Effect of enhanced homestead food production on anaemia among Cambodian women and children: A cluster randomized controlled trial

Designing nutrition-sensitive agriculture (NSA) interventions with multi-criteria decision analysis (MCDA): a review

Despite the efforts to end malnutrition through intensive agriculture of caloric crops, micronutrient deficiencies and other forms of malnutrition persist in vulnerable communities worldwide. Nutrition-sensitive agriculture (NSA) interventions are recognized as chances to address the causes of malnutrition. In this work, the different types of NSA interventions were explored, as well as the pathways through which they can improve nutrition (e.g., increasing biofortified crops and income generation via agricultural sales for a positive impact on access to nutritious foods, and simultaneously involving nutrition education to improve care practices and eventually nutritional status). Some NSA interventions focus on one pathway. Well-designed interventions, however, should follow multi-pathway approaches targeting the underlying causes of undernutrition within the selected population. The circumstances in which certain indicators should be used to measure the impact of an NSA intervention in each stage of the full pathway were also explained, as well as the need of enhancing the design of such interventions. Multi-criteria decision analysis (MCDA) has been employed to solve agriculture-related issues, but it has not been used to identify the optimal types of NSA interventions, metrics, and indicators based on the context of the community, priorities and objectives of the project managers and designers, etc.

Ownership of small livestock species, but not aggregate livestock, is associated with an increased risk of anemia among children in Ethiopia: A propensity score matching analysis

Consumption of animal source foods, through livestock production, improves children's growth and micronutrient status. However, research on the relationship between livestock ownership and childhood anemia has produced conflicting results. The current study used robust analytical approaches to examine the effect of household livestock ownership on children's anemia using the most recent secondary data from the national demographic and health survey. We followed a 1:1 closest neighborhood propensity score matching analysis. A propensity score was generated using the binary logistic regression model to compute the probability of owning livestock. From a total of 18,008 households enrolled in the latest Ethiopian Demographic and Health Survey (EDHS 2016), data of 721 index children aged 6-59 months from households owning livestock were matched with a comparable number (721) of children from households without livestock. The paired and independent t-test, matched relative risk (RR), and standardized mean differences were used to compare the distributions of hemoglobin concentration and anemia risks between treatment and control groups. Anemia was found in more than half (54.1% and 58.8%) of children aged 6-59 months from livestock-owning and nonowning families, respectively (p > .05). Aggregate ownership of livestock was not associated with hemoglobin concentration or anemia status (RR = 0.95, 95% confidence interval [95% CI] [0.87-1.04]). Species-wise, poultry was associated with a lower (RR = 0.88, 95% CI [0.84-0.95]) anemia risk, while ownership of goat/sheep was associated with higher (RR = 1.10, 95% CI [1.03-1.17]) risk. In conclusion, ownership of small livestock species (sheep/goats and poultry), but not aggregate livestock ownership, was associated with the risk of anemia among children in Ethiopia. Therefore, agriculture-sensitive nutrition, with a One Health lens approach, is recommended to mitigate the high burden of anemia among children in Ethiopia. In the future, a well-controlled interventional study with more extended periods may be required to fully understand the effects of livestock production and highlight the differences seen across livestock species.

Effect of an Integrated School Garden and Home Garden Intervention on Anemia Among School-Aged Children in Nepal: Evidence From a Cluster Randomised Controlled Trial

BACKGROUND

Integrated school and home garden interventions can improve health outcomes in low-income countries, but rigorous evidence remains scarce, particularly for school-aged children and to reduce anemia.

OBJECTIVE

We test if an integrated school and home garden intervention, implemented at pilot stage, improves hemoglobin levels among school children (aged 9-13 years) in a rural district in the mid-hills of Nepal.

METHODS

We use a cluster randomized controlled trial with 15 schools each in the control and treatment groups (n = 680 school children). To test if nutritional improvements translate into a reduction of anemia prevalence, hemoglobin data were collected 6 months after intervention support had ended. Using structural equation modeling, we estimate the direct and indirect effects of the treatment through several pathways, including nutritional knowledge, good food and hygiene practices, and dietary diversity.

