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Singh SK, Chauhan A, Alderman H, Avula R, Dwivedi LK, Kapoor R, Meher T, Menon P, Nguyen PH, Pedgaonker S, Puri P, Chakrabarti S. Utilization of Integrated Child Development Services (ICDS) and its linkages with undernutrition in India. Matern Child Nutr 2024:e13644. [PMID: 38586943 DOI: 10.1111/mcn.13644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/29/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024]
Abstract
The Integrated Child Development Services (ICDS) programme has been the central focus of the POSHAN Abhiyaan to combat maternal and child malnutrition under the national nutrition mission in India. This paper examined the linkages between utilization of ICDS and underweight among children aged 6-59 months. The study utilized data from two recent rounds of the National Family Health Survey (NFHS-4 [2015-2016] and NFHS-5 [2019-2021]). Descriptive analyses were used to assess the change in utilization of ICDS and the prevalence of underweight at the national and state levels. Multivariable logistic regressions were performed to examine factors associated with the utilization of ICDS and underweight. Linkages between utilization of ICDS and underweight were examined using the difference-in-differences (DID) approach. Utilization of ICDS increased from 58% in 2015-2016 to 71% in 2019-2021. The prevalence of underweight decreased from 37% to 32% in the same period. Changes in ICDS utilization and underweight prevalence varied considerably across states, socioeconomic and demographic characteristics. Results from decomposition of DID models suggest that improvements in ICDS explained 9%-12% of the observed reduction in underweight children between 2016 and 2021, suggesting that ICDS made a modest but meaningful contribution in addressing undernutrition among children aged 6-59 months in this period.
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Affiliation(s)
- Shri K Singh
- International Institute for Population Sciences, Mumbai, India
| | - Alka Chauhan
- The International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Harold Alderman
- The International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Rasmi Avula
- The International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Laxmi K Dwivedi
- International Institute for Population Sciences, Mumbai, India
| | - Rati Kapoor
- The International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Trupti Meher
- International Institute for Population Sciences, Mumbai, India
| | - Purnima Menon
- The International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Phuong H Nguyen
- The International Food Policy Research Institute, Washington, District of Columbia, USA
| | | | - Parul Puri
- International Institute for Population Sciences, Mumbai, India
| | - Suman Chakrabarti
- The International Food Policy Research Institute, Washington, District of Columbia, USA
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Kim SS, Ashok S, Avula R, Mahapatra T, Gokhale P, Walton S, Heidkamp RA, Munos MK. Moderate Accuracy of Survey Responses about Infant and Young Child Feeding Counseling Reported by Mothers with Children Less than 1 Year of Age in India. J Nutr 2023; 153:1220-1230. [PMID: 36796483 DOI: 10.1016/j.tjnut.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Counseling on infant and young child feeding (IYCF) to support optimal breastfeeding and complementary feeding practices is an essential intervention, and accurate coverage data is needed to identify gaps and monitor progress. However, coverage information captured during household surveys has not yet been validated. OBJECTIVES We examined the validity of maternal reports of IYCF counseling received during community-based contacts and factors associated with reporting accuracy. METHODS Direct observations of home visits conducted by community workers in 40 villages in Bihar, India served as the "gold standard" to maternal reports of IYCF counseling received during 2-wk follow-up surveys (n = 444 mothers with children less than 1 y of age, interviews matched to direct observations). Individual-level validity was assessed by calculating sensitivity, specificity, and AUC. Population-level bias was measured using the inflation factor (IF). Multivariable regression models were used to examine factors associated with response accuracy. RESULTS Prevalence of IYCF counseling during home visits was very high (90.1%). Maternal report of any IYCF counseling received in the past 2 wk was moderate (AUC: 0.60; 95% CI: 0.52, 0.67), and population bias was low (IF = 0.90). However, the recall of specific counseling messages varied. Maternal report of any breastfeeding, exclusive breastfeeding, and dietary diversity messages had moderate validity (AUC > 0.60), but other child feeding messages had low individual validity. Child age, maternal age, maternal education, mental stress, and social desirability were associated with reporting accuracy of multiple indicators. CONCLUSIONS Validity of IYCF counseling coverage was moderate for several key indicators. IYCF counseling is an information-based intervention that may be received from various sources, and it may be challenging to achieve higher reporting accuracy over a longer recall period. We consider the modest validity results as positive and suggest that these coverage indicators may be useful for measuring coverage and tracking progress over time.
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Affiliation(s)
- Sunny S Kim
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA.
| | | | | | | | - Priya Gokhale
- CARE India Solutions for Sustainable Development, Bihar, India
| | - Shelley Walton
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rebecca A Heidkamp
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda K Munos
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Avula R, Nguyen PH, Ashok S, Bajaj S, Kachwaha S, Pant A, Walia M, Singh A, Paul A, Singh A, Kulkarni B, Singhania D, Escobar-Alegria J, Augustine LF, Khanna M, Krishna M, Sundaravathanam N, Nayak PK, Sharma PK, Makkar P, Ghosh P, Subramaniam S, Mala S, Giri R, Jain S, Banjara SK, Nair S, Ghosh S, Das S, Patil S, Mahapatra T, Forissier T, Nanda P, Krishnan S, Menon P. Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study. PLoS One 2022; 17:e0269674. [PMID: 35895693 PMCID: PMC9328539 DOI: 10.1371/journal.pone.0269674] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020. METHODS We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August-October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2. RESULTS In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges. CONCLUSIONS Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.
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Affiliation(s)
- Rasmi Avula
- International Food Policy Research Institute, Washington, DC, United States of America
| | - Phuong Hong Nguyen
- International Food Policy Research Institute, Washington, DC, United States of America
| | - Sattvika Ashok
- International Food Policy Research Institute, Washington, DC, United States of America
| | | | - Shivani Kachwaha
- Johns Hopkins University, Baltimore, MD, United States of America
| | - Anjali Pant
- International Food Policy Research Institute, Washington, DC, United States of America
| | | | | | | | - Ayushi Singh
- ASER Centre- Pratham Education Foundation, New Delhi, India
| | | | | | | | | | | | | | | | | | | | - Prerna Makkar
- ASER Centre- Pratham Education Foundation, New Delhi, India
| | | | | | - Sai Mala
- Independent Consultant, New Delhi, India
| | - Rakesh Giri
- National Institute of Nutrition, Hyderabad, India
| | | | | | | | | | | | | | | | | | - Priya Nanda
- Bill & Melinda Gates Foundation, New Delhi, India
| | | | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, United States of America
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Patil SR, Nimmagadda S, Gopalakrishnan L, Avula R, Bajaj S, Diamond-Smith N, Paul A, Fernald L, Menon P, Walker D. Can digitally enabling community health and nutrition workers improve services delivery to pregnant women and mothers of infants? Quasi-experimental evidence from a national-scale nutrition programme in India. BMJ Glob Health 2022; 6:bmjgh-2021-007298. [PMID: 35835476 PMCID: PMC9296874 DOI: 10.1136/bmjgh-2021-007298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 04/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background India’s 1.4 million community health and nutrition workers (CHNWs) serve 158 million beneficiaries under the Integrated Child Development Services (ICDS) programme. We assessed the impact of a data capture, decision support, and job-aid mobile app for the CHNWs on two primary outcomes—(1) timeliness of home visits and (2) appropriate counselling specific to the needs of pregnant women and mothers of children <12 months. Methods We used a quasi-experimental pair-matched controlled trial using repeated cross-sectional surveys to evaluate the intervention in Bihar and Madhya Pradesh (MP) separately using an intention-to-treat analysis. The study was powered to detect difference of 5–9 percentage points (pp) with type I error of 0.05 and type II error of 0.20 with endline sample of 6635 mothers of children <12 months and 2398 pregnant women from a panel of 841 villages. Results Among pregnant women and mothers of children <12 months, recall of counselling specific to the trimester of pregnancy or age of the child as per ICDS guidelines was higher in both MP (11.5pp (95% CI 7.0pp to 16.0pp)) and Bihar (8.0pp (95% CI 5.3pp to 10.7pp)). Significant differences were observed in the proportion of mothers of children <12 months receiving adequate number of home visits as per ICDS guidelines (MP 8.3pp (95% CI 4.1pp to 12.5pp), Bihar: 7.9pp (95% CI 4.1pp to 11.6pp)). Coverage of children receiving growth monitoring increased in Bihar (22pp (95% CI 0.18 to 0.25)), but not in MP. No effects were observed on infant and young child feeding practices. Conclusion The at-scale app integrated with ICDS improved provision of services under the purview of CHNWs but not those that depended on systemic factors, and was relatively more effective when baseline levels of services were low. Overall, digitally enabling CHNWs can complement but not substitute efforts for strengthening health systems and addressing structural barriers. Trial registration number ISRCTN83902145.
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Affiliation(s)
- Sumeet R Patil
- Center for Causal Research and Evaluations, NEERMAN, Mumbai, India
| | - Sneha Nimmagadda
- Center for Causal Research and Evaluations, NEERMAN, Mumbai, India
- Department of Economics, University of Southern California, Los Angeles, CA, USA
| | | | - Rasmi Avula
- International Food Policy Research Institute, New Delhi, India
| | - Sumati Bajaj
- International Food Policy Research Institute, New Delhi, India
| | - Nadia Diamond-Smith
- Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Anshuman Paul
- Center for Causal Research and Evaluations, NEERMAN, Mumbai, India
| | - Lia Fernald
- Community Health Sciences, School of Public Health, UC Berkeley, Berkeley, CA, USA
| | - Purnima Menon
- International Food Policy Research Institute, New Delhi, India
| | - Dilys Walker
- Department of Obstetrics Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
- Global Health Sciences, University of California San Francisco, San Francisco, California, USA
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Nguyen PH, Pramanik P, Billah SM, Avula R, Ferdous T, Sarker BK, Rahman M, Ireen S, Mahmud Z, Menon P, Ash D. Using scenario‐based assessments to examine the feasibility of integrating preventive nutrition services through the primary health care system in Bangladesh. Maternal & Child Nutrition 2022; 18:e13366. [PMID: 35508919 PMCID: PMC9218316 DOI: 10.1111/mcn.13366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/12/2022] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Abstract
The National Nutrition Services of Bangladesh aims to deliver nutrition services through the primary health care system. Little is known about the feasibility of reshaping service delivery to close gaps in nutrition intervention coverage and utilization. We used a scenario‐based feasibility testing approach to assess potential implementation improvements to strengthen service delivery. We conducted in‐depth interviews with 31 service providers and 12 policymakers, and 5 focus group discussions with potential beneficiaries. We asked about the feasibility of four hypothetical scenarios for preventive and promotive nutrition service delivery: community‐based events (CBE) for pregnant women, well‐child services integrated into immunization contacts; CBE for well‐children, and well‐child visits at facilities. Opinions on service delivery platforms were mixed; some recommended new platforms, but others suggested strengthening existing delivery points. CBE for pregnant women was perceived as feasible, but workforce shortages emerged as a key barrier. Challenges such as equipment portability, upset children and a fast‐moving service environment suggested low feasibility of integrating nutrition into outreach immunization contacts. In contrast, CBE and facility‐based well‐child visits emerged as feasible options, conditional on having the necessary workforce, structural readiness and budget support. On the demand side, enabling factors include using interpersonal communication and involving community leaders to increase awareness, organizing events at a convenient time and place for both providers and beneficiaries, and incentives for beneficiaries to encourage participation. In conclusion, integrating preventive and promotive nutrition services require addressing current challenges in the health system, including human resource and logistic gaps, and investing in creating demand for preventive services. This study uses a scenario‐based feasibility testing approach to explore potential interventions to strengthen preventive and promotive nutrition service delivery through the primary health care system. Our findings highlight three highly feasible potential platforms (community‐based events [CBE] for pregnant women, CBE for well‐children and well‐child visits at facilities) to expand preventive services. Scaling these community‐based services requires addressing current challenges in the health system (including human resource and logistic gaps) and investment in demand creation for these services.
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Affiliation(s)
- Phuong H. Nguyen
- International Food Policy Research Institute Washington District of Columbia USA
| | | | - Sk. Masum Billah
- International Centre for Diarrheal Disease Research, Bangladesh (icddr, b) Dhaka Bangladesh
- The University of Sydney School of Public Health Sydney New South Wales Australia
| | - Rasmi Avula
- International Food Policy Research Institute New Delhi India
| | - Tarana Ferdous
- International Centre for Diarrheal Disease Research, Bangladesh (icddr, b) Dhaka Bangladesh
| | - Bidhan K. Sarker
- International Centre for Diarrheal Disease Research, Bangladesh (icddr, b) Dhaka Bangladesh
| | - Musfikur Rahman
- International Centre for Diarrheal Disease Research, Bangladesh (icddr, b) Dhaka Bangladesh
| | | | | | - Purnima Menon
- International Food Policy Research Institute Washington District of Columbia USA
- International Food Policy Research Institute New Delhi India
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Ashok S, Kim S, Mahapatra T, Gokhale P, Munos M, Heidkamp R, Avula R. Validation of Survey Questions on Counseling About Infant and Young Child Feeding Received by Mothers in Bihar, India. Curr Dev Nutr 2022. [DOI: 10.1093/cdn/nzac060.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Scarce data exists on coverage of infant and young child feeding (IYCF) counseling, which includes counseling about breastfeeding and complementary feeding, because few large-scale surveys have included questions to capture the coverage of these essential nutrition interventions. Consequently, maternal report of this information during household surveys has not been validated. We examined the validity of maternal report of IYCF counseling received during home visits and factors associated with response accuracy.
