Strengthening implementation and utilization of nutrition interventions through research: a framework and research agenda

The costs of Suaahara II, a complex scaled-up multisectoral nutrition programme in Nepal

Limited evidence exists on the costs of scaled-up multisectoral nutrition programmes. Such evidence is crucial to assess intervention value and affordability. Evidence is also lacking on the opportunity costs of implementers and participants engaging in community-level interventions. We help to fill this gap by estimating the full financial and economic costs of the United States Agency for International Development-funded Suaahara II (SII) programme, a scaled-up multisectoral nutrition programme in Nepal (2016-2023). We applied a standardized mixed methods costing approach to estimate total and unit costs over a 3.7-year implementation period. Financial expenditure data from national and subnational levels were combined with economic cost estimates assessed using in-depth interviews and focus group discussions with staff, volunteers, community members, and government partners in four representative districts. The average annual total cost was US$908,948 per district, with economic costs accounting for 47% of the costs. The annual unit cost was US$132 per programme participant (mother in the 1000-day period between conception and a child's second birthday) reached. Annual costs ranged from US$152 (mountains) to US$118 (plains) per programme participant. Personnel (63%) were the largest input cost driver, followed by supplies (11%). Community events (29%) and household counselling visits (17%) were the largest activity cost drivers. Volunteer cadres contributed significant time to the programme, with female community health volunteers spending a substantial amount of time (27 h per month) on SII activities. Multisectoral nutrition programmes can be costly, especially when taking into consideration volunteer and participant opportunity costs. This study provides much-needed evidence of the costs of scaled-up multisectoral nutrition programmes for future comparison against benefits.

Impact of Suaahara, an integrated nutrition programme, on maternal and child nutrition at scale in Nepal

Suaahara was an innovative, complex, multi-sectoral, large-scale, nutrition programme in Nepal to increase exposure to nutrition-related information and services, improve nutrition-related knowledge and practices among pregnant women and mothers of infants and young children, and improve their nutrition. This study evaluated the effectiveness of Suaahara to improve nutrition and nutrition-related practices by comparing changes over 10 years between intervention and comparison districts. The samples of households at baseline in 2012 and endline in 2022 were 2040 and 2480, respectively, from 120 old wards. The impact was estimated using intent-to-treat regression models in which survey year, arm and their interaction were fixed effects, accounting for district clustering, with the interaction estimating differences between arms in changes over time. The intervention, relative to comparison, reduced maternal underweight by 8.43 percentage points (p < 0.001), consistent with improved maternal and fetal condition that was manifested as the greater length of 0.761 z-scores (p = 0.004) of infants 0-5.9 months. Complementary feeding practices with children between 6 and 23.9 months of age improved more in the intervention than comparison districts: child dietary diversity by 0.294 food groups (p = 0.072) and minimum dietary diversity by 9.51 percentage points (p = 0.028), feeding sick child more (p = 0.002) and administering oral rehydration solution and zinc for diarrhoea (p = 0.057) by about 17 percentage points each, and minimum meal frequency (p = 0.004) and minimum acceptable diet (p = 0.022) by about 15 percentage points each. Substantial impacts were demonstrated despite political restructuring, earthquakes, and other major challenges that Nepal and Suaahara faced and limitations in statistical power because of the reduced number of districts that then could be included in the study. Registered at clinicaltrials.gov with identifier NCT05448287.

Availability of national policies, programmes, and survey-based coverage data to track nutrition interventions in South Asia

Progress to improve nutrition among women, infants and children in South Asia has fallen behind the pace needed to meet established global targets. Renewed political commitment and monitoring of nutrition interventions are required to improve coverage and quality of care. Our study aimed to assess the availability of national nutrition policies, programmes, and coverage data of nutrition interventions for women, children, and adolescents in eight countries in South Asia. We reviewed relevant policy and programme documents, examined questionnaires used in the most recent rounds of 20 nationally representative surveys, and generated an evidence gap map on the availability of policies, programmes, and survey data to track progress on coverage of globally recommended nutrition interventions. Current policies and programmes in South Asian countries addressed almost all the recommended nutrition interventions targeted at women, children, and adolescents. There was a strong policy focus in all countries, except Maldives, on health system platforms such as antenatal and postnatal care and child growth and development. Survey data on nutrition intervention coverage was most available in India and Nepal, while Bangladesh and Bhutan had the least. Though countries in South Asia have committed to national nutrition policies and strategies, national surveys had substantial data gaps, precluding progress tracking of nutrition intervention coverage. Greater attention and effort are needed for multisectoral collaboration to promote and strengthen nutrition data systems.

Methodological choices for an economic evaluation of a combined psychosocial and nutrition treatment intervention for children with severe acute malnutrition: The FUSAM trial in Nepal

As a public health burden, severe acute malnutrition (SAM) among children has been increasingly studied to determine the optimal combination of treatment approaches. Among the new approaches is the addition of early childhood development sessions to standard nutrition-based treatment for SAM which can enhance both nutrition and development outcomes among young children. However, few studies demonstrate the relationship between the costs of such combined programs and the benefits accrued to the children and their caregivers. This article describes our experience of designing and conducting an economic evaluation alongside a cluster randomized controlled trial assessing a combined nutrition and psychosocial intervention for the treatment of SAM in children aged 6-24 months in Nepal. We present key lessons learned regarding methodological choices, the challenges of field data collection, as well as study adjustment when data analysis did not unfold as anticipated. With the view to transparency, this manuscript provides some clarifications on the evaluation processes for funders and policy makers on what economic evaluations entail and what information they convey for the purpose of supporting policy decision-making around limited resource allocation.

Changing maternal, infant and young child nutrition practices through social and behaviour change interventions implemented at scale: Lessons learned from Alive & Thrive

Alive & Thrive (A&T) is an initiative designed to advance the implementation of maternal, infant and young child nutrition (MIYCN) social and behaviour change (SBC) at a large scale. The aims of this research were to: (1) describe A&T's SBC implementation processes and their impact based on a review of programme documents and peer-reviewed publications and (2) gather lessons learned from key informant interviews (N = 23) with A&T staff and stakeholders in Bangladesh, Burkina Faso, Ethiopia, India, Nigeria and Vietnam. A&T's SBC approach used interpersonal communication, community mobilization and mass media to address knowledge gaps, strengthen self-efficacy and shift social norms. The initiative used data for design and evaluation and facilitated scale and sustainability through close collaboration with governments and other stakeholders. A&T's approach increased exclusive breastfeeding, minimum meal frequency of children and use of iron and folic acid tablets by pregnant women, but had mixed impacts on early initiation of breastfeeding and maternal and child dietary diversity. Multiple SBC channels and frequent contacts strengthened the impact of SBC on MIYCN practices. Lessons learned included: using existing large-scale platforms for interpersonal communication, improving counselling skills of health workers, delivering timely tailored messages, engaging key influencers to take specific actions, using research to address underlying behavioural concerns and maximize mass media reach and frequency, using simple memorable messages and employing additional channels to reach low media coverage areas. A&T developed and implemented at-scale MIYCN SBC in multiple countries, providing lessons learned about intervention strategies, engagement of influencers and mass media campaign development, which governments and other implementers can adapt and replicate.

Training Packages and Patient Management Tools for Healthcare Staff Working with Small, Nutritionally At-Risk Infants Aged under 6 Months: A Mixed-Methods Study

Skilled staff are essential for successfully managing child malnutrition, especially when dealing with small, nutritionally at-risk infants aged under 6 months. Training and patient management tools provide healthcare workers with core knowledge, skills, and support. To inform more effective future approaches and support the rollout of new WHO wasting prevention/treatment guidelines, we aimed to map and understand globally available training and patient management tools. In a mixed-methods study, we searched the literature to identify different training packages and management tools and conducted semi-structured key informant interviews with staff working in a variety of internationally organizations and settings. Data were analyzed using a phenomenological approach. We found 14 different training packages targeting different settings, including inpatient, outpatient, and humanitarian contexts. Curricula varied, especially around breastfeeding and maternal assessment, mental health, and nutritional status. Key informants (n = 9) reported gaps regarding counseling skills, time for practice, and how to effectively provide mental health counseling. Training delivery was highly dependent on resources and setting. In conclusion, future training should consider setting-specific needs, opportunities, and limitations. Emphasis on breastfeeding-support skills, mental health support, and counseling skills is needed. Enhanced practical sessions, refresher trainings, and ongoing monitoring and support are vital to ensure sustained high-quality services.

