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A theory‐driven evaluation was conducted to assess performance of a trial to deliver micronutrient powder (MNP) through the Ethiopian Ministry of Health. We adapted an approach to coverage assessment, originally developed to identify bottlenecks in health service delivery, to examine sequential program outcomes and their correlates using cross‐sectional survey data of caregivers of children 6–23 months (N = 1915). Separate multivariable Poisson regression models were used to estimate adjusted risk ratios of conceptually relevant determinants of coverage and adherence. Caregivers of children >11 months were more likely to have received MNP than caregivers of younger infants, yet children 12–17 months were 32% (P

Summary Background Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. Methods We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. Findings Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08–0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28–2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. Interpretation Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. Funding Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.

This commentary on the Integrated Strategy for Attention to Nutrition (EsIAN) journal supplement begins with a discussion about the challenges that implementation researchers confront with respect to analyzing complex impact pathways. We note that the research on the implementation of the EsIAN component of Mexico's conditional cash transfer program was based implicitly or explicitly on a program impact pathway approach, which used both quantitative and qualitative methods to examine bottlenecks in program implementation. We then identify 5 categories of contexts that affect the impact, implementation, and survival of intervention programs: 1) biological, 2) social-cultural, 3) delivery modalities and platforms, 4) bureaucratic, and 5) political. Each of these contexts presents theoretical and methodological challenges for investigators. In this commentary, we focus primarily on biological and social-cultural contexts, discussing the theoretical and methodological challenges the investigators faced and the research strategies they used to address them, which have produced a unique compilation of “learning by doing” studies. We also touch briefly on the political context in which the Prospera program research was conducted. We conclude with statements that highlight the exceptional value of the journal supplement, not only with respect to the analysis of the interventions the studies cover and the sustained examination of a long-term program but also as a major contribution to the literature in implementation science in nutrition.

Background Focusing on adolescent schoolgirls in rural Bangladesh, this study aimed to describe the nutrition-relevant context required for effective intervention planning. It included attention to dietary behaviors, daily schedules and activities, and girls' beliefs and values. We placed a special emphasis on iron because anemia has been identified as a significant problem in adolescent girls in Bangladesh. Objectives The study was undertaken to inform a larger project to develop a replicable model for integrating nutrition activities into the multiple social programs in BRAC, a large nongovernmental service delivery organization in Bangladesh. Methods Following an initial phase of exploratory key informant interviewing, data collection was conducted through the use of focused ethnographic methods in 2 additional phases. Phase II consisted of in-depth interviews with school-going adolescents in rural communities in Rangpur District (n = 23). Interview modules included sociodemographic information; a qualitative 24-h dietary recall; respondents' concepts of "health," "healthy foods," and "anemia"; exposure to nutrition messages and ratings of their importance and feasibility; and actions to maintain health. In phase III, ratings and other data were collected systematically from a separate sample of 20 adolescent girls. Analyses included thematic analysis of transcribed and translated text and quantitative analysis of numeric data. Results Key findings include evidence that school-going girls consume a variety of foods and have substantial knowledge about good health and nutrition practices. However, we also found beliefs and practices that challenge the development of nutritionally sound food practices, including iron nutrition. The study revealed the importance of teachers and mothers as information sources, and the dietary and cultural roles of purchased snacks, which occur in connection with school attendance. Conclusions These findings, together with insights about girls' values, particularly conceptions related to "a healthy life," have implications for expanding BRAC activities to support the nutrition of adolescent school girls.

Prechewing of food by caregivers is a common infant feeding practice both globally and in the United States, where the highest rates of the practice are found among African-Americans and Alaska Natives. The objective of this study was to determine if prechewing of infant food is associated with increased diarrhoea prevalence of 10-month-old infants in the United States. The study used cross-sectional data from the Infant Feeding Practices Study II to test for associations between prechewing and 2-week-period prevalence of infant diarrhoea. At 10 months of age, infants who received prechewed food (n = 203) had a diarrhoea prevalence of 16.1%, compared with 10.9% of children who did not receive prechewed food (n = 1567) [relative risk (RR) = 1.48, 95% confidence interval (CI) 1.03-2.11]. After adjusting for covariates, including breastfeeding and consuming sweets and dairy, prechewing was associated with a 58% higher risk (RR = 1.58, 95% CI 1.10-2.26) of 2-week diarrhoea prevalence. Consumption of sweets (RR = 1.35, 95% CI 1.03-1.78) and dairy (RR = 1.41, 95% CI 1.03-1.93) was also associated with increased diarrhoea risk. Continued breastfeeding at 10 months of age was associated with a reduced risk of diarrhoea (RR = 0.68, 95% CI 0.50-0.91). Prechewing of infant food is associated with increased diarrhoea among 10-month-old infants. The high RR found in this study suggests that prechewing may be an important factor in public health efforts to reduce the burden of diarrhoeal disease. However, further research is needed to establish that prechewing causes increased diarrhoea risk and to explore potential benefits of prechewing.

