based design. The program's ultimate objective was to foster the development of human capital through 3 components-education, health, and food. Rigorous impact evaluation generated evidence of impact on several outcomes, including child growth, but also aspects of program design and implementation challenges that may have limited impact. The objective of this supplement is to present research that led to the redesign of the health component, its implementation and evaluation at pilot scale, and its scale-up to national level, representing >15 y of collaboration among evaluators, program implementers, and funders. The studies used various methodologies, including process evaluation, cohort studies, ethnographic assessments, and a cluster-randomized trial, among others. The articles report previously unpublished results and citations of published literature. Article 1 uses an impact pathway to highlight gaps and bottlenecks that limited potential for greater impact, the original recognition of which was the impetus for this long collaboration. Article 2 explores the social and cultural factors that influence decisions to participate in programs and to adopt the actions proposed by them. Article 3 presents a cluster-randomized trial implemented to inform the choice of nutritional supplements for pregnant and lactating women and children 6-59 mo of age and how this and other evidence from the studies were used to redesign the health component of the program. Articles 4 and 5 present results of the development and pilot testing of the modified health component, the Integrated Strategy for Attention to Nutrition (abbreviated to EsIAN from its name in Spanish) (article 4), and the process and challenges of training and supervision in taking the EsIAN to scale (article 5). The final article provides reflections on the relevance of this body of work for implementation research in nutrition.
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Affiliation(s)
| | - Rogelio Grados
- National Coordination of the Prospera Program of Social Inclusion, Mexico City, Mexico
| | | | - Concepción Steta
- Department of Social Protection and Jobs, Latin America and Caribbean, The World Bank, Washington, DC, USA
| | - Ferdinando Regalia
- Social Protection and Health Division, Inter-American Development Bank, Washington, DC, USA
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García-Guerra A, Neufeld LM, Bonvecchio Arenas A, Fernández-Gaxiola AC, Mejía-Rodríguez F, García-Feregrino R, Rivera-Dommarco JA. Closing the Nutrition Impact Gap Using Program Impact Pathway Analyses to Inform the Need for Program Modifications in Mexico's Conditional Cash Transfer Program. J Nutr 2019; 149:2281S-2289S. [PMID: 31793648 PMCID: PMC6887996 DOI: 10.1093/jn/nxz169] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/08/2019] [Accepted: 06/26/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Mexico's Prospera-Oportunidades-Progresa Conditional Cash Transfer Program (CCT-POP) included the distribution of fortified food supplements (FFS) for pregnant and lactating women and young children. Rigorous evaluations showed significant impacts on nutrition outcomes but also substantial gaps in addressing nutrition problems. OBJECTIVES To highlight the program design-related and implementation-related gaps and challenges that motivated further research and the eventual design and roll-out of a modified nutrition component for CCT-POP. METHODS We used a program impact pathway approach to highlight the extent and quality of implementation of CCT-POP, and its impact on nutrition outcomes. We drew on previously published and new primary data, organized into 3 sources: impact evaluations, studies to inform reformulation of the FFS, and a longitudinal follow-up study using qualitative and quantitative methods to document FFS use and the dietary intake of women and children. RESULTS Despite positive impacts, a high prevalence of malnutrition persisted in the population. Coverage and use of health services improved, but quality of care was lacking. Consumption of FFS among lactating women was irregular. Micronutrient intake improved among children who consumed FFS, but the pattern of use limited frequency and quantity consumed. Substantial diversity in the prevalence of undernutrition was documented, as was an increased risk of overweight and obesity among women. CONCLUSIONS Three key design and implementation challenges were identified. FFS, although well accepted for children, had limited potential to substantially modify the quality of children's diets because of the pattern of use in the home. The communications strategy was ineffective and ill-suited to its objective of motivating FFS use. Finally, the program with its common design across all regions of Mexico was not well adapted to the special needs of some subgroups, particularly indigenous populations. The studies reviewed in this paper motivated additional research and the eventual redesign of the nutrition component.
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Affiliation(s)
- Armando García-Guerra
- Instituto Nacional de Salud Pública México (INSP), Cerrada Los Pinos y Caminera, Cuernavaca, Morelos, Mexico
| | | | - Anabelle Bonvecchio Arenas
- Instituto Nacional de Salud Pública México (INSP), Cerrada Los Pinos y Caminera, Cuernavaca, Morelos, Mexico
| | - Ana C Fernández-Gaxiola
- Instituto Nacional de Salud Pública México (INSP), Cerrada Los Pinos y Caminera, Cuernavaca, Morelos, Mexico
| | - Fabiola Mejía-Rodríguez
- Instituto Nacional de Salud Pública México (INSP), Cerrada Los Pinos y Caminera, Cuernavaca, Morelos, Mexico
| | - Raquel García-Feregrino
- Instituto Nacional de Salud Pública México (INSP), Cerrada Los Pinos y Caminera, Cuernavaca, Morelos, Mexico
| | - Juan A Rivera-Dommarco
- Instituto Nacional de Salud Pública México (INSP), Cerrada Los Pinos y Caminera, Cuernavaca, Morelos, Mexico
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