National nutrition strategies that focus on maternal, infant, and young child nutrition in Southeast Asia do not consistently align with regional and international recommendations.

We examined the consistency of national nutrition strategies and action plans (NNS) focusing on maternal, infant, and young child nutrition in Southeast Asia with regional and international recommendations. Between July and December 2017, we identified and extracted information on context, objectives, interventions, indicators, strategies, and coordination mechanisms from the most recent NNS in nine Southeast Asian countries. All NNS described context, objectives, and the following interventions: antenatal care, micronutrient supplementation during pregnancy, breastfeeding promotion, improved complementary feeding, nutrition in emergencies, and food fortification or dietary diversity. Micronutrient supplementation for young children was included in eight NNS; breastfeeding promotion during pregnancy and support at birth in seven; and school feeding, deworming, and treatment of severe acute malnutrition in six. All NNS contained programme monitoring and evaluation plans with measurable indicators and targets. Not all NNS covered wasting, exclusive breastfeeding, low birthweight, and childhood overweight. Strategies for achieving NNS goals and objectives were health system strengthening (nine), social and behaviour change communication (nine), targeting vulnerable groups (eight), and social or community mobilization (four). All addressed involvement, roles and responsibilities, and collaboration mechanisms among sectors and stakeholders. There was a delay in releasing NNS in Indonesia, Myanmar, and the Philippines. In conclusion, although Southeast Asian NNS have similarities in structure and contents, some interventions and indicators vary by country and do not consistently align with regional and international recommendations. A database with regularly updated information on NNS components would facilitate cross-checking completeness within a country, comparison across countries, and knowledge sharing and learning.

Social, economic, and political events affect gender equity in China, Nepal, and Nicaragua: a matched, interrupted time-series study.

Background: Progress in gender equity can improve health at the individual and country levels.Objectives: This study's objective was to analyze recent trends in gender equity and identify historical and contextual factors that contributed to changes in gender equity in three countries: China, Nepal, and Nicaragua.Methods: To assess gender equity trends, we used the Gender Gap Index (GGI) from the World Economic Forum's Global Gender Gap Report (2006-2017). The GGI incorporated data on economic participation, educational attainment, health, and political empowerment for almost 150 countries. We selected China, Nepal, and Nicaragua because of their major changes in GGI and diversity in geographical location and economic status. We reviewed major social, economic, and political events during 2006-2017, and identified key events in each country. We compared countries' GGI with matched controls average using interrupted time-series analysis.Results: Nepal and Nicaragua both had dramatic increases in GGI (improvement in equity), Nepal (ß = 0.029; 95% CI: 0.003, 0.056) and Nicaragua (ß = 0.035; 95% CI: 0.005, 0.065). This was strongly influenced by political empowerment, which likely impacted access to education and employment opportunities. Despite major economic growth and new policies to address gender inequities (e.g. the One-Child Policy), China saw a significant decline in GGI between 2010 and 2017 (ß = -0.014; 95% CI: -0.024, -0.004), largely resulting from decreased gender equity in educational attainment, economic participation, and health/survival sub-indices.Conclusions: Key social, economic, and political events helped explain trends in countries' gender equity. Our study suggested that supportive social and political environments would play important roles in empowering women, which would advance human rights and promote health and well-being of individuals, households, communities, and countries.

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

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

Appropriate Use of Linear Growth Measures to Assess Impact of Interventions on Child Development and Catch-Up Growth.

Linear growth is increasingly used as the sole or primary outcome for evaluating interventions, but impact is often not seen. Sometimes there is interest in whether children catch up to where they otherwise would have been had detrimental conditions not occurred, but the literature is confusing because of claims for evidence of catch-up growth based on inappropriate methods. This article examines the use of linear growth measures to evaluate intervention impact and catch-up. Focus on linear growth as a measure of impact has resulted in a lack of demonstrable intervention effects, evaluations that do not use measures responsive to nutrition-sensitive and integrated interventions, insufficient emphasis on adolescent girls and women before conception and children after the first 1000 d, and insufficient investment in developing other measures. Nutrition interventions may benefit children but may not discernibly affect linear growth deficits in immediate or intermediate periods. Interventions intended to affect one domain may have positive or negative impacts on others. Child nutrition and growth are part of early childhood development; the focus should be on improving conditions in which children grow and develop throughout childhood and adolescence because poor conditions in a population affect all children. To assess the impact of nutrition interventions, it is important to use a broad set of measures and indicators of outcomes and immediate and underlying determinants. The 4 criteria for demonstrating catch-up in growth, which are much more stringent than those for demonstrating intervention impact, require demonstration of the following: 1) an inhibiting condition and 2) reduced velocity during 1 period, 3) followed by alleviation of or compensation for the inhibiting condition, and 4) higher-than-normal velocity during a subsequent period. Partial catch-up growth is sometimes possible when constraints are removed, but whether it is beneficial to the child is not clear. Research is needed to develop, refine, and validate measures and indicators for the purposes intended.

