Perceptions, knowledge, and practices of breastfeeding in indigenous regions of Mexico during Covid-19 pandemic.

OBJECTIVE: To explore the perceptions, knowledge, and practices of breastfeeding in the context of Covid-19 of pregnant and postpartum women, midwives, and health providers in an indigenous region of Chiapas, Mexico. MATERIALS AND METHODS: Qualitative thematic analysis study involving semi-structured interviews (n = 46) with pregnant women (n = 19), postpartum women (n = 6), health providers (n = 10, i.e., doctors/nurses), and midwives (n = 11). RESULTS: Among mothers, 47% (n = 11) did not know if Covid-19 is transmitted through breastfeeding. They mentioned that they would stay away from their newborns if infected. Health providers and midwives have not received education or any supporting material on the value of breastfeeding during Covid-19 infection. CONCLUSION: Breastfeeding mothers' promotion and counseling remain poor in indigenous communities and have worsened during the Covid-19 pandemic. Breastfeeding training among health providers and midwives should be provided or strengthened even more in emergency situations.

Prácticas de alimentación infantil antes y después de la pandemia por Covid-19, Ensanut 2012 a 2022.

OBJETIVO: Describir la tendencia en las prácticas de alimentación infantil en México antes y después de la pandemia por Covid-19, usando datos de la Encuesta Nacional de Salud y Nutrición (Ensanut) 2012, 2018-19, 2021 y 2022. Material y métodos. Población: mujeres 12-59 años y sus hijos/as < 24 meses. Se calcularon los indicadores de alimentación infantil según la Organización Mundial de la Salud 2021. Se realizaron modelos de regresión logística para analizar tendencias entre encuestas ajustando por variables sociodemográficas, considerando el diseño muestral. Se muestran las tendencias de lactancia materna (LM) y fórmula comercial infantil (FCI) por área urbano/rural y ocupación de la madre. RESULTADOS: La prevalencia ajustada de LM exclusiva en niñas/os menores de seis meses aumentó (14.8% en 2012; 28.6% en 2018-19 y 33.6% en 2021-22; p<0.001). El consumo de FCI en niñas/os < 12 meses se redujo de 62.8 a 42.8% entre 2012 y 2018-19 y permaneció en 43.3% en 2021-22 (p<0.001). CONCLUSIONES: Las prácticas de alimentación infantil mejoraron principalmente entre 2012 y 2018-19, y la tendencia positiva se desaceleró en 2021-22.

Prácticas de lactancia materna y alimentación complementaria en menores de dos años de edad en México.

OBJETIVO: Estimar prevalencias de indicadores de prácticas de alimentación infantil en menores de 24 meses en México. Material y métodos. Análisis de la Encuesta Nacional de Salud y Nutrición Continua 2021 y 2022 (Ensanut Continua 2021 y 2022) en mujeres de 14-59 años y sus hijos/as menores de 24 meses (<24 meses). Se calcularon los indicadores ajustando por diseño muestral de las encuestas. RESULTADOS: El 33.6% de niñas/os <6 meses recibió lactancia materna exclusiva (LME). El 27.2% de niñas/os <24 meses no recibió LME durante los primeros tres días de vida y fue alimentado con fórmula comercial infantil (FCI) u otro líquido. El 42% de niñas/os de entre 6 y 23 meses consumió alimentos no saludables. CONCLUSIONES: Las prácticas de alimentación infantil en México deben ser protegidas mediante políticas que regulen la comercialización de FCI y promuevan un entorno laboral, social y político propicio para la lactancia materna y el cuidado infantil, para que madres, padres y cuidadores puedan adoptar prácticas de lactancia y alimentación complementaria adecuadas.

Acceso a servicios de salud prenatal y para primera infancia.

