Understanding differential reductions in undernutrition among districts in Rwanda through the perspectives of mid-level and community actors on policy commitment and policy coherence.

Understanding the drivers of improvements in child undernutrition at only the national level can mask subnational differences. This paper aimed to understand the contributions of factors in the enabling environment to observed differences in stunting reduction between districts in Rwanda. In 2017, we conducted 58 semi-structured interviews with mid-level actors (n = 38) and frontline workers (n = 20) implementing Rwanda's multi-sectoral nutrition policy in five districts in which stunting decreased (reduced districts) and five where it increased or stagnated (non-reduced districts) based on Rwanda's 2010 and 2014/15 Demographic and Health Surveys. Mid-level actors are government officials and service providers at the subnational level who represent the frontline of government policy. Interviews focused on political commitment to and policy coherence in nutrition, and contributors to nutrition changes. Responses were coded to capture themes on the changes and challenges of these topics and compared between reduced and non-reduced districts. Descriptive statistics described district characteristics. Political commitment to nutrition was high in both reduced and non-reduced districts. Respondents from reduced districts were more likely to define commitment to nutrition as an optimal implementation of policy, whereas those from non-reduced districts focused more on financial commitment. Regarding coherence, respondents from reduced compared to non-reduced districts were more likely to report the optimal implementation of multi-sectoral nutrition planning meetings, using data to assess plans and progress in nutrition outcomes and integration of nutrition into the agriculture sector. In contrast, respondents from non-reduced districts more often reported challenges in their relationships with national-level stakeholders and nutrition and/or monitoring and evaluation capacities. Enhancing the integration of nutrition in different sectors and improving mid-level actors' capacity to plan and advocate for nutrition programming may contribute to reductions in stunting.

Social assistance programme impacts on women's and children's diets and nutritional status.

Investments in social assistance programmes (SAPs) have accelerated alongside interest in using SAPs to improve health and nutrition outcomes. However, evidence of how design features within and across programme types influence the effectiveness of SAPs for improving diet and nutrition outcomes among women and children is limited. To address this, we reviewed evaluations of cash, in-kind and voucher programmes conducted between 2010 and 2020 among women and children, and examined associations between design features (targeting, including household and individual transfers, fortified foods and behaviour change communication) and positive impacts on diet (diet diversity, micronutrient intake) and nutrition (anthropometric indicators, haemoglobin, anaemia) outcomes. Our review has several key findings. First, SAPs improve dietary diversity and intake of micronutrient-rich foods among women and children, as well as improve several nutrition outcomes. Second, SAPs were more likely to impact diet and nutrition outcomes among women compared with children (23/45 [51%] vs. 52/144 [36%] of outcomes measured). Third, in-kind (all but one of which included fortified foods) compared with cash transfer programmes were more likely to significantly increase women's body mass index and children's weight-for-height/length Z-score, and both women's and children's haemoglobin and anaemia. However, there is limited evidence on the effectiveness of SAPs for improving micronutrient status and preventing increased prevalence of overweight and obesity for all populations and for improving diet and nutrition outcomes among men, adolescents and the elderly. Further research in these areas is urgently needed to optimize impact of SAPs on diet and nutrition outcomes as countries increase investments in SAPs.

Tubaramure, a Food-Assisted Integrated Health and Nutrition Program, Reduces Child Wasting in Burundi: A Cluster-Randomized Controlled Intervention Trial.

BACKGROUND: Little is known about the impact of food-assisted maternal and child health programs (FA-MCHN) on child wasting. OBJECTIVES: We assessed the impact of Tubaramure, a FA-MCHN program in Burundi, on child (0 to 24 months) wasting and the differential impacts by socio-economic characteristics and age. The program targeted women and their children during the first 1000 days and included 1) food rations, 2) strengthening and promotion of use of health services, and 3) behavior change communication (BCC). METHODS: We conducted a 4-arm, cluster-randomized, controlled trial (2010-2012). Clusters were defined as "collines" (communities). Impact was estimated using repeated cross-sectional data (n = ∼2620 children in each round). Treatment arms received household and individual (mother or child in the first 1000 days) food rations (corn-soy blend and micronutrient-fortified vegetable oil) from pregnancy to 24 months (T24 arm), from pregnancy to 18 months (T18), or from birth to 24 months (TNFP). All beneficiaries received the same BCC for the first 1000 days. The control arm received no rations or BCC. RESULTS: Wasting (weight-for-length Z-score <2 SD) increased from baseline to follow-up in the control group (from 6.5% to 8%), but Tubaramure had a significant (P < 0.05) protective effect on wasting [treatment arms combined, -3.3 percentage points (pp); T18, -4.5 pp] and on the weight-for-length z-score (treatment arms combined, +0.15; T24, +0.20; T18, +0.17). The effects were limited to children whose mother and household head had no education, and who lived in the poorest households. The largest effect was found in children 6 to 12 months of age: the group with the highest wasting prevalence. CONCLUSIONS: FA-MCHN programs in highly food-insecure regions can protect the most disadvantaged children from wasting. These findings are particularly relevant in the context of the economic crisis due to the coronavirus disease 2019 pandemic, which is expected to dramatically increase child wasting.

