Defining a Dichotomous Indicator for Population-Level Assessment of Dietary Diversity Among Pregnant Adolescent Girls and Women: A Secondary Analysis of Quantitative 24-h Recalls from Rural Settings in Bangladesh, Burkina Faso, India, and Nepal

Background

The Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) indicator was validated as a proxy of micronutrient adequacy among nonpregnant women in low- and middle-income countries (LMICs). At that time, indeed, there was insufficient data to validate the indicator among pregnant women, who face higher micronutrient requirements.

Objective

This study aimed to validate a minimum food group consumption threshold, out of the 10 food groups used to construct MDD-W, to be used as a population-level indicator of higher micronutrient adequacy among pregnant women aged 15-49 y in LMICs.

Methods

We used secondary quantitative 24-h recall data from 6 surveys in 4 LMICs (Bangladesh, Burkina Faso, India, and Nepal, total n = 4909). We computed the 10-food group Women's Dietary Diversity Score (WDDS-10) and calculated the mean probability of adequacy (MPA) of 11 micronutrients. Linear regression models were fitted to assess the associations between WDDS-10 and MPA. Sensitivity, specificity, and proportion of individuals correctly classified were used to assess the performance of MDD-W in predicting an MPA of >0.60.

Results

In the pooled sample, median values (interquartile range) of WDDS-10 and MPA were 3 (1) and 0.20 (0.34), respectively, whereas the proportion of pregnant women with an MPA of >0.60 was 9.6%. The WDDS-10 was significantly positively associated with MPA in each survey. Although the acceptable food group consumption threshold varied between 4 and 6 food groups across surveys, the threshold of 5 showed the highest performance in the pooled sample with good sensitivity (62%), very good specificity (81%), and percentage of correctly classified individuals (79%).

Conclusions

The WDDS-10 is a good predictor of dietary micronutrient adequacy among pregnant women aged 15-49 y in LMICs. Moreover, the threshold of 5 or more food groups for the MDD-W indicator may be extended to all women of reproductive age, regardless of their physiologic status.

Opportunities and barriers for maternal nutrition behavior change: an in-depth qualitative analysis of pregnant women and their families in Uttar Pradesh, India

Background

Maternal undernutrition during pregnancy remains a critical public health issue in India. While evidence-based interventions exist, poor program implementation and limited uptake of behavior change interventions make addressing undernutrition complex. To address this challenge, Alive & Thrive implemented interventions to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in Uttar Pradesh, India.

Objective

This qualitative study aimed to: (1) examine pregnant women's experiences of key nutrition-related behaviors (ANC attendance, consuming a diverse diet, supplement intake, weight gain monitoring, and breastfeeding intentions); (2) examine the influence of family members on these behaviors; and (3) identify key facilitators and barriers that affect behavioral adoption.

Methods

We conducted a qualitative study with in-depth interviews with 24 pregnant women, 13 husbands, and 15 mothers-in-law (MIL). We analyzed data through a thematic approach using the Capability-Opportunity-Motivation-Behavior (COM-B) framework.

Results

For ANC checkups and maternal weight gain monitoring, key facilitators were frontline worker home visits, convenient transportation, and family support, while the primary barrier was low motivation and lack understanding of the importance of ANC checkups. For dietary diversity, there was high reported capability (knowledge related to the key behavior) and most family members were aware of key recommendations; however, structural opportunity barriers (financial strain, lack of food availability and accessibility) prevented behavioral change. Opportunity ranked high for iron and folic acid supplement (IFA) intake, but was not consistently consumed due to side effects. Conversely, lack of supply was the largest barrier for calcium supplement intake. For breastfeeding, there was low overall capability and several participants described receiving inaccurate counseling messages.

Conclusion

Key drivers of maternal nutrition behavior adoption were indicator specific and varied across the capability-opportunity-motivation behavior change spectrum. Findings from this study can help to strengthen future program effectiveness by identifying specific areas of program improvement.

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

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.

Specificity Matters: Unpacking Impact Pathways of Individual Interventions within Bundled Packages Helps Interpret the Limited Impacts of a Maternal Nutrition Intervention in India

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.

Maternal Diets in India: Gaps, Barriers, and Opportunities

Suboptimal dietary intake is a critical cause of poor maternal nutrition, with several adverse consequences both for mothers and for their children. This study aimed to (1) assess maternal dietary patterns in India; (2) examine enablers and barriers in adopting recommended diets; (3) review current policy and program strategies to improve dietary intakes. We used mixed methods, including empirical analysis, compiling data from available national and subnational surveys, and reviewing literature, policy, and program strategies. Diets among pregnant women are characterized by low energy, macronutrient imbalance, and inadequate micronutrient intake. Supply- and demand-side constraints to healthy diets include food unavailability, poor economic situation, low exposure to nutrition counselling, food restrictions and taboos, adverse family influence and gender norms, and gaps in knowledge. Intervention strategies with potential to improve maternal diets include food-based programs, behavior change communication, and nutrition-sensitive agriculture interventions. However, strategies face implementation bottlenecks and limited effectiveness in real-world at-scale impact evaluations. In conclusion, investments in systems approaches spanning health, nutrition, and agriculture sectors, with evaluation frameworks at subnational levels, are needed to promote healthy diets for women.

