78 results on '"Avula, Rasmi'
Search Results
2. Stories of change in nutrition: lessons from a new generation of studies from Africa, Asia and Europe
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Nicholas Nisbett, Jody Harris, Derek Headey, Mara van den Bold, Stuart Gillespie, Noora-Lisa Aberman, Olutayo Adeyemi, Richmond Aryeetey, Rasmi Avula, Elodie Becquey, Scott Drimie, Elyse Iruhiriye, Leah Salm, and Zuzanna Turowska
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Development ,Agronomy and Crop Science ,Food Science - Abstract
How does nutrition improve? We need to understand better what drives both positive and negative change in different contexts, and what more can be done to reduce malnutrition. Since 2015, the Stories of Change in Nutrition studies have analysed and documented experiences in many different African and Asian countries, to foster empirically-grounded experiential learning across contexts. This article provides an overview of findings from 14 studies undertaken in nine countries in South Asia, sub-Saharan Africa, and Europe between 2017 and 2021. The studies used a combination of methods, including regression-decomposition analyses of national datasets to assess determinants of nutritional change; policy process and food environment analyses; and community-level research assessing attitudes to change. This article takes a narrative synthesis approach to identify key themes across the studies, paying particular attention to multisectoral determinants, changes in the food environment, the role of structural factors (including longstanding social inequities), and changes in political commitment, cross-sectoral coherence and capacity. Given the inherent multisectoral nature of nutrition, many countries are experimenting with different models of ensuring coherence across sectors that are captured in this body of work. The relative immaturity of the policy sector in dealing with issues such as obesity and overweight, and associated influences in the wider food environment, adds a further challenge. To address these interrelated issues, policy must simultaneously tackle nutrition’s upstream (social/economic/equity) and downstream (health and dietary) determinants. Studies synthesised here provide empirically-driven inspiration for action.
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- 2022
3. Reducing childhood stunting in India: Insights from four subnational success cases
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Rasmi Avula, Phuong Hong Nguyen, Lan Mai Tran, Supreet Kaur, Neena Bhatia, Rakesh Sarwal, Arjan de Wagt, Deepika Nayar Chaudhery, and Purnima Menon
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Development ,Agronomy and Crop Science ,Food Science - Abstract
Global success case analyses have identified factors supporting reductions in stunting across countries; less is known about successes at the subnational levels. We studied four states in India, assessing contributors to reductions in stunting between 2006 and 2016. Using public datasets, literature review, policy analyses and stakeholder interviews, we interpreted changes in the context of policies, programs and enabling environment. Primary contributors to stunting reduction were improvements in coverage of health and nutrition interventions (ranged between 11 to 23% among different states), household conditions (22-47%), and maternal factors (15-30%). Political and bureaucratic leadership engaged civil society and development partners facilitated change. Policy and program actions to address the multidimensional determinants of stunting reduction occur in sectors addressing poverty, food security, education, health services and nutrition programs. Therefore, for stunting reduction, focus should be on implementing multisectoral actions with equity, quality, and intensity with assured convergence on the same geographies and households.The online version contains supplementary material available at 10.1007/s12571-021-01252-x.
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- 2022
4. Specificity Matters: Unpacking Impact Pathways of Individual Interventions within Bundled Packages Helps Interpret the Limited Impacts of a Maternal Nutrition Intervention in India
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Melissa F Young, Edward A. Frongillo, Sebanti Ghosh, Thomas Forissier, Purnima Menon, Lan Mai Tran, Phuong H. Nguyen, Shivani Kachwaha, Jessica Escobar-Alegria, Rasmi Avula, and Praveen Kumar Sharma
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Counseling ,Nutrition and Dietetics ,Service delivery framework ,media_common.quotation_subject ,Supply chain ,Psychological intervention ,India ,Nutritional Status ,Medicine (miscellaneous) ,Prenatal Care ,Maternal Nutritional Physiological Phenomena ,medicine.disease ,Work (electrical) ,Acquired immunodeficiency syndrome (AIDS) ,Nursing ,Pregnancy ,Data quality ,Intervention (counseling) ,medicine ,Humans ,Female ,Quality (business) ,Psychology ,Delivery of Health Care ,media_common - Abstract
To address gaps in coverage and quality of nutrition services, AliveThrive (AT) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the AT interventions compared intensive ANC (I-ANC) with standard ANC (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight-gain monitoring.This study examined intervention-specific program impact pathways (PIPs) and identified reasons for limited impacts of the AT maternal nutrition intervention package.We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling.Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs' knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of micronutrient supplement benefits and recommended foods was insufficient (50%). Most FLWs received supervision (90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30-50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52% compared with 36%) but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight-gain monitoring was low (30-40%).Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact.
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- 2022
5. Take-home rations in the Integrated Child Development Services (ICDS): Study of coverage and uptake in Tamil Nadu
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Rasmi Avula, Purnima Menon, Sattvika Ashok, and Sapna Nair
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- 2023
6. Strengthening Nutrition Interventions in Antenatal Care Services Affects Dietary Intake, Micronutrient Intake, Gestational Weight Gain, and Breastfeeding in Uttar Pradesh, India: Results of a Cluster-Randomized Program Evaluation
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Rasmi Avula, Praveen Kumar Sharma, Jessica Escobar-Alegria, Shivani Kachwaha, Edward A. Frongillo, Phuong H. Nguyen, Sumeet Patil, Thomas Forissier, Lan M. Tran, Sebanti Ghosh, Melissa F Young, and Purnima Menon
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breastfeeding ,030309 nutrition & dietetics ,Breastfeeding ,India ,Medicine (miscellaneous) ,micronutrient intake ,Prenatal care ,Food group ,Eating ,AcademicSubjects/MED00060 ,03 medical and health sciences ,0302 clinical medicine ,Pregnancy ,hemic and lymphatic diseases ,Environmental health ,medicine ,Humans ,Longitudinal Studies ,030212 general & internal medicine ,reproductive and urinary physiology ,interpersonal counseling ,0303 health sciences ,Nutrition and Dietetics ,Prenatal nutrition ,business.industry ,Behavior change ,Prenatal Care ,diet quality ,medicine.disease ,Micronutrient ,female genital diseases and pregnancy complications ,Gestational Weight Gain ,Community and International Nutrition ,Breast Feeding ,Cross-Sectional Studies ,AcademicSubjects/SCI00960 ,Female ,business ,Breast feeding ,Program Evaluation ,maternal nutrition - Abstract
Background Maternal nutrition interventions are inadequately integrated into antenatal care (ANC). Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization through government ANC services. Objectives We compared nutrition-intensified ANC (I-ANC) with standard ANC (S-ANC) on coverage of nutrition interventions and maternal nutrition practices. Methods We used a cluster-randomized design with cross-sectional baseline (2017) and endline (2019) surveys (n ∼660 pregnant and 1800 recently delivered women per survey) and a repeated-measures longitudinal study in 2018–2019 (n = 400). We derived difference-in-difference effect estimates (DIDs) for diet diversity, consumption of micronutrient supplements, weight monitoring, and early breastfeeding practices. Results Despite substantial secular improvements in service coverage from India's national nutrition program, women in the I-ANC arm received more home visits [DID: 7–14 percentage points (pp)] and counseling on core nutrition messages (DID: 10–23 pp) than in the S-ANC arm. One-third of women got ≥3 home visits and one-fourth received ≥4 ANC check-ups in the I-ANC arm. Improvements were greater in the I-ANC arm than in the S-ANC arm for any receipt and consumption of iron–folic acid (DID: 7.5 pp and 9.5 pp, respectively) and calcium supplements (DID: 14.1 pp and 11.5 pp, respectively). Exclusive breastfeeding improved (DID: 7.5 pp) but early initiation of breastfeeding did not. Maternal food group consumption (∼4 food groups) and probability of adequacy of micronutrients (∼20%) remained low in both arms. Repeated-measures longitudinal analyses showed similar results, with additional impact on consumption of vitamin A–rich foods (10 pp, 11 g/d), other vegetables and fruits (22–29 g/d), and gestational weight gain (0.4 kg). Conclusions Intensifying nutrition in government ANC services improved maternal nutrition practices even with strong secular trends in service coverage. Dietary diversity, supplement consumption, and breastfeeding practices remained suboptimal. Achieving greater behavior changes will require strengthening the delivery and use of maternal nutrition services integrated into ANC services in the health system. This trial was registered at clinicaltrials.gov as NCT03378141.
