A Qualitative Exploratory Study of the Political Commitment for Nutrition Programming: A Case Study of Anambra and Kebbi States of Nigeria.

In Nigeria, varying levels of malnutrition across states present a critical challenge to public health, demanding tailored policy responses. This paper delves into the specific issues and dynamics influencing nutrition programs in the country. Advocating for nutrition-sensitive actions requires analyzing context-specific political commitment. This article presents a case study on two Nigerian states with varying malnutrition profiles to explore the political economy of nutrition. The study used stakeholder analysis, in-depth interviews, and semi-structured interviews through workshops, incorporating the Political Commitment Rapid Assessment Tool. The objective was to measure political commitment, the window of opportunity for action, and stakeholder analysis. The results showed that despite having a significant child malnutrition problem, Kebbi State received a high political commitment to nutrition, with proportions ranging from 0.67 to 1 in each of the six domains measured. On the other hand, Anambra State, where malnutrition was less severe, had varying commitment levels. Institutional commitment was marginally high (0.67), expressed commitment was high (0.71), and budgetary commitment was lower at 0.33. Kebbi had better support for programs dependent on foreign donors than Anambra. Both states need to use media to increase awareness about nutrition issues. When the nutrition situation is severe, foreign donors' influence grows. In conclusion, there are opportunities for strategic framing and advocacy of the nutrition profile of the states. Local state media can be effective, and institutional coordination committees that include various sectors already facilitate commitment to nutrition actions. However, individual, uncoordinated sectoral action can counterbalance the benefits of these committees. Further possibilities to generate political commitment for nutrition in the states are available. This study not only offers insights into the effectiveness of political strategies in addressing malnutrition but also lays the groundwork for future research and provides actionable recommendations for government policymaking.

Childhood circumstances, social mobility and the obesity transition: Evidence from South Africa.

The distribution of obesity tends to shift from rich to poor individuals as countries develop, in a process of shifting sociodemographic patterns of obesity that has been called the 'obesity transition'. This change tends to happen with economic development, but little is known about the specific mechanisms that drive the change. We propose that improvements in childhood circumstances with economic development may be one of the drivers of the obesity transition. We explore whether the social gradient in body weight differs by childhood socioeconomic status (SES), proxied by the respondent's mother having Grade 12, using South Africa's nationally representative panel National Income Dynamics Study. In support of our hypothesis, we find that the social gradient in body weight is less positive for adults who had a high childhood SES, and already appears to have reversed among high-SES women who also had a high childhood SES. Upward social mobility over an individual's life course or across a single generation is associated with higher body weight compared to a stable high SES. But a high SES sustained in childhood and adulthood - or across more than one generation - may decrease adult obesity risk, and result in a reversal of the social gradient in body weight. Random effects within-between models show that the social gradient in body weight and its interaction with childhood SES are driven more by differences in income between individuals than by short-run changes in income within individuals, again suggesting that the obesity transition is driven by long-run changes rather than by very short-run changes. Our results are broadly robust to using several alternative measures of body weight, childhood SES and adult SES. Our results are consistent with the hypothesis that widespread improvements in childhood circumstances and nutrition with economic development may contribute to the shift to later stages of the obesity transition.

Can women's reports in client exit interviews be used to measure and track progress of antenatal care services quality? Evidence from a facility assessment census in Malawi.

