Social Assistance Programs and Birth Outcomes: A Systematic Review and Assessment of Nutrition and Health Pathways.

BACKGROUND: Poor birth outcomes are an important global public health problem. Social assistance programs that provide cash or in-kind transfers, such as food or vouchers, hold potential to improve birth outcomes but the evidence on their effectiveness has not been reviewed. OBJECTIVES: We systematically reviewed studies that used experimental or quasi-experimental methods to evaluate the impacts of social assistance programs on outcomes in low- and middle-income countries. METHODS: The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to assess the certainty of the evidence for birth weight and neonatal mortality (most common outcomes reported). We summarized the evidence on hypothesized nutrition and health pathways of impact. RESULTS: We included 6 evaluations of 4 different cash transfer programs and 1 evaluation of a community-based participatory learning and action program that provided food and cash transfers. The 4 studies that assessed birth weight impacts found significant (P < 0.05) effects ranging from 31 to 578 g. Out of 3 studies that assessed neonatal mortality impacts, 2 found significant effects ranging from 0.6 to 3.1 deaths/1000 live births. The certainty of the evidence for both outcomes was rated as very low due to several methodological limitations. In terms of potential pathways, some studies documented positive effects on maternal diet, antenatal care (ANC) utilization, and delivery in a health facility. CONCLUSIONS: Better-designed evaluations are needed to strengthen the evidence base on these programs. Evaluation studies should elucidate underlying mechanisms of impact by including outcomes related to maternal diet, ANC seeking, use of skilled delivery, and women's empowerment in nutrition and health domains. Studies should also assess potential unintended negative consequences of social assistance, such as reduced birth spacing and excess pregnancy weight gain.

Randomized controlled trials of multi-sectoral programs: Lessons from development research.

Development is a multi-faceted process; achieving development goals thus requires a multi-sectoral approach. For over two decades, our research group of economists and nutritionists has designed and implemented randomized trials to assess the effectiveness of multisectoral programs in improving nutrition, food security, and other measures of well-being, largely at the request of developing country governments, development partners, and non-governmental organizations. Our approach addresses three perceived pitfalls of RCTs: the "black box" nature of RCTs, limited external validity, and challenges in translation of results to impacts at scale. We address these concerns by identifying and assessing programmatic pathways to impact with quantitative and qualitative methods; studying similar programs implemented by different organizations across various settings; and working closely with implementing partners in the design, research, and dissemination processes to inform adaptation and scale-up of programs and policies.

Bargaining power, decision making, and biofortification: The role of gender in adoption of orange sweet potato in Uganda.

We examine the role of gender dimensions of intrahousehold bargaining power and decision making in the adoption and diffusion of orange sweet potato (OSP), a biofortified crop being promoted to increase dietary intakes of vitamin A in Uganda. We use patterns of ownership and control of land and other assets by married men and women to create gender-disaggregated indicators of bargaining power, allowing for joint and sole ownership and control of land and assets. Using data from an experimental evaluation of a project promoting OSP adoption, we find that the probability of adopting OSP is not affected by the exclusive or joint control of assets by women at the household level. However, within households, parcels of land under joint control, in which the woman has primary control over decision making, are significantly more likely to contain OSP. Women who control a higher share of household nonland resources are more likely to share OPS vines, showing that women use greater bargaining power to facilitate diffusion of this health-promoting technology. We do not find any impact of women's bargaining power on children's dietary intakes of Vitamin A, possibly because husbands and wives have the same preferences regarding their children's nutritional status. These results contribute to reshaping our understanding of household decision making to inform the design and implementation of agriculture-nutrition interventions.

School Feeding Reduces Anemia Prevalence in Adolescent Girls and Other Vulnerable Household Members in a Cluster Randomized Controlled Trial in Uganda.

