Heavy agricultural workloads and low crop diversity are strong barriers to improving child feeding practices in the Bolivian Andes.

Most nutrition initiatives to date aimed at improving infant and young child feeding (IYCF) have emphasized addressing knowledge gaps through behavior change messaging with less focus on addressing the underlying environmental barriers that may shape these behaviors. This research integrates an analysis of longitudinal dietary data with qualitative data on barriers to improved child feeding to identify the nature and extent of the barriers caregivers face to improving IYCF practices in a farming region of the Bolivian Andes, and to determine the relative influence of these barriers on caregivers' abilities to improve IYCF practices. Sixty-nine caregivers were selected from a sample of 331 households that participated in a longitudinal survey assessing changes in IYCF practices among caregivers with children aged 0-36 months from March 2009 to March 2010. Forty-nine barriers within 12 categories of barriers were identified through semi-structured interviews with the 69 caregivers. The most frequently reported barriers were those related to women's time dedicated to agricultural labor, the limited diversity of household agricultural production, and lack of support for child feeding from spouses and mothers-in-law. In multivariate analyses controlling for several variables that could potentially influence IYCF practices, these barriers were negatively associated with changes to the diversity of child diets, child dietary energy intake, and child meal frequency. While knowledge gaps and individual-level influences affected IYCF practices, physical and social caregiving environments in this region of Bolivia were even more important. Behavior change communication alone will likely not address the social and environmental barriers to improved child feeding that often prevent translation of improved knowledge into action. Particularly in rural regions, agriculture may strongly influence child feeding, not only indirectly through household food security, but also directly by affecting women's caregiving capacity.

Maternal and child undernutrition: effective action at national level.

80% of the world's undernourished children live in just 20 countries. Intensified nutrition action in these countries can lead to achievement of the first Millennium Development Goal (MDG) and greatly increase the chances of achieving goals for child and maternal mortality (MDGs 4 and 5). Despite isolated successes in specific countries or for interventions--eg, iodised salt and vitamin A supplementation--most countries with high rates of undernutrition are failing to reach undernourished mothers and children with effective interventions supported by appropriate policies. This paper reports on an assessment of actions addressing undernutrition in the countries with the highest burden of undernutrition, drawing on systematic reviews and best-practice reports. Seven key challenges for addressing undernutrition at national level are defined and reported on: getting nutrition on the list of priorities, and keeping it there; doing the right things; not doing the wrong things; acting at scale; reaching those in need; data-based decisionmaking; and building strategic and operational capacity. Interventions with proven effectiveness that are selected by countries should be rapidly implemented at scale. The period from pregnancy to 24 months of age is a crucial window of opportunity for reducing undernutrition and its adverse effects. Programme efforts, as well as monitoring and assessment, should focus on this segment of the continuum of care. Nutrition resources should not be used to support actions unlikely to be effective in the context of country or local realities. Nutrition resources should not be used to support actions that have not been proven to have a direct effect on undernutrition, such as stand-alone growth monitoring or school feeding programmes. In addition to health and nutrition interventions, economic and social policies addressing poverty, trade, and agriculture that have been associated with rapid improvements in nutritional status should be implemented. There is a reservoir of important experience and expertise in individual countries about how to build commitment, develop and monitor nutrition programmes, move toward acting at scale, reform or phase-out ineffective programmes, and other challenges. This resource needs to be formalised, shared, and used as the basis for setting priorities in problem-solving research for nutrition.