Beliefs, values, and sociocultural patterns related to food safety in low- and middle-income countries: A synthesis of the descriptive ethnographic literature.

Foodborne disease is intimately connected to nutrition and causes considerable harm to health and economic wellbeing. Consumers play a key role in food safety, making it essential to understand the motivations, beliefs, and practices that shape their decisions. Ethnographic research methods are well suited to understanding such topics but have rarely been applied to food safety. This paper presents an evidence synthesis of ethnographic studies, with an emphasis on food safety beliefs, values, and related socio-cultural information, and a focus on consumers' purchasing behaviors. Vendor perspectives are also briefly considered. Key findings include the importance of trust, strategies to reduce risk, the effects of economic status and gender, and broader cultural concepts about foods that influence food purchasing. The synthesis demonstrates that there are numerous social and cultural factors that influence decision making related to food safety, offering insights for the design of interventions to reduce exposure to foodborne disease and improve nutrition.

Maternal caregiving capabilities are associated with child linear growth in rural Zimbabwe.

Between birth and 2 years, children's well-being depends on the quality of care they receive from caregivers, primarily their mothers. We developed a quantitative survey instrument to assess seven psychosocial characteristics of women that determine their caregiving ability ('maternal capabilities': physical health, mental health, decision-making autonomy, social support, mothering self-efficacy, workload and time stress, and gender norm attitudes). We measured maternal capabilities in 4,025 mothers and growth in their 4,073 children participating in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe. We used generalized estimating equation models with exchangeable correlation structure to test the association between each maternal capability during pregnancy, and infant length-for-age Z (LAZ) at 18 months, accounting only for within-cluster correlation and intervention arms in unadjusted analyses and for potential confounders in adjusted analyses to examine the association between each capability, assessed during pregnancy, with child LAZ at 18 months of age. In adjusted models, each unit increase in gender norm attitudes score (reflecting more equitable gender norm attitudes) was associated with +0.09 LAZ (95% CI: 0.02, 0.16) and a decreased odds of stunting (adjusted odds ratio [AOR]: 0.86; 95% CI: 0.74, 1.01); each unit increase in social support score was associated with +0.11 LAZ (95% CI: 0.05, 0.17, p < 0.010) and decreased odds of stunting (AOR: 0.83; 95% CI: 0.73, 0.96). Each unit increase in decision-making autonomy was associated with a 6% reduced odds of stunting (AOR: 0.94; 95% CI: 0.89, 0.996, p = 0.04). Interventions and social programming that strengthen these maternal capabilities may improve child nutritional status.

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.

Is there a "complementary feeding cultural core" in rural Kenya? Results from ethnographic research in five counties.

This investigation used data from focused ethnographic studies in five rural counties in Kenya to determine whether the concept of "special foods for infants and young children" exists in the different ethnic groups in these areas as an identifiable component of cultural beliefs and knowledge, as well as in practice, and whether they can be characterized as a "complementary feeding cultural core." The concept of "cultural core foods" refers to the set of foods that have a central role in diets of a population and, as a consequence, also have significant social and emotional components. We used the ethnographic cognitive mapping technique of "free listing" and a qualitative 24-hr recall of infants and young children (IYC) intake, with probing, to obtain data on caregivers' beliefs and behaviours. The results show that an IYC cultural food core can be identified in all of the counties. A related finding that supports the argument for an "IYC cultural core" with respect to appropriate foods for IYC is the clear cognitive consensus within sites about its content, although in practice, food insecurity and food shortage constrain household abilities to put their beliefs into practice. We conclude that interventions to improve IYC feeding in rural Kenya that build on the concept of "IYC cultural core foods" will be congruent with basic cultural ideas about managing IYC feeding and could take advantage of this cultural feature.

Ethiopian mothers' experiences with micronutrient powders: Perspectives from continuing and noncontinuing users.