Nutrition-sensitive agriculture programme impacts on time use and associations with nutrition outcomes.

Success of nutrition-sensitive agriculture programmes targeted to women may be influenced by increased demands on women's and other household members' time and by time-related trade-offs to accommodate programme participation. However, evidence of how such programmes impact time use and whether changes in time-related demands negatively influence maternal or child health and nutrition outcomes is limited. This paper examines the impact of Helen Keller International's Enhanced Homestead Food Production programme in Burkina Faso (2010-2012) on women's and men's time use and associations between changes in women's time use and maternal and child health and nutrition outcomes. We used quantitative data from a cluster-randomized controlled trial (baseline 2010, endline 2012) and qualitative data from two rounds of process evaluation (2011, 2012). Two-stage analyses were used to first assess programme impacts on women's and men's time use using difference-in-difference impact estimates and second to evaluate whether programme impacts on women's time use were associated with changes in women's and children's health and nutrition outcomes. Programme impacts were considered significant if corrected P < 0.01, and associations were considered significant if p < 0.05 and p < 0.01. Qualitative data were analysed through manual coding and by calculating the means and standard deviations for the time spent by women and men on activities in intervention and control groups. Findings show that the programme significantly increased the amount of time women spent on agriculture in the intervention compared to the control group, but this was not associated with changes in maternal or child health or nutrition outcomes. Process evaluation data supported these findings.

Tubaramure, a Food-Assisted Maternal and Child Health and Nutrition Program in Burundi, Increased Household Food Security and Energy and Micronutrient Consumption, and Maternal and Child Dietary Diversity: A Cluster-Randomized Controlled Trial.

BACKGROUND: Food-assisted maternal and child health and nutrition programs are a widely used approach to address undernutrition. Little is known about the effects of these programs' combined household and individual food rations on household and individual food consumption. Tubaramure in Burundi targeted women and children during the first 1000 d of life, and included: 1) food rations (corn-soy blend and micronutrient-fortified vegetable oil); 2) health services strengthening and promotion of their use; and 3) behavior change communication on nutrition, hygiene, and health practices. OBJECTIVES: The objectives were: 1) to assess Tubaramure's impact on household food consumption and food security, maternal dietary diversity, and infant and young child feeding practices; 2) to explore the role of the food rations; and 3) assess 6-8 mo impacts around 8 mo after the end of the program. METHODS: We used a 4-arm cluster-randomized controlled repeated cross-sectional design (11,906 observations). The treatment arms received the same food ration but differed in the ration timing and duration: 1) the first 1000 d; 2) from pregnancy through 17.9 mo of age; or 3) from birth through 23.9 mo of age. RESULTS: Tubaramure significantly (P < 0.05) improved the percentage of food secure households [from 4.5 to 7.3 percentage points (pp)], and increased household energy consumption (from 17% to 20%) and micronutrient consumption. The program had a positive effect on maternal dietary diversity (+0.4 food groups, P < 0.05) and increased the proportion of children aged 6-23.9 mo consuming ≥4 food groups (from 8.0 to 9.6 pp, P < 0.05). The effects on many outcomes were attributable to the food rations. Postprogram effects (P < 0.05) were found on household food security, maternal dietary diversity, and younger sibling's complementary feeding practices. CONCLUSIONS: Programs such as Tubaramure have the potential to improve food security and household and individual energy and micronutrient consumption in severely resource-constrained populations, as seen in rural Burundi. This trial was registered at clinicaltrials.gov as NCT01072279.

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.

Validation of 24-h dietary recall for estimating nutrient intakes and adequacy in adolescents in Burkina Faso.