Methods
Direct observations of home visits conducted by community workers in 40 villages in Bihar, India, served as the “gold standard” to maternal report of IYCF counseling received during 2-week follow-up surveys (n = 444 mothers with children less than 1 year of age, interviews matched to direct observations). Individual-level validity was assessed by calculating sensitivity, specificity, and area under ROC curve (AUC). Population-level bias was measured using the inflation factor (IF). Multivariable regression models were used to examine factors associated with response accuracy.
Results
Actual prevalence of IYCF counseling during home visits was very high (90.1%). Maternal report of any IYCF counseling received in the past 2 weeks had moderate validity (AUC = 0.60, 95% CI: 0.52, 0.67), and population bias was low (IF = 0.90). However, recall of specific counseling messages varied. Maternal report of any breastfeeding, exclusive breastfeeding, and dietary diversity messages had moderate validity (AUC > 0.60), but other child feeding messages had low individual validity. Maternal characteristics associated with response accuracy varied by indicator, but accuracy on reporting of any IYCF counseling received was associated with higher education level and lower mental stress scores.
Conclusions
Validity of IYCF counseling coverage varied by indicator but was moderate for several key indicators and performed comparably to other health counseling coverage indicators. Given that counseling is an intervention involving intangible inputs, we consider these modest validity results as positive and suggest that these coverage indicators may be useful for measuring coverage and tracking progress over time.
Funding Sources
Bill & Melinda Gates Foundation, through IMPROVE-Coverage and DataDENT, managed by Johns Hopkins University.
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Affiliation(s)
| | - Sunny Kim
- International Food Policy Research Institute
| | | | | | | | | | - Rasmi Avula
- International Food Policy Research Institute
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Gopalakrishnan L, Diamond-Smith N, Avula R, Menon P, Fernald L, Walker D, Patil S. Association between supportive supervision and performance of community health workers in India: a longitudinal multi-level analysis. Hum Resour Health 2021; 19:145. [PMID: 34838060 PMCID: PMC8627081 DOI: 10.1186/s12960-021-00689-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 11/13/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services. OBJECTIVES We examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge. METHODS We used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong. RESULTS Among 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge. CONCLUSION Higher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes. TRIAL REGISTRATION Trial registration number: https://doi.org/10.1186/ISRCTN83902145.
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Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute, Washington, DC, USA
| | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, USA
| | - Lia Fernald
- University of California Berkeley, Berkeley, USA
| | - Dilys Walker
- University of California San Francisco, San Francisco, USA
| | - Sumeet Patil
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
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Kachwaha S, Nguyen PH, Tran LM, Avula R, Young MF, Ghosh S, Forissier T, Escobar-Alegria J, Sharma PK, Frongillo EA, Menon P. Specificity Matters: Unpacking Impact Pathways of Individual Interventions within Bundled Packages Helps Interpret the Limited Impacts of a Maternal Nutrition Intervention in India. J Nutr 2021; 152:612-629. [PMID: 34792151 PMCID: PMC8826931 DOI: 10.1093/jn/nxab390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/17/2021] [Accepted: 11/11/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive ANC (I-ANC) with standard ANC (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight-gain monitoring. OBJECTIVES This study examined intervention-specific program impact pathways (PIPs) and identified reasons for limited impacts of the A&T maternal nutrition intervention package. METHODS We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling. RESULTS Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs' knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of micronutrient supplement benefits and recommended foods was insufficient (<50%). Most FLWs received supervision (>90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30-50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52% compared with 36%) but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight-gain monitoring was low (30-40%). CONCLUSIONS Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact.
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Affiliation(s)
- Shivani Kachwaha
- International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | | | | | - Rasmi Avula
- International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | | | | | | | | | | | | | - Purnima Menon
- International Food Policy Research Institute (IFPRI), Washington, DC, USA
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Ashok S, Kim SS, Heidkamp RA, Munos MK, Menon P, Avula R. Using cognitive interviewing to bridge the intent-interpretation gap for nutrition coverage survey questions in India. Matern Child Nutr 2021; 18:e13248. [PMID: 34431603 PMCID: PMC8710093 DOI: 10.1111/mcn.13248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/18/2021] [Accepted: 07/02/2021] [Indexed: 11/30/2022]
Abstract
Designing survey questions that clearly and precisely communicate the question's intent and elicit responses based on the intended interpretation is critical but often undervalued. We used cognitive interviewing to qualitatively assess respondents' interpretation of and responses to questions pertaining to maternal and child nutrition intervention coverage. We conducted interviews to cognitively test 25 survey questions with mothers (N = 21) with children less than 1 year in Madhya Pradesh, India. Each question was followed by probes to capture information on four cognitive stages—comprehension, retrieval, judgement, and response. Data were analysed for common and unique patterns across the survey questions. We identified four types of cognitive challenges: (1) retention of multiple concepts in long questions: difficulty in comprehending and retaining questions with three or more key concepts; (2) temporal confusion: difficulty in conceptualizing recall periods such as “in the last 6 months” as compared to life stages such as pregnancy; (3) interpretation of concepts: mismatch of information being asked, meaning of certain terms and intervention scope; and (4) understanding of technical terms: difficulty in understanding commonly used technical words such as “breastfeeding” and “antenatal care” and requiring use of simple alternative language. Findings from this study will be useful for stakeholders involved in survey design and implementation, especially those conducting large‐scale household surveys to measure coverage of essential nutrition interventions.
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Affiliation(s)
- Sattvika Ashok
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Sunny S Kim
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Rebecca A Heidkamp
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda K Munos
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Rasmi Avula
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, New Delhi, India
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10
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Nguyen PH, Kachwaha S, Pant A, Tran LM, Walia M, Ghosh S, Sharma PK, Escobar-Alegria J, Frongillo EA, Menon P, Avula R. COVID-19 Disrupted Provision and Utilization of Health and Nutrition Services in Uttar Pradesh, India: Insights from Service Providers, Household Phone Surveys, and Administrative Data. J Nutr 2021; 151:2305-2316. [PMID: 34236434 PMCID: PMC8195077 DOI: 10.1093/jn/nxab135] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The coronavirus (COVID-19) pandemic may substantially affect health systems, but little primary evidence is available on disruption of health and nutrition services. OBJECTIVES This study aimed to 1) determine the extent of disruption in provision and utilization of health and nutrition services induced by the pandemic in Uttar Pradesh, India; and 2) identify how adaptations were made to restore service provision in response to the pandemic. METHODS We conducted longitudinal surveys with frontline workers (FLWs, n = 313) and mothers of children <2 y old (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests. RESULTS Compared with prepandemic, service provision reduced substantially during lockdown (83-98 percentage points, pp), except for home visits and take-home rations (∼30%). Most FLWs (68%-90%) restored service provision in July 2020, except for immunization and hot cooked meals (<10%). Administrative data showed similar patterns of disruption and restoration. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service provision. Key adaptations made to provide services were delivering services to beneficiary homes (∼40%-90%), social distancing (80%), and using PPE (40%-50%) and telephones for communication (∼20%). On the demand side, service utilization reduced substantially (40-80 pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing the challenges of limited travel (30%), nonavailability of services (26%), and fear of catching the virus when leaving the house (22%) or meeting service providers (14%). CONCLUSIONS COVID-19 disrupted the provision and use of health and nutrition services in Uttar Pradesh, India, despite adaptations to restore services. Strengthening logistical support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19.
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Affiliation(s)
- Phuong H Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA,Address correspondence to PHN (e-mail: mailto:)
| | - Shivani Kachwaha
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Anjali Pant
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | | | - Monika Walia
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | | | | | | | - Edward A Frongillo
- Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
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11
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Kohli N, Nguyen PH, Avula R, Menon P. The role of the state government, civil society and programmes across sectors in stunting reduction in Chhattisgarh, India, 2006-2016. BMJ Glob Health 2021; 5:bmjgh-2019-002274. [PMID: 32636312 PMCID: PMC7342433 DOI: 10.1136/bmjgh-2019-002274] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 12/31/2022] Open
Abstract
Introduction Childhood stunting has declined in India between 2006 and 2016, but not uniformly across all states. Little is known about what helped some states accelerate progress while others did not. Insights on subnational drivers of progress are useful not just for India but for other decentralised policy contexts. Thus, we aimed to identify the factors that contributed to declines in childhood stunting (from 52.9% to 37.6%) between 2006 and 2016 in the state of Chhattisgarh, a subnational success story in stunting reduction in India. Methods We examined time trends in determinants of stunting using descriptive and regression decomposition analysis of National Family Health Survey data from 2005 to 2006 and 2015–2016. We reviewed nutrition-relevant policies and programmes associated with the drivers of change to construct a policy timeline. Finally, we interviewed multiple stakeholders in the state to understand the changes in the drivers of undernutrition. Results The regression decomposition analysis shows that multiple factors explain 66% of the change in stunting between 2006 and 2016. Improvements in three key drivers—health and nutrition services, household assets, and sanitation and hygiene—explained 47% of the change in stunting. A shared vision for impact, political stability and capable bureaucracy, state-level innovations, support from development partners and civil society, and community mobilisation were found to contribute to improvements in programmes for health, poverty and sanitation. Conclusion Change in multiple sectors is important for stunting reduction and can be achieved in subnational contexts. More work lies ahead to close gaps in various determinants of stunting.
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Affiliation(s)
- Neha Kohli
- Geography, University of Florida, Gainesville, Florida, USA
| | - Phuong H Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
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12
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Nguyen PH, Avula R, Tran LM, Sethi V, Kumar A, Baswal D, Hajeebhoy N, Ranjan A, Menon P. Missed opportunities for delivering nutrition interventions in first 1000 days of life in India: insights from the National Family Health Survey, 2006 and 2016. BMJ Glob Health 2021; 6:bmjgh-2020-003717. [PMID: 33627359 PMCID: PMC7908280 DOI: 10.1136/bmjgh-2020-003717] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 12/25/2022] Open
Abstract
Objectives Existing health and community nutrition systems have the potential to deliver many nutrition interventions. However, the coverage of nutrition interventions across the delivery platforms of these systems has not been uniform. We (1) examined the opportunity gaps between delivery platforms and corresponding nutrition interventions through the continuum of care in India between 2006 and 2016 and and (2) assessed inequalities in these opportunity gaps. Methods We used two rounds of the National Family Health Survey data from 2005 to 2006 and 2015–2016 (n=36 850 and 190 898 mother–child dyads, respectively). We examine the opportunity gaps over time for seven nutrition interventions and their associated delivery platforms at national and state levels. We assessed equality and changes in equality between 2006 and 2016 for opportunity gaps by education, residence, socioeconomic status (SES), public and private platforms. Results Coverage of nutrition interventions was consistently lower than the reach of their associated delivery platforms; opportunity gaps ranging from 9 to 32 percentage points (pp) during the pregnancy, 17 pp during delivery and 9–26 pp during childhood in 2006. Between 2006 and 2016, coverage improved for most indicators, but coverage increases for nutrition interventions was lower than for associated delivery platforms. The opportunity gaps were larger among women with higher education (22–57 pp in 2016), higher SES status and living in urban areas (23–57 pp), despite higher coverage of most interventions and the delivery platforms among these groups. Opportunity gaps vary tremendously by state with the highest gaps observed in Tripura, Andaman and Nicobar islands, and Punjab for different indicators. Conclusions India’s progress in coverage of health and nutrition interventions in the last decade is promising, but both opportunity and equality gaps remained. It is critical to close these gaps by addressing policy and programmatic delivery systems bottlenecks to achieve universal coverage for both health and nutrition within the delivery system.
