The role of national nutrition programs on stunting reduction in Rwanda using machine learning classifiers: a retrospective study.

BACKGROUND: In Rwanda, the prevalence of childhood stunting has slightly decreased over the past five years, from 38% in 2015 to about 33% in 2020. It is evident whether Rwanda's multi-sectorial approach to reducing child stunting is consistent with the available scientific knowledge. The study was to examine the benefits of national nutrition programs on stunting reduction under two years in Rwanda using machine learning classifiers. METHODS: Data from the Rwanda DHS 2015-2020, MEIS and LODA household survey were used. By evaluating the best method for predicting the stunting reduction status of children under two years old, the five machine learning algorithms were modelled: Support Vector Machine, Logistic Regression, K-Near Neighbor, Random Forest, and Decision Tree. The study estimated the hazard ratio for the Cox Proportional Hazard Model and drew the Kaplan-Meier curve to compare the survivor risk of being stunted between program beneficiaries and non-beneficiaries. Logistic regression was used to identify the nutrition programs related to stunting reduction. Precision, recall, F1 score, accuracy, and Area under the Curve (AUC) are the metrics that were used to evaluate each classifier's performance to find the best one. RESULTS: Based on the provided data, the study revealed that the early childhood development (ECD) program (p-value = 0.041), nutrition sensitive direct support (NSDS) program (p-value = 0.03), ubudehe category (p-value = 0.000), toilet facility (p-value = 0.000), antenatal care (ANC) 4 visits (p-value = 0.002), fortified blended food (FBF) program (p-value = 0.038) and vaccination (p-value = 0.04) were found to be significant predictors of stunting reduction among under two children in Rwanda. Additionally, beneficiaries of early childhood development (p < .0001), nutrition sensitive direct support (p = 0.0055), antenatal care (p = 0.0343), Fortified Blended Food (p = 0.0136) and vaccination (p = 0.0355) had a lower risk of stunting than non-beneficiaries. Finally, Random Forest performed better than other classifiers, with precision scores of 83.7%, recall scores of 90.7%, F1 scores of 87.1%, accuracy scores of 83.9%, and AUC scores of 82.4%. CONCLUSION: The early childhood development (ECD) program, receiving the nutrition sensitive direct support (NSDS) program, focusing on households with the lowest wealth quintile (ubudehe category), sanitation facilities, visiting health care providers four times, receiving fortified blended food (FBF), and receiving all necessary vaccines are what determine the stunting reduction under two among the 17 districts of Rwanda. Finally, when compared to other models, Random Forest was shown to be the best machine learning (ML) classifier. Random forest is the best classifier for predicting the stunting reduction status of children under two years old.

Identifying measures for coverage of nutrition-sensitive social protection programs: Learnings from India.

Optimal child growth requires a combination of nutrition-specific and sensitive interventions in the first 1,000 days. There is limited guidance on how to measure the population-level coverage of nutrition-sensitive social protection (NSSP), which is designed with explicit nutrition goals and often provides food or cash transfers and co-coverage with nutrition and health intervention. In this study in India, we designed a questionnaire that captures seven core NSSP program elements (transfer type, size, modality, population, timing, provider, conditionalities), then used cognitive testing to refine the questionnaire, and then implemented the questions as part of a telephone survey. Cognitive testing indicated variability in understanding the terms used to specify NSSP programs, including the need to use regional program names. Respondents also had difficulty recalling the timing of the benefit receipt. We included the refined NSSP coverage questions in a phone-based survey with 6,627 mothers with children <2 years across six states. Coverage of subsidized food was 73% across all households. Women were more likely to report receiving food than cash transfers during pregnancy (89% vs. 60%) and during lactation (75% vs. 13%). Co-coverage of NSSP with nutrition and health interventions during pregnancy (16%) and early childhood (3%) was low. It was feasible to measure coverage of NSSP investments in these populations; however, further research is needed to comprehensively assess all the dimensions of the NSSP benefits, including benefit adequacy and the validity of these questions when administered in person and by phone.

Systematic review on the impacts of agricultural interventions on food security and nutrition in complex humanitarian emergency settings.