OBJETIVO: Conocer las prevalencias de acceso a servicios de salud maternoinfantil. Material y métodos. Se estimaron prevalencias e intervalos de confianza al 95% de acceso a servicios de salud prenatal de madres de niñas/os menores de dos años y de servicios de salud para niñas/os menores de cinco años. RESULTADOS: El 62.6, 82.8 y 95.8% de las madres de niñas/os menores de dos años reportaron control prenatal oportuno, adecuado y atención del parto por personal médico, respectivamente. El 90.2% de las madres recibieron suplementación con ácido fólico y 79.5% con hierro y otros micronutrientes durante el embarazo. El 18.4% de las niñas/os asistieron a ocho consultas del niño sano en el primer año de vida y 27.1% de las niñas/os menores de cinco años tiene evaluación de desarrollo infantil temprano. Conclusión. Los indicadores de atención de salud maternoinfantil son particularmente bajos. Debe fortalecerse el acceso a los servicios a nivel nacional.

Latin America and the Caribbean Code Against Cancer 1st edition: Building capacity on cancer prevention to primary healthcare professionals.

INTRODUCTION: Every year 1.5 million new cancer cases are diagnosed in Latin America and the Caribbean (LAC). Of these, about 40 % could be prevented. Health illiteracy has been identified as a main barrier for cancer prevention. Primary healthcare professionals (HCP) are key in cancer prevention as they are the first entry point of the population into the healthcare system. The LAC Code Against Cancer 1st edition aims to improve health literacy and awareness of cancer prevention in the LAC population, through building capacity of primary HCP. METHODS: The definition and development of the learning objectives, curriculum, structure, and evaluation of an online learning program for primary HCP was led by a dedicated group of experts from the LAC Code Against Cancer project. A pedagogical guideline and a template to ensure harmonization across topics were produced to guide the program development. Two rounds of internal revisions and an editorial process were performed. RESULTS: An online competency-based microlearning program for primary HCP was produced, taking the LAC Code Against Cancer as a basis. The competences addressed in the curriculum are core knowledge, communication skills, decision-making and applying knowledge to real-world situations. A comprehensive evaluation to assess acquisition of these competences, based on the Miller's Pyramid, was designed with three data collection points: a) immediately before, to assess baseline knowledge and skills; b) immediately after, to determine acquired competences; and c) at 3-6 months follow-up, to assess performance in daily practice. The e-learning will be freely available in the Virtual Campus for Public Health of the Pan American Health Organization in Spanish, English, and Portuguese. CONCLUSION: Primary HCP, perceived as trustworthy sources of information, are key actors to increase the population's awareness and literacy on cancer prevention. Building capacity of these professionals has the potential to increase dissemination and impact of the LAC Code Against Cancer by prompting communication with the public and offering personalized actionable preventive messages through counselling.

Investment case for the prevention and reduction of childhood and adolescent overweight and obesity in Mexico.

Despite efforts to curb the rise in Mexico's child and adolescent overweight and obesity rates, prevalence in Mexico has grown by 120% since 1990 to 43.3% in 2022. This investment case identifies policies that will produce the largest returns for Mexico. The investment case model builds beyond a cost-of-illness analysis by predicting the health and societal economic impact of implementing child and adolescent overweight and obesity interventions in a cohort aged 0-19 from 2025 to 2090. The Markov model's impacts include healthcare expenditures, years of life lost, and reduced wages and productivity. We projected and compared costs in a status quo scenario to an intervention scenario to estimate cost savings and calculate return-on-investment (ROI). Total lifetime health and economic costs amount to USD 1.8 trillion-USD 30 billion on average per year. Implementing five interventions can reduce lifetime costs by approximately 7%. Each intervention has a low cost per disability-adjusted life year averted over 30-year, 50-year, and lifetime horizons. The findings demonstrate that a package of interventions mitigating child and adolescent overweight and obesity offers a strong ROI. The novel investment case methods should be applied to other countries, particularly low- and middle-income countries.

Anaemia in adolescent women: A priority for the nutrition agenda in Mexico. A comparison of data from the ENSANUT 2012 and 2018-2019 surveys.

