Program Impact Pathways and Contexts: A Commentary on Theoretical Issues and Research Applications to Support the EsIAN Component of Mexico's Conditional Cash Transfer Program.

This commentary on the Integrated Strategy for Attention to Nutrition (EsIAN) journal supplement begins with a discussion about the challenges that implementation researchers confront with respect to analyzing complex impact pathways. We note that the research on the implementation of the EsIAN component of Mexico's conditional cash transfer program was based implicitly or explicitly on a program impact pathway approach, which used both quantitative and qualitative methods to examine bottlenecks in program implementation. We then identify 5 categories of contexts that affect the impact, implementation, and survival of intervention programs: 1) biological, 2) social-cultural, 3) delivery modalities and platforms, 4) bureaucratic, and 5) political. Each of these contexts presents theoretical and methodological challenges for investigators. In this commentary, we focus primarily on biological and social-cultural contexts, discussing the theoretical and methodological challenges the investigators faced and the research strategies they used to address them, which have produced a unique compilation of "learning by doing" studies. We also touch briefly on the political context in which the Prospera program research was conducted. We conclude with statements that highlight the exceptional value of the journal supplement, not only with respect to the analysis of the interventions the studies cover and the sustained examination of a long-term program but also as a major contribution to the literature in implementation science in nutrition.

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.

Capturing Changes in HIV-Infected Breastfeeding Mothers' Cognitive Processes from Before Delivery to 5 Months Postpartum: An Application of the Pile-Sorting Technique in Haiti.

BACKGROUND: The cognitive processes involved in individuals' perceptions and prioritization of information, and how these change with experience or exposure to interventions, are rarely examined in the evaluation of nutrition interventions. Exclusive breastfeeding counseling is a common infant and young-child feeding intervention and is used to promote HIV-free survival in the prevention of mother-to-child transmission programs. However, it is often designed without adequate attention to the changes in mothers' perceptions over the course of their early breastfeeding experiences. OBJECTIVE: The aim of this study was to identify HIV-infected breastfeeding mothers' cognitive structure (their organization of messages and ideas) of infant feeding messages and to characterize whether their cognitive organization of infant feeding messages changed from pregnancy through the first 5 mo postpartum. METHODS: With the use of semistructured interviews and the cognitive mapping technique of pile sorting, we interviewed 30 HIV-infected breastfeeding mothers in Port-au-Prince, Haiti. We asked them to sort and rate 18 infant feeding messages 3 times (during pregnancy, 0- to 1-mo postpartum, and 3- to 5-mo postpartum). We analyzed their responses by using multidimensional scaling, property fitting, and partition analyses. RESULTS: At all 3 visits, we found consistency in women's cognitive mapping of messages. For example, mothers consistently differentiated messages pertinent for exclusive breastfeeding compared with those that pertained to other practices. However, subtle variations in mothers' cognition over time were also evident, particularly at 0- to 1-mo postpartum, when message proximity was tightly clustered compared with the earlier and later periods. CONCLUSIONS: We conclude that mothers share a common cognitive organization of infant feeding messages and that this organization changes over time. Attention to variations in cognition can support context-sensitive, patient-centered counseling by practitioners and improve the effectiveness of nutrition interventions. Pile sorting is an efficient, systematic technique to examine cognitive processes related to health and nutrition.

Who knows what: An exploration of the infant feeding message environment and intracultural differences in Port-au-Prince, Haiti.

Worldwide, mothers with young children receive many messages about infant feeding. Some messages are generated by health providers and others by the households, communities, and social contexts in which women live. We aimed to determine the scope of infant feeding messages in urban Haiti and to examine intracultural differences in salience of these messages and their alignment with international guidelines. We applied the method of free listing with 13 health workers and 15 human immunodeficiency virus (HIV)-infected and 15 HIV-uninfected mothers with infants 0-6 months old at Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince, Haiti. Participants listed all messages women receive about infant feeding and specifically about HIV and infant feeding. Message salience was determined by frequency of mention and recall order; messages were coded for key themes. For all groups, the World Health Organization infant feeding recommendations were salient, especially those related to exclusive breastfeeding. Messages across all groups focused on infant health outcomes, with less emphasis on maternal outcomes. Cultural beliefs were also elicited and showed higher salience for mothers than health workers, particularly for consequences of poor maternal nutrition. Health workers' free lists were poorly correlated to those of mothers, whereas those of mothers were highly correlated, regardless of HIV status. Inasmuch as many salient messages were culturally generated, and differences existed between mothers and health workers, we conclude that it is important for health workers to acknowledge the broader infant feeding message environment, and discrepancies within that environment, to address successes and failures in the messages reaching mothers, given potential consequences for mothers' breastfeeding behaviours.

Maternal knowledge after nutrition behavior change communication is conditional on both health workers' knowledge and knowledge-sharing efficacy in rural Haiti.

