Food Systems Interventions for Nutrition: Lessons from 6 Program Evaluations in Africa and South Asia.

Although there is growing global momentum behind food systems strategies to improve planetary and human health-including nutrition-there is limited evidence of what types of food systems interventions work. Evaluating these types of interventions is challenging due to their complex and dynamic nature and lack of fit with standard evaluation methods. In this article, we draw on a portfolio of 6 evaluations of food systems interventions in Africa and South Asia that were intended to improve nutrition. We identify key methodological challenges and formulate recommendations to improve the quality of such studies. We highlight 5 challenges: a lack of evidence base to justify the intervention, the dynamic and multifaceted nature of the interventions, addressing attribution, collecting or accessing accurate and timely data, and defining and measuring appropriate outcomes. In addition to more specific guidance, we identify 6 cross-cutting recommendations, including a need to use multiple and diverse methods and flexible designs. We also note that these evaluation challenges present opportunities to develop new methods and highlight several specific needs in this space.

Using Novel Multimethod Evaluation Approaches to Understand Complex Food System Interventions: Insights from a Supply Chain Intervention Intended to Improve Nutrition.

Background: A "food system" approach to improve diet quality by intervening within areas such as food supply chains is gaining prominence. However, evidence of such interventions' impact, and understanding of appropriate methods to evaluate them, is lacking. Objectives: We present an impact evaluation of an intervention that aimed to increase consumption of nutritious foods by supporting food-producing firms in Kenya. In doing so, we demonstrate how multiple methods, including those from other disciplines, can be used to evaluate a complex food systems intervention. Methods: Four methods focused on food-producing firms and their management, including a survey of intervention participants (n = 83 individuals), a "laboratory-in-the-field" experiment (n = 83 individuals), baseline/endline data on firm performance (n = 71 firms), and semistructured interviews (n = 19 firms). Three methods focused on consumers in neighborhoods targeted by a supported firm: a randomized field experiment tested effects of making a supported product exhaustively available on consumers' purchases and consumption (n = 1295 consumers); 3 discrete choice experiments (n = 1295 consumers) tested factors influencing consumers' willingness to pay for foods with relevant characteristics. Results: Among firms, we saw suggestive evidence of increased networking and business relationships, while laboratory-in-the-field experiments indicated the intervention might foster cooperation among participants. Qualitative interviews suggested that the intervention enabled firms to increase production, improve management, increase revenues, and lower costs. Baseline/endline data confirmed a positive effect only on the launch of new products and hiring workers. In the field experiment, consumption of the supported product increased in areas where it was made available relative to a control group, but this did not increase overall consumption of the food type or dietary diversity. Conclusions: Results showed positive signs of the intervention improving firm-level outcomes but limited impact on consumers' diet quality. The evaluation also demonstrates how diverse methods can be used to evaluate complex interventions.

The epidemiology of spontaneous fever and hypothermia on admission of brain injury patients to intensive care units: a multicenter cohort study.

OBJECTIVES: Fever and hypothermia (dysthermia) are associated with poor outcomes in patients with brain injuries. The authors sought to study the epidemiology of dysthermia on admission to the intensive care unit (ICU) and the effect on in-hospital case fatality in a mixed cohort of patients with brain injuries. METHODS: The authors conducted a multicenter retrospective cohort study in 94 ICUs in the United States. Critically ill patients with neurological injuries, including acute ischemic stroke (AIS), aneurysmal subarachnoid hemorrhage (aSAH), intracerebral hemorrhage (ICH), and traumatic brain injury (TBI), who were older than 17 years and consecutively admitted to the ICU from 2003 to 2008 were selected for analysis. RESULTS: In total, 13,587 patients were included in this study; AIS was diagnosed in 2973 patients (22%), ICH in 4192 (31%), aSAH in 2346 (17%), and TBI in 4076 (30%). On admission to the ICU, fever was more common among TBI and aSAH patients, and hypothermia was more common among ICH patients. In-hospital case fatality was more common among patients with hypothermia (OR 12.7, 95% CI 8.4-19.4) than among those with fever (OR 1.9, 95% CI 1.7-2.1). Compared with patients with ICH (OR 2.0, 95% CI 1.8-2.3), TBI (OR 1.5, 95% CI 1.3-1.8), and aSAH (OR 1.4, 95% CI 1.2-1.7), patients with AIS who developed fever had the highest risk of death (OR 3.1, 95% CI 2.5-3.7). Although all hypothermic patients had an increased mortality rate, this increase was not significantly different across subgroups. In a multivariable analysis, when adjusted for all other confounders, exposure to fever (adjusted OR 1.3, 95% CI 1.1-1.5) or hypothermia (adjusted OR 7.8, 95% CI 3.9-15.4) on admission to the ICU was found to be significantly associated with in-hospital case fatality. CONCLUSIONS: Fever is frequently encountered in the acute phase of brain injury, and a small proportion of patients with brain injuries may also develop spontaneous hypothermia. The effect of fever on mortality rates differed by neurological diagnosis. Both early spontaneous fever and hypothermia conferred a higher risk of in-hospital death after brain injury.