BACKGROUND: Food for education (FFE) programs that include school meals are widely used to improve school participation and performance, but evidence on nutritional benefits is limited. OBJECTIVE: This study tested whether food fortified with multiple micronutrients provided in FFE programs reduced anemia prevalence of primary-school-age adolescent girls, adult women, and preschool children. METHODS: Through the use of a cluster randomized controlled trial with individual-level repeated cross-sectional data, we measured impacts on anemia prevalence from 2 FFE programs, a school feeding program (SFP) providing multiple-micronutrient-fortified meals and a nutritionally equivalent take-home ration (THR). Camps for internally displaced people (IDP) (n = 31) in Northern Uganda were randomly assigned to SFP, THR, or a control group with no FFE. Rations were provided for 15 mo at SFP and THR schools. A survey of households (n = 627) with children aged 6-17 y was conducted (baseline and 18 mo later). Analyses used difference-in-differences by intent to treat. RESULTS: Adolescent girls aged 10-13 y in FFE schools experienced a significant (P < 0.05) 25.7 percentage point reduction (95% CI: -0.43, -0.08) in prevalence of any anemia [hemoglobin (Hb) <11.5 g/dL, age 10-11 y; Hb <12 g/dL, age 12-13 y] and a significant 19.5 percentage point reduction (95% CI: -0.35, -0.04) in moderate-to-severe anemia (Hb <11 g/dL) relative to the control group, with no difference in impact between SFP and THR. The THR reduced moderate-to-severe anemia prevalence (Hb <11g/dL) of adult women aged ≥18 y (12.8 percentage points, 95% CI: -0.24, -0.02). All IDP camps initially received micronutrient-fortified rations through a separate humanitarian program; in one district where most households stopped receiving these rations, SFP reduced moderate-to-severe anemia of children aged 6-59 mo by 22.1 percentage points (95% CI: -0.42, -0.02). CONCLUSIONS: FFE programs reduced any anemia and moderate-to-severe anemia in primary-school-age adolescent girls and reduced moderate-to-severe anemia for adult women and preschool children. This study was registered with clinicaltrials.gov as NCT01261182.

Biofortification, Crop Adoption and Health Information: Impact Pathways in Mozambique and Uganda.

Biofortification is a promising strategy to combat micronutrient malnutrition by promoting the adoption of staple food crops bred to be dense sources of specific micronutrients. Research on biofortified orange-fleshed sweet potato (OFSP) has shown that the crop improves the vitamin A status of children who consume as little as 100 grams per day, and intensive promotion strategies improve dietary intakes of vitamin A in field experiments. However, little is known about OFSP adoption behavior, or about the role that nutrition information plays in promoting adoption and changing diet. We report evidence from similar randomized field experiments conducted in Mozambique and Uganda to promote OFSP. We further use causal mediation analysis to study impact pathways for adoption and dietary intakes. Despite different agronomic conditions and sweet potato cropping patterns across the two countries, the project had similar impacts, leading to adoption by 61% to 68% of farmers exposed to the project, and doubling vitamin A intakes in children. In both countries, two intervention models that differed in training intensity and cost had comparable impacts relative to the control group. The project increased the knowledge of key nutrition messages; however, added knowledge of nutrition messages appears to have minimally affected adoption, conditional on assumptions required for causal mediation analysis. Increased vitamin A intakes were largely explained by adoption and not by nutrition knowledge gained, though in Uganda a large share of impacts on vitamin A intakes cannot be explained by mediating variables. Similar impacts could likely have been achieved by reducing the scope of nutrition trainings. JEL codes: I15, O12, O13, Q12.

Introduction of ß-carotene-rich orange sweet potato in rural Uganda resulted in increased vitamin A intakes among children and women and improved vitamin A status among children.