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- 2021
7. Using scenario‐based assessments to examine the feasibility of integrating preventive nutrition services through the primary health care system in Bangladesh
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Phuong H. Nguyen, Priyanjana Pramanik, Sk. Masum Billah, Rasmi Avula, Tarana Ferdous, Bidhan K. Sarker, Musfikur Rahman, Santhia Ireen, Zeba Mahmud, Purnima Menon, and Deborah Ash
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Bangladesh ,Nutrition and Dietetics ,Pregnancy ,Preventive Health Services ,Pediatrics, Perinatology and Child Health ,Public Health, Environmental and Occupational Health ,Feasibility Studies ,Humans ,Nutritional Status ,Obstetrics and Gynecology ,Female ,Delivery of Health Care - Abstract
The National Nutrition Services of Bangladesh aims to deliver nutrition services through the primary health care system. Little is known about the feasibility of reshaping service delivery to close gaps in nutrition intervention coverage and utilization. We used a scenario-based feasibility testing approach to assess potential implementation improvements to strengthen service delivery. We conducted in-depth interviews with 31 service providers and 12 policymakers, and 5 focus group discussions with potential beneficiaries. We asked about the feasibility of four hypothetical scenarios for preventive and promotive nutrition service delivery: community-based events (CBE) for pregnant women, well-child services integrated into immunization contacts; CBE for well-children, and well-child visits at facilities. Opinions on service delivery platforms were mixed; some recommended new platforms, but others suggested strengthening existing delivery points. CBE for pregnant women was perceived as feasible, but workforce shortages emerged as a key barrier. Challenges such as equipment portability, upset children and a fast-moving service environment suggested low feasibility of integrating nutrition into outreach immunization contacts. In contrast, CBE and facility-based well-child visits emerged as feasible options, conditional on having the necessary workforce, structural readiness and budget support. On the demand side, enabling factors include using interpersonal communication and involving community leaders to increase awareness, organizing events at a convenient time and place for both providers and beneficiaries, and incentives for beneficiaries to encourage participation. In conclusion, integrating preventive and promotive nutrition services require addressing current challenges in the health system, including human resource and logistic gaps, and investing in creating demand for preventive services.
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- 2022
8. Response rate in phone surveys: Experiments to test the effect of pre-visits and financial incentives
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Rebecca A. Heidkamp, Sara Shapleigh, Rasmi Avula, Phuong Hong Nguyen, and Sumanta Neupane
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- 2022
9. Coverage of nutrition and health Interventions in INDIA: Insights from the National Family Health Surveys
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Alka Chauhan, Parul Puri, Sarang Pedgaonkar, L.K. Dwivedi, S.K. Singh, Purnima Menon, Phuong Hong Nguyen, Rasmi Avula, Soyra Gune, and Anita Christopher
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- 2022
10. State nutrition profile: Goa
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Phuong Hong Nguyen, Purnima Menon, William Joe, Robert Johnston, Neena Bhatia, Rakesh Sarwal, Sudhir.K. Singh, Rasmi Avula, and Vishakha Wadhwani
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- 2022
11. State nutrition profile: Himachal Pradesh
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Robert Johnston, Rasmi Avula, William Joe, Anita Christopher, Rakesh Sarwal, Neena Bhatia, Esha Sarswat, Purnima Menon, S. K. Singh, and Phuong Hong Nguyen
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Geography ,State (functional analysis) ,Socioeconomics - Published
- 2022
12. State nutrition profile: Sikkim
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Robert Johnston, Rasmi Avula, Sattvika Ashok, Rakesh Sarwal, Neena Bhatia, William Joe, Purnima Menon, Shambhavi Singh, and Phuong Hong Nguyen
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Geography ,State (functional analysis) ,Socioeconomics - Published
- 2022
13. State nutrition profile: Chandigarh
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Phuong Hong Nguyen, Purnima Menon, Esha Sarswat, William Joe, Robert Johnston, Neena Bhatia, Rakesh Sarwal, Sudhir.K. Singh, Rasmi Avula, and Aditya Madhusudan
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- 2022
14. State nutrition profile: Karnataka
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Phuong Hong Nguyen, Purnima Menon, Esha Sarswat, William Joe, Robert Johnston, Neena Bhatia, Rakesh Sarwal, Sudhir.K. Singh, Rasmi Avula, and Soyra Gune
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- 2022
15. State nutrition profile: Kerala
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Phuong Hong Nguyen, Purnima Menon, Esha Sarswat, William Joe, Robert Johnston, Neena Bhatia, Rakesh Sarwal, Sudhir.K. Singh, Rasmi Avula, and Soyra Gune
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- 2022
16. Smarter policies for enhanced food security and food system outcomes
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Michael Wang, Purnima Menon, Rasmi Avula, Shivani Kachwaha, and Phuong Hong Nguyen
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- 2022
17. COVID-19 disruptions to health and nutrition services in Uttar Pradesh, India
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Michael Wang, Purnima Menon, Rasmi Avula, Shivani Kachwaha, and Phuong Hong Nguyen
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- 2022
18. Can digitally enabling community health and nutrition workers improve services delivery to pregnant women and mothers of infants? Quasi-experimental evidence from a national-scale nutrition programme in India
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Sumeet R Patil, Sneha Nimmagadda, Lakshmi Gopalakrishnan, Rasmi Avula, Sumati Bajaj, Nadia Diamond-Smith, Anshuman Paul, Lia Fernald, Purnima Menon, and Dilys Walker
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Pediatric ,Community Health Workers ,and promotion of well-being ,Health Policy ,Public Health, Environmental and Occupational Health ,Infant ,Mothers ,Reproductive health and childbirth ,Prevention of disease and conditions ,maternal health ,health services research ,nutrition ,Good Health and Well Being ,Cross-Sectional Studies ,Clinical Research ,Pregnancy ,child health ,3.1 Primary prevention interventions to modify behaviours or promote wellbeing ,Humans ,Female ,Pregnant Women ,Public Health ,Child ,health systems evaluation - Abstract
