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.

Understanding the role of intersectoral convergence in the delivery of essential maternal and child nutrition interventions in Odisha, India: a qualitative study.

BACKGROUND: Convergence of sectoral programs is important for scaling up essential maternal and child health and nutrition interventions. In India, these interventions are implemented by two government programs - Integrated Child Development Services (ICDS) and National Rural Health Mission (NRHM). These programs are designed to work together, but there is limited understanding of the nature and extent of coordination in place and needed at the various administrative levels. Our study examined how intersectoral convergence in nutrition programming is operationalized between ICDS and NRHM from the state to village levels in Odisha, and the factors influencing convergence in policy implementation and service delivery. METHODS: Semi-structured interviews were conducted with state-level stakeholders (n = 12), district (n = 19) and block officials (n = 66), and frontline workers (FLWs, n = 48). Systematic coding and content analysis of transcripts were undertaken to elucidate themes and patterns related to the degree and mechanisms of convergence, types of actions/services, and facilitators and barriers. RESULTS: Close collaboration at state level was observed in developing guidelines, planning, and reviewing programs, facilitated by a shared motivation and recognized leadership for coordination. However, the health department was perceived to drive the agenda, and different priorities and little data sharing presented challenges. At the district level, there were joint planning and review meetings, trainings, and data sharing, but poor participation in the intersectoral meetings and limited supervision. While the block level is the hub for planning and supervision, cooperation is limited by the lack of guidelines for coordination, heavy workload, inadequate resources, and poor communication. Strong collaboration among FLWs was facilitated by close interpersonal communication and mutual understanding of roles and responsibilities. CONCLUSIONS: Congruent or shared priorities and regularity of actions between sectors across all levels will likely improve the quality of coordination, and clear roles and leadership and accountability are imperative. As convergence is a means to achieving effective coverage and delivery of services for improved maternal and child health and nutrition, focus should be on delivering all the essential services to the mother-child dyads through mechanisms that facilitate a continuum of care approach, rather than sectorally-driven, service-specific delivery processes.

Is There an Enabling Environment for Nutrition-Sensitive Agriculture in South Asia? Stakeholder Perspectives from India, Bangladesh, and Pakistan.

BACKGROUND: Almost half of all children in South Asia are stunted. Although agriculture has the potential to be a strong driver of undernutrition reduction and serves as the main source of livelihood for over half of South Asia's population, its potential to reduce undernutrition is currently not being realized. OBJECTIVE: The Leveraging Agriculture for Nutrition in South Asia (LANSA) research consortium seeks to understand how agriculture and agrifood systems can be better designed to improve nutrition in South Asia. In 2013 and 2014, LANSA carried out interviews with stakeholders influential in, and/or knowledgeable of, agriculture-nutrition policy in India, Pakistan, and Bangladesh, to gain a better understanding of the institutional and political factors surrounding the nutrition sensitivity of agriculture in the region. METHODS: Semistructured interviews were carried out in India, Bangladesh, and Pakistan with a total of 56 stakeholders representing international organizations, research, government, civil society, donors, and the private sector. RESULTS: The findings point to mixed perspectives on countries' policy sensitivity toward nutrition. There was consensus among stakeholders on the importance of political commitment to nutrition, improving nutrition literacy, strengthening capacities, and improving the use of financial resources. CONCLUSIONS: Although there are different ways in which South Asian agriculture can improve its impact on nutrition, sensitizing key influencers to the importance of nutrition for the health of a country's population appears as a critical issue. This should in turn serve as the premise for political commitment, intersectoral coordination to implement nutrition-relevant policies, adequately resourced nutrition-specific and nutrition-sensitive programs, and sufficient capacities at all levels.

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.

Changes in Nigeria's enabling environment for nutrition from 2008 to 2019 and challenges for reducing malnutrition.

Key 2025 global nutrition targets are unlikely to be met at current rates of progress. Although actions necessary to reduce undernutrition are already mostly known, knowledge gaps remain about how to implement these actions in contextually appropriate ways, and at scales commensurate with the magnitude of the problem. This study describes the nutrition enabling environment in Nigeria, a country that contributes significantly to the global undernutrition burden, and identifies potential entry points for improving the enabling environment that could facilitate implementation and scale-up of essential intervention coverage. Study data were obtained from two sources: content analysis of 48 policies/strategies from agriculture, economic, education, environment, health, nutrition, and water/sanitation/hygiene sectors; and interviews at federal level (16) and in two states (Jigawa (10) and Kaduna (9) States). The study finds that aspects of the enabling environment improved between 2008 and 2019 and facilitated improvements in implementation of nutrition-specific and nutrition-sensitive interventions. Enabling environment components that improved included the framing of nutrition as a multisectoral issue, nutrition advocacy, political attention, evidence around intervention coverage, civil society involvement, and activity of nutrition champions. These factors have been especially important in creating and sustaining momentum for addressing malnutrition. While challenges remain in these aspects, greater challenges persist for factors needed to convert momentum into improvements in nutrition outcomes. Research and data that facilitate shared understanding of nutrition; improved multisectoral and vertical coordination; increased and improved delivery and operational capacity; and increased resource mobilization will be especially important for achieving future progress in nutrition in Nigeria. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-022-01328-2.