Data on dietary nutrient intakes of adolescents in low- and middle-income countries (LMIC) is lacking partly due to the absence of validation studies of the 24-h recall method in adolescents. We conducted a validation study of 24-h recall (24HR) compared with observed weighed records (OWR) in adolescents (n = 132, 10-11 years; n = 105, 12-14 years). Dietary data were collected for the same day by both methods by conducting the 24HR the day after the OWR. For OWR, all foods consumed by adolescents from the first to last meal of the day were weighed; for 24HR adolescents reported foods consumed using portion aids. Food intakes were converted to nutrients. Nutrient intakes by both methods were tested for equivalence by comparing the ratios (24HR/OWR) with equivalence margins of within ±10%, 15% and 20% of the ratio. Prevalences of inadequacy (POIs) were obtained using the NCI method. Mean ratios for energy were 0.88 and 0.92, for younger and older adolescents, respectively, and other nutrients ranged between 0.84 and 1.02. Energy intakes were equivalent within the 15% bound, and most nutrients fell within the 20% bound. POI was overestimated by 24HR, but differences were less than 25 percentage points for most nutrients. Half of adolescents omitted foods in recalls, mainly sweet or savoury snacks, fruits and beverages. Our study showed that adolescents underestimated intakes by 24HR; however, the degree of underestimation was generally acceptable for 12-14-year-olds within a bound of 15%. Errors could possibly be reduced with further training and targeted probing.

Using structural equation modelling to understand the contributors to anaemia among young Burkinabe children.

Anaemia is a persistent problem among young Burkinabe children, yet population-specific information on its determinants is scant. We used baseline data from an evaluation of Helen Keller International's Enhanced Homestead Food Production Program (n=1210 children) to quantify household-, mother-, and child-level factors associated with anaemia in Burkinabe children aged 6-12 months. We used structural equation modelling to assess a theoretical model, which tested four categories of factors: (a) household food security and dietary diversity, (b) household sanitation and hygiene (latrine and poultry access and bednet ownership), (c) maternal factors (anaemia, stress, cleanliness, and health, hygiene and feeding knowledge and practices), and (d) child nutrition and health (iron deficiency (ID), retinol binding protein (RBP), malaria, and inflammation). The model also included household socio-economic status, size, and polygamy; maternal age and education; and child age and sex. Results showed that ID, malaria, and inflammation were the primary direct determinants of anaemia, contributing 15%, 10%, and 10%, respectively. Maternal knowledge directly explained improved child feeding practices and household bednet ownership. Household dietary diversity directly explained 18% of child feeding practices. Additionally, RBP, child age and sex, and maternal anaemia directly predicted child haemoglobin. Our findings suggest that program effectiveness could be increased by addressing the multiple, context-specific contributors of child anaemia. For young Burkinabe children, anaemia control programs that include interventions to reduce ID, malaria, and inflammation should be tested. Other potential intervention entry points suggested by our model include improving maternal knowledge of optimal health, hygiene, and nutrition practices and household dietary diversity.

The cost of improving nutritional outcomes through food-assisted maternal and child health and nutrition programmes in Burundi and Guatemala.

Evidence on the cost-effectiveness of multisectoral maternal and child health and nutrition programmes is scarce. We conducted a prospective costing study of two food-assisted maternal and child health and nutrition programmes targeted to pregnant women and children during the first 1,000 days (pregnancy to 2 years). Each was paired with a cluster-randomized controlled trial to evaluate impact and compare the optimal quantity and composition of food rations (Guatemala, five treatment arms) and their optimal timing and duration (Burundi, three treatment arms). We calculated the total and per beneficiary cost, conducted cost consequence analyses, and estimated the cost savings from extending the programme for 2 years. In Guatemala, the programme model with the lowest cost per percentage point reduction in stunting provided the full-size family ration with an individual ration of corn-soy blend or micronutrient powder. Reducing family ration size lowered costs but failed to reduce stunting. In Burundi, providing food assistance for the full 1,000 days led to the lowest cost per percentage point reduction in stunting. Reducing the duration of ration eligibility reduced per beneficiary costs but was less effective. A 2-year extension could have saved 11% per beneficiary in Guatemala and 18% in Burundi. We found that investments in multisectoral nutrition programmes do not scale linearly. Programmes providing smaller rations or rations for shorter durations, although less expensive per beneficiary, may not provide the necessary dose to improve (biological) outcomes. Lastly, delivering effective programmes for longer periods can generate cost savings by dispersing start-up costs and lengthening peak operating capacity.

A Multisectoral Food-Assisted Maternal and Child Health and Nutrition Program Targeted to Women and Children in the First 1000 Days Increases Attainment of Language and Motor Milestones among Young Burundian Children.