BackgroundIndia’s 1.4 million community health and nutrition workers (CHNWs) serve 158 million beneficiaries under the Integrated Child Development Services (ICDS) programme. We assessed the impact of a data capture, decision support, and job-aid mobile app for the CHNWs on two primary outcomes—(1) timeliness of home visits and (2) appropriate counselling specific to the needs of pregnant women and mothers of children MethodsWe used a quasi-experimental pair-matched controlled trial using repeated cross-sectional surveys to evaluate the intervention in Bihar and Madhya Pradesh (MP) separately using an intention-to-treat analysis. The study was powered to detect difference of 5–9 percentage points (pp) with type I error of 0.05 and type II error of 0.20 with endline sample of 6635 mothers of children ResultsAmong pregnant women and mothers of children ConclusionThe at-scale app integrated with ICDS improved provision of services under the purview of CHNWs but not those that depended on systemic factors, and was relatively more effective when baseline levels of services were low. Overall, digitally enabling CHNWs can complement but not substitute efforts for strengthening health systems and addressing structural barriers.Trial registration numberISRCTN83902145.
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- 2021
19. Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study
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Rasmi Avula, Phuong Hong Nguyen, Sattvika Ashok, Sumati Bajaj, Shivani Kachwaha, Anjali Pant, Monika Walia, Anshu Singh, Anshuman Paul, Ayushi Singh, Bharati Kulkarni, Deepak Singhania, Jessica Escobar-Alegria, Little Flower Augustine, Madhulika Khanna, Maitreiyee Krishna, Nandhini Sundaravathanam, Prakash Kumar Nayak, Praveen Kumar Sharma, Prerna Makkar, Puspen Ghosh, Sadhana Subramaniam, Sai Mala, Rakesh Giri, Sameeksha Jain, Santosh Kumar Banjara, Sapna Nair, Sebanti Ghosh, Suman Das, Sumeet Patil, Tanmay Mahapatra, Thomas Forissier, Priya Nanda, Suneeta Krishnan, and Purnima Menon
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Multidisciplinary ,Pregnancy ,Communicable Disease Control ,COVID-19 ,Humans ,India ,Nutritional Status ,Female ,Child ,Child Nutritional Physiological Phenomena ,Pandemics - Abstract
Background Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020. Methods We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August–October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2. Results In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by Conclusions Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.
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- 2021
20. Validation of Survey Questions on Counseling About Infant and Young Child Feeding Received by Mothers in Bihar, India
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Sattvika Ashok, Sunny Kim, Tanmay Mahapatra, Priya Gokhale, Melinda Munos, Rebecca Heidkamp, and Rasmi Avula
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Nutrition and Dietetics ,Medicine (miscellaneous) ,Food Science - Published
- 2022
21. Association between supportive supervision and performance of community health workers in India: a longitudinal multi-level analysis
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Lakshmi Gopalakrishnan, Dilys Walker, Rasmi Avula, Purnima Menon, Lia C. H. Fernald, Sumeet Patil, and Nadia Diamond-Smith
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Medicine (General) ,Mediation (statistics) ,Integrated Child Development Services ,Public Administration ,Service delivery framework ,Impact evaluation ,Population ,ICDS ,India ,Context (language use) ,Supervision ,Nursing ,Basic Behavioral and Social Science ,Health administration ,R5-920 ,Clinical Research ,Behavioral and Social Science ,Medicine ,Humans ,Health system ,CHWs ,education ,Child ,Nutrition ,Pediatric ,Community Health Workers ,education.field_of_study ,Motivation ,business.industry ,Research ,Public Health, Environmental and Occupational Health ,Health services research ,Infant ,Bihar ,Health Services ,Anganwadi worker ,Supervisor ,Health Policy & Services ,Zero Hunger ,Catchment area ,Generic health relevance ,Public aspects of medicine ,RA1-1270 ,Madhya Pradesh ,business - Abstract
Introduction Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services. Objectives We examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge. Methods We used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong. Results Among 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge. Conclusion Higher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes. Trial registration : Trial registration number: https://doi.org/10.1186/ISRCTN83902145
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- 2021
22. Additional file 1 of Association between supportive supervision and performance of community health workers in India: a longitudinal multi-level analysis
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Gopalakrishnan, Lakshmi, Diamond-Smith, Nadia, Avula, Rasmi, Menon, Purnima, Fernald, Lia, Walker, Dilys, and Patil, Sumeet
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Additional file 1: Table S3. Full regression results of supportive supervision on CHW performance (odds ratios and robust 95 percent confidence intervals)
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- 2021
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23. State nutrition profile: Karnataka
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Rakesh Sarwal, Soyra Gune, Neena Bhatia, William Joe, Phuong Hong Nguyen, Purnima Menon, Shambhavi Singh, Robert Johnston, and Rasmi Avula
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Geography ,State (functional analysis) ,Socioeconomics - Published
- 2021
24. State nutrition profile: Kerala
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Purnima Menon, Rasmi Avula, Rakesh Sarwal, Neena Bhatia, S. K. Singh, Phuong Hong Nguyen, Soyra Gune, William Joe, and Robert Johnston
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Political science ,State (functional analysis) ,Socioeconomics - Published
- 2021
25. State nutrition profile: Assam
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Esha Sarswat, Rakesh Sarwal, Neena Bhatia, Purnima Menon, S. K. Singh, Robert Johnston, Rasmi Avula, Nishmeet Singh, Phuong Hong Nguyen, and William Joe
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Geography ,State (functional analysis) ,Socioeconomics - Published
- 2021
26. How childhood stunting reduced in Gujarat: An analysis of change between 1992 and 2016
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Nitya Rachel George, Sneha Mani, Neha Kohli, Rasmi Avula, Shubhada Kanani, Phuong Hong Nguyen, and Purnima Menon
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- 2021
27. How childhood stunting reduced in Tamil Nadu: An analysis of change between 1992 and 2016
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Neha Kohli, Shilpa Constantinides, Phuong Hong Nguyen, Purnima Menon, and Rasmi Avula
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- 2021
28. Improving maternal nutrition in India through integrated hot-cooked meal programs: A review of implementation evidence
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Shivani Kachwaha, Vani Sethi, William Joe, Rasmi Avula, Avula Laxmaiah, and Purnima Menon
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Meal ,business.industry ,Environmental health ,Medicine ,business - Published
- 2021
29. State nutrition profile: Jammu and Kashmir
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Rasmi Avula, Robert Johnston, Purnima Menon, S. K. Singh, Phuong Hong Nguyen, Anita Christopher, William Joe, Rakesh Sarwal, and Neena Bhatia
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Geography ,State (polity) ,media_common.quotation_subject ,Socioeconomics ,media_common - Published
- 2021
30. Tackling nutrition in Odisha: Looking back, looking forward
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Purnima Menon, Rasmi Avula, Nihar Mishra, Neha Kohli, and Phuong H. Nguyen