RESULTS

The integrated school and home garden intervention did not lead to a direct significant reduction in anemia. Causal positive changes of the treatment on nutritional outcomes, although significant, are not strong enough to impact hemoglobin levels. The program improved hemoglobin levels indirectly for children below 12 by increasing the use of good food and hygiene practices at home. These practices are associated with higher hemoglobin levels, particularly for girls, young children, and in households where caregivers are literate.

CONCLUSIONS

Even integrated school and home garden interventions are not sufficient to reduce anemia among school children. Incorporating behavioral change components around food and hygiene practices into integrated garden interventions is important to unlocking their health impacts.

Qualitative evidence for improved caring, feeding and food production practices after nutrition-sensitive agriculture interventions in rural Vietnam

Background

Research on nutrition-sensitive agriculture (NSA) has mostly been aimed at demonstrating its impact on nutrition and explicating underlying pathways, and more rarely at understanding processes and lessons learnt from them. This study aimed to gain insights into the processes that influence behaviour change, contributing to improved caring, feeding and food production practices, using a program theory perspective. It also investigated perceived challenges to the sustainability of interventions and potential solutions, in the context of an NSA program in rural Vietnam. Using a participatory approach, data were gathered on impact pathways and perceived outcomes, on elements of program theory that led to behavioural change, as well as barriers and facilitators. Respondents in semi-structured interviews (n = 30) and seven focus group discussions (total n = 76) were selected purposively among program participants. Data was collected and triangulated across several stakeholder groups.

Results

The impact pathways (production-consumption, caring and feeding, and home-grown school feeding) envisaged in the NSA program functioned as intended; synergies were revealed. The increased supply of locally produced nutrient-rich foods not only contributed to the emergence of a promising income sub-pathway but also reinforced synergy with the home-grown school feeding pathway. Improved diets, feeding and caring practices, and school attendance were key outcomes of the program. Successful elements were pathway-specific, such as flexibility in implementing context-appropriate agricultural models. Others, such as benefit-driven motivation and improved knowledge, triggered changes in multiple pathways. Role models, increased self-confidence, and change agents were the main process facilitators. The biggest barrier to both implementation and sustainability was the poor socio-economic conditions of the most disadvantaged households.

Conclusions

This study showed the relevance of NSA programs in addressing undernutrition in remote areas by enhancing self-reliance in local communities. The integration of behaviour change activities proved to be a key strategy in the process to enhance the impact of agriculture on nutrition outcomes. Though outcomes and influencing factors are very context-dependent, lessons on what worked and what did not work could inform the design and implementation of effective behaviour change strategies in future NSA programs in Vietnam and elsewhere.

Effect of integrated nutrition-sensitive and nutrition-specific intervention package on maternal malnutrition among pregnant women in Rwanda

Maternal undernutrition remains a major public health concern in Rwanda despite significant gains and progress. An integration of nutrition-specific and nutrition-sensitive interventions was implemented in five districts of Rwanda to improve maternal and child nutrition. The package included nutrition education and counselling, promotion of agricultural productivity, promotion of financial literacy/economic resilience and provision of Water, Hygiene and Sanitation services. However, there is limited evidence about the effect of such interventions in reducing maternal undernutrition. A postintervention quasi-experimental study was conducted among pregnant women to determine the effect of the integrated intervention on their nutritional status. It was carried out in two intervention districts, namely Kicukiro and Kayonza, and two control districts, namely Gasabo and Gisagara between November 2020 and June 2021. Five hundred and fifty-two women were recruited for the intervention arm, while 545 were recruited for the control arm. Maternal undernutrition was defined as either having low mid-upper arm circumference (<23 cm) during delivery or low body mass index (<18.5 kg/m2 ) in the first trimester or both. A multivariable logistic regression model was used to assess the effect of the integrated interventions. The prevalence of maternal undernutrition was significantly lower in the intervention group compared with the control group (4.7% vs. 18.2%; p < 0.001). After controlling the potential confounders, the risk of maternal undernutrition was 77.0% lower in the intervention group than in the control group [adjusted odds ratio= 0.23; 95% confidence interval = 0.15-0.36; p < 0.001]. Further studies are therefore recommended to establish causation and inform the potential scale-up of these interventions nationally in Rwanda.