Complex humanitarian emergencies are a main driver of food and nutritional insecurity. Agricultural interventions are key to improving nutrition and food security, and their positive impacts are well-documented in stable developing countries. However, it is unclear if their positive effects on food security hold in complex emergency settings, too. In this paper, we systematically review empirical articles that apply rigorous designs to assess the causal impacts of agricultural interventions on food security, nutrition, or health outcomes in complex humanitarian emergencies. We only find six articles matching these criteria, which have mixed results on dietary diversity and food security, and little evidence on child nutrition. Our review underscores the need for more rigorous research on the impacts of agricultural interventions in complex humanitarian emergency settings.

Impact of a Homestead Food Production Program on Dietary Diversity: Seasonal and Annual Results from the Cluster-Randomized FAARM Trial in Sylhet, Bangladesh.

BACKGROUND: Rice-predominant diets are common in Bangladesh, leading to widespread nutritional deficiencies. The Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial in rural Sylhet, Bangladesh evaluated a homestead food production intervention implemented 2015-2018 through Helen Keller International, aiming to improve child growth. OBJECTIVES: We estimated the intervention's impact on women's and children's dietary diversity, a secondary trial objective. METHODS: We collected dietary diversity throughout the trial (March 2015 to June 2020) at multiple times each year using standard, United Nations-endorsed, self-reported measures for women (10-food group scale) and children (7-food group scale). We included 28,282 observations of 2701 women (out of 2705 enrolled) and 17,445 observations of their 3257 children (aged 6-37 mo) in 96 settlements, 48 of which received the intervention. We estimated the intervention's impact on dietary diversity by year of intervention, overall periods following the start of the intervention, and seasonally, using multilevel regression with the control group as the counterfactual, controlling for seasonality, baseline dietary diversity, and clustering by settlement and repeated measures. RESULTS: At baseline, approximately one-third of women and children consumed a minimally diverse diet. Over the entire intervention and postintervention period, women's and children's odds of consuming a minimally diverse diet nearly doubled (odds ratio [OR] 1.8, P < 0.001, for both). This benefit was barely present in the first year, increased in the second, and peaked in the last intervention year (OR 2.4 for women, OR 2.5 for children, both P < 0.001) before settling at around double the odds in postintervention years (P < 0.001). Dietary improvement was observed throughout the year for both women and children with incremental increases in nearly all food groups. CONCLUSIONS: The nutrition-sensitive agriculture intervention successfully increased dietary diversity in women and children, and these impacts persisted after the project closed, including during the early COVID 19 lockdown period. This trial was registered at clinicaltrials.gov as NCT02505711.

Child development beyond the nutrition-specific models: bridging the pathways via psychosocial stimulation.

Background: Undernutrition has severe and lasting consequences on child development. Evidently, the interventions based on the biomedical model with food and direct supplementation have failed to produce the desired outcomes for decades. In light of the established positive effects of psychosocial stimulation on developmental outcomes, we propose that the observed failures relate to not including psychosocial stimulation within the interventions. Here we test whether psychosocial stimulation mediates the association between nutritional status and motor and mental development in a large cohort from Madhya Pradesh, India. Method: Using a correlational design in children below 3 years of age (N = 275; Males = 148, Females = 127) nutritional status was measured through mid-upper arm circumference (MUAC), psychosocial stimulation was assessed with the HOME-inventory, and motor and mental development were assessed with the Developmental Assessment Scales for Indian Infants (DASII). We assessed the effectiveness of 25-week intervention model incorporating psychosocial stimulation on 95 undernourished children in experimental group and 77 in control group. Results: The study found that psychosocial stimulation fully mediated the relationship between nutritional status and the motor development [Effect = 1.03, 95% C.I. (0.19, 2.04), p = 0.05] and mental development [Effect = 0.49, 95% C.I. (0.09, 1.03), p = 0.05] in children under 3 years of age. Nutritional status significantly predicted the psychosocial stimulation to the child (R2 = 0.77). Analyzing the effectiveness of the intervention program revealed significant reduction in the developmental delays in both the motor [t(81) = 2.568, p = 0.012] and mental development [t(81) = 4.506, p = 0.001] of the undernourished children. Conclusion: Findings indicate that nutrition translates into positive developmental outcomes in a child only with the scaffolding effects of psychosocial stimulation primarily received from home. Integrating psychosocial stimulation activities like storytelling, play, art and crafts, puppets, travel etc. in the intervention programs designed to address undernutrition may yield rich dividends in bridging the developmental delays among undernourished children.