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Business - Published
- 2020
31. Tracking India’s progress on addressing malnutrition: What will it take?
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Anamika Singh, Purnima Menon, Divya Nair, Alok Kumar Dubey, Nitya Agrawal, Shuchita Gupta, Manita Jangid, Rasmi Avula, Sneha Mani, Supreet Kaur, Esha Sarswat, and Pulkit Agarwal
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Malnutrition ,Economic growth ,Geography ,South asia ,medicine ,Tracking (education) ,medicine.disease ,Breast feeding - Published
- 2020
32. What lies at the root of child undernutrition in India? Understanding trends and patterns in underlying determinants between 2006 and 2016
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Sattvika Ashok, Phuong H. Nguyen, Esha Sarswat, Purnima Menon, Rasmi Avula, and Pratima Mathews
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Root (linguistics) ,Malnutrition ,medicine ,Biology ,medicine.disease ,Demography - Published
- 2020
33. Tracking India’s progress on addressing malnutrition and enhancing the use of data to improve programs
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Purnima Menon, Rasmi Avula, Esha Sarswat, Sneha Mani, and Manita Jangid
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Malnutrition ,Risk analysis (engineering) ,Computer science ,medicine ,Tracking (education) ,medicine.disease - Published
- 2020
34. India’s 2.42 Million Frontline Health Workers Enable Restoration of Health and Nutrition Service Delivery After Early COVID-19 Lockdowns
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Deepak Singhania, Shivani Kachwaha, Rasmi Avula, Madhulika Khanna, Monika Walia, Sattvika Ashok, Thomas Forissier, Anshuman Paul, Alok Singh, Jessica Escobar-Alegria, Purnima Menon, Bharati Kulkarni, Phuong H. Nguyen, Anjali Pant, Little Flower Augustine, Anshu Singh, and Sumati Bajaj
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Nutrition and Dietetics ,Coronavirus disease 2019 (COVID-19) ,Service delivery framework ,Medicine (miscellaneous) ,language.human_language ,Nursing ,Immunization ,Pandemic ,Food policy ,language ,Business ,COVID-19 and Nutrition ,Home Childbirth ,Food Science - Abstract
OBJECTIVES: Modeling studies have estimated impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes, but little is known about actual delivery status. We studied disruptions and restorations of health and nutrition services by frontline workers (FLWs) in India during COVID-19. METHODS: We conducted phone surveys with 5500 FLWs in seven states between August–October 2020, asking about service delivery during April 2020 (T1) and in the August-October period (T2) and analyzed changes between T1 and T2. We also analyzed publicly available administrative data (AD) from 704 districts including the pre-pandemic period (T0) to examine disruptions and restoration of services. RESULTS: Phone surveys suggest, in T1, opening of village centers, fixed day events, growth monitoring, and immunization services was 33% in >= 3 states. Food supplementation was least disrupted both in T1 and T2. AD highlights geographic variability both in disruptions in T1 compared to T0 and restorations in T2. FLWs’ adaptations to ensure service provision included home delivery (60 to 96%), ensuring physical distancing (33 to 86%), coordinating with other FLWs (7 to 49%), and using phone (∼2 to 65%). Challenges included personal fears, walking long distances, and beneficiaries’ non-cooperation. CONCLUSIONS: Services to mothers and children were disrupted during lockdown and restored thereafter. Rapid policy guidance and local adaptations by a strong cadre of FLWs likely enabled service resumption. However, gaps remain, and more research is needed on use of services by clients. FUNDING SOURCES: Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.
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- 2021
35. The Impact of COVID-19 on Household Food Insecurity and Interlinkages With Child Feeding Practices and Coping Strategies in Uttar Pradesh, India
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Phuong H. Nguyen, Lan Mai Tran, Purnima Menon, Rasmi Avula, Vishal Dev Shashtri, Sebanti Ghosh, Anjali Pant, Praveen Kumar Sharma, Shivani Kachwaha, and Jessica Escobar-Alegria
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Nutrition and Dietetics ,Food security ,Multivariate analysis ,Coronavirus disease 2019 (COVID-19) ,Medicine (miscellaneous) ,Coping behavior ,language.human_language ,Food insecurity ,AcademicSubjects/MED00060 ,Geography ,Pandemic ,Food policy ,language ,COVID-19 and Nutrition ,Uttar pradesh ,Socioeconomics ,Food Science - Abstract
Objectives The Coronavirus (COVID-19) pandemic has profound negative impacts on people's lives, but little is known on the effect of COVID-19 on household food insecurity (HFI) in poor setting resources. This study aimed to assess the changes in HFI during the pandemic and examine the interlinkages between HFI with child feeding practices and coping strategies in Uttar Pradesh, India. Methods We conducted a longitudinal quantitative survey with 569 mothers with children
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- 2021
36. Understanding Implementation and Improving Nutrition Interventions: Barriers and Facilitators of Using Data Strategically to Inform the Implementation of Maternal Nutrition in Uttar Pradesh, India
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Phuong H. Nguyen, Purnima Menon, Shivani Kachwaha, Rasmi Avula, Vishal Dev Shastri, Thomas Forissier, Praveen Kumar Sharma, Sebanti Ghosh, Ahad Bootwala, and Melissa F Young
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030309 nutrition & dietetics ,India ,Medicine (miscellaneous) ,Political structure ,AcademicSubjects/MED00060 ,03 medical and health sciences ,0302 clinical medicine ,030212 general & internal medicine ,Human resources ,implementation science ,0303 health sciences ,Government ,Medical education ,Nutrition and Dietetics ,Data collection ,Nutrition Interventions ,business.industry ,data use ,Community and Global Nutrition ,ORIGINAL RESEARCH ,Psychology ,business ,Uttar pradesh ,qualitative research ,maternal nutrition ,Food Science ,Health department ,Qualitative research - Abstract
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., Despite intensive data-collection efforts, the use of data to inform decision making remains limited. Structural barriers such as staff vacancies need to be addressed to improve data utilization.