Are home gardening programs a sustainable way to improve nutrition? Lessons from a cluster-randomized controlled trial in Rufiji, Tanzania

Homestead food production (HFP) programs may improve diet and nutrition outcomes by increasing availability of nutrient dense foods such as vegetables and supporting livelihoods. We conducted a pair-matched cluster-randomized controlled trial to investigate whether vegetable home gardens could improve women's dietary diversity, household food security, maternal and child iron status, and the probability of women consuming nutrient-rich food groups. We enrolled 1,006 women of reproductive age (18-49 years) in ten villages in Pwani Region, Eastern Tanzania, matched the villages into pairs according to village characteristics, and randomly allocated villages to intervention or control. Households in the intervention villages received agricultural training, inputs to promote home production of nutritious crops, and nutrition and health education. Data were collected in 2016, 2017, and 2019 and analyzed using linear regression models with propensity score weighting adjusting for individual-level confounders, differential loss to follow-up, and fixed effects for village pairs to accommodate the pair-matched design. Results after one year of the intervention (previously published) found significant improvements in dietary diversity. However, three years after the start of the intervention the difference in dietary diversity disappeared, even though the number of women who grew at least one crop was significantly higher (75 percentage points, 95% CI: 72, 81) in treatment households compared to controls. Barriers to maintaining a home garden, including lack of irrigation opportunities and fencing materials, and social disruption may have precluded sustained impacts from home gardening in this context. Future home garden programs should carefully consider mechanisms and investments needed for sustained impact over time.

Impact and distributional effects of a home garden and nutrition intervention in Cambodia

Home garden interventions combining training in agriculture and nutrition have the potential to increase vegetable production and consumption in lower-income countries, but there remains a need for better evidence for impact. This study contributes to filling this gap by evaluating the impact and distributional effects of a home garden intervention in Cambodia. We used a cluster randomized controlled trial with before and after data for a sample of 500 rural households with children under five and women 16–49 years old. Impact was estimated using analysis of covariance (ANCOVA) and conditional quantile regressions with non-parametric bounds. The results show that the intervention significantly increased the adoption of nearly all promoted gardening methods. More households (+ 35%; p < 0.01) produced vegetables, and the production period was extended by five months on average. One-month recall data show an increase in vegetables harvested (+ 25 kg; p < 0.01) and consumed (+ 10 kg; p < 0.01) from the garden. Quantile regressions confirm these findings and show that nearly all households benefitted, but households that were already doing better at baseline tended to benefit more. Seven-day recall data show an increase in the quantity of vegetables consumed (+ 61 g/day/capita; p < 0.01) and an increased quantity of vitamin A, folate, iron, and zinc contained in these vegetables. Women contributed more to the garden work than men and their time spent in the garden increased by 29 min/day on average. These results add further evidence that integrated home garden interventions can contribute to nutrition outcomes and that almost all participants can benefit.

Aquaculture for improving productivity, income, nutrition and women's empowerment in low- and middle-income countries: A systematic review and meta-analysis

Background

A steady increase in the international production and consumption of fish has positioned aquaculture as a development option. Previous literature has highlighted the potential of aquaculture to improve economic, nutritional and gender equality outcomes, however, the evidence on the effectiveness of these programmes remains unclear.

Objectives

The review assessed whether aquaculture interventions increase the productivity, income, nutrition, and women's empowerment of individuals. We additionally aimed to identify barriers and facilitators that could affect the effectiveness of these interventions, and the cost-effectiveness of such programmes.

Methods

We searched for experimental and quasi-experimental studies focused on low- and middle-income countries. We used standard methodological procedures expected by The Campbell Collaboration for the data collection and analysis.

Results

We identified 21 impact evaluations assessing the effect of 13 aquaculture interventions in low- and lower-middle income countries. Twelve of these studies have a high risk of bias. Aquaculture interventions lead to a small increase in the production value, income, total expenditures and food consumption of participants. The limited availability of evidence prevented us from assessing other nutritional and women's empowerment outcomes. We identified barriers and facilitators affecting the programmes' set up, the participation of beneficiaries, and the level of productive activities. Insufficient cost data hindered full comparisons across programmes.

