Promoting Child Growth and Development in the Sustainable Development Goals Era: Is It Time for New Thinking?

Growth monitoring and promotion (GMP) programs have been implemented worldwide for decades. Consistent evidence of their effectiveness is lacking and complicated by design and operational differences. Nevertheless, tracking child growth and development is a fundamental component of routine preventive child health care, and governments in 178 countries implement some form of GMP. This article makes the point that despite implementation challenges, there is a compelling need for GMP. It enables a crucial dialogue with families and communities about how to support the healthy growth and development of their children and can be a powerful tool for stimulating action and accountability for child nutrition and development at household, community, subnational, and national levels. We propose that GMP deserves a fresh rethink, with a paradigm shift that tailors GMP programs and activities for different development, geographic, and cultural contexts and considers how to optimize implementation for scalability.

Impact Evaluation of a Comprehensive Nutrition Program for Reducing Stunting in Children Aged 6-23 Months in Rural Malawi.

BACKGROUND: The prevalence of stunting in central rural Malawi is ∼50%, which prompted a multipronged nutrition program in 1 district from 2014 to 2016. The program distributed a daily, fortified, small-quantity lipid-based nutritional supplement, providing 110 kcal and 2.6 g of protein to children aged 6-23 mo, and behavior change messages around optimal infant and young child feeding (IYCF) and water, sanitation, and hygiene. OBJECTIVES: Our objective was to perform an impact evaluation of the program using a neighboring district as comparison. METHODS: Using a quasi-experimental study design, with cross-sectional baseline (January-March, 2014; n = 2404) and endline (January-March, 2017; n = 2453) surveys, we evaluated the program's impact using a neighboring district as comparison. Impact on stunting was estimated using propensity score weighted difference-in-differences regression analyses to account for baseline differences between districts. RESULTS: No differences in mean length-for-age z-score or prevalence of stunting were found at endline. However, mean weight, weight-for-length z-score, and mid-upper arm circumference were higher at endline by 150 g, 0.22, and 0.19 cm, respectively, in the program compared with the comparison district (all P < 0.05). Weekly reports of high fever and malaria were also lower by 6.4 and 4.7 percentage points, respectively, in the program compared with the comparison district (both P < 0.05). There was no impact on anemia. Children's dietary diversity score improved by 0.17, and caregivers' infant and young child feeding and hand-washing practices improved by 8-11% in the program compared with the comparison district (all P < 0.05). CONCLUSIONS: An impact evaluation of a comprehensive nutrition program in rural Malawi demonstrated benefit for child ponderal growth and health, improved maternal IYCF and hand-washing practices, but a reduction in stunting prevalence was not observed.

Household food insecurity is associated with low dietary diversity among pregnant and lactating women in rural Malawi.

OBJECTIVE: To examine the association between household food insecurity and dietary diversity in the past 24h (dietary diversity score (DDS, range: 0-9); minimum dietary diversity (MDD, consumption of three or more food groups); consumption of nine separate food groups) among pregnant and lactating women in rural Malawi. DESIGN: Cross-sectional study. SETTING: Two rural districts in Central Malawi. SUBJECTS: Pregnant (n 589) and lactating (n 641) women. RESULTS: Of surveyed pregnant and lactating women, 66·7 and 68·6 %, respectively, experienced moderate or severe food insecurity and only 32·4 and 28·1 %, respectively, met MDD. Compared with food-secure pregnant women, those who reported severe food insecurity had a 0·36 lower DDS (P<0·05) and more than threefold higher risk (OR; 95 % CI) of not consuming meat/fish (3·19; CI 1·68, 6·03). The risk of not consuming eggs (3·77; 1·04, 13·7) was higher among moderately food-insecure pregnant women. Compared with food-secure lactating women, those who reported mild, moderate and severe food insecurity showed a 0·36, 0·44 and 0·62 lower DDS, respectively (all P<0·05). The risk of not achieving MDD was higher among moderately (1·95; 1·06, 3·59) and severely (2·82; 1·53, 5·22) food-insecure lactating women. The risk of not consuming meat/fish and eggs increased in a dose-response manner among lactating women experiencing mild (1·75; 1·01, 3·03 and 2·81; 1·09, 7·25), moderate (2·66; 1·47, 4·82 and 3·75; 1·40, 10·0) and severe (5·33; 2·63, 10·8 and 3·47; 1·19, 10·1) food insecurity. CONCLUSIONS: Addressing food insecurity during and after pregnancy needs to be considered when designing nutrition programmes aiming to increase dietary diversity in rural Malawi.