INTRODUCTION: Unlike household surveys, client exit interviews are conducted immediately after a consultation and therefore provides an opportunity to capture routine performance and level of service quality. This study examines the validity and reliability of women's reports on selected ANC interventions in exit interviews conducted in Malawi. METHODS: Using data from the 2013-2014 Malawi service provision facility census, we compared women's reports in exit interviews regarding the contents of ANC received with reports obtained through direct observation by a trained healthcare professional. The validity of six indicators was tested using two measures: the area under the receiver operating characteristic curve (AUC), and the inflation factor (IF). Reliability of women's reports was measured using the Kappa coefficient (κ) and the prevalence-adjusted bias-adjusted kappa (PABAK). Finally, we examined whether reporting reliability varied significantly by individual and facility characteristics. RESULTS: Of the six indicators, two concrete and observable measures had high reporting accuracy and met the validity criteria for both AUC ≥ 0.7 and 0.75>IF>1.25, namely whether the provider prescribed or gave malaria prophylaxis (AUC: 0.84, 95% CI: 0.83-0.86; IF: 0.96) or iron/folic tablets (AUC: (0.84 95% CI: 0.81-0.87; IF:1.00). Whereas four measures related to counselling had lower reporting accuracy: whether the provider offered counselling about nutrition in pregnancy (AUC: 0.69, 95%CI: 0.67-0.71; IF = 1.26), delivery preparation (AUC: 0.62, 95% CI: 0.60-065; IF = 0.99), pregnancy related complications (AUC: 0.59, 95%CI: 0.56-0.61; IF = 1.11), and iron/folic acid side effects (AUC:0.58, 95% CI: 0.55-0.60; IF = 1.42). Similarly, the observable measures had high reliability with both κ and PABAK values in the ranges of ≥ 0.61 and ≥ 0.80. Respondent's age, primiparous status, number of antenatal visits, and the type of health provider increased the likelihood of reporting reliability. CONCLUSION: In order to enhance the measurement of quality of ANC services, our study emphasizes the importance of carefully considering the type of information women are asked to recall and the timing of the interviews. While household survey programmes such as the demographic health survey and multiple indicator cluster survey are commonly used as data sources for measuring intervention coverage and quality, policy makers should complement such data with more reliable sources like routine data from health information systems.

Decomposing inequality of opportunity in child health in Tanzania: The role of access to water and sanitation.

Poor child nutrition is a major public health challenge in Tanzania. Large between and within regional nutritional inequalities exist in rural and urban areas. We looked at how locational circumstances hinder children from having an equal opportunity for good nutrition. We used the 2008/09 Living Standards Measurement Study data for Tanzania to identify the part played by water and sanitation in rural and urban inequality of opportunity in child nutrition. We used the dissimilarity index and the Shapley decomposition technique to quantify and decompose inequality of opportunity in nutrition. We find that 16% of the circumstance-driven inequality of opportunity needs to be redistributed for equality of opportunity to prevail. We find that in rural areas, about 42% of the inequality of opportunity in nutrition is due to water and sanitation problems and 22% to child age. In urban areas, we find that the inequality of opportunity is related mainly to the child's sex, price fluctuations and intergenerational factors. The findings suggest that policies to improve water and sanitation coverage could help equalize opportunities for children in rural areas. In urban areas, policies that could help equalize opportunities require incentives to change social norms and behavior around feeding practices and vaccination.

Stunting, double orphanhood and unequal access to public services in democratic South Africa.

Orphans who lack household or community support face significant socio-economic disadvantages. In particular, they are at greater risk of malnutrition and stunting in developing countries. Children who have no living parents, also called double orphans, are most likely to require support from extended families or public institutions. This paper explores how WASH infrastructure, and public health and social services relate to stunting. It is one of the first studies to analyse these factors with a specific focus on double orphans, who tend to live in under-serviced areas with high stunting rates and poor access to public resources. We collate a cross sectional spatial dataset with local child stunting rates from 2013, rates of double orphanhood, private household resources, and public services from 2011 for South Africa, a country where the HIV/AIDS pandemic has led to high rates of double orphanhood. We estimate spatial econometric models that account for unobserved regional shocks and measurement bias, but which do not address other biases. Our results show that high stunting rates, particularly in areas with high proportions of double orphans, overlap strongly with poor provision of WASH and the availability of household resources. By contrast, other softer services accessed outside the home, such as access to health, social welfare and early childhood development facilities are not correlated with stunting in the same way. WASH is more strongly related to reduced stunting when infrastructure covers larger geographic areas and with the combined use of services from adjacent areas. This occurs because of economies of scale in provision and preventing transmission of disease across regions. Policy makers can explore the option to reduce stunting by expanding geographic networks of WASH service delivery into under-serviced areas where double orphans tend to locate.

Validation of a roadmap for mainstreaming nutrition-sensitive interventions at state level in Nigeria.