Conclusions

The review suggests a lack of rigorous evidence assessing the effectiveness of aquaculture programmes. Future research could focus on evaluating nutrition and women's empowerment impacts, promoting reporting standards, and the use of cost data to continue building quality evidence around aquaculture interventions.

Effect of nutrition-sensitive agriculture interventions with participatory videos and women's group meetings on maternal and child nutritional outcomes in rural Odisha, India (UPAVAN trial): a four-arm, observer-blind, cluster-randomised controlled trial

BACKGROUND

Almost a quarter of the world's undernourished people live in India. We tested the effects of three nutrition-sensitive agriculture (NSA) interventions on maternal and child nutrition in India.

METHODS

We did a parallel, four-arm, observer-blind, cluster-randomised trial in Keonjhar district, Odisha, India. A cluster was one or more villages with a combined minimum population of 800 residents. The clusters were allocated 1:1:1:1 to a control group or an intervention group of fortnightly women's groups meetings and household visits over 32 months using: NSA videos (AGRI group); NSA and nutrition-specific videos (AGRI-NUT group); or NSA videos and a nutrition-specific participatory learning and action (PLA) cycle meetings and videos (AGRI-NUT+PLA group). Primary outcomes were the proportion of children aged 6-23 months consuming at least four of seven food groups the previous day and mean maternal body-mass index (BMI). Secondary outcomes were proportion of mothers consuming at least five of ten food groups and child wasting (proportion of children with weight-for-height Z score SD <-2). Outcomes were assessed in children and mothers through cross-sectional surveys at baseline and at endline, 36 months later. Analyses were by intention to treat. Participants and intervention facilitators were not blinded to allocation; the research team were. This trial is registered at ISRCTN, ISRCTN65922679.

FINDINGS

148 of 162 clusters assessed for eligibility were enrolled and randomly allocated to trial groups (37 clusters per group). Baseline surveys took place from Nov 24, 2016, to Jan 24, 2017; clusters were randomised from December, 2016, to January, 2017; and interventions were implemented from March 20, 2017, to Oct 31, 2019, and endline surveys done from Nov 19, 2019, to Jan 12, 2020, in an average of 32 households per cluster. All clusters were included in the analyses. There was an increase in the proportion of children consuming at least four of seven food groups in the AGRI-NUT (adjusted relative risk [RR] 1·19, 95% CI 1·03 to 1·37, p=0·02) and AGRI-NUT+PLA (1·27, 1·11 to 1·46, p=0·001) groups, but not AGRI (1·06, 0·91 to 1·23, p=0·44), compared with the control group. We found no effects on mean maternal BMI (adjusted mean differences vs control, AGRI -0·05, -0·34 to 0·24; AGRI-NUT 0·04, -0·26 to 0·33; AGRI-NUT+PLA -0·03, -0·3 to 0·23). An increase in the proportion of mothers consuming at least five of ten food groups was seen in the AGRI (adjusted RR 1·21, 1·01 to 1·45) and AGRI-NUT+PLA (1·30, 1·10 to 1·53) groups compared with the control group, but not in AGRI-NUT (1·16, 0·98 to 1·38). We found no effects on child wasting (adjusted RR vs control, AGRI 0·95, 0·73 to 1·24; AGRI-NUT 0·96, 0·72 to 1·29; AGRI-NUT+PLA 0·96, 0·73 to 1·26).

INTERPRETATION

Women's groups using combinations of NSA videos, nutrition-specific videos, and PLA cycle meetings improved maternal and child diet quality in rural Odisha, India. These components have been implemented separately in several low-income settings; effects could be increased by scaling up together.

FUNDING

Bill & Melinda Gates Foundation, UK AID from the UK Government, and US Agency for International Development.

