Evidence-Based Nutrition Interventions Improved Adolescents' Knowledge and Behaviors in Indonesia.

Adolescence is a nutritionally vulnerable and critical life stage. However, few programs and policies focus on improving adolescent nutrition in Indonesia. To address this gap, we implemented a gender-responsive package of interventions: (1) breakfast and weekly iron-folic acid supplementation (WIFS), (2) a school-based nutrition education program, and (3) a social behavior change communication strategy. We surveyed 514 adolescents at baseline (2019) and endline (2020) in Klaten and Lombok Barat districts in Indonesia. The survey included a knowledge assessment on nutrition, as well as indicators of attitudes and behaviors on diet, physical activity, and WIFS. We employed multivariable linear and logistic regression to test for pre-post intervention differences. Overall knowledge was significantly higher post-intervention (ß: 3.3; 95% confidence interval [CI]: 2.6, 3.9). Diet diversity was high at both timepoints, however, at post-intervention there was significantly higher odds of consuming vitamin A-rich fruits and vegetables (Odds Ratio [OR]: 1.5; 95% CI: 1.1, 2.0) and lower odds of consuming sugar-sweetened beverages (OR: 0.4; 95% CI: 0.3, 0.5). Post-intervention, there was higher odds of reporting 60 min of daily physical activity (OR: 2.3; 95% CI: 1.7, 3.2) and WIFS among girls (OR: 6.7; 95% CI: 1.5, 30.9). The package of interventions may be a promising first step to improving adolescent nutrition in Indonesia.

Maternal and Child Health Benefits of the Mamata Conditional Cash Transfer Program in Odisha, India.

BACKGROUND: Conditional cash transfers (CCTs) are demand-side interventions that link cash receipt to fulfilment of health-promoting conditions such as regular health check-ups and investment in human capital. In 2011, the Indian state of Odisha, implemented a statewide CCT program-the Mamata Scheme-towards improving maternal/child health outcomes and promoting health-seeking behavior. Mamata targets pregnant and lactating women aged ≥19 y, and provides a sizable financial incentive relative to household income levels. OBJECTIVES: We aimed to longitudinally examine whether, and to what extent, initiation of the Mamata scheme corresponded with changes in health and nutrition outcomes in Odisha, relative to comparison states in India. METHODS: Outcomes included maternal health service utilization [antenatal care (ANC), iron-folic acid supplementation, breastfeeding counseling, full child immunization, tetanus vaccination, vitamin A supplementation] and nutrition [anemia during pregnancy and stunting, anemia in children <5 y old (U5)]. Data on outcomes and covariates were obtained from 3 waves of India's National Family Health Surveys corresponding to the years 1999, 2006, and 2016. We used difference-in-differences (DID) estimation strategy to estimate the impact of the program. RESULTS: The pooled sampled size comprised >200,000 mother-child dyads. Tests of parallel trends indicated that preintervention trends were similar across all outcomes in Odisha with the exception of anemia. When comparing Odisha with other states for health services, DID models indicated that exposure to Mamata corresponded with increased odds of counseling for breastfeeding (OR: 2.74; 95% CI: 1.97, 3.80), ANC receipt (OR: 1.51; 95% CI: 1.15, 1.99), and full immunization (OR: 1.69; 95% CI: 1.37, 2.08). DID models also indicated decline in stunting (OR: 0.92; 95% CI: 0.84, 1.02) and anemia (OR: 0.62; 95% CI: 0.54, 0.71) among U5 children in Odisha following Mamata, relative to comparison states. Models comparing poor with nonpoor groups indicated the presence of heterogeneous effects. CONCLUSIONS: This study provides proof-of-concept for potential improvements in maternal and child nutrition outcomes following CCTs that incentivize health care utilization in India.

India's Integrated Child Development Services programme; equity and extent of coverage in 2006 and 2016.