BACKGROUND: Nearly one-half of Guatemalan children experience growth faltering more so in indigenous than in nonindigenous children. OBJECTIVES: On the basis of ethnographic interviews in Totonicapan Guatemala which revealed differences in maternal perceptions about food needs in infant girls and boys we predicted a cumulative sex difference in favor of girls that occurred at approximately 6 mo of age and diminished markedly thereafter. We examined whether the predicted differences in age-sex patterns were observed in the village replicated the examination nationally for indigenous children and examined whether the pattern in nonindigenous children was different. DESIGN: Ethnographic interviews (n = 24) in an indigenous village were conducted. Anthropometric measurements of the village children aged 0-35 mo (n = 119) were obtained. National-level growth patterns were analyzed for indigenous (n = 969) and nonindigenous (n = 1374) children aged 0-35 mo with the use of Demographic and Health Survey (DHS) data. RESULTS: Mothers reported that compared with female infants male infants were hungrier were not as satisfied with breastfeeding alone and required earlier complementary feeding. An anthropometric analysis confirmed the prediction of healthier growth in indigenous girls than in indigenous boys throughout the first year of life which resulted in a 2.98-cm height-for-age difference (HAD) between sexes in the village and a 1.61-cm HAD (P < 0.001) in the DHS data between 6 and 17 mo of age in favor of girls. In both data sets the growth sex differences diminished in the second year of life (P < 0.05). No such pattern was seen in nonindigenous children. CONCLUSIONS: We propose that the differences in the HAD that first favor girls and then favor boys in the indigenous growth patterns are due to feeding patterns on the basis of gendered cultural perceptions. Circumstances that result in differential sex growth patterns need to be elucidated in particular the favorable growth in girls in the first year of life. (c) 2015 American Society for Nutrition.

Growth faltering is usually assessed using height-for-age Z-scores (HAZs), which have been used for comparisons of children of different age and sex composition across populations. Because the SD (denominator) for calculating HAZ increases with age, the usefulness of HAZs to assess changes in height over time (across ages) is uncertain. We posited that population-level changes in height as populations age should be assessed using absolute height-for-age differences (HADs) and not HAZs. We used data from 51 nationwide surveys from low- and middle-income countries and graphed mean HAZs and HADs by age. We also calculated annual changes in HAZs and HADs and percentage of total height deficit accumulated annually from birth to age 60 mo using both approaches. Mean HAZ started at -0.4 Z-scores and dropped dramatically up to 24 mo, after which it stabilized and had no additional deterioration. Mean HAD started at -0.8 cm, with the most pronounced faltering occurring between 6 and 18 mo, similar to HAZ. However, in sharp contrast to HAZ, HAD curves had continued increases in the deficit of linear growth from 18 to 60 mo, with no indication of a leveling off. Globally, 70% of the absolute deficit accumulated in height (HAD) at 60 mo was found to be due to faltering during the first "1000 days" (conception to 24 mo), but 30% was due to continued increases in deficit from age 2 to 5 y. The use of HAZ masks these changes because of age-related changes in SD. Therefore, HAD, rather than HAZ, should be used to describe and compare changes in height as children age because detecting any deficit compared with expected changes in height as children grow is important and only HAD does this accurately at all ages. Our findings support the current global programmatic momentum to focus on the first 1000 d. Research is needed to better understand the dynamics and timing of linear growth faltering using indices and indicators that accurately reflect changes over ages and to identify cost-effective ways to prevent growth faltering and its consequences throughout the lifecycle.

The biological efficacy of nutritional supplements to complement usual diets in poor populations is well established. This knowledge rests on decades of methodologic research development and, more recently, on codification of methods to compile and interpret results across studies. The challenge now is to develop implementation (delivery) science knowledge and achieve a similar consensus on efficacy criteria for the delivery of these nutrients by public health and other organizations. This requires analysis of the major policy instruments for delivery and well-designed program delivery studies that examine the flow of a nutrient through a program impact pathway. This article discusses the differences between biological and program efficacy, and why elucidating the fidelity of delivery along the program impact pathways is essential for implementing a program efficacy trial and for assessing its internal and external validity. Research on program efficacy is expanding, but there is a lack of adequate frameworks to facilitate the process of harmonizing concepts and vocabulary, which is essential for communication among scientists, policy planners, and program implementers. There is an urgent need to elaborate these frameworks at national and program levels not only for program efficacy studies but also for the broader research agenda to support and improve the science of delivering adequate nutrition to those who need it most.

In the context of a food assistance program in rural Haiti, we developed measures of the effectiveness of community health worker (CHW)-delivered behavior change communication (BCC). We administered knowledge tests to 954 mothers and 38 CHWs to define 4 measures: CHW knowledge, maternal knowledge, knowledge-sharing efficacy (proportion of CHW knowledge shared), and shared correct knowledge between the CHWs and the mothers with whom they interacted. On the basis of the tests, CHWs had high knowledge (93% correct), mothers scored 72% on maternal knowledge, the proportion of CHW knowledge shared was 75%, and shared correct knowledge between CHWs and mothers was 70%. Factors affecting maternal knowledge included CHW characteristics (unmarried: β = -0.070, P0.05), long duration (19-45 mo) of program participation (β = 0.034, P0.05), and having multiple sources of health and nutrition information (β = 0.072, P0.01). Shared correct knowledge and CHW knowledge-sharing efficacy were positively associated with CHW (age, education) and program participation characteristics. We parsed the relative contributions of CHW characteristics to total and proportion of shared CHW knowledge. We observed a positive association between CHW education and shared correct knowledge between the CHWs and mothers (β = 0.328, P0.01), not because of more knowledge (β = -0.012, P0.05) but rather because of greater knowledge-sharing efficacy (β = 0.340, P0.01). These measures provide a means of examining features of program delivery and interpreting impact evaluation results. They show that BCC outcomes are conditional on both frontline workers' knowledge and knowledge-sharing efficacy. Whereas most programs focus on content training to improve CHWs' knowledge, it is also important to strengthen process training and support to foster knowledge-sharing efficacy.