Physical and sociocultural facilitators and barriers to access and utilization of a nutrition program in rural Malawi: a qualitative study.

Childhood stunting holds consequences for child development. A nutrition program delivering small-quantity lipid based nutrient supplements (SQ-LNS) to children 6-23 months and child feeding messages was implemented in Malawi to reduce stunting. This study sought to understand the facilitators and barriers to program participation using in-depth interviews, pile sorts, direct observations, and focus group discussions with caretakers, village leaders and program volunteers. Perceptions of the LNS were positive, and visible changes in child health contributed to program participation. Conflicting priorities that prevented monthly collection of SQ-LNS and limited knowledge of child feeding messages constituted barriers to program participation.

Delivery platforms for reaching adolescents with nutrition interventions in low- and middle-income countries.

Adolescents in low- and middle-income countries (LMICs) are a vulnerable population given increased nutritional needs as puberty approaches. School-based nutrition programs exist in some settings, but the comprehensive provision of nutrition services requires knowledge of the mechanisms to reach out-of-school adolescents. A comprehensive scoping review was performed using formal and informal search strategies to landscape all potential delivery platforms with nutrition services to reach adolescents. Peer-reviewed studies, institutional strategies, program evaluations, and programmatic reports in LMICs were reviewed, including gray literature. A total of 87 out of 270 identified publications and reports describing nutrition programs for adolescents were identified. Although nutrition programs targeted at adolescents were sparse, various innovative and inclusive delivery platforms were included, such as school feeding programs, school-based anemia control, and nutrition-friendly school initiatives; health facility-based, youth-friendly health and nutrition services; social safety nets targeted at adolescents; community-based approaches targeting youth development and peer education within youth centers and faith-based settings; and technology-based platforms, including digital health services and mass media communication sensitization and mobilization efforts. Existing delivery mechanisms and platforms in health and other sectors that target adolescents offer great potential to extend nutrition interventions to this vulnerable yet hard-to-reach population.

Resilience of front-line facilities during COVID-19: evidence from cross-sectional rapid surveys in eight low- and middle-income countries.

Responsive primary health-care facilities are the foundation of resilient health systems, yet little is known about facility-level processes that contribute to the continuity of essential services during a crisis. This paper describes the aspects of primary health-care facility resilience to coronavirus disease 2019 (COVID-19) in eight countries. Rapid-cycle phone surveys were conducted with health facility managers in Bangladesh, Burkina Faso, Chad, Guatemala, Guinea, Liberia, Malawi and Nigeria between August 2020 and December 2021. Responses were mapped to a validated health facility resilience framework and coded as binary variables for whether a facility demonstrated capacity in eight areas: removing barriers to accessing services, infection control, workforce, surge capacity, financing, critical infrastructure, risk communications, and medical supplies and equipment. These self-reported capacities were summarized nationally and validated with the ministries of health. The analysis of service volume data determined the outcome: maintenance of essential health services. Of primary health-care facilities, 1,453 were surveyed. Facilities maintained between 84% and 97% of the expected outpatient services, except for Bangladesh, where 69% of the expected outpatient consultations were conducted between March 2020 and December 2021. For Burkina Faso, Chad, Guatemala, Guinea and Nigeria, critical infrastructure was the largest constraint in resilience capabilities (47%, 14%, 51%, 9% and 29% of facilities demonstrated capacity, respectively). Medical supplies and equipment were the largest constraints for Liberia and Malawi (15% and 48% of facilities demonstrating capacity, respectively). In Bangladesh, the largest constraint was workforce and staffing, where 44% of facilities experienced moderate to severe challenges with human resources during the pandemic. The largest constraints in facility resilience during COVID-19 were related to health systems building blocks. These challenges likely existed before the pandemic, suggesting the need for strategic investments and reforms in core capacities of comprehensive primary health-care systems to improve resilience to future shocks.

