Increasing Production Diversity and Diet Quality: Evidence from Bangladesh.

In the context of rural Bangladesh, we assess whether agriculture training alone, nutrition Behavior Communication Change (BCC) alone, combined agriculture training and nutrition BCC, or agriculture training and nutrition BCC combined with gender sensitization improve: (a) production diversity, either on household fields or through crop, livestock or aquaculture activities carried out near the family homestead and (b) diet diversity and the quality of household diets. All treatment arms were implemented by government employees. Implementation quality was high. No treatment increased production diversification of crops grown on fields. Treatment arms with agricultural training did increase the number of different crops grown in homestead gardens and the likelihood of any egg, dairy, or fish production but the magnitudes of these effect sizes were small. All agricultural treatment arms had, in percentage terms, large effects on measures of levels of homestead production. However, because baseline levels of production were low, the magnitude of these changes in absolute terms was modest. Nearly all treatment arms improved measures of food consumption and diet with the largest effects found when nutrition and agriculture training were combined. Relative to treatments combining agriculture and nutrition training, we find no significant impact of adding the gender sensitization on our measures of production diversity or diet quality. Interventions that combine agricultural training and nutrition BCC can improve both production diversity and diet quality, but they are not a panacea. They can, however, contribute towards better diets of rural households.

Utilization of Integrated Child Development Services (ICDS) and its linkages with undernutrition in India.

The Integrated Child Development Services (ICDS) programme has been the central focus of the POSHAN Abhiyaan to combat maternal and child malnutrition under the national nutrition mission in India. This paper examined the linkages between utilization of ICDS and underweight among children aged 6-59 months. The study utilized data from two recent rounds of the National Family Health Survey (NFHS-4 [2015-2016] and NFHS-5 [2019-2021]). Descriptive analyses were used to assess the change in utilization of ICDS and the prevalence of underweight at the national and state levels. Multivariable logistic regressions were performed to examine factors associated with the utilization of ICDS and underweight. Linkages between utilization of ICDS and underweight were examined using the difference-in-differences (DID) approach. Utilization of ICDS increased from 58% in 2015-2016 to 71% in 2019-2021. The prevalence of underweight decreased from 37% to 32% in the same period. Changes in ICDS utilization and underweight prevalence varied considerably across states, socioeconomic and demographic characteristics. Results from decomposition of DID models suggest that improvements in ICDS explained 9%-12% of the observed reduction in underweight children between 2016 and 2021, suggesting that ICDS made a modest but meaningful contribution in addressing undernutrition among children aged 6-59 months in this period.

Behavior Change Interventions to Address Unhealthy Food Consumption: A Scoping Review.

High intakes of sodium, sugar, saturated fats, and trans-fats contributed to 187.7 million disability adjusted life years from noncommunicable diseases globally. Understanding of the global evidence on interventions to reduce consumption of various types of unhealthy food across diverse contexts is needed. We conducted a scoping review to examine the existing evidence on behavior change interventions (BCIs) to address unhealthy food consumption. Through a systematic search of 3 databases conducted in December 2022, 2730 records were retrieved, and 145 studies met the eligibility criteria for review. Only 19% of the studies (n = 28) were from low- and middle-income countries. The key target group for most BCIs was adults ≥20 y (n = 79). Interventions were conducted across 7 types of settings: schools (n = 52), digital (n = 30), community (n = 28), home (n = 14), health facility (n = 12), worksite (n = 6), and market (n = 3). There were 4 mutually inclusive intervention types-information, education, and communication (n = 141); food/beverage substitution (n = 10); interactive games (n = 7); and labeling/warnings at point-of-purchase (n = 3). The study outcomes included consumption of sugar-sweetened beverages (n = 74), packaged salty snacks/fast food (n = 61), sweets (n = 43), and saturated fat (n = 41). Drivers of food choice behaviors, such as knowledge, attitudes, and beliefs; motivation and expectancies; and self-efficacy were reported in 43% of studies. On the basis of reported impact of BCIs on study outcomes, more interventions targeted at adults had positive impacts compared with those targeted at children; intervention packages, including multiple information, education, and communication components also reported impacts more often than single informational interventions. Interpretation of the findings was complicated by the lack of comparability in interventions, evaluation designs, outcome measures of unhealthy food consumption, duration of interventions, and study contexts. Future studies should invest in critical yet underrepresented regions, examine behavioral determinants of unhealthy food consumption and the sustainability of behavior change, and conduct further analysis of effectiveness from experimental studies.