BACKGROUND: Child development is affected by multiple factors throughout pregnancy and childhood. Multisectoral programs addressing these factors may improve children's development. OBJECTIVE: We evaluated the impact of a food-assisted multisectoral nutrition program (Tubaramure) on children's (4-41.9 mo) motor and language development. Tubaramure was targeted to Burundian women and children in the first 1000 d and provided micronutrient-fortified food rations; nutrition, health, and hygiene behavior change communication; and health system-strengthening activities. METHODS: Program impact was assessed using a cluster-randomized controlled trial with repeated cross-sections: 2010 (baseline, children 4-41.9 mo), 2012 (follow-up during implementation, children 4-23.9 mo), and 2014 (follow-up postimplementation, children 24-41.9 mo). Sixty villages were randomly assigned to 4 groups with varying timing and duration of food rations: pregnancy-24 mo; pregnancy-18 mo; 0-24 mo; and control, no direct Tubaramure benefits. Treatment groups were pooled and compared with control using difference-in-difference estimates. We examined impact pathways by assessing program impacts on intermediary variables and their associations with development outcomes. RESULTS: At first follow-up, Tubaramure positively affected language (0.4 milestones, P < 0.05) but not motor development among children aged 4-23.9 mo. Among the 12-23.9 mo age subgroup, the program positively affected language (0.7 milestones, P < 0.01) and motor (0.6 milestones, P = 0.08) development. At second follow-up, among children aged 24-41.9 mo, Tubaramure marginally affected motor development (0.4 milestones, P = 0.09). In age subgroup analyses, program impacts were limited to children aged 24-29.9 mo [0.4 motor (P = 0.09) and 1.0 language (P < 0.01) milestones]. Pathway analyses revealed significant positive impacts on diet, health, and nutritional indicators of children aged 12-23.9 mo and health and nutritional indicators of children aged 24-29.9 mo, supporting the plausibility of program impacts on child development. CONCLUSIONS: Tubaramure had small positive impacts on children's motor and language development through multiple pathways, demonstrating the role multisectoral nutrition programs can play in improving children's development. This trial was registered at clinicaltrials.gov as NCT01072279.

PROCOMIDA, a Food-Assisted Maternal and Child Health and Nutrition Program, Contributes to Postpartum Weight Retention in Guatemala: A Cluster-Randomized Controlled Intervention Trial.

BACKGROUND: Food-assisted maternal and child health and nutrition (FA-MCHN) programs are widely used to reduce household food insecurity and maternal and child undernutrition in low- and middle-income countries. These programs, however, may unintentionally lead to excessive energy intake and unhealthy weight gain, especially in food-secure populations. OBJECTIVE: We evaluated the impact of an FA-MCHN program implemented in Guatemala on maternal weight from pregnancy to 24 mo postpartum. The program was earlier shown to reduce stunting. METHODS: We used a longitudinal, cluster-randomized controlled trial with arms varying in family ration size [full (FFR), reduced (RFR), none (NFR)] and individual maternal ration type [corn-soy blend (CSB), lipid-based nutrient supplement (LNS), micronutrient powder (MNP)]: A: FFR + CSB; B: RFR + CSB; C: NFR + CSB; D: FFR + LNS; E: FFR + MNP; F: control. Weight was measured during pregnancy and at 1, 4, 6, 9, 12, 18, and 24 mo postpartum. We used linear mixed models controlling for pregnancy weight with random cluster and mother effects. Data on 3535 women were analyzed. RESULTS: Significant (P < 0.05) or marginally significant (P < 0.10) effects of 0.50-0.65 kg were found at all time points (except 9 mo) in arm A. Similar-sized effects were found in arms B (1, 4, 6, and 12 mo) and C (1 and 12 mo). Marginally significant effects (0.51-0.66 kg) were found in arm D (1, 6, 9, and 12 mo); in arm E, marginally significant effects (0.48-0.75 kg) were found from 6 to 24 mo. CONCLUSIONS: The effect on maternal postpartum weight is of concern because of the high existing prevalence of overweight. Programs need to include "double-duty" objectives and actions, to ensure that addressing child undernutrition does not exacerbate the problem of unhealthy weight gain. This trial was registered at clinicaltrials.gov as NCT01072279.

Tubaramure, a Food-Assisted Integrated Health and Nutrition Program, Reduces Child Stunting in Burundi: A Cluster-Randomized Controlled Intervention Trial.