Restoring Food Systems with Nutritious Native Plants: Experiences from the African Drylands.

BACKGROUND: Twenty-seven African countries have committed to restore more than 100 million hectares of degraded land by 2030 as part of the African Forest Landscape Restoration Initiative (AFR100). In addition, for the same period of time, the African-led Great Green Wall initiative seeks to restore 100 million hectares of degraded agro-sylvo-pastoral lands in the Sahel. The current UN Decade on Ecosystem Restoration (2021-2030) moreover marks an unprecedented opportunity to shape future landscapes, and forge more biodiverse and nutritious food systems. Yet most large-scale restoration actions continue to be largely isolated from socioeconomic challenges facing dryland communities, not least food security and acute malnutrition. Such isolations contribute to low restoration successes and outcomes in Africa's drylands. At the same time, international interventions aimed at improving acute malnutrition in the drylands have not adequately considered the agriculture-nutrition linkages, particularly "pre-farm gate"-including consumption pathways which optimize the use of native plant diversity. OBJECTIVES: This article identifies priority action areas emerging from experiences over 5 years of restoration activities carried out in the Sahel through Food and Agriculture Organization's (FAO) Action Against Desertification Programme supporting the implementation of Africa's Great Green Wall. These actions aim to inform development and humanitarian interventions on the ground to render restoration interventions nutrition-sensitive and hence more effective in practice. RESULTS: Recognizing the symbiotic relationship between landscapes and livelihoods, FAO developed a blueprint for large-scale restoration that combines biophysical and socioeconomic aspects for the benefit of rural communities. The approach builds climate and nutritional resilience into its restoration interventions as a preventative approach to reverse land degradation and ultimately improve livelihoods, food security, and nutrition. CONCLUSIONS: FAO's experience demonstrated that what is planted and when has the potential to not only significantly improve biodiversity and reverse land degradation, but also positively influence nutrition outcomes. Future interventions in the drylands must involve joint efforts between nutritionists and natural resource managem prove both human and planetary health.

Plain language titleRestoring Africa's Drylands With Nutritious Native PlantsPlain language summaryThe African-led Great Green Wall (GGW) initiative seeks to restore 100 million hectares of degraded lands in the Sahel, in the context of the current UN Decade on Ecosystem Restoration by 2030, marking an unprecedented opportunity to shape future landscapes, and forge more biodiverse and nutritious food systems. At the same time, international interventions aimed at improving acute malnutrition have not adequately considered the agriculture-nutrition linkages, particularly "pre-farm gate," including consumption pathways which optimize the use of native plant diversity. Recognizing the symbiotic relationship between landscapes and livelihoods, Food and Agriculture Organization (FAO) developed a blueprint for large-scale restoration that combines biophysical and socioeconomic aspects for the benefit of rural communities and builds climate and nutritional resilience into its restoration interventions as a preventative approach to reverse land degradation and ultimately improve livelihoods, food security, and nutrition. This article identifies priority action areas emerging from experiences over 5 years of restoration activities carried out in the Sahel through FAO's Action Against Desertification supporting the implementation of the GGW. The results demonstrated that what is planted and when has the potential to not only significantly improve biodiversity and reverse land degradation but also positively influence nutrition outcomes. Future interventions in the drylands must involve joint efforts between nutritionists and natural resource management specialists in order to improve both human and planetary health.

Mapping of nutrition policies and programs in South Asia towards achieving the Global Nutrition targets.

