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PR, IFPRI4; 2 Promoting Healthy Diets and Nutrition for all; ISI; DCA; POSHAN, PHND, 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.

PR, IFPRI3; ISI; DCA; DataDENT; CRP4; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Objective: To examine inequalities and opportunity gaps in co-coverage of health and nutrition interventions in seven countries. Methods: We used data from the most recent (2015–2018) demographic and health surveys of mothers with children younger than 5 years in Afghanistan (n = 19 632), Bangladesh (n = 5051), India (n = 184 641), Maldives (n = 2368), Nepal (n = 3998), Pakistan (n = 8285) and Sri Lanka (n = 7138). We estimated co-coverage for a set of eight health and eight nutrition interventions and assessed within-country inequalities in co-coverage by wealth and geography. We examined opportunity gaps by comparing coverage of nutrition interventions with coverage of their corresponding health delivery platforms. Findings: Only 15% of 231 113 mother–child pairs received all eight health interventions (weighted percentage). The percentage of mother–child pairs who received no nutrition interventions was highest in Pakistan (25%). Wealth gaps (richest versus poorest) for co-coverage of health interventions were largest for Pakistan (slope index of inequality: 62 percentage points) and Afghanistan (38 percentage points). Wealth gaps for co-coverage of nutrition interventions were highest in India (32 percentage points) and Bangladesh (20 percentage points). Coverage of nutrition interventions was lower than for associated health interventions, with opportunity gaps ranging from 4 to 54 percentage points. Conclusion: Co-coverage of health and nutrition interventions is far from optimal and disproportionately affects poor households in south Asia. Policy and programming efforts should pay attention to closing coverage, equity and opportunity gaps, and improving nutrition delivery through health-care and other delivery platforms.

PR, IFPRI3; ISI; POSHAN; 2 Promoting Healthy Diets and Nutrition for all; IFPRIOA, PHND; SAR, Background: Anemia and poor physical growth during adolescence have far-ranging consequences, but limited longitudinal evidence exists on how changes in these factors relate to changes in learning skills as adolescents mature. Objectives: We examined the association between changes in anemia and physical growth during adolescence and learning outcomes. Methods: We used longitudinal data from the Understanding the Lives of Adolescents and Young Adults (UDAYA) project, which surveyed adolescents aged 10–19 years in northern India in 2015–16 and 2018–19 (n = 5963). We used multilevel mixed-effects logistic regression models to examine associations between changes in anemia/thinness/stunting status (four groups: never, improved, new, and persistent) and reading (ability to read a story) and math proficiency (ability to solve division problems) at follow-up. Results: Persistent anemia and stunting were higher among girls than boys (46% vs.8% and 37% vs. 14%, respectively), but persistent thinness was lower (7% vs. 16%). Improvement in anemia, thinness and stunting was 1.4–1.7 times higher among boys than girls. Boys who were anemic in both waves were 74% (adjusted odds ratio [AOR] 0.26, 95% confidence interval [CI)]: 0.12,0.59) and 65% (AOR 0.35, 95%CI: 0.16,0.76) less likely to be able to read a story and solve division problems, respectively, compared to boys who were non-anemic in both waves. Persistent thinness in boys was negatively associated with both reading (AOR 0.37, 95% CI: 0.21,0.66) and math proficiency (AOR 0.27, 95% CI: 0.16,0.46). Persistent stunting contributed to lower reading and math proficiency in boys and girls (AORs: 0.29 to 0.46). Boys whose anemia or thinness status improved and girls whose stunting status improved had similar learning skills at follow-up as those who were never anemic/thin/stunted. Conclusions: Persistent anemia, thinness and short stature during adolescence was associated with poor learning. Programs targeted at adolescents sho