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | | | | | - Alok Kumar
- Department of Health & Family Welfare, Government of Uttar Pradesh, Formerly with NITI Aayog, New Delhi, Delhi, India
| | - Dinesh Baswal
- Formerly with the Maternal Health Division, India Ministry of Health and Family Welfare, New Delhi, Delhi, India
| | | | - Alok Ranjan
- Bill & Melinda Gates Foundation, Delhi, India
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
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13
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Kachwaha S, Nguyen P, Pant A, Tran LM, Ghosh S, Sharma PK, Shashtri VD, Escobar-Alegria J, Avula R, Menon P. The Impact of COVID-19 on Household Food Insecurity and Interlinkages With Child Feeding Practices and Coping Strategies in Uttar Pradesh, India. Curr Dev Nutr 2021. [PMCID: PMC8195076 DOI: 10.1093/cdn/nzab029_029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives The Coronavirus (COVID-19) pandemic has profound negative impacts on people's lives, but little is known on the effect of COVID-19 on household food insecurity (HFI) in poor setting resources. This study aimed to assess the changes in HFI during the pandemic and examine the interlinkages between HFI with child feeding practices and coping strategies in Uttar Pradesh, India. Methods We conducted a longitudinal quantitative survey with 569 mothers with children
<2y in December 2019 (in-person) and August 2020 (by phone). We measured HFI by using the Household Food Insecurity Access Scale and examined the changes in HFI during the pandemic using the Wilcoxon matched-pairs signed-rank tests. We then assessed child feeding practices and coping strategies by HFI status using multivariable regression models. Results HFI increased sharply from 21% to 80% before and during COVID-19, with 62% households changing the status from food security to insecurity and 17% remaining food insecure. Children belonging to newly and consistently food-insecure households were less likely to consume a diversified diet (adjusted odds ratio, AOR: 0.56, P = 0.03 and AOR: 0.45, P = 0.04, respectively) compared to those in food-secure households. Households with food insecurity were more likely to engage in coping strategies for obtaining foods including reducing other essential non-food expenditures (AOR: 1.7–2.2), borrowing money to buy food (AOR: 3.6–4.3), selling jewelry (AOR: 3.0–5.0), and spending savings or selling other assets (AOR∼2.0), all P < 0.05. Conclusions COVID-19 had a significant negative impact on HFI, which in turn had implications for child feeding practices and coping strategies. Our findings highlighted the need for further investment in targeted social protection strategies and safety nets as part of multisectoral solutions to improve HFI during and post-COVID-19. Funding Sources Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute; and Alive & Thrive, led by FHI Solutions.
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Affiliation(s)
| | | | - Anjali Pant
- International Food Policy Research Institute
| | | | | | | | | | | | - Rasmi Avula
- International Food Policy Research Institute
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14
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Ashok S, Kim SS, Avula R, Heidkamp RA, Munos MK, Menon P. Bridging the Gap Between Intent & Interpretation: Enhancing Survey Questions on Maternal & Child Nutrition Intervention Coverage Through Cognitive Interviewing in India. Curr Dev Nutr 2021. [DOI: 10.1093/cdn/nzab048_004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Designing survey questions that clearly and precisely communicate the question's intent and elicit responses based on the intended interpretation is critical but often undervalued. We used cognitive interviewing to qualitatively assess respondents’ interpretation and responses to questions pertaining to maternal and child nutrition intervention coverage.
Methods
We conducted interviews with mothers (N = 21) with children less than one year in Madhya Pradesh, India, to cognitively test 25 survey questions. Each question was followed by probes to capture information on four cognitive stages - comprehension, retrieval, judgement, and response. Interviews were recorded and notes were taken on verbal and non-verbal cues. Data were analyzed for common and unique patterns across the survey questions within the cognitive domains and grouped into challenges.
Results
We identified four types of cognitive challenges: 1) Poor retention of multiple concepts in long questions: difficulty in comprehending and retaining questions with three or more key concepts; 2) Temporal confusion: difficulty in conceptualizing recall periods such as “in the last 6 months” as compared to life stages such as pregnancy; 3) Misinterpretation of concepts: misinterpretation of the information being asked; meaning of certain terms such as “animal-source foods” was considered as referring to meat products only and not milk and eggs; scope of intervention using the phrase “talk with you” in referring to counseling was interpreted in different ways by respondents; and 4) Poor understanding of technical terms: difficulty in understanding even commonly-used technical words such as “breastfeeding” and “antenatal care” requiring the use of plain and simple alternative language.
Conclusions
Findings from this study will be useful for stakeholders involved in survey design and implementation, especially those conducting large-scale household surveys to improve coverage data of essential nutrition interventions, which is critical for policy actions
Funding Sources
Bill & Melinda Gates Foundation through the DataDENT initiative and the Improving Measurement and Program Design grant, and the CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by the International Food Policy Research Institute.
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Affiliation(s)
| | - Sunny S Kim
- International Food Policy Research Institute
| | - Rasmi Avula
- International Food Policy Research Institute
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15
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Constantinides S, Blake C, Frongillo E, Thow AM, Avula R, Liese A. The Role of Stakeholder Framing in Nutrition Agenda-Setting to Address the Double Burden of Malnutrition in Tamil Nadu, India. Curr Dev Nutr 2021. [DOI: 10.1093/cdn/nzab045_019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Addressing the double burden of malnutrition in many low- and middle-income countries through double duty strategies requires understanding of how stakeholder framing influences nutrition agenda-setting at the subnational level where policies are translated to address local context. We aimed to identify differences in frames of undernutrition and nutrition-related non-communicable diseases (NCDs) in Tamil Nadu, India and to show how the frames reflect stakeholder intention and action regarding nutrition actions.
Methods
Tamil Nadu is experiencing chronic undernutrition and increasing NCDs and has a history of commitment to addressing undernutrition. We conducted in-depth interviews with stakeholders from nutrition-sensitive disciplines using semi-structured questionnaires (n = 28). Stakeholder responses and established policy process frameworks guided interview coding and thematic analysis.
Results
The frames of undernutrition and NCDs comprised five domains: problem identification, risk factors, target populations, roles for stakeholders, and policy and program response. To address undernutrition, stakeholders consistently identified problems, risk factors, and target populations. Roles and responsibilities for stakeholders were defined, resulting in multisectoral strategies. For NCDs, stakeholders inconsistently identified the same domains, resulting in lack of convergence and bottlenecks to implementing double duty actions.
Conclusions
Nutrition-related NCDs have not reached a critical level of priority and coherence among state-level stakeholders regarding problem identification, risk factors, target populations, responsibility, and solutions, preventing political commitment to addressing them through inclusion in the policy agenda, dedicated resources, and convergence of multisectoral efforts. Development and implementation of multisectoral double duty strategies likely to be effective at the subnational level will require stakeholders to address three challenges in agenda-setting: adequate priority given to the problem, coherence of the policy community, and convergence of actions by multisectoral stakeholders.
Funding Sources
The Bill & Melinda Gates Foundation through POSHAN, led by the International Food Policy Research Institute.
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Affiliation(s)
| | | | | | | | - Rasmi Avula
- International Food Policy Research Institute
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16
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Avula R, Nguyen P, Ashok S, Bajaj S, Kachwaha S, Pant A, Walia M, Singh A, Paul A, Singh A, Kulkarni B, Singhania D, Escobar-Alegria J, Augustine LF, Forissier T, Menon P, Khanna M. India's 2.42 Million Frontline Health Workers Enable Restoration of Health and Nutrition Service Delivery After Early COVID-19 Lockdowns. Curr Dev Nutr 2021. [PMCID: PMC8181453 DOI: 10.1093/cdn/nzab029_007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives Modeling studies have estimated impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes, but little is known about actual delivery status. We studied disruptions and restorations of health and nutrition services by frontline workers (FLWs) in India during COVID-19. Methods We conducted phone surveys with 5500 FLWs in seven states between August–October 2020, asking about service delivery during April 2020 (T1) and in the August-October period (T2) and analyzed changes between T1 and T2. We also analyzed publicly available administrative data (AD) from 704 districts including the pre-pandemic period (T0) to examine disruptions and restoration of services. Results Phone surveys suggest, in T1, opening of village centers, fixed day events, growth monitoring, and immunization services was <50% in several states. In T2, restorations of center-based services were seen, with increases of >33% in >= 3 states. Food supplementation was least disrupted both in T1 and T2. AD highlights geographic variability both in disruptions in T1 compared to T0 and restorations in T2. FLWs’ adaptations to ensure service provision included home delivery (60 to 96%), ensuring physical distancing (33 to 86%), coordinating with other FLWs (7 to 49%), and using phone (∼2 to 65%). Challenges included personal fears, walking long distances, and beneficiaries’ non-cooperation. Conclusions Services to mothers and children were disrupted during lockdown and restored thereafter. Rapid policy guidance and local adaptations by a strong cadre of FLWs likely enabled service resumption. However, gaps remain, and more research is needed on use of services by clients. Funding Sources Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.
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Affiliation(s)
- Rasmi Avula
- International Food Policy Research Institute
| | | | | | | | | | - Anjali Pant
- International Food Policy Research Institute
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17
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Nguyen P, Kachwaha S, Pant A, Tran LM, Walia M, Ghosh S, Sharma PK, Escobar-Alegria J, Menon P, Avula R. Impacts of COVID-19 on Provision and Utilization of Health and Nutrition Services in Uttar Pradesh, India: Insights From Phone Surveys and Administrative Data. Curr Dev Nutr 2021. [PMCID: PMC8181393 DOI: 10.1093/cdn/nzab045_054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objectives The COVID-19 pandemic has significant potential implications for health systems, but little primary evidence is available on effects on health and nutrition services. We aimed to examine changes in service provision and utilization during the pandemic in Uttar Pradesh, India and identify positive adaptations to service delivery. Methods We conducted longitudinal surveys with frontline workers (FLW, n = 313) and mothers of children < 2 years (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests. Results Compared to pre-pandemic, service provision reduced substantially during lockdown (83–98 percentage points, pp), except for home visits and take-home-rations (∼30%). Most FLWs (68–90%) resumed service provision in July 2020, except for immunization and hot-cooked meals (< 10%). Administrative data showed similar patterns of disruption and resumption. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service delivery. Key adaptations made to provide services included: delivering services to beneficiary homes (∼40–90%), social distancing (80%), using PPE (40–50%), and telephones for communication (∼20%). On the demand side, service utilization also reduced substantially (40–80pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing challenges of limited travel (30%), non-availability of services (26%), fear of catching virus when leaving the house (22%) or meeting service providers (14%). Conclusions COVID-19 affected the provision and use of health and nutrition services despite efforts at service restoration and adaptations. Strengthening logistics support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19. Funding Sources Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute; and Alive & Thrive, led by FHI Solutions.
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Affiliation(s)
| | | | - Anjali Pant
- International Food Policy Research Institute
| | | | | | | | | | | | | | - Rasmi Avula
- International Food Policy Research Institute
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18
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Young MF, Bootwala A, Kachwaha S, Avula R, Ghosh S, Sharma PK, Shastri VD, Forissier T, Menon P, Nguyen PH. Understanding Implementation and Improving Nutrition Interventions: Barriers and Facilitators of Using Data Strategically to Inform the Implementation of Maternal Nutrition in Uttar Pradesh, India. Curr Dev Nutr 2021; 5:nzab081. [PMID: 34222761 PMCID: PMC8242137 DOI: 10.1093/cdn/nzab081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In response to the high levels of maternal nutrition in Uttar Pradesh, Alive & Thrive (A&T) aimed to strengthen the delivery of nutrition interventions through the government antenatal care platform, including leveraging ongoing data collection to improve program delivery and reach (registered at clinicaltrials.gov as NCT03378141). However, we have a limited understanding of providers' experiences and challenges in collecting and using data for decision making. OBJECTIVE The aim was to identify barriers and facilitators to the 1) collection of data and 2) use of data for decision making. METHODS In-depth interviews (n = 35) were conducted among block-level government staff, frontline worker (FLW) supervisors, and A&T staff in 2 districts in Uttar Pradesh. Systematic coding of verbatim transcripts and detailed summaries were undertaken to elucidate themes related to data collection and use. FLW supervisors (n = 103) were surveyed to assess data use experiences. RESULTS Data were used to understand the reach of maternal nutrition services, estimate the demand for supplements, and guide identification of areas of low FLW performance. About half of supervisors reported using data to identify areas of improvement; however, only 23% reported using data to inform decision making. Facilitators of data collection and use included collaboration between health department officials, perceived importance of block ranking, and monthly review meetings with staff and supervisors to review and discuss data. Barriers to data collection and use included human resource gaps, inadequate technology infrastructure, FLW educational level, political structure, and lack of cooperation between FLWs and supervisors. CONCLUSIONS The use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Despite intensive data-collection efforts, the use of data to inform decision making remains limited. Collaboration facilitated data collection and use, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions.
