Understanding Implementation and Improving Nutrition Interventions: Barriers and Facilitators of Using Data Strategically to Inform the Implementation of Maternal Nutrition in Uttar Pradesh, India.

BACKGROUND: In response to the high levels of maternal nutrition in Uttar Pradesh, Alive & Thrive (A&T) aimed to strengthen the delivery of nutrition interventions through the government antenatal care platform, including leveraging ongoing data collection to improve program delivery and reach (registered at clinicaltrials.gov as NCT03378141). However, we have a limited understanding of providers' experiences and challenges in collecting and using data for decision making. OBJECTIVE: The aim was to identify barriers and facilitators to the 1) collection of data and 2) use of data for decision making. METHODS: In-depth interviews (n = 35) were conducted among block-level government staff, frontline worker (FLW) supervisors, and A&T staff in 2 districts in Uttar Pradesh. Systematic coding of verbatim transcripts and detailed summaries were undertaken to elucidate themes related to data collection and use. FLW supervisors (n = 103) were surveyed to assess data use experiences. RESULTS: Data were used to understand the reach of maternal nutrition services, estimate the demand for supplements, and guide identification of areas of low FLW performance. About half of supervisors reported using data to identify areas of improvement; however, only 23% reported using data to inform decision making. Facilitators of data collection and use included collaboration between health department officials, perceived importance of block ranking, and monthly review meetings with staff and supervisors to review and discuss data. Barriers to data collection and use included human resource gaps, inadequate technology infrastructure, FLW educational level, political structure, and lack of cooperation between FLWs and supervisors. CONCLUSIONS: The use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Despite intensive data-collection efforts, the use of data to inform decision making remains limited. Collaboration facilitated data collection and use, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions.

Impact of COVID-19 on household food insecurity and interlinkages with child feeding practices and coping strategies in Uttar Pradesh, India: a longitudinal community-based study.

OBJECTIVES: The COVID-19 pandemic has profound negative impacts on people's lives, but little is known on its effect on household food insecurity (HFI) in poor setting resources. This study assessed changes in HFI during the pandemic and examined the interlinkages between HFI with child feeding practices and coping strategies. DESIGN: A longitudinal survey in December 2019 (in-person) and August 2020 (by phone). SETTING: Community-based individuals from 26 blocks in 2 districts in Uttar Pradesh, India. PARTICIPANTS: Mothers with children <2 years (n=569). MAIN OUTCOMES AND ANALYSES: We measured HFI by using the HFI Access Scale and examined the changes in HFI during the pandemic using the Wilcoxon matched-pairs signed-rank tests. We then assessed child feeding practices and coping strategies by HFI status using multivariable regression models. RESULTS: HFI increased sharply from 21% in December 2019 to 80% in August 2020, with 62% households changing the status from food secure to insecure over this period. Children in newly or consistently food-insecure households were less likely to consume a diverse diet (adjusted OR, AOR 0.57, 95% CI 0.34 to 0.95 and AOR 0.51, 95% CI 0.23 to 1.12, respectively) compared with those in food-secure households. Households with consistent food insecurity were more likely to engage in coping strategies such as reducing other essential non-food expenditures (AOR 2.2, 95% CI 1.09 to 4.24), borrowing money to buy food (AOR 4.3, 95% CI 2.31 to 7.95) or selling jewellery (AOR 5.0, 95% CI 1.74 to 14.27) to obtain foods. Similar findings were observed for newly food-insecure households. CONCLUSIONS: The COVID-19 pandemic and its lockdown measures posed a significant risk to HFI which in turn had implications for child feeding practices and coping strategies. Our findings highlight the need for further investment in targeted social protection strategies and safety nets as part of multisectoral solutions to improve HFI during and after COVID-19.

Malnutrition and poverty in India: does the use of public distribution system matter?

BACKGROUND: Large scale public investment in Public Distribution System (PDS) have aimed to reduce poverty and malnutrition in India. The PDS is the largest ever welfare programme which provides subsidised food grain to the poor households. This study attempt to examine the extent of stunting and underweight among the children from poor and non-poor households by use of public distribution system (PDS) in India. METHODS: Data from the National Family and Health Survey-4 (NFHS-4), was used for the analysis. A composite variable based on asset deprivation and possession of welfare card provided under PDS (BPL card), was computed for all households and categorised into four mutually exclusive groups, namely real poor, excluded poor, privileged non-poor and non-poor. Real poor are those economically poor and have a welfare card, excluded poor are those economically poor and do not have welfare card, privileged poor are those economically non-poor but have welfare card, and non-poor are those who are not economically poor and do not have welfare card. Estimates of stunting and underweight were provided by these four categories. Descriptive statistics and logistic regression were used for the analysis. RESULTS: About half of the children from each real poor and excluded poor, two-fifths among privileged non-poor and less than one-third among non-poor households were stunted in India. Controlling for socio-economic and demographic covariates, the adjusted odds ratio of being stunted among real poor was 1.42 [95% CI: 1.38, 1.46], 1.43 [95% CI: 1.39, 1.47], among excluded poor and 1.15 [95% CI: 1.12, 1.18], among privileged non-poor. The pattern was similar for underweight and held true in most of the states of India. CONCLUSIONS: Undernutrition among children from poor households those excluded from PDS is highest, and it warrants inclusion in PDS. Improving the quality of food grains and widening food basket in PDS is recommended for reduction in level of malnutrition in India.

Effect of enhanced detailing and mass media on community use of oral rehydration salts and zinc during a scale-up program in Gujarat and Uttar Pradesh.

BACKGROUND: The Clinton Health Access Initiative implemented a program from 2012-2016 to increase use of oral rehydration salts (ORS) and zinc to treat diarrhea in children under five in three states in India: Gujarat, Madhya Pradesh, and Uttar Pradesh. The program interventions included detailing and development of a rural supply chain to reach private rural health care providers, training of Accredited Social Health Activists (ASHAs), technical support to the state governments, and a mass media campaign targeted at caregivers. In Gujarat and Uttar Pradesh, some of the program activities, such as detailing and ASHA trainings, were targeted to high-burden focal districts, thus providing an opportunity to study their effect compared to statewide activities that covered all districts, such as the mass media campaign. Our study aimed to estimate the effect of activities on ORS and zinc use. METHODS: Household surveys were conducted at two points during the program and in both focal and non-focal districts. We used a difference-in-difference quasi-experimental approach to estimate the effect of the enhanced activities in focal districts and mass media campaign on the odds of a child being treated with ORS and zinc. FINDINGS: Focal district interventions were associated with a significant increase in the odds of a diarrhea episode receiving ORS in Gujarat and Uttar Pradesh. Living in focal districts increased the odds of receiving ORS in Gujarat and Uttar Pradesh by factors of 3.42 (95% CI = 1.39-8.33) and 2.29 (95% CI = 1.19-4.39), respectively. Focal district interventions were also associated with 15.02 (95% CI = 2.97-75.19) greater odds of receiving both ORS and zinc in Gujarat. In Uttar Pradesh, where the mass media campaign was focused, exposure to the campaign further modified the odds of receiving ORS and combined ORS and zinc by 1.38 (95% CI = 1.04-1.84) and 1.57 (95% CI = 1.01-2.46), respectively. CONCLUSION: Comprehensive public and private provider interventions combined with mass media are effective strategies for increasing ORS and zinc use.