BACKGROUND: South Asia continues to host the triple burden of child malnutrition with high levels of child undernutrition, hidden hunger (micronutrient deficiencies) and childhood overweight/obesity. To combat malnutrition, the international community along with the National governments have launched initiatives to track the country's progress towards achieving the Global Nutrition targets by 2025. This review captures the country-specific efforts of nutrition-specific and nutrition-sensitive sectoral programs and policies towards achieving these targets for eight South Asian countries. METHODS: A systematic internet search was undertaken to search relevant policies and programs from Government websites and twelve International Organisations working in the region. The authors developed a template to map the policies against the following criteria: (i) enabling supportive environment; (ii) Initiatives targeted at nutrition-specific interventions; and (iii) Initiatives targeted at nutrition-specific interventions that impact child malnutrition. A narrative descriptive approach was used to present findings. RESULTS: All eight countries had relevant policies and programs to address child malnutrition and macronutrient deficiencies with targets for significant reductions in stunting and improved breastfeeding. However, despite the outlined there are major challenges of implementation, monitoring, evaluation and quality that persist with increased dependency on international donors and organisations for funding and/or implementation of nutrition plans. CONCLUSION: There is a need to contextualise efforts designated to donors and governments to improve the tracking of efforts that impact nutrition.

A Mixed Methods Exploration of the Role of Participation in a Nutrition-Sensitive Agroecology Intervention in Rural Tanzania.

Background: Participation is key to the successful implementation of nutrition-related interventions, but it has been relatively overlooked. Objective: We sought to describe participation intensity among smallholder farmers in a randomized nutrition-sensitive agroecology study in rural Tanzania. We explored the association between baseline characteristics and overall participation intensity (quantitatively at the individual level and qualitatively at the group level), the association of participation intensity with 2 process indicators, and the association between participation intensity and key study outcomes. Methods: Data came from 7 rounds of surveys with 295 women and 267 men across 29 months and 2 rounds of semi-structured interviews with the 20 "mentor farmers" who delivered the intervention. Participation intensity was based on the number of months of attendance at village-level project meetings or household visits (range: 0-29). Multivariable models of participation were built. Results: Women and men participated for 17.5 ± 7.2 and 13.6 ± 8.3 months, respectively. Participation intensity followed 1 latent trajectory: initially low, with a sharp increase after month 7, and plateaued after the first year. At baseline, higher participation intensity was associated with older age, higher education, level of women's empowerment, being in the middle quintile of wealth, and qualitatively, village residence. Higher participation intensity was associated with 2 process indicators - better recall of topics discussed during meetings and greater knowledge about key agroecological methods. High participation intensity was positively associated with increased use of sustainable agricultural practices among all participants, and among women, with husband's involvement in household tasks and child's dietary diversity score. Conclusions: Participation intensity covaried with key study outcomes, suggesting the value of increased attention to implementation in nutrition-related programs for providing insights into drivers of impact. We hope that investigations of participation, including participation intensity, will become more widespread so that intervention impacts, or lack thereof, can be better understood.

Increasing Household Diet Diversity and Food Security in Rural Rwanda Using Small-Scale Nutrition-Sensitive Agriculture: A Community-Engaged Proof-of-Concept Study.

Malnutrition and food insecurity remain high in rural Rwanda, where residents consume a low-diversity diet provided through subsistence farming. Agricultural interventions using kitchen gardens may improve diet diversity in some populations. However, little is known about their efficacy when developed using community-based participatory research in combination with nutrition education focused on the empowerment of women. The objective of this study was to develop and implement a kitchen garden and nutrition education intervention using a community-engaged model and examine its impact on household diet diversity and food security. Using a mixed methods community-level design, we assessed a 16-week intervention implemented in Cyanika, Rwanda. Stratified purposeful sampling was used to select women participants representing 42 households. Household diet diversity scores (HHDS) and hunger scores were calculated at the baseline, post-intervention and one-year follow-up. HDDS increased after intervention from a pre-intervention intake of 2.59 [1.3] food groups/day, to 4.85 [1.6] at four months post-intervention and at one year post-intervention, reaching 5.55 [1.3]. There were no significant changes in household hunger scores. Our results indicate that collaborative community-engaged nutrition-sensitive agricultural interventions can increase household diet diversity; however, future work should explore whether this type of intervention strategy can lead to sustained changes and impact nutritional adequacy in this population.

The potential repositioning of South African underutilised plants for food and nutrition security: A scoping review.