Evidence for the efficacy of multiple micronutrient (MMN) supplementation has been established by state-of-the-art randomized controlled trials (RCT). These efficacy trials have also provided strong evidence of the widespread occurrence of deficiencies. Trials intended to demonstrate a public health benefit must show that the magnitude of benefit is adequate for policy considerations. In the MMN efficacy studies the magnitude of impact was generally inadequate. The extent to which this was due to various factors that affect individuals' potential to respond to MMN supplementation has not been examined, and trials have not been designed to provide insights into why impact is below expectation. For instance, when birth weight was the outcome of concern, impact was not related to presumed need, judged by baseline birth-weight values. Also, contrary to expectations, the impacts were greater among the heavier mothers. Our inability to examine issues of adequacy, plausibility, and implementation with efficacy trial approaches as they are currently conducted, calls into question the present standards for designing and interpreting community RCT in nutrition. Improving the capacity of efficacy studies to yield more meaningful data requires a number of modifications to current practices, such as including measures of the intermediary behavioral and biological steps between intervention and biological outcomes to assess the adequacy and plausibility of the findings. The progression from RCT to program interventions must also extend research to program delivery and uptake to ascertain the full program impact pathway. This in turn requires novel organizations of relationships between research and program development and implementation.

Rigorous evaluations of food-assisted maternal and child health and nutrition programs are stymied by the ethics of randomizing recipients to a control treatment. Using nonexperimental matching methods, we evaluated the effect of 2 such programs on child linear growth in Haiti. The 2 well-implemented programs offered the same services (food assistance, behavior change communication, and preventive health services) to pregnant and lactating women and young children. They differed in that one (the preventive program) used blanket targeting of all children 6-23 mo, whereas the other (the recuperative program) targeted underweight (weight-for-age Z score < -2) children 6-59 mo, as traditionally done. We estimated program effects on height-for-age Z scores (HAZ) and stunting (HAZ < -2) by comparing outcomes of children in program areas with matched children from comparable populations in the Haiti Demographic and Health Survey. Children 12-41 mo in the preventive and recuperative program areas had lower prevalence of stunting than those in the matched control group [16 percentage points (pp) lower in preventive and 11 pp in recuperative]. Children in the 2 program areas also were more likely than those in the matched control group to be breast-fed up to 24 mo (25 pp higher in preventive, 22 in recuperative) and children 12 mo and older were more likely to have received the recommended full schedule of vaccinations (32 pp higher in preventive, 31 in recuperative). Both programs improved targeted behaviors and protected child growth in a time of deteriorating economic circumstances.

This article presents evidence that the high-nutrient supplement in the Oriente study (Atole) improved child growth. The evidence is presented at 4 levels. There was a causal effect of the intervention on child length, as assessed by probability analyses of the randomized, controlled trial (P< 0.05). The plausibility analyses, which included an examination of wasting, showed that the nutritional impact was due to the Afole, especially in those who were

Although studying the effect of supplementation on maternal health or the outcome of pregnancy was not a primary goal of the Institute of Nutrition of Central America and Panama Oriente Longitudinal Study, many important findings in these areas were produced. As part of the study, a food supplementation program was implemented. Two villages received Atole, a gruel containing protein and energy, and 2 matched villages received a refreshing, low-energy drink containing no protein. Both drinks contained micronutrients. Some women did not choose to consume the supplements and those who did consumed widely varying amounts. More volume of Fresco was consumed than Atole. The energy in the supplements improved birthweight, with no apparent additional benefit from protein or micronutrients. Researchers identified several groups of women who benefited from supplementation more than others by having babies with higher birthweights, including those with poorer current nutritional status and those who consumed high amounts of the supplement continuously from one pregnancy to the next. Results from the study provided an early indication that supplementation might increase the duration of gestation and, thus, reduce preterm birth. On the other hand, maternal supplementation did not substantially alter the duration of postpartum amenorrhea once concurrent infant supplementation was taken into account. Finally, findings from this study provided evidence of a biological trade-off between maintenance of maternal nutritional status and increasing fetal size that was responsive to both current maternal nutritional status and supplement intake but not to the mother's nutritional status earlier in life.