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

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.

Provision and utilisation of health and nutrition services during COVID-19 pandemic in urban Bangladesh

The COVID-19 pandemic is expected to have profound effects on healthcare systems, but little evidence exists on service provision, utilisation, or adaptations. This study aimed to (1) examine the changes to health and nutrition service delivery and utilisation in urban Bangladesh during and after enforcement of COVID-19 restrictions and (2) identify adaptations and potential solutions to strengthen delivery and uptake. We conducted longitudinal surveys with health care providers (n = 45), pregnant women (n = 40), and mothers of children <2 years (n = 387) in February 2020 (in-person) and September 2020 (by phone). We used Wilcoxon matched-pairs signed-rank tests to compare the changes before and during the pandemic. Services delivery for women and children which require proximity were severely affected; weight and height measurements fell by 20-29 percentage points (pp) for pregnant women and 37-57 pp for children, and child immunisations fell by 38 pp. Declines in service utilisation were large, including drops in facility visitations (35 pp among pregnant women and 67 pp among mothers), health and nutrition counselling (up to 73 pp), child weight measurements (50 pp), and immunisations (61 pp). The primary method of adaptation was provision of services over phone (37% for antenatal care services, 44%-49% for counselling). Despite adaptations to service provision, continued availability of routine maternal and child health services did not translate into service utilisation. Further investments are needed to provide timely and accurate information on COVID-19 to the general public, improve COVID-19 training and provide incentives for health care providers and ensure availability of personal protective equipment for providers and beneficiaries.

Not just money: what mothers value in conditional cash transfer programs in India

Introduction

Conditional cash transfers (CCTs) have become an important policy tool for increasing demand for key maternal and child health services in low/middle-income countries. Yet, these programs have had variable success in increasing service use. Understanding beneficiary preferences for design features of CCTs can increase program effectiveness.

Methods

We conducted a Discrete choice experiment in two districts of Uttar Pradesh, India in 2018 with 405 mothers with young children (<3 years). Respondents were asked to choose between hypothetical CCT programme profiles described in terms of five attribute levels (cash, antenatal care visits, growth-monitoring and immunisation visits, visit duration and health benefit received) and responses were analysed using mixed logit regression.

Results

Mothers most valued the cash transfer amount, followed by the health benefit received from services. Mothers did not have a strong preference for conditionalities related to the number of health centre visits or for time spent seeking care; however, service delivery points were in close proximity to households. Mothers were willing to accept lower cash rewards for better perceived health benefits—they were willing to accept 2854 Indian rupees ($41) less for a programme that produced good health, which is about half the amount currently offered by India’s Maternal Benefits Program. Mothers who had low utilisation of health services, and those from poor households, valued the cash transfer and the health benefit significantly more than others.

Conclusion

Both cash transfers and the perceived health benefit from services are highly valued, particularly by infrequent service users. In CCTs, this highlights the importance of communicating value of services to beneficiaries by informing about health benefits of services and providing quality care. Conditionalities requiring frequent health centre visits or time taken for seeking care may not have large negative effects on CCT participation in contexts of good service coverage.

The Impact of COVID-19 on Household Food Insecurity and Interlinkages With Child Feeding Practices and Coping Strategies in Uttar Pradesh, India

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.

Provision and Utilization of Health and Nutrition Services During the COVID-19 Pandemic in Urban Bangladesh

Objectives

The COVID-19 pandemic is expected to have extensive effects on healthcare systems. The Government of Bangladesh has concerns about diminished coverage and quality of maternal and child health services, but little published information exists on service provision, utilization, and adaptations. We examined changes to maternal and child health and nutrition service delivery and utilization in urban Bangladesh during and after the enforcement of COVID-19 restrictions and identified adaptations and potential solutions to strengthen service delivery and uptake.

Methods

We conducted longitudinal surveys with health care providers (n = 45), pregnant women (n = 40), and mothers of children < 2 years (n = 387) in February 2020 (in-person) and September 2020 (by phone). We used Wilcoxon matched-pairs signed-rank tests to compare the changes before and during the pandemic.