- Published
- 2021
37. Reprint of 'What will it take to accelerate improvements in nutrition outcomes in Odisha? Learning from the past'
- Author
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Purnima Menon, Mara van den Bold, Elisabeth Becker, Nicholas Nisbett, Rasmi Avula, Neha Kohli, and Lawrence Haddad
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0301 basic medicine ,Government ,Civil society ,Economic growth ,030109 nutrition & dietetics ,Food security ,Ecology ,Sanitation ,business.industry ,Service delivery framework ,Psychological intervention ,Livelihood ,Social group ,03 medical and health sciences ,0302 clinical medicine ,Medicine ,030212 general & internal medicine ,Safety, Risk, Reliability and Quality ,business ,Safety Research ,Food Science - Abstract
The Indian state of Odisha has made significant strides to address health and nutrition in the last 25 years. We used public data, policy and program documents, published literature, and interviews with program and policy decision-makers, development partners, civil society members (n=29) and community members (n=45) to analyze these changes. Factors that contributed to scale up of health and nutrition interventions and the food security program included overarching policy support, financing at the national and state level, leadership across sectors from government to civil society and development partners, capacity and stability of tenure of bureaucrats, and state innovations in service delivery interventions. Barriers that may impede further progress include lack of sanitation, low levels of women's education, early marriage in girls, livelihood distress, and uneven progress across social groups.
- Published
- 2017
38. What will it take to accelerate improvements in nutrition outcomes in Odisha? Learning from the past
- Author
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Neha Kohli, Rasmi Avula, Mara van den Bold, Elisabeth Becker, Nicholas Nisbett, Lawrence Haddad, and Purnima Menon
- Subjects
0301 basic medicine ,03 medical and health sciences ,030109 nutrition & dietetics ,Ecology ,0502 economics and business ,05 social sciences ,050202 agricultural economics & policy ,Safety, Risk, Reliability and Quality ,Safety Research ,Food Science - Published
- 2017
39. Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors
- Author
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Rasmi Avula, Shivani Kachwaha, Melissa F Young, Sebanti Ghosh, Phuong H. Nguyen, Jessica Escobar-Alegria, Sumeet Patil, Purnima Menon, Lan Mai Tran, and Rajeev Agrawal
- Subjects
0301 basic medicine ,Health Knowledge, Attitudes, Practice ,Iron ,Maternal Health ,Family support ,India ,Nutritional Status ,Supply and demand ,diverse diet ,03 medical and health sciences ,Household survey ,Folic Acid ,0302 clinical medicine ,Pregnancy ,Environmental health ,Humans ,Medicine ,030212 general & internal medicine ,Consumption (economics) ,calcium ,030109 nutrition & dietetics ,Nutrition and Dietetics ,business.industry ,Public Health, Environmental and Occupational Health ,Obstetrics and Gynecology ,Prenatal Care ,Maternal Nutritional Physiological Phenomena ,Original Articles ,Odds ratio ,medicine.disease ,Diet ,iron and folic acid ,Dietary Supplements ,Pediatrics, Perinatology and Child Health ,Attributable risk ,Female ,Original Article ,Uttar pradesh ,business ,maternal nutrition - Abstract
Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self‐efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization‐recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change.
- Published
- 2019
40. A Double Edged Sword? Improvements in Economic Conditions over a Decade in India Led to Declines in Undernutrition as Well as Increases in Overweight among Adolescents and Women
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Rasmi Avula, Phuong H. Nguyen, Lan Mai Tran, Melissa F Young, and Purnima Menon
- Subjects
Adult ,Male ,Adolescent ,Medicine (miscellaneous) ,India ,Overweight ,Young Adult ,Risk Factors ,medicine ,Prevalence ,Humans ,Socioeconomic status ,Nutrition and Dietetics ,business.industry ,Malnutrition ,Middle Aged ,medicine.disease ,Obesity ,Social Class ,Lower prevalence ,Latrine ,Residence ,Female ,medicine.symptom ,Underweight ,business ,Demography - Abstract
Background India is facing a dual burden of undernutrition and overweight/obesity, and there are gaps in our understanding of the driving factors over time. Objective This study examined the national and state trends for BMI and identified the determinants of underweight and overweight/obesity among adolescent girls and women. Methods We used India's National Family Health Surveys data collected in 2005-2006 (n = 110,887) and 2015-2016 (n = 645,193). We applied multiple regression and decomposition analysis to assess determinants of underweight (BMI z score 1 SD; ≥25 kg/m2). Results Over the past decade, the prevalence of underweight decreased (43% to 38% and 33% to 19%) and the prevalence of overweight/obesity increased (3% to 5% and 15% to 24%), among adolescents and women, respectively, with high heterogeneity across states. Factors associated with a lower prevalence of underweight among women included higher socioeconomic status (SES) (OR: 0.35; 95% CI: 0.31, 0.41), urban residence (OR: 0.49; 95% CI: 0.45, 0.54), improved diet diversity (OR: 0.75; 95% CI: 0.69, 0.82), and latrine use (OR: 0.76; 95% CI: 0.70, 0.82). Higher education levels, decision-making, and ownership of money were also associated with a lower prevalence of underweight. Factors positively associated with overweight/obesity among women included SES (OR: 3.24; 95% CI: 2.81, 3.73), urban residence (OR: 2.23; 95% CI: 2.05, 2.42), diet diversity (OR: 1.21; 95% CI: 1.10, 1.32), latrine use (OR: 1.31; 95% CI: 1.21, 1.43), and education (OR: 1.39; 95% CI: 1.24, 1.55). Adolescents shared similar determinants to women. Overall, SES was a key driver of changes in women's BMI, explaining 29% of the reduction in undernutrition and 46% of the increase in overweight/obesity. Conclusions Despite overall declines, regional and age disparities remain in the overall burden of underweight and the increases in overweight/obesity are concerning. The identified divergent risk factors (SES, residence, diet, education) highlight that simply improving economic status will not ensure healthy BMI status for women and girls. Balanced multidisciplinary approaches are needed to address both undernutrition and overweight.