Temporary childbirth migration and maternal health care in India.

BACKGROUND: Women in South Asia often return to their natal home during pregnancy, for childbirth, and stay through the postpartum period-potentially impacting access to health care and health outcomes in this important period. However, this phenomenon is understudied (and not even named) in the demographic or health literature, nor do we know how it impacts health. OBJECTIVE: The aim of this study is to measure the magnitude, timing, duration, risk factors and impact on care of this phenomenon, which we name Temporary Childbirth Migration. METHODS: Using data from 9,033 pregnant and postpartum women collected in 2019 in two large states of India (Madhya Pradesh and Bihar) we achieve these aims using descriptive statistics and logistic regression models, combined with qualitative data from community health workers about this practice. RESULTS: We find that about one third of women return to their natal home at some point in pregnancy or postpartum, mostly clustered close to the time of delivery. Younger, primiparous, and non-Hindu women were more likely to return to their natal home. Women reported that they went to their natal home because they believed that they would receive better care; this was born out by our analysis in Bihar, but not Madhya Pradesh, for prenatal care. CONCLUSIONS: Temporary childbirth migration is common, and, contrary to expectations, did not lead to disruptions in care, but rather led to more access to care. CONTRIBUTION: We describe a hitherto un-named, underexplored yet common phenomenon that has implications for health care use and potentially health outcomes.

Availability of national policies, programmes, and survey-based coverage data to track nutrition interventions in South Asia.

Progress to improve nutrition among women, infants and children in South Asia has fallen behind the pace needed to meet established global targets. Renewed political commitment and monitoring of nutrition interventions are required to improve coverage and quality of care. Our study aimed to assess the availability of national nutrition policies, programmes, and coverage data of nutrition interventions for women, children, and adolescents in eight countries in South Asia. We reviewed relevant policy and programme documents, examined questionnaires used in the most recent rounds of 20 nationally representative surveys, and generated an evidence gap map on the availability of policies, programmes, and survey data to track progress on coverage of globally recommended nutrition interventions. Current policies and programmes in South Asian countries addressed almost all the recommended nutrition interventions targeted at women, children, and adolescents. There was a strong policy focus in all countries, except Maldives, on health system platforms such as antenatal and postnatal care and child growth and development. Survey data on nutrition intervention coverage was most available in India and Nepal, while Bangladesh and Bhutan had the least. Though countries in South Asia have committed to national nutrition policies and strategies, national surveys had substantial data gaps, precluding progress tracking of nutrition intervention coverage. Greater attention and effort are needed for multisectoral collaboration to promote and strengthen nutrition data systems.

Feasibility and impact of school-based nutrition education interventions on the diets of adolescent girls in Ethiopia: a non-masked, cluster-randomised, controlled trial.

BACKGROUND: Adolescence is a critical period of physical and psychological development, especially for girls, because poor nutrition can affect their wellbeing as well as that of their children. We aimed to assess the feasibility and impact of a package of nutrition education interventions delivered through public primary schools on the diets of adolescent girls in Ethiopia. METHODS: In this non-masked, cluster-randomised, controlled trial, primary schools (clusters) in the Southern Nations, Nationalities, and People's Region and Somali region of Ethiopia were randomly allocated to the intervention group (nutrition information provided during flag ceremonies, classroom lessons, school club meetings, peer group mentoring, BMI measurement and counselling, and parent-teacher meetings) or the control group (standard academic curriculum on health and nutrition) by use of computer-generated pseudo-random numbers. Duration of the school-based interventions was 4 months, and the key messages were related to dietary diversity (eating a variety of foods), energy adequacy (eating breakfast and healthy snacks), and healthy food choices (avoiding junk foods). Adolescent girls were eligible for participation if aged 10-14 years and enrolled in grades 4-8 in a study school. Data were collected with two independent cross-sectional surveys: baseline before the start of implementation and endline 1·5 years later. The primary outcome of impact was dietary diversity score, defined as the number of food groups (out of ten) consumed over the previous 24 h using a list-based method, and minimum dietary diversity, defined as the proportion of girls who consumed foods from at least five of the ten food groups, in the intention-to-treat population. We also assessed intervention exposure as a measure of feasibility. We estimated intervention effects using linear regression models for mean differences at endline, with SEs clustered at the school level, and controlled for adolescent age, region, household food security, and wealth. The trial is registered with ClinicalTrials.Gov, NCT04121559, and is complete. FINDINGS: 27 primary schools were randomly allocated to the intervention group and 27 to the control group. Between March 22 and April 29, 2021, 536 adolescent girls participated in the endline survey (270 in the intervention group and 266 in the control group), with median age of 13·3 years (IQR 12·1-14·0). At endline, the dietary diversity score was 5·37 (SD 1·66) food groups in the intervention group and 3·98 (1·43) food groups in the control group (adjusted mean difference 1·33, 95% CI 0·90-1·75, p<0·0001). Increased minimum dietary diversity was also associated with the intervention (182 [67%] of 270 in the intervention group vs 76 [29%] of 266 in the control group; adjusted odds ratio 5·37 [95% CI 3·04-9·50], p<0·0001). 256 (95%) of 270 adolescent girls in the intervention group were exposed to at least one of the five in-school intervention components. INTERPRETATION: Integrating nutrition interventions into primary schools in Ethiopia was feasible and increased dietary diversity incrementally among adolescent girls, but could be limited in changing other food choice behaviours, such as junk food consumption, based on nutrition education alone. FUNDING: Bill & Melinda Gates Foundation.