The DASH model: Data for addressing social determinants of health in local health departments

Recent frameworks, models, and reports highlight the critical need to address social determinants of health for achieving health equity in the United States and around the globe. In the United States, data play an important role in better understanding community-level and population-level disparities particularly for local health departments. However, data-driven decision-making-the use of data for public health activities such as program implementation, policy development, and resource allocation-is often presented theoretically or through case studies in the literature. We sought to develop a preliminary model that identifies the factors that contribute to data-driven decision-making in US local health departments and describe relationships between them. Guided by implementation science literature, we examined organizational-level capacity and individual-level factors contributing to using data for decision-making related to social determinants of health and the reduction of county-level disparities. This model has the potential to improve implementation of public health interventions and programs aimed at upstream structural factors, by elucidating the factors critical to incorporating data in decision-making.

Tensions and Paradoxes of Scaling Up: A Critical Reflection on Physical Activity Promotion

Achieving system-level, sustainable 'scale-up' of interventions is the epitome of successful translation of evidence-based approaches in population health. In physical activity promotion, few evidence-based interventions reach implementation at scale or become embedded within systems for sustainable health impact. This is despite the vast published literature describing efficacy studies of small-scale physical activity interventions. Research into physical activity scale-up (through case-study analysis; evaluations of scale-up processes in implementation trials; and mapping the processes, strategies, and principles for scale-up) has identified barriers and facilitators to intervention expansion. Many interventions are implemented at scale by governments but have not been evaluated or have unpublished evaluation information. Further, few public health interventions have evaluations that reveal the costs and benefits of scaled-up implementation. This lack of economic information introduces an additional element of risk for decision makers when deciding which physical activity interventions should be supported with scarce funding resources. Decision-makers face many other challenges when scaling interventions which do not relate to formal research trials of scale-up; Methods: To explore these issues, a multidisciplinary two-day workshop involving experts in physical activity scale-up was convened by the University of Newcastle, Australia, and the University of Ottawa, Canada (February 2019); Results: In this paper we discuss some of the scale-up tensions (challenges and conflicts) and paradoxes (things that are contrary to expectations) that emerged from this workshop in the context of the current literature and our own experiences in this field. We frame scale-up tensions according to epistemology, methodology, time, and partnerships; and paradoxes as 'reach without scale', 'planned serendipity' and 'simple complexity'. We reflect on the implications of these scale-up tensions and paradoxes, providing considerations for future scale-up research and practice moving forward; Conclusions: In this paper, we delve deeper into stakeholders' assumptions, processes and expectations of scaling up, and challenge in what ways as stakeholders, we all contribute to desired or undesired outcomes. Through a lens of 'tensions' and 'paradoxes', we make an original contribution to the scale-up literature that might influence current perspectives of scaling-up, provide future approaches for physical activity promotion, and contribute to understanding of dynamic of research-practice partnerships.

Complexities and Context of Scaling Up: A Qualitative Study of Stakeholder Perspectives of Scaling Physical Activity and Nutrition Interventions in Australia

Background

Scaling up population health interventions is a context-orientated, dynamic and multi-stakeholder process; understanding its influences is essential to enhance future scaling efforts. Using physical activity and nutrition interventions in Australia as case examples, the aim of this paper is to identify core influences involved in scaling up physical activity and nutrition interventions, and how these may differ by context and stakeholder.

Methods

A qualitative study involving semi-structured telephone interviews with individuals representing academic, government and non-government organizations with involvement in scaling up state and national physical activity and nutrition interventions. Interview questions were derived from the WHO report “20 Questions for Developing a Scaling up Case Study”, and mapped against four key principles and five core areas in the WHO ExpandNet framework for scaling up: (1) The innovation; (2) User organization; (3) Environment; (4) Resource team and; (5) Scale up strategy. Data were analyzed thematically.

Results

Nineteen interviews were conducted (government = 3; non-government = 5; and academic = 11 sectors) involving eight scaled up interventions, targeting nutrition (n = 2), physical activity (n = 1) or a combination (n = 5). Most themes aligned to the “Environment”, including: (i) political (e.g., personal agendas); (ii) social (e.g., lack of urgency); and (iii) sector/workforce (e.g., scale up accountability) factors. Themes relating to “Scale up strategy” (e.g., flexibility and evaluation transparency) were next most commonly occurring. Whilst themes were broadly consistent across participants, government participants had a more policy-oriented perspective on the scale up process. Academics discussed a tension between the generation and use of evidence, and the influence of political climates/interest on scale up decisions.

Conclusion

Attributes of the “Environment” and “Scale up strategy” consistently featured as major influences on successful outcomes, while the role of evidence differed greatly between participant groups. A multisector scale up strategy for future interventions may enable the complexities of environmental and political contexts to be incorporated into scale up planning.

Maternal Participation Level in a Nutrition-Sensitive Agriculture Intervention Matters for Child Diet and Growth Outcomes in Rural Ghana

Background

Little is known about how the level of program participation affects child nutrition in rural interventions.

Objectives

This study examined the association between participation level in a nutrition-sensitive agriculture intervention and children's diet and anthropometric outcomes in rural Ghana.

Methods

Nutrition Links was a cluster randomized controlled trial (clinicaltrials.gov NCT01985243), which enrolled caregivers with children (aged less than 2 mo in 2014-2015 and less than 18 mo in 2016-2017). Of the 287 caregivers in 19 intervention communities who enrolled, 233 adopted the intervention and received layer poultry, garden inputs, and weekly child feeding education. The egg production and repayment of poultry were monitored, and feed was sold at the weekly meetings. After endline, the nutrition educators rated each woman who adopted the intervention on a scale [very poor (1) to excellent (5)] for: 1) meeting attendance, 2) egg productivity, 3) feed and poultry loan payment, 4) contributions during meetings, and 5) attentiveness towards group members. Participation level was classified as high, medium, and low by dividing the sum of these 5 items into tertiles; 54 women who did not adopt the intervention were classified as "no participation." Generalized mixed linear models tested the difference in changes in children's diet and anthropometric indices between the participation levels and the control category - 213 caregiver-child dyads in 20 communities who received standard-of-care health and agricultural services.

Results

Compared with the control category, only high participation was associated with egg consumption [adjusted OR (aOR) = 3.03; 95% CI: 1.15, 7.94]. Both medium and high participation levels were associated with length-for-age z-scores (LAZ)/height-for-age z-scores (HAZ) [adjusted β-coefficients (aβ) = 0.44; 95% CI: 0.16, 0.72 and 0.40; 95% CI: 0.12, 0.67, respectively].

Conclusion

These results highlight the importance of promoting and monitoring the level of beneficiary participation to estimate the full potential of nutrition-sensitive agriculture interventions to improve nutritional outcomes.

Frameworks for implementation of policies promoting healthy nutrition and physically active lifestyle: systematic review

Background

Policy frameworks focusing on policy implementation may vary in terms of their scope, included constructs, relationships between the constructs, and context factors. Although multiple policy implementation frameworks exist, the overarching synthesis characterizing differences between the frameworks is missing. This study investigated frameworks guiding implementation of policies aiming at healthy nutrition, physical activity promotion, and a reduction of sedentary behavior. In particular, we aimed at examining the scope of the frameworks and the content of included constructs (e.g., referring to implementation processes, determinants, or implementation evaluation), the level at which these constructs operate (e.g., the individual level, the organizational/community level), relationships between the constructs, and the inclusion of equity factors.

Methods

A systematic review (the PROSPERO registration no. CRD42019133251) was conducted using 9 databases and 8 stakeholder websites. The content of 38 policy implementation frameworks was coded and analyzed.

Results

Across the frameworks, 47.4% (18 in 38) addressed three aims: description of the process, determinants, and the evaluation of implementation. The majority of frameworks (65.8%; 25 in 38) accounted for constructs from three levels: individual, organizational/community, and the system level. System-level constructs were included less often (76.3%; 29 in 38) than individual-level or organizational/community-level constructs (86.8% [33 in 38 frameworks] and 94.7% [36 in 38 frameworks] respectively). The majority of frameworks (84.2%, 32 in 38) included at least some sections that were solely of descriptive character (a list of unassociated constructs); 50.0% (19 in 38) included sections of prescriptive character (general steps of implementation); 60.5% (23 in 38) accounted for explanatory sections (assuming bi- or uni-directorial associations). The complex system approach was accounted for only in 21.1% (8 in 38) of frameworks. More than half (55.3%; 21 in 38) of frameworks did not account for any equity constructs (e.g., socioeconomic status, culture).