Linkages of agroecosystems producing farmed seafood on food security, nutritional status and adolescent health in Bangladesh

This narrative review aims to provide an interdisciplinary perspective on actors that link global aquatic food production systems with fish consumption and nutritional status, with a special focus on adolescent girls in Bangladesh. The writing of this narrative perspective was undertaken within the framework of the Aquatic Food for Health and Nutrition (AQN) project that aimed to develop a metric for assessing the impacts on nutrition and health of agroecosystems producing farmed seafood. Previous studies evaluating links between agricultural ecosystems, aquaculture, food security and human health have systemically ignored the importance of diet and nutrition. Such studies have also ignored the importance of local communities, cultural norms and household composition and behaviours to identify vulnerable groups such as adolescent girls. This narrative review presents our current understanding of the relationships between aquaculture, fish production and consumption patterns, food security, optimal nutrition and health. It also highlights the importance of research into aquaculture food systems, linking aquatic food production systems with nutritional status, health and socioeconomic prosperity, which would help to develop more integrated and relevant food policies.

A Multi-Sectoral Approach Improves Early Child Development in a Disadvantaged Community in Peru: Role of Community Gardens, Nutrition Workshops and Enhanced Caregiver-Child Interaction: Project "Wawa Illari"

Background: Multi-dimensional monitoring evaluation and learning strategies are needed to address the complex set of factors that affect early child development in marginalized populations, but few studies have explored their effectiveness.

Objective: To compare improvement of health and development of children 0–3 years between intervention communities (IC) and control communities (CC) from peripheral settlements of Lima. Sequential interventions included: (1) home and community gardens, (2) conscious nutrition, and (3) parenting workshops following the International Child Development Program (ICDP).

Methods: Interventions were delivered by community health promoters (CHPs) using a “step-by-step” learning system. Both IC and CC were monitored before the interventions began, at 8 and 12 months (n = 113 IC and 127 CC children). Data were collected on household characteristics, diet, food security, health indicators (history of diarrhea and respiratory infections, hemoglobin, intestinal parasites, anthropometry), caregiver-child interactions and stress, and achievement of Pan-American Health Organization age-specific developmental milestones. Stepwise multiple logistic regressions were used to determine if the interventions affected food insecurity, as well as motor, social/cognitive and language delays.

Results: At baseline, 2.6% were categorized as “suspected developmental delay” and 14.2% were on “alert for development delay.” Food insecurity, diarrhea and respiratory infections were lowered following the interventions. Through the “step-by-step” approach, caregivers in IC gained skills in gardening, conscious nutrition and parenting that reduced the risk of food insecurity [Adjusted Risk Ratio = 0.20 (95% CI: 0.08–0.51)] and language delay [0.39 (0.19–0.82)] but not motor or social/cognitive delay. Use of a multiple micronutrient supplement decreased the risk of motor delay [0.12 (0.03–0.56)], but more pets were associated with higher risk of motor [3.24 (1.47–7.14)] and social/cognitive delay [2.72 (1.33–5.55)], and of food insecurity [1.73 (1.13–2.66)].

Conclusion: The combined interventions delivered by CHPs helped to mitigate the impact of adversity on food insecurity and language delay. Additional improvements may have been detected if the interventions had continued for a longer time. Our results indicate that control of infections and pets may be needed to achieve measurable results for motor and social/cognitive development. Continuous monitoring facilitated adjusting implementation strategies and achieving positive developmental outcomes.

Community-level interventions for improving access to food in low- and middle-income countries

BACKGROUND

After decades of decline since 2005, the global prevalence of undernourishment reverted and since 2015 has increased to levels seen in 2010 to 2011. The prevalence is highest in low- and middle-income countries (LMICs), especially Africa and Asia. Food insecurity and associated undernutrition detrimentally affect health and socioeconomic development in the short and long term, for individuals, including children, and societies. Physical and economic access to food is crucial to ensure food security. Community-level interventions could be important to increase access to food in LMICs.

OBJECTIVES

To determine the effects of community-level interventions that aim to improve access to nutritious food in LMICs, for both the whole community and for disadvantaged or at-risk individuals or groups within a community, such as infants, children and women; elderly, poor or unemployed people; or minority groups.