BACKGROUND: National programs are often developed with little consideration to the sub-national local factors that might affect program success. These factors include political support, capacity for implementation of program and variation in malnutrition indices being tackled. State context factors are evident in the distribution of malnutrition (e.g. high prevalence or gap among Local Government Areas), in the implementation of nutrition-sensitive interventions (e.g. access to early childhood education) and in the political economic context (e.g. presence of external funding agencies). Context is shaped by the economy, population, religion, and poverty, which impact everyday lives. Considering these contexts, a roadmap was developed and validated. The aim of this paper is to report expert review and stakeholder validation to determine feasibility of the developed contextualised roadmap for two Nigerian states. METHODS: A validation tool was developed and reviewed using three experts. The content review occurred in two rounds to obtain recommendation and revisions of the developed roadmap and the validation tool. A pilot test of the roadmap and validation tool was done using two stakeholders in South Africa. The roadmap and the validation tool were then sent to the stakeholders and potential end-users in Nigeria using electronic media. Two research assistants were also engaged to deliver and collect hard copies to those who preferred it. RESULTS: Of the ten stakeholders invited, nine responded. All participants showed an adequate understanding of the roadmap as evidenced by the scores given. Responses regarding the translation of the roadmap to implementation varied. The majority (86,6%) either strongly agreed or agreed that the actions were translatable (43.0 and 43.6% respectively). CONCLUSIONS: The final roadmap comprises of actions that are appropriate for the state's context. It is recommended that stakeholders or end-users of any programme must be involved in the validation of such contextual programmes to improve chances of success.

Intergenerational transfer of health inequalities: exploration of mechanisms in the Birth to Twenty cohort in South Africa.

South Africa's history of colonialism and Apartheid contributed to its extreme levels of inequality. Twenty-five years after the transition to democracy, socio-economic and health inequalities continue to rank among the highest in the world. The Birth to Twenty+ study follows a cohort born in urban Johannesburg in 1990 through their early lives and into young adulthood. Also known as 'Mandela's Children', these 'children of the '90s' were the first generation to be raised in a democratic society, whose elected government implemented policies to achieve greater socio-economic and health equality. Correlating early life outcomes to those of their parents provides a baseline estimate of intergenerational transmission of historical inequality. Analyses of their early life course indicates the potential breakdown in inequality in the first generation. This paper provides an overview of empirical results on intergenerational change in socio-economic status and health during South Africa's political transition. Access to infrastructural services improved, and poverty reduced following the rapid expansion of unconditional cash transfers mainly to children and pensioners. However, unemployment remained high and job discrimination continued. Inequalities in health follow similar patterns, and progress did not equate to convergence. Some catch-up physical growth occurred-both across groups and over time-but not sufficient to bridge cognitive inequalities. Socio-economic and health inequalities continued as the children of the '90s reached young adulthood. Based on knowledge of other transitions, it is likely that these inequalities will only start to break down in later generations, provided social and economic progress holds steady.

Examining the impact of WHO's Focused Antenatal Care policy on early access, underutilisation and quality of antenatal care services in Malawi: a retrospective study.

BACKGROUND: A variety of antenatal care models have been implemented in low and middle-income countries over the past decades, as proposed by the World Health Organisation (WHO). One such model is the 2001 Focused Antenatal Care (FANC) programme. FANC recommended a minimum of four visits for women with uncomplicated pregnancies and emphasised quality of care to improve both maternal and neonatal outcomes. Malawi adopted FANC in 2003, however, up to now no study has been done to analyse the model's performance with regards to antenatal care service quality and utilisation patterns. METHODS: The paper is based on data pooled from three comparable nationally representative Malawi Demographic and Health Survey (MDHS) datasets (2000, 2004 and 2010). The DHS collects data on demographics, socio-economic indicators, antenatal care, and the fertility history of reproductive women aged between 15 and 49. We pooled a sample of 8545 women who had a live birth in the last 5 years prior to each survey. We measure the impact of FANC on early access to care, underutilisation of care and quality of care with interrupted time series analysis. This method enables us to track changes in both levels and the trends of our outcome variables. RESULTS: We find that FANC is associated with earlier access to care. However, it has also been associated with unintended increases in underutilisation. We see no change in the quality of ANC services. CONCLUSION: In light of the WHO 2016 ANC guidelines, which recommend an increase of visits to eight, these results are important. Given that we find underutilisation when the benchmark is set at four visits, eight visits are unlikely to be feasible in low-resource settings.