Stories of change in nutrition in Burkina Faso 1992-2018: a macro-level perspective.

Looking back at the development of successful enabling environments for nutrition may inform policymakers on how to accelerate progress to end all forms of malnutrition by 2030. As under-five stunting declined substantially in Burkina Faso, from a peak at 45% in 1998/99 to 25% in 2018, we analyzed through a stories of change approach the actors, ideas, initiatives, policies and capacities which enabled wide-scale nutrition progress. We triangulated findings from policy analysis, stakeholder mapping, and national-level semi-structured interviews (n = 20). We found that since 2002, nutrition has been anchored in the Ministry of Health, where leadership advocated for the creation of coordination bodies, enabling a coherent defining of nutrition and laying groundwork for better integration of nutrition into and prioritization of nutrition by the health and tangential ministries. Under the leadership of the Ministry of Health and its partners, horizontal and vertical coherence in nutrition action increased, through effective cooperation between nutrition actors; increasing intersectoral collaboration, particularly with the influential agriculture sector; and increasing funding to support nutrition-sensitive programming and build the capacity of nutrition staff. Nevertheless, sustainably organizing funding and human resources at the decentralized level remained challenging, in a context of emerging threats such as climate change and insecurity. Burkina Faso's health sector's success in creating an enabling environment for nutrition may have contributed to improvements in child nutrition alongside other sectoral improvements. Enhancing accountability of the Health, Agriculture, WASH, Education and Social Protection sectors and empowering decentralized bodies to take nutrition-relevant decisions may help accelerating progress in nutrition.

Stories of change in nutrition: lessons from a new generation of studies from Africa, Asia and Europe.

How does nutrition improve? We need to understand better what drives both positive and negative change in different contexts, and what more can be done to reduce malnutrition. Since 2015, the Stories of Change in Nutrition studies have analysed and documented experiences in many different African and Asian countries, to foster empirically-grounded experiential learning across contexts. This article provides an overview of findings from 14 studies undertaken in nine countries in South Asia, sub-Saharan Africa, and Europe between 2017 and 2021. The studies used a combination of methods, including regression-decomposition analyses of national datasets to assess determinants of nutritional change; policy process and food environment analyses; and community-level research assessing attitudes to change. This article takes a narrative synthesis approach to identify key themes across the studies, paying particular attention to multisectoral determinants, changes in the food environment, the role of structural factors (including longstanding social inequities), and changes in political commitment, cross-sectoral coherence and capacity. Given the inherent multisectoral nature of nutrition, many countries are experimenting with different models of ensuring coherence across sectors that are captured in this body of work. The relative immaturity of the policy sector in dealing with issues such as obesity and overweight, and associated influences in the wider food environment, adds a further challenge. To address these interrelated issues, policy must simultaneously tackle nutrition's upstream (social/economic/equity) and downstream (health and dietary) determinants. Studies synthesised here provide empirically-driven inspiration for action.

Forging just dietary futures: bringing mainstream and critical nutrition into conversation.

Despite decades of action to reduce global malnutrition, rates of undernutrition remain stubbornly high and rates of overweight, obesity and chronic disease are simultaneously on the rise. Moreover, while volumes of robust research on causes and solutions to malnutrition have been published, and calls for interdisciplinarity are on the rise, researchers taking different epistemological and methodological choices have largely remained disciplinarily siloed. This paper works to open a scholarly conversation between "mainstream" public health nutrition and "critical" nutrition studies. While critical nutrition scholars collectively question aspects of mainstream nutrition approaches, they also chart a different way to approach malnutrition research by focusing on politics, structural conditions, and the diverse ways people make sense of food and malnutrition. In this paper, we highlight the key research agendas and insights within both mainstream and critical nutrition in order to suggest spaces for their potential conversation. We ultimately argue that global public health nutrition interventions might achieve greater success in more equitable ways if they are informed by critical nutrition research. We aim for this intervention to facilitate more substantial crossing of disciplinary boundaries, critical to forging more socially and environmentally just dietary futures in the global South and beyond.

Understanding drivers of stunting reduction in Nigeria from 2003 to 2018: a regression analysis.