Background: In South Africa (SA), there is a reported shift from the consumption of grains, pulses, fruits and vegetables by most households to the consumption of easily accessible, high-energy, ultra-processed foods. Despite their high nutritional value and affordability, indigenous, local, traditional wild and domesticated plant foods abundant in SA are still neglected and less consumed than conventional and exotic foods. Objectives: The purpose of this study is to undertake a scoping/mapping review to evaluate the potential role of underutilised local, indigenous and traditional plant species in addressing (through improving food and nutrition security) the adverse effects of the nutrition transition, which involves increased use of ultra-processed foods, on the health and nutritional status of current households in SA as well as preventing the same adverse affecting future generations. Design: Online databases were used to identify literature published between 2000 and 2022.A total of 88 articles, books, book chapters and literature materials were selected using the Google Scholar search engine, where literature from Sub-Saharan Africa and global that used food and nutrition security, as well as underutilised and indigenous plant species. Results and conclusion: Evaluation of the gathered literature revealed that the "food security" concept had been measured based on the available quantity of food. In contrast, the quality of food is severely neglected. The literature indicated a strong link between the "food environment" concept, ultra-processed foods and nutrition transition. The shift, especially by the youth, from consuming underutilised plant foods to ultra-processed foods has left older people to be the only consumers of underutilised plant foods. Monotonous preparation, the unavailability of nutritive local traditional and indigenous plant foods at supermarkets and the unappealing packaging methods of such foods were some contributors to the limited or no consumption-these challenges need to be addressed.

Effect and Challenges of an Integrated Nutrition-Intervention Package Utilization among Pregnant Women and Lactating Mothers in Rwanda: An Exploratory Qualitative Study.

Background: Malnutrition among pregnant women and lactating mothers remains an issue of public health concern in developing countries. The Gikuriro program, an integrated nutrition-specific and nutrition-sensitive intervention, was implemented in 5 districts of Rwanda for 5 y to address this problem. Postprogram quasi-experiments showed significant effect of the intervention on maternal and child undernutrition. Notwithstanding, there was a need for a qualitative study to explore the views of the beneficiaries and implementers regarding its benefits, challenges, and limitations to inform future interventions. Objective: This study aimed to explore the effect and challenges of an integrated nutrition-intervention program among pregnant women and lactating mothers. Methods: This was a qualitative study involving 25 community health officers and 27 nutritionists as key informants and 80 beneficiaries in 10 focus group discussions. All interviews and group discussions were audio-recorded, transcribed verbatim, translated into English, and double coded. A deductive and inductive content analysis approach was used with the help of ATLAS.ti, version 9.15. Results: The study identified several positive effects, such as improved knowledge and skills on nutrition, a positive mindset toward a balanced diet, perceived improved nutrition, and economic independence among pregnant women and lactating mothers. However, some of the main obstacles of the integrated nutrition intervention were lack of awareness of the program, negative beliefs, poverty, lack of spousal support, and time constraints. Moreover, the study identified a main limitation: the lack of inclusiveness for all social categories. Conclusions: This study demonstrates that integrated nutrition interventions have perceived positive effect on nutrition; however, such interventions may face some challenges and limitations. These findings suggest that, apart from contributing to the body of evidence for scale up of such interventions in resource-limited settings, economic challenges and misconceptions have to be addressed to maximize the effect of such interventions.

Intrahousehold power inequalities and cooperation: Unpacking household responses to nutrition-sensitive agriculture interventions in rural India.

Nutrition-sensitive agriculture (NSA) interventions offer a means to improve the dietary quality of rural, undernourished populations. Their effectiveness could be further increased by understanding how household dynamics enable or inhibit the uptake of NSA behaviours. We used a convergent parallel mixed-methods design to describe the links between household dynamics-specifically intrahousehold power inequalities and intrahousehold cooperation-and dietary quality and to explore whether household dynamics mediated or modified the effects of NSA interventions tested in a cluster-randomized trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN). We use quantitative data from cross-sectional surveys in 148 village clusters at UPAVAN's baseline and 32 months afterwards (endline), and qualitative data from family case studies and focus group discussions with intervention participants and facilitators. We found that households cooperated to grow and buy nutritious foods, and gendered power inequalities were associated with women's dietary quality, but cooperation and women's use of power was inhibited by several interlinked factors. UPAVAN interventions were more successful in more supportive, cooperative households, and in some cases, the interventions increased women's decision-making power. However, women's decisions to enter into negotiations with family members depended on whether women deemed the practices promoted by UPAVAN interventions to be feasible, as well as women's confidence and previous cultivation success. We conclude that interventions may be more effective if they can elicit cooperation from the whole household. This will require a move towards more family-centric intervention models that empower women while involving other family members and accounting for the varied ways that families cooperate and negotiate.