Iron deficiency and anemia remain among the most important global public health problems facing school children. Helminth infections often peak at school age and aggravate nutritional risks. We conducted a 12-wk randomized controlled trial in 406 Malian anemic schoolchildren infected with Schistosoma hematobium to examine the effects of 2 doses of praziquantel (P) (40 mg/kg body weight), P + 60 mg/d iron (Fe), and/or a multiple micronutrient supplement (MM) that included 18 mg/d Fe. Supplements were administered to the children each school day (5 d/wk) throughout the study. Changes in hemoglobin (Hb), serum ferritin (SF), and serum transferrin receptors (s-TfR) were followed. We also examined interactions between Fe and MM supplements on Hb and SF concentrations and malaria incidence. The effects of Fe on Hb and SF concentrations were greater than the effects of P alone and MM with or without added Fe at 6 and 12 wk (P < 0.001). In all groups, s-TfR decreased at 6 and 12 wk compared with baseline. The decrease was most pronounced in the P + Fe group compared with the other 3 groups at wk 6 (P = 0.05). Fe and MM interacted negatively at wk 6 and 12 to affect Hb (beta = -0.43, 95% CI = -0.77, -0.09; P = 0.01 and beta = -0.47, 95% CI = -0.83, -0.11; P = 0.01, respectively) and SF (beta = -0.42, 95% CI = -25.60, 12.31; P < 0.001, and beta = -0.37, 95% CI = -0.63, -0.12; P = 0.004, respectively). Malaria incidence was higher in the groups treated with added Fe (relative risk: 1.66; 95% CI: 0.75, 3.67). In this context, MM with added iron were not more effective than Fe without MM. Fe supplementation of schoolchildren with 60 mg/d for anemia control should be considered carefully.

When complementary foods should be introduced in the diets of infants in poor environments remains controversial. Resolution has been hampered by inadequate study designs. A study in Honduras has demonstrated an experimental design assessing multiple infant and maternal outcomes and provides information for planning sample size and accounting for dropouts in future studies. Further research to understand the cultural, social, and biologic aspects of complementary feeding is needed.

This paper uses programme theory to assess, in the context of an effectiveness evaluation, the feasibility and acceptability of distributing micronutrient Sprinkles through a food-assisted maternal and child health and nutrition programme in rural Haiti. We laid out the steps related to programme delivery and household utilization of Sprinkles and used qualitative and quantitative methods to gather data on these steps. Methods included structured observations, checks of beneficiary ration cards, exit interviews, focus group discussions (FGD), individual interviews and survey data from the effectiveness evaluation. Results are as follows: (1) information on use of Sprinkles was provided before mothers first received them, as planned; (2) Sprinkles were re-packaged and distributed as planned and in the appropriate amount; (3) almost all mothers (96%) received two monthly rations of Sprinkles and received timely information on their use; (4) mothers understood instructions about use of Sprinkles and acceptance was high, and no selling of the product was reported or observed; and (5) mothers reported using Sprinkles as instructed, every day (63% in survey; 86% at exit interviews), and for the child only (99%). FGD with staff highlighted the acceptance of the intervention, with a reported 'modest' increase in workload. Within this well-established programme, it proved feasible to distribute Sprinkles and to ensure appropriate use by beneficiary mothers. Existing programme venues were suitable for distributing Sprinkles and educating mothers about their use. Use of programme theory helped to assess feasibility and acceptability of the Sprinkles intervention and provided useful information for programme replication or scale-up.

High iron needs and low-iron diets combine to make early childhood one of the highest risk periods for iron deficiency. Recommendations for iron supplementation for this age group have been based on positive effects on anemia and child development. In contrast, the evidence regarding growth and morbidity outcomes has been equivocal, with some evidence of risk. The new evidence from Nepal and Zanzibar is reviewed, and possible interpretations are discussed. The Zanzibar trial found significant adverse effects in the overall population with poor malaria services and substantial benefit to iron-deficient children (the majority) in an area where access to treatments was provided. Cost-effectiveness analysis suggests that targeting supplements to iron-deficient children in Zanzibar may not increase costs (relative to universal supplementation) and would increase benefit. Operations research is needed to test this. We conclude with three options for maximizing the benefits and minimizing the risks of iron supplements.

Background Evidence from studies conducted in nutritionally deprived children in low- and middle-income countries (LIMC) in past decades showed little or no population-level catch-up in linear growth (mostly defined as reductions in the absolute height deficit) after 2 years of age. Recent studies, however, have reported population-level catch-up growth in children, defined as positive changes in mean height-for-age z-scores (HAZ). The aim of this paper was to assess whether population-level catch-up in linear growth is found when height-for-age difference (HAD: child’s height compared to standard, expressed in centimeters) is used instead of HAZ. Our premise is that HAZ is inappropriate to measure changes in linear growth over time because they are constructed using standard deviations from cross-sectional data. Methods We compare changes in growth in populations of children between 2 and 5 years using HAD vs. HAZ using cross-sectional data from 6 Demographic and Health Surveys (DHS) and longitudinal data from the Young Lives and the Consortium on Health-Orientated Research in Transitional Societies (COHORTS) studies. Results Using HAD, we find not only an absence of population-level catch-up in linear growth, but a continued deterioration reflected in a decrease in mean HAD between 2 and 5 years; by contrast, HAZ shows either no change (DHS surveys) or an improvement in mean HAZ (some of the longitudinal data). Population-level growth velocity was also lower than expected (based on standards) in all four Young Lives data sets, confirming the absence of catch-up growth in height. Discussion We show no evidence of population-level catch-up in linear growth in children between 2 to 5 years of age when using HAD (a measure more appropriate than HAZ to document changes as populations of children age), but a continued deterioration reflected in a decrease in mean HAD. Conclusions The continued widening of the absolute height deficit after 2 years of age does not challenge the critical importance of investing in improving nutrition during the first 1000 days (i.e., from conception to 2 years of age), but raises a number of research questions including how to prevent continued deterioration and what is the potential of children to benefit from nutrition interventions after 2 years of age. Preventing, rather than reversing linear growth retardation remains the priority for reducing the global burden of malnutritionworldwide.

