Identifying measures for coverage of nutrition-sensitive social protection programs: Learnings from India.

Optimal child growth requires a combination of nutrition-specific and sensitive interventions in the first 1,000 days. There is limited guidance on how to measure the population-level coverage of nutrition-sensitive social protection (NSSP), which is designed with explicit nutrition goals and often provides food or cash transfers and co-coverage with nutrition and health intervention. In this study in India, we designed a questionnaire that captures seven core NSSP program elements (transfer type, size, modality, population, timing, provider, conditionalities), then used cognitive testing to refine the questionnaire, and then implemented the questions as part of a telephone survey. Cognitive testing indicated variability in understanding the terms used to specify NSSP programs, including the need to use regional program names. Respondents also had difficulty recalling the timing of the benefit receipt. We included the refined NSSP coverage questions in a phone-based survey with 6,627 mothers with children <2 years across six states. Coverage of subsidized food was 73% across all households. Women were more likely to report receiving food than cash transfers during pregnancy (89% vs. 60%) and during lactation (75% vs. 13%). Co-coverage of NSSP with nutrition and health interventions during pregnancy (16%) and early childhood (3%) was low. It was feasible to measure coverage of NSSP investments in these populations; however, further research is needed to comprehensively assess all the dimensions of the NSSP benefits, including benefit adequacy and the validity of these questions when administered in person and by phone.

Availability of national policies, programmes, and survey-based coverage data to track nutrition interventions in South Asia.

Progress to improve nutrition among women, infants and children in South Asia has fallen behind the pace needed to meet established global targets. Renewed political commitment and monitoring of nutrition interventions are required to improve coverage and quality of care. Our study aimed to assess the availability of national nutrition policies, programmes, and coverage data of nutrition interventions for women, children, and adolescents in eight countries in South Asia. We reviewed relevant policy and programme documents, examined questionnaires used in the most recent rounds of 20 nationally representative surveys, and generated an evidence gap map on the availability of policies, programmes, and survey data to track progress on coverage of globally recommended nutrition interventions. Current policies and programmes in South Asian countries addressed almost all the recommended nutrition interventions targeted at women, children, and adolescents. There was a strong policy focus in all countries, except Maldives, on health system platforms such as antenatal and postnatal care and child growth and development. Survey data on nutrition intervention coverage was most available in India and Nepal, while Bangladesh and Bhutan had the least. Though countries in South Asia have committed to national nutrition policies and strategies, national surveys had substantial data gaps, precluding progress tracking of nutrition intervention coverage. Greater attention and effort are needed for multisectoral collaboration to promote and strengthen nutrition data systems.

Climate shocks and nutrition: The role of food security policies and programs in enhancing maternal and neonatal survival in Niger.

Niger is afflicted with high rates of poverty, high fertility rates, frequent environmental crises, and climate change. Recurrent droughts and floods have led to chronic food insecurity linked to poor maternal and neonatal nutrition outcomes in vulnerable regions. We analyzed maternal and neonatal nutrition trends and subnational variability between 2000 and 2021 with a focus on the implementation of policies and programs surrounding two acute climate shocks in 2005 and 2010. We used four sources of data: (a) national household surveys for maternal and newborn nutritional indicators allowing computation of trends and differences at national and regional levels; (b) document review of food security reports; (c) 30 key informant interviews and; (d) one focus group discussion. Many food security policies and nutrition programs were enacted from 2000 to 2020. Gains in maternal and neonatal nutrition indicators were more significant in targeted vulnerable regions of Maradi, Zinder, Tahoua and Tillabéri, from 2006 to 2021. However, poor access to financial resources for policy execution and suboptimal implementation of plans have hindered progress. In response to the chronic climate crisis over the last 20 years, the Nigerien government and program implementers have demonstrated their commitment to reducing food insecurity and enhancing resilience to climate shocks by adopting a deliberate multisectoral effort. However, there is more that can be achieved with a continued focus on vulnerable regions to build resilience, targeting high risk populations, and investing in infrastructure to improve health systems, food systems, agriculture systems, education systems, and social protection.

Moderate Accuracy of Survey Responses about Infant and Young Child Feeding Counseling Reported by Mothers with Children Less than 1 Year of Age in India.