- Published
- 2019
41. Effects of an mHealth intervention for community health workers on maternal and child nutrition and health service delivery in India: protocol for a quasi-experimental mixed-methods evaluation
- Author
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Sneha, Nimmagadda, Lakshmi, Gopalakrishnan, Rasmi, Avula, Diva, Dhar, Nadia, Diamond-Smith, Lia, Fernald, Anoop, Jain, Sneha, Mani, Purnima, Menon, Phuong Hong, Nguyen, Hannah, Park, Sumeet R, Patil, Prakarsh, Singh, and Dilys, Walker
- Subjects
Community Health Workers ,Nutritional Support ,Child Health Services ,impact evaluation ,child health and nutrition ,India ,Nutritional Status ,Global Health ,Telemedicine ,mhealth ,quality in health care ,Observational Studies as Topic ,Pregnancy ,Protocol ,Humans ,Female ,Maternal Health Services ,Child ,Child Nutritional Physiological Phenomena ,Delivery of Health Care - Abstract
Introduction Millions of children in India still suffer from poor health and under-nutrition, despite substantial improvement over decades of public health programmes. The Anganwadi centres under the Integrated Child Development Scheme (ICDS) provide a range of health and nutrition services to pregnant women, children
- Published
- 2019
42. Effects of an mHealth intervention for community health workers on maternal and child nutrition and health service delivery in India: protocol for a quasi-experimental mixed-methods evaluation
- Author
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Nimmagadda, Sneha, Gopalakrishnan, Lakshmi, Avula, Rasmi, Dhar, Diva, Diamond-Smith, Nadia, Fernald, Lia, Jain, Anoop, Mani, Sneha, Menon, Purnima, Nguyen, Phuong Hong, Park, Hannah, Patil, Sumeet R, Singh, Prakarsh, and Walker, Dilys
- Subjects
and promotion of well-being ,Child Health Services ,impact evaluation ,Clinical Sciences ,child health and nutrition ,Nutritional Status ,India ,Reproductive health and childbirth ,quality in health care ,Pregnancy ,Clinical Research ,Behavioral and Social Science ,Humans ,Maternal Health Services ,Child ,Community Health Workers ,Pediatric ,Other Medical and Health Sciences ,Nutritional Support ,Prevention ,Health Services ,Prevention of disease and conditions ,Telemedicine ,mhealth ,Observational Studies as Topic ,Good Health and Well Being ,Public Health and Health Services ,3.1 Primary prevention interventions to modify behaviours or promote wellbeing ,Female ,Generic health relevance ,Child Nutritional Physiological Phenomena ,Delivery of Health Care - Abstract
INTRODUCTION:Millions of children in India still suffer from poor health and under-nutrition, despite substantial improvement over decades of public health programmes. The Anganwadi centres under the Integrated Child Development Scheme (ICDS) provide a range of health and nutrition services to pregnant women, children
- Published
- 2019
43. Feeding India's babies: Trends and patterns in infant and young child feeding practices across India's states and districts
- Author
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Purnima Menon, Esha Sarswat, Anjali Pant, Phuong Hong Nguyen, Pratima Mathews, and Rasmi Avula
- Subjects
Geography ,Young child ,Socioeconomics - Published
- 2019
44. Supporting efforts to address malnutrition in the context of the COVID-19 pandemic in India: An emergency need
- Author
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Kartheek Reddy, Sujeet Ranjan, Pratima Mathews, Purnima Menon, Vignesh Reddy, Arjan de Wagt, Sahil Sharma, Chandrakant S Pandav, Rasmi Avula, Rajan Sankar, Sameer Pawar, and Supreet Kaur
- Subjects
Economic growth ,food ,pandemic ,Social distance ,Safety net ,coronavirus ,social distancing ,Context (language use) ,malnutrition ,General Medicine ,medicine.disease ,CLARION ,Malnutrition ,nutrition ,novel covid-19 ,Action (philosophy) ,Political science ,Pandemic ,medicine ,Medicine ,Food systems ,poshan abhiyaan ,anganwadi - Abstract
India has been on a steady march to address malnutrition in the last decade. The nutrition community has worked on building consensus on key actions, implementation platforms were put in place and financing for nutrition slowly increased. Under the strong leadership of the Prime Minister, a revolutionary program to address malnutrition was launched in 2018. As actions under the mission accelerated, the COVID-19 pandemic arrived in early 2020. Affecting health systems, food systems, nutrition programs, social safety nets, and the economy, the pandemic has the potential to exacerbate the challenge of malnutrition in multiple ways. India can mitigate some of the possible ways in which COVID-19 will affect malnutrition but will require strong leadership and continued commitment, adaptation of the national nutrition mission, strengthening of the social safety net and innovative evidence-based data to take informed decisions, implement them and ensure feedback to take necessary corrective action. In this article, we outline some challenges and key areas for action. We conclude that India's nutrition journey is too important to be derailed by a crisis like COVID-19. This is a clarion call for the nutrition community in India to rally strongly to support continued attention to malnutrition in all its forms, to generate relevant evidence, and to support and engage all of society to urgently and adequately address malnutrition in the context of the COVID-19 pandemic. We have come too far to turn back now.