"Stronger with Breastmilk Only" Initiative in 5 African Countries: Case Study on the Implementation Process and Contribution to the Enabling Environment for Breastfeeding.

Background: The practice of giving water before 6 mo of age is the biggest barrier to exclusive breastfeeding in West and Central Africa. To address this challenge, a regional initiative, "Stronger with Breastmilk Only" (SWBO), was rolled out at country level in several countries of the region. Objective: We examined the implementation process of the SWBO initiative and the contribution of its advocacy component to a more supportive environment for breastfeeding policies and programs. Methods: This study was based on 2 assessments at the national level carried out in 5 countries (Burkina Faso, Chad, Democratic Republic of the Congo, Senegal, and Sierra Leone) using qualitative methods. We combined 2 evaluative approaches (contribution analysis and outcome harvesting) and applied 2 theoretical lenses (Breastfeeding Gear Model and Consolidated Framework for Implementation Research) to examine the implementation process and the enabling environment for breastfeeding. Data sources included ∼300 documents related to the initiative and 43 key informant interviews collected between early 2021 and mid-2022. Results: First, we show how a broad initiative composed of a set of combined interventions targeting multiple levels of determinants of breastfeeding was set up and implemented. All countries went through a similar pattern of activities for the implementation process. Second, we illustrate that the initiative was able to foster an enabling environment for breastfeeding. Progress was achieved notably on legislation and policies, coordination, funding, training and program delivery, and research and evaluation. Third, through a detailed contribution story of the case of Burkina Faso, we illustrate more precisely how the initiative, specifically its advocacy component, contributed to this progress. Conclusion: This study shed light on how an initiative combining a set of interventions to address determinants of breastfeeding at multiple levels can be implemented regionally and contributes to fostering an enabling environment for breastfeeding at scale.

Comparing delivery channels to promote nutrition-sensitive agriculture: A cluster-randomized controlled trial in Bangladesh.

We use a randomized controlled trial in rural Bangladesh to compare two models of delivering nutrition content jointly to husbands and wives: deploying female nutrition workers versus mostly male agriculture extension workers. Both approaches increased nutrition knowledge of men and women, household and individual diet quality, and women's empowerment. Intervention effects on agriculture and nutrition knowledge, agricultural production diversity, dietary diversity, women's empowerment, and gender parity do not significantly differ between models where nutrition workers versus agriculture extension workers provide the training. The exception is in an attitudes score, where results indicate same-sex agents may affect scores differently than opposite-sex agents. Our results suggest opposite-sex agents may not necessarily be less effective in providing training. In South Asia, where agricultural extension systems and the pipeline to those systems are male-dominated, training men to deliver nutrition messages may offer a temporary solution to the shortage of female extension workers and offer opportunities to scale and promote nutrition-sensitive agriculture. However, in both models, we find evidence that the presence of mothers-in-law within households modifies the programs' effectiveness on some nutrition, empowerment, and attitude measures, suggesting that accounting for other influential household members is a potential area for future programming.

Intensified Nutrition Interventions in Antenatal Care Services Increased Consumption of Iron and Folic Acid Supplements and Early Breastfeeding Practices in Burkina Faso: Results of a Cluster-Randomized Program Evaluation.