PR, IFPRI3; ISI; CRP4; 2 Promoting Healthy Diets and Nutrition for all; POSHAN, PHND; A4NH; SAR, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Background: The coronavirus (COVID-19) pandemic may substantially affect health systems, but little primary evidence is available on disruption of health and nutrition services. Objectives: This study aimed to 1) determine the extent of disruption in provision and utilization of health and nutrition services induced by the pandemic in Uttar Pradesh, India; and 2) identify how adaptations were made to restore service provision in response to the pandemic. Methods: We conducted longitudinal surveys with frontline workers (FLWs, n = 313) and mothers of children <2 y old (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests. Results: Compared with prepandemic, service provision reduced substantially during lockdown (83–98 percentage points, pp), except for home visits and take-home rations (∼30%). Most FLWs (68%–90%) restored service provision in July 2020, except for immunization and hot cooked meals (<10%). Administrative data showed similar patterns of disruption and restoration. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service provision. Key adaptations made to provide services were delivering services to beneficiary homes (∼40%–90%), social distancing (80%), and using PPE (40%–50%) and telephones for communication (∼20%). On the demand side, service utilization reduced substantially (40–80 pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing the challenges of limited travel (30%), nonavailability of services (26%), and fear of catching the virus when leaving the house (22%) or meeting service providers (14%). Conclusions: COVID-19 disrupted the provision and use of health and nutrition servi

Non-PR, IFPRI5; POSHAN; CRP4; Alive and Thrive, PHND; A4NH; SAR, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Objectives: The COVID-19 pandemic has significant potential implications for health systems, but little primary evidence is available on effects on health and nutrition services. We aimed to examine changes in service provision and utilization during the pandemic in Uttar Pradesh, India and identify positive adaptations to service delivery. Methods: We conducted longitudinal surveys with frontline workers (FLW, n = 313) and mothers of children < 2 years (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests. Results: Compared to pre-pandemic, service provision reduced substantially during lockdown (83–98 percentage points, pp), except for home visits and take-home-rations (∼30%). Most FLWs (68–90%) resumed service provision in July 2020, except for immunization and hot-cooked meals (< 10%). Administrative data showed similar patterns of disruption and resumption. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service delivery. Key adaptations made to provide services included: delivering services to beneficiary homes (∼40–90%), social distancing (80%), using PPE (40–50%), and telephones for communication (∼20%). On the demand side, service utilization also reduced substantially (40–80pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing challenges of limited travel (30%), non-availability of services (26%), fear of catching virus when leaving the house (22%) or meeting service providers (14%). Conclusions: COVID-19 affected the provision and use of health and nutrition services despite efforts at service restoration and adaptations. Strengthening logistics support, capacity enhancement, performance m

Non-PR, IFPRI5; CRP4, PHND; A4NH, CGIAR Research Programs on Agriculture for Nutrition and Health (A4NH), Objectives: Limited evidence exists on longitudinal impacts of undernutrition on learning skills as adolescents mature. This study aimed to examine the effect of undernutrition in early adolescence on learning skills in late adolescence. Methods: We used longitudinal data from a project called UDAYA that surveyed 16,929 adolescents aged 10–19 years from Bihar and Uttar Pradesh, India in 2015–16 (wave 1) and again in 2018–19 (wave 2). Adolescents’ ability to read a story and solve division problems at age 19–22 years was assessed using the Annual Status of Education Report tools. We characterized adolescents’ nutrition status into 4 groups: never undernourished (e.g., not stunted in wave 1 and 2), recovered (e.g., stunted in in wave 1 but not stunted in wave 2), faltered (e.g., not stunted in wave 1 but stunted in wave 2), and persistent (e.g., stunted in both waves). These 4 groups were created for stunting, thinness, and anemia. We used multivariable logistic regression models adjusted for key demographics, environmental factors, and sampling design. Results: Undernutriton was high (51% were anemic, 19% thin, and 36% stunted) in both survey rounds. Nearly one third of adolescents had persistent stunting or anemia, and 11% had persistent thinness. Compared to those who were never stunted, adolescents with persistent stunting had poorer reading (adjusted odds ratio: 0.66, 95% confidence interval: 0.53–0.83) and math (0.70, 0.56–0.89) skills. Reading ability was also poorer in adolescents who experienced growth faltering (0.61, 0.42–0.90) or who were stunted in wave 1 but not stunted in wave 2 (0.64, 0.44–0.93). Persistent thinness was negatively associated with reading (0.71, 0.54–0.93) but not math skills. Persistent anemia was also negatively associated with reading skills, but the association did not remain significant in the fully adjusted model. Conclusions: In a high poverty sample of Indian adolescents, persistent undernutrition during adolescence was associat

Non-PR, IFPRI5; POSHAN; CRP4, PHND; A4NH; SAR, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), 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 <50% in several states. In T2, restorations of center-based services were seen, with increases of >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.