Conclusions

The majority of policy implementation frameworks have two or three aims (combining processes, determinants and/or the evaluation of implementation), include multi-level constructs (although the system-level determinants are less frequently included than those from the individual- or organizational/community-level), combine sections of purely descriptive character with sections accounting for prescriptive and/or explanatory associations, and are likely to include a little or no equity constructs.

Registration

PROSPERO, #CRD42019133251.

Comprehensive evaluation of Salud Escolar a health school program in Mexico: Rationale, design and methods

The prevalence of obesity and overweight in Mexican children and adolescents is high (greater than 30%) and lifestyle behaviors are far from achieving health recommendations. Salud Escolar is a complex cross-sectoral multi-level policy-based program in Mexico aiming to support schoolchildren healthy behaviors. We describe the rationale, design and methods for the comprehensive evaluation of Salud Escolar during its first phase of implementation. Using a mixed-methods approach and the logic model of Salud Escolar as a guide, a comprehensive evaluation involving 3 types of evaluations was designed: 1) A design evaluation before program implementation, to determine the consistency between the design of Salud Escolar and the problem to be addressed (i.e., childhood obesity), 2) An implementation evaluation to assess potential execution bottlenecks, and 3) An outcomes evaluation, to measure short-term (i.e., knowledge, attitudes and practices related to healthy eating, drinking plain water and doing regular physical activity) and intermediate outcomes (i.e., fruit and vegetable intake, water consumption and daily moderate to vigorous physical activity). This evaluation will provide essential knowledge about program design and implementation processes, which are vital for drawing robust conclusions about the effectiveness of the program. Results and lessons learned from this comprehensive evaluation will provide evidence to improve Salud Escolar program and facilitate its upscaling process and may provide relevant information for school-based programs in other places sharing socio-contextual conditions.

Policy-makers' perspectives on implementation of cross-sectoral nutrition policies, Western Pacific Region

Implementation of effective cross-sectoral nutrition policies remains a challenge worldwide. By reviewing reports from World Health Organization meetings and consultations - convened for policy-makers representing Member States of the Western Pacific Region - we provide an insight into how national policy-makers and external actors can support different dimensions of nutrition policy implementation. Key insights of policy-makers attending food and nutrition-centred meetings include that country-level implementation of nutrition policy relies on strong policy design, organizational planning and governance mechanisms that promote collective responsibility across multiple sectors. Policy-makers responsible for implementing nutrition policies face major challenges resulting from limited capacity, both within and external to government, particularly in relation to monitoring and enforcement activities. Successful implementation of nutrition policy measures will require greater political will to provide the requisite resources and institutional structures to ensure sustained policy effectiveness. Nongovernmental partners, including international agencies and researchers, have an opportunity to support policy implementation by providing technical support to Member States to frame action on nutrition in a more compelling way. They can also help policy-makers to build the organizational and structural capacity to coordinate cross-sectoral policy. Improved policy design, planning and governance and strategic capacity-building, supported by external partners, can strengthen the sustained implementation of cross-sectoral nutrition policy and improve nutrition outcomes.

Leveraging the Scaling Up Nutrition Movement to Operationalize Stunting Prevention Activities: Implementation Lessons From Rural Malawi

BACKGROUND

The rural district of Ntchisi is in the central region of Malawi. Among children aged 6 to 23 months, the stunting prevalence is 40% to 50%. To address this high prevalence, the World Food Programme, with cooperating partners, supported the Government of Malawi to implement an integrated stunting prevention program entitled The Right Foods at the Right Time from 2013 to 2018.

OBJECTIVE

To provide implementation lessons learned from systematic documentation of how the Scaling Up Nutrition (SUN) movement, combined with other international and national initiatives and policies, was translated into tailored programming.

METHODS

During program conception, early design, and implementation, this descriptive study systematically documented the process of translating SUN principles and government policies into an operational stunting prevention program in rural Malawi.

RESULTS

We identified 8 factors that contributed to successful translation of policy into program activities: (1) well-structured National SUN framework, (2) reliable coordination platforms and district ownership, (3) systematic and evidence-informed program design, (4) multiple forms of data used to inform program planning, (5) multisectoral implementation approaches to stunting prevention, (6) innovation in technology to improve overall program efficiency, (7) systematic collaboration among diverse stakeholders, and (8) strong public health nutrition capacity of program team members.

CONCLUSIONS

Lessons from this nutrition program in Ntchisi, Malawi, provide one case illustrating how the SUN movement, government policies, and global evidence base can be operationalized into tailored programming for improving nutrition.

Making programmes worth their salt: Assessing the context, fidelity and outcomes of implementation of the double fortified salt programme in Uttar Pradesh, India

Double fortified salt (DFS) has proven efficacy in addressing iron deficiency and anaemia, thus improving maternal and child nutrition outcomes. However, DFS delivery in large‐scale settings is less understood, with limited documentation of its fidelity of implementation (FOI). We assessed the FOI of the DFS intervention in Uttar Pradesh, India, to improve the design and implementation of such programmes that aim to reduce the anaemia burden, especially in women of reproductive age (WRA). We conducted in‐depth interviews with DFS programme staff (n = 25) and end‐user WRAs (23), guided by a programme impact pathway. We transcribed and thematically analysed the interviews and used an adapted analytic framework to document FOI across four domains—objects of intervention, implementation staff, implementation context and target of implementation. DFS utilisation remained low due to a combination of factors including poor product quality, distribution challenges, ineffective promotion and low awareness amongst end‐user WRAs. Motivation levels were higher amongst district‐level staff compared to frontline staff, who lacked supervisory support and effective incentives to promote DFS. Three typologies of DFS users emerged—‘believers’, ‘thrifters’ and ‘naysayers’—who indicated differing reasons for DFS purchase and its use or nonuse. The implementation of the DFS programme varied significantly from its theorised programme impact pathway. The adapted analytic framework helped document FOI and assess the programme's readiness for impact assessments and subsequent scale‐up. The programme needs product quality improvements, incentivised distribution and stronger promotion to effectively deliver and improve the realisation of its potential as an anaemia prevention strategy.

A Mixed-Methods Study of Factors Influencing Access to and Use of Micronutrient Powders in Rwanda

Gaps in complementary feeding practices hinder the use of multiple micronutrients powder (MNP) in Rutsiro district in Rwanda. Successful MNP program implementation requires uninterrupted availability and accessibility to the product, as well as greater understanding of health benefits of the MNP.

The World Health Organization recommends point-of-use fortification with multiple micronutrients powder (MNP) for foods consumed by children aged 6–23 months in populations where anemia prevalence among children under 2 years or under 5 years of age is 20% or higher. In Rwanda, anemia affects 37% of children under 5 years. The MNP program was implemented to address anemia, but research on factors affecting the implementation of the MNP program is limited. We conducted a mixed-methods study to examine the factors influencing access to and use of MNP among mothers (N=379) in Rutsiro district, northwest Rwanda. Inductive content analysis was used for qualitative data. Logistic regression analysis was used to determine factors associated with the use of MNP. Qualitative results indicated that the unavailability of MNP supplies and distribution issues were major barriers to accessing MNP. Factors influencing the use of MNP included mothers' perceptions of side effects and health benefits of MNP, as well as inappropriate complementary feeding practices. Mothers of older children (aged 12–23 months) were more likely to use MNP than those of younger children (aged 6–11 months) (adjusted odds ratio [aOR]=3.63, P<.001). Mothers whose children participated in the supplementary food program were nearly 3 times more likely to use MNP than those whose children had never participated in the program (aOR=2.84, P=.001). Increasing household hunger score was significantly associated with lower odds of using MNP (aOR=0.80, P=.038). Mechanisms to monitor MNP supply and program implementation need to be strengthened to ensure mothers have access to the product. MNP program implementers should address gaps in complementary feeding practices and ensure mothers have access to adequate complementary foods.

Systematic Process Framework for Conducting Implementation Science Research in Food Fortification Programs

Many challenges still exist to fully scaling up food fortification in lower resource settings. To address this need, a collective group of experts in the fields of food fortification and implementation science developed a systematic process framework to provide a tool for identifying and working through challenges.