Studies conducted in past decades showed little or no population-level linear catch-up growth (defined as reductions in absolute height deficit) in children after 2 y of age. Recent studies, howeve...

Effective programs to promote improved dietary practices among low-income families depend on the motivation and performance of front-line nutrition educators, yet little is known about the work context experienced by nutrition workers or how their perceptions of work context relate to program effectiveness. This research examined the perceived work context of nutrition educators, a multidimensional construct developed through formative research, in the Expanded Food and Nutrition Education Program (EFNEP) in New York State. We proposed that work context, program management, and program and educator characteristics would be related to program effectiveness (reported behavior change among participants). A state-wide survey of paraprofessional Community Nutrition Educators (CNEs) in 30 program sites was conducted and analyzed in relation to program monitoring data. Greater behavior change was reported by participants in sites whose CNEs gave positive ratings to the value of EFNEP (P < 0.02) and to the managerial practices of their supervisors (P < 0.001). To our knowledge, this is the first time that an association was demonstrated between perceived work context at the front lines and effectiveness of a nutrition program. Higher behavior change scores were also reported at sites in which a greater proportion of participants received individual rather than group instruction (P < 0.001). Associations between participants' reported behavior change and CNEs' perceptions of program value and program management suggest that improvements in these areas could enhance nutrition program success.

Sound policy and program decisions require timely information based on valid and relevant measures. Recent findings suggest that despite the availability of effective and affordable guidelines for the management of sick children in first-level health facilities in developing countries, the quality and coverage of these services remains low. We report on the development and evaluation of a set of summary indices reflecting the quality of care received by sick children in first-level facilities. The indices were first developed through a consultative process to achieve face validity by involving technical experts and policymakers. The definition of evaluation measures for many public health programs stops at this point. We added a second phase in which standard statistical techniques were used to evaluate the content and construct validity of the indices and their reliability, drawing on data sets from the multi-country evaluation of integrated management of childhood illness (MCE) in Brazil, Tanzania and Uganda. The statistical evaluation identified important conceptual errors in the indices arising from the theory-driven expert review. The experts had combined items into inappropriate indicators resulting in summary indices that were difficult to interpret and had limited validity for program decision making. We propose a revised set of summary indices for the measurement of child health care in developing countries that is supported by both expert and statistical reviews and that led to similar programmatic insights across the three countries. We advocate increased cross-disciplinary research within public health to improve measurement approaches. Child survival policymakers, program planners and implementers can use these tools to improve their monitoring and so increase the health impact of investments in health facility care.

The present study reports 5,029 length and weight measurements as well as percentile distributions for a mixed longitudinal series of 1,119 rural Guatemalan Ladino children. The study sample, birth through seven years, is representative of children in clinically good health, but of suboptimal nutrition. Boys are longer and heavier than girls over the age range. Guatemalan children of both sexes are smaller than American white children from Denver. Differences are least at birth, and increase through two years of age. Between two and five years, differences between the rural Guatemalan Ladino and Denver samples are rather stable, but then increase through seven years. Despite these differences there is a linear weight for length relationship which is the same across all preschool ages, both sexes, and for both the Guatemalan and Denver populations. This implies that age, sex, ethnic differences between the two groups compared, and mild-to-moderate protein-calorie malnutrition do not affect the relationship between weight and length in preschool children.

The previous articles presented different aspects of targeting: the implicit political implications, the trade-offs in giving power to different stakeholders to decide and to implement targeting, perceptions of frontline workers in implementing a program, and a technical article about selecting a scale for targeting, which we review in greater detail. It is well recognized that targeting results in a trade-off between not serving those who should be served and including those who should not be served. Less well recognized are the trade-offs that are the consequences of deciding between using indicators of risk vs. using indicators that predict benefit.

A community food security movement has begun to address problems of hunger and food insecurity by utilizing a community-based approach. Although various models have been implemented, little empirical research has assessed how power operates within community-based food security initiatives. The purpose of this research was to determine how power influenced participation in decision-making, agenda setting, and the shaping of perceived needs within a community-based food security planning process, with particular reference to disenfranchised stakeholders. Power influenced participation in decision-making, agenda setting, and the shaping of perceived needs through managing 1) problem framing, 2) trust, 3) knowledge, and 4) consent. To overcome these mechanisms of power, practitioners need to address individual-, community-, and institutional-level barriers to participation in community-based food security planning processes. Practitioners and researchers can work with disenfranchised groups to determine which agents have the power to create desired changes by utilizing theory-based methods and strategies that focus on changing external determinants at multiple levels.

The Multi-Country Evaluation of the Integrated Management of Childhood Illness (IMCI) includes studies of the effectiveness, cost, and impact of the IMCI strategy in Bangladesh, Brazil, Peru, Tanzania, and Uganda. Seven questions were addressed when the evaluation was designed: who would be in charge, through what mechanisms IMCI could affect child health, whether the focus would be efficacy or effectiveness, what indicators would be measured, what types of inference would be made, how costs would be incorporated, and what elements would constitute the plan of analysis. We describe how these questions were answered, the challenges encountered in implementing the evaluation, and the 5 study designs. The methodological insights gained can improve future evaluations of public health programs.