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Affiliation(s)
- Melissa F Young
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - Ahad Bootwala
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - Shivani Kachwaha
- International Food Policy Research Institute, Washington, DC, USA
| | - Rasmi Avula
- International Food Policy Research Institute, Washington, DC, USA
| | | | | | | | | | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, USA
| | - Phuong H Nguyen
- International Food Policy Research Institute, Washington, DC, USA
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19
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Nguyen PH, Kachwaha S, Tran LM, Avula R, Young MF, Ghosh S, Sharma PK, Escobar-Alegria J, Forissier T, Patil S, Frongillo EA, Menon P. Strengthening Nutrition Interventions in Antenatal Care Services Affects Dietary Intake, Micronutrient Intake, Gestational Weight Gain, and Breastfeeding in Uttar Pradesh, India: Results of a Cluster-Randomized Program Evaluation. J Nutr 2021; 151:2282-2295. [PMID: 34038529 PMCID: PMC8349122 DOI: 10.1093/jn/nxab131] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/19/2021] [Accepted: 04/16/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Maternal nutrition interventions are inadequately integrated into antenatal care (ANC). Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization through government ANC services. OBJECTIVES We compared nutrition-intensified ANC (I-ANC) with standard ANC (S-ANC) on coverage of nutrition interventions and maternal nutrition practices. METHODS We used a cluster-randomized design with cross-sectional baseline (2017) and endline (2019) surveys (n ∼660 pregnant and 1800 recently delivered women per survey) and a repeated-measures longitudinal study in 2018-2019 (n = 400). We derived difference-in-difference effect estimates (DIDs) for diet diversity, consumption of micronutrient supplements, weight monitoring, and early breastfeeding practices. RESULTS Despite substantial secular improvements in service coverage from India's national nutrition program, women in the I-ANC arm received more home visits [DID: 7-14 percentage points (pp)] and counseling on core nutrition messages (DID: 10-23 pp) than in the S-ANC arm. One-third of women got ≥3 home visits and one-fourth received ≥4 ANC check-ups in the I-ANC arm. Improvements were greater in the I-ANC arm than in the S-ANC arm for any receipt and consumption of iron-folic acid (DID: 7.5 pp and 9.5 pp, respectively) and calcium supplements (DID: 14.1 pp and 11.5 pp, respectively). Exclusive breastfeeding improved (DID: 7.5 pp) but early initiation of breastfeeding did not. Maternal food group consumption (∼4 food groups) and probability of adequacy of micronutrients (∼20%) remained low in both arms. Repeated-measures longitudinal analyses showed similar results, with additional impact on consumption of vitamin A-rich foods (10 pp, 11 g/d), other vegetables and fruits (22-29 g/d), and gestational weight gain (0.4 kg). CONCLUSIONS Intensifying nutrition in government ANC services improved maternal nutrition practices even with strong secular trends in service coverage. Dietary diversity, supplement consumption, and breastfeeding practices remained suboptimal. Achieving greater behavior changes will require strengthening the delivery and use of maternal nutrition services integrated into ANC services in the health system. This trial was registered at clinicaltrials.gov as NCT03378141.
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Affiliation(s)
| | - Shivani Kachwaha
- International Food Policy Research Institute, Washington, DC, USA
| | | | - Rasmi Avula
- International Food Policy Research Institute, Washington, DC, USA
| | - Melissa F Young
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | | | | | | | | | - Sumeet Patil
- Network for Engineering, Economics, Research and Management (NEERMAN), Delhi,
India
| | - Edward A Frongillo
- Health Department of Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, USA
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20
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Nguyen PH, Kachwaha S, Pant A, Tran LM, Ghosh S, Sharma PK, Shastri VD, Escobar-Alegria J, Avula R, Menon P. Impact of COVID-19 on household food insecurity and interlinkages with child feeding practices and coping strategies in Uttar Pradesh, India: a longitudinal community-based study. BMJ Open 2021; 11:e048738. [PMID: 33883156 PMCID: PMC8061560 DOI: 10.1136/bmjopen-2021-048738] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/03/2021] [Accepted: 04/08/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The COVID-19 pandemic has profound negative impacts on people's lives, but little is known on its effect on household food insecurity (HFI) in poor setting resources. This study assessed changes in HFI during the pandemic and examined the interlinkages between HFI with child feeding practices and coping strategies. DESIGN A longitudinal survey in December 2019 (in-person) and August 2020 (by phone). SETTING Community-based individuals from 26 blocks in 2 districts in Uttar Pradesh, India. PARTICIPANTS Mothers with children <2 years (n=569). MAIN OUTCOMES AND ANALYSES We measured HFI by using the HFI Access Scale and examined the changes in HFI during the pandemic using the Wilcoxon matched-pairs signed-rank tests. We then assessed child feeding practices and coping strategies by HFI status using multivariable regression models. RESULTS HFI increased sharply from 21% in December 2019 to 80% in August 2020, with 62% households changing the status from food secure to insecure over this period. Children in newly or consistently food-insecure households were less likely to consume a diverse diet (adjusted OR, AOR 0.57, 95% CI 0.34 to 0.95 and AOR 0.51, 95% CI 0.23 to 1.12, respectively) compared with those in food-secure households. Households with consistent food insecurity were more likely to engage in coping strategies such as reducing other essential non-food expenditures (AOR 2.2, 95% CI 1.09 to 4.24), borrowing money to buy food (AOR 4.3, 95% CI 2.31 to 7.95) or selling jewellery (AOR 5.0, 95% CI 1.74 to 14.27) to obtain foods. Similar findings were observed for newly food-insecure households. CONCLUSIONS The COVID-19 pandemic and its lockdown measures posed a significant risk to HFI which in turn had implications for child feeding practices and coping strategies. Our findings highlight the need for further investment in targeted social protection strategies and safety nets as part of multisectoral solutions to improve HFI during and after COVID-19.
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Shivani Kachwaha
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Anjali Pant
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Lan M Tran
- Alive & Thrive, FHI Solutions, Hanoi, Vietnam
| | | | | | | | | | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
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21
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Pandav C, Menon P, de Wagt A, Reddy V, Reddy K, Avula R, Mathews P, Kaur S, Pawar S, Ranjan S, Sharma S, Sankar R. Supporting efforts to address malnutrition in the context of the COVID-19 pandemic in India: An emergency need. Med J DY Patil Vidyapeeth 2021. [DOI: 10.4103/mjdrdypu.mjdrdypu_338_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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22
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Jain A, Walker DM, Avula R, Diamond-Smith N, Gopalakrishnan L, Menon P, Nimmagadda S, Patil SR, Fernald LCH. Anganwadi worker time use in Madhya Pradesh, India: a cross-sectional study. BMC Health Serv Res 2020; 20:1130. [PMID: 33287800 PMCID: PMC7722292 DOI: 10.1186/s12913-020-05857-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 10/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anganwadi Workers (AWWs) are a group of 1.4 million community health workers that operate throughout rural India as a part of the Integrated Child Development Services program. AWWs are responsible for disseminating key health information regarding nutrition, family planning, and immunizations to the women and children in their catchment area, while maintaining detailed registers that track key beneficiary data, updates on health status, and supply inventory beneficiaries. There is a need to understand how AWWs spend their time on all of these activities given all of their responsibilities, and the factors that are associated with their time use. METHODS This cross-sectional study conducted in Madhya Pradesh, collected time use data from AWWs using a standard approach in which we asked participants how much time they spent on various activities. Additionally, we estimated a logistic regression model to elucidate what AWW characteristics are associated with time use. RESULTS We found that AWWs spend substantial amounts of time on administrative tasks, such as filling out their paper registers. Additionally, we explored the associations between various AWW characteristics and their likelihood of spending the expected amount of time on preschool work, filling out their registers, feeding children, and conducting home visits. We found a positive significant association between AWW education and their likelihood of filling out their registers. CONCLUSIONS AWWs spend substantial amounts of time on administrative tasks, which could take away from their ability to spend time on providing direct care. Additionally, future research should explore why AWW characteristics matter and how such factors can be addressed to improve AWWs' performance and should explore the associations between Anganwadi Center characteristics and AWW time use.
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Affiliation(s)
| | - Dilys M Walker
- University of California San Francisco, San Francisco, USA
| | - Rasmi Avula
- International Food Policy Research Institute, Washington, DC, USA
| | | | | | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, USA
| | - Sneha Nimmagadda
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
| | - Sumeet R Patil
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
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23
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Kachwaha S, Nguyen PH, DeFreese M, Avula R, Cyriac S, Girard A, Menon P. Assessing the Economic Feasibility of Assuring Nutritionally Adequate Diets for Vulnerable Populations in Uttar Pradesh, India: Findings from a "Cost of the Diet" Analysis. Curr Dev Nutr 2020; 4:nzaa169. [PMID: 33313474 PMCID: PMC7721462 DOI: 10.1093/cdn/nzaa169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/10/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Healthy diets can help reduce undernutrition, morbidity, and mortality. However, evidence on the accessibility and affordability of recommended diets is limited, particularly in poor-resource settings including India. OBJECTIVES This study examined: 1) the minimum cost of different types of household diets; 2) how economic constraints can prevent households from accessing a nutritious diet; and 3) how home production and social protection can improve access to nutritious diets. METHODS We conducted 24 market and 125 household surveys in Uttar Pradesh, India, to obtain food prices and consumption patterns. Cost of Diet, a linear programming software, was used to assess the minimum cost of different diets, estimate affordability of nutritious diets, and model scenarios of home production and social protection interventions to improve affordability. RESULTS The minimum-cost nutritious diet that met all recommended nutrient requirements [904 US dollars (US$)/y] was over twice as expensive as the diet that only met energy requirements (US$393/y). The nutritious diet was unaffordable for 75% of households given current income levels, consumption patterns, and food prices. Household income and dietary preferences, rather than food availability, were the key barriers to obtain nutritious diets. Home production had potential to reduce the cost of nutritious diets by 35%, subsidized grains by 19%, and supplementary food by 10%. The poorest households could only afford recommended nutritious diets with access to multiple interventions. CONCLUSIONS Practical, habitual, diet-related behavior change communication to middle- and high-income households and additional social protection for poorer households could enable individuals to achieve optimal nutrient intakes.
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Affiliation(s)
- Shivani Kachwaha
- International Food Policy Research Institute, Washington, DC, USA
| | | | | | - Rasmi Avula
- International Food Policy Research Institute, Washington, DC, USA
| | - Shruthi Cyriac
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - Amy Girard
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, USA
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24
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John A, Nisbett N, Barnett I, Avula R, Menon P. Factors influencing the performance of community health workers: A qualitative study of Anganwadi Workers from Bihar, India. PLoS One 2020; 15:e0242460. [PMID: 33237939 PMCID: PMC7688170 DOI: 10.1371/journal.pone.0242460] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 11/03/2020] [Indexed: 11/18/2022] Open
Abstract
Globally, there remain significant knowledge and evidence gaps around how to support Community Health Worker (CHW) programmes to achieve high coverage and quality of interventions. India's Integrated Child Development Services scheme employs the largest CHW cadre in the world-Anganwadi Workers (AWWs). However, factors influencing the performance of these workers remain under researched. Lessons from it have potential to impact on other large scale global CHW programmes. A qualitative study of AWWs in the Indian state of Bihar was conducted to identify key drivers of performance in 2015. In-depth interviews were conducted with 30 AWWs; data was analysed using both inductive and deductive thematic analysis. The study adapted and contextualised existing frameworks on CHW performance, finding that factors affecting performance occur at the individual, community, programme and organisational levels, including factors not previously identified in the literature. Individual factors include initial financial motives and family support; programme factors include beneficiaries' and AWWs' service preferences and work environment; community factors include caste dynamics and community and seasonal migration; and organisational factors include corruption. The initial motives of the worker (the need to retain a job for family financial needs) and community expectations (for product-oriented services) ensure continued efforts even when her motivation is low. The main constraints to performance remain factors outside of her control, including limited availability of programme resources and challenging relationships shaped by caste dynamics, seasonal migration, and corruption. Programme efforts to improve performance (such as incentives, working conditions and supportive management) need to consider these complex, inter-related multiple determinants of performance. Our findings, including new factors, contribute to the global literature on factors affecting the performance of CHWs and have wide application.
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Affiliation(s)
- Aparna John
- Department of International Development, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Nicholas Nisbett
- Health and Nutrition Cluster, Institute of Development Studies, University of Sussex, Brighton, United Kingdom
| | - Inka Barnett
- Health and Nutrition Cluster, Institute of Development Studies, University of Sussex, Brighton, United Kingdom
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, New Delhi, India
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25
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Bajaj S, Avula R, Pant A, Nguyen P, Ruel M, Menon P. Routine Growth Monitoring Processes in Nutrition Programs in India Have Multiple Falter Points with Implications for Quality of Care. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa053_011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Growth monitoring (GM) and promotion is a routine part of primary healthcare for children in >80% of countries. In India, 57.5 million children are measured every month by frontline workers to assess their growth and to trigger preventive or curative services. Standard guidance for anthropometry suggests that quality can be compromised by the choice of measurement equipment, placement of equipment, and positioning of children during measurement. Little is known about the quality of measurement processes during GM. We compared child height and weight measurement processes with standards for anthropometry to assess GM quality.
Methods
We observed the process of measuring weight and height of <5 years-old-children (N = 681) in 4 states using a checklist based on standards for anthropometry. We summarized data along critical measurement falter points that could affect quality. Open-ended interviews were conducted with caregivers to assess how they value GM.
Results
Most children (75%) were weighed using age-appropriate weighing scales (baby-weighing scales, salter scales, and on adult scales with a caregiver). However, for Salter scales, only 44% of children were placed in a sling/pants appropriate for their age. More than 30% of children wore heavy clothing and 45% were not calm during weighing. Over 60% were weighed in a sitting/standing position on a baby-weighing scale. More than 50% of infants were not measured using age-appropriate height equipment. Height equipment was placed on a stable surface while measuring a majority of children, but a large proportion of children were incorrectly positioned on the equipment. Caregivers valued GM and reported having children weighed to learn about any changes; nearly half the caregivers considered weight as a marker for child growth.
Conclusions
Multiple measurement-related falter points were observed during GM. Most were measured incorrectly, increasing the potential for under-or over estimation of their weight/height and consequent misclassification for screening and referrals. As routine GM appears to be an assurance of child growth to caregivers, it is imperative to strengthen the quality of measurements, focusing on the falter points to ensure better data for programs and for caregiver use.