Impact of a Homestead Food Production program on poultry rearing and egg consumption: A cluster-randomized controlled trial in Bangladesh.

Women and children in Bangladesh face high levels of micronutrient deficiencies from inadequate diets. We evaluated the impact of a Homestead Food Production (HFP) intervention on poultry production, as a pathway outcome, and women's and children's egg consumption, as secondary outcomes, as part of the Food and Agricultural Approaches to Reducing Malnutrition cluster-randomized trial in Sylhet division, Bangladesh. The 3-year intervention (2015-2018) promoted home gardening, poultry rearing, and nutrition counseling. We randomly allocated 96 clusters to intervention (48 clusters; 1337 women) or control (48 clusters; 1368 women). Children < 3 years old born to participants were enrolled during the trial. We analyzed poultry production indicators, measured annually, and any egg consumption (24-h recall), measured every 2-6 months for women and their children. We conducted intention-to-treat analyses using mixed-effects logistic regression models with repeat measures, with minimal adjustment to increase precision. Poultry ownership increased by 16% points (pp) and egg production by 13 pp in the final intervention year. The intervention doubled women's odds of egg consumption in the final year (Odds Ratio [OR]: 2.31, 95% CI: 1.68-3.18), with positive effects sustained 1-year post-intervention (OR: 1.58, 95% CI: 1.16-2.15). Children's odds of egg consumption were increased in the final year (OR: 3.04, 95% CI: 1.87-4.95). Poultry ownership was associated with women's egg consumption, accounting for 12% of the total intervention effect, but not with children's egg consumption. Our findings demonstrate that an HFP program can have longer-term positive effects on poultry production and women's and children's diets.

Opportunities to Strengthen Fish Supply Chain Policy to Improve External Food Environments for Nutrition in the Solomon Islands.

Malnutrition and food insecurity have significant social and economic impacts in small island developing states, such as the Solomon Islands. Enhancing the domestic supply of fish, the main source of local protein, can contribute to improved nutrition and food security. This research aimed to improve understanding of the policy interface between the fisheries and health sectors and identify opportunities to strengthen fish supply chain policy to improve domestic (particularly urban) access to fish in the Solomon Islands. The study design drew on theories of policy learning and policy change and analysed policies using a consumption-oriented supply chain approach. Interviews were conducted with 12 key informants in the Solomon Islands, and 15 policy documents were analysed. Analysis of policy documents and interview data indicated that there were strengths as well as opportunities in the existing policy context. In particular, community-based fisheries management approaches and explicit recognition of the links between fisheries and nutrition were key strengths. Challenges included gaps in implementation, variations in capacities across government actors and communities, and limited attention to domestic monitoring and enforcement. Improving the effectiveness of resource management efforts may result in sustainable outcomes for both livelihoods and health, which will accomplish priorities at the national and sub-national levels and support the achievement of the Solomon Islands' commitments to the Sustainable Development Goals.

Development and validation of a health and nutrition module for the project-level Women's Empowerment in Agriculture Index (pro-WEAI+HN).

Agricultural development projects increasingly aim to improve health and nutrition outcomes, often by engaging women. Although evidence shows such projects can improve women's and children's health and nutrition and empower women, little is known about their impacts on women's health- and nutrition-related agency and the extent to which impacts emerge through women's empowerment, largely due to a lack of instruments that measure the dimensions of women's agency that are directly relevant to health and nutrition outcomes. We developed an optional, complementary module for the project-level women's empowerment in agriculture index (pro-WEAI) to measure health- and nutrition-related agency (pro-WEAI + HN). Our method for developing related indicators used data collected from six agricultural development programmes implemented across Bangladesh, Burkina Faso and Mali (pooled sample = 12,114) and applied psychometric analysis (exploratory and confirmatory factor analysis) and the Alkire-Foster methodology. Results revealed seven indicators covering women's agency in the areas of her own health and diet; her health and diet during pregnancy; her child's diet; breastfeeding and weaning; purchasing food and health products; and acquiring food and health products. Multigroup confirmatory factor analysis revealed measurement invariance across contexts and samples. Tests of association (Cramer's V) and redundancy suggest that the pro-WEAI + HN indicators measured aspects of agency that are distinct from the core pro-WEAI. The uptake of these indicators in studies of nutrition-sensitive agricultural development projects may strengthen the evidence on how such programming can enhance women's empowerment to improve health and nutrition outcomes for themselves and their children.