Results

Most services for pregnant women remained available during COVID-19 restrictions, with the provision of antenatal care (ANC) services falling by 6.6 percentage points (pp). Services for women and children which require proximity, however, were more severely affected; weight and height measurements fell by 20–29pp for pregnant women and 37–57pp for children, and child immunizations fell by 38pp. Declines in service utilization were large, including drops in facility visitations (35pp among pregnant women and 67pp among mothers), health and nutrition counseling (up to 73pp), child weight measurements (50pp), and immunizations (61pp). The primary method of adaptation was provision of services over phone (37% for ANC services and 44–49% for counselling of pregnant women or mothers with young children).

Conclusions

Despite adaptations to service provisions, continued availability of routine maternal and child health services did not translate into service utilization. Further investments are needed to provide timely and accurate information on COVID-19 to the public, improve COVID-19 training and provide incentives for health care providers, and ensure availability of personal protective equipment for both providers and beneficiaries.

Funding Sources

Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute; and Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI Solutions.

India's 2.42 Million Frontline Health Workers Enable Restoration of Health and Nutrition Service Delivery After Early COVID-19 Lockdowns

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.

Impacts of COVID-19 on Provision and Utilization of Health and Nutrition Services in Uttar Pradesh, India: Insights From Phone Surveys and Administrative Data

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.

Understanding Implementation and Improving Nutrition Interventions: Barriers and Facilitators of Using Data Strategically to Inform the Implementation of Maternal Nutrition in Uttar Pradesh, India

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.

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

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.

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

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.

Assessing the Economic Feasibility of Assuring Nutritionally Adequate Diets for Vulnerable Populations in Uttar Pradesh, India: Findings from a "Cost of the Diet" Analysis

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.

Nutrient Adequacy Is Low among Both Self-Declared Lacto-Vegetarian and Non-Vegetarian Pregnant Women in Uttar Pradesh

Poor dietary intake during pregnancy remains a significant public health concern, affecting the health of the mother and fetus. This study examines the adequacy of energy, macronutrient, and micronutrient intakes among self-declared lacto-vegetarian and non-vegetarian pregnant women. We analyzed dietary data from 627 pregnant women in Uttar Pradesh, India, using a multiple-pass 24 h diet recall. Compared to non-vegetarians, lacto-vegetarians (~46%) were less likely to report excessive carbohydrate (78% vs. 63%) and inadequate fat intakes (70% vs. 52%). In unadjusted analyses, lacto-vegetarians had a slightly higher mean PA for micronutrients (20% vs. 17%), but these differences were no longer significant after controlling for caste, education, and other demographic characteristics. In both groups, the median intake of 9 out of 11 micronutrients was below the Estimated Average Requirement. In conclusion, the energy and micronutrient intakes were inadequate, and the macronutrient intakes were imbalanced, regardless of stated dietary preferences. Since diets are poor across the board, a range of policies and interventions that address the household food environment, nutrition counseling, behavior change, and supplementation are needed in order to achieve adequate nutrient intake for pregnant women in this population.

Self-Identified Vegetarian Pregnant Women in India Have Better Diets Than Self-Identified Non-Vegetarian Women Because of the Intersections of Caste and Economic Status

Objectives

Poor dietary intake during pregnancy remains a significant public health concern affecting the health of the mother and fetus. This study examines the adequacy of energy, macronutrient and micronutrient intakes among vegetarian and non-vegetarian pregnant women.

Methods

We analyzed dietary data from 627 pregnant women enrolled at baseline from an Alive &Thrive maternal nutrition program in Uttar Pradesh, India. Dietary intake was assessed using a multiple-pass 24-hour diet recall. We compared differences between vegetarian and non-vegetarian women in dietary diversity (calculated using the minimum dietary diversity for women guidelines), probability of adequacy, and mean probability of adequacy (MPA) for 11 micronutrients.

Results

Women who identified themselves as vegetarians (∼47%) were more likely to have higher education and socioeconomic status, and belong to upper caste groups than non-vegetarians. Average dietary diversity score was 4 out of 10 food groups for both groups. Vegetarian women were more likely to meet the MDD-W cutoff of five or more food groups compared to non-vegetarian women (39.2% compared to 32.4% respectively) (P &lt; 0.05). Average MPA for vegetarians was 20% (SD:15.3) compared to 17% (SD:13.7) for non-vegetarian group (P = 0.02). In both groups, median intake of 9 out of 11 micronutrients was below the Estimated Average Requirement (EAR). Only zinc and thiamin had a median intake slightly above EAR. Starchy staple foods accounted for 62.4% of total energy for vegetarians and 69.1% for non-vegetarians. Dairy foods were an important source of fat, calcium, and vitamin B12 for both groups. Among non-vegetarian women, consumption of animal source foods was low (&lt;8%).