As part of a formative evaluation of a micronutrient powder (MNP) trial in Ethiopia that was organized according to a programme impact pathway model, we conducted in-depth focused ethnographic interviews with caregivers of children between 6 and 23 months who had accepted to try "Desta," a locally branded MNP. After stratification into two subgroups by child age, respondents were randomly selected from lists of caregivers who had received MNP from government health workers between 1 and 3 months prior to the interview date. Thirty women who were either currently giving Desta to their child ("continuing users," n = 14) or had stopped feeding Desta ("noncontinuing users," n = 16) were purposefully recruited from both urban and rural areas in the two different regions where the trial was conducted. Interviews were recorded, transcribed and translated, and coded for both emerging and prespecified themes. On the basis of identifiable components in the caregiver adherence process, this paper focuses exclusively on factors that facilitated and inhibited "appropriate use" and "continued use." For "appropriate use," defined as the caregiver preparing and child consuming MNP as directed, we identified four common themes in caregiver narratives. With respect to "continued use," the caregiver providing and child consuming the minimum number of MNP sachets over a recommended time period, our interviews spontaneously elicited five themes. We also examined caregivers' perceptions related to problems in obtaining refills. Attention to caregivers' perspectives reflected in their narratives offers opportunities to improve MNP utilization in Ethiopia, with potential application in other social and cultural settings.

Designing an ethnographic interview for evaluation of micronutrient powder trial: Challenges and opportunities for implementation science.

The evidence base for micronutrient powder (MNP) interventions predominantly consists of quantitative studies focused on measuring coverage, utilization, and/or biological outcomes. We need other types of studies to broaden the scope of our knowledge about determinants of MNP programme effectiveness. Addressing this knowledge gap, this paper focuses on the process of designing an ethnographic research protocol to obtain caregivers' perspectives on the factors that influenced their use of intervention delivery services and their adherence to MNP recommendations. The research was undertaken within the context of formative evaluations conducted in Mozambique and Ethiopia. Ethnography provides a means for acquiring and interpreting this knowledge and is an approach particularly well suited for formative evaluation to understand the response of a population to new interventions and programme delivery processes. We describe decisions made and challenges encountered in developing the protocol, and their implications for advancing methodology in implementation research science. In addition to a core team of three investigators, we added an "advisory group" of 10 experts to advise us as we developed the protocol. The advisory group reviewed multiple drafts of the interview protocol and participated in mock interviews. In the protocol development process, we faced the issues and made decisions about concerned gaps in content, cultural adaptations and comprehension, and interview guide structure and format. Differences between the core team and the advisory group in methodological approaches to the structure and content of questions call attention to the importance of establishing greater communication among implementation scientists working in nutrition interventions.

Mixed methods evaluation explains bypassing of vouchers in micronutrient powder trial in Mozambique.

Micronutrient powders (MNP) are recommended by the World Health Organization as an effective intervention to address anaemia in children. A formative process evaluation was conducted to assess the viability of a model using free vouchers in two districts of Mozambique to deliver MNP and motivate adherence to recommendations regarding its use. The evaluation consisted of (a) an examination of programme outcomes using a cross-sectional survey among caregivers of children 6-23 months (n = 1,028) and (b) an ethnographic study to investigate delivery experiences and MNP use from caregiver perspectives (n = 59), programme managers (n = 17), and programme implementers (n = 168). Using a mixed methods approach allowed exploration of unexpected programme outcomes and triangulation of findings. The survey revealed that receiving a voucher was the main implementation bottleneck. Although few caregivers received vouchers (11.5%, CI [9.7, 13.6]), one-fourth received MNP by bypassing the voucher system (26.3%, CI [23.6, 29.0]). Caregivers' narratives indicated that caregivers were motivated to redeem vouchers but encountered obstacles, including not knowing where or how to redeem them or finding MNP were not available at the shop. Observing these challenges, many programme implementers redeemed vouchers and distributed MNP to caregivers. Virtually, all caregivers who received MNP reported ever feeding it to their child. This study's findings are consistent with other studies across a range of contexts suggesting that although programmes are generally effective in motivating initial use, more attention is required to improve access to MNP and support continued use.