BACKGROUND: Alive & Thrive supported the Government of Burkina Faso to strengthen the provision of iron and folic acid (IFA) supplementation and interpersonal counseling on maternal nutrition and breastfeeding through antenatal care (ANC) services and community-based contacts in 2 regions. OBJECTIVES: We assessed the impacts of intensified nutrition interventions during ANC compared with standard ANC services on intervention coverage and maternal nutrition practices. METHODS: A cluster-randomized evaluation compared 40 health center catchment areas in intervention areas with 40 in control areas. Repeated cross-sectional surveys in 2019 and 2021 (960 pregnant women and 1920 women with children 0-5 mo of age per survey round) provided data on impact indicators, intervention exposure, and other factors. We derived difference-in-difference (DID) effect estimates, adjusted for geographic clustering, for maternal dietary diversity, IFA consumption, and early breastfeeding practices. RESULTS: More women in intervention areas had 4+ ANC visits (DID: 8.3 percentage points [pps]) and started ANC during the first trimester (DID: 10.5 pp), compared with control areas. Improvements were achieved in exposure to nutrition counseling on dietary diversity (DID: 44.4 pp), food quantity (DID: 42.9 pp), adequate weight gain (DID: 35.1 pp), and breastfeeding (DID: 25.9 pp). Women in intervention areas consumed more IFA supplements during pregnancy (DID: 21 tablets). Early initiation of and exclusive breastfeeding also improved (DID: 17.0 and 8.3 pp, respectively). However, dietary diversity (4 out of 10 food groups) and mean probability of adequacy of micronutrient intake (14%) among pregnant women remained low in both areas. CONCLUSIONS: Strengthening maternal nutrition interventions delivered through government ANC services was feasible and effective in improving maternal nutrition practices. Continued efforts to strengthen the delivery and use of maternal nutrition services may be required for greater behavior changes, and to address family support, social norms, and other factors to improve women's diets during pregnancy.

More is not enough: High quantity and high quality antenatal care are both needed to prevent low birthweight in South Asia.

Antenatal care (ANC) is an opportunity to receive interventions that can prevent low birth weight (LBW). We sought to 1) estimate LBW prevalence and burden in South Asia, 2) describe the number of ANC visits (quantity) and interventions received (quality), and 3) explore associations between ANC quantity, quality and LBW. We used Demographic and Health Survey (DHS) data from Afghanistan (2015), Bangladesh (2018), India (2016), Nepal (2016), Pakistan (2018) and Sri Lanka (2016) (n = 146,284 children <5y). Women were categorized as follows: 1) low quantity (<4 ANC visits) and low quality (<5 of 10 interventions received during ANC), 2) low quantity and high quality (≥5 of 10 interventions), 3) high quantity (≥4 visits) and low quality, 4) high quantity and high quality. We used fixed effect logistic regressions to examine associations between ANC quality/quantity and LBW (<2500 grams). LBW prevalence was highest in Pakistan (23%) and India (18%), with India accounting for two-thirds of the regional burden. Only 8% of women in Afghanistan received high quantity and high quality ANC, compared to 42-46% in Bangladesh, India, and Pakistan, 65% in Nepal and 92% in Sri Lanka. Compared to the low quantity/quality reference group, children of women with high quantity/quality ANC had lower odds of LBW in India (Adjusted Odds Ratio 0.84, 95% CI 0.78-0.89), Nepal (0.57, 0.35-0.94), Pakistan (0.45, 0.23-0.86), and Sri Lanka (0.73, 0.57-0.92). Low quantity but high quality ANC was protective in India (0.90, 0.84-0.96), Afghanistan (0.53, 0.27-1.05) and Pakistan (0.49, 0.23-1.05). High quantity but low quality ANC was protective in Sri Lanka (0.76, 0.61-0.93). Neither frequent ANC without appropriate interventions nor infrequent ANC with appropriate interventions are sufficient to prevent LBW in most South Asian countries, though quality may be more important than quantity. Consistent measurement of interventions during ANC is needed.

Strengthening Nutrition Interventions during Antenatal Care Improved Maternal Dietary Diversity and Child Feeding Practices in Urban Bangladesh: Results of a Quasi-Experimental Evaluation Study.