SEARCH METHODS

We searched for relevant studies in 16 electronic databases, including trial registries, from 1980 to September 2019, and updated the searches in six key databases in February 2020. We applied no language or publication status limits.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster randomised controlled trials (cRCTs) and prospective controlled studies (PCS). All population groups, adults and children, living in communities in LMICs exposed to community-level interventions aiming to improve food access were eligible for inclusion. We excluded studies that only included participants with specific diseases or conditions (e.g. severely malnourished children). Eligible interventions were broadly categorised into those that improved buying power (e.g. create income-generation opportunities, cash transfer schemes); addressed food prices (e.g. vouchers and subsidies); addressed infrastructure and transport that affected physical access to food outlets; addressed the social environment and provided social support (e.g. social support from family, neighbours or government).

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts, and full texts of potentially eligible records, against the inclusion criteria. Disagreements were resolved through discussion or arbitration by a third author, if necessary. For each included study, two authors independently extracted data and a third author arbitrated disagreements. However, the outcome data were extracted by one author and checked by a biostatistician. We assessed risk of bias for all studies using the Effective Practice and Organization of Care (EPOC) risk of bias tool for studies with a separate control group. We conducted meta-analyses if there was a minimum of two studies for interventions within the same category, reporting the same outcome measure and these were sufficiently homogeneous. Where we were able to meta-analyse, we used the random-effects model to incorporate any existing heterogeneity. Where we were unable to conduct meta-analyses, we synthesised using vote counting based on effect direction.

MAIN RESULTS

We included 59 studies, including 214 to 169,485 participants, and 300 to 124, 644 households, mostly from Africa and Latin America, addressing the following six intervention types (three studies assessed two different types of interventions). Interventions that improved buying power: Unconditional cash transfers (UCTs) (16 cRCTs, two RCTs, three PCSs): we found high-certainty evidence that UCTs improve food security and make little or no difference to cognitive function and development and low-certainty evidence that UCTs may increase dietary diversity and may reduce stunting. The evidence was very uncertain about the effects of UCTs on the proportion of household expenditure on food, and on wasting. Regarding adverse outcomes, evidence from one trial indicates that UCTs reduce the proportion of infants who are overweight. Conditional cash transfers (CCTs) (nine cRCTs, five PCSs): we found high-certainty evidence that CCTs result in little to no difference in the proportion of household expenditure on food and that they slightly improve cognitive function in children; moderate-certainty evidence that CCTs probably slightly improve dietary diversity and low-certainty evidence that they may make little to no difference to stunting or wasting. Evidence on adverse outcomes (two PCSs) shows that CCTs make no difference to the proportion of overweight children. Income generation interventions (six cRCTs, 11 PCSs): we found moderate-certainty evidence that income generation interventions probably make little or no difference to stunting or wasting; and low-certainty evidence that they may result in little to no difference to food security or that they may improve dietary diversity in children, but not for households. Interventions that addressed food prices: Food vouchers (three cRCTs, one RCT): we found moderate-certainty evidence that food vouchers probably reduce stunting; and low-certainty evidence that that they may improve dietary diversity slightly, and may result in little to no difference in wasting. Food and nutrition subsidies (one cRCT, three PCSs): we found low-certainty evidence that food and nutrition subsidies may improve dietary diversity among school children. The evidence is very uncertain about the effects on household expenditure on healthy foods as a proportion of total expenditure on food (very low-certainty evidence). Interventions that addressed the social environment: Social support interventions (one cRCT, one PCS): we found moderate-certainty evidence that community grants probably make little or no difference to wasting; low-certainty evidence that they may make little or no difference to stunting. The evidence is very uncertain about the effects of village savings and loans on food security and dietary diversity. None of the included studies addressed the intervention category of infrastructure changes. In addition, none of the studies reported on one of the primary outcomes of this review, namely prevalence of undernourishment.

AUTHORS' CONCLUSIONS

The body of evidence indicates that UCTs can improve food security. Income generation interventions do not seem to make a difference for food security, but the evidence is unclear for the other interventions. CCTs, UCTs, interventions that help generate income, interventions that help minimise impact of food prices through food vouchers and subsidies can potentially improve dietary diversity. UCTs and food vouchers may have a potential impact on reducing stunting, but CCTs, income generation interventions or social environment interventions do not seem to make a difference on wasting or stunting. CCTs seem to positively impact cognitive function and development, but not UCTs, which may be due to school attendance, healthcare visits and other conditionalities associated with CCTs.