Background: Food-assisted maternal and child health and nutrition (FA-MCHN) programs are widely used to address undernutrition, but little is known about their effectiveness in improving child linear growth. Objective: We assessed the impact of Burundi's Tubaramure FA-MCHN program on linear growth. The program targeted women and their children during the first 1000 d and included 1) food rations, 2) strengthening of health services and promotion of their use, and 3) behavior change communication (BCC). A second objective was to assess the differential effect when varying the timing and duration of receiving food rations. Methods: We used a 4-arm, cluster-randomized controlled study to assess program impact with the use of cluster fixed-effects double-difference models with repeated cross-sectional data (baseline and follow-up 4 y later with ∼3550 children in each round). Treatment arms received food rations (corn-soy blend and micronutrient-fortified vegetable oil) for the first 1000 d (T24), from pregnancy through the child reaching 18 mo (T18), or from birth through the child reaching 24 mo ["no food during pregnancy" (TNFP)]. All treatment arms received BCC for the first 1000 d. The control arm received no food rations or BCC. Results: Stunting (height-for-age z score <2 SDs) increased markedly from baseline to follow-up, but Tubaramure had a significant (P < 0.05) beneficial effect in the T24 [7.4 percentage points (pp); P < 0.05], T18 (5.7 pp; P < 0.05), and TNFP (4.6; P = 0.09) arms; the differences in effect across arms were not significant (P > 0.01). Secondary analyses showed that the effect was limited to children whose mother and head of household had some primary education and who lived in households with above-median assets. Conclusions: FA-MCHN programs are an effective development tool to improve child linear growth and can protect children from political and economic shocks in vulnerable countries such as Burundi. A better understanding of how to improve the nutritional status of children in the worst-off households is needed. This trial was registered at www.clinicaltrials.gov as NCT01072279.

PROCOMIDA, a Food-Assisted Maternal and Child Health and Nutrition Program, Reduces Child Stunting in Guatemala: A Cluster-Randomized Controlled Intervention Trial.

Background: Food-assisted maternal and child health and nutrition (FA-MCHN) programs may foster child growth during the first 1000 d (pregnancy and the first 2 y of a child's life), but evidence is scant. Objective: We evaluated the impact of an FA-MCHN program, PROCOMIDA, on linear growth (stunting [length-for-age z score (LAZ) < -2] and length-for-age difference [LAD]) among children aged 1-24 mo. PROCOMIDA was implemented in Guatemala by Mercy Corps and was available to beneficiaries throughout the first 1000 d. Methods: We used a longitudinal, cluster-randomized controlled trial with groups varying in family ration sizes [full (FFR), reduced (RFR), and none (NFR)] and individual ration types provided to mothers (pregnancy to 6 mo postpartum) and children (6-24 mo of age) [corn-soy blend (CSB), lipid-based nutrient supplement (LNS), micronutrient powder (MNP)]: 1) FFR + CSB (n = 576); 2) RFR + CSB (n = 575); 3) NFR + CSB (n = 542); 4) FFR + LNS (n = 550); 5) FFR + MNP (n = 587); 6) control (n = 574). Program impacts compared with control, and differential impacts between groups varying family ration size or individual ration type, were assessed through the use of linear mixed-effects models and post hoc simple effect tests (significant if P < 0.05). Results: PROCOMIDA significantly reduced stunting at age 1 mo in FFR + CSB, RFR + CSB, and FFR + MNP groups compared with control [5.05, 4.06, and 3.82 percentage points (pp), respectively]. Stunting impact increased by age 24 mo in FFR + CSB and FFR + MNP relative to control (impact = 11.1 and 6.5 pp at age 24 mo, respectively). For CSB recipients, the FFR compared with RFR or NFR significantly reduced stunting (6.47-9.68 pp). CSB reduced stunting significantly more than LNS at age 24 mo (8.12 pp). Conclusions: FA-MCHN programs can reduce stunting during the first 1000 d, even in relatively energy/food-secure populations. Large family rations with individual rations of CSB or MNP were most effective. The widening of impact as children age highlights the importance of intervening throughout the full first 1000 d. This trial was registered at clinicaltrials.gov as NCT01072279.

Process evaluation improves delivery of a nutrition-sensitive agriculture programme in Burkina Faso.

