The economic costs of a multisectoral nutrition programme implemented through a credit platform in Bangladesh.

Bangladesh struggles with undernutrition in women and young children. Nutrition-sensitive agriculture programmes can help address rural undernutrition. However, questions remain on the costs of multisectoral programmes. This study estimates the economic costs of the Targeting and Re-aligning Agriculture to Improve Nutrition (TRAIN) programme, which integrated nutrition behaviour change and agricultural extension with a credit platform to support women's income generation. We used the Strengthening Economic Evaluation for Multisectoral Strategies for Nutrition (SEEMS-Nutrition) approach. The approach aligns costs with a multisectoral nutrition typology, identifying inputs and costs along programme impact pathways. We measure and allocate costs for activities and inputs, combining expenditures and micro-costing. Quantitative and qualitative data were collected retrospectively from implementers and beneficiaries. Expenditure data and economic costs were combined to calculate incremental economic costs. The intervention was designed around a randomised control trial. Incremental costs are presented by treatment arm. The total incremental cost was $795,040.34 for a 3.5-year period. The annual incremental costs per household were US$65.37 (Arm 2), USD$114.15 (Arm 3) and $157.11 (Arm 4). Total costs were led by nutrition counselling (37%), agriculture extension (12%), supervision (12%), training (12%), monitoring and evaluation (9%) and community events (5%). Total input costs were led by personnel (68%), travel (12%) and supplies (7%). This study presents the total incremental costs of an agriculture-nutrition intervention implemented through a microcredit platform. Costs per household compare favourably with similar interventions. Our results illustrate the value of a standardised costing approach for comparison with other multisectoral nutrition interventions.

Nutrition-sensitive agriculture programs increase dietary diversity in children under 5 years: A review and meta-analysis.

BACKGROUND: Low-quality diets contribute to the burden of malnutrition and increase the risk of children not achieving their developmental potential. Nutrition-sensitive agriculture programs address the underlying determinants of malnutrition, though their contributions to improving diets do not factor into current nutrition impact modeling tools. OBJECTIVE: To synthesize the evidence on the effectiveness of nutrition-sensitive agriculture programs in improving dietary diversity in young children (6-23.9 months and 6-60 months). METHODS: A literature search was conducted for published trials through existing systematic reviews and individual database search of the ISI Web of Science. All dietary diversity measures in the studies selected to be in the analysis were extracted. Estimation of main pooled effects were conducted on outcomes of minimum diet diversity (MDD) and diet diversity score (DDS) using random-effects meta-regression models. We report pooled effect sizes as standardized mean differences (SMDs) or odds ratios (ORs). RESULTS: Nutrition-sensitive agricultural interventions have a significant positive impact on the diet diversity scores of children aged 6-23.9 months (SMD = 0.22, 95% confidence interval (CI) = 0.09-0.36) and on the odds of reaching minimum diet diversity (OR = 1.45, 95% CI = 1.20, 1.76). Similar impacts are found when analyses are expanded to include studies for children aged 6-60 months (DDS SMD = 0.22, 95% CI = 0.12-0.32) (MDD OR = 1.64, 95% CI: = 1.38-1.94). CONCLUSION: Nutrition-sensitive agriculture interventions consistently have a positive impact on child dietary diversity. Incorporating this evidence in nutrition modeling tools can contribute to decision-making on the relative benefits of nutrition-sensitive interventions as compared with other maternal, newborn, child health and nutrition (MNCHN) interventions.

When Communities Pull Their Weight: The Economic Costs of an Integrated Agriculture and Nutrition Home-Grown Preschool Meal Intervention in Malawi.

BACKGROUND: Community-based preschool meals can provide an effective platform for implementing integrated agriculture and nutrition programs. However, there is little evidence on the costs and cost-efficiency of implementing these types of multisectoral interventions. OBJECTIVES: Assess the economic costs and cost-efficiency of implementing an effective integrated nutrition-sensitive intervention through a preschool platform in Malawi, including community-level contributions. METHODS: The Strengthening Economic Evaluation for Multisectoral Strategies for Nutrition (SEEMS-Nutrition) framework and methods were applied to assess financial and economic costs of the intervention. A mixed-methods approach was used to measure and allocate costs for program activities and inputs using financial expenditure data combined with micro-costing. All costs were allocated to input and expenditure categories using the SEEMS-Nutrition framework. To facilitate comparisons with existing school meals programs, activities were also mapped against a standardized school feeding supply chain framework. RESULTS: The total annualized cost of the program was US$197 377, inclusive of both financial and economic costs. The annual economic cost of the program ranged from US$160 per preschool child to US$41 per beneficiary. The principal drivers of cost by program activity were training (46%), school meals provision (19%), monitoring and evaluation (12%), and establishing and running community groups (6.5%). Notably, community contributions accounted for 25% and were driven by food donations and volunteer labor. CONCLUSIONS: Cost per beneficiary estimates of implementing an integrated agriculture-nutrition intervention through an early childhood development platform compare favorably with similar interventions. Further research is needed that applies a standardized economic evaluation framework to such multisectoral interventions.