OBJECTIVE: To investigate coverage and equity of India's Integrated Child Development Services programme across the continuum of care from pregnancy to early childhood, before and after the programme was expanded to provide universal access. METHODS: The programme offers nutrition and health services to pregnant and lactating mothers and young children. We used data from nationally representative surveys in 2005-2006 and 2015-2016, including 36 850 mother-child pairs in 2006 and 190 804 in 2016. We assessed changes in the equity of use of programme services by socioeconomic quintile, caste, education and rural or urban residence. We used regression models to investigate the determinants of programme use. FINDINGS: The mean proportion of respondents using programme services increased between 2006 and 2016, from 9.6% to 37.9% for supplementary food, 3.2% to 21.0% for health and nutrition education, 4.5% to 28% for health check-ups and 10.4% to 24.2% for child-specific services (e.g. immunization, growth monitoring). Wealth, maternal education and caste showed the largest positive associations with use of services. However, expansion in service use varied at the sub-national level. Although overall use had improved and reached marginalized groups such as disadvantaged castes and tribes, the poorest quintiles of the population were still left behind, especially in the largest states that carry the highest burden of undernutrition. CONCLUSION: India's policy reforms have increased coverage of the programme at the national level, including for marginalized groups. With further scaling-up, the programme needs to focus on reaching households from the lowest socioeconomic strata and women with low schooling levels.

Identifying sociodemographic, programmatic and dietary drivers of anaemia reduction in pregnant Indian women over 10 years.

OBJECTIVE: Anaemia is a major contributor to the global disease burden and half of pregnant women in India were anaemic in 2016. The aetiology of anaemia is complex, yet anaemia determinants are frequently examined in isolation. We sought to explore how shifts in sociodemographic (wealth, age at pregnancy, education, open defecation, cooking fuel type, household size), programmatic (iron-folic acid tablet consumption, antenatal care visits) and dietary factors (intake of Fe, folic acid, vitamin B12, phytate) predicted changes in anaemia prevalence. DESIGN: Nutrient levels for eighty-eight food items were multiplied by household consumption of these foods to estimate household-level nutrient supply. A synthetic panel data set was created from two rounds of the District Level Household and Facility Survey (2002-04 and 2012-13) and Household Consumer Expenditures Survey (2004-05 and 2011-12). Ordinary least-squares multivariate regression models were used. SETTING: Districts (n 446) spanning north, north-east, central and south India. SUBJECTS: Pregnant women aged 15-49 years (n 17 138). RESULTS: In the model accounting for both non-dietary and dietary factors, increased age at pregnancy (P<0·001), reduced village-level open defecation (P=0·001), consuming more Fe (P<0·001) and folic acid (P=0·018) and less phytate (P=0·002), and urbanization (P=0·015) were associated with anaemia reductions. A 10 mg increase in daily household Fe supply from 2012 levels was associated with a 10 % reduction in anaemia. CONCLUSIONS: Public health interventions to combat anaemia in pregnant women should use a holistic approach, including promotion of delayed marriage, construction and use of toilets, and measures that facilitate adoption of nutrient-rich diets.

Estimating the cost of delivering direct nutrition interventions at scale: national and subnational level insights from India.

India's national nutrition and health programmes are largely designed to provide evidence-based nutrition-specific interventions, but intervention coverage is low due to a combination of implementation challenges, capacity and financing gaps. Global cost estimates for nutrition are available but national and subnational costs are not. We estimated national and subnational costs of delivering recommended nutrition-specific interventions using the Scaling Up Nutrition (SUN) costing approach. We compared costs of delivering the SUN interventions at 100% scale with those of nationally recommended interventions. Target populations (TP) for interventions were estimated using national population and nutrition data. Unit costs (UC) were derived from programmatic data. The cost of delivering an intervention at 100% coverage was calculated as (UC*projected TP). Cost estimates varied; estimates for SUN interventions were lower than estimates for nationally recommended interventions because of differences in choice of intervention, target group or unit cost. US$5.9bn/year are required to deliver a set of nationally recommended nutrition interventions at scale in India, while US$4.2bn are required for the SUN interventions. Cash transfers (49%) and food supplements (40%) contribute most to costs of nationally recommended interventions, while food supplements to prevent and treat malnutrition contribute most to the SUN costs. We conclude that although such costing is useful to generate broad estimates, there is an urgent need for further costing studies on the true unit costs of the delivery of nutrition-specific interventions in different local contexts to be able to project accurate national and subnational budgets for nutrition in India.