Availability and use of personal protective equipment in low- and middle-income countries during the COVID-19 pandemic.

BACKGROUND: Availability and appropriate use of personal protective equipment (PPE) is of particular importance in Low and Middle-Income countries (LMICs) where disease outbreaks other than COVID-19 are frequent and health workers are scarce. This study assesses the availability of necessary PPE items during the COVID-19 pandemic at health facilities in seven LMICs. METHODS: Data were collected using a rapid-cycle survey among 1554 health facilities in seven LMICs via phone-based surveys between August 2020 and December 2021. We gathered data on the availability of World Health Organization (WHO)-recommended PPE items and the use of items when examining patients suspected to be infected with COVID-19. We further investigated the implementation of service adaptation measures in a severe shortage of PPE. RESULTS: There were major deficiencies in PPE availability at health facilities. Almost 3 out of 10 health facilities reported a stock-out of medical masks on the survey day. Forty-six percent of facilities did not have respirator masks, and 16% did not have any gloves. We show that only 43% of health facilities had sufficient PPE to comply with WHO guidelines. Even when all items were available, healthcare workers treating COVID-19 suspected patients were reported to wear all the recommended equipment in only 61% of health facilities. We did not find a statistically significant difference in implementing service adaptation measures between facilities experiencing a severe shortage or not. CONCLUSION: After more than a year into the COVID-19 pandemic, the overall availability of PPE remained low in our sample of low and middle-income countries. Although essential, the availability of PPE did not guarantee the proper use of the equipment. The lack of PPE availability and improper use of available PPE enable preventable COVID-19 transmission in health facilities, leading to greater morbidity and mortality and risking the continuity of service delivery by healthcare workers.

Adaptive Implementation of a Community Nutrition and Asset Transfer Program during the COVID-19 Pandemic in Rural Bangladesh.

Background: Reduced health and nutrition services as a result of coronavirus disease 2019 (COVID-19) measures endanger children's well-being. The Bangladesh Rajshahi Division of Maternal and Child Nutrition (BRDMCN; 2018-2020) involving social behavior change communication (SBCC) and an economic development (ED) of asset transfer was implemented. Objectives: This study describes how the implementation modality of the BRDMCN was adapted, and changes in the program's short/intermediate-term outcomes during the COVID-19 pandemic compared with pre-pandemic. Methods: The following evaluation components were assessed: 1) program fidelity, 2) program reach, 3) program acceptance, 4) perceived influence of COVID-19, and 5) short-term outcomes over the 3 y. We compared the first 2 y ("pre-COVID-19," from April 2018 through December 2019) and the final year ("during COVID-19," from January to December 2020) for all components except for (3) and (4). Data were collected through multiple sources: reviews of program annual progress reports, monitoring records of SBCC and ED programs, and cohort surveys (n = 1094). Results: The percentage dose delivery of activities decreased from 66.7-118% at pre-COVID-19 to 0-90% during COVID-19. The SBCC programs were altered to reduce the frequency of activities as well as the number of participants per session. The ED program involving large group meetings was modified to include within-member meetings, individual visits of community facilitators, or virtual discussions. Production activity using received assets continued during the pandemic, with no significant reduction compared with pre-COVID-19. The percentage of children recovering from underweight after 30 d of a Positive deviance/Hearth (PD/Hearth) session, a component of the SBCC program, remained constant at 16.5-20.3 percentage points before and during the COVID-19 pandemic. Conclusions: Program activities were scaled back and changed due to the pandemic. The BRDMCN maintained asset management and the degree of short-term outcomes over the course of a 3-y project. Further study is required to determine whether adaptive program management would achieve the long-term expected impact at a population level.