Training to Build Nutrition Capacity in the Nigerian Agricultural Sector: Initial Assessment and Future Directions.

BACKGROUND: In response to calls to increase nutrition-sensitive agriculture (NSA), the Federal Ministry of Agriculture and Rural Development developed the Nigeria Agricultural Sector Food Security and Nutrition Strategy 2016-2025 (AFSNS). Capacity development activities to facilitate the AFSNS implementation subsequently commenced. OBJECTIVE: This study analyzed the processes and outputs of initial capacity development efforts, examined findings from the analysis using existing literature, and identified critical next steps for nutrition capacity development in the Nigerian agriculture sector. METHODS: The study reviewed documents including a proposal for nutrition training of agriculture sector actors, reports of meetings held among 6 resource persons who designed and/or delivered training, training reports, participants' pre- and posttraining assessments, and participants' training evaluation. Interviews were conducted with 2 resource persons involved in training design and delivery. Documents and interviews were coded and analyzed to identify emergent themes. Participants' pre- and posttests results were compared using paired t test in Stata 12.0. RESULTS: Knowledge and practice gaps were more extensive than had been anticipated. Training had some but limited effects on knowledge scores at the federal level. Modules addressing implementation practices had to be scaled down for participants to keep up with the learning pace. Existing literature indicates that such training would have been better planned as part of a broader sectoral nutrition workforce strategy, to facilitate greater tailoring of training to participants' job roles. CONCLUSION: Effective AFSNS implementation requires developing and operationalizing a comprehensive short-, medium- and long-term Agriculture Sector Nutrition Capacity Development Strategy for Nigeria.

The Association of Women's Participation in Farmer-Based Organizations with Female and Male Empowerment and its Implication for Nutrition-Sensitive Agriculture Interventions in Rural Ghana.

Background: Few studies have examined the influence of women's participation in farmer groups on female and male empowerment, which is considered essential to improving nutrition. Objectives: The study aimed to 1) assess the empowerment of Ghanaian women farmers, 1 adult male family decision-maker per household, and the household gender equality; and 2) investigate the relation of empowerment and household gender equality with women's participation in farmer-based organizations (FBOs), women's and men's nutritional status, and household food security. Methods: A cross-sectional study investigated secondary outcomes using baseline data from a nutrition-sensitive agriculture intervention implemented through FBOs in rural Ghana. Existing FBOs in 8 communities were selected based on 6 criteria (e.g., participation level, readiness to change). Female FBO (n = 166) and non-FBO (n = 164) members together with a male family member (n = 205) provided data on individual and household characteristics; empowerment was measured across 11 indicators with the project-level Women's Empowerment in Agriculture Index. Generalized linear mixed models tested the associations of empowerment and household gender equality with FBO membership, nutritional status, and household food security. Results: Women's FBO membership was associated with an increased likelihood of women's empowerment [adjusted odds ratio (aOR): 3.25; 95% CI: 1.97, 5.33] and household gender parity (aOR: 2.82; 95% CI: 1.39, 5.84) but not men's empowerment. Household food insecurity, but not nutritional status, was positively associated with women's FBO participation and individual empowerment indicators (financial services). Food insecurity was negatively associated with the women's empowerment indicator related to attitudes about domestic violence [adjusted ß coefficient (aß): -0.78; 95% CI: -1.35, -0.21] and men's overall empowerment (aß: -0.79; 95% CI: -1.58, -0.01). Conclusions: Understanding the complexity in which FBO participation, empowerment, nutritional status, and food security are linked is critical in designing interventions that promote gender equality and improved nutrition.This trial was registered at clinicaltrials.gov as NCT03869853.

Beneficiary and Local Stakeholder Participation in Community-Based Nutrition Interventions.