BACKGROUND: Counseling on infant and young child feeding (IYCF) to support optimal breastfeeding and complementary feeding practices is an essential intervention, and accurate coverage data is needed to identify gaps and monitor progress. However, coverage information captured during household surveys has not yet been validated. OBJECTIVES: We examined the validity of maternal reports of IYCF counseling received during community-based contacts and factors associated with reporting accuracy. METHODS: Direct observations of home visits conducted by community workers in 40 villages in Bihar, India served as the "gold standard" to maternal reports of IYCF counseling received during 2-wk follow-up surveys (n = 444 mothers with children less than 1 y of age, interviews matched to direct observations). Individual-level validity was assessed by calculating sensitivity, specificity, and AUC. Population-level bias was measured using the inflation factor (IF). Multivariable regression models were used to examine factors associated with response accuracy. RESULTS: Prevalence of IYCF counseling during home visits was very high (90.1%). Maternal report of any IYCF counseling received in the past 2 wk was moderate (AUC: 0.60; 95% CI: 0.52, 0.67), and population bias was low (IF = 0.90). However, the recall of specific counseling messages varied. Maternal report of any breastfeeding, exclusive breastfeeding, and dietary diversity messages had moderate validity (AUC > 0.60), but other child feeding messages had low individual validity. Child age, maternal age, maternal education, mental stress, and social desirability were associated with reporting accuracy of multiple indicators. CONCLUSIONS: Validity of IYCF counseling coverage was moderate for several key indicators. IYCF counseling is an information-based intervention that may be received from various sources, and it may be challenging to achieve higher reporting accuracy over a longer recall period. We consider the modest validity results as positive and suggest that these coverage indicators may be useful for measuring coverage and tracking progress over time.

Factors associated with diet diversity among infants and young children in the Eastern and Southern Africa region.

This study explores common factors associated with not meeting minimum dietary diversity (MDD) among 27,072 children aged 6-23 months in Eastern and Southern Africa using data from nine Demographic and Health Surveys from 2013 to 2016. MDD was defined as consumption of more than or equals to five of eight food groups including breast milk in the past 24 h. Equity gaps were calculated as the difference in MDD prevalence between the top and bottom wealth quintiles. Logistic regression was conducted to identify common factors for not meeting MDD at the household, maternal and child levels across two or more countries to inform regional policies to improve children's diets. Kenya had the highest MDD wealth equity gap (40.4 pts), and South Africa had the smallest (14.4 pts). Equity gaps for flesh foods or eggs (up to 39.8 pp) were larger than for grain or legumes (up to 20 pp). Common risk factors for not reaching MDD included younger child age (6-11 months) (n = 9 countries), no formal maternal occupation (n = 6), not receiving vitamin-A supplementation (n = 3), younger maternal age (n = 3), lower maternal education (n = 3), no media (n = 3) or newspaper (n = 3) exposure, lower household wealth quintile (n = 3), use of nonefficient cooking fuel (n = 2), longer time to get to the water source (n = 2), not listening to the radio (n = 2) and higher birth order (n = 2). Priorities for improving MDD in the region include introducing diverse foods at a young age from 6 months with early nutrition counselling, promoting higher maternal education, increasing food purchasing power and ensuring the support of younger mothers.

Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action.

As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.

Unequal coverage of nutrition and health interventions for women and children in seven countries.

OBJECTIVE: To examine inequalities and opportunity gaps in co-coverage of health and nutrition interventions in seven countries. METHODS: We used data from the most recent (2015-2018) demographic and health surveys of mothers with children younger than 5 years in Afghanistan (n = 19 632), Bangladesh (n = 5051), India (n = 184 641), Maldives (n = 2368), Nepal (n = 3998), Pakistan (n = 8285) and Sri Lanka (n = 7138). We estimated co-coverage for a set of eight health and eight nutrition interventions and assessed within-country inequalities in co-coverage by wealth and geography. We examined opportunity gaps by comparing coverage of nutrition interventions with coverage of their corresponding health delivery platforms. FINDINGS: Only 15% of 231 113 mother-child pairs received all eight health interventions (weighted percentage). The percentage of mother-child pairs who received no nutrition interventions was highest in Pakistan (25%). Wealth gaps (richest versus poorest) for co-coverage of health interventions were largest for Pakistan (slope index of inequality: 62 percentage points) and Afghanistan (38 percentage points). Wealth gaps for co-coverage of nutrition interventions were highest in India (32 percentage points) and Bangladesh (20 percentage points). Coverage of nutrition interventions was lower than for associated health interventions, with opportunity gaps ranging from 4 to 54 percentage points. CONCLUSION: Co-coverage of health and nutrition interventions is far from optimal and disproportionately affects poor households in south Asia. Policy and programming efforts should pay attention to closing coverage, equity and opportunity gaps, and improving nutrition delivery through health-care and other delivery platforms.