Non-PR, IFPRI5; CRP4, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Objectives: Home to one in five adolescents globally and a tradition of marrying young, India faces a huge challenge of teenage births. Early birth can be detrimental to the health and wellbeing of the teenage mother and her child, but few studies have followed teenage girls over time to understand these effects. We assessed the impact of early birth on female adolescents' undernutrition status. Methods: We used longitudinal data collected under a project called UDAYA that surveyed adolescent girls in northern India (Uttar Pradesh and Bihar) in 2015–16, with a follow-up round in 2018–19. Girls with no prior birth in round one were grouped as follows: still no birth in round two (reference group; n = 7,197), birth at age < 19 years by round two (early birth group; EB; n = 1,192), and birth at age > = 19 years by round two (later birth group; LB; n = 1,474). Using multivariate logistic and ordinary least square regression models, we examined whether EB or LB predicted height for age z-score (HAZ), stunting, BMI for age z-score (BMIZ), thinness, hemoglobin (Hb), and anemia. Models were controlled for cluster sampling design and individual and household characteristics. Results: The prevalence of undernutrition was higher in the EB group (stunting: 53%, thinness: 23%, anemia: 77%) and the LB group (stunting: 55%, thinness: 29%, anemia: 64%) compared to the reference group (stunting: 35%, thinness: 16%, anemia: 63%). The EB group was more likely to be short for their age (adjusted odds ratio (AOR): 1.30, 95% confidence interval (95%CI): 0.96,1.76), thin (AOR: 1.09, 95%CI: 0.68, 1.75), and anemic (AOR: 2.01, 95%CI: 1.39, 2.90) compared to the reference group. HAZ and Hb levels were on average 0.16 SD (95%CI: –0.30, –0.03) and 0.49 gm/DL (95%CI: –0.76, –0.22) lower, respectively, and BMIZ level was 0.22 SD (95%CI: 0.00, 0.43) higher for the EB group. Similar findings were observed for the LB group but were non-significant. The impact of EB on stunting and thinness was non

PR, IFPRI3; 2 Promoting Healthy Diets and Nutrition for all; 1 Fostering Climate-Resilient and Sustainable Food Supply; ISI, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Introduction: The impact of climate change on agriculture and food security has been examined quite thoroughly by researchers globally as well as in India. While existing studies provide evidence on how climate variability affects the food security and nutrition, research examining the extent of effect vulnerability of agriculture to climate change can have on nutrition in India are scarce. This study examined a) the association between the degree of vulnerability in agriculture to climate change and child nutrition at the micro-level b) spatial effect of climate vulnerability on child nutrition, and c) the geographical hotspots of both vulnerability in agriculture to climate change and child malnutrition. Methods: The study used an index on vulnerability of agriculture to climate change and linked it to child malnutrition indicators (stunting, wasting, underweight and anaemia) from the National Family Health Survey 4 (2015–16). Mixed-effect and spatial autoregressive models were fitted to assess the direction and strength of the relationship between vulnerability and child malnutrition at macro and micro level. Spatial analyses examined the within-district and across-district spill-over effects of climate change vulnerability on child malnutrition. Results: Both mixed-effect and spatial autoregressive models found that the degree of vulnerability was positively associated with malnutrition among children. Children residing in districts with a very high degree of vulnerability were more like to have malnutrition than those residing in districts with very low vulnerability. The analyses found that the odds of a child suffering from stunting increased by 32%, wasting by 42%, underweight by 45%, and anaemia by 63% if the child belonged to a district categorised as very highly vulnerable when compared to those categorised as very low. The spatial analysis also suggested a high level of clustering in the spatial distribution of vulnerability and malnutrition. Hotspots of