The risk of anaemia in adolescence increases due to accelerated growth. This study aims to: (1) estimate the prevalence of anaemia in 2012 and 2018-2019 (Encuesta Nacional de Salud y Nutricion - ENSANUT [n = 5841 in 2012 and n = 2380 in 2018-2019]) in non-pregnant, Mexican adolescent women aged 12-19 years, and the changes in prevalence over this period according to sociodemographic, health and nutrition characteristics; (2) estimate the associations between anaemia and sociodemographic, health and nutrition characteristics in each year and overall, in non-pregnant Mexican adolescent women. Anaemia was defined as capillary haemoglobin <12 g/dL. The distribution of characteristics and their changes between 2012 and 2018-2019 were described. The covariate-adjusted prevalence of anaemia in 2012 and 2018-2019 and the changes over that period were estimated from a multiple log-binomial regression model and the factors associated with anaemia were assessed in each survey year and in both years combined. The prevalence of anaemia was 7.7% in 2012 and 13.1% in 2018-2019 (69% increase, Prevalence Ratio: PR = 1.69; 95%CI: 1.35, 2.13). The covariate-adjusted prevalence of anaemia increased from 6.9% to 10.5% in the overall population (PR = 1.53, 95%CI: 1.19, 1.96), and increased considerably in the age group 12-14 years (PR = 1.94, 95%CI: 1.36, 2.75), and in the northern region (PR = 3.68, 95%CI: 2.55, 5.32). Those receiving iron supplements or school breakfasts did not register a significant increase. A higher household wellbeing status and older age were associated with a lower prevalence of anaemia. Anaemia in non-pregnant adolescent women continues to be a public health problem. To improve the development and health of adolescent women in Mexico and to pave the way to a healthy pregnancy for the next generation, the causes of anaemia should be identified.

Hacia el diseño de Vida Saludable, un nuevo programa de estudios para la educación básica en México.

OBJETIVO: Describir el proceso de diseño de Vida Saludable, un nuevo programa de estudios para la educación básica en México. Material y métodos. Se conformó un equipo de trabajo entre especialistas en salud y la Secretaría de Educación Pública. Se establecieron las bases científicas de Vida Saludable, se seleccionaron y evaluaron materiales para Vida Saludable, y se revisaron contenidos vigentes de salud incluidos en otras asignaturas. RESULTADOS: Alimentación, actividad física e higiene y limpieza fueron definidos como los tres ejes temáticos para Vida Saludable. Se aprobaron 3 de 228 insumos para usarse en Vida Saludable y 71.7% de los con-tenidos vigentes en educación básica sobre salud requieren ediciones. CONCLUSIONES: Vida Saludable es un parteaguas hacia la alfabetización en materia de salud en educación básica en México, que se alinea con la agenda global para preservar la salud humana y planetaria.

Diseño de una estrategia de comunicación para la promoción del uso del etiquetado de advertencia en niños, niñas y adolescentes mexicanos.

OBJETIVO: Describir el proceso para diseñar una estrategia de comunicación con el fin de promover el uso del etiqueta-do frontal de advertencia (EFA) y la selección de alimentos saludables en niños, niñas y adolescentes (NNA) mexicanos. Material y métodos. Estudio de cuatro fases con esco-lares, adolescentes y cuidadores: 1) investigación formativa (18 grupos focales, n= 179); 2) talleres de cocreación con NNA (n= 33); 3) diseño de la estrategia, con base en el modelo de comportamiento COM-B; y 4) prueba piloto (seis grupos focales, n= 52). RESULTADOS: La estrategia de comunicación debería mejorar la comprensión del EFA y los conocimientos sobre la relación de los ingredientes críticos (calorías, grasas saturadas, grasas trans, sodio, edulcorantes y cafeína) y la enfermedad; asimismo, debería resaltar las consecuencias positivas de una alimentación saludable y las negativas del consumo excesivo de alimentos con sellos, así como destacar que los alimentos naturales tienen un menor costo y mejor calidad que los alimentos con sellos; se deben ofrecer sugerencias de preparaciones atractivas y saludables con alimentos naturales. Conclusión. La investigación formativa y la participación de NNA en la creación de la campaña fueron esenciales para diseñar una estrategia cultu-ralmente pertinente con potencial de impacto. El proceso y los resultados del estudio podrían informar sobre esfuerzos en contextos parecidos al de México.