Evidence is emerging from rigorous evaluations about the effectiveness of nutrition-sensitive agriculture programmes in improving nutritional outcomes. Additional evidence can elucidate how different programme components and pathways contribute and can be optimized for impact. The International Food Policy Research Institute, with Helen Keller International, designed a comprehensive framework to evaluate the delivery, utilization, and impact of Helen Keller International's enhanced homestead food production programme in Burkina Faso. After 18 months of implementation, a process evaluation was conducted to examine programme impact pathways, using key informant and semistructured interviews with implementing agents and beneficiaries, and with residents of control communities. Data were analyzed by International Food Policy Research Institute and reviewed with project managers and partners through multiple workshops to identify opportunities to strengthen implementation. Findings illuminated gaps between intended and actual delivery schemes, including input constraints, knowledge gaps among community agents in agriculture and young child nutrition practices, and lower than expected activity by community volunteers. In response, staff developed measures to overcome water constraints and expand vegetable and poultry production, retrained volunteers in certain techniques of food production and counselling for nutrition behaviour change, added small incentives to motivate volunteers, and shaped both immediate and long-term changes to the programme model. Working closely with International Food Policy Research Institute on the evaluation activities also expanded the repertoire of research methods and skills of Helen Keller International staff. Process evaluation can strengthen programme delivery, utilization, and design. Collaboration between researchers and implementers can improve programme effectiveness, project staff capacity, and advance delivery science.

Tubaramure, a Food-Assisted Integrated Health and Nutrition Program in Burundi, Increases Maternal and Child Hemoglobin Concentrations and Reduces Anemia: A Theory-Based Cluster-Randomized Controlled Intervention Trial.

BACKGROUND: Despite their popularity, food-assisted maternal and child health and nutrition (MCHN) programs have not been evaluated rigorously, and evidence of their impacts on maternal and child outcomes is scant. OBJECTIVE: This study estimated the impact of Tubaramure, a food-assisted MCHN program implemented by Catholic Relief Services and partners in eastern Burundi, on hemoglobin and anemia (primary outcome) in children aged 0-23.9 mo and their mothers and explored the impact pathways. The program targeted women and their children during their first 1000 d of life and included 1) food rations, 2) strengthening and promotion of the use of health services, and 3) behavior change communication. METHODS: This was a cluster-randomized controlled study to assess program impact by using cluster fixed-effects double-difference models with repeated cross-sectional data (baseline and follow-up 2 y later). We explored impact pathways by estimating impact on intermediary factors addressed by Tubaramure that are known determinants of hemoglobin and anemia and by regressing hemoglobin and anemia on each determinant to assess the plausibility that the effect operated through each determinant. RESULTS: Hemoglobin decreased and anemia increased markedly from baseline to follow-up, but Tubaramure had a significant (P < 0.05) beneficial effect on both children [6.1 percentage points (pps)] and mothers who had given birth in the previous 3 mo (34.9 pps). The program also had significant (P < 0.05) impacts on factors along the hypothesized impact pathways: dietary diversity, consumption of iron-rich foods, morbidity, and fever for child hemoglobin and dietary diversity, consumption of iron-rich foods, and current bed-net use for maternal anemia. CONCLUSIONS: We showed, for the first time to our knowledge, that a food-assisted MCHN program had a positive impact on anemia and hemoglobin in both mothers and children. The plausible pathways identified highlight the importance of addressing multiple determinants of anemia. This trial was registered at clinicaltrials.gov as NCT01072279.

A 2-Year Integrated Agriculture and Nutrition Program Targeted to Mothers of Young Children in Burkina Faso Reduces Underweight among Mothers and Increases Their Empowerment: A Cluster-Randomized Controlled Trial.

BACKGROUND: Recent evidence demonstrates the benefits of integrated agriculture and nutrition programs for children's health and nutrition outcomes. These programs may also improve mothers' nutrition and empowerment outcomes. However, evidence from rigorous evaluations is scarce. OBJECTIVE: We examined impacts of Helen Keller International's 2-y enhanced-homestead food production (E-HFP) program in Burkina Faso on the secondary impact measures of mothers' nutrition and empowerment. METHODS: We used a cluster-randomized controlled trial whereby 55 villages with 1767 mothers of young children were randomly assigned to 3 groups: 1) control, 2) E-HFP with the behavior change communication (BCC) strategy implemented by older women leaders, or 3) E-HFP with BCC implemented by health committee members. Data for the treatment groups were pooled for this analysis because no differences were found between the 2 groups in key mothers' outcomes. We used difference-in-differences (DID) estimates to assess impacts on mothers' dietary intake, diversity, body mass index (BMI; in kg/m(2)), prevalence of underweight (BMI <18.5), and empowerment. RESULTS: The E-HFP program significantly increased mothers' intake of fruit (DID = 15.8 percentage points; P = 0.02) and marginally increased their intake of meat/poultry (DID = 7.5 percentage points; P = 0.08) and dietary diversity (DID = 0.3 points; P = 0.08). The prevalence of underweight was significantly reduced among mothers in treatment compared with control villages by 8.7 percentage points (P < 0.01). Although the changes in BMI did not differ between mothers in treatment and control villages, there was a marginally significant interaction (baseline underweight × change in BMI; P-interaction = 0.07), indicating that underweight mothers had a greater increase in BMI than did mothers who were not underweight. The E-HFP program also positively affected mothers' overall empowerment score (DID = 3.13 points out of 37 possible points; P < 0.01) and 3 components of empowerment: meeting with women (DID = 1.21 points out of 5 possible points; P < 0.01), purchasing decisions (DID = 0.86 points out of 8 possible points; P = 0.01), and health care decisions (DID = 0.24 points out of 2 possible points; P = 0.05). CONCLUSIONS: Helen Keller International's E-HFP program in Burkina Faso substantially improved mothers' nutrition and empowerment outcomes. These positive impacts benefit the mothers themselves and may also improve their ability to care for their children. This trial was registered at clinicaltrials.gov as NCT01825226.