A Community-Based Early Childhood Development Center Platform Promoting Diversified Diets and Food Production Increases the Mean Probability of Adequacy of Intake of Preschoolers in Malawi: A Cluster Randomized Trial.

BACKGROUND: Young children in Malawi consume low-quality diets lacking micronutrients critical for their development. OBJECTIVE: To evaluate the impact of an agriculture and nutrition behavior change communication (BCC) intervention implemented through community-based childcare centers on the nutrient adequacy of diets of children living in food-insecure settings in Malawi. METHODS: A cluster randomized trial was undertaken in 60 community-based childcare centers, including 1248 children aged 3-6 y. Nutrient intakes were estimated using interactive, multipass 24-h recall. Dietary adequacy was estimated through the probability of adequacy (PA) and mean probability of adequacy (MPA) of 11 micronutrients. Impacts were assessed by difference-in-difference (DID) estimates, adjusted for geographic clustering and child age and sex. RESULTS: Intervention groups were similar for most baseline characteristics. Loss to follow-up was low (7% over a 12-mo period) and participation in the intervention was high (>90% enrollment and 80% attendance during the 5 d before the survey). Positive impacts were found for the PA of several individual micronutrient intakes: vitamin A [DID: 9 percentage points (pp), SE 3 pp], vitamin C (14 pp, SE 3 pp), riboflavin (11 pp, SE 3 pp), zinc (8 pp, SE 3 pp), and for the MPA for the 11 nutrients considered (5 pp, SE 1 pp). These impacts were driven by effects on younger children (aged 3-4 y). CONCLUSIONS: Using a preschool platform to implement a nutrition-sensitive BCC intervention is an effective strategy to improve the adequacy of micronutrient intake of preschool children in food-insecure settings. The trial was registered at ISCRCTN as ISCRCTN96497560.

Using a Community-Based Early Childhood Development Center as a Platform to Promote Production and Consumption Diversity Increases Children's Dietary Intake and Reduces Stunting in Malawi: A Cluster-Randomized Trial.

Background: Children in Malawi face nutritional risks related to low-quality diets and chronic malnutrition. Objective: This study evaluated the impact of a 1-y early childhood development (ECD) center-based agriculture and nutrition intervention aimed at improving household production diversity, maternal knowledge on child nutrition and feeding practices, and children's diets and anthropometric measures. Methods: A longitudinal cluster-randomized controlled trial was implemented in 60 community-based childcare centers (CBCCs), covering 1248 preschool children (aged 36-72 mo) and 304 younger siblings (aged 6-24 mo). CBCCs were randomly assigned to 1) a control group providing the Save the Children's ECD program or 2) a treatment group providing a standard ECD program with additional activities to improve nutritious food production and behavior change communication to improve diets and care practices for young children. Primary outcomes were household production and production diversity, preschooler enrollment and attendance, and dietary intake measured by quantitative 24-h recall and minimum diet diversity for younger siblings. Secondary outcomes included anthropometric measures for preschoolers and younger siblings, child development scores for preschoolers, and women's asset ownership and time use (the latter 2 are not discussed in this article). We used difference-in-difference (DID) estimates to assess impacts. Results: Compared with the control group, preschool children in the intervention group had greater increases in nutrient intakes and in dietary diversity. No impacts on anthropometric measures were seen in preschoolers. Younger siblings in the intervention group had greater increases in height-for-age z scores than did children in the control group (DID: 0.44; P < 0.05) and greater reductions in the prevalence of stunting (DID: -17 percentage points; P < 0.05). The plausibility of the impact on growth in younger siblings was supported by effects along program impact pathways, including production of nutritious foods, caregiver knowledge, and dietary diversity. Conclusion: Implementing an integrated agriculture and nutrition intervention through an ECD platform benefited children's diets and reduced stunting among younger siblings of targeted preschoolers. This trial was registered on the ISRCTN registry as ISCRCTN96497560.

Improving child nutrition and development through community-based childcare centres in Malawi - The NEEP-IE study: study protocol for a randomised controlled trial.