Using cognitive interviewing to bridge the intent-interpretation gap for nutrition coverage survey questions in India.

Designing survey questions that clearly and precisely communicate the question's intent and elicit responses based on the intended interpretation is critical but often undervalued. We used cognitive interviewing to qualitatively assess respondents' interpretation of and responses to questions pertaining to maternal and child nutrition intervention coverage. We conducted interviews to cognitively test 25 survey questions with mothers (N = 21) with children less than 1 year in Madhya Pradesh, India. Each question was followed by probes to capture information on four cognitive stages-comprehension, retrieval, judgement, and response. Data were analysed for common and unique patterns across the survey questions. We identified four types of cognitive challenges: (1) retention of multiple concepts in long questions: difficulty in comprehending and retaining questions with three or more key concepts; (2) temporal confusion: difficulty in conceptualizing recall periods such as "in the last 6 months" as compared to life stages such as pregnancy; (3) interpretation of concepts: mismatch of information being asked, meaning of certain terms and intervention scope; and (4) understanding of technical terms: difficulty in understanding commonly used technical words such as "breastfeeding" and "antenatal care" and requiring use of simple alternative language. Findings from this study will be useful for stakeholders involved in survey design and implementation, especially those conducting large-scale household surveys to measure coverage of essential nutrition interventions.

Advancing nutrition measurement: Developing quantitative measures of nutrition service quality for pregnant women and children in low- and middle-income country health systems.

The health sector plays an important role in the delivery of high-quality nutrition interventions to women and children in low- and middle-income countries (LMICs). However, there are no standardized approaches to defining and measuring nutrition service quality in these contexts. This study aims to systematically develop quality of care indices for direct health systems nutrition interventions using a five-step process: (1) identify recommended interventions for inclusion in indices, (2) extract service readiness, provision of care, and experience of care items from intervention-specific clinical guidelines, (3) map items to data available in global health facility surveys, (4) conduct an expert survey to prioritize interventions and items, and (5) use findings from previous steps to propose quality of care metrics. Thirty-two recommended interventions were identified, for which the guidelines review yielded 763 unique items that were reviewed by experts. The proposed nutrition quality of care indices for pregnant women reflects eight interventions and the indices for children under 5 reflects six interventions. The indices provide a standardized measure for nutrition intervention quality and can be operationalized using existing health facility assessment data, facilitating their use by LMIC decision makers for planning and resource allocation.

Validation of maternal report of nutrition-related interventions and counselling during antenatal care in southern Nepal.

The delivery of nutrition-related interventions and counselling during antenatal care is critical for a healthy pregnancy for both mother and child. However, the accuracy of maternal reports of many of these services during household surveys has not yet been examined. Our objectives were to assess the validity of the maternal reports of 10 antenatal nutrition interventions, including counselling, and examine associates between maternal characteristics and accuracy. Maternal report of services received collected during a post-partum survey was compared to the gold standard, the direct observation of all women's antenatal care visits. Individual-level validity was assessed by calculating indicator sensitivity, specificity and area under the operating curve (AUC). The inflation factor (IF) measured population-level bias. For five indicators, the high true coverage limited our ability to assess the validity of the maternal reports. There were no indicators that had both high individual-level validity (AUC > 0.70) and low population bias (0.75 < IF < 1.25). Indicators with greater true coverage estimates had higher sensitivity and lower specificity estimates compared to those indicators with lower true coverage. There were no maternal characteristics associated with the accuracy of the report. Maternal report of antenatal nutrition-related interventions and counselling during household surveys was found to have variable validity across indicators. Additional research in settings with varying coverage levels should be considered to best inform antenatal care coverage measurement in household surveys.

Critical assessment of the current indicator for antenatal iron-containing supplementation coverage: Insights from a mixed-methods study.