Funding Sources
Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.
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Affiliation(s)
| | - Rasmi Avula
- International Food Policy Research Institute
| | - Anjali Pant
- International Food Policy Research Institute
| | | | - Marie Ruel
- International Food Policy Research Institute
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26
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Nguyen P, Menon P, Avula R, Tran LM, Kumar A, Baswal D, Sethi V, Hajeebhoy N, Ranjan A. Can Health Systems Platforms Do More for Nutrition in India? Insights on Missed Opportunities from India's National Family Health Survey, 2015–2016. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa053_079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Most nutrition interventions can be delivered through health systems. However, the progress to scale up effective nutrition interventions and achieve universal health coverage has not been uniform. We aimed to 1) examine the opportunity gaps (OGs) between delivery platforms and corresponding nutrition interventions through the continuum of care (from pregnancy up to early childhood) in India between 2006 and 2016; and 2) assess inequalities in these OGs.
Methods
We used two rounds of National Family Health Survey data collected in 2005–06 and 2015–16 (n = 36,850 and 190,898 mother-child dyads with the last child aged of 0–5 years, respectively). We examine the OGs over time for a set of seven nutrition interventions and their associated delivery platforms during antenatal, delivery, postnatal and early childhood care at the national, state and district levels. We then assessed equality and changes in equality between 2006–2016 for the OGs by education, residence, socioeconomic status, public and private platforms.
Results
Coverage of nutrition interventions was consistently lower than the reach of their associated delivery platforms, with the OGs ranging from 9–32 percentage points (pp) during pregnancy, 17pp during delivery, and 9–26pp during childhood in 2006. Between 2006 and 2016, coverage improved for most indicators but the OGs became wider. The OGs were larger among women with higher education, higher SES status and living in urban areas, despite higher coverage of most interventions and the delivery platforms among these groups. Compared to private facilities, public facilities performed better in counseling/support for breastfeeding but were poorer in iron and folic acid supplementation. OGs vary tremendously by state and district, highlighting governance and implementation successes and challenges.
Conclusions
India's progress in coverage of health and nutrition interventions in the last decade is promising, but both opportunity and equity gaps must be closed by addressing policy and programmatic health systems bottlenecks to achieve universal coverage for both health and nutrition. We recommend this analytic approach to track and assess OGs in scaling up nutrition through health systems in India and worldwide.
Funding Sources
Bill & Melinda Gates Foundation through POSHAN, led by IFPRI.
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Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute
| | | | | | - Dinesh Baswal
- National Health Systems Resource Centre, New Delhi, India
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27
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Kachwaha S, Nguyen P, Tran LM, Avula R, Young M, Ghosh S, Escobar-Alegria J, Frongillo E, Menon P. Health Systems Strengthening Efforts Help to Improve the Delivery of Maternal Nutrition Interventions in Antenatal Care in Uttar Pradesh (UP), India but Gaps Remain. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa059_031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Frontline workers (FLWs) deliver essential nutrition services to reduce maternal undernutrition in India, but coverage and quality remain sub-optimal. Alive & Thrive aimed to strengthen delivery of interpersonal counselling, community mobilization and micronutrient supplements through the government antenatal care (ANC) platform in UP. We studied pathways through which the nutrition-intensified ANC (I-ANC) was intended to impact FLWs capacity, knowledge, and service delivery, compared to standard ANC (S-ANC).
Methods
We used a cluster-randomized design with cross-sectional surveys at baseline (2017) and endline (2019), ∼500 FLWs per survey. Differences between I-ANC and S-ANC were compared along six impact pathway components (training, availability of materials, supportive supervision, knowledge, service delivery, and counselling content) using mixed-effects regression adjusted for clustering.
Results
Training exposure was higher in I-ANC than S-ANC (9 percentage points, pp). Nutrition training topics were low-moderate (30–60%) in both arms. Job aids were more available in I-ANC (70–80%) than S-ANC (30–40%). Supply of iron-folate and calcium supplements were low in both arms, with 10–50% having stock-outs. FLWs in I-ANC were more likely to receive supervision visits (7 pp), but gaps remained in both arms. Compared to S-ANC, FLWs in I-ANC had higher knowledge on diet diversity (6 pp), adequate intake (10 pp), iron-folate (10 pp) and calcium supplements (30 pp), pregnancy weight gain (20–30 pp), and early breastfeeding (5 pp), but similarly low knowledge of exclusive breastfeeding. ANC check-ups by FLWs were 20 pp higher in I-ANC. FLWs in I-ANC did more counselling on adequate diet, supplements, and weight gain (10–20 pp). Counselling on diet diversity and breastfeeding were low in both arms.
Conclusions
Health systems strengthening efforts helped improve the delivery of maternal nutrition interventions in antenatal care in this context, but gaps remain. Several health system elements along the program pathway – supply chain management, training, supervisory practices – require strengthening to further improve FLW knowledge and nutrition service delivery.
Funding Sources
Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.
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Affiliation(s)
| | | | | | - Rasmi Avula
- International Food Policy Research Institute
| | - Melissa Young
- Hubert Department of Global Health, Emory University
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28
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Avula R, Menon P, Bajaj S, Saxena M, Deshpande S, Gopalakrishnan L, Patil S, Nimmagadda S, Diamond-Smith N, Fernald L, Walker D. M-Health Intervention Has the Potential to Alleviate Constraints in Using Administrative Data Systems for Improving Service Delivery in India. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa053_007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Administrative Data (AD) are a key component of nutrition data systems, but little is known about how AD are used or can be reshaped for accountability and action. We studied factors influencing AD use in India's Integrated Child Development Services (ICDS), in two Indian states; and assessed how an m-Health intervention (Common Application Software (CAS)) changes it. ICDS-AD system consolidates data from 11-recording registers updated every month by ∼1.3 million frontline workers (FLW). CAS digitizes these records and creates dashboards for real-time monitoring.
Methods
We conducted semi-structured interviews (n = 82) with supervisory staff at sub-district [Lady Supervisors (LS); Child Development Project Officer (CDPO)] and district level [District Program Officer (DPO)] to understand AD use patterns, facilitators and barriers. Data were coded, summarized and analysed across levels of supervisory staff.
Results
LS supervise FLWs, visit villages monthly to monitor data, and collate it to the sub-district level. Due to limited time and pressures to update AD on time, LS focus on data completeness and not on quality or data use. At the next level, CDPOs review and discuss program targets for indicators with LS, and check data completeness. They create monthly reports on targets for the districts, based on LS reports. At the district, DPOs use compiled reports to review subdistrict performance and discuss any gaps with CDPOs. CAS makes the data entry, compilation and report generation easier for all users. LS can monitor data entry daily in CAS and data collation is automated. CDPOs can review the CAS dashboard and use it to discuss issues with LS and DPOs. However, program target indicators dominate use of data. In CAS areas, these include growth monitoring completion, home visits, identification of malnourished children, and their referral. Overall, data use is target-driven, with indicators for monitoring prioritized by program management.
Conclusions
Focus of data use has been on reporting up on target indicators rather than on local program improvement, due to staff and time constraints. CAS can address some AD use constraints by easing data entry and data compilation but a data culture that focuses on predetermined target indicators can limit use for local program improvement.
Funding Sources
Bill & Melinda Gates Foundation via grants to IFPRI and UCSF.
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Affiliation(s)
- Rasmi Avula
- International Food Policy Research Institute
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29
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Avula R, Nguyen P, Kohli N, Kanani S, Menon P. No Magic Bullets: Insights on Drivers of Stunting Decline from an Analysis of Subnational Success Cases in India. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa053_008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Global attention to reducing childhood stunting has increased the demand for guidance on translating policies into impact. Evidence from national-level success cases is emerging but little is known about how subnational entities can accelerate change. In India, despite a common national framework of programs/policies targeting many determinants of child growth, stunting reduction has varied across states. We aimed to understand drivers of change in stunting at state-level and to identify programmatic, social and political factors that contributed to these changes.
Methods
We studied three states that had achieved substantial stunting declines between 2005 and 2016 [Chhattisgarh (CG) 14 percentage points (pp); Gujarat (GJ) 13pp; Odisha (OD) 11 pp]. We used regression-decomposition analysis to assess contributions of various determinants of height-for-age Z-score (HAZ) using two rounds of national data. We reviewed nutrition-relevant policies and programs linked to these drivers of change and interviewed stakeholders in government, development partners (DPs), academia and civil society (n = 61) to understand how change occurred.
Results
Main contributors to gains in HAZ were coverage of health and nutrition interventions (21% CG; 11% GJ; 25% OD), household assets (10% CG; 13% GJ; 18% OD), and sanitation (7% CG; 6% GJ; 5% OD). Maternal education, age at marriage, community-level hygiene, and electrification also contributed. Political leadership and an outcome-focused vision were crucial for action. Although vision varied, capable administrators were able to secure adequate finances, strengthen implementation systems, and invest in state-specific innovations, creating an enabling environment for change. Varied actors, including civil society and DPs, played a catalytic role in spurring action through advocacy, technical and financial inputs, and vigilance.
Conclusions
Similar drivers were responsible for stunting reduction in 3 states. Ingredients for success highlight the importance of political leadership, targeting multiple determinants and improving implementation systems. Supportive civil society, political and bureaucratic leadership motivated by the well-being of communities remain crucial.
Funding Sources
Bill & Melinda Gates Foundation through POSHAN, led by IFPRI.
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Affiliation(s)
- Rasmi Avula
- International Food Policy Research Institute
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30
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Pramanik P, Nguyen P, Avula R, Billah SM, Ferdous T, Sarker BK, Ireen S, Mahmud Z, Ash D, Menon P. Using Novel Scenario-Based Assessments to Examine Feasibility of Integrating Preventive Nutrition Services Through the Primary Healthcare System in Bangladesh. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa043_116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Bangladesh's National Nutrition Services aims to deliver nutrition services to pregnant women and children through the primary health care system. Previous research highlighted gaps in coverage of preventive nutrition intervention delivery through this system but little is known about feasibility of reshaping service delivery to close the gaps. Prior to designing new approaches, we used a novel scenario-based feasibility testing approach to assess potential to strengthen service delivery.
Methods
We interviewed 32 service providers and 16 policymakers and conducted 4 focus group discussions with potential beneficiaries, asking respondents about the feasibility of four hypothetical scenarios for preventive service delivery: community-based events (CBE) for pregnant women; well-child services integrated into immunization contacts; CBE for well-children and well-child visits at facilities. Transcribed interviews were systematically coded, synthesized and interpreted using a pre-defined framework.
Results
Opinions on the need for new platforms for preventive services were mixed; some recommended new platforms, but others suggested strengthening existing delivery points. CBE for pregnant women were perceived as feasible, but workforce shortages emerged as a key challenge. Challenges such as equipment portability, upset children, and a fast-moving service environment suggested low feasibility of integrating nutrition into immunization contacts. In contrast, CBE and facility-based well-child visits emerged as feasible options, conditional on having the necessary workforce, structural readiness and budget support. On the demand side, enabling factors include using interpersonal communication and involving community leaders to increase awareness, organizing events at a convenient time and place for both providers and beneficiaries, and incentives for beneficiaries to encourage participation.
Conclusions
A scenario-based approach is an efficient method to assess potential feasibility options for nutrition service delivery. Introducing preventive nutrition services requires addressing current challenges in the health system, including human resource and logistic gaps, and investing in creating demand for preventive services.
Funding Sources
Bill & Melinda Gates Foundation, through A&T, managed by FHI 360.
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Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute
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31
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Bootwala A, Nguyen P, Kachwaha S, Avula R, Ghosh S, Forissier T, Menon P, Young M. Understanding How the Strategic Use of Data Can Improve the Implementation of Maternal Nutrition Interventions in Uttar Pradesh (UP), India. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa054_017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Maternal undernutrition remains high in India and is associated with maternal mortality and adverse birth outcomes. To address this challenge, Alive & Thrive (A&T) aimed to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in UP. The nutrition-intensified ANC (I-ANC) intervention facilitated regular use of data to enable corrective actions. We aimed to understand how maternal health data was used for improving the delivery of maternal nutrition services and to identify factors associated with data use.
Methods
In-depth interviews (N = 35) were conducted among sub-district government staff, frontline worker (FLW) supervisors and A&T staff in two districts in UP. Systematic coding of verbatim transcripts and detailed summaries was undertaken to elucidate themes and patterns related to data use and facilitators and barriers.
Results
Sub-district government staff reported using government data (i.e., HMIS) to estimate demand for prenatal supplements. Sub-district government staff, FLW supervisors and A&T staff used government and intervention monitoring data to understand the impact and reach of services delivered to women. Key indicators on the attendance of pregnant women at community health events and number of women receiving adequate supplements was discussed with FLWs in monthly review meetings. Data review guided identification of areas of low FLW performance (i.e., monitoring weight gain) and prompted refresher trainings. Facilitators of data use included collaboration between sub-district health department officials on data analysis and monthly review meetings to provide feedback on improving performance (including counseling topics and stock of supplements). Barriers to data use included staff vacancies, education level of FLWs and conflicts between FLWs and supervisors.