Vitamin A deficiency (VAD) persists in Uganda and the consumption of ß-carotene-rich orange sweet potato (OSP) may help to alleviate it. Two large-scale, 2-y intervention programs were implemented among Ugandan farmer households to promote the production and consumption of OSP. The programs differed in their inputs during year 2, with one being more intensive (IP) and the other being reduced (RP). A randomized, controlled effectiveness study compared the impact of the IP and RP with a control on OSP and vitamin A intakes among children aged 6-35 mo (n = 265) and 3-5 y (n = 578), and women (n = 573), and IP compared with control on vitamin A status of 3- to 5-y-old children (n = 891) and women (n = 939) with serum retinol <1.05 µmol/L at baseline. The net OSP intake increased in both the IP and RP groups (P < 0.01), accounting for 44-60% of vitamin A intake at follow-up. The prevalence of inadequate vitamin A intake was reduced in the IP and RP groups compared with controls among children 6-35 mo of age (>30 percentage points) and women (>25 percentage points) (P < 0.01), with no differences between the IP and RP groups of children (P = 0.75) or women (P = 0.17). There was a 9.5 percentage point reduction in prevalence of serum retinol <1.05 µmol/L for children with complete data on confounding factors (n = 396; P < 0.05). At follow-up, vitamin A intake from OSP was positively associated with vitamin A status (P < 0.05). Introduction of OSP to Ugandan farming households increased vitamin A intakes among children and women and was associated with improved vitamin A status among children.

A large-scale intervention to introduce orange sweet potato in rural Mozambique increases vitamin A intakes among children and women.

ß-Carotene-rich orange sweet potato (OSP) has been shown to improve vitamin A status of infants and young children in controlled efficacy trials and in a small-scale effectiveness study with intensive exposure to project inputs. However, the potential of this important food crop to reduce the risk of vitamin A deficiency in deficient populations will depend on the ability to distribute OSP vines and promote its household production and consumption on a large scale. In rural Mozambique, we conducted a randomised, controlled effectiveness study of a large-scale intervention to promote household-level OSP production and consumption using integrated agricultural, demand creation/behaviour change and marketing components. The following two intervention models were compared: a low-intensity (1 year) and a high-intensity (nearly 3 years) training model. The primary nutrition outcomes were OSP and vitamin A intakes by children 6-35 months and 3-5·5 years of age, and women. The intervention resulted in significant net increases in OSP intakes (model 1: 46, 48 and 97 g/d) and vitamin A intakes (model 1: 263, 254 and 492 µg retinol activity equivalents/d) among the younger children, older children and women, respectively. OSP accounted for 47-60 % of all sweet potato consumed and, among reference children, provided 80 % of total vitamin A intakes. A similar magnitude of impact was observed for both models, suggesting that group-level trainings in nutrition and agriculture could be limited to the first project year without compromising impact. Introduction of OSP to rural, sweet potato-producing communities in Mozambique is an effective way to improve vitamin A intakes.

Intergenerational nutrition benefits of India's national school feeding program.

India has the world's highest number of undernourished children and the largest school feeding program, the Mid-Day Meal (MDM) scheme. As school feeding programs target children outside the highest-return "first 1000-days" window, they have not been included in the global agenda to address stunting. School meals benefit education and nutrition in participants, but no studies have examined whether benefits carry over to their children. Using nationally representative data on mothers and their children spanning 1993 to 2016, we assess whether MDM supports intergenerational improvements in child linear growth. Here we report that height-for-age z-score (HAZ) among children born to mothers with full MDM exposure was greater (+0.40 SD) than that in children born to non-exposed mothers. Associations were stronger in low socioeconomic strata and likely work through women's education, fertility, and health service utilization. MDM was associated with 13-32% of the HAZ improvement in India from 2006 to 2016.

Building evidence for sustainability of food and nutrition intervention programs in developing countries.

After making large investments to put in place effective health and nutrition interventions, researchers, program implementers, policy makers, and donors all expect lasting effects. However, it is uncertain whether this is the case, and there is less certainty on how to approach the study of program sustainability. This symposium, "Building Evidence for Sustainability of Food and Nutrition Intervention Programs in Developing Countries," provided not only frameworks for conceptualizing sustainability but concrete evidence about the approaches and methods used as well as lessons on how they do or do not work in particular contexts. We presented the following findings: 1) sustainability of activities and impacts of Title II food aid programs in Bolivia and Kenya, 2) sustainability of impact in terms of adoption and consumption of a biofortified orange sweet potato in Uganda, and 3) lessons from incorporating pro-sustainability investment strategies in child survival programs in Guinea. Our symposium introduced a new important body of research on program sustainability to provide insights and stimulate innovative thinking in the design and planning of further applied research and future prosustainability intervention programs.