In the context of a food assistance program in rural Haiti, we developed measures of the effectiveness of community health worker (CHW)-delivered behavior change communication (BCC). We administered knowledge tests to 954 mothers and 38 CHWs to define 4 measures: CHW knowledge, maternal knowledge, knowledge-sharing efficacy (proportion of CHW knowledge shared), and shared correct knowledge between the CHWs and the mothers with whom they interacted. On the basis of the tests, CHWs had high knowledge (93% correct), mothers scored 72% on maternal knowledge, the proportion of CHW knowledge shared was 75%, and shared correct knowledge between CHWs and mothers was 70%. Factors affecting maternal knowledge included CHW characteristics (unmarried: ß = -0.070, P < 0.05), long duration (19-45 mo) of program participation (ß = 0.034, P < 0.05), and having multiple sources of health and nutrition information (ß = 0.072, P < 0.01). Shared correct knowledge and CHW knowledge-sharing efficacy were positively associated with CHW (age, education) and program participation characteristics. We parsed the relative contributions of CHW characteristics to total and proportion of shared CHW knowledge. We observed a positive association between CHW education and shared correct knowledge between the CHWs and mothers (ß = 0.328, P < 0.01), not because of more knowledge (ß = -0.012, P > 0.05) but rather because of greater knowledge-sharing efficacy (ß = 0.340, P < 0.01). These measures provide a means of examining features of program delivery and interpreting impact evaluation results. They show that BCC outcomes are conditional on both frontline workers' knowledge and knowledge-sharing efficacy. Whereas most programs focus on content training to improve CHWs' knowledge, it is also important to strengthen process training and support to foster knowledge-sharing efficacy.

Constructing maternal knowledge frameworks. How mothers conceptualize complementary feeding.

This ethnographic study examines maternal knowledge, and develops an emic framework to help explain and interpret maternal complementary feeding behaviors. In-depth interviews and home observations among 29 women with young children 6-18 mo were conducted in Morelos, Mexico. Transcripts were systematically reviewed to identify major themes related to feeding young children, and data were coded using a combination of preselected codes and codes that emerged from the identification of themes. Observations augmented the information that was obtained through verbal exchange. We identified eight concepts: (1) probaditas (the idea of introducing small tastes of foods), (2) preparing separate foods for infants, (3) readiness to eat solid foods, (4) appropriate consistency, (5) the value of variety, (6) child likes and dislikes, (7) money and food costs, and (8) healthiness of foods (positive and negative foods). There was strong evidence of cultural consensus (sharing of knowledge among the respondents), and the underlying motivation was to provide foods to ensure good growth and health. This knowledge framework guided practices. Mothers fed their children liquid and semi-liquid foods, and fruits, but few vegetables, meats, and legumes. Variation in the variety of children's diets was associated with household factors, which emerged in the ethnographic interviews. We conclude that elucidating maternal knowledge frameworks is crucial for explaining maternal behavior, and argue that these frameworks are the foundation for developing behavior-change interventions.

Organoleptic properties, ease of use, and perceived health effects are determinants of acceptability of micronutrient supplements among poor Mexican women.

We assessed the acceptability of 3 micronutrient supplements for pregnant and lactating women: micronutrient powder (Sprinkles), a fortified food (Nutrivida), and tablets. Pregnant or lactating beneficiaries of the Oportunidades program participating in a cluster randomized supplementation trial in urban Mexico were surveyed about the acceptability of 1 of 3 supplements (n = 268). Semistructured interviews (n = 40) were also conducted with a subset of women in the trial and from adjacent rural areas. Acceptability of the supplements was evaluated based on women's perceptions and experiences with organoleptic qualities, ease of use, and perceived health effects (positive and negative). The median Likert scale ranking of organoleptic and use qualities for all 3 supplements was "I liked it" (2 on a scale of 1-5). However, responses to open-ended survey questions and semistructured interviews indicated decided preferences. Tablets and Sprinkles were strongly preferred over Nutrivida. In interviews, women expressed dislike of the smell, taste, and texture of Nutrivida; they found it cumbersome to store and prepare and reported the most negative effects with it. Between tablets and Sprinkles, tablets were preferred because of the absence of perceptible taste or smell and the simplicity of use. This study provides valuable insights into our currently limited understanding of women's perceptions and preferences among supplements by broadening the concept of acceptability beyond organoleptic properties. Such an analytical approach is useful for identifying both appropriate nutritional supplements within a given sociocultural context as well as the information that should be included in nutrition education to improve adherence.

Maternal knowledge and use of a micronutrient supplement was improved with a programmatically feasible intervention in Mexico.