Considerations for Monitoring School Health and Nutrition Programs.

School health and nutrition (SHN) interventions are among the most ubiquitous public health investments and comprise a key mechanism for reaching populations that are otherwise difficult to reach through the health system. Despite the critical role of monitoring these multisectoral programs to enable data-informed adaptive programming, information to guide program implementers is scant. This manuscript provides an overview of how monitoring indicators can be selected across a SHN program's logical framework, with specific examples across five SHN implementation models. Adaptation of SHN programs in times of school closures, such as those currently being experienced globally due to the emergence of COVID-19, is also addressed. Key aspects of SHN program monitoring are explored, including: (1) why monitor; (2) what to measure; (3) how to measure; and (4) who measures. In situations of school closures, strategies to shift both program activities and corresponding monitoring mechanisms are critical to understanding the rapidly evolving situation and subsequently guiding policy actions to protect vulnerable populations.

A longitudinal impact evaluation of a comprehensive nutrition program for reducing stunting among children aged 6-23 months in rural Malawi.

BACKGROUND: Growth failure in sub-Saharan Africa leads to a high prevalence of child stunting starting in infancy, and is attributed to dietary inadequacy, poor hygiene, and morbidity. OBJECTIVES: To evaluate the impact of a program in Malawi providing a lipid-based nutrient supplement to infants from 6-23 months of age, accompanied by a social and behavior change communication intervention to optimize caregiver feeding and handwashing practices. METHODS: This impact evaluation was a quasi-experimental, longitudinal study with 1 program and 1 comparison district. Infants were enrolled at 6-7 months of age. Anthropometry, child morbidity, and caregiver feeding and handwashing practices were assessed at enrollment and at 6, 12, and 18 month follow-ups (ages 6, 12, 18, and 24 months, respectively). Changes in the length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and midupper arm circumference (MUAC) were compared using mixed-effects models. Program impacts on child stunting (LAZ < -2), wasting (WLZ < -2), morbidity, and feeding and handwashing practices were estimated using difference-in-differences. RESULTS: We enrolled 367 infants across the program (n = 176) and comparison (n = 191) districts. The combined prevalences of stunting and wasting at enrollment were 42.1% and 1.4%, respectively, and did not differ by district. At enrollment, the prevalence of severe stunting (LAZ < -3) was higher in the program (15.5%) versus comparison (7.6%) district (P = 0.02), with corresponding lower LAZ scores (-1.9 vs. -1.7, respectively; P = 0.12). Growth velocities favored program children, such that LAZ, WLZ, and MUAC measurements increased by +0.12/y (P = 0.06), +0.12/y (P = 0.04), and +0.24 cm/y (P < 0.001), respectively, leading to comparable LAZ distributions across districts by 24 months of age. Program exposure was associated with 19.8 percentage point (pp) and 13.8 pp reductions in the prevalences of malaria (P = 0.001) and fever (P = 0.02), respectively, at the 18-month follow-up. Improvements of 20 pp (P < 0.01) in minimum dietary diversity and minimum acceptable diet were seen in the program versus comparison district at 18 months of follow-up. CONCLUSIONS: The program improved child growth patterns, with benefits to health and diet apparent after 18 months of exposure. This trial was registered at clinicaltrials.gov as NCT02985359.

Process Evaluation of a Large-Scale Community-Based Nutrition Program in Malawi.