Community-level interventions for improving access to food in low- and middle-income countries

BACKGROUND

After decades of decline since 2005, the global prevalence of undernourishment reverted and since 2015 has increased to levels seen in 2010 to 2011. The prevalence is highest in low- and middle-income countries (LMICs), especially Africa and Asia. Food insecurity and associated undernutrition detrimentally affect health and socioeconomic development in the short and long term, for individuals, including children, and societies. Physical and economic access to food is crucial to ensure food security. Community-level interventions could be important to increase access to food in LMICs.

OBJECTIVES

To determine the effects of community-level interventions that aim to improve access to nutritious food in LMICs, for both the whole community and for disadvantaged or at-risk individuals or groups within a community, such as infants, children and women; elderly, poor or unemployed people; or minority groups.

SEARCH METHODS

We searched for relevant studies in 16 electronic databases, including trial registries, from 1980 to September 2019, and updated the searches in six key databases in February 2020. We applied no language or publication status limits.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster randomised controlled trials (cRCTs) and prospective controlled studies (PCS). All population groups, adults and children, living in communities in LMICs exposed to community-level interventions aiming to improve food access were eligible for inclusion. We excluded studies that only included participants with specific diseases or conditions (e.g. severely malnourished children). Eligible interventions were broadly categorised into those that improved buying power (e.g. create income-generation opportunities, cash transfer schemes); addressed food prices (e.g. vouchers and subsidies); addressed infrastructure and transport that affected physical access to food outlets; addressed the social environment and provided social support (e.g. social support from family, neighbours or government).

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts, and full texts of potentially eligible records, against the inclusion criteria. Disagreements were resolved through discussion or arbitration by a third author, if necessary. For each included study, two authors independently extracted data and a third author arbitrated disagreements. However, the outcome data were extracted by one author and checked by a biostatistician. We assessed risk of bias for all studies using the Effective Practice and Organization of Care (EPOC) risk of bias tool for studies with a separate control group. We conducted meta-analyses if there was a minimum of two studies for interventions within the same category, reporting the same outcome measure and these were sufficiently homogeneous. Where we were able to meta-analyse, we used the random-effects model to incorporate any existing heterogeneity. Where we were unable to conduct meta-analyses, we synthesised using vote counting based on effect direction.

MAIN RESULTS

We included 59 studies, including 214 to 169,485 participants, and 300 to 124, 644 households, mostly from Africa and Latin America, addressing the following six intervention types (three studies assessed two different types of interventions). Interventions that improved buying power: Unconditional cash transfers (UCTs) (16 cRCTs, two RCTs, three PCSs): we found high-certainty evidence that UCTs improve food security and make little or no difference to cognitive function and development and low-certainty evidence that UCTs may increase dietary diversity and may reduce stunting. The evidence was very uncertain about the effects of UCTs on the proportion of household expenditure on food, and on wasting. Regarding adverse outcomes, evidence from one trial indicates that UCTs reduce the proportion of infants who are overweight. Conditional cash transfers (CCTs) (nine cRCTs, five PCSs): we found high-certainty evidence that CCTs result in little to no difference in the proportion of household expenditure on food and that they slightly improve cognitive function in children; moderate-certainty evidence that CCTs probably slightly improve dietary diversity and low-certainty evidence that they may make little to no difference to stunting or wasting. Evidence on adverse outcomes (two PCSs) shows that CCTs make no difference to the proportion of overweight children. Income generation interventions (six cRCTs, 11 PCSs): we found moderate-certainty evidence that income generation interventions probably make little or no difference to stunting or wasting; and low-certainty evidence that they may result in little to no difference to food security or that they may improve dietary diversity in children, but not for households. Interventions that addressed food prices: Food vouchers (three cRCTs, one RCT): we found moderate-certainty evidence that food vouchers probably reduce stunting; and low-certainty evidence that that they may improve dietary diversity slightly, and may result in little to no difference in wasting. Food and nutrition subsidies (one cRCT, three PCSs): we found low-certainty evidence that food and nutrition subsidies may improve dietary diversity among school children. The evidence is very uncertain about the effects on household expenditure on healthy foods as a proportion of total expenditure on food (very low-certainty evidence). Interventions that addressed the social environment: Social support interventions (one cRCT, one PCS): we found moderate-certainty evidence that community grants probably make little or no difference to wasting; low-certainty evidence that they may make little or no difference to stunting. The evidence is very uncertain about the effects of village savings and loans on food security and dietary diversity. None of the included studies addressed the intervention category of infrastructure changes. In addition, none of the studies reported on one of the primary outcomes of this review, namely prevalence of undernourishment.