Beneficiary and local stakeholder participation is an essential element to the success of community-based nutrition interventions. We sought to define active participation and review the available evidence on beneficiary and local stakeholder participation in community-based nutrition interventions in Africa. From reviewing the literature, we provide a reflective assessment on the process and findings. Participation falls on a continuum of community involvement from passive (no real involvement) to empowerment and community ownership (full active involvement). However, we found a clear gap in the research on defining active participation and identifying what constitutes active participation on behalf of beneficiaries and local stakeholders. However, progress was found; evidence included the use of participatory methods to engage beneficiaries and local stakeholders in the assessment and design phase. Beneficiary and local stakeholder participation in delivering interventions has moved forward with quantitative measures from process evaluation and implementation science. Research has started on the extent of beneficiary engagement (as recipients) and connecting this to outcomes. Evaluation has benefited from qualitative inquiry with insights from participants on engagement itself, and the barriers and facilitators to engagement. Yet questions remain in each study phase around defining and quantifying active participation and in understanding the personal, social, and motivational elements of active participation. We offer a simple framework to stimulate thought and commitment to research on participation in community-based nutrition interventions.

Identifying effective message-framing techniques in behaviour change communication for healthy diets: An experimental study of promoting biofortified maize adoption in Ethiopia.

There is an increasing interest in using insights from behavioural economics and psychology to influence people's decisions. However, little is known as to how to leverage these insights to inform educational campaigns in the context of nutrition-sensitive agriculture. We help to fill this void by investigating the effect of framed messages (gain vs loss) in stimulating demand for nutritionally enhanced crops. We conducted a field experiment with 648 farmers and found the following key results. First, nutrition education stimulates demand for nutritionally enhanced crops among smallholder farmers. Without nutrition education, farmers are less likely to switch from producing conventional maize to nutritionally enhanced maize. Second, gain-framed messages are slightly more effective: they result in a higher willingness to pay for nutritionally enhanced maize than loss-framed messages. Third, motivational orientations and risk perceptions of individuals moderate the effect of the framed messages.

Economic Evaluation of Nutrition-Sensitive Agricultural Interventions to Increase Maternal and Child Dietary Diversity and Nutritional Status in Rural Odisha, India.

BACKGROUND: Economic evaluations of nutrition-sensitive agriculture (NSA) interventions are scarce, limiting assessment of their potential affordability and scalability. OBJECTIVES: We conducted cost-consequence analyses of 3 participatory video-based interventions of fortnightly women's group meetings using the following platforms: 1) NSA videos; 2) NSA and nutrition-specific videos; or 3) NSA videos with a nutrition-specific participatory learning and action (PLA) cycle. METHODS: Interventions were tested in a 32-mo, 4-arm cluster-randomized controlled trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) in the Keonjhar district, Odisha, India. Impacts were evaluated in children aged 0-23 mo and their mothers. We estimated program costs using data collected prospectively from expenditure records of implementing and technical partners and societal costs using expenditure assessment data collected from households with a child aged 0-23 mo and key informant interviews. Costs were adjusted for inflation, discounted, and converted to 2019 US$. RESULTS: Total program costs of each intervention ranged from US$272,121 to US$386,907. Program costs per pregnant woman or mother of a child aged 0-23 mo were US$62 for NSA videos, US$84 for NSA and nutrition-specific videos, and US$78 for NSA videos with PLA (societal costs: US$125, US$143, and US$122, respectively). Substantial shares of total costs were attributable to development and delivery of the videos and PLA (52-69%) and quality assurance (25-41%). Relative to control, minimum dietary diversity was higher in the children who underwent the interventions incorporating nutrition-specific videos and PLA (adjusted RRs: 1.19 and 1.27; 95% CIs: 1.03-1.37 and 1.11, 1.46, respectively). Relative to control, minimum dietary diversity in mothers was higher in those who underwent NSA video (1.21 [1.01, 1.45]) and NSA with PLA (1.30 [1.10, 1.53]) interventions. CONCLUSION: NSA videos with PLA can increase both maternal and child dietary diversity and have the lowest cost per unit increase in diet diversity. Building on investments made in developing UPAVAN, cost-efficiency at scale could be increased with less intensive monitoring, reduced startup costs, and integration within existing government programs. This trial was registered at clinicaltrials.gov as ISRCTN65922679.