ABSTRACT
Objectives: Little is known about how different delivery platforms can be used to reach at-risk populations with micronutrient-powders (MNPs). We conducted a process-evaluation of a marketbased model where frontline-workers (FLW) sell MNPs at home visits, and provide IYCFcounseling. We sought to understand factors influencing sales of MNPs, household awareness, purchase, and use. Methods: Within a cluster-randomized evaluation design where 5 sub-districts were assigned to the MNP+IYCF intervention and 5 sub-districts to the MNP-only intervention, we conducted surveys among FLWs and mothers with children 6-24-months in 2012 (n=462) and 2013 (n=500). Results: In the MNP+IYCF group, FLW awareness of MNP was high, and >90% reported having sold MNPs in 2013. However, intermittent gaps in upstream supply were a constraint to sales. Reach of the FLW-network was higher in the MNP+IYCF group (92%) compared to the MNP-only group (23%). Maternal MNP awareness was variable (68% in the MNP+IYCF group and 43% in the MNP-only group). Any purchase of MNPs from FLWs was higher in 2013 compared to 2012, ranging from 5-37%, with higher purchase in the IYCF+MNP group, and among higher SES households. In the IYCF+MNP group, households purchased a mean of 33 sachets during the previous 6-months, half the program recommendation. Qualitative research further indicates that child illness, and confusion around the recommended dose and appropriate use affect sustained use. Conclusions: Increases over time, in sales, awareness and purchase highlight the potential for this delivery model to succeed. However, strategies to raise awareness and messaging to support routine use appear necessary to achieve impact.
ABSTRACT
Objectives: In India, 79% of children less than three years are anemic. Intermittent iron supplementation, home-fortification with multiple micronutrient powders (MMP), and delayed cord clamping are scientifically recommended interventions to prevent pediatric anemia. Little is known about the extent to which these interventions are integrated into programs in India. Examine to what extent anemia control programs in India incorporate scientific recommendations and analyze their operational evidence-base. Methodology: We critically reviewed published (2000-2012) and grey literature, and government and non-government program documentation. Results: Published literature on interventions to reduce pediatric anemia in India is scant; there are six efficacy studies (1-delayed cord clamping; 1-use of MMP; 3- iron supplementation; 1- fortified milk) and no effectiveness studies. Intermittent iron supplementation delivered by frontline workers is the only intervention included in government programs. Only 2 of the 22 NGO programs reviewed provided iron supplements. Little is known about the operational successes and challenges on the demand and supply-side of the programs and of effectiveness of these programs. Neither national nor NGO programs include newer interventions such as MNPs or delayed cord-clamping. Conclusions: A poor evidence base on challenges and solutions to delivering iron supplementation in India precludes from strengthening operational strategies for iron supplementation. Lack of evidence on the efficacy and effectiveness of other recommended interventions prevents identification of alternate strategies for addressing pediatric anemia in India. A research agenda that focuses on closing these operational and effectiveness knowledge gaps is essential to make progress towards reducing the burden of anemia in India.
ABSTRACT
Objectives: Evidence-based solutions are available and there is global momentum for scaling up nutrition interventions. However, the impact of evidence-based interventions is limited by poor evidence on operational strategies for scaling up nutrition interventions. The objective of this work was to develop a framework to inform a larger research agenda around delivery and utilization of nutrition interventions. Methods: The paper draws on the deliberations of a high-level working group, a web-based econsultation, a conference of global nutrition experts and a review of the published literature. Based on these methods, the paper authors develop a framework and propose areas of research that have been quite neglected, and yet, are critical to enable better translation of global and national political momentum for nutrition into public health impact. Results: The framework includes distinct components, with embedded sub-elements: 1) the logic of results frameworks (inputs, processes, outcomes and impacts); 2) Program Impact Pathways and program theory; 3) "implementation core" elements related to midstream implementation processes; 4) contextual factors at multiple evels; 5) the enabling policy environment and governance; and 6) strategic and management capacities for commitment-building, adaptive management and sustainability. Each framework component is expandable and the overall framework is adaptable to different nutrition interventions and settings. Examples are provided from behavior change communications and micronutrient interventions. Conclusions: A systematic and complete understanding of program implementation, service delivery and coverage, using the framework and research approaches identified in this review, can strengthen successful scale-up and sustain actions for nutrition.
ABSTRACT
Indicators of family care for development are essential for ascertaining whether families are providing their children with an environment that leads to positive developmental outcomes. This project aimed to develop indicators from a set of items, measuring family care practices and resources important for caregiving, for use in epidemiologic surveys in developing countries. A mixed method (quantitative and qualitative) design was used for item selection and evaluation. Qualitative and quantitative analyses were conducted to examine the validity of candidate items in several country samples. Qualitative methods included the use of global expert panels to identify and evaluate the performance of each candidate item as well as in-country focus groups to test the content validity of the items. The quantitative methods included analyses of item-response distributions, using bivariate techniques. The selected items measured two family care practices (support for learning/stimulating environment and limit-setting techniques) and caregiving resources (adequacy of the alternate caregiver when the mother worked). Six play-activity items, indicative of support for learning/stimulating environment, were included in the core module of UNICEF’s Multiple Cluster Indictor Survey 3. The other items were included in optional modules. This project provided, for the first time, a globally-relevant set of items for assessing family care practices and resources in epidemiological surveys. These items have multiple uses, including national monitoring and cross-country comparisons of the status of family care for development used globally. The obtained information will reinforce attention to efforts to improve the support for development of children.