Physician behavior and caregiver retention of nutrition advice were examined as potential mediating factors in the success of a nutrition counseling efficacy trial in Pelotas, Brazil, which reduced growth faltering in children 12-24 mo old. After pair-matching on socioeconomic status and nutrition indicators, municipal health centers were randomly assigned to an intervention group, in which physicians were trained with an IMCI-derived (Integrated Management of Childhood Illness) nutrition counseling protocol, or to a control group, without continuing education in nutrition. In a substudy of the larger trial, direct observation of consultations, followed by home interviews with mothers, provided data on physician counseling behavior and mothers' retention of nutrition advice. Trained providers were more likely to engage in nutrition counseling (P < 0.013) and to deliver more extensive advice (P < 0.02). They also used communication skills designed to improve rapport and ensure that mothers understood the advice (P < 0.01). Mothers who received advice from trained providers had high rates of recalling the messages on specific foods (95 vs.27%; P < 0.01) and feeding practice and food preparation recommendations (90 vs. 20%; P < 0.01), whereas the proportions of the messages recalled on breast-feeding (60% vs. 30%) did not differ significantly (P < 0.20). The training course contained several elements that may explain why intervention group mothers were better able to recall nutrition advice. These include locally appropriate messages, tools for assessing individual problems, and counseling skills.

Gaps in child mortality between rich and poor countries are unacceptably wide and in some areas are becoming wider, as are the gaps between wealthy and poor children within most countries. Poor children are more likely than their better-off peers to be exposed to health risks, and they have less resistance to disease because of undernutrition and other hazards typical in poor communities. These inequities are compounded by reduced access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Experience and evidence about how to reach poor populations are growing, albeit largely through small-scale case studies. Successful approaches include those that improve geographic access to health interventions in poor communities, subsidized health care and health inputs, and social marketing. Targeting of health interventions to poor people and ensuring universal coverage are promising approaches for improvement of equity, but both have limitations that necessitate planning for child survival and effective delivery at national level and below. Regular monitoring of inequities and use of the resulting information for education, advocacy, and increased accountability among the general public and decision makers is urgently needed, but will not be sufficient. Equity must be a priority in the design of child survival interventions and delivery strategies, and mechanisms to ensure accountability at national and international levels must be developed.

This is the third paper in the series on child survival. The second paper in the series, published last week, concluded that in the 42 countries with 90% of child deaths worldwide in 2000, 63% of these deaths could have been prevented through full implementation of a few known and effective interventions. Levels of coverage with these interventions are still unacceptably low in most low-income and middle-income countries. Worse still, coverage for some interventions, such as immunisations and attended delivery, are stagnant or even falling in several of the poorest countries. This paper highlights the importance of separating biological or behavioural interventions from the delivery systems required to put them in place, and the need to tailor delivery strategies to the stage of health-system development. We review recent initiatives in child health and discuss essential aspects of delivery systems, including: need for data at the subnational level to support health planning; regular monitoring of provision and use of health services, and of intervention coverage; and the need to achieve high and equitable coverage with selected interventions. Community-based initiatives can extend the delivery of interventions in areas where health services are hard to access, but strengthening national health systems should be the long-term aim. The millennium development goal for child survival can be achieved, but only if strategies for delivery interventions are greatly improved and scaled-up.

According to our current understanding iron absorption with weekly iron supplements is not higher than that with daily supplements (ie there is no mucosal block). However community-based trials have repeatedly shown that a weekly regimen is as effective as a daily one. Furthermore when differences in absorption are found they are commonly smaller than would be expected on the basis of differences in the amount of iron provided. The possibility of differential compliance between the regimens needs to be evaluated to explain these findings. Taking compliance into account we compared the efficacy and trial effectiveness of weekly and daily iron supplementation during pregnancy. In Bangladesh 50 antenatal centers were randomly assigned to prescribe either 2 doses of 60 mg Fe once weekly or 1 dose of 60 mg Fe/d. Compliance was monitored by using a pill bottle equipped with an electronic counting device. Hemoglobin concentrations were measured at baseline and after 4 8 and 12 wk of supplementation. There was no differential effect per iron tablet between weekly and daily regimens. A 12-wk daily regimen (68% compliance) produced a small but significantly greater hemoglobin response than did the weekly regimen (104% compliance). The first 20 tablets consumed produced most of the effect; after 40 tablets there was no further response. There was no evidence of a mucosal block in the daily regimen. Over 12 wk 50% of the amount of iron in a daily regimen was sufficient for maximum hemoglobin effect. The weekly regimen provided a large part of this amount explaining the limited difference in effect. It appears that the current international recommendation for iron supplementation in pregnancy is higher than necessary. (authors)

Any evaluation should start with the question: “Who will use the information and for what purpose?” This question implies that one must consider not only the facts presented in the evaluation, but also whether the person who receives the information is motivated and has the authority and resources to implement changes that emerge from the evaluation. The similarities and differences among summative, formative, and process evaluations are discussed. Particular attention is given to stakeholder participation, choosing the appropriate level of statistical significance, and separating issues relevant to public-sector versus private-sector investment as they relate to evaluating the targeting and effect of processed complementary foods.