Daily consumption of iron-containing supplements is recommended for all pregnant women but there is no approved global standard indicator for assessing supplementation coverage. Furthermore, the validity of commonly used coverage indicators for iron-containing supplement consumption is questionable. The WHO-UNICEF Technical Expert Advisory Group on Nutrition Monitoring, and partners, have systematically worked to identify a feasible and valid indicator of iron-containing supplement coverage for reporting by countries. In 2019, we conducted key informant interviews with respondents in eight countries, fielded an online survey (in three languages using SurveyMonkey) to which 142 nutrition professionals from 52 countries responded, and used Demographic and Health Surveys (DHS) data from four countries to assess determinants of the quality of iron-containing supplement coverage data. Less than half (45%) of online survey respondents were satisfied with the current methods for collecting iron-containing supplement coverage data in their context. Recommended changes by study respondents include recall period <5 years, adding questions about counselling, including other beneficiary groups, and assessing supply chain functionality. The DHS analysis suggested an association between time since pregnancy and data quality. Data heaping on multiples of 30 was observed in 40%-75% of data. There is a clear demand for a revised indicator and measurement guidance for coverage of iron-containing supplementation during pregnancy. Future research should continue the development and validation of a global indicator, to more precisely validate the quality of recall data, including the distinction between distribution and consumption using various question formulations.

Obtaining district-level health estimates using geographically masked location from Demographic and Health Survey data.

BACKGROUND: Demographic and Health Survey (DHS) data are an important source of maternal, newborn, and child health as well as nutrition information for low- and middle-income countries. However, DHSs are often unavailable at the administrative unit that is most interesting or useful for program planning. In addition, the location of DHS survey clusters are geomasked within 10 km, and prior to 2009, may have crossed district boundaries. We aim to use DHS surveyed information with these geomasked coordinates to estimate district assignments for use in health program planning and evaluation. METHODS: We developed three methods to assign a district to a geomasked survey cluster in two DHS surveys from Malawi: 2000 and 2004. Method A assigns districts of origin in proportion to the likelihood that results from repeated simulated geomasking, allowing more than one possible district of origin. Method B assigns a single district of origin which contains the greatest proportion of simulated geomasked survey clusters. Method C maps the geomasked survey cluster's location to a district polygon. We used these method assignments to estimate a selection of commonly used coverage indicators for each district. We compared the district coverage estimates, confidence intervals, and concordance correlation coefficients, by each of the methods, to those which used validated district assignments in 2004, and we looked at coverage change from 2000 to 2004. RESULTS: The methods we tested each approximated the validated estimates in 2004 by confidence interval comparison and concordance correlation coefficient. Estimated agreement for method A was between .14 and .98, for method B the estimated agreement was between .97 and .99, and for method C the agreement ranged from .93 to .99 when compared with the validated district assignments. Therefore, we recommend the protocol which is the simplest to implement-method C-overlaying geomasked survey cluster within district polygon. CONCLUSIONS: Using geomasked survey clusters from DHSs to assign districts provided district level coverage rates similar to those using the validated surveyed locations. This method may be applied to data sources where survey cluster centroids are available and where district level estimates are needed for program implementation and evaluation in low- and middle-income settings. This method is of special interest to those using DHSs to study spatiotemporal trends as it allows for the utilization of historic DHS data where geomasking hinders the generation of reliable subnational estimates of health in areas smaller than the first-order administrative unit (ADM1).

How do nutrition professionals working in low-income countries perceive and prioritize actions to prevent wasting? A mixed-methods study.

Despite a shared commitment to achieving global nutrition targets, development and emergency-humanitarian actors tend to prioritize different nutrition outcomes and actions. New approaches are needed to bridge the divide between these communities and to strengthen the overall evidence base for prevention of wasting. To better understand how these different groups perceive and prioritize actions for wasting prevention, key informant interviews (n = 21) were conducted, and an online survey was fielded among nutrition professionals working in low-income countries (n = 107). Additionally, nutrition policy and strategy documents for select global and country institutions (n = 12) were analysed to identify interventions and approaches for addressing different forms of undernutrition. The findings of this study suggest that at both global and country levels, development actors tend to prioritize stunting prevention, and emergency-humanitarian actors tend to prioritize treatment of acute malnutrition. It was less common for wasting prevention to be mentioned as an explicit priority. Many interventions were perceived by respondents to influence both stunting and wasting despite limited published evidence of effectiveness on wasting for water, sanitation and hygiene, growth monitoring and promotion, breastfeeding promotion and micronutrient supplementation. To help unify the nutrition community around prevention of wasting, the discourse about priority interventions should shift from 'stunting versus wasting' and 'prevention versus treatment' to a life-course framing around child survival, growth and development. Respondents identified a need for more programme and research funding that prioritizes both wasting and stunting as outcomes. They also suggest leveraging existing national coordination bodies that bring development and emergency-humanitarian partners together.

Measuring coverage of infant and young child feeding counselling interventions: A framework and empirical considerations for survey question design.