Food fortification has proven to be an effective approach for preventing micronutrient deficiencies in many settings. Factors that lead to successful fortification programs are well established. However, due to the multisectoral nature of fortification and the added complexities present in many settings, the barriers to success are not always evident and the strategies to address them are not always obvious. We developed a systematic process for identifying and addressing gaps in the implementation of a food fortification program. The framework is composed of 4 phases: (1) connect program theory of change to program implementation; (2) develop an implementation research agenda; (3) conduct implementation research; and (4) analyze findings and develop/disseminate recommendations for next steps. We detail steps in each phase to help guide teams through the process. To our knowledge, this is the first attempt to outline a systematic process for applying implementation science research to food fortification. The development of this framework is intended to promote implementation research in the field of food fortification, thus improving access to and effectiveness of this key public health intervention.

Mechanisms of scaling up: combining a realist perspective and systems analysis to understand successfully scaled interventions

Background

Sustainable shifts in population behaviours require system-level implementation and embeddedness of large-scale health interventions. This paper aims to understand how different contexts of scaling up interventions affect mechanisms to produce intended and unintended scale up outcomes.

Methods

A mixed method study combining a realist perspective and systems analysis (causal loop diagrams) of scaled-up physical activity and/or nutrition interventions implemented at a state/national level in Australia (2010–18). The study involved four distinct phases: Phase 1 expert consultation, database and grey literature searches to identify scaled-up interventions; Phase 2 generating initial Context-Mechanism-Outcome configurations (CMOs) from the WHO ExpandNet framework for scaling up; Phase 3 testing and refining CMOs via online surveys and realist interviews with academics, government and non-government organisations (NGOs) involved in scale up of selected interventions (Phase 1); and Phase 4 generating cross-case mid-range theories represented in systems models of scaling up; validated by member checking. Descriptive statistics were reported for online survey data and realist analysis for interview data.

Results

Seven interventions were analysed, targeting nutrition (n = 1), physical activity (n = 1), or a combination (n = 5). Twenty-six participants completed surveys; 19 completed interviews. Sixty-three CMO pathways underpinned successful scale up, reflecting 36 scale up contexts, 8 key outcomes; linked via 53 commonly occurring mechanisms. All five WHO framework domains were represented in the systems models. Most CMO pathways included ‘intervention attributes’ and led to outcomes ‘community sustainability/embeddedness’ and ‘stakeholder buy-in/perceived value’. Irrespective of interventions being scaled in similar contexts (e.g., having political favourability); mechanisms still led to both intended and unintended scale up outcomes (e.g., increased or reduced sustainability).

Conclusion

This paper provides the first evidence for mechanisms underpinning outcomes required for successful scale up of state or nationally delivered interventions. Our findings challenge current prerequisites for effective scaling suggesting other conditions may be necessary. Future scale up approaches that plan for complexity and encourage iterative adaptation throughout, may enhance scale up outcomes. Current linear, context-to-outcome depictions of scale up oversimplify what is a clearly a complex interaction between perceptions, worldviews and goals of those involved. Mechanisms identified in this study could potentially be leveraged during future scale up efforts, to positively influence intervention scalability and sustainability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01103-0.

Implementation science in nutrition: a summary and synthesis

Objective:

This paper aimed to summarise and critically synthesise the key findings of the articles included in the supplement entitled ‘Nutrition Implementation Science: The Experience of a Large-Scale Home Fortification in Bangladesh’.

Design:

Commentary, summary and synthesis.

Settings:

Low- and middle-income country.

Results:

The supplement included six articles, including this summary paper. The second article presented an implementation science framework that facilitated conceptualising and evaluating the home-fortification programme in Bangladesh implemented by the Bangladesh Rural Advancement Committee (BRAC). The framework encompasses five components: identifying an ‘effective’ intervention; scaling-up and implementation fidelity; course corrections during implementation and assessing the implementation’s effectiveness; promoting sustainability of interventions and consideration of a concurrent evaluation to identify ‘effective’ interventions and to assess the process and outcome indicators of implementation. The other four articles in this supplement addressed the different components of the framework. For example, the third article addressed the implementation fidelity of a home-fortification programme, and the fourth article described the use of concurrent evaluation to course correct the implementation plan that resulted in improved implementation fidelity. The fifth article explained the outcome of course correction in the programme coverage, and the sixth article described the cost-effectiveness of the BRAC home-fortification programme.

Conclusions:

Overall, the supplement provides a comprehensive understanding of nutrition implementation science, which is very new in the field. The lessons learned in this supplement may enhance the capacity of researchers, policymakers and key stakeholders in the nutrition field to scale up new nutrition interventions and sustain them until malnutrition is alleviated.

Implementation Science in Evidence-based Nutrition Practice: Considerations for the Registered Dietitian Nutritionist

Nutrition and dietetics practice should be based on the highest-quality and most recent available evidence. Unfortunately, translating research to day-to-day practice often involves long lag times. Implementation science is an emerging field that evaluates methods that promote uptake of research findings into daily practice. Numerous theories and frameworks have been developed to provide guidance for implementation research and operationalization of recommendations. This paper provides a broad overview of implementation science and highlights frameworks such as the Normalization Process Theory that can be used by registered dietitian nutritionist (RDNs) to encourage systematic uptake of evidence into practice.

High Coverage and Low Utilization of the Double Fortified Salt Program in Uttar Pradesh, India: Implications for Program Implementation and Evaluation

BACKGROUND

Double fortified salt (DFS) is efficacious in addressing iron deficiency, but evidence of its effectiveness is limited. The few published evaluations do not include details on program implementation, limiting their utility for programmatic decisions.

OBJECTIVES

We sought to characterize the coverage of a DFS program implemented through the Public Distribution System (PDS) in Uttar Pradesh, India, and understand the drivers of DFS adherence.

METHODS

After 8 mo of implementation, we surveyed 1202 households in 5 districts and collected data on sociodemographic characteristics, asset ownership, food security, and regular PDS utilization. We defined DFS program coverage as the proportion of PDS beneficiaries who had heard of and purchased DFS, and we defined DFS adherence as DFS use reported by households. We used principal component analysis to create an asset-based index of relative wealth, and we categorized households into higher/lower relative wealth quintiles. We conducted path analyses to examine the drivers of DFS adherence, particularly the mediated influence of household wealth on DFS adherence. The evaluation is registered with 3ie's Registry for International Development Impact Evaluations (RIDIE-STUDY-ID-58f6eeb45c050).

RESULTS

The DFS program had good coverage: 83% of respondents had heard of DFS and 74% had purchased it at least once. However, only 23% exclusively used DFS. Respondents had low awareness about DFS benefits and considered DFS quality as poor. Being in a lower household wealth quintile and being food insecure were significant drivers of DFS adherence, and regular PDS utilization acted as a mediator. Adherence was lower in urban areas.

CONCLUSIONS

We observed significant heterogeneity in DFS implementation as reflected by high coverage and low adherence. Findings from this process evaluation informed the design of an adaptive impact evaluation and provided generalizable insights for ensuring that the potential for impact is realized. Efforts are needed to increase awareness, improve product quality, as well as mitigate against the sensory challenges identified.

Uptake and impact of priority setting exercises in nutrition research publications

OBJECTIVE

To assess how priority setting exercises for nutrition research are considered in publication.

DESIGN

Cross-sectional design.

SETTINGS

First, a citation analysis of priority setting exercises found in nutrition research until 2019 was conducted. The reasons for citation were extracted from the text of citing papers and the reasons were defined as: (i) acting on the research questions identified as priorities, (ii) acknowledging the priority setting exercise, (iii) using the same method, or (iv) previous knowledge to support evidence. Second, a survey with authors of the priority setting exercises was done to understand priority setters' perspectives on the impact and satisfaction of their work.

PARTICIPANTS

Twenty-one priority setting exercise papers were included. In all, 434 citing papers were found, of which 338 were considered in the citation analysis. A sample of 17 authors representing 13 priority setting exercise papers completed the impact and satisfaction survey.

RESULTS

Half of the priority setting exercise papers were published by 2013. After excluding self-citations (n = 60), the priority setting papers had on average 18 citations. Priority setting exercises had a median of 1 (IQR = 0-1) citing manuscript that acted on the recommendations produced from priority setting exercises. Authors of the priority setting exercises expressed a desire for increased uptake of the results of the priority setting exercises by funding agencies. Key barriers for uptake were identified as challenges in involving stakeholders and the general public for participation in the priority setting exercise.