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

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

Willingness to pay for lipid-based nutrient supplements for young children in four urban sites of Ethiopia.

Malnutrition in children under 5 years of age is pervasive in Ethiopia across all wealth quintiles. The objective of this study was to determine the willingness to pay (WTP) for a week's supply of Nutributter® (a lipid-based nutrient supplement, or LNS) through typical urban Ethiopian retail channels. In February, 2012, 128 respondents from 108 households with 6-24-month-old children had the opportunity to sample Nutributter® for 2 days in their homes as a complementary food. Respondents were asked directly and indirectly what they were willing to pay for the product, and then participated in market simulation where they could demonstrate their WTP through an exchange of real money for real product. Nearly all (96%) of the respondents had a positive WTP, and 25% were willing to pay the equivalent of at least $1.05, which we calculated as the likely minimum, unsubsidised Ethiopian retail price of Nutributter® for 1 week for one child. Respondents willing to pay at least $1.05 included urban men and women with children 6-24 months old from low-, middle- and high-wealth groups from four study sites across three cities. Additionally, we estimated the initial annual market size for Nutributter® in the cities where the study took place to be around $500 000. The study has important implications for retail distribution of LNS in Ethiopia, showing who the most likely customers could be, and also suggesting why the initial market may be too small to be of interest to food manufacturers seeking profit maximisation.

Organizational factors, planning capacity, and integration challenges constrain provincial planning processes for nutrition in decentralizing Vietnam.

BACKGROUND: Translating national policies and guidelines into effective action at the subnational level (e.g., province or region) is a prerequisite for ensuring an impact on nutrition. In several countries, including Vietnam, the focus of this paper, this process is affected by the quality of the decentralized process of planning and action. OBJECTIVE: This study examined how provincial planning processes for nutrition occurred in Vietnam during 2009 and 2010. Key goals were to understand variability in processes across provinces, identify factors that influenced the process, and assess the usefulness of the process for individuals involved in planning and action. METHODS: A qualitative case-study methodology was used. Data were drawn from interviews with 51 government officials in eight provinces. RESULTS: The study found little variability in the planning process among these eight provinces, probably due to a planning process that was predominantly a fiscal exercise within the confines of a largely centralized structure. Respondents were almost unanimous about the main barriers: a top-down approach to planning, limited human capacity for effective planning at subnational levels, and difficulty in integrating actions from multiple sectors. Provincial-level actors were deeply dissatisfied with the nature of their role in the process. CONCLUSIONS: Despite the rhetoric to the contrary, too much power is probably still retained at the central level. A strategic multiyear approach is needed to strengthen the provincial planning process and address many of the key barriers identified in this study.

Using an evidence-based approach to design large-scale programs to improve infant and young child feeding.

BACKGROUND: Global interest in scaling up nutrition outcomes has focused attention on the need for more effective programs to improve infant and young child feeding (IYCF). However there are few examples in the literature of comprehensive programs that have been systematically designed. OBJECTIVE: To describe an evidence-based approach for designing large-scale yet tailored IYCF programs in varied country settings. METHODS: Behavior change principles, epidemiological data, situational analysis, stakeholder consultations, formative research, and feasibility studies informed the design of IYCF programs delivered at scale in Bangladesh, Ethiopia, and Vietnam. RESULTS: Impact, scale, and sustainability objectives guided the choice of partners, service delivery platforms, and advocacy, systems strengthening, and communication strategies for reaching mothers and decision makers. All programs focused on the critical first 2 years of life, followed global World Health Organization and UNICEF guidelines for IYCF, and applied a common theory of change. Formative research, stakeholder consultations, trials of improved practices, and assessments of media habits were most useful for making program decisions. Opinion leader research, monitoring of the policy environment, and stakeholder analysis were key elements in the design of advocacy strategies. All programs found that setting measurable and explicit targets, strengthening systems to provide support for mothers, multichannel communication, and advocacy for opinion leaders were vital components in the design. CONCLUSIONS: A systematic, evidence-based collaborative approach can facilitate the design of comprehensive IYCF programs. Programs should also embed design flexibility to enable changes as new challenges and opportunities arise.

Prospective analysis of the development of the national nutrition agenda in Vietnam from 2006 to 2008.