In Mexico, the potential impact on child malnutrition from a nutritional supplement (papilla) delivered through a conditional transfer program (Oportunidades) was attenuated by problems of household utilization. A behavioral change through communication intervention was developed to improve supplement utilization. Our study assessed the efficacy of this intervention through the results of a randomized trial. In 2 states (Veracruz and Chiapas) 2 clusters of communities were randomly assigned to intervention or control groups. Data were obtained from 176-198 mothers in intervention and control communities using a survey questionnaire at preintervention baseline and at a 5-mo follow-up. Concordance between reported and observed behaviors was examined through an observational substudy. The 4 behavioral recommendations were: 1) prepare papilla as a pap; 2) administer the preparation every day; 3) administer it between breakfast and dinner; and 4) administer it only to target children. The intervention resulted in a significant increase (P<0.05) in the prevalence of reported correct behaviors in the intervention group compared with the control for 3 of the behaviors: a mean increase of 42.5% for preparing papilla as pap, 64.4% for daily administration, and 61.5% for giving papilla between breakfast and dinner. Administering to a target child increased significantly in Veracruz (from 51.5% to 90.6%), but not in Chiapas (20.6% to 33.3%). Reported behaviors agreed with observed behaviors in the substudy. With the exception of the target-child administration in Chiapas, adopting the recommendations was culturally acceptable and feasible. The results indicate that improvements in household utilization of the supplement can be achieved with a communication intervention that is potentially feasible for implementation on a large scale within the Oportunidades Program.

Nutrition counseling training changes physician behavior and improves caregiver knowledge acquisition.

Physician behavior and caregiver retention of nutrition advice were examined as potential mediating factors in the success of a nutrition counseling efficacy trial in Pelotas, Brazil, which reduced growth faltering in children 12-24 mo old. After pair-matching on socioeconomic status and nutrition indicators, municipal health centers were randomly assigned to an intervention group, in which physicians were trained with an IMCI-derived (Integrated Management of Childhood Illness) nutrition counseling protocol, or to a control group, without continuing education in nutrition. In a substudy of the larger trial, direct observation of consultations, followed by home interviews with mothers, provided data on physician counseling behavior and mothers' retention of nutrition advice. Trained providers were more likely to engage in nutrition counseling (P < 0.013) and to deliver more extensive advice (P < 0.02). They also used communication skills designed to improve rapport and ensure that mothers understood the advice (P < 0.01). Mothers who received advice from trained providers had high rates of recalling the messages on specific foods (95 vs.27%; P < 0.01) and feeding practice and food preparation recommendations (90 vs. 20%; P < 0.01), whereas the proportions of the messages recalled on breast-feeding (60% vs. 30%) did not differ significantly (P < 0.20). The training course contained several elements that may explain why intervention group mothers were better able to recall nutrition advice. These include locally appropriate messages, tools for assessing individual problems, and counseling skills.

Interrelationships between power-related and belief-related factors determine nutrition in populations.

The vast majority of social research in nutrition has focused either on economic, material and political factors ("power-related" variables) or on psychological, cultural and attitudinal factors ("belief-related" variables). Even when data on both classes of factors are collected, the orientation in analysis is to treat one of the two classes as "confounding" or "control" variables. Although single-focus studies have yielded essential knowledge about the role of specific factors, they fail to reveal the mechanisms through which belief-related and power-related variables interact to produce nutritional outcomes. Data from the Nutrition CRSP project in Mexico are used to illustrate the interactions between household economic conditions and maternal education on household diet. As has been seen in other developing country contexts, women in more favorable economic circumstances, and who have more education, tend to feed their children a higher quality diet. However, even in better-off households dietary quality is not uniformly high, a finding that reflects the operation of other values and cultural factors that direct resource allocation to other sectors of family activity.

Household trials with very small samples predict responses to nutrition counseling intervention.

Household trials were conducted to test the acceptability and feasibility of the recommendations to be delivered to the mothers in the context of a randomized intervention implemented in Pelotas, Brazil. A first home visit was paid to assess child health and feeding problems. In a second visit, the mother was encouraged to select one or two recommendations to try out over five days. The last visit was used to assess the mothers' experiences in attempting to implement the recommendations. Nonexclusive breastfeeding, use of the bottle, monotonous diet, and low energy density of foods were the most common problems. The most frequently selected recommendations were those aiming to increase the energy density of foods. Mothers generally reported positive responses to the recommendations. The household trials highlighted the acceptability and feasibility of the planned recommendations and correctly predicted the changes that were successfully implemented by the mothers in the large intervention study.

Diet and iron status of nonpregnant women in rural Central Mexico.