BACKGROUND: Global attention to the study of nutrition program implementation has been inadequate yet is critical for effective delivery and impact at scale. OBJECTIVES: The objective of this mixed-methods process evaluation study was to measure the recruitment, fidelity, and reach of a large-scale, community-based nutrition program in Malawi. METHODS: The nutrition program delivered a small-quantity lipid-based nutrient supplement (SQ-LNS) and social and behavior change communication (SBCC) to improve infant and young child feeding (IYCF) and water, sanitation, and hygiene (WASH) practices in households with children aged 6-23 mo. Program monitoring and evaluation data were used to measure program recruitment, reach, and fidelity. Structured direct observations and knowledge questionnaires with program volunteers measured quality aspects of program fidelity. The number of times activities were done correctly was used to tabulate proportions used to represent program functioning. RESULTS: Half (49.5%) of eligible children redeemed program benefits by 8 mo of age during the first 4 y of program implementation. Implementation of training activities for SBCC cadres exceeded program targets (100.6%), but the completion of certain modules (breastfeeding and complementary feeding) was lower (22.9% and 18.6%, respectively). Knowledge of IYCF, WASH, and SQ-LNS messages by volunteers was >85% for most messages, except ability to list the 6 food groups (35.7%). Structured direct observations of SQ-LNS distributions indicated high fidelity to program design, whereas those of household-level counseling sessions revealed lack of age-appropriate messaging. Program reach showed participation in monthly distribution sessions of 81.0%, group counseling of 93.3%, and individual-level counseling of 36.9%. CONCLUSIONS: This community-based nutrition program was implemented with high fidelity and quality, with specific interventions requiring further attention. The documentation of implementation contributes to our understanding about how program impacts were achieved.

Monitoring and evaluation design of Malawi's Right Foods at the Right Time nutrition program.

Child stunting is a public health problem in Malawi. In 2014, the Government of Malawi launched the Right Foods at the Right Time (RFRT) program in Ntchisi district delivering nutrition social and behavior change communication, a small-quantity lipid-based nutrient supplement to children 6-23 months, and nutrition sensitive activities. Monitoring and evaluation (M&E) systems are key aspects of successful program implementation. We describe these and the methodology for an impact evaluation that was conducted for this program. Two monitoring systems using traditional and electronic platforms were established to register and track program delivery and processes including number of eligible beneficiaries, worker performance, program participation, and to monitor input, output, and outcome indicators. The impact evaluation used comparative cross-sectional and longitudinal designs to assess impact on anthropometric and infant and young child feeding outcomes. Three cross-sectional surveys (base-, mid-, and end-line) and two longitudinal cohorts of children followed in 6-month intervals from 6 to 24 months of age, were conducted in sampled households in the program and a neighboring comparison district. Additional M&E included qualitative studies, a process evaluation, and a cost-effectiveness study. The current paper describes lessons from this program's M&E, and demonstrates how multiple implementation research activities can inform course-correction and program scale-up.

Global Update and Trends of Hidden Hunger, 1995-2011: The Hidden Hunger Index.

BACKGROUND: Deficiencies in essential vitamins and minerals-also termed hidden hunger-are pervasive and hold negative consequences for the cognitive and physical development of children. METHODS: This analysis evaluates the change in hidden hunger over time in the form of one composite indicator-the Hidden Hunger Index (HHI)-using an unweighted average of prevalence estimates from the Nutrition Impact Model Study for anemia due to iron deficiency, vitamin A deficiency, and stunting (used as a proxy indicator for zinc deficiency). Net changes from 1995-2011 and population weighted regional means for various time periods are measured. FINDINGS: Globally, hidden hunger improved (-6.7 net change in HHI) from 1995-2011. Africa was the only region to see a deterioration in hidden hunger (+1.9) over the studied time period; East Asia and the Pacific performed exceptionally well (-13.0), while other regions improved only slightly. Improvements in HHI were mostly due to reductions in zinc and vitamin A deficiencies, while anemia due to iron deficiency persisted and even increased. INTERPRETATION: This analysis is critical for informing and tracking the impact of policy and programmatic efforts to reduce micronutrient deficiencies, to advance the global nutrition agenda, and to achieve the Millennium Development Goals (MDGs). However, there remains an unmet need to invest in gathering frequent, nationally representative, high-quality micronutrient data as we renew our efforts to scale up nutrition, and as we enter the post-2015 development agenda. FUNDING: Preparation of this manuscript was funded by Sight and Life. There was no funding involved in the study design, data collection, analysis, or decision to publish.