Conclusions
Use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Collaboration facilitated the use of data, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions.
Funding Sources
Bill & Melinda Gates Foundation (through Alive & Thrive, managed by FHI 360) and Emory University.
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Affiliation(s)
| | | | | | - Rasmi Avula
- International Food Policy Research Institute
| | | | | | | | - Melissa Young
- Hubert Department of Global Health, Emory University
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Jangid M, Menon P, Avula R, Sarswat E, Nair D, Agrawal N, Singh A, Kaur S, Kumar A. Tracking India's Progress on Addressing Malnutrition Will Require Strengthening Survey and Administrative Data Systems. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa064_006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
India has a nutrition policy framework that includes several evidence-based interventions. However, the availability of data to analyze coverage, assess equity and track progress on scaling up interventions is not known. We assessed data availability for nutrition interventions by reviewing multiple data systems in India.
Methods
Using the national policy framework, we identified 55 nutrition interventions for which coverage data were necessary to track progress. We examined questionnaires of three major household surveys. We also assessed monitoring data available in three major administrative systems. We summarized overall data availability by type of data system and across the life course.
Results
Of the 55 interventions, six interventions had data across all data sources. For nine interventions, no data was available from any source. For the remaining 46 interventions, data is available from at least one data source. Surveys had data on 36 interventions and administrative systems had data on 42 interventions. However, data definitions and denominators vary by source, making comparisons challenging.
For adolescents, coverage data is scarce both in surveys and administrative systems. For pregnancy, multiple data sources are available on antenatal care, but gaps exist for nutrition interventions such as calcium supplementation, counseling and maternity benefits. For delivery and postnatal care, data is available on institutional deliveries and postnatal care but is limited for kangaroo mother care and breastfeeding counseling. Data is very limited for newborn care interventions. For early childhood, 9 of 13 interventions are available from different data sources.
Conclusions
Data on India's nutrition interventions are available from multiple sources but vary by intervention and by life-stage. Data are often not comparable across sources. Multiple data sources for some interventions requires careful reconciliation of findings from survey and administrative data systems. Data stewardship is critical to ensure effective use of data.
Funding Sources
Data for Decisions to Expand Nutrition Transformation (DataDENT) and Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India (POSHAN), supported by the Bill and Melinda Gates Foundation.
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Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute
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Nguyen P, Kachwaha S, Tran LM, Avula R, Young M, Ghosh S, Agrawal R, Escobar-Alegria J, Forissier T, Frongillo E, Patil S, Menon P. Strengthening Nutrition Interventions in Antenatal Care Services Had Modest Impacts on Diet Diversity, Micronutrient Intake, and Breastfeeding in Uttar Pradesh, India. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa054_122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Interventions to improve maternal nutrition are poorly integrated into antenatal care (ANC) services in India. Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization implemented through government ANC services. We evaluated the impact of nutrition-intensified ANC (I-ANC) compared to standard ANC (S-ANC) on diet diversity, consumption of iron-folic acid (IFA) and calcium supplements, and early breastfeeding practices.
Methods
We used a cluster-randomized design with cross-sectional surveys at baseline (2017) and endline (2019) (n ∼660 pregnant women and 1800 recently delivered women per survey) and a process evaluation. We derived difference-in-difference effect estimates, adjusted for geographic clustering, gestational age, infant age, and sex.
Results
Coverage of interventions was high at endline; 70–90% women were contacted by frontline workers at home or nutrition centers. Women in the I-ANC arm were significantly more likely to have received counseling on core nutrition messages (10–18 percentage points [pp]) than those in the S-ANC arm. Dietary diversity improved modestly among pregnant women in the I-ANC arm compared to the S-ANC arm (effect: 8.3 pp). The number of food groups consumed increased slightly over time but remained low in both arms. The percentage of women who consumed 100 + IFA improved equally in both arms (from 8 to 25%). Small significant impacts were observed for any consumption of IFA and calcium supplements (effects 10.3 and 12.4 pp, respectively). Significant impacts were also observed for non-prelacteal feeding (effect: −6.3 pp) and exclusive breastfeeding (effect: 7.4 pp) but not for early initiation of breastfeeding. The process evaluation found that system-level and supply-chain challenges, household context, and local diet preferences affected implementation and uptake.
Conclusions
Intensifying nutrition in existing government ANC services resulted in modest improvements in maternal nutrition practices. Dietary diversity and consumption of supplements remained sub-optimal. Additional efforts are needed for further improvement of maternal nutrition services.
Funding Sources
Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.
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Affiliation(s)
| | | | | | - Rasmi Avula
- International Food Policy Research Institute
| | - Melissa Young
- Hubert Department of Global Health, Emory University
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Young MF, Nguyen P, Tran LM, Avula R, Menon P. A Double Edged Sword? Improvements in Economic Conditions over a Decade in India Led to Declines in Undernutrition as Well as Increases in Overweight among Adolescents and Women. J Nutr 2020; 150:364-372. [PMID: 31618429 DOI: 10.1093/jn/nxz251] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/15/2019] [Accepted: 09/18/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND India is facing a dual burden of undernutrition and overweight/obesity, and there are gaps in our understanding of the driving factors over time. OBJECTIVE This study examined the national and state trends for BMI and identified the determinants of underweight and overweight/obesity among adolescent girls and women. METHODS We used India's National Family Health Surveys data collected in 2005-2006 (n = 110,887) and 2015-2016 (n = 645,193). We applied multiple regression and decomposition analysis to assess determinants of underweight (BMI z score < -1 SD; <18.5 kg/m2) and overweight/obesity (BMI z score >1 SD; ≥25 kg/m2). RESULTS Over the past decade, the prevalence of underweight decreased (43% to 38% and 33% to 19%) and the prevalence of overweight/obesity increased (3% to 5% and 15% to 24%), among adolescents and women, respectively, with high heterogeneity across states. Factors associated with a lower prevalence of underweight among women included higher socioeconomic status (SES) (OR: 0.35; 95% CI: 0.31, 0.41), urban residence (OR: 0.49; 95% CI: 0.45, 0.54), improved diet diversity (OR: 0.75; 95% CI: 0.69, 0.82), and latrine use (OR: 0.76; 95% CI: 0.70, 0.82). Higher education levels, decision-making, and ownership of money were also associated with a lower prevalence of underweight. Factors positively associated with overweight/obesity among women included SES (OR: 3.24; 95% CI: 2.81, 3.73), urban residence (OR: 2.23; 95% CI: 2.05, 2.42), diet diversity (OR: 1.21; 95% CI: 1.10, 1.32), latrine use (OR: 1.31; 95% CI: 1.21, 1.43), and education (OR: 1.39; 95% CI: 1.24, 1.55). Adolescents shared similar determinants to women. Overall, SES was a key driver of changes in women's BMI, explaining 29% of the reduction in undernutrition and 46% of the increase in overweight/obesity. CONCLUSIONS Despite overall declines, regional and age disparities remain in the overall burden of underweight and the increases in overweight/obesity are concerning. The identified divergent risk factors (SES, residence, diet, education) highlight that simply improving economic status will not ensure healthy BMI status for women and girls. Balanced multidisciplinary approaches are needed to address both undernutrition and overweight.
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Affiliation(s)
- Melissa F Young
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - Phuong Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Lan Mai Tran
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Rasmi Avula
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
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35
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Young MF, Nguyen P, Kachwaha S, Tran Mai L, Ghosh S, Agrawal R, Escobar-Alegria J, Menon P, Avula R. It takes a village: An empirical analysis of how husbands, mothers-in-law, health workers, and mothers influence breastfeeding practices in Uttar Pradesh, India. Matern Child Nutr 2019; 16:e12892. [PMID: 31773869 PMCID: PMC7083414 DOI: 10.1111/mcn.12892] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/17/2019] [Accepted: 08/29/2019] [Indexed: 12/03/2022]
Abstract
Evidence on strategies to improve infant and young child feeding in India, a country that carries the world's largest burden of undernutrition, is limited. In the context of a programme evaluation in two districts in Uttar Pradesh, we sought to understand the multiple influences on breastfeeding practices and to model potential programme influence on improving breastfeeding. A cross‐sectional survey was conducted among 1,838 recently delivered women, 1,194 husbands, and 1,353 mothers/mothers‐in‐law. We used bivariate and multivariable logistic regression models to examine the association between key determinants (maternal, household, community, and health services) and breastfeeding outcomes [early initiation of breastfeeding (EIBF)], prelacteal feed, and exclusive breastfeeding (EBF). We used population attributable risk analysis to estimate potential improvement in breastfeeding practices. Breastfeeding practices were suboptimal: EIBF (26.3%), EBF (54%), and prelacteal feeding (33%). EIBF was positively associated with maternal knowledge, counselling during pregnancy/delivery, and vaginal delivery at a health facility. Prelacteal feeds were less likely to be given when mothers had higher knowledge, beliefs and self‐efficacy, delivered at health facility, and mothers/mothers‐in‐law had attended school. EBF was positively associated with maternal knowledge, beliefs and self‐efficacy, parity, and socio‐economic status. High maternal stress and domestic violence contributed to lower EBF. Under optimal programme implementation, we estimate EIBF can be improved by 25%, prelacteal feeding can be reduced by 25%, and EBF can be increased by 23%. A multifactorial approach, including maternal‐, health service‐, family‐, and community‐level interventions has the potential to lead to significant improvements in breastfeeding practices in Uttar Pradesh.
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Affiliation(s)
- Melissa F Young
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | - Phuong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Shivani Kachwaha
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | | | | | | | | | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
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36
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Nguyen PH, Avula R, Headey D, Tran LM, Ruel MT, Menon P. Progress and inequalities in infant and young child feeding practices in India between 2006 and 2016. Matern Child Nutr 2019; 14 Suppl 4:e12663. [PMID: 30499255 PMCID: PMC6518921 DOI: 10.1111/mcn.12663] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/12/2018] [Accepted: 07/19/2018] [Indexed: 01/24/2023]
Abstract
Limited evidence exists on socio‐economic status (SES) inequalities in infant and young child feeding (IYCF) in India. We examine trends and changes in inequalities for IYCF practices over 2006–2016 and identify factors that may explain differences in IYCF across SES groups. We use data from the 2015–2016 and 2005–2006 National Family Health Surveys (n = 112,133 children < 24 months). We constructed SES quintiles (Q) and assessed inequalities using concentration and slope indices. We applied path analyses to examine the relationship between SES inequalities, intermediate determinants, and IYCF. Breastfeeding improved significantly over 2006–2016: from 23% to 42% for early initiation of breastfeeding (EIBF) and 46% to 55% for exclusive breastfeeding (EBF). Minimum dietary diversity (MDD) improved modestly (15% to 21%), but adequate diet did not change (~9%). Large SES gaps (Q5–Q1) were found for EIBF (8–17%) and EBF (−15% to −10%) in 2006; these gaps closed in 2016. The most inequitable practices in 2006 were MDD and iron‐rich foods (Q5 ~ 2–4 times higher than Q1); these gaps narrowed in 2016, but levels are low across SES groups. Factors along the path from SES inequalities to IYCF practices included health and nutrition services, information access, maternal education, number of children < 5 years, and urban/rural residence. The improvements in breastfeeding and narrowing of equity gaps in IYCF practices in India are significant achievements. However, ensuring the health and well‐being of India's large birth cohort will require more efforts to further improve breastfeeding, and concerted actions to address all aspects of complementary feeding across SES quintiles.
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Derek Headey
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | | | - Marie T Ruel
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
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37
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Nguyen PH, Kachwaha S, Avula R, Young M, Tran LM, Ghosh S, Agrawal R, Escobar-Alegria J, Patil S, Menon P. Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors. Matern Child Nutr 2019; 15:e12839. [PMID: 31066195 PMCID: PMC6852235 DOI: 10.1111/mcn.12839] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 04/08/2019] [Accepted: 04/23/2019] [Indexed: 01/29/2023]
Abstract
Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self‐efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization‐recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change.
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Shivani Kachwaha
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | | | | | | | | | | | - Sumeet Patil
- Network for Engineering, Economics, Research and Management (NEERMAN), Mumbai, India
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
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Constantinides S, Blake C, Frongillo E, Avula R, Thow AM. Double Burden of Malnutrition: The Role of Framing in Development of Political Priority in the Context of Rising Diet-related Non-communicable Diseases in Tamil Nadu, India (P22-005-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz042.p22-005-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
In low- and middle-income countries, non-communicable disease (NCD) prevalence is increasing while undernutrition persists, resulting in a double-burden of malnutrition. How policy actors frame malnutrition may shape policy, programming, and investment. In India, where NCDs are rising rapidly and undernutrition persists throughout the country, much of food and health policy is decentralized, but little is known of how the double burden of malnutrition is understood at the state level. This study aimed to identify and compare frames and priorities for nutrition used by relevant policy actors to help understand the narrative emerging around policy solutions for the double burden of malnutrition.