Most countries implement nutrition counselling interventions as part of programmes to support breastfeeding and complementary feeding. However, data to track coverage of counselling interventions are rarely available. As a result, little is known about the coverage of counselling on infant and young child feeding (IYCF). Survey-based data collection systems generally collect data on IYCF practices but do not collect data on coverage of interventions to support IYCF, and those surveys that do collect this information do not do so consistently. We present a framework to guide the design of survey questions to measure IYCF counselling coverage. We provide examples of how large-scale surveys for programme evaluation and national monitoring have included survey questions to address these data gaps. Our review suggests that elements relevant to designing survey questions to capture coverage of counselling interventions include timing of contact, target behaviour and message content, place of contact, type of service provider, frequency of contact and mode of intervention. Application of this framework may help strengthen harmonized measurement of IYCF counselling coverage to enable better tracking of programme investments, document progress in scaling up nutrition services and allow for cross-country comparisons. Thus, improving measurement of counselling coverage may lead to improved reach of programmes to support optimal IYCF practices.

Prevalence thresholds for wasting, overweight and stunting in children under 5 years.

OBJECTIVE: Prevalence ranges to classify levels of wasting and stunting have been used since the 1990s for global monitoring of malnutrition. Recent developments prompted a re-examination of existing ranges and development of new ones for childhood overweight. The present paper reports from the WHO-UNICEF Technical Expert Advisory Group on Nutrition Monitoring. DESIGN: Thresholds were developed in relation to sd of the normative WHO Child Growth Standards. The international definition of 'normal' (2 sd below/above the WHO standards median) defines the first threshold, which includes 2·3 % of the area under the normalized distribution. Multipliers of this 'very low' level (rounded to 2·5 %) set the basis to establish subsequent thresholds. Country groupings using the thresholds were produced using the most recent set of national surveys. SETTING: One hundred and thirty-four countries. SUBJECTS: Children under 5 years. RESULTS: For wasting and overweight, thresholds are: 'very low' (≈6 times 2·5 %). For stunting, thresholds are: 'very low' (≈12 times 2·5 %). CONCLUSIONS: The proposed thresholds minimize changes and keep coherence across anthropometric indicators. They can be used for descriptive purposes to map countries according to severity levels; by donors and global actors to identify priority countries for action; and by governments to trigger action and target programmes aimed at achieving 'low' or 'very low' levels. Harmonized terminology will help avoid confusion and promote appropriate interventions.

Complementary Feeding Interventions Have a Small but Significant Impact on Linear and Ponderal Growth of Children in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

Background: World Health Assembly member states have committed to ambitious global targets for reductions in stunting and wasting by 2025. Improving complementary diets of children aged 6-23 mo is a recommended approach for reducing stunting in children <5 y old. Less is known about the potential of these interventions to prevent wasting.Objective: The aim of this article was to review and synthesize the current literature for the impact of complementary feeding interventions on linear [length-for-age z score (LAZ)] and ponderal [weight-for-length z score (WLZ)] growth of children aged 6-23 mo, with the specific goal of updating intervention-outcome linkages in the Lives Saved Tool (LiST).Methods: We started our review with studies included in the previous LiST review and searched for articles published since January 2012. We identified longitudinal trials that compared children aged 6-23 mo who received 1 of 2 types of complementary feeding interventions (nutrition education or counseling alone or complementary food supplementation with or without nutrition education or counseling) with a no-intervention control. We assessed study quality and generated pooled estimates of LAZ and WLZ change, as well as length and weight gain, for each category of intervention.Results: Interventions that provided nutrition education or counseling had a small but significant impact on linear growth in food-secure populations [LAZ standardized mean difference (SMD): 0.11; 95% CI: 0.01, 0.22] but not on ponderal growth. Complementary food supplementation interventions with or without nutrition education also had a small, significant effect in food-insecure settings on both LAZ (SMD: 0.08; 95% CI: 0.04, 0.13) and WLZ (SMD: 0.05; 95% CI: 0.01, 0.08).Conclusions: Nutrition education and complementary feeding interventions both had a small but significant impact on linear growth, and complementary feeding interventions also had an impact on ponderal growth of children aged 6-23 mo in low- and middle-income countries. The updated LiST model will support nutrition program planning and evaluation efforts by allowing users to model changes in intervention coverage on both stunting and wasting.

Modeling the Impact of Nutrition Interventions on Birth Outcomes in the Lives Saved Tool (LiST).