- Published
- 2021
45. Assessing the Economic Feasibility of Assuring Nutritionally Adequate Diets for Vulnerable Populations in Uttar Pradesh, India: Findings from a 'Cost of the Diet' Analysis
- Author
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Shivani Kachwaha, Shruthi Cyriac, Amy Webb Girard, Purnima Menon, Michelle DeFreese, Phuong H. Nguyen, and Rasmi Avula
- Subjects
0301 basic medicine ,Behavior change communication ,Food prices ,Psychological intervention ,India ,Medicine (miscellaneous) ,AcademicSubjects/MED00060 ,03 medical and health sciences ,0302 clinical medicine ,Nutrient ,Environmental health ,medicine ,030212 general & internal medicine ,affordability ,030109 nutrition & dietetics ,Nutrition and Dietetics ,Prenatal nutrition ,Community and Global Nutrition ,ORIGINAL RESEARCH ,Micronutrient ,medicine.disease ,language.human_language ,accessibility ,Malnutrition ,nutritious diet ,Food policy ,language ,Business ,cost of diet ,Food Science - Abstract
Uttar Pradesh (UP) is the most populous state with the highest burden of undernutrition in India. Alive & Thrive is working to strengthen behavior change communication (BCC) on diet diversity and quantity, using health systems platforms to deliver maternal nutrition intervention. However, evidence on the accessibility and affordability associated with recommended diets is limited. This study aims to: 1) examine the costs of nutritious foods in local markets, 2) identify inexpensive sources of essential micronutrients which could be promoted through BCC interventions. Data collection included 24 market surveys and 125 household interviews to obtain food prices and consumption patterns. Cost of Diet (CotD), a linear programing software, was used to estimate the lowest cost for meeting nutrient requirements of 4 types of diet: 1) energy only diet (EO), 2) energy and macronutrient diets (MAC); 3) nutritious diet (NUT-meets recommended intakes for energy and nutrients), and 4) a food habits diet (FHAB-meet energy and nutrient requirements based upon local dietary habits). The diets were compared to identify relative costs and nutrient requirements met. The FHAB diet (USD 90/month for a household of 6 people) was over twice as expensive compared to the energy only diet. EO and MAC diets were affordable for all households, but they indicated inadequate nutrient intakes for vitamins A, C, B-12, folic acid, calcium, and iron. NUT and FHAB diets met all nutrient requirements but were not affordable for the lowest quartile of households. Recommended intakes of Vitamins A, C, B12, and calcium were most difficult to meet. Key foods identified which provided majority of essential macro and micronutrients included wheat flour, buffalo milk, soybean, and spinach. Multiple sources of iron and calcium were identified as affordable and accessible in local markets. Foods available in local market are sufficient for households to obtain recommended intakes of macro- and micronutrients. Economic constraints and dietary habits are key barriers to achieve a nutritious diet. Practical, habitual diet-related behavior change communication to middle and high-income households and additional social protection for poorer households could improve optimal nutrient intakes. Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.
- Published
- 2020
46. Routine Growth Monitoring Processes in Nutrition Programs in India Have Multiple Falter Points with Implications for Quality of Care
- Author
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Sumati Bajaj, Marie T. Ruel, Rasmi Avula, Anjali Pant, Purnima Menon, and Phuong H. Nguyen
- Subjects
Global Nutrition ,Nutrition and Dietetics ,Sling (implant) ,business.industry ,Primary health care ,Medicine (miscellaneous) ,Anthropometry ,Clothing ,medicine.disease ,language.human_language ,Patient referral ,Growth monitoring ,Food policy ,language ,medicine ,Medical emergency ,Quality of care ,business ,Food Science - Abstract
OBJECTIVES: Growth monitoring (GM) and promotion is a routine part of primary healthcare for children in >80% of countries. In India, 57.5 million children are measured every month by frontline workers to assess their growth and to trigger preventive or curative services. Standard guidance for anthropometry suggests that quality can be compromised by the choice of measurement equipment, placement of equipment, and positioning of children during measurement. Little is known about the quality of measurement processes during GM. We compared child height and weight measurement processes with standards for anthropometry to assess GM quality. METHODS: We observed the process of measuring weight and height of
- Published
- 2020
47. No Magic Bullets: Insights on Drivers of Stunting Decline from an Analysis of Subnational Success Cases in India
- Author
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Phuong H. Nguyen, Purnima Menon, Rasmi Avula, Shubhada Kanani, and Neha Kohli
- Subjects
Global Nutrition ,Government ,Economic growth ,Nutrition and Dietetics ,Sanitation ,Political science ,media_common.quotation_subject ,Academia (organization) ,Medicine (miscellaneous) ,Magic (paranormal) ,Food Science ,media_common - Abstract
OBJECTIVES: Global attention to reducing childhood stunting has increased the demand for guidance on translating policies into impact. Evidence from national-level success cases is emerging but little is known about how subnational entities can accelerate change. In India, despite a common national framework of programs/policies targeting many determinants of child growth, stunting reduction has varied across states. We aimed to understand drivers of change in stunting at state-level and to identify programmatic, social and political factors that contributed to these changes. METHODS: We studied three states that had achieved substantial stunting declines between 2005 and 2016 [Chhattisgarh (CG) 14 percentage points (pp); Gujarat (GJ) 13pp; Odisha (OD) 11 pp]. We used regression-decomposition analysis to assess contributions of various determinants of height-for-age Z-score (HAZ) using two rounds of national data. We reviewed nutrition-relevant policies and programs linked to these drivers of change and interviewed stakeholders in government, development partners (DPs), academia and civil society (n = 61) to understand how change occurred. RESULTS: Main contributors to gains in HAZ were coverage of health and nutrition interventions (21% CG; 11% GJ; 25% OD), household assets (10% CG; 13% GJ; 18% OD), and sanitation (7% CG; 6% GJ; 5% OD). Maternal education, age at marriage, community-level hygiene, and electrification also contributed. Political leadership and an outcome-focused vision were crucial for action. Although vision varied, capable administrators were able to secure adequate finances, strengthen implementation systems, and invest in state-specific innovations, creating an enabling environment for change. Varied actors, including civil society and DPs, played a catalytic role in spurring action through advocacy, technical and financial inputs, and vigilance. CONCLUSIONS: Similar drivers were responsible for stunting reduction in 3 states. Ingredients for success highlight the importance of political leadership, targeting multiple determinants and improving implementation systems. Supportive civil society, political and bureaucratic leadership motivated by the well-being of communities remain crucial. FUNDING SOURCES: Bill & Melinda Gates Foundation through POSHAN, led by IFPRI.
- Published
- 2020
48. Understanding How the Strategic Use of Data Can Improve the Implementation of Maternal Nutrition Interventions in Uttar Pradesh (UP), India
- Author
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Thomas Forissier, Rasmi Avula, Shivani Kachwaha, Melissa F Young, Phuong H. Nguyen, Ahad Bootwala, Purnima Menon, and Sebanti Ghosh
- Subjects
Maternal, Perinatal and Pediatric Nutrition ,Pregnancy ,Government ,Nutrition and Dietetics ,Prenatal nutrition ,Nutrition Interventions ,business.industry ,Medicine (miscellaneous) ,Prenatal care ,medicine.disease ,Micronutrient ,Maternal malnutrition ,Environmental health ,medicine ,business ,Uttar pradesh ,Food Science - Abstract
OBJECTIVES: Maternal undernutrition remains high in India and is associated with maternal mortality and adverse birth outcomes. To address this challenge, Alive & Thrive (A&T) aimed to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in UP. The nutrition-intensified ANC (I-ANC) intervention facilitated regular use of data to enable corrective actions. We aimed to understand how maternal health data was used for improving the delivery of maternal nutrition services and to identify factors associated with data use. METHODS: In-depth interviews (N = 35) were conducted among sub-district government staff, frontline worker (FLW) supervisors and A&T staff in two districts in UP. Systematic coding of verbatim transcripts and detailed summaries was undertaken to elucidate themes and patterns related to data use and facilitators and barriers. RESULTS: Sub-district government staff reported using government data (i.e., HMIS) to estimate demand for prenatal supplements. Sub-district government staff, FLW supervisors and A&T staff used government and intervention monitoring data to understand the impact and reach of services delivered to women. Key indicators on the attendance of pregnant women at community health events and number of women receiving adequate supplements was discussed with FLWs in monthly review meetings. Data review guided identification of areas of low FLW performance (i.e., monitoring weight gain) and prompted refresher trainings. Facilitators of data use included collaboration between sub-district health department officials on data analysis and monthly review meetings to provide feedback on improving performance (including counseling topics and stock of supplements). Barriers to data use included staff vacancies, education level of FLWs and conflicts between FLWs and supervisors. CONCLUSIONS: Use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Collaboration facilitated the use of data, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions. FUNDING SOURCES: Bill & Melinda Gates Foundation (through Alive & Thrive, managed by FHI 360) and Emory University.