BACKGROUND: Few studies have examined the relation of iron status to diet in populations from developing countries with high levels of iron deficiency and diets of poor quality. OBJECTIVE: The objective was to identify nutrients, dietary constituents, and foods that are associated with better iron status in a rural Mexican population. DESIGN: A prospective cohort study was conducted in rural central Mexico. The subjects were 125 nonpregnant women aged 16-44 y. During the 12 mo before blood collection, food intakes were assessed repeatedly by a combination of dietary recalls, food weighing, and food diaries [mean (+/-SD) days of food intake data: 18.8 +/- 5.9 d]. Hemoglobin, hematocrit, and plasma ferritin were measured at the end of the study. RESULTS: Higher plasma ferritin concentrations were associated with greater intakes of nonheme iron and ascorbic acid after control for age, BMI, breast-feeding, season, and the time since the birth of the last child. Higher ascorbic acid intakes, but not higher intakes of heme and nonheme iron, predicted a lower risk of low hemoglobin and hematocrit values after control for the background variables. Consumption of the alcoholic beverage pulque predicted a lower risk of low ferritin and low hemoglobin values. Seasonal variation in ferritin, hemoglobin, and hematocrit values was observed. CONCLUSION: Better iron status was associated with greater intakes of foods containing nonheme iron and ascorbic acid. PULQUE:a beverage containing iron, ascorbic acid, and alcohol-may influence the iron status of women in rural central Mexico.

Etnografía de la infección respiratoria aguda en zona rural del altiplano mexicano / Ethnography of acute respiratory illnesses in a rural zone of the Mexican central highlands

Objetivo. Identificar los términos utilizados por las madres para referirse a enfermedades, signos y síntomas relacionados con infecciones respiratorias aguda, así como los signos de alarma que las motivan a buscar atención médica; asimismo, describir prácticas comunes de manejo de la enfermedad en el hogar. Material y métodos. Se trata de un estudio etnográfico en seis comunidades rurales del altiplano mexicano. Se entrevistó a 12 informantes clave, a seis madres de niños fallecidos por infección respiratoria aguda, y a 24 madres de niños menores de cinco años, con diversas técnicas etnográficas para complementar la información obtenida ("triangulación"). Resultados. Las enfermedades comúnmente identificadas incluyeron gripa, anginas, tos, bronquitis, pulmonía, neumonía y "broncomonía". Los síntomas clave para el diagnóstico fueron escurrimiento de moco nasal, dolor de garganta, tos, dolor de cabeza o de cuerpo, calentura, "hervor" de pecho, y referencias a que el niño "está molesto o llorón", y se pone morado o le hace falta el aire. La taquipnea fue referida como "respira fuerte", "respira mucho", "respira rápido" y "tiene sesido", el tiraje, "se le hunde el pecho", el estridor, como "quejido o ronquido de pecho"; la sibilancia, como "ronquido de pecho", y para la cianosis, "se pone morado". Entre los tratamientos ofrecidos en el hogar destacan el uso de tés, aplicación de sebo o pomada en pecho y espalda. No fue común la autoprescripción de antibióticos pero sí la de antipiréticos. La mayoría de las madres reconoció enfermedades leves y, en menor proporción, graves. Ante un caso grave de insuficiencia respiratoria aguda, la opción más frecuentemente elegida fue acudir a la clínica del proyecto; en segundo lugar al médico particular en la cabecera municipal, y al hospital de la Secretaría de Salud en la Jurisdicción. La cercanía y el menor costo fueron razones frecuentemente aducidas para estas elecciones. Conclusiones. Esta información puede resultar útil para mejorar la comunicación con las madres

Methodological issues for eliciting local signs/symptoms/illness terms associated with acute respiratory illnesses

Acute respiratory infections (ARI) are among the principal causes of mortality of children under 5 years of age. Most deaths are due to pneumonia. which, when timely identified and properly treated, could be avoided. An effective case management scheme, based on early recognition of pneumonia and prompt antibiotic treatment, relies on early recognition of alarm signs by mothers and community health workers. For mothers to undestand and act on advice from health workers, language and concepts commonly used by mothers should be utilized. The present study was carried out to compare the relative effectiveness of two different methods to elicit local terms used by mothers to refer to ARI symptoms/signs/treatments. A comparison was made among the terms elicited by a free listing o common terms mentioned by mothers in relation to ARI, and the terms they recognized when looking at a video that showed children with different ARI signs. The video was shown in a community and a clinical setting, in order to identify strengths and weaknesses of showing it in these settings. The video elicited more signs dealing with serious illness, respiratory distresss and general malaise, but missed non-visual signs, such as fever, lack of appetite or pain. Also, mothers tended to be distracted by trivial signs, such as skin color. Free listing was easier to administer and elicited more non-life-threatenin symptoms/signs, but mothers were more prone to drift away and mention terms not related to respiratory illness. Showing the video in the clinic elicited more medical-related terms, and was easier to show than in the community. In conclusion. choice of either of the two methods depends on the researcher's purpose. Using both methods produced a larger list of terms associated with ARI