Nigeria is a high burden country for stunting. Stunting reduction has been slow and characterized by unequal progress across the 36 states and federal capital territory of the country. This study aimed to assess the changes in prevalence of stunting and growth determinants from 2003 to 2018, identify factors that predicted the change in stunting, and project future stunting prevalence if these predicted determinants improve. Trend and linear decomposition analyses of growth outcomes and determinants were conducted using 2003, 2008, 2013, and 2018 Nigeria Demographic and Health Survey data. Pooled data included 57,507 children 0 to 59 months old. Findings show that stunting and severe stunting significantly reduced from 43 to 37% and 23% to 17%, respectively (p < 0.001), between 2003 and 2018. Disturbingly, height-for-age z-scores at birth significantly decreased, indicating risks of potential future stunting increase. Improvements in nine stunting determinants (maternal body mass index, maternal height, ≥ 4 antenatal care visits, health facility delivery, reduced child illnesses, asset index, maternal education, paternal education, and preceding birth interval) predicted stunting reductions in children 0-59 months. Few of these nine determinants improved in subpopulations with limited stunting progress. Intra-sectoral and multisectoral coordination were potentially inadequate; 12% of children had received all of three selected health sector interventions along a continuum of care and 6% had received all of six selected multisector interventions. Forward looking projections suggest that increased efforts to improve the nine predictors of stunting change can reduce under-five stunting in Nigeria to ≤ 27% in the short term. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-022-01279-8.

Stories of change in nutrition from Africa and Asia: an introduction to a special series in Food Security.

Malnutrition in all its forms continues to be a massive global challenge, and the past decade has seen a growing political attention to addressing malnutrition in different contexts. What has been largely missing so far, and is in growing demand from countries, is tangible, practical and rigorous insights and lessons (from other countries or contexts) on how to translate this burgeoning political momentum into effective policies and programme implementation strategies - and ultimately impact on the ground. This new climate of learning from experience and evidence led to the launch in 2015 of the Stories of Change initiative. This series presents a second wave of studies from six countries (Tanzania, Rwanda, Vietnam, Ghana, Burkina Faso, Nigeria,) and three Indian states (Chhattisgarh, Gujarat, Tamil Nadu). These provide clear evidence combined with compelling narratives on what drives success in addressing all forms of malnutrition - evidence that is necessary for turning global momentum into actual results on the ground. This introductory Opinion is published with the first set of papers. It will be followed by a thorough synthesis of papers as a conclusion of the Series. We hope that the lessons embedded in these Stories of Change will inform and inspire the deliberations and outcomes of the UN Food Systems Summit and the second Nutrition for Growth Summit to be held this year, and the actions of those in the global food and nutrition system working for positive change.

Evidence to Action: Highlights From Transform Nutrition Research (2012-2017).

BACKGROUND: The Transform Nutrition ( Transform) research consortium (2012-2017), led by the International Food Policy Research Institute, sought to generate evidence to inform and inspire action to address undernutrition in 4 high-burden countries (India, Bangladesh, Kenya, and Ethiopia) and globally. OBJECTIVE: Within the context of the literature, this synthesis article brings together core findings of Transform, highlighting priorities for future research. METHODS: This article uses a narrative approach to synthesize diverse study findings that collectively address Transform's three primary research questions: (1) How can nutrition-specific interventions be appropriately designed, implemented, scaled, and sustained in different settings?; (2) How can the nutritional impact of social protection and agriculture be improved?; and (3) How can enabling environments be promoted so as to use existing political and economic resources more effectively? RESULTS: Highlights of Transform include (1) improved understanding of the relative effectiveness of different combinations of nutrition-specific interventions and the ways in which they can be scaled for maximal impact; (2) evidence that shows that social protection and agriculture need to be explicitly linked to nutrition in order to contribute to stunting reduction; (3) identification of key components of "enabling environments" for nutrition and how they can be cultivated/sustained; (4) research that examines ways in which leaders emerge and operate to change the political and policy landscape in different settings; and (5) "stories of change" that provide in-depth contextual knowledge of how transformative change has been driven in countries that have made inroads in reducing malnutrition. The conclusion highlights the contributions of the consortium and provides recommendations for future research.

Agriculture, Food Systems, and Nutrition: Meeting the Challenge.

Malnutrition is a global challenge with huge social and economic costs; nearly every country faces a public health challenge, whether from undernutrition, overweight/obesity, and/or micronutrient deficiencies. Malnutrition is a multisectoral, multi-level problem that results from the complex interplay between household and individual decision-making, agri-food, health, and environmental systems that determine access to services and resources, and related policy processes. This paper reviews the theory and recent qualitative evidence (particularly from 2010 to 2016) in the public health and nutrition literature, on the role that agriculture plays in improving nutrition, how food systems are changing rapidly due to globalization, trade liberalization, and urbanization, and the implications this has for nutrition globally. The paper ends by summarizing recommendations that emerge from this research related to (i) knowledge, evidence, and communications, (ii) politics, governance, and policy, and (iii) capacity, leadership, and financing.