Background: Negative birth outcomes [small-for-gestational age (SGA) and preterm birth (PTB)] are common in low- and middle-income countries and have important subsequent health and developmental impacts on children. There are numerous nutritional and non-nutritional interventions that can decrease the risk of negative birth outcomes and reduce subsequent risk of mortality and growth faltering.Objective: The objective of this article was to review the current evidence for the impact of nutritional interventions in pregnancy [calcium supplementation, iron and folic acid supplementation, multiple micronutrient (MMN) supplementation, and balanced energy supplementation (BES)] and risk factors (maternal anemia) on birth outcomes, with the specific goal of determining which intervention-outcome linkages should be included in the Lives Saved Tool (LiST) software.Methods: A literature search was conducted by using the WHO e-Library of Evidence for Nutrition Actions as the starting point. Recent studies, meta-analyses, and systematic reviews were reviewed for inclusion on the basis of their relevance to LiST.Results: On the basis of the available scientific evidence, the following linkages were found to be supported for inclusion in LiST: calcium supplementation on PTB (12% reduction), MMN supplementation on SGA (9% reduction), and BES on SGA (21% reduction among food-insecure women).Conclusions: The inclusion of these linkages in LiST will improve the utility of the model for users who seek to estimate the impact of antenatal nutrition interventions on birth outcomes. Scaling up these interventions should lead to downstream impacts in reducing stunting and child mortality.

Metrics for Identifying Food Security Status and the Population with Potential to Benefit from Nutrition Interventions in the Lives Saved Tool (LiST).

Background: The Lives Saved Tool (LiST) uses the poverty head-count ratio at $1.90/d as a proxy for food security to identify the percentage of the population with the potential to benefit from balanced energy supplementation and complementary feeding (CF) interventions, following the approach used for the Lancet's 2008 series on Maternal and Child Undernutrition. Because much work has been done in the development of food security indicators, a re-evaluation of the use of this indicator was warranted.Objective: The aim was to re-evaluate the use of the poverty head-count ratio at $1.90/d as the food security proxy indicator in LiST.Methods: We carried out a desk review to identify available indicators of food security. We identified 3 indicators and compared them by using scatterplots, Spearman's correlations, and Bland-Altman plot analysis. We generated LiST projections to compare the modeled impact results with the use of the different indicators.Results: There are many food security indicators available, but only 3 additional indicators were identified with the data availability requirements to be used as the food security indicator in LiST. As expected, analyzed food security indicators were significantly positively correlated (P < 0.001), but there was generally poor agreement between them. The disparity between the indicators also increases as the values of the indicators increase. Consequently, the choice of indicator can have a considerable effect on the impact of interventions modeled in LiST, especially in food-insecure contexts.Conclusions: There was no single indicator identified that is ideal for measuring the percentage of the population who is food insecure for LiST. Thus, LiST will use the food security indicators that were used in the meta-analyses that produced the effect estimates. These are the poverty head-count ratio at $1.90/d for CF interventions and the prevalence of a low body mass index in women of reproductive age for balanced energy supplementation interventions.

The Lives Saved Tool (LiST) as a Model for Prevention of Anemia in Women of Reproductive Age.

Background: Anemia in women is a major public health burden worldwide, particularly in low- and middle-income countries (LMICs). It is a complex condition with multiple nutritional and non-nutritional causes, and geographic heterogeneity of burden. The World Health Assembly has set a target of a 50% reduction in anemia among women of reproductive age (WRA) by 2025.Objective: This article seeks to identify the leading causes of anemia among women in LMICs, review the evidence supporting interventions to address anemia in these settings, and ultimately use this information to decide which interventions should be included in the Lives Saved Tool (LiST) model of anemia. It also seeks to examine the link between anemia and cause-specific maternal mortality.Methods: The leading causes of anemia in WRA were inventoried to identify preventive and curative interventions available for implementation at the public health scale. A literature review was then conducted for each identified intervention, as well as for the link between anemia and maternal mortality.Results: The interventions for which data were available fell into the following categories: provision of iron, malaria prevention, and treatment of parasitic infestation. Ultimately, 5 interventions were included in the LiST model for anemia: blanket iron supplementation or fortification, iron and folic acid supplementation in pregnancy, multiple micronutrient supplementation in pregnancy, intermittent preventive treatment of malaria in pregnancy, and household ownership of an insecticide-treated bednet. In addition, anemia was linked in the model with risk of maternal mortality due to hemorrhage.Conclusion: The updated LiST model for anemia reflects the state of the current scientific evidence and should be of use to researchers, program managers, and policymakers who seek to model the impact of scaling up nutrition and health interventions on anemia, and ultimately on maternal mortality.