AUTHORS' CONCLUSIONS

The body of evidence indicates that UCTs can improve food security. Income generation interventions do not seem to make a difference for food security, but the evidence is unclear for the other interventions. CCTs, UCTs, interventions that help generate income, interventions that help minimise impact of food prices through food vouchers and subsidies can potentially improve dietary diversity. UCTs and food vouchers may have a potential impact on reducing stunting, but CCTs, income generation interventions or social environment interventions do not seem to make a difference on wasting or stunting. CCTs seem to positively impact cognitive function and development, but not UCTs, which may be due to school attendance, healthcare visits and other conditionalities associated with CCTs.

Effect of enhanced homestead food production on anaemia among Cambodian women and children: A cluster randomized controlled trial

There is inconsistent evidence on the efficacy of agriculture programmes at improving women and children's anaemia and nutritional status. The primary aim of this study was to evaluate the impact of a nutrition‐sensitive enhanced homestead food production (EHFP) programme on anaemia in women (18–45 years) and children (6–59 months) in rural Cambodia. Secondary outcomes were women's micronutrient status and women and children's anthropometry. In this cluster‐randomized controlled trial, 900 households from 90 villages (clusters) were randomized to either (a) home gardens and behaviour change communication (BCC) on nutrition, hygiene, women's empowerment, and marketing (EHFP); (b) home gardens plus fishponds and BCC (EHFP + F); or (c) control (no intervention). Haemoglobin concentration and anthropometry were measured in women and children at baseline and at 22 months. Venous blood samples were collected in a subset of women (n = 450) at baseline and at 22 months. Generalized linear mixed effect models with repeated measures were used to evaluate the difference across groups and the change from baseline to end of study. Ninety clusters, 552 women, and 754 children completed the trial. Compared with control, we found a statistically significant impact on anaemia prevalence in children (−14.0 percentage points; P = 0.02) and retinol binding protein concentrations in women (difference in difference: 0.34; P = 0.02) randomized to EHFP and EHFP + F groups, respectively. No other statistically significant effects on anaemia, nutritional biomarker concentrations, or anthropometry were observed. Future research is needed to examine longer term impacts of EHFP on anthropometry in women and children and into the nutritional causes of anaemia among children in Cambodia.

Integrating nutrition outcomes into agriculture development for impact at scale: Highlights from the Canadian International Food Security Research Fund

The Canadian International Food Security Research Fund programme supported research and scaling up of nutrition‐ and gender‐sensitive agriculture innovations from 2009 to 2018. Women and girls were identified as agents of change and were targeted as the main programme beneficiaries. Projects were implemented in 25 countries through multistakeholder partnerships among universities, research institutions, public and private sectors, and civil society groups, reaching over 78 million people, mainly women and children. Approaches specific to nutrition included growing more nutritious crops, improving dietary diversity, value added processing, food fortification, and nutrition education. Scale‐up for impact was achieved through a number of pathways that started with evidence through rigorous research, followed by a combination of elements such as understanding local and regional contexts to identify specific bottlenecks and opportunities for the deployment and adoption of successful innovations, selecting politically effective or influential partners to lead the scaling up process, and investing in long‐term local capacity and leadership building. Overall, the knowledge generated in the programme indicate that well‐designed nutrition‐sensitive agriculture and food‐based interventions can have meaningful impacts on pathways that will lead to better health and well‐being of women and children through improving household and individual access to nutrient‐rich foods. Longer intervention times are needed to demonstrate changes in health indicators such as reduced stunting. This overview paper summarises the programme and showcases examples from studies that demonstrate the impact pathway for nutrition interventions that encompass efficacy and effectiveness studies, value‐added processing, cost effectiveness of interventions, and bringing a proven intervention to scale.