To evaluate whether milk production can be improved by increasing food intake, a randomized, double-blind, supplementation trial was completed among 102 lactating Guatemalan women. The subjects were undernourished, as indicated by their low values for calf circumference (CC) and the small size of their infants at birth. A high-energy (2.14 MJ/d, HES) and a low-energy (0.50 MJ/d, LES) supplement were distributed 6 d/wk from wk 5 to 25 of lactation. Data were evaluated using repeated-measures analysis of variance on the increments from initial values for each outcome variable with one-tailed tests of statistical significance. The maternal energy intake increased 1.18 MJ/d (P < 0.01) more among the HES than the LES women. Benefit from supplementation was more evident among the more undernourished (CC

The provision of vitamin A in food sources of beta-carotene is an alternative to the distribution of high-dose capsules. To examine factors that may influence the success of food-based programs, a study was carried out in Sumatra, Indonesia, of the effect of food sources of beta-carotene, extra dietary fat, and Ascaris lumbricoides infection on serum retinol concentrations in children. Meals and snacks with various amounts of beta-carotene and fat were fed at midday to children 3-6 y of age for 3 wk. Some groups of children were dewormed with the anthelmintic levamisole before the feeding period, whereas others remained infected. Results showed that the incorporation of beta-carotene sources (mainly in the form of red sweet potatoes) into the meal significantly increased serum retinol concentrations. The greatest rise in serum retinol occurred when meals contained added beta-carotene sources and added fat and the children were dewormed. Adding more fat to the meal and deworming the children caused a rise in serum retinol similar to that seen when feeding additional beta-carotene sources. Moreover, the effects of fat and deworming together were additive to the effects of additional beta-carotene sources. When the meal contained additional beta-carotene sources, added fat caused a further improvement in serum retinol concentrations but only if A. lumbricoides infection was low. These studies indicated that food-based interventions in vitamin A-deficient areas might be successful and that other interventions such as increasing dietary fat concentrations and anthelmintic treatment should be considered along with increasing consumption of beta-carotene-rich food.

We examined the effects of household participation in the Food Stamp and WIC Nutrition Programs on the nutrient intakes of preschoolers using data from the 1989-1991 Continuing Survey of Food Intake by Individuals. Nonbreastfeeding children, 1-4 y of age, with 3 d of dietary data and whose households had incomes < 130% of the poverty level were included in the study sample (n = 499). Nutrient adequacy ratios for each of 15 nutrients were the dependent variables in multiple regression models that controlled for the following: age, sex and ethnicity of the individual; income, size and location of the household; schooling of the household head; home ownership; school lunch and breakfast participation; and season in which the interview was conducted. WIC benefits positively influenced (P < 0. 05) the intakes of 10 nutrients. For iron and zinc, the average increase due to WIC represented 16.6 and 10.6%, respectively, of the preschooler recommended dietary allowance (RDA) for these nutrients. The same analyses of the Food Stamp Program revealed increases in five nutrients. For iron and zinc, the average increase due to Food Stamps represented 12.3 and 9.2%, respectively, of the preschooler RDA. The effects of the WIC Program on the intakes of iron and zinc were greater than that of cash income, and neither program affected the intakes of fat, saturated fat or cholesterol.

SUMMARY To explain how and why food insecurity occurs in families in our society, we conducted a qualitative study using taped focus groups and semi-structured individual interviews. Data were gathered in 1996 through a purposive sample study of 98 members of low-income and very low-income households in twelve urban and rural municipalites in and around Quebec City. A questionnaire on socio-demographic characteristics and the Radimer/Cornell Hunger and Food Insecurity Measures Index were also administered to respondents. Based on an analysis of the content of the data, we constructed a model depicting major elements of vulnerability to food insecurity. Analysis of these elements showed that the food insecurity of a household can be explained both by elements of risks and by the capacity to face those risks. Within the range of income levels examined, significant risks included lack of income; living in an apartment or in an urban area; underlying problems related to means of livelihood, including chronic ...

Child feeding recommendations include breastfeeding beyond 12 months, however, some researchers have reported increased rates of malnutrition in breastfed toddlers. A negative association between growth and breast-feeding may reflect reverse causality; that is, the outcome (growth) is a determinant of the predictor (breastfeeding), and not vice versa. We examined this question with data from 134 Peruvian toddlers.A linear regression analysis predicted length at the age of 15 months by length at 12 months, study interval, and 12-14.9-month breastfeeding, complementary food intake, and diarrhoeal incidence. This analysis defined the association between breastfeeding and linear growth. To elucidate the direction of the effect between breastfeeding and linear growth, logistic regression was used to predict the probability of weaning by the end of 14 months. Determinants included weight-for-age (W/A) at 12 months, complementary food intake at 9-11.9 months, and change in diarrhoeal incidence between 9 and 14.9 months.There was a significant (P0.01) interaction of breastfeeding, diarrhoeal incidence, and complementary food intake on length at 15 months. Increased breastfeeding was associated with a 1.0 cm decrease in length gain when dietary intake was low and diarrhoeal morbidity was high, implying that breastfeeding is harmful. The logistic analysis, however, demonstrated that the risk of weaning decreased only when W/A and dietary intake were low and diarrhoeal morbidity was high.The negative association between breastfeeding and linear growth reflected reverse causality. Increased breastfeeding did not lead to poor growth; children's poor growth and health led to increased breastfeeding. Children's health must be considered when evaluating the association of breastfeeding with anthropometric outcomes.There has been a perplexing finding, in many developing countries, of increased rates of stunting and growth faltering in breast-fed toddlers receiving complementary foods relative to their non-breast-fed counterparts. Longitudinal data on 134 children 12-15 months of age from Lima, Peru, were used to investigate the hypothesis that the negative association between growth and breast feeding reflects reverse causality. The toddlers were participants in a broader persistent diarrhea surveillance survey conducted during 1985-87. 72.9% of children were breast-fed beyond 12 months (median duration, 16.8 months). Anthropometric measurements revealed stunting in 19.4% of toddlers at 12 months and in 29.1% at 15 months. Linear growth between 12 and 15 months had a complex relationship with breast feeding, diarrhea, and dietary factors. Increased breast feeding was associated with a 1.0 cm decrease in length gain between 12 and 15 months when dietary intake was low and diarrheal morbidity was high. However, logistic analysis demonstrated that mothers whose children had low dietary intakes, low weight-for-age, and increased incidence of diarrhea were less likely to wean their infants at 12 and 14 months. This finding that mothers modified their children's feeding practices according to the child's health and growth status supports a reverse causality process in which poor growth is a determinant rather than a result of breast feeding.