Methods
Key informants in the health, nutrition, and agriculture fields were identified from policy documents and purposive and snowball sampling. In-depth, semi-structured interviews were held with 28 key informants including international policy advocates, government officials, and state-level implementers in Tamil Nadu. Interviews were audio-recorded, transcribed, and coded with Nvivo 12. Major themes were identified using elements from prior published work: actor power, internal frame, issue characteristics, evaluative dimensions of target populations, priorities emphasized, and potential effects of the frame or likely policy result.
Results
Different actors reported differing priorities for the double burden of malnutrition. There was almost universal concern about stunting and anemia in children and women and consensus on sanitation and dietary diversity as causes of undernutrition, but a lack of clarity regarding diet-related NCDs. Respondents were unclear about which populations to target for the double burden, compared to clear targeting of women and children to address undernutrition. They described lack of convergence or clear roles for actors addressing the double burden, unlike for undernutrition.
Conclusions
There is a lack of consensus on the causes, manifestation, and solutions for the double burden of malnutrition within the policy community. Creating a shared narrative is critical for cohesive and efficient programming to address the double burden of malnutrition.
Funding Sources
Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.
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Affiliation(s)
| | | | | | - Rasmi Avula
- International Food Policy Research Institute
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39
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Menon P, Nguyen P, Avula R, Mani S, Tran L, Victora C. A Decade of Progress on Scaling up Health and Nutrition Interventions in India: a Countdown to 2030 Case Study (P04-115-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz051.p04-115-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
India rolled out ambitious program efforts for health and nutrition (H&N) in 2005–06, scaling up community H&N services through the National Rural Health Mission and the Integrated Child Development Services (ICDS). Evidence on the combined reach and impact of these programs on closing equity gaps is limited. We aimed to assess how coverage and equity in interventions have changed between 2006 and 2016.
Methods
We used two rounds of National Family Health Survey data collected in 2006 and 2016 (n = 36,850 and 190,898 mother-child dyads with the last child aged of 0–5 y, respectively). We selected a key set of interventions in India's policy frameworks, spanning the continuum of care for maternal, newborn and child H&N. We examine progress over time at national and state level, then assess equity and changes in equity by state, urban/rural, caste and socioeconomic status using concentration and slope indices. We complemented the data analysis with policy analyses and highlight state-specific success case studies.
Results
Coverage of all H&N interventions improved, and equity gaps decreased at all levels examined between 2006 and 2016. Institutional deliveries, some components of antenatal care and immunization reached high coverage (80–90%). For nutrition, consumption of iron folic supplements during pregnancy nearly doubled (from 16 to 30%) and receiving food supplements during lactation tripled (from 15 to 48%). Although the trends are positive, achieving full coverage of interventions to every woman and every child remains a significant challenge. Levels of achieved coverage and trends over time vary tremendously by state, highlighting governance and implementation successes and challenges. Health interventions reach more rich than poor, whereas ICDS interventions are overwhelmingly used by the poor. Equity gains for antenatal care, institutional delivery and immunizations for the poor come primarily from increased use of public sector services.
Conclusions
India's progress in coverage of H&N interventions and narrowing of equity gaps in the last decade are significant achievements. As India looks ahead to the Sustainable Development Goals, a stronger focus on closing gaps in coverage, state-by-state, is needed.
Funding Sources
Bill & Melinda Gates Foundation through POSHAN, led by IFPRI.
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Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute
| | - Sneha Mani
- International Food Policy Research Institute
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40
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Bajaj S, Menon P, Nguyen P, Avula R, Mani S, Gopalakrishnan L, Nimmagadda S, Patil S, Fernald L, Walker D. Use of Situational Vignettes Helps Assess the Competence of Frontline Workers (FLW) in Nutrition Counseling Programs (OR13-07-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz050.or13-07-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Behavior change communication (BCC) effectiveness depends on the knowledge of frontline workers (FLWs) who counsel clients. Most studies assess content-based knowledge of FLWs but do not examine their ability to apply this content. We tested the use of situational vignettes to assess ‘application knowledge’ and examined gaps between content and application knowledge, and the association between both types of FLW knowledge and that of clients (mothers).
Methods
Data are from a survey of 100 FLWs and 409 mothers with children <2y in Madhya Pradesh, India. Content knowledge was assessed using questions on nutrition. Application knowledge to assess FLW knowledge of topics to cover in specific counselling contacts was measured using situation-based vignettes and follow-up questions. Gap was defined as FLW demonstrating content knowledge without application knowledge. Regression models were used to assess determinants of knowledge, gaps in types of knowledge and associations with mothers’ knowledge.
Results
Many FLWs had reasonable content knowledge of family planning (94%), iron-folic acid during pregnancy (68%) and exclusive breastfeeding (93%). However, vignette-based application knowledge was lower than content knowledge. FLW education was associated with higher content knowledge (β = 0.69; P < 0.05) and higher application knowledge (β = 1.08; P < 0.01) of FLWs. FLWs’ age and caste were associated with gaps between content and application knowledge (β = 0.03 and β = 0.51, P < 0.10). The magnitude of association of FLWs’ application knowledge with maternal knowledge (β = 0.07; P < 0.10) was nearly twice the association of FLWs’ content knowledge with maternal knowledge (β = 0.04; P < 0.10), adjusted for maternal characteristics.
Conclusions
Assessing application-based knowledge using situational vignettes was feasible and helped understand FLW competence more than content-based knowledge tests only. Counseling programs must strengthen both content and application knowledge.
Funding Sources
Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.
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Affiliation(s)
| | | | | | - Rasmi Avula
- International Food Policy Research Institute
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Nguyen P, Scott S, Avula R, Agarwal A, Menon P, Headey D, Ruel M. Urbanization and the Double Burden: Trends and Inequalities in Under- and Over-nutrition by Residence and Wealth Among 1.22 Million Indian Children, Women and Men over 10 Years (P10-078-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz034.p10-078-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
We examined trends and inequities in the double burden of malnutrition among girls, boys, women and men by residence and wealth between 2006 and 2016 in India where 590 million individuals are expected to live in cities by 2030.
Methods
Two rounds of National Family Health Survey data collected in 2006 and 2016 (n = 276,000 children 0–59 mo; 768,000 women 15–49y; and 178,000 men 15–54y) were used. Residence was categorized as rural (RUR), urban non-slum (U-NS) and urban slum (U-SL). Multivariate regression analyses were used to examine differences and changes over time in outcomes by residential group and gender. A socioeconomic status (SES) index was created for each residential area and inequalities were assessed using concentration and slope indices.
Results
Children in different residential areas were born with similar height-for-age Z-scores, but growth faltering during the first two years of life was most rapid among children in RUR areas, followed by U-SL and U-NS areas. Boys and girls were equally likely to be stunted (48% in 2006 to 38% in 2016) or overweight (7–8% at both times). SES gaps were large for undernutrition, small for overnutrition, and did not change greatly in the past decade.
Among adults, underweight prevalence decreased equally across residential areas (4–5%) to reach 20% on average in both men and women. Overweight prevalence increased more rapidly among those living in RUR areas (7–9%) compared to U-SL (4–6%) and U-NS (1–3%) areas, and also reached ∼20%. The SES gap for underweight was narrower in 2016 than in 2006, mainly due to improvements among the poor in all residential areas. Overweight prevalence increased in all SES quintiles in RUR and U-SL areas and increased among the poor in U-NS areas.
Conclusions
The double burden of malnutrition is now a reality among adults in India. Although undernutrition has been reduced in both rural and urban areas over the past decade, the rate of increase in overweight was much larger in rural compared to urban areas; and more so in slums compared to non-slum areas. A further examination of changing living conditions, food environments, and physical activity levels is needed to identify and address the causes for these rapid changes in nutrition outcomes.
Funding Sources
Bill & Melinda Gates Foundation through POSHAN, led by IFPRI.
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Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute
| | | | | | | | - Marie Ruel
- International Food Policy Research Institute
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42
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Nguyen P, Kachwaha S, Avula R, Young MF, Tran L, Ghosh S, Agrawal R, Escobar-Alegria J, Patil S, Menon P. Maternal Nutrition Practices in Uttar Pradesh, India: Role of Key Influential Demand and Supply Factors (P11-002-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz048.p11-002-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examines multi-factorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India.
Methods
Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation.
Results
During pregnancy, women consumed ∼40 IFA and calcium tablets, 18% consumed diverse diet and 17% were weighed ≥ 3 times. Nutrition knowledge was a key modifiable factor associated with consumption of diverse diet (OR = 2.2 times, β = 0.7 food groups), IFA (2.3 times, 17 tablets), calcium (11.7 times, 18 tablets) and weight monitoring (0.7 times). Beliefs and self-efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better maternal nutrition practices. Under optimal program implementation, we estimate 51% women would have adequate diet diversity, an average consumption of 100 IFA and 90 calcium tablets, and women would be weighed 4.4 times during pregnancy
Conclusions
While the current situation is bleak, many of the key factors associated with maternal dietary diversity, IFA/calcium consumption and weight gain monitoring are modifiable. Strengthening existing program operations to improve the supply of interventions and to create adequate demand through behavior change communication has the potential to result in large improvements in maternal nutrition practices from their baseline levels. However, these efforts will not be sufficient to meet WHO-recommended levels without also putting in place more favorable socio-economic conditions and additional resources.
Funding Sources
Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360. Additional funding support is from CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by the International Food Policy Research Institute.
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Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute
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Avula R, Nguyen P, Pramanik P, Tran L, Sr. MR, Menon P. Can Multiple Forms of Undernutrition Among Children and Women Be Tackled Efficiently? A Case of Shared Determinants (P11-124-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz048.p11-124-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Globally, it is recognized that multiple forms of undernutrition exist. Yet, little evidence exists on co-existence of multiple forms of undernutrition or on the potential shared determinants of these manifestations. Therefore, using data from India, we aimed to: 1) estimate the co-occurrence of undernutrition among children (stunting and anemia) and women (underweight and anemia); and 2) identify their shared determinants.
Methods
We used National Family Health Survey data from 2016 (n = 126,338 children 6–59 mo; 159,752 women). We examined co-occurrence of stunting and anemia among children and underweight and anemia among women, comparing observed versus expected frequencies using chi-square tests. We used multivariate logistic regression models to study associations between nutrition outcomes and determinants (household, maternal and child-level), and identified determinants that were shared across the outcomes.
Results
The observed co-occurrence of stunting and anemia among children was 25% and of underweight and anemia among women was 15%. Observed frequencies were significantly greater than expected frequencies for all comparisons (P < 0.0001). Women's education (OR: 0.60 to 0.84), wealth status (OR: 0.56 to 0.81) and improved sanitation (OR: 0.74 to 0.94) were protective against all forms of undernutrition. Care during pregnancy was protective against stunting (OR = 0.83; P < 0.001) and anemia (OR = 0.94; P < 0.001) among children and underweight (OR = 0.88; P < 0.001) among women. Maternal underweight (OR = 1.31; P < 0.001) and anemia (OR = 1.09; P < 0.001) were risk factors for child undernutrition.
Conclusions
Co-occurrence of undernutrition is prevalent among women and children in India. Multiple forms of undernutrition also share similar determinants. Investing in reducing poverty, improving education, sanitation, and use of antenatal care could address multiple forms of undernutrition, thus ensuring more efficient use of resources.
Funding Sources
Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.
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Affiliation(s)
- Rasmi Avula
- International Food Policy Research Institute
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Young MF, Nguyen P, Avula R, Tran L, Menon P. Trends and Determinants of Low Body Mass Index (BMI) Among 750,000 Adolescents and Women of Reproductive Age in India (P10-086-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz034.p10-086-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Low BMI among women and girls has implications for their health and that of the next generation. Yet, little is known about the determinants of low BMI despite the known high burden of undernutrition in India. We aimed to use nationally representative data to examine national and state trends for BMI and to identify the determinants of low BMI among adolescent girls and women.
Methods
We used India's National Family Health Survey (NFHS), collected in 2005–2006 and 2015–16. Using data on adolescents 15–19y (N = 21,450; N = 117,722) and women 20–49y (N = 89,437; N = 527,471), we examined national and state trends for BMI. We used multiple regression analysis to examine the role of individual (e.g., diet), interpersonal (e.g., domestic violence) and family-level factors (e.g., socio-economic status (SES)) on low BMI (defined as BMI z-score <-1 for adolescents; BMI <18.5 for adults).
Results
Between 2006 and 2016, at the national level there was right shift in BMI distributions with concurrent decreases in low BMI and increases in overweight/obesity. Low BMI declined from 42.7% to 38.3% among adolescents and 33.0% to 18.8% among women, while overweight/obesity increased by 2 to 14%, respectively. The prevalence of low BMI among women was less than 30% in all states in 2016, a shift from 2006 when nearly half were over 30%. In contrast, only 4 states moved from a high prevalence of low BMI among adolescents to less than 30% in 2016. There was large variation in improvement and low BMI burden across states. Key protective factors among adolescents and women, respectively, included improved diet diversity (OR: 0.90 and 0.75), higher SES (OR: 0.75 and 0.37) and access to improved latrine (OR 0.94 and 0.77). Higher education levels, decision-making, and ownership of money among women was protective; while working for pay contributed to low BMI.