Bottlenecks and predictors of coverage and adherence outcomes for a micronutrient powder program in Ethiopia.

A theory-driven evaluation was conducted to assess performance of a trial to deliver micronutrient powder (MNP) through the Ethiopian Ministry of Health. We adapted an approach to coverage assessment, originally developed to identify bottlenecks in health service delivery, to examine sequential program outcomes and their correlates using cross-sectional survey data of caregivers of children 6-23 months (N = 1915). Separate multivariable Poisson regression models were used to estimate adjusted risk ratios of conceptually relevant determinants of coverage and adherence. Caregivers of children >11 months were more likely to have received MNP than caregivers of younger infants, yet children 12-17 months were 32% (P < 0.001) and children 18-23 months 38% (P < 0.001) less likely to have been fed MNP in the 14 days preceding the survey than children 6-11 months. Among caregivers who initiated feeding MNP, the most frequently reported reasons for discontinuing use were not obtaining additional supply (36.1%) and perceived child rejection of food with MNP (22.9%). For each additional time a caregiver met with frontline workers in the 3 months preceding the survey, they were 13% more likely to have recently fed MNP (P < 0.001). Caregivers' perception that MNP produced positive changes in children was associated with a 14% increase in the likelihood of having recently fed it (P < 0.001). These results emphasize the importance of counselling for MNP and infant and young child feeding for initial use and the importance of multiple contacts with frontline workers for continued use.

The Pathways from a Behavior Change Communication Intervention to Infant and Young Child Feeding in Bangladesh Are Mediated and Potentiated by Maternal Self-Efficacy.

Background: Although self-efficacy is a potential determinant of feeding and care behaviors, there is limited empirical analysis of the role of maternal self-efficacy in low- and middle-income countries. In the context of behavior change interventions (BCIs) addressing complementary feeding (CF), it is possible that maternal self-efficacy can mediate or enhance intervention impacts. Objective: In the context of a BCI in Bangladesh, we studied the role of maternal self-efficacy for CF (MSE-CF) for 2 CF behaviors with the use of a theoretically grounded empirical model of determinants to illustrate the potential roles of MSE-CF. Methods: We developed and tested a locally relevant scale for MSE-CF and included it in a survey (n = 457 mothers of children aged 6-24 mo) conducted as part of a cluster-randomized evaluation. Qualitative research was used to inform the selection of 2 intervention-targeted behaviors: feeding green leafy vegetables in the last 24 h (GLV) and on-time introduction of egg (EGG) between 6 and 8 mo of age. We then examined direct, mediated, and potentiated paths of MSE-CF in relation to the impacts of the BCI on these behaviors with the use of regression and structural equation modeling. Results: GLV and EGG were higher in the intensive group than in the nonintensive control group (16.0 percentage points for GLV; P < 0.001; 11.2 percentage points for EGG; P = 0.037). For GLV, MSE-CF mediated (ß = 0.345, P = 0.010) and potentiated (ß = 0.390, P = 0.038) the effect of the intensive group. In contrast, MSE-CF did not mediate or potentiate the effect of the intervention on EGG. Conclusions: MSE-CF was a significant mediator and potentiator for GLV but not for EGG. The divergent findings highlight the complex determinants of individual specific infant and young child feeding behaviors. The study shows the value of measuring behavioral determinants, such as MSE-CF, that affect a caregiver's capability to adopt intervention-targeted behaviors.

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.

Adherence-Specific Social Support Enhances Adherence to Calcium Supplementation Regimens among Pregnant Women.