Improved understanding of how to advance national nutrition policy is critical to ensure greater policy investments in nutrition. We used a participant-observer, change-agent model to prospectively study why and how national nutrition policy advanced in Vietnam between 2006 and 2008. Our goal was to understand strategies used, factors that shaped policy advancement, and the interaction of strategies with factors in this context. Data were collected using questionnaires, informant interviews, programme visits, document reviews and documentation of key events. For analysis, we created a chronology of events, examined strategies and actions used and their results by event, coded interviews and summarized findings using a well-known framework for policy analysis. Our analysis shows that the following elements were critical to bring greater attention to nutrition policy in this context: (1) building a cohesive nutrition policy community through creation and support of an alliance; (2) clearly defining internal and external frames for the nutrition problem; (3) using and creating high-profile internal and external policy windows; and (4) capitalizing on cultural motivations and values. Findings indicate that that rapid nutrition policy advancement is possible if purposeful, contextually sensitive strategies are used where favourable conditions exist, or can be created. The participant-observer, change-agent model was successful in both contributing to policy advancement and documenting it.

Comparison of a positive deviance inquiry with a case-control study to identify factors associated with nutritional status among Afghan refugee children in Pakistan.

We compared the positive deviance (PD) approach in Save the Children's field guide with a case-control study (CCS) to identify behaviors associated with good nutritional status in Afghan refugee children 6 to 24 months of age in the Northwest Frontier Province (NWFP), Pakistan. The positive deviance inquiry (PDI), utilizing observations and interviews with mothers, fathers, and secondary caregivers in eight households, identified 12 feeding, caring, and health-seeking behaviors that were not widely practiced. The CCS, using the same selection criteria and content as the PDI with 50 mother-child pairs not in the PDI, yielded six significant associations with good nutritional status. Both the PDI and CCS detected feeding behaviors. The PDI alone identified complex phenomena (active feeding and maternal affect). The CCS alone confirmed the beneficial use of health services. The PD approach was an affordable, participatory, and valid method to identify feeding behaviors and other factors associated with good nutrition in this context.

Identification of model newborn care practices through a positive deviance inquiry to guide behavior-change interventions in Haripur, Pakistan.

A positive deviance (PD) inquiry identifies uncommon, model practices that a follow-on program can spread. PD has been used to rehabilitate malnourished children, but not for improving newborn health. Save the Children Federation/US (SC) conducted newborn PD cycles in communities (total population about 5,000 each) in two project areas in Haripur District, Pakistan among Afghan refugees and among local Pakistanis. Each PD cycle included planning, community orientation, situation analysis, PD inquiries, and community feedback with action planning. PD inquiries were in-depth interviews to identify uncommon behaviors among surviving asphyxiated newborns, thriving low birthweight babies, surviving newborns who had danger signs, and normal newborns. The Afghan caregivers showed better use of services and some household practices than their Pakistani counterparts, consistent with duration of SC presence (15 years vs. 18 months, respectively). The practices of both groups for clean delivery, thermal control, immediate and exclusive breastfeeding, and fathers' involvement were weak. But PD individuals, families, and/or birth attendants modeled good maternal care and immediate, routine and special newborn care. Communities enthusiastically committed to change behavior and form neighborhood support groups for better newborn care, including a demand for hygienic delivery. The PD approach for the newborn is more complex than for child nutrition. Yet this pilot-test proposed a conceptual framework for household newborn care, suggested tools and methods for information gathering, identified PDs in two settings of different risk, galvanized SC staff to the potential of the approach, mobilized communities for better newborn health, and drafted a newborn PD training curricula.

The positive deviance approach: challenges and opportunities for the future.

The positive deviance (PD) approach offers an alternative to needs-based approaches for development. The "traditional" application of the PD approach for childhood malnutrition involves studying children who grow well despite adversity, identifying uncommon, model practices among PD families, and designing an intervention to transfer these behaviors to the mothers of malnourished children. A common intervention for child malnutrition, the so-called "hearth," brings mothers together to practice new feeding and caring behaviors under the encouragement of a village volunteer. Hearths probably work because they modify unmeasured behavioral determinants and unmonitored behaviors, which, in turn, result in better child growth. Some health outcomes require a better understanding of behavioral determinants and are not best served by hearth-like facilitated group skills-building. We propose testing "booster PD inquiries" during implementation to confirm behavioral determinants and efficiently focus interventions. We share early experience with the PD approach for HIV/AIDS and food security. The attributable benefit of the PD approach within a program has not been quantified, but we suspect that it is a catalyst that accelerates change through the processes of community attention getting, awareness raising, problem-solving, motivating for behavior change, advocacy, and actual adopting new behaviors. Program-learners should consider identifying and explicitly attempting to modify the determinants of critical behavior(s), even if the desired outcome is a change in health status that depends on multiple behaviors; measure and maintain program quality, especially at scale; and creatively expand and test additional roles for PD within a given program.