CONCLUSIONS

Priority settings exercises are important efforts to guide nutrition research toward effective allocation of resources. However, there seems to be a limited consideration of these priority setting exercises in research papers.

Making the health system work for the delivery of nutrition interventions

Addressing malnutrition requires strategies that are comprehensive and multi‐sectoral. Within a multi‐sectoral approach, the health system is essential to deliver 10 nutrition‐specific interventions, which, if scaled up, could substantially reduce under‐5 deaths in high‐burden countries through improving maternal and child undernutrition. This study identifies the health system components required for the effective delivery of these interventions, highlighting opportunities and challenges for nutrition programmes and policies. We reviewed implementation guidance for each nutrition‐specific intervention, mapping the delivery process for each intervention and determining the health system components required for their delivery. We integrated the components into a single health systems framework for nutrition, illustrating the pathways by which health system components influence household‐level determinants of nutrition and individual‐level health outcomes. Nutrition‐specific interventions are typically delivered in one of four ways: (i) when nutrition interventions are intentionally sought out, (ii) when care is sought for other, unrelated interventions, (iii) at a health facility after active community case finding and referral, and (iv) in the community after active community case finding. A health system enables these processes by providing health services and facilitating care seeking for services, which together require a skilled and motivated health workforce, an effective supply chain, demand for services and access to services. The nutrition community should consider the processes by which nutrition‐specific interventions are delivered and the health system components required for their success. Programmes should encourage the delivery of nutrition interventions at every client–provider interaction and should actively generate demand for services—in general, and for nutrition services specifically.

Facility- and community-based delivery of micronutrient powders in Uganda: Opening the black box of implementation using mixed methods

Micronutrient powders (MNP) have the potential to increase micronutrient intake, yet documentation of implementation lessons remains a gap. This paper presents results of a pilot in Uganda comparing community- and facility-based delivery of MNP and documenting experiences of caregivers and distributors. The pilot's mixed method evaluation included a cross-sectional endline survey, monthly household visits, and midline and endline interviews. Primary outcomes were ever-covered (received ≥1 MNP packet), repeat-coverage (received ≥2 MNP packets), and adherence (consumed no more than 1 MNP sachet per day, consumed MNP with food, and consumed MNP 3+ days in past week). An adjusted Wald chi-square test compared differences in programme outcomes between arms, and logit regression identified predictors to adherence. Key informant interviews were coded thematically. Most programme outcomes in the endline survey were statistically significantly higher in the community arm, although in both arms, adherence was lower than other outcomes (adherence 31.4% in facility vs. 58.3% in community arm). Counselling, receipt of communication materials, perceived positive effects, MNP knowledge, and child liking MNP were consistent predictors of adherence in both arms. Qualitative findings corroborated survey results, revealing that social encouragement and advocacy facilitated use and that forgetting to give MNP was a barrier. Facility arm caregivers also cited distance, time, and transportation cost as barriers. Distributors had positive experiences with training and supervision but experienced increased workloads in both arms. MNP programme design is context-specific but could benefit from strengthened community sensitization, continued and more effective counselling for caregivers, and increased support for distributors.

Use of concurrent evaluation to improve implementation of a home fortification programme in Bangladesh: a methodological innovation

Objective:

This paper focuses on the use of ‘concurrent evaluation’ to evaluate a nationally scaled-up programme in Bangladesh that was implemented by BRAC (an international development organisation) using Shasthya Shebika (SS) – volunteer community health workers – to promote home fortification with micronutrient powders (MNP) for children under-five.

Design:

We developed a programme impact pathway to conceptualise the implementation and evaluation strategy and developed a strategic partnership among the key programme stakeholders for better use of evaluation evidence. We developed a multi-method concurrent evaluation strategy to provide insights into the BRAC programme and created provision for course correction to the implementation plan while it was in operation.

Setting:

One hundred sixty-four sub-districts and six urban slums in Bangladesh.

Participants:

Caregivers of children 6–59 months, SS and BRAC’s staff members.

Results:

The evaluation identified low awareness about home fortification among caregivers, inadequate supply and frequent MNP stockouts, and inadequate skills of BRAC’s SS to promote MNP at the community level as hindrances to the achievement of programme goals. The partners regularly discussed evaluation results during and after implementation activities to assess progress in programme coverage and any needs for modification. BRAC initiated a series of corrections to the original implementation plan to address these challenges, which improved the design of the MNP programme; this resulted in enhanced programme outcomes.

Conclusions:

Concurrent evaluation is an innovative approach to evaluate complex real-world programmes. Here it was utilised in implementing a large-scale nutrition programme to measure implementation process and effectiveness.

Impact of stakeholder perspectives on cost-effectiveness estimates of four specialized nutritious foods for preventing stunting and wasting in children 6-23 months in Burkina Faso

Background

Multiple specialized nutritious food options are programmed for supplementation in humanitarian and development settings. However, comparative cost-effectiveness evidence is lacking, let alone incorporation of perspectives from uncompensated stakeholders. A Burkina Faso trial evaluated the cost-effectiveness of Corn Soy Blend Plus w/ oil (CSB+ w/oil, reference arm), Corn Soy Whey Blend w/oil (CSWB w/oil), Super Cereal Plus (SC+), and Ready-to-Use Supplementary Food (RUSF) in reducing stunting and wasting among children 6–23 months old. This paper presents cost-effectiveness findings from multiple stakeholders’ perspectives, including caregivers and program volunteers.

Methods

An activity-based costing with ingredients approach was used to summarize cost of the 18-month-long blanket supplementary feeding for each enrolled child (in 2018 USD). Time data were collected using self-reported and observational instruments. Cost-effectiveness relative to CSB+ w/oil assessed incremental cost per enrolled child against incremental outcomes: prevalence of stunting at 23 months of age and number of months of wasting. Two combined perspectives were compared: program (donor, implementer, and volunteer) versus program and caregiver (adding caregiver).

Results

A total of 6112 children were enrolled. While similar effectiveness was found in three arms (CSWB w/oil was less effective), costs differed. Product cost and caregiver time to prepare study foods were major drivers of cross-arm cost differences from the respective combined perspective. The two major drivers were used to construct uncertainty ranges of cost per enrolled child from program and caregiver perspective: $317 ($279- $355) in CSB+ w/oil, $350 ($327- $373) in CSWB w/oil, $387 ($371- $403) in RUSF, and $434 ($365- $503) in SC+. Cost from program and caregiver perspective was a substantial increase from program perspective. CSB+ w/oil was most cost-effective in reducing stunting and wasting, and this main finding was robust to changing perspectives and all corresponding sensitivity analyses when uncompensated time was valued at minimum wage ($0.36/h). The break-even point for uncompensated time valuation is >$0.84/h, where RUSF became the most cost-effective from the program and caregiver perspective. Relative cost-effectiveness rankings among the other three arms depended on choice of perspectives, and were sensitive to values assigned to product cost, international freight cost, opportunity cost of time, and outcomes of a hypothetical control. Volunteer opportunity cost did not affect arm comparisons, but lack of compensation resulted in negative financial consequences for caregivers.

Conclusions

Evaluating cost-effectiveness by incorporating uncompensated stakeholders provided crucial implementation insights around nutrition products and programming.

Trial registration

Trial registration number: NCT02071563.

Name of registry: ClinicalTrials.gov

URL of registry: https://clinicaltrials.gov/ct2/show/NCT02071563?type=Intr&cond=Malnutrition&cntry=BF&draw=2&rank=9

Date of registration: February 26, 2014.

Date of enrollment of first participant: July 2014.

Developing a conceptual framework for implementation science to evaluate a nutrition intervention scaled-up in a real-world setting

Objective:

The aim of this paper is to identify and develop a comprehensive conceptual framework using implementation science that can be applied to assess a nutrition intervention in a real-world setting.

Design:

We conducted a narrative review using electronic databases and a manual search to identify implementation science frameworks, models and theories published in peer-reviewed journals. We performed a qualitative thematic analysis of these publications to generate a framework that could be applied to nutrition implementation science.

Results:

Based on this review, we developed a comprehensive framework which we have conceptualised as an implementation science process that describes the transition from the use of scientific evidence through to scaling-up with the aim of making an intervention sustainable. The framework consisted of three domains: Domain i – efficacy to effectiveness trials, Domain ii – scaling-up and Domain iii – sustainability. These three domains encompass five components: identifying an ‘effective’ intervention; scaling-up and implementation fidelity; course corrections during implementation; promoting sustainability of interventions and consideration of a comprehensive methodological paradigm to identify ‘effective’ interventions and to assess the process and outcome indicators of implementation. The framework was successfully applied to a nutrition implementation program in Bangladesh.