Background: WHO guidelines recommend integrating calcium supplementation into antenatal care (ANC) alongside iron and folic acid (IFA) to reduce maternal mortality. However, supplementation programs face multiple barriers, and strategies to improve adherence are needed. An adherence partner is someone whom pregnant women ask to support adherence at home.Objectives: This study 1) assessed adherence partner acceptability, feasibility, and associations with calcium and IFA supplement adherence and 2) examined relations between social support and adherence.Methods: This secondary analysis is from a trial integrating calcium supplementation into ANC in Kenya. ANC providers were trained on calcium and IFA supplementation and counseling, provided with behavior change materials, and given adequate supplement supplies. Pregnant women from 16 government health facilities were recruited (n = 1036); sociodemographic and adherence data were collected at baseline and at 4- to 6-wk follow-up visits. Adherence was measured with pill counts and self-reports. Culturally adapted scales measured social support in general and specific to adherence. Mixed-effects regression analyses were used to examine factors associated with adherence partners, social support, and adherence.Results: Most participants received information about adherence partners (91%) and had a partner at follow-up (89%). Participants with adherence partners reported higher adherence support (OR: 2.10; 95% CI: 1.32, 3.34). Mean ± SD adherence was high for calcium (88.3% ± 20.7%) and IFA (86.1% ± 20.9%). Adherence support was positively associated with calcium adherence at follow-up by using pill counts (OR: 2.2; 95% CI: 1.1, 2.6) and self-report data (OR: 1.9; 95% CI: 1.2, 2.9), but there was not a direct relation between adherence partners and adherence.Conclusions: Adherence support enhanced adherence to calcium supplements. The adherence partner strategy was highly acceptable and feasible but warrants further study. This research demonstrates the importance of adherence support and suggests that interventions to increase household-level support for antenatal micronutrient supplementation may be needed to implement the WHO guidelines. This trial was registered at clinicaltrials.gov as NCT02238704.

Adherence partners are an acceptable behaviour change strategy to support calcium and iron-folic acid supplementation among pregnant women in Ethiopia and Kenya.

Antenatal calcium and iron-folic acid (IFA) supplementation can reduce maternal mortality and morbidity. Yet, even when pregnant women have a stable supply of supplements, forgetting is often a barrier to adherence. We assessed the acceptability of adherence partners to support calcium and IFA supplementation among pregnant women in Kenya and Ethiopia. Adherence partners are a behaviour change strategy to improve adherence, where pregnant women are counselled to select a partner (e.g. spouse, relative) to remind them to take their supplements. We conducted trials of improved practices, a formative research method that follows participants over time as they try a new behaviour. We provided pregnant women in Ethiopia (n = 50) and Kenya (n = 35) with calcium and IFA supplements and counselling, and suggested selecting an adherence partner. For each participant, we conducted semi-structured interviews about acceptability and adherence during four interviews over six weeks. We analysed interview transcripts thematically and tallied numerical data. In Kenya, 28 of 35 women agreed to try an adherence partner; almost all selected their husbands. In Ethiopia, 42 of 50 women agreed to try an adherence partner; half asked their husbands, others asked children or relatives. Most women who did not select adherence partners reported not needing help or not having anyone to ask. Participants reported adherence partners reminded and encouraged them, brought supplements, provided food and helped address side-effects. Almost all women with adherence partners would recommend this strategy to others. Adherence partners are an acceptable, low-cost strategy with the potential to support antenatal micronutrient supplementation adherence.

Addressing epidemiological and public health analytic challenges in outcome and impact research: a commentary on 'Prechewing Infant Food, Consumption of Sweets and Dairy and Not Breastfeeding are Associated with Increased Diarrhea Risk of Ten Month Old Infants'.

Based on a paper by Conkle et al 2016, in which the authors use a descriptive epidemiological design to examine the relationship of premastication and other dietary behavioral variables to childhood diarrhea in the US, we address larger issues of "plausible causality" and the challenges involved in moving from epidemiological studies to public health policy. Drawing on examples from breastfeeding research and water, sanitation and hygiene (WASH) research, we discuss the following propositions: 1. Effective outcome analyses require simultaneous investigation of different, even contradictory, pathways; 2. Outcome versus impact assessments require different analytic procedures including context analysis; 3. Impact analysis requires understanding the trade-offs between detrimental and beneficial outcomes in relation to potential interventions; 4. No estimates exist for the likely detrimental and beneficial impacts of banning premastication, much less for their trade-offs.