The World Health Organization (WHO) convened an Expert Committee to re-evaluate the use of anthropometry at different ages for assessing health, nutrition, and social well-being. The Committee's task included identifying reference data for anthropometric indices when appropriate, and providing guidelines on how the data should be used. For foetal growth, the Committee recommended an existing sex-specific multiracial reference. In view of the significant technical drawbacks of the current National Center for Health Statistics (NCHS)/WHO reference and its inadequacy for assessing the growth of breastfed infants, the Committee recommended the development of a new reference concerning weight and length/height for infants and children, which will be a complex and costly undertaking. Proper interpretation of mid-upper-arm circumference for pre-schoolers requires age-specific reference data. To evaluate adolescent height-for-age, the Committee recommended the current NCHS/WHO reference. Use of the NCHS body mass index (BMI) data, with their upper percentile elevations and skewness, is undesirable for setting health goals; however, these data were provisionally recommended for defining obesity based on a combination of elevated BMI and high subcutaneous fat. The NCHS values were provisionally recommended as reference data for subscapular and triceps skinfold thicknesses. Guidelines were also provided for adjusting adolescent anthropometric comparisons for maturational status. Currently, there is no need for adult reference data for BMI; interpretation should be based on pragmatic BMI cut-offs. Finally, the Committee noted that few normative anthropometric data exist for the elderly, especially for those over 80 years of age. Proper definitions of health status, function, and biologic age remain to be developed for this group.

The WHO evidence-informed guidelines provide recommendations to Member States and their partners on interventions with vitamins and minerals. Evidence gathered and synthesized through systematic reviews contributes to the development of these guidelines, a process that is dependent on the availability and quality of evidence. Although the guideline development process is stringently governed and supervised to maintain clarity and transparency, the lack of adequacy and specificity of available evidence poses limitations to the formulation of recommendations that can be easily applied for policy and program decision making in diverse contexts. The symposium created a space for dialogue among scientists and public health practitioners to improve the understanding of how evidence fulfills the needs and reflect on mechanisms by which policy and program guidance and priorities for research could be better informed by policy and program needs. Ultimately, programmatic success depends not only on identifying efficacious agents but ensuring effective delivery to those with the potential to respond. To do this, we must understand the rationale for recommending interventions, the biological pathways by which interventions work, delivery systems required to make efficacious interventions work, and other contextual factors that might limit or facilitate successful implementation.

The classical risk approach to predicting who benefits from an intervention is unsound because it relies on the theoretical assumption that those at risk will necessarily benefit. A better approach to systematically test who benefits from nutrition supplementation is proposed using interactive models.Differential effects of nutrition supplementation during early childhood on stature at adolescence were studied in 245 males and 215 females to identify determinants of long-term benefit from food supplementation. Factors studied included family socioeconomic status (SES) and children's home diet and diarrhoea during the first 3 years of life. To determine whether a factor conferred benefit, the statistical significance of the interaction between this factor and the intervention was tested. Data from the INCAP supplementation trial in Guatemala and from the follow-up of the same subjects at adolescence were used.Ordinary least squares (OLS) showed that high rates of diarrhoea in males and poor SES in females were significant determinants of benefit from supplementation at adolescence, and that the effects were mediated by length at 3 years old. Results of two-stage least squares (2SLS) analysis showed that length at 36 months, maturation and maternal height were significant determinants of height at adolescence but SES was not.Nutrition supplementation in early childhood has long-lasting effects on body size and the larger benefits acquired by some groups of children remain throughout early adulthood. The relevance of these findings for screening and targeting of nutritional interventions is discussed.Differential effects of nutrition supplementation during early childhood on stature at adolescence were studied in 245 males and 215 females, 14-20 years old, who had been exposed to either a high-calorie, high-protein drink (Atole) in 2 villages or a low-calorie, non-protein drink (Fresco) in 2 other villages from birth to 3 years of age in order to identify determinants of long-term benefit from food supplementation. Factors studied included family socioeconomic status (SES), children's home diet, and