Conclusions:

Our conceptual framework built from an implantation science perspective offers a comprehensive approach supported by a foundational and holistic understanding of its key components. This framework provides guidance for implementation researchers, policy-makers and programme managers to identify and review an effective intervention, to scale it up and to sustain it over time.

The Effects of Community Home Visit and Peer Group Nutrition Intervention Delivery Platforms on Nutrition Outcomes in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis

Weak delivery systems reduce the potential of evidence-supp orted interventions to improve nutrition. We synthesized the evidence for the effectiveness of nutrition-specific intervention delivery platforms for improving nutrition outcomes in low and middle-income countries (LMIC). A systematic literature search for studies published from 1997 to June 2018 resulted in the inclusion of 83 randomized controlled trials (RCTs), quasi-randomized, and controlled before-after studies across a variety of delivery platforms. In this paper, we report on meta-analysed outcomes for community health worker (CHW) home visits and mother/peer group delivery platforms. Compared to care as usual, CHW home visits increased early initiation of breastfeeding (EIBF) (OR: 1.50; 95% CI: 1.12, 1.99; n = 10 RCTs) and exclusive breastfeeding (EBF) (OR: 4.42; 95% CI: 2.28, 8.56; n = 9 RCTs) and mother/peer groups were effective for improving children's minimum dietary diversity (OR: 2.34; 95% CI: 1.17, 4.70; n = 4) and minimum meal frequency (OR: 2.31; 95% CI: 1.61, 3.31; n = 3). Pooled estimates from studies using both home visit and group platforms showed positive results for EIBF (OR: 2.13; 95% CI: 1.12, 4.05; n = 9), EBF (OR: 2.43; 95% CI: 1.70, 3.46; n = 12), and < 5 wasting (OR: 0.77; 95% CI: 0.67, 0.89; n = 4). Our findings underscore the importance of interpersonal community platforms for improving infant and young child feeding practices and children's nutritional status in LMICs.

Translating Evidence-Based Program Recommendations into Action: The Design, Testing, and Scaling Up of the Behavior Change Strategy EsIAN in Mexico

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.

Sociocultural Influences on Poor Nutrition and Program Utilization of Mexico's Conditional Cash Transfer Program

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.

Closing the Nutrition Impact Gap Using Program Impact Pathway Analyses to Inform the Need for Program Modifications in Mexico's Conditional Cash Transfer Program

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.

Development and testing of locally-produced ready-to-use therapeutic and supplementary foods (RUTFs and RUSFs) in Cambodia: lessons learned

Background

Rates of childhood undernutrition are persistently high in Cambodia. Existing ready-to-use supplementary and therapeutic foods (RUSFs and RUTFs) have had limited acceptance and effectiveness. Therefore, our project developed and trialled a locally-produced, multiple micronutrient fortified lipid-based nutrient supplement (LNS) with therapeutic and supplementary versions. This ready-to-use food (RUF) is innovative in that, unlike many RUFs, it contains fish instead of milk. Development began in 2013 and the RUF was finalised in 2015. From 2015 until the present, both the RUTF and the RUSF versions were trialled for acceptability and effectiveness.

Methods

This paper draws on project implementation records and semi-structured interviews to describe the partnership between the Cambodian Ministries of Health and Agriculture, Forestry and Fisheries, UNICEF, the French National Research Institute for Sustainable Development (IRD), universities, and Vissot factory. It discusses the project implementation and lessons learned from the development and trialling process, and insights into positioning nutrition on the health agenda in low and middle-income countries.

Results

The lessons learned relate to the importance of project planning, management, and documentation in order to seize opportunities in the research, policy, advocacy, and programming environment while ensuring adequate day-to-day project administration and resourcing.

Conclusions

We conclude that projects such as ours, that collaborate to develop and test novel, locally-produced RUTFs and RUSFs, offer an exciting opportunity to respond to both local programmatic and broader research needs.

Degree of exposure to interventions influences maternal and child dietary practices: Evidence from a large-scale multisectoral nutrition program

The prevalence of maternal and child malnutrition in Nepal is among the highest in the world, despite substantial reductions in the last few decades. One effort to combat this problem is Suaahara II (SII), a multi-sectoral program implemented in 42 of Nepal’s 77 districts to improve dietary diversity (DD) and reduce maternal and child undernutrition. Using cross-sectional data from SII’s 2017 annual monitoring survey, this study explores associations between exposure to SII and maternal and child DD. The study sample included 3635 mothers with at least one child under the age of five. We focused on three primary SII intervention platforms: interpersonal communication (IPC) by frontline workers, community mobilization (CM) via events, and mass media through a weekly radio program (Bhanchhin Aama); and also created an exposure scale to assess the dose-response relationship. DD was measured both as a continuous score and as a binary measure of meeting the recommended minimum dietary diversity of consuming foods from at least 5 of 10 food groups for mothers and at least 4 of 7 food groups for children. We used linear and logistic regression models, controlling for potentially confounding factors at the individual and household level. We found a positive association between any exposure to SII platforms and maternal DD scores (b = 0.09; p = 0.05), child (aged 2–5 years) DD scores (b = 0.11; p = 0.03), and mothers meeting minimum dietary diversity (OR = 1.16; p = 0.05). There were significant, positive associations between both IPC and CM events and meeting minimum DD (IPC: OR = 1.31, p = 0.05; CM: OR = 1.37; p<0.001) and also between CM events and DD scores (b = 0.14; p = 0.03) among mothers. We found significant, positive associations between mass media and meeting minimum DD (OR: 1.38; p = 0.04) among children aged 6–24 months and between mass media and DD scores (b = 0.15; p = 0.01) among children aged 2–5 years. We also found that exposure to all three platforms, versus fewer platforms, had the strongest association with maternal DD scores (b = 0.45; p = 0.01), child (aged 2–5 years) DD scores (b = 0.41; p<0.001) and mothers meeting MDD (OR = 2.33; p<0.001). These findings suggest that a multi-pronged intervention package is necessary to address poor maternal and child dietary practices and that the barriers to behavior change for maternal diets may differ from those for child diets. They also highlight the importance of IPC and CM for behavior change and as a pre-requisite to mass media programs being effective, particularly for maternal diets.

Measuring the cost of investing in early childhood interventions and applications of a standardized costing tool

In this paper we analyze the need for consistent and accurate cost data on early childhood development (ECD) interventions as a basis for increasing and improving the effectiveness of current spending on ECD. We establish the key components necessary in a costing model and present a new standardized costing tool intended for use across a broad range of stakeholders and contexts. Learnings from piloting the tool in Bangladesh, Malawi, Mali, Mexico, and Mozambique are shared. Providing a standardized methodology for costing ECD is an important contribution to the field and has the potential to improve both the volume and effectiveness of ECD financing.

Leaders' Experiences in Planning, Implementing, and Evaluating Complex Public Health Nutrition Interventions

OBJECTIVE

To explore California local health department leaders' experiences planning, implementing, and evaluating nutrition promotion and obesity prevention programs for low-income families.

DESIGN

Qualitative, cross-sectional study using semi-structured in-depth interviews and panel interviews conducted in 2015-2016.

SETTING

California local health departments (LHDs) funded by the California Department of Public Health to implement Supplemental Nutrition Assistance Program-Education (SNAP-Ed).

PARTICIPANTS

The authors recruited SNAP-Ed leaders from all 58 California LHDs implementing SNAP-Ed. Leaders from 49 LHDs participated: 36 in hour-long, in-depth interviews and 13 in 1 of 3 90-minute group panel interviews.

PHENOMENON OF INTEREST

Processes, facilitators, and barriers connected to delivering SNAP-Ed reported by leaders in planning, implementing, and evaluating local programs.

ANALYSIS

Interviews were transcribed, coded, and analyzed using Dedoose software.

RESULTS

Leaders grappled with introducing, implementing, and integrating policy, systems, and environmental change interventions (PSEs). Information used to make planning decisions varied widely across LHDs. Partnership with nontraditional organizations was described as a resource- intensive, nonlinear process with recognized potential for benefit. Rural programs reported specific and different experiences compared with their urban counterparts.