Perspectives and reflections on the practice of behaviour change communication for infant and young child feeding.

Behaviour change communication (BCC) is a critical component of infant and young child feeding (IYCF) interventions. In this study we asked BCC practitioners working in low- and middle-income countries to participate in an examination of BCC practice. We focus here on results of their personal reflections related to larger issues of practice. We used a combination of iterative triangulation and snowball sampling procedures to obtain a sample of 29 BCC professionals. Major themes include (1) participants using tools and guidelines to structure their work, and many consider their organisation's tools to be their most important contribution to the field; (2) they value research to facilitate programme design and implementation; (3) half felt research needed to increase; (4) they have a strong commitment to respecting cultural beliefs and culturally appropriate programming; (5) they are concerned about lack of a strong theoretical foundation for their work. Based on participants' perspectives and the authors' reflections, we identified the following needs: (1) conducting a systematic examination of the alternative theoretical structures that are available for nutrition BCC, followed by a review of the evidence base and suggestions for future programmatic research to fill the gaps in knowledge; (2) developing a checklist of common patterns to facilitate efficiency in formative research; (3) developing an analytic compendium of current IYCF BCC guidelines and tools; (4) developing tools and guidelines that cover the full programme process, including use of innovative channels to support 'scaling up nutrition'; and (5) continued support for programmes of proven effectiveness.

The scope and practice of behaviour change communication to improve infant and young child feeding in low- and middle-income countries: results of a practitioner study in international development organizations.

We describe features of the landscape of behaviour change communication (BCC) practice devoted to infant and young child feeding (IYCF) in low- and middle-income countries by practitioners in international development organizations. We used an iterative, snowball sampling procedure to identify participants, and the self-administered questionnaire contained pre-coded questions and open-ended questions, relying primarily on content analysis to derive generalizations. Highlights of findings include (i) IYCF-specific BCC is usually delivered within the context of other public health messages and programmes; (ii) technical assistance with programme development and implementation are primary activities, and evaluation-related work is also common; and (iii) formative research and evaluation is universal, but process evaluation is not. With respect to scaling up nutrition: (i) use of mass media and digital technology generally play only a minor role in BCC activities and are not currently an integral part of BCC programming strategies and (ii) only 58% of the participants report activities related to communication with policy makers. The individuals who comprise the community of BCC leaders in the area of IYCF are a diverse group from the perspective of academic backgrounds and nationalities. In addition to nutrition, public health, agriculture and adult learning are common disciplinary backgrounds. In our view, this diversity is a source of strength. It facilitates continuing growth and maturation in the field by assuring inputs of different perspectives, theoretical orientations and experiences.

Design of an Intervention to Minimize Ingestion of Fecal Microbes by Young Children in Rural Zimbabwe.

We sought to develop a water, sanitation, and hygiene (WASH) intervention to minimize fecal-oral transmission among children aged 0-18 months in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial. We undertook 4 phases of formative research, comprising in-depth interviews, focus group discussions, behavior trials, and a combination of observations and microbiological sampling methods. The resulting WASH intervention comprises material inputs and behavior change communication to promote stool disposal, handwashing with soap, water treatment, protected exploratory play, and hygienic infant feeding. Nurture and disgust were found to be key motivators, and are used as emotional triggers. The concept of a safe play space for young children was particularly novel, and families were eager to implement this after learning about the risks of unprotected exploratory play. An iterative process of formative research was essential to create a sequenced and integrated longitudinal intervention for a SHINE household as it expects (during pregnancy) and then cares for a new child.