BACKGROUND: The Nutrition Embedded Evaluation Programme Impact Evaluation (NEEP-IE) study is a cluster randomised controlled trial designed to evaluate the impact of a childcare centre-based integrated nutritional and agricultural intervention on the diets, nutrition and development of young children in Malawi. The intervention includes activities to improve nutritious food production and training/behaviour-change communication to improve food intake, care and hygiene practices. This paper presents the rationale and study design for this randomised control trial. METHODS: Sixty community-based childcare centres (CBCCs) in rural communities around Zomba district, Malawi, were randomised to either (1) a control group where children were attending CBCCs supported by Save the Children's Early Childhood Health and Development (ECD) programme, or (2) an intervention group where nutritional and agricultural support activities were provided alongside the routine provision of the Save the Children's ECD programme. Primary outcomes at child level include dietary intake (measured through 24-h recall), whilst secondary outcomes include child development (Malawi Development Assessment Tool (MDAT)) and nutritional status (anthropometric measurements). At household level, primary outcomes include smallholder farmer production output and crop-mix (recall of last production season). Intermediate outcomes along theorised agricultural and nutritional pathways were measured. During this trial, we will follow a mixed-methods approach and undertake child-, household-, CBCC- and market-level surveys and assessments as well as in-depth interviews and focus group discussions with project stakeholders. DISCUSSION: Assessing the simultaneous impact of preschool meals on diets, nutrition, child development and agriculture is a complex undertaking. This study is the first to explicitly examine, from a food systems perspective, the impact of a preschool meals programme on dietary choices, alongside outcomes in the nutritional, child development and agricultural domains. The findings of this evaluation will provide evidence to support policymakers in the scale-up of national programmes. TRIAL REGISTRATION: ISRCTN registry, ID: ISRCTN96497560 . Registered on 21 September 2016.

Lean-Season Food Transfers Affect Children's Diets and Household Food Security: Evidence from a Quasi-Experiment in Malawi.

Background: There is evidence that social transfers increase food consumption, improving the quantity and quality of food consumed by poor households. Questions remain on how to improve the effectiveness of social programs.Objective: The aim was to assess the impact of a lean-season food transfer on household food security, diet, and nutrition status of young children during the lean season in Malawi and to understand processes through which transfers operated.Methods: This was a longitudinal, quasi-experimental study based on 2 survey rounds in the Zomba district in Malawi. Data were collected from 60 communities randomly selected among food-insecure villages. Twenty households were randomly selected for interviews within each community. Study outcomes included household expenditures and food consumption (measured by using 7-d recall) and child-level dietary diversity (measured by using 24-h recall) and nutritional status (anthropometric measurements). We followed a mixed-methods approach involving child- and household-level assessments, as well as interviews with community stakeholders. We estimated program impact by combining propensity score matching and difference-in-difference methods.Results: The per capita effect of food transfers on food expenditure was estimated at 36 Malawian kwachas/d, corresponding to an increase of 19% from baseline. There was evidence of increased iron availability in household intake. Highly significant effects were found on children's dietary diversity score, corresponding to an increase of 15%, as well as a positive effect on weight-for-height z scores (WHZs) of >0.25 SDs. Effects on food expenditure and dietary diversity were robust to alternative matching specifications, although the effect on WHZs was not. Examination of the targeting of the transfer showed evidence of large errors of inclusion and exclusion.Conclusion: During the lean season in food-insecure settings, where important declines in food insecurity, diet quality, and nutrition status are present, food transfers may have a protective effect on household food security and diets of young children.

Adapting Agriculture Platforms for Nutrition: A Case Study of a Participatory, Video-Based Agricultural Extension Platform in India.

Successful integration of nutrition interventions into large-scale development programmes from nutrition-relevant sectors, such as agriculture, can address critical underlying determinants of undernutrition and enhance the coverage and effectiveness of on-going nutrition-specific activities. However, evidence on how this can be done is limited. This study examines the feasibility of delivering maternal, infant, and young child nutrition behaviour change communication through an innovative agricultural extension programme serving nutritionally vulnerable groups in rural India. The existing agriculture programme involves participatory production of low-cost videos promoting best practices and broad dissemination through village-level women's self-help groups. For the nutrition intervention, 10 videos promoting specific maternal, infant, and young child nutrition practices were produced and disseminated in 30 villages. A range of methods was used to collect data, including in-depth interviews with project staff, frontline health workers, and self-help group members and their families; structured observations of mediated video dissemination sessions; nutrition knowledge tests with project staff and self-help group members; and a social network questionnaire to assess diffusion of promoted nutrition messages. We found the nutrition intervention to be well-received by rural communities and viewed as complementary to existing frontline health services. However, compared to agriculture, nutrition content required more time, creativity, and technical support to develop and deliver. Experimentation with promoted nutrition behaviours was high, but sharing of information from the videos with non-viewers was limited. Key lessons learned include the benefits of and need for collaboration with existing health services; continued technical support for implementing partners; engagement with local cultural norms and beliefs; empowerment of women's group members to champion nutrition; and enhancement of message diffusion mechanisms to reach pregnant women and mothers of young children at scale. Understanding the experience of developing and delivering this intervention will benefit the design of new nutrition interventions which seek to leverage agriculture platforms.