CONCLUSIONS AND IMPLICATIONS

Implementing new, complex interventions to improve diet and activity environments and behaviors is both exciting and challenging for local leaders. They expressed a desire for additional resources and capacity building to facilitate success, particularly related to policy, systems, and environmental change programs. Attention to the specific needs of rural counties is needed.

Implementation Science in Nutrition: Concepts and Frameworks for an Emerging Field of Science and Practice

Malnutrition in all its forms has risen on global and national agendas in recent years because of the recognition of its magnitude and its consequences for a wide range of human, social, and economic outcomes. Although the WHO, national governments, and other organizations have endorsed targets and identified appropriate policies, programs, and interventions, a major challenge lies in implementing these with the scale and quality needed to achieve population impact. This paper presents an approach to implementation science in nutrition (ISN) that builds upon concepts developed in other policy domains and addresses critical gaps in linking knowledge to effective action. ISN is defined here as an interdisciplinary body of theory, knowledge, frameworks, tools, and approaches whose purpose is to strengthen implementation quality and impact. It includes a wide range of methods and approaches to identify and address implementation bottlenecks; means to identify, evaluate, and scale up implementation innovations; and strategies to enhance the utilization of existing knowledge, tools, and frameworks based on the evolving science of implementation. The ISN framework recognizes that quality implementation requires alignment across 5 domains: the intervention, policy, or innovation being implemented; the implementing organization(s); the enabling environment of policies and stakeholders; the individuals, households, and communities of interest; and the strategies and decision processes used at various stages of the implementation process. The success of aligning these domains through implementation research requires a culture of inquiry, evaluation, learning, and response among program implementers; an action-oriented mission among the research partners; continuity of funding for implementation research; and resolving inherent tensions between program implementation and research. The Society for Implementation Science in Nutrition is a recently established membership society to advance the science and practice of nutrition implementation at various scales and in varied contexts.

Situation analysis of procurement and production of multiple micronutrient supplements in 12 lower and upper middle-income countries

Globally, there are few vitamin and mineral ingredient manufacturers. To support local, in-country or regional procurement and production of multiple micronutrient supplements (MMS), the following production scenarios are possible: (a) straight ingredients of vitamins and minerals forms imported or locally produced that are mixed, tableted, or encapsulated and packaged by a local manufacturer; (b) import or local production of a vitamin and minerals premix that is tableted or encapsulated and packaged locally; (c) import of a bulk, finished product (tablets or capsules) that is packaged and branded; and (d) or import of a branded packaged product. This paper is a situation analysis of the market, manufacturing, and policy factors that are driving the production of MMS in 12 lower and upper middle-income countries. Key informants completed a self-administered structured questionnaire, which examined the local context of products available in the market and their cost, regulations and policies, in Brazil, Colombia, Guatemala, Mexico, Peru, Bangladesh, India, Vietnam, Ghana, Kenya, Nigeria, and South Africa. Our study found that although most countries have the capacity to produce locally MMS, the major barriers observed for sustainable and affordable production include (a) poor technical capacity and policies for ensuring quality along the value chain and (b) lack of policy coherence to incentivize local production and lower the manufacture and retail price of MMS. Also, better guidelines and government oversight will be required because not one country had an MMS formulation that matched the globally recommended formulation of the United Nations Multiple Micronutrient Preparation (UNIMMAP).

Perspective: Consideration of Values When Setting Priorities in Nutrition Research: Guidance for Transparency

Nutrition research can guide interventions to tackle the burden of diet-related diseases. Setting priorities in nutrition research, however, requires the engagement of various stakeholders with diverse insights. Consideration of what matters most in research from a scientific, social, and ethical perspective is therefore not an automatic process. Systematic ways to explicitly define and consider relevant values are largely lacking. Here, we review existing nutrition research priority-setting exercises, analyze how values are reported, and provide guidance for transparent consideration of values while setting priorities in nutrition research. Of the 27 (n = 22 peer-reviewed manuscripts and 5 grey literature documents) studies reviewed, 40.7% used a combination of different methods, 59.3% described the represented stakeholders, and 49.1% reported on follow-up activities. All priority-setting exercises were led by research groups based in high-income countries. Via an iterative qualitative content analysis, reported values were identified (n = 22 manuscripts). Three clusters of values (i.e., those related to impact, feasibility, and accountability) were identified. These values were organized in a tool to help those involved in setting research priorities systematically consider and report values. The tool was finalized through an online consultation with 7 international stakeholders. The value-oriented tool for priority setting in nutrition research identifies and presents values that are already implicitly and explicitly represented in priority-setting exercises. It provides guidance to enable explicit deliberation on research priorities from an ethical perspective. In addition, it can serve as a reporting tool to document how value-laden choices are made during priority setting and help foster the accountability of stakeholders involved.

Mapping Nutrition Interventions, a Key Analytical Tool for Informing the Multisectoral Planning Process: Example From Burkina Faso

Background:

The government of Burkina Faso, along with the United Nations Network for Nutrition (UNN), activity REACH (Renewed Efforts Against Child Hunger and undernutrition) partnership, conducted a mapping of nutrition interventions and stakeholders to identify the best approaches for scaling up priority nutrition interventions and to strengthen a multisectoral response to fight malnutrition.

Objective:

The objectives include describing the process used to map a set of country-prioritized nutrition interventions and to describe how the results contributed to the multisectoral nutrition planning process in Burkina Faso.

Methods:

The mapping exercise was designed as a cross-sectional study using the Excel-based Scaling Up Nutrition Planning and Monitoring Tool (SUN PMT) to collect, store, and analyze data.

Results:

The results present different analyses produced by the SUN PMT for 29 prioritized nutrition interventions. The analyses include the distribution of nutrition stakeholders for each intervention, the calculation of geographic and population coverage for each intervention, and the utilization of delivery mechanisms to reach beneficiaries.

Conclusions:

The mapping of key nutrition interventions and stakeholders supporting those interventions in Burkina Faso was an important tool in the multisectoral planning process. The exercise made it possible to identify gaps and needs; launch a discussion on nutrition planning and the scaling up of interventions; and mobilize sectors and development partners around nutrition.

WASH Benefits Bangladesh trial: management structure for achieving high coverage in an efficacy trial

BACKGROUND

Water, sanitation, and hygiene (WASH) efficacy trials deliver interventions to the target population under optimal conditions to estimate their effects on outcomes of interest, to inform subsequent selection for inclusion in routine programs. A systematic and intensive approach to intervention delivery is required to achieve the high-level uptake necessary to measure efficacy. We describe the intervention delivery system adopted in the WASH Benefits Bangladesh study, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance.

METHODS

Community Health Workers (CHWs) delivered individual and combined WASH and nutrition interventions to 4169 enrolled households in geographically matched clusters. Households were provided with free enabling technologies and supplies, integrated with parallel behaviour-change promotion. Behavioural objectives were drinking treated, safely stored water, safe feces disposal, handwashing with soap at key times, and age-appropriate nutrition behaviours (birth to 24 months). The intervention delivery system built on lessons learned from prior WASH intervention effectiveness, implementation, and formative research studies. We recruited local CHWs, residents of the study villages, through transparent merit-based selection methods, and consultation with community leaders. CHW supervisors received training on direct intervention delivery, then trained their assigned CHWs. CHWs in turn used the technologies in their own homes. Each CHW counseled six to eight intervention households spread across a 0.2-2.2-km radius, with a 1:12 supervisor-to-CHW ratio. CHWs met monthly with supervisor-trainers to exchange experiences and adapt technology and behaviour-change approaches to evolving conditions. Intervention uptake was tracked through fidelity measures, with a priori benchmarks necessary for an efficacy study.

RESULTS

Sufficient levels of uptake were attained by the fourth intervention assessment month and sustained throughout the intervention period. Periodic internal CHW monitoring resulted in discontinuation of a small number of low performers.

CONCLUSIONS

The intensive intervention delivery system required for an efficacy trial differs in many respects from the system for a routine program. To implement a routine program at scale requires further research on how to optimize the supervisor-to-CHW-to-intervention household ratios, as well as other program costs without compromising program effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCC01590095 . Registered on 2 May 2012.