BACKGROUND: Bangladesh is urbanizing rapidly, facing challenges of malnutrition, low coverage and poor quality of urban nutrition services. OBJECTIVES: We assessed the effect of integrating maternal, infant, and young child nutrition interventions, delivered at urban Maternal Neonatal and Child Health facilities, on maternal dietary diversity, iron and folic acid (IFA) and calcium consumption, and child feeding practices. METHODS: We used a quasi-experimental design with a nonrandom assignment of 20 health care facilities in Dhaka to intensive and standard service arms. We conducted facility-based observations and community-based surveys at baseline (2020) and endline (2022) (n = 2455 observations and surveys with 1678 pregnant women [PW] or recently delivered women [RDW] at endline). We derived difference-in-difference (DID) estimates, adjusted for characteristics that differed at baseline or endline, and accounted for clustering. RESULTS: Exposure to antenatal care (ANC) was similar in both arms: two-thirds of RDW received ANC during the first trimester and three-fourths received ≥4 ANC checkups. Compared to the standard arm, a higher proportion of PW in the intensive arm received counseling on dietary diversity (DID: 45 percentage points [pp]), and a higher proportion of RDW received IFA (25 pp) and calcium supplementation (19 pp), showed adequate weight gain (44 pp), and recorded appropriate child feeding (27 pp). Improvements were greater in the intensive than the standard arm for the number of food groups consumed (DID: 1.1 food groups) and minimum dietary diversity (23 pp); no effect was observed for IFA and calcium consumption during pregnancy. However, effects were observed for early initiation of (20 pp) and exclusive breastfeeding (45 pp), introduction of solid or semisolid foods (28 pp), and egg and/or flesh food consumption (33 pp) among children. Minimum dietary diversity and acceptable diet remained low in both arms. CONCLUSIONS: Intensifying nutrition in government-aligned health care services delivered by experienced nongovernmental organization-run facilities is a feasible model to address the urban health gap, nutrition services coverage, and improve practices. The trial was registered at clinicaltrials.gov as NCT03882268.

Assessing the hidden burden and costs of COVID-19 pandemic in South Asia: Implications for health and well-being of women, children and adolescents.

The COVID-19 pandemic has disproportionately affected vulnerable populations. With its intensity expected to be cyclical over the foreseeable future, and much of the impact estimates still modeled, it is imperative that we accurately assess the impact to date, to help with the process of targeted rebuilding of services. We collected data from administrative health information systems in six South Asian countries (Afghanistan, Bangladesh, Nepal, India, Pakistan and Sri Lanka), to determine essential health services coverage disruptions between January-December 2020, and January-June 2021, compared to the same calendar months in 2019, and estimated the impact of this disruption on maternal and child mortality using the Lives Saved Tool. We also modelled impact of prolonged school closures on continued enrollment, as well as potential sequelae for the cohort of girls who have likely dropped out. Coverage of key maternal and child health interventions, including antenatal care and immunizations, decreased by up to 60%, with the largest disruptions observed between April and June 2020. This was followed by a period of recovery from July 2020 to March 2021, but a reversal of most of these gains in April/May 2021, likely due to the delta variant-fueled surge in South Asia at the same time. We estimated that disruption of essential health services between January 2020 and June 2021 potentially resulted in an additional 19,000 maternal and 317,000 child deaths, an increase of 19% and 13% respectively, compared to 2019. Extended school closures likely resulted in 9 million adolescents dropping out permanently, with 40% likely being from poorest households, resulting in decreased lifetime earnings. A projected increase in early marriages for girls who dropped out could result in an additional 500,000 adolescent pregnancies, 153,000 low birthweight births, and 27,000 additional children becoming stunted by age two years. To date, the increase in maternal and child mortality due to health services disruption has likely exceeded the overall number of COVID-19 deaths in South Asia. The indirect effects of the pandemic were disproportionately borne by the most vulnerable populations, and effects are likely to be long-lasting, permanent and in some cases inter-generational, unless policies aimed at alleviating these impacts are instituted at scale and targeted to reach the poorest of the poor. There are also implications for future pandemic preparedness.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world.

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Multiple modifiable maternal, household and health service factors are associated with maternal nutrition and early breastfeeding practices in Burkina Faso.