A 2-year integrated agriculture and nutrition and health behavior change communication program targeted to women in Burkina Faso reduces anemia, wasting, and diarrhea in children 3-12.9 months of age at baseline: a cluster-randomized controlled trial.

BACKGROUND: Among young children in Burkina Faso, anemia and chronic and acute undernutrition are widespread. OBJECTIVE: This study assessed the impact of Helen Keller International's (HKI) 2-y integrated agriculture [homestead food production (HFP)] and nutrition and health behavior change communication (BCC) program, targeted to women, on children's (3-12.9 mo old at baseline) anthropometry (stunting, wasting, and underweight), mean hemoglobin (Hb), anemia (Hb < 11 g/dL), and diarrhea prevalence. METHODS: We used a cluster-randomized controlled trial, with 55 villages randomly assigned to a control group (n = 25) or 1 of 2 treatment groups (n = 15 each), which differed by who delivered the BCC messages [older women leaders or health committee (HC) members]. We used difference-in-difference (DID) estimates to assess impacts on child outcomes. RESULTS: We found marginally significant (P < 0.10) impacts on Hb (DID: 0.51 g/dL; P = 0.07) and wasting [DID: -8.8 percentage point (pp); P = 0.08] and statistically significant (P < 0.05) impacts on diarrhea (-15.9 pp; P = 0.00) in HC compared with control villages among children aged 3-12.9 mo and larger impacts for anemia (DID: -14.6 pp; P = 0.03) and mean Hb (DID: 0.74 g/dL; P = 0.03) among younger children (aged 3-5.9 mo). However, we found no significant impacts on stunting or underweight prevalence. Plausibility was supported by greater improvements in women's agricultural production and maternal infant and young child feeding and care knowledge and practices in HC compared with control villages. CONCLUSIONS: HKI's 2-y integrated HFP+BCC program (HC group) significantly improved several child outcomes, including wasting (marginal), diarrhea, Hb, and anemia, especially among the youngest children. This is the first cluster-randomized controlled trial of an HFP program that documents statistically significant positive effects on these child nutrition outcomes. This trial was registered at clinicaltrials.gov as NCT01825226.

Can Integrated Agriculture-Nutrition Programmes Change Gender Norms on Land and Asset Ownership? Evidence from Burkina Faso.

This article uses a mixed-methods approach to analyse the impact of an integrated agriculture and nutrition programme in Burkina Faso on women's and men's assets, and norms regarding ownership, use and control of assets. We use a cluster-randomised controlled trial to determine whether productive asset transfers and increased income-generating opportunities for women increase women's assets over time. Qualitative work on gender norms finds that although men still own and control most assets, women have greater decision-making power and control over home gardens and their produce, and attitudes towards women owning property have become more favourable in treatment areas.

Using program impact pathways to understand and improve program delivery, utilization, and potential for impact of Helen Keller International's homestead food production program in Cambodia.