Lessons learned and insights from the implementation of a food and physical activity policy to prevent obesity in Mexican schools: An analysis of nationally representative survey results

Obesity is a serious problem among children in Mexico. In 2010, the government implemented a national food and physical activity policy in elementary schools, to prevent obesity. The goal of this study is to assess the implementation of this policy, using the logic model from a descriptive survey with national representativeness at the elementary school level and based on a stratified cluster design. We used a systematic random sampling of schools (n = 122), stratified into public and private. We administered questionnaires to 116 principals, 165 members of the Food and Physical Activity Committees, 132 food school food vendors, 119 teachers, 348 parents. This study evidences a significant deviation in implementation from what had been planned. Our lessons learned are the importance to: base the design/implementation of the policy on a theoretical framework, make programs appealing to stakeholders, select concrete and measurable objective or goals, and support stakeholders during the implementation process.

Using Ethnography to Identify Barriers and Facilitators to Optimal Infant and Young Child Feeding in Rural Ghana: Implications for Programs

BACKGROUND

Understanding the context of infant and young child feeding (IYCF) is recognized as essential for designing appropriate complementary feeding interventions.

OBJECTIVE

Our objective was to study household IYCF behaviors in 2 districts in southern and northern Ghana to identify opportunities to improve existing nutrition programs.

METHODS

We interviewed 80 caregivers of children aged 6 to 23 months using ethnographic methods, including free listing, guided discussions and cognitive mapping techniques, and 24-hour dietary recall. Descriptive statistics and thematic content analysis were used to analyze quantitative and qualitative data.

RESULTS

In both settings, children's diets were predominantly maize based. Fish, the main animal source food, was consumed daily but in very small quantities. Milk was consumed by only a few children, in tea and porridge. Fruits were seldom consumed. Household food production did not meet requirements, and the markets were heavily relied on for staples and other key ingredients. Most caregivers demonstrated basic knowledge and understanding of key health and nutrition concepts. Barriers to optimal child feeding identified were lack of money to purchase the nutritious foods recommended for children, seasonal food insecurity, and some caregiver beliefs, practices, and nutrition knowledge gaps. Positive contextual features include caregiver recognition of the dietary needs of young children and commitment to provide foods to meet these needs.

CONCLUSION

Our findings suggest that complementary feeding in these rural settings can be improved through reinforcement or modification of strategic components of local health and nutrition education in light of existing barriers and enablers to optimal IYCF.

Multiple-micronutrient supplementation: Evidence from large-scale prenatal programmes on coverage, compliance and impact

Micronutrient deficiencies during pregnancy pose important challenges for public-health, given the potential adverse outcomes not only during pregnancy but across the life-course. Provision of iron-folic acid (IFA) supplements is the strategy most commonly practiced and recommended globally. How to successfully implement IFA and multiple micronutrient supplementation interventions among pregnant women and to achieve sustainable/permanent solutions to prenatal micronutrient deficiencies remain unresolved issues in many countries. This paper aims to analyse available experiences of prenatal IFA and multiple micronutrient interventions to distil learning for their effective planning and large-scale implementation. Relevant articles and programme-documentation were comprehensively identified from electronic databases, websites of major-agencies and through hand-searching of relevant documents. Retrieved documents were screened and potentially relevant reports were critically examined by the authors with the aim of identifying a set of case studies reflecting regional variation, a mix of implementation successes and failures, and a mix of programmes and large-scale experimental studies. Information on implementation, coverage, compliance, and impact was extracted from reports of large-scale interventions in Central America, Southeast Asia, South Asia, and Sub-Saharan Africa. The WHO/CDC Logic-Model for Micronutrient Interventions in Public Health was used as an organizing framework for analysing and presenting the evidence. Our findings suggest that to successfully implement supplementation interventions and achieve sustainable-permanent solutions efforts must focus on factors and processes related to quality, cost-effectiveness, coverage, utilization, demand, outcomes, impacts, and sustainability of programmes including strategic analysis, management, collaborations to pilot a project, and careful monitoring, midcourse corrections, supervision and logistical-support to gradually scaling it up.

Exploring barriers and enablers for scaling up a community-based grain bank intervention for improved infant and young child feeding in Ethiopia: A qualitative process evaluation

Child malnutrition remains high in Ethiopia, and inadequate complementary feeding is a contributing factor. In this context, a community‐based intervention was designed to provide locally made complementary food for children 6–23 months, using a bartering system, in four Ethiopian regions. After a pilot phase, the intervention was scaled up from 8 to 180 localities. We conducted a process evaluation to determine enablers and barriers for the scaling up of this intervention. Eight study sites were selected to perform 52 key informant interviews and 31 focus group discussions with purposely selected informants. For analysis, we used a framework describing six elements of successful scaling up: socio‐political context, attributes of the intervention, attributes of the implementers, appropriate delivery strategy, the adopting community, and use of research to inform the scale‐up process. A strong political will, alignment of the intervention with national priorities, and integration with the health care system were instrumental in the scaling up. The participatory approach in decision‐making reinforced ownership at community level, and training about complementary feeding motivated mothers and women's groups to participate. However, the management of the complex intervention, limited human resources, and lack of incentives for female volunteers proved challenging. In the bartering model, the barter rate was accepted, but the bartering was hindered by unavailability of cereals and limited financial and material resources to contribute, threatening the project's sustainability. Scaling up strategies for nutrition interventions require sufficient time, thorough planning, and assessment of the community's capacity to contribute human, financial, and material resources.

Suaahara in Nepal: An at-scale, multi-sectoral nutrition program influences knowledge and practices while enhancing equity

The burden of undernutrition in South Asia is greater than anywhere else. Policies and programmatic efforts increasingly address health and non-health determinants of undernutrition. In Nepal, one large-scale integrated nutrition program, Suaahara, aimed to reduce undernutrition among women and children in the 1,000-day period, while simultaneously addressing inequities. In this study, we use household-level process evaluation data (N = 480) to assess levels of exposure to program inputs and levels of knowledge and practices related to health, nutrition, and water, sanitation, and hygiene (WASH). We also assess Suaahara's effect on the differences between disadvantaged (DAG) and non-disadvantaged households in exposure, knowledge, and practice indicators. All regression models were adjusted for potential confounders at the child-, maternal-, and household levels, as well as clustering. We found a higher prevalence of almost all exposure and knowledge indicators and some practice indicators in Suaahara areas versus comparison areas. A higher proportion of DAG households in Suaahara areas reported exposure, were knowledgeable, and practiced optimal behaviors related to nearly all maternal and child health, nutrition, and WASH indicators than DAG households in non-Suaahara areas and sometimes even than non-DAG households in Suaahara areas. Moreover, differences in some of these indicators between DAG and non-DAG households were significantly smaller in Suaahara areas than in comparison areas. These results indicate that large-scale integrated interventions can influence nutrition-related knowledge and practices, while simultaneously reducing inequities.

Using implementation research for evidence-based programme development: a case study from Kenya

The few available studies of programme effectiveness in nutrition find that programmes are less effective than would be predicted from the efficacy trials that are the basis for evidence‐based programming. Some of these are due to gaps in utilisation within households. To a greater extent, these gaps can be attributed to problems in programme design and implementation. ‘Implementation research in nutrition’ is an emerging area of study aimed at addressing this problem, by building an evidence base and a sound theory to design and implement programmes that will effectively deliver nutrition interventions. The purpose of this supplement to Maternal & Child Nutrition is to contribute to this growing area of implementation research. The series of papers presented and the reflections for policymaking and programmes, combined with the reflections on the application of ethnography to this area of inquiry, illustrate the value of systematic research undertaken for the purpose of supporting the design of nutrition interventions that are appropriate for the specific populations in which they are undertaken. © 2015 Blackwell Publishing Ltd

Theory-Driven Process Evaluation of the SHINE Trial Using a Program Impact Pathway Approach

Two reasons for the lack of success of programs or interventions are poor alignment of interventions with the causes of the problem targeted by the intervention, leading to poor efficacy (theory failure), and failure to implement interventions as designed (program failure). These failures are important for both public health programs and randomized trials. In the Sanitation Hygiene and Infant Nutrition Efficacy (SHINE) Trial, we utilize the program impact pathway (PIP) approach to track intervention implementation and behavior uptake. In this article, we present the SHINE PIP including definitions and measurements of key mediating domains, and discuss the implications of this approach for randomized trials. Operationally, the PIP can be used for monitoring and strengthening intervention delivery, facilitating course-correction at various stages of implementation. Analytically, the PIP can facilitate a richer understanding of the mediating and modifying determinants of intervention impact than would be possible from an intention-to-treat analysis alone.