Low coverage of effective nutrition interventions in many high-burden countries, due to service provision and demand factors, result in poor uptake of recommended practices and nutrition outcomes. We examined the factors that influence maternal nutrition and early breastfeeding practices and determined the extent that the key factors could improve these practices in two regions in Burkina Faso. We used household survey data among pregnant (n = 920) and recently delivered women (n = 1840). Multivariable regression analyses were conducted to identify the determinants of a diverse diet and iron-folic acid (IFA) supplement consumption, weight monitoring during pregnancy and early initiation of breastfeeding (EIBF). Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal conditions of interventions that address the modifiable determinants. During pregnancy, 21% of women achieved minimum diet diversity (MDD-W), 70% consumed 90+ IFA tablets and 65% were weighed 4+ times; EIBF was 40%. Nutrition knowledge was associated with MDD-W (odds ratio [OR]: 3.2), 90+ IFA (OR: 1.5) and EIBF (OR: 1.9). Positive social norms and family support were associated with 90+ IFA (OR: 1.5). Early and 4+ ANC visits were associated with 90+ IFA (OR: 1.5 and 10) and 4+ weight monitoring (OR: 6.2). Nutrition counselling was associated with 90+ IFA (OR: 2.5) and EIBF (OR: 1.5). Under optimal programme conditions, 41% of women would achieve MDD-W, 93% would consume 90+ IFA, 93% would be weighed 4+ times and 57% would practice EIBF. Strengthening the delivery and uptake of interventions targeted at these modifiable factors has the potential to improve maternal nutrition practices.

Underweight, overweight or obesity, diabetes, and hypertension in Bangladesh, 2004 to 2018.

BACKGROUND AND OBJECTIVES: Bangladesh is experiencing a nutrition transition with an increase in the double burden of malnutrition and non-communicable diseases (NCDs). This study sought to: 1) examine trends and differences in underweight, overweight/obesity, hypertension and diabetes by gender, area of residence, and wealth in Bangladesh from 2004 to 2018, 2) assess what factors contributed to changes in these outcomes. METHODS: We used data from five rounds of the Bangladesh Demographic and Health Surveys (n = 76,758 women 15-49y and 10,900 men 18-95y in total). We calculated differences, slope index of inequality (SII) and concentration index (CIX) to examine trends over time and differences in outcomes by wealth and residence. We identified determinants and estimated drivers of changes in outcomes using regression-based decomposition. RESULTS: Between 2004 and 2018, underweight prevalence decreased in both women (33% to 12%) and men (26% to 18%), whereas overweight/obesity increased (17% to 49% in women and 21% to 34% in men). Hypertension also increased in both women (31% to 44%) and men (19% to 33%) while diabetes changed marginally (11% to 14%). In all years, underweight was concentrated in poorer and rural households while overweight/obesity, diabetes and hypertension were concentrated in wealthier and urban households. Wealth inequity decreased over time for underweight, changed little for overweight/obesity, and increased for hypertension and diabetes among men. Increases in wealth explained 35% to 50% of the reduction in underweight and 30% to 57% of the increase in overweight/obesity. CONCLUSION: Our findings imply that double duty actions are required to sustain the decrease in undernutrition and slow the increase in overweight/obesity and NCDs across diverse socioeconomic sections of the population in Bangladesh.

Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study.

BACKGROUND: Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020. METHODS: We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August-October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2. RESULTS: In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges. CONCLUSIONS: Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.

Storytelling for persuasion: Insights from community health workers on how they engage family members to improve adoption of recommended maternal nutrition and breastfeeding behaviours in rural Bangladesh.

Community health workers (CHWs) increasingly provide interpersonal counselling to childbearing women and their families to improve adoption of recommended maternal and child nutrition behaviours. Little is known about CHWs' first-hand experiences garnering family support for improving maternal nutrition and breastfeeding practices in low-resource settings. Using focused ethnography, we drew insights from the strategies that CHWs used to persuade influential family members to support recommendations on maternal diet, rest and breastfeeding in a behaviour change communication trial in rural Bangladesh. We interviewed 35 CHWs providing at-home interpersonal counselling to pregnant women and their families in seven 'Alive & Thrive' intervention sites. In-depth probing focused on how CHWs addressed lack of family support. Thematic coding based on Fisher's narrative paradigm revealed strategic use of three rhetorical principles by CHWs: ethos (credibility), pathos (emotion) and logos (logic). CHWs reported selectively targeting pregnant women, husbands and mothers-in-law based on their influence on behavioural adoption. Key motivators to support recommended behaviours were improved foetal growth and child intelligence. Improved maternal health was the least motivating outcome, even among mothers. Logically coherent messaging resonated well with husbands, while empathetic counselling was additionally required for mothers. Mothers-in-law were most intransigent, but were persuaded via emotional appeals. Persuasion on maternal rest was most effort-intensive, resulting in contextually appealing but scientifically inaccurate messaging. Our study demonstrates that CHWs can offer important insights on context-relevant, feasible strategies to improve family support and uptake of nutrition recommendations. It also identifies the need for focused CHW training and monitoring to address scientifically flawed counselling narratives.