BACKGROUND: Evidence of the impact of homestead food production programs on nutrition outcomes such as anemia and growth is scant. In the absence of information on program impact pathways, it is difficult to understand why these programs, which have been successful in increasing intake of micronutrient-rich foods, have had such limited documented impact on nutrition outcomes. OBJECTIVE: To conduct a process evaluation of Helen Keller International's (HKI's) homestead food production program in Cambodia to assess whether the program was operating as planned (in terms of design, delivery, and utilization) and to identify ways in which the program might need to be strengthened in order to increase its potential for impact. METHODS: A program theory framework, which laid out the primary components along the hypothesized program impact pathways, was developed in collaboration with HKI and used to design the research. Semistructured interviews and focus group discussions with program beneficiaries (n = 36 and 12, respectively), nonbeneficiaries (n = 12), and program implementers (n = 17 and 2, respectively) and observations of key program delivery points, including health and nutrition training sessions (n = 6), village model farms (n = 6), and household gardens of beneficiaries (n = 36) and nonbeneficiaries (n = 12), were conducted to assess the delivery and utilization of the primary program components along the impact pathways. RESULTS: The majority of program components were being delivered and utilized as planned. However, challenges with some of the key components posited to improve outcomes such as anemia and growth were noted. Among these were a gap in the expected pathway from poultry production to increased intake of eggs and poultry meat, and some weaknesses in the delivery of the health and nutrition training sessions and related improvements in knowledge among the village health volunteers and beneficiaries. CONCLUSIONS: Although the program has been successful in delivering the majority of the program components as planned and has documented achievements in improving household production and intake of micronutrient-rich foods, it is likely that strengthening delivery and increasing utilization of some program components would increase its potential for nutritional impacts. This research has highlighted the importance of designing a program theory framework and assessing the components that lie along the primary program impact pathways to optimize program service delivery and utilization and, in turn, potential for impact.

Food Insecurity and Perceived Effects of COVID-19 on Livelihoods in Rural Sri Lanka.

BACKGROUND: Little is known about how the COVID-19 pandemic has affected food security and livelihoods in Sri Lanka. OBJECTIVE: This article aims to assess food insecurity, perceived effects of COVID-19, and coping mechanisms among agriculture-based households in rural Sri Lanka. METHODS: We used 2 rounds of panel data from phone surveys (n = 1057 households) conducted in 5 districts. Food insecurity (30-day recall), perceived impacts of COVID-19 (6-month recall), and coping mechanisms (6-month recall) were assessed using a household questionnaire. To assess food insecurity, we used the 8-item Food Insecurity Experience Scale. We tested for differences between T1 (baseline: December 2020-February 2021) and T2 (follow-up: July 2021-September 2021) and explored the association between food insecurity and the perceived effect of COVID-19 on income using a logistic regression model. RESULTS: Food insecurity was highly prevalent (T1: 75%, T2: 80%) but varied across districts. Most respondents were affected by COVID-19 and/or COVID-19-associated mitigation measures (T1: 84%, T2: 89%). Among affected households, commonly reported impacts included those on income (T1: 77%, T2: 76%), food costs (T1: 84%, T2: 83%), and travel (∼90% in both rounds). Agricultural activities were also adversely affected (T1: 64%, T2: 69%). About half of COVID-19-affected households reported selling livestock or assets to meet basic needs. Households whose income was impacted by COVID-19 were more likely to be food insecure (adjusted odds ratio: 2.56, P < .001). CONCLUSIONS: Households in rural Sri Lanka experienced food insecurity and livelihood disturbances during the COVID-19 pandemic. Additional surveys are needed to assess recovery post-COVID-19 and to understand if programs that support livelihoods have been protective.

METHOD: This original article used household level survey data from 2 rounds of phone surveys conducted in 5 districts of Sri Lanka.Using a household-level questionnaire, we recorded experience of food insecurity in the last 30 days, perceived impact of COVID-19, and adopted coping mechanism in the 6 months prior to the survey.We reported statistical means and tested for differences between 2 survey rounds.We also explored association between food insecurity and the perceived effect of COVID-19 on income. RESULTS: Household-level food insecurity was highly prevalent during the pandemic.Households perceived a negative effect of the pandemic on their income and employment sources.Households whose income was impacted by the pandemic were more likely to be food insecure. CONCLUSION: Agriculture-based households in rural Sri Lanka experienced food insecurity and livelihood disturbances during the COVID-19 pandemic.Additional research is needed to assess recovery post COVID-19 and to understand whether livelihood support programs have been protective.

Plain language titleFood Insecurity and Perceived Effects of COVID-19 on Livelihoods in Rural Sri LankaPlain language summaryBackground: Sustained levels of high food insecurity are associated with a range of negative health, nutrition, and well-being effects.The COVID-19 pandemic is expected to aggravate food insecurity and worsen the livelihood situation.Little is known about how the COVID-19 pandemic affected food security and livelihoods of agriculture-based households in rural Sri Lanka.