Identifying interventions to help rural Kenyan mothers cope with food insecurity: results of a focused ethnographic study.

An ethnographic study was conducted in two areas in southern and western Kenya to identify potential interventions to improve the quality, availability and affordability of foods consumed by infants and young children. A cultural-ecological model of determinants of nutrition identified the sectors of information for data collection related to infant and young child (IYC) diet and feeding-related behaviours, and the focused ethnographic study manual was used to guide the research. The results provide qualitative evidence about facilitators and constraints to IYC nutrition in the two geographical areas and document their inter-connections. We conclude with suggestions to consider 13 potential nutrition-sensitive interventions. The studies provide empirical ethnographic support for arguments concerning the importance of combining nutrition-specific and nutrition-sensitive interventions through a multi-sectoral, integrated approach to improve the nutrition of infants and young children in low-income, resource-constrained populations. They also document the value of ethnography as a component of landscape analysis in nutrition programme and policy planning. Key messages In addition to constraints on infant and young child diet that originate in environmental and technological conditions in both agro-ecological zones, other factors that affect feeding practices include features of social organisation, household access to social support, caregivers income-earning activities and their own health. The results of the ethnographies, which highlight the importance of obtaining the knowledge and perspectives of caregivers of infants and young children, reveal the interactions of the multiple factors that affect child nutrition and the need for simultaneous nutrition-sensitive interventions to complement nutrition-specific intervention actions. Most caregivers in both areas not only understood the importance of diet and food quality for child survival, they also regarded it as essential for child growth and development. This indicates that caregivers in these rural Kenyan communities have adopted the basic biomedical interpretation of the importance of child nutrition as an integral part of their 'knowledge frameworks'.

Using ethnography in implementation research to improve nutrition interventions in populations.

'Implementation research in nutrition' is an emerging area of study aimed at building evidence-based knowledge and sound theory to design and implement programs that will effectively deliver nutrition interventions. This paper describes some of the basic features of ethnography and illustrates its applications in components of the implementation process. We review the central purpose of ethnography, which is to obtain the emic view--the insider's perspective--and how ethnography has historically interfaced with nutrition. We present examples of ethnographic studies in relation to an analytic framework of the implementation process, situating them with respect to landscape analysis, formative research, process evaluation and impact evaluation. These examples, conducted in various parts of the world by different investigators, demonstrate how ethnography provided important, often essential, insights that influenced programming decisions or explained programme outcomes. Key messages Designing, implementing and evaluating interventions requires knowledge about the populations and communities in which interventions are situated, including knowledge from the 'emic' (insider's) perspective. Obtaining emic perspectives and analysing them in relation to cultural, economic and structural features of social organisation in societies is a central purpose of ethnography. Ethnography is an essential aspect of implementation research in nutrition, as it provides important insights for making decisions about appropriate interventions and delivery platforms; determining how best to fit aspects of programme design and implementation into different environmental and cultural contexts; opening the 'black box' in interventions to understand how delivery and utilisation processes affect programme outcomes or impacts; and understanding how programme impacts were achieved, or not.

Using implementation research for evidence-based programme development: a case study from Kenya.

The few available studies of programme effectiveness in nutrition find that programmes are less effective than would be predicted from the efficacy trials that are the basis for evidence-based programming. Some of these are due to gaps in utilisation within households. To a greater extent, these gaps can be attributed to problems in programme design and implementation. 'Implementation research in nutrition' is an emerging area of study aimed at addressing this problem, by building an evidence base and a sound theory to design and implement programmes that will effectively deliver nutrition interventions. The purpose of this supplement to Maternal & Child Nutrition is to contribute to this growing area of implementation research. The series of papers presented and the reflections for policymaking and programmes, combined with the reflections on the application of ethnography to this area of inquiry, illustrate the value of systematic research undertaken for the purpose of supporting the design of nutrition interventions that are appropriate for the specific populations in which they are undertaken.