Can digitally enabling community health and nutrition workers improve services delivery to pregnant women and mothers of infants? Quasi-experimental evidence from a national-scale nutrition programme in India.

BACKGROUND: India's 1.4 million community health and nutrition workers (CHNWs) serve 158 million beneficiaries under the Integrated Child Development Services (ICDS) programme. We assessed the impact of a data capture, decision support, and job-aid mobile app for the CHNWs on two primary outcomes-(1) timeliness of home visits and (2) appropriate counselling specific to the needs of pregnant women and mothers of children <12 months. METHODS: We used a quasi-experimental pair-matched controlled trial using repeated cross-sectional surveys to evaluate the intervention in Bihar and Madhya Pradesh (MP) separately using an intention-to-treat analysis. The study was powered to detect difference of 5-9 percentage points (pp) with type I error of 0.05 and type II error of 0.20 with endline sample of 6635 mothers of children <12 months and 2398 pregnant women from a panel of 841 villages. RESULTS: Among pregnant women and mothers of children <12 months, recall of counselling specific to the trimester of pregnancy or age of the child as per ICDS guidelines was higher in both MP (11.5pp (95% CI 7.0pp to 16.0pp)) and Bihar (8.0pp (95% CI 5.3pp to 10.7pp)). Significant differences were observed in the proportion of mothers of children <12 months receiving adequate number of home visits as per ICDS guidelines (MP 8.3pp (95% CI 4.1pp to 12.5pp), Bihar: 7.9pp (95% CI 4.1pp to 11.6pp)). Coverage of children receiving growth monitoring increased in Bihar (22pp (95% CI 0.18 to 0.25)), but not in MP. No effects were observed on infant and young child feeding practices. CONCLUSION: The at-scale app integrated with ICDS improved provision of services under the purview of CHNWs but not those that depended on systemic factors, and was relatively more effective when baseline levels of services were low. Overall, digitally enabling CHNWs can complement but not substitute efforts for strengthening health systems and addressing structural barriers. TRIAL REGISTRATION NUMBER: ISRCTN83902145.

A Quasi-Experimental Evaluation of a Nutrition Behavior Change Intervention Delivered Through Women's Self-Help Groups in Rural India: Impacts on Maternal and Young Child Diets, Anthropometry, and Intermediate Outcomes.

Background: Women's self-help groups (SHGs) have become one of the largest institutional platforms serving the poor. Nutrition behavior change communication (BCC) interventions delivered through SHGs can improve maternal and child nutrition outcomes. Objectives: The objective was to understand the effects of a nutrition BCC intervention delivered through SHGs in rural India on intermediate outcomes and nutrition outcomes. Methods: We compared 16 matched blocks where communities were supported to form SHGs and improve livelihoods; 8 blocks received a 3-y nutrition intensive (NI) intervention with nutrition BCC, and agriculture- and rights-based information, facilitated by a trained female volunteer; another 8 blocks received standard activities (STD) to support savings/livelihoods. Repeated cross-sectional surveys of mother-child pairs were conducted in 2017-2018 (n = 1609 pairs) and 2019-2020 (n = 1841 pairs). We matched treatment groups over time and applied difference-in-difference regression models to estimate impacts on intermediate outcomes (knowledge, income, agriculture/livelihoods, rights, empowerment) and nutrition outcomes (child feeding, woman's diet, woman and child anthropometry). Analyses were repeated on households with ≥1 SHG member. Results: Forty percent of women were SHG members and 50% were from households with ≥1 SHG member. Only 10% of women in NI blocks had heard of intervention content at endline. Knowledge improved in both NI and STD groups. There was a positive NI impact on knowledge of timely introduction of animal-sourced foods to children (P < 0.05) but not on other intermediate outcomes. No impacts were observed for anthropometry or diet indicators except child animal-source food consumption (P < 0.01). In households with ≥1 SHG member, there was a positive NI impact on child unhealthy food consumption (P < 0.05). Conclusions: Limited impacts could be due to limited exposure or skills of volunteers, and a concurrent national nutrition campaign. Our findings add to a growing literature on SHG-based BCC interventions and the conditions necessary for their success.