Conclusions
Despite overall declines in low BMI among women and adolescents in India, regional and age disparities remain and further improvements are required. Furthermore, the reductions in low BMI are accompanied with concerning increases in overweight/obesity calling for multidisciplinary approaches for ensuring heathy BMI status among adolescent girls and women in India.
Funding Sources
Bill & Melinda Gates Foundation, led by International Food Policy Research Institute.
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Affiliation(s)
| | | | - Rasmi Avula
- International Food Policy Research Institute
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Kachwaha S, Nguyen P, DeFreese M, Cyriac S, Girard AW, Avula R, Menon P. Assessing the Economic Feasibility of Assuring Nutritionally Adequate Diets for Vulnerable Populations in Uttar Pradesh, India: Key Findings from ‘Cost of the Diet’ Analysis (OR21-05-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz034.or21-05-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Uttar Pradesh (UP) is the most populous state with the highest burden of undernutrition in India. Alive & Thrive is working to strengthen behavior change communication (BCC) on diet diversity and quantity, using health systems platforms to deliver maternal nutrition intervention. However, evidence on the accessibility and affordability associated with recommended diets is limited. This study aims to: 1) examine the costs of nutritious foods in local markets, 2) identify inexpensive sources of essential micronutrients which could be promoted through BCC interventions.
Methods
Data collection included 24 market surveys and 125 household interviews to obtain food prices and consumption patterns. Cost of Diet (CotD), a linear programing software, was used to estimate the lowest cost for meeting nutrient requirements of 4 types of diet: 1) energy only diet (EO), 2) energy and macronutrient diets (MAC); 3) nutritious diet (NUT-meets recommended intakes for energy and nutrients), and 4) a food habits diet (FHAB-meet energy and nutrient requirements based upon local dietary habits). The diets were compared to identify relative costs and nutrient requirements met.
Results
The FHAB diet (USD 90/month for a household of 6 people) was over twice as expensive compared to the energy only diet. EO and MAC diets were affordable for all households, but they indicated inadequate nutrient intakes for vitamins A, C, B-12, folic acid, calcium, and iron. NUT and FHAB diets met all nutrient requirements but were not affordable for the lowest quartile of households. Recommended intakes of Vitamins A, C, B12, and calcium were most difficult to meet. Key foods identified which provided majority of essential macro and micronutrients included wheat flour, buffalo milk, soybean, and spinach. Multiple sources of iron and calcium were identified as affordable and accessible in local markets.
Conclusions
Foods available in local market are sufficient for households to obtain recommended intakes of macro- and micronutrients. Economic constraints and dietary habits are key barriers to achieve a nutritious diet. Practical, habitual diet-related behavior change communication to middle and high-income households and additional social protection for poorer households could improve optimal nutrient intakes.
Funding Sources
Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.
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Affiliation(s)
| | | | | | | | | | - Rasmi Avula
- International Food Policy Research Institute
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Nimmagadda S, Gopalakrishnan L, Avula R, Dhar D, Diamond-Smith N, Fernald L, Jain A, Mani S, Menon P, Nguyen PH, Park H, Patil SR, Singh P, Walker D. Effects of an mHealth intervention for community health workers on maternal and child nutrition and health service delivery in India: protocol for a quasi-experimental mixed-methods evaluation. BMJ Open 2019; 9:e025774. [PMID: 30918034 PMCID: PMC6475202 DOI: 10.1136/bmjopen-2018-025774] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Millions of children in India still suffer from poor health and under-nutrition, despite substantial improvement over decades of public health programmes. The Anganwadi centres under the Integrated Child Development Scheme (ICDS) provide a range of health and nutrition services to pregnant women, children <6 years and their mothers. However, major gaps exist in ICDS service delivery. The government is currently strengthening ICDS through an mHealth intervention called Common Application Software (ICDS-CAS) installed on smart phones, with accompanying multilevel data dashboards. This system is intended to be a job aid for frontline workers, supervisors and managers, aims to ensure better service delivery and supervision, and enable real-time monitoring and data-based decision-making. However, there is little to no evidence on the effectiveness of such large-scale mHealth interventions integrated with public health programmes in resource-constrained settings on the service delivery and subsequent health and nutrition outcomes. METHODS AND ANALYSIS This study uses a village-matched controlled design with repeated cross-sectional surveys to evaluate whether ICDS-CAS can enable more timely and appropriate services to pregnant women, children <12 months and their mothers, compared with the standard ICDS programme. The study will recruit approximately 1500 Anganwadi workers and 6000+ mother-child dyads from 400+ matched-pair villages in Bihar and Madhya Pradesh. The primary outcomes are the proportion of beneficiaries receiving (a) adequate number of home visits and (b) appropriate level of counselling by the Anganwadi workers. Secondary outcomes are related to improvements in other ICDS services, and knowledge and practices of the Anganwadi workers and beneficiaries. ETHICS AND DISSEMINATION Ethical oversight is provided by the Committee for the Protection of Human Subjects at the University of California at Berkeley, and the Suraksha Independent Ethics Committee in India. The results will be published in peer-reviewed journals and analysis data will be made public. TRIAL REGISTRATION NUMBER ISRCTN83902145.
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Affiliation(s)
- Sneha Nimmagadda
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
| | | | - Rasmi Avula
- International Food Policy Research Institute, New Delhi, India
| | - Diva Dhar
- Bill and Melinda Gates Foundation India, New Delhi, Delhi, India
| | | | - Lia Fernald
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Anoop Jain
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Sneha Mani
- International Food Policy Research Institute, New Delhi, India
| | - Purnima Menon
- International Food Policy Research Institute, New Delhi, India
| | - Phuong Hong Nguyen
- International Food Policy Research Institute, Washington, District of Columbia, USA
| | - Hannah Park
- University of California San Fransisco, San Fransisco, USA
| | - Sumeet R Patil
- NEERMAN, Center for Causal Research and Impact Evaluation, Mumbai, India
| | - Prakarsh Singh
- Institute of Labour Economics (IZA), Seattle, Washington, USA
| | - Dilys Walker
- University of California San Fransisco, San Fransisco, USA
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Nguyen PH, Scott S, Avula R, Tran LM, Menon P. Trends and drivers of change in the prevalence of anaemia among 1 million women and children in India, 2006 to 2016. BMJ Glob Health 2018; 3:e001010. [PMID: 30397516 PMCID: PMC6202996 DOI: 10.1136/bmjgh-2018-001010] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/19/2018] [Accepted: 09/10/2018] [Indexed: 12/03/2022] Open
Abstract
Introduction India carries the largest burden of anaemia globally. Progress to reduce anaemia has been slow despite substantial economic growth and 50 years of programmatic efforts. Identification of the factors that contribute to anaemia reductions is needed to accelerate progress. We examined changes in haemoglobin (Hb) and anaemia among women and children in India from 2006 to 2016 and identified drivers of changes in these outcomes over time. Methods We used two rounds of National Family Health Survey data collected in 2005–2006 and 2015–2016 (n=245 346 children 6–59 months; 37 165 pregnant women (PW) 15–49 years; 760 460 non-pregnant women (NPW) 15–49 years). We first examined trends in Hb and anaemia, and changes in 30 selected variables (including immediate and underlying determinants, and nutrition and health interventions (NHIs)). We identified drivers of Hb and anaemia using multivariate regression and estimated their contribution to changes in these outcomes over time using regression-based decomposition. Results Hb and anaemia improved significantly between 2006 and 2016 in children (4.5 g/L and 11 percentage points (pp), respectively) and PW (3.2 g/L and 7.6 pp), but not in NPW. Despite these changes, anaemia is still very high (>50%) and progress varied considerably by state (−33 pp to +16 pp). Most immediate and underlying determinants, and NHIs improved significantly over time. Changes among a set of drivers common to children and PW accounted for the changes in Hb; these included maternal schooling (children, 10%; PW, 24%), coverage of NHIs (children, 18%; PW, 7%), socioeconomic status (children, 7%; PW, 17%), sanitation (children, 3%; PW, 9%), and meat and fish consumption (children, 3%; PW, 1%). The decomposition models moderately explained Hb changes over time (children, 49%; PW, 66%). Conclusions Multiple common drivers have contributed to the anaemia changes among children and pregnant women in India. Further improvements in these drivers can have population-level effects by simultaneously influencing both maternal and child anaemia.
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, District of Columbia, USA
| | - Samuel Scott
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, District of Columbia, USA
| | - Rasmi Avula
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, District of Columbia, USA
| | | | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, District of Columbia, USA
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Menon P, Headey D, Avula R, Nguyen PH. Understanding the geographical burden of stunting in India: A regression-decomposition analysis of district-level data from 2015-16. Matern Child Nutr 2018; 14:e12620. [PMID: 29797455 PMCID: PMC6175441 DOI: 10.1111/mcn.12620] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/09/2018] [Accepted: 04/06/2018] [Indexed: 01/09/2023]
Abstract
India accounts for approximately one third of the world's total population of stunted preschoolers. Addressing global undernutrition, therefore, requires an understanding of the determinants of stunting across India's diverse states and districts. We created a district-level aggregate data set from the recently released 2015-2016 National and Family Health Survey, which covered 601,509 households in 640 districts. We used mapping and descriptive analyses to understand spatial differences in distribution of stunting. We then used population-weighted regressions to identify stunting determinants and regression-based decompositions to explain differences between high- and low-stunting districts across India. Stunting prevalence is high (38.4%) and varies considerably across districts (range: 12.4% to 65.1%), with 239 of the 640 districts have stunting levels above 40% and 202 have prevalence of 30-40%. High-stunting districts are heavily clustered in the north and centre of the country. Differences in stunting prevalence between low and high burden districts were explained by differences in women's low body mass index (19% of the difference), education (12%), children's adequate diet (9%), assets (7%), open defecation (7%), age at marriage (7%), antenatal care (6%), and household size (5%). The decomposition models explained 71% of the observed difference in stunting prevalence. Our findings emphasize the variability in stunting across India, reinforce the multifactorial determinants of stunting, and highlight that interdistrict differences in stunting are strongly explained by a multitude of economic, health, hygiene, and demographic factors. A nationwide focus for stunting prevention is required, while addressing critical determinants district-by-district to reduce inequalities and prevalence of childhood stunting.
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Affiliation(s)
- Purnima Menon
- Poverty, Health and Nutrition DivisionInternational Food Policy Research Institute (IFPRI)WashingtonDCUSA
| | - Derek Headey
- Poverty, Health and Nutrition DivisionInternational Food Policy Research Institute (IFPRI)WashingtonDCUSA
| | - Rasmi Avula
- Poverty, Health and Nutrition DivisionInternational Food Policy Research Institute (IFPRI)WashingtonDCUSA
| | - Phuong Hong Nguyen
- Poverty, Health and Nutrition DivisionInternational Food Policy Research Institute (IFPRI)WashingtonDCUSA
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49
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Affiliation(s)
- Rasmi Avula
- International Food Policy Research Institute (IFPRI), New Delhi, India
| | - Neha Raykar
- Public Health Foundation of India (PHFI), New Delhi, India
| | - Purnima Menon
- International Food Policy Research Institute (IFPRI), New Delhi, India
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Raghunathan K, Chakrabarti S, Avula R, Kim SS. Can conditional cash transfers improve the uptake of nutrition interventions and household food security? Evidence from Odisha's Mamata scheme. PLoS One 2017; 12:e0188952. [PMID: 29228022 PMCID: PMC5724821 DOI: 10.1371/journal.pone.0188952] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 11/14/2017] [Indexed: 11/18/2022] Open
Abstract
There is considerable global evidence on the effectiveness of cash transfers in improving health and nutrition outcomes; however, the evidence from South Asia, particularly India, is limited. In the context of India where more than a third of children are undernourished, and where there is considerable under-utilization of health and nutrition interventions, it is opportune to investigate the impact of cash transfer programs on the use of interventions. We study one conditional cash transfer program, Mamata scheme, implemented in the state of Odisha, in India that targeted pregnant and lactating women. Using survey data on 1161 households from three districts in the state of Odisha, we examine the effect of the scheme on eight outcomes: 1) pregnancy registration; 2) receipt of antenatal services; 3) receipt of iron and folic acid (IFA) tablets; 4) exposure to counseling during pregnancy; 5) exposure to postnatal counseling; 6) exclusive breastfeeding; 7) full immunization; and 8) household food security. We conduct regression analyses and correct for endogeneity using nearest-neighbor matching and inverse-probability weighting models. We find that the receipt of payments from the Mamata scheme is associated with a 5 percentage point (pp) increase in the likelihood of receiving antenatal services, a 10 pp increase in the likelihood of receiving IFA tablets, and a decline of 0.84 on the Household Food Insecurity Access Scale. These results provide the first quantitative estimates of effects associated with the Mamata scheme, which can inform the design of government policies related to conditional cash transfers.
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Affiliation(s)
- Kalyani Raghunathan
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), New Delhi, India
- * E-mail:
| | - Suman Chakrabarti
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), New Delhi, India
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), New Delhi, India
| | - Sunny S. Kim
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington D.C., United States of America
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