Conclusions

Vegetarian women were more likely to have probability of nutrient adequacy and diet diversity during pregnancy than non-vegetarian women, but these differences are likely confounded by socio-economic and caste status. Since diets are poor for both groups, a range of policies and interventions that address the food environment, nutrition counseling during pregnancy, behavior change, and supplementation are needed in order to achieve adequate nutrient intake for pregnant women in this population.

Funding Sources

Bill and Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.

Health Systems Strengthening Efforts Help to Improve the Delivery of Maternal Nutrition Interventions in Antenatal Care in Uttar Pradesh (UP), India but Gaps Remain

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.

Understanding How the Strategic Use of Data Can Improve the Implementation of Maternal Nutrition Interventions in Uttar Pradesh (UP), India

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.

Strengthening Nutrition Interventions in Antenatal Care Services Had Modest Impacts on Diet Diversity, Micronutrient Intake, and Breastfeeding in Uttar Pradesh, India

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.

It takes a village: An empirical analysis of how husbands, mothers-in-law, health workers, and mothers influence breastfeeding practices in Uttar Pradesh, India

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.

Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors

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.

Maternal Nutrition Practices in Uttar Pradesh, India: Role of Key Influential Demand and Supply Factors (P11-002-19)

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.

Women's Stated Preferences for Conditional Cash Transfer Programs Focused on Maternal and Child Health and Nutrition in India (P22-012-19)

Objectives

Conditional Cash Transfers (CCTs) are important national strategies to improve maternal and child health and nutrition. India recently began implementing a Maternity Benefit Program (MBP) to encourage health care use during pregnancy and early childhood; under discussion is to include child nutrition services within a CCT program. This paper aims to understand the preferences of mothers with young children for design features (cash transfer amount and conditionalities) of CCT programs.

Methods

We conducted a Discrete Choice Experiment in Uttar Pradesh, India where 405 mothers with children below three years of age were interviewed. Respondents were presented 18 hypothetical CCT program profiles defined by five attributes – cash transfer amount, number of ante-natal care visits, number of visits for child immunization/growth monitoring, time taken to complete a visit, and health benefit received (proxy for service quality). Conditional logit regression was used to analyze respondent choices.

Results

Mothers valued the amount of cash transfer, quality of services, and quicker health center visits. They did not have a strong preference for the number of visits required. Higher cash amounts are associated with greater probability of participation. For any given amount of cash amount, better service quality (produced better health) elicited greater participation. Mothers put high valuation on service quality; they were willing-to-pay (give up) INR 2858 ($41) for a program that produced good health. Without any cash transfer, only improving service quality from average to good would increase participation by 27%. A cash transfer amount of INR 6000 ($86, currently offered by MBP) combined with fair (good) quality services would increase participation by 78% (85%). Preference for CCT programs differed across sub-groups defined by prior users of government health services and socioeconomic status. Poor households valued a given cash transfer amount more than better-off households, while better-off households valued good health outcomes more than poorer households.

Conclusions

Aligning maternal and child health CCT programs with user preferences can increase program participation. This study provides guidance on incorporating user preferences in the CCT program design.

Funding Sources

Department of International Health, Johns Hopkins University.

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)

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.

Health inequalities research in India: a review of trends and themes in the literature since the 1990s

BACKGROUND

Research on health inequalities can be instrumental in drawing attention to the health of socioeconomically vulnerable groups in India in the context of rapid economic growth. It can shape the dialogue for public health action, emphasizing the need for greater investments in health, and monitor effectiveness of health programs. Our objective was to examine trends in studies on health inequalities in the last 25 years.

METHODS

We conducted a systematic literature review of studies on health inequalities published from 1990. The year, 1990, marked the beginning of economic reforms and liberalization in India. We searched PubMED using key terms to identify 8800 articles between 1990 and 2016; we identified 1,312 final studies for review. Key domains of analysis included measures of equity, health outcomes, populations studied, year of publication, study methodology, study focus (descriptive versus analytical), and location of main author.

RESULTS

We found an increase in studies on health inequalities after 2005. About 88 % of the studies utilized quantitative methods for analysis. About 8 % of the studies related to health interventions or programs; the number of intervention studies have been increasing since 2010. A majority of studies were led by authors based in India. Early studies focused on mortality, communicable and non-communicable diseases, and nutrition, while later studies have focused on non-communicable diseases, mental health, risk factors, and injuries. Studies on women and children comprised nearly half of the literature; studies on the youth (15-24 years or as defined by the study) and elderly have been rising. Wealth and income were the most common measures of equity, followed by education and gender. The proportion of studies on wealth, education, region and caste have stayed consistent over time, while studies on gender disparities have been rising.

CONCLUSION

In a country as diverse as India with large social inequalities combined with rapid economic growth, research on health inequalities has a special significance for policy. We recommend that studies on health inequalities in the future focus on evaluations of policy and health programs, and on underrepresented health outcomes and populations.