- Published
- 2020
49. Strengthening Nutrition Interventions in Antenatal Care Services Had Modest Impacts on Diet Diversity, Micronutrient Intake, and Breastfeeding in Uttar Pradesh, India
- Author
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Edward Frongillo, Purnima Menon, Lan Mai Tran, Phuong H. Nguyen, Shivani Kachwaha, Jessica Escobar-Alegria, Melissa F Young, Rajeev Agrawal, Thomas Forissier, Rasmi Avula, Sebanti Ghosh, and Sumeet Patil
- Subjects
Maternal, Perinatal and Pediatric Nutrition ,Pregnancy ,Nutrition and Dietetics ,Prenatal nutrition ,business.industry ,media_common.quotation_subject ,Breastfeeding ,Medicine (miscellaneous) ,Gestational age ,Prenatal care ,medicine.disease ,Micronutrient ,Environmental health ,medicine ,business ,Breast feeding ,Food Science ,Diversity (politics) ,media_common - Abstract
OBJECTIVES: Interventions to improve maternal nutrition are poorly integrated into antenatal care (ANC) services in India. Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization implemented through government ANC services. We evaluated the impact of nutrition-intensified ANC (I-ANC) compared to standard ANC (S-ANC) on diet diversity, consumption of iron-folic acid (IFA) and calcium supplements, and early breastfeeding practices. METHODS: We used a cluster-randomized design with cross-sectional surveys at baseline (2017) and endline (2019) (n ∼660 pregnant women and 1800 recently delivered women per survey) and a process evaluation. We derived difference-in-difference effect estimates, adjusted for geographic clustering, gestational age, infant age, and sex. RESULTS: Coverage of interventions was high at endline; 70–90% women were contacted by frontline workers at home or nutrition centers. Women in the I-ANC arm were significantly more likely to have received counseling on core nutrition messages (10–18 percentage points [pp]) than those in the S-ANC arm. Dietary diversity improved modestly among pregnant women in the I-ANC arm compared to the S-ANC arm (effect: 8.3 pp). The number of food groups consumed increased slightly over time but remained low in both arms. The percentage of women who consumed 100 + IFA improved equally in both arms (from 8 to 25%). Small significant impacts were observed for any consumption of IFA and calcium supplements (effects 10.3 and 12.4 pp, respectively). Significant impacts were also observed for non-prelacteal feeding (effect: −6.3 pp) and exclusive breastfeeding (effect: 7.4 pp) but not for early initiation of breastfeeding. The process evaluation found that system-level and supply-chain challenges, household context, and local diet preferences affected implementation and uptake. CONCLUSIONS: Intensifying nutrition in existing government ANC services resulted in modest improvements in maternal nutrition practices. Dietary diversity and consumption of supplements remained sub-optimal. Additional efforts are needed for further improvement of maternal nutrition services. FUNDING SOURCES: Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.
- Published
- 2020
50. Using Novel Scenario-Based Assessments to Examine Feasibility of Integrating Preventive Nutrition Services Through the Primary Healthcare System in Bangladesh
- Author
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Purnima Menon, Deborah Ash, Bidhan Krishna Sarker, Sk Masum Billah, Phuong H. Nguyen, Zeba Mahmud, Rasmi Avula, Priyanjana Pramanik, Santhia Ireen, and Tarana E Ferdous
- Subjects
Well child visit ,medicine.medical_specialty ,Nutrition and Dietetics ,Scenario based ,business.industry ,Primary health care ,Medicine (miscellaneous) ,Community and Public Health Nutrition ,Incentive ,Immunization ,Preventive nutrition ,Family medicine ,Workforce ,Medicine ,Well child ,business ,Food Science - Abstract
OBJECTIVES: Bangladesh's National Nutrition Services aims to deliver nutrition services to pregnant women and children through the primary health care system. Previous research highlighted gaps in coverage of preventive nutrition intervention delivery through this system but little is known about feasibility of reshaping service delivery to close the gaps. Prior to designing new approaches, we used a novel scenario-based feasibility testing approach to assess potential to strengthen service delivery. METHODS: We interviewed 32 service providers and 16 policymakers and conducted 4 focus group discussions with potential beneficiaries, asking respondents about the feasibility of four hypothetical scenarios for preventive service delivery: community-based events (CBE) for pregnant women; well-child services integrated into immunization contacts; CBE for well-children and well-child visits at facilities. Transcribed interviews were systematically coded, synthesized and interpreted using a pre-defined framework. RESULTS: Opinions on the need for new platforms for preventive services were mixed; some recommended new platforms, but others suggested strengthening existing delivery points. CBE for pregnant women were perceived as feasible, but workforce shortages emerged as a key challenge. Challenges such as equipment portability, upset children, and a fast-moving service environment suggested low feasibility of integrating nutrition into immunization contacts. In contrast, CBE and facility-based well-child visits emerged as feasible options, conditional on having the necessary workforce, structural readiness and budget support. On the demand side, enabling factors include using interpersonal communication and involving community leaders to increase awareness, organizing events at a convenient time and place for both providers and beneficiaries, and incentives for beneficiaries to encourage participation. CONCLUSIONS: A scenario-based approach is an efficient method to assess potential feasibility options for nutrition service delivery. Introducing preventive nutrition services requires addressing current challenges in the health system, including human resource and logistic gaps, and investing in creating demand for preventive services. FUNDING SOURCES: Bill & Melinda Gates Foundation, through A&T, managed by FHI 360.
- Published
- 2020
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