Consumption of Micronutrient Powder, Syrup or Fortified Food Significantly Improves Zinc and Iron Status in Young Mexican Children: A Cluster Randomized Trial.

The objective of this study was to compare the effect of three micronutrient products on biomarkers of iron and zinc status of Mexican children 6−12 months of age. As part of research to improve the impact of a national program, 54 communities were randomly assigned to receive: (1) fortified food (FF), provided by the program at the time, or (2) micronutrient powders (MNP) or (3) syrup. Each product contained 10 mg each of zinc and iron, plus other micronutrients. Children consumed the product 6 days/week for four months. Primary outcomes were changes in serum zinc, ferritin, soluble transferrin receptor, hemoglobin concentrations, and their deficiencies. Zinc concentration increased significantly from baseline to follow-up in all groups, with the largest change in the syrup group (geometric mean difference: +4.4 µmol/L; 95%CI: 3.2, 5.5), followed by MNP (+2.9 µmol/L; 95%CI: 2.1, 3.6) and FF (+0.9 µmol/L; 95%CI: 0.3, 1.6). There was a significant increase in hemoglobin concentration (+5.5 g/L; 2.5, 8.4) and a significant reduction in anemia prevalence (44.2% to 26.8%, p < 0.01) only in the MNP group. Compliance differed significantly among groups (MNP vs. FF, p = 0.04; MNP vs. syrup, p = 0.04), but may not fully explain the greater improvement in zinc and iron status in the syrup and MNP groups. The food matrix may influence nutrient utilization from supplements.

Development of a live coding method to assess infant/toddler food acceptance.

Validated measures predicting infant consumption of nutrient supplements or fortified foods are essential for the success of nutritional interventions to improve undernutrition. Behavioural coding of food acceptance is one promising approach, though the required time and resources are limiting. The overarching goal of the present study was to adapt a video coding (VC) protocol for use as a live coding (LC) method to assess infant food acceptance in naturalistic settings. Infants (n = 59; ages 7-24 months) were fed a small-quantity lipid-based nutrient supplement (SQ-LNS) mixed with a familiar food by caregivers in the State of Morelos, Mexico. Trained coders used a VC scheme to rate infant acceptance of each spoon offer using a 4-point scale. The VC scheme was subsequently adapted for use as an LC method to be used in participant homes and a video live coding (VLC) method to monitor reliability. Reliability and validity of the LC method were tested in a subsample of dyads (n = 20). Intraclass correlation coefficients (ICCs) indicated that the inter-rater reliability between coders using the LC method was moderate or good when compared to VC methods (ICCs = 0.75 and 0.87). Live coded acceptance scores were also moderately associated with consumption of the SQ-LNS (ρ = 0.50, p = 0.03). The LC scheme demonstrated initial reliability and validity as an assessment of infant food acceptance. Since VC is both resource and time-intensive, the LC scheme may be useful for assessing infant food acceptance in resource-limited settings.

Comprehensive evaluation of Salud Escolar a health school program in Mexico: Rationale, design and methods.

The prevalence of obesity and overweight in Mexican children and adolescents is high (greater than 30%) and lifestyle behaviors are far from achieving health recommendations. Salud Escolar is a complex cross-sectoral multi-level policy-based program in Mexico aiming to support schoolchildren healthy behaviors. We describe the rationale, design and methods for the comprehensive evaluation of Salud Escolar during its first phase of implementation. Using a mixed-methods approach and the logic model of Salud Escolar as a guide, a comprehensive evaluation involving 3 types of evaluations was designed: 1) A design evaluation before program implementation, to determine the consistency between the design of Salud Escolar and the problem to be addressed (i.e., childhood obesity), 2) An implementation evaluation to assess potential execution bottlenecks, and 3) An outcomes evaluation, to measure short-term (i.e., knowledge, attitudes and practices related to healthy eating, drinking plain water and doing regular physical activity) and intermediate outcomes (i.e., fruit and vegetable intake, water consumption and daily moderate to vigorous physical activity). This evaluation will provide essential knowledge about program design and implementation processes, which are vital for drawing robust conclusions about the effectiveness of the program. Results and lessons learned from this comprehensive evaluation will provide evidence to improve Salud Escolar program and facilitate its upscaling process and may provide relevant information for school-based programs in other places sharing socio-contextual conditions.

Talla baja y sobrepeso en menores de 5 años que habitan la Sierra Tarahumara, México / Stunting and overweight in children under 5y who inhabit the Sierra Tarahumara in northern Mexico

La doble carga de la desnutrición y el exceso de peso (o mala nutrición) es uno de los indicadores que mejor ilustra las inequidades en salud que existen en zonas indígenas de México. Por otro lado, existe escasa evidencia del estado de nutrición en población Tarahumara. Objetivo: Estimar indicadores del estado de nutrición y su asociación con factores sociodemográficos en población indígena Tarahumara menor de 5 años. Métodos: Estudio transversal en 21 localidades indígenas de la Sierra Tarahumara en Chihuahua, México, que analizó información sociodemográfica, de salud y antropométrica en población infantil de 6 a 59 meses de edad (n=323). Se estimaron índices antropométricos y su asociación con variables de interés mediante regresión logística múltiple. Un valor de p ≤0,05 fue considerado como estadísticamente significativo. Todos los análisis se realizaron en el paquete estadístico Stata v14.2. Resultados: Se encontraron altas prevalencias de talla baja (44,4%), emaciación (5,3%), bajo peso (11,9%) y sobrepeso (15,2%). El sexo masculino se asoció significativamente con talla baja (Razón de Momios (RM)=2,5; 1,45-4,34), mientras que, ninguna escolaridad de la madre (RM=0,39; 0,15-0,99) y ser beneficiario de un programa local de nutrición por más de 2 años se asoció con sobrepeso (RM=2,97; 1,26 -6,97). Conclusión: Se encontraron indicadores de mala nutrición en la muestra estudiada; éstos hallazgos podrían sugerir la existencia de inequidad y rezago en salud y nutrición de población infantil indígena Tarahumara. Se requieren más estudios que puedan orientar programas y acciones de salud y nutrición para atender a esta población de forma prioritaria(AU)

The double burden of malnutrition and excess weight (or poor nutrition) is one of the indicators that best illustrates the health inequities that exist in indigenous areas of Mexico. On the other hand, there is scarce evidence of the nutritional status of the Tarahumara population. Objective: To estimate indicators of the nutritional status and its association with sociodemographic factors in the Tarahumara indigenous population under 5 years of age. Methods: A cross-sectional study in 21 indigenous localities of the Sierra Tarahumara in Chihuahua, Mexico, which analyzed sociodemographic, health and anthropometric information in children from 6 to 59 months of age (n=323). Anthropometric indices and their association with variables of interest was estimated by multiple logistic regression. A value of p ≤0.05 was considered statistically significant. All analyzes were performed using the Stata v14.2 statistical package. Results: It were founded high prevalences of short stature (44.4%), emaciation (5.3%), underweight (11.9%) and overweight (15.2%). Male sex was significantly associated with short stature (Odds Ratio (OR) = 2.5; 1.45-4.34), while no education of the mother (OR = 0.39; 0.15-0.99) and being a beneficiary of a local nutrition program for more than 2 years it was associated with being overweight (OR = 2.97; 1.26-6.97). Conclusion: Indicators of malnutrition and overweight were founded in the sample studied; these findings suggest inequity and delays in health and nutrition of the indigenous Tarahumara child population. More research is required that can guide health and nutrition programs and actions to serve this indigenous population as a priority(AU)

Factors associated with changes in movement behaviors in toddlers and preschoolers during the COVID-19 pandemic: A national cross-sectional study in Mexico.

Little is known about physical activity, screen time and sleep among Mexican toddlers and preschoolers. The COVID-19 pandemic led to the closure of childcare education centers and restrictions to spend time outdoors. This study aimed to investigate the correlates of changes in movement behaviors from before to during the early stages of the COVID-19 lockdown in a national sample of toddlers and preschoolers in Mexico. A cross-sectional study was conducted using an open online survey completed by caretakers of children aged 1-5 years from April to July 2020. The questionnaire enquired about the time spent in each movement behavior during a regular week before and during lockdown, and family and household characteristics. Factors associated with changes in movement behaviors were explored using adjusted linear regression models. A total of 631 children (3.3y, 95% CI: 3.1, 3.4) were included in the study. During lockdown, physical activity decreased by 25%, screen time doubled, and sleep quality declined in 17% (p < 0.001). Toddlers and preschoolers of older age, attending a childcare education center before the lockdown, with a screen in their bedroom, higher access to electronic devices, and lower socioeconomic level experienced greater changes during this period. Those with limits on the use of electronic devices, who had someone available to play with them, and availability of toys experienced less pronounced changes. Pandemic restrictions have impacted movement behaviors of toddlers and preschoolers, with disproportionate effects among lower socioeconomic levels. Interventions with a multi-level equity-oriented approach are urgently needed to mitigate these effects.

[Breastfeeding and complementary feeding practices in Mexico: results from Ensanut 2018-19]. / Situación de las prácticas de lactancia materna y alimentación complementaria en México: resultados de la Ensanut 2018-19.

OBJECTIVE: To update the prevalence of infant and young child feeding indicators (IYCFI) in children under 24 months in Mexico. MATERIALS AND METHODS: Ensanut 2018-19 national representative survey with probabilistic design. Popu-lation: Women 12-59 years and their children <24 months. The indicators proposed by the World Health Organization were assessed by sociodemographic variables of the mothers using the sample design. Wald's test was used to compare between categories. RESULTS: The prevalence of exclusive breastfeeding in children under six months was 28.3%, 42.9% of children under 12 months consumed infant formula and 29% continued breastfeeding at two years. Around 30% of children between 6 and 11 months did not meet the recom-mended minimum dietary diversity and only 49.4% consumed iron-rich foods. CONCLUSIONS: There are improvements in breastfeeding practices in Mexico, although the figures are low. The coordinated contribution from all sectors of society is required to improve infant feeding practices.

OBJETIVO: Actualizar prevalencias de indicadores de prác-ticas de lactancia materna y alimentación complementaria (PLMAC) en menores de 24 meses en México. MATERIAL Y MÉTODOS: Análisis de la Encuesta Nacional de Salud y Nutrición (Ensanut 2018-19) con diseño probabilístico. Po-blación: Mujeres 12-59 años y sus hijos <24 meses. Cálculo de indicadores propuestos por la Organización Mundial de la Salud (OMS) por variables sociodemográficas utilizando el diseño muestral. Se usó la prueba de Wald para comparar entre categorías. RESULTADOS: El 28.3% de los niños <6 meses recibió lactancia materna exclusiva (LME), 42.9% de los niños <12 meses consumió fórmula infantil y 29% continuó lactando a los dos años. Sólo 49.4% de los niños de 6-11 meses consumió alimentos ricos en hierro. CONCLUSIONES: Existen mejoras en las prácticas de lactancia materna, aunque las cifras siguen siendo bajas. Se requiere de la contribución de todos los sectores de la sociedad para mejorar las prácticas de alimentación infantil.

Situación de las prácticas de lactancia materna y alimentación complementaria en México: resultados de la Ensanut 2018-19 / Breastfeeding and complementary feeding practices in Mexico: results from Ensanut 2018-19

Resumen Objetivo . Actualizar prevalencias de indicadores de prácticas de lactancia materna y alimentación complementaria (PLMAC) en menores de 24 meses en México. Material y métodos. Análisis de la Encuesta Nacional de Salud y Nutrición (Ensanut 2018-19) con diseño probabilístico. Población: Mujeres 12-59 años y sus hijos <24 meses. Cálculo de indicadores propuestos por la Organización Mundial de la Salud (OMS) por variables sociodemográficas utilizando el diseño muestral. Se usó la prueba de Wald para comparar entre categorías. Resultados. El 28.3% de los niños <6 meses recibió lactancia materna exclusiva (LME), 42.9% de los niños <12 meses consumió fórmula infantil y 29% continuó lactando a los dos años. Sólo 49.4% de los niños de 6-11 meses consumió alimentos ricos en hierro. Conclusiones: Existen mejoras en las prácticas de lactancia materna, aunque las cifras siguen siendo bajas. Se requiere de la contribución de todos los sectores de la sociedad para mejorar las prácticas de alimentación infantil.

Abstract: Objective. To update the prevalence of infant and young child feeding indicators (IYCFI) in children under 24 months in Mexico. Materials and methods: Ensanut 2018-19 national representative survey with probabilistic design. Population: Women 12-59 years and their children <24 months. The indicators proposed by the World Health Organization were assessed by sociodemographic variables of the mothers using the sample design. Wald's test was used to compare between categories. Results: The prevalence of exclusive breastfeeding in children under six months was 28.3%, 42.9% of children under 12 months consumed infant formula and 29% continued breastfeeding at two years. Around 30% of children between 6 and 11 months did not meet the recommended minimum dietary diversity and only 49.4% consumed iron-rich foods. Conclusions: There are improvements in breastfeeding practices in Mexico, although the figures are low. The coordinated contribution from all sectors of society is required to improve infant feeding practices.

Sociocultural Influences on Poor Nutrition and Program Utilization of Mexico's Conditional Cash Transfer Program.

BACKGROUND: The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze. OBJECTIVES: We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program. METHODS: We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions. RESULTS: Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions. CONCLUSIONS: Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented.

A Fortified Food Can Be Replaced by Micronutrient Supplements for Distribution in a Mexican Social Protection Program Based on Results of a Cluster-Randomized Trial and Costing Analysis.

BACKGROUND: Despite positive nutrition impacts, the prevalence of malnutrition among beneficiaries of Mexico's conditional cash transfer (CCT) program remains high. Greater nutrition impact may have been constrained by the type of nutritional supplements provided. OBJECTIVE: The objective of this study was to inform a potential modification to the supplements distributed to pregnant and lactating women and children. METHODS: Impact was assessed using 2 cluster-randomized trials (pregnant women, children) run simultaneously. Communities (n = 54) were randomly assigned to the fortified foods provided by the program (Nutrivida women, Nutrisano children) or alternatives: tablets (women), syrup (children), or micronutrient powders for women (MNP-W) and children (MNP-C). Each supplement for women/children contained the same micronutrients based on the formulations of Nutrivida and Nutrisano, respectively. Pregnant women (aged >18 y) were recruited before 25 weeks of gestation and followed to 3 mo postpartum. Children aged 6-12 mo were recruited and followed to age 24 mo. Primary outcomes were anemia for women and length growth for children. Statistical analyses appropriate for cluster-randomized designs were used, and structural equation modeling to estimate dose-response effects. Supplement costs per beneficiary (daily dose for 18 mo) were estimated for production and distribution. RESULTS: There was no significant difference in change of anemia prevalence between supplement groups in women, or in length growth between groups in children. One daily dose of any supplement was associated with 0.8 cm greater length growth. From baseline to age 24 mo, the prevalence of anemia in the Nutrisano, syrup, and MNP-C groups decreased by 36.7, 40.8, and 37.9 percentage points, respectively (within-group, P < 0.05; between groups, P > 0.05). Costs per beneficiary ranged from $12.1 (MNP-C) to $94.8 (Nutrivida). CONCLUSIONS: The CCT program could distribute alternative supplements at lower cost per beneficiary without compromising potential for impact. Acceptance among beneficiaries should also be considered in choice of alternatives. This trial was registered at www.clinicaltrials.gov as NCT00531674.

Translating Evidence-Based Program Recommendations into Action: The Design, Testing, and Scaling Up of the Behavior Change Strategy EsIAN in Mexico.

BACKGROUND: The Integrated Strategy for Attention to Nutrition (EsIAN in Spanish) is a national strategy within Mexico's conditional cash transfer program (initially Progresa, then Oportunidades, then Prospera, CCT-POP) designed to strengthen the health and nutrition component, address the nutrition transition, and improve the health and nutritional status of its beneficiaries, through 3 main components: 1) procurement of functioning equipment to primary health care (PHC) units; 2) providing free micronutrient supplements to beneficiary women and children; 3) implementing a behavior change communication (BCC) strategy and a training system for PHC providers (PHCPs). OBJECTIVE: We aim to describe the iterative process and evidence-based approach used to design and roll-out the EsIAN at scale, by focusing on the BCC component. METHODS: The BCC strategy was developed by following an iterative process through the following phases: situational analysis, formative research and design of the BCC strategy (using the socioecological framework and the social marketing approach), large-scale feasibility study, redesign, and national scale-up. RESULTS: The review and formative research revealed several barriers and issues that limited program coverage, utilization, and acceptance. These included misconceptions about pregnancy and infant feeding, nonalignment of practices with international recommendations, and lack of knowledge on nutrition and related topics, among others. These results were used to identify priority behaviors and elaborate key messages for mothers/caregivers and providers to develop the BCC strategy. The feasibility study resulted in significant improvements in PHCPs' knowledge, counseling (breastfeeding, and supplement use and consumption), and caregivers' complementary feeding behaviors, and highlighted several design and delivery aspects that needed strengthening. Based on these findings, the BCC strategy was adapted prior to a national scale-up. CONCLUSIONS: The theory-based iterative approach resulted in the identification of specific actions to target, and approaches to do so, as part of the design and roll-out of the BCC strategy at scale.

Closing the Nutrition Impact Gap Using Program Impact Pathway Analyses to Inform the Need for Program Modifications in Mexico's Conditional Cash Transfer Program.

BACKGROUND: Mexico's Prospera-Oportunidades-Progresa Conditional Cash Transfer Program (CCT-POP) included the distribution of fortified food supplements (FFS) for pregnant and lactating women and young children. Rigorous evaluations showed significant impacts on nutrition outcomes but also substantial gaps in addressing nutrition problems. OBJECTIVES: To highlight the program design-related and implementation-related gaps and challenges that motivated further research and the eventual design and roll-out of a modified nutrition component for CCT-POP. METHODS: We used a program impact pathway approach to highlight the extent and quality of implementation of CCT-POP, and its impact on nutrition outcomes. We drew on previously published and new primary data, organized into 3 sources: impact evaluations, studies to inform reformulation of the FFS, and a longitudinal follow-up study using qualitative and quantitative methods to document FFS use and the dietary intake of women and children. RESULTS: Despite positive impacts, a high prevalence of malnutrition persisted in the population. Coverage and use of health services improved, but quality of care was lacking. Consumption of FFS among lactating women was irregular. Micronutrient intake improved among children who consumed FFS, but the pattern of use limited frequency and quantity consumed. Substantial diversity in the prevalence of undernutrition was documented, as was an increased risk of overweight and obesity among women. CONCLUSIONS: Three key design and implementation challenges were identified. FFS, although well accepted for children, had limited potential to substantially modify the quality of children's diets because of the pattern of use in the home. The communications strategy was ineffective and ill-suited to its objective of motivating FFS use. Finally, the program with its common design across all regions of Mexico was not well adapted to the special needs of some subgroups, particularly indigenous populations. The studies reviewed in this paper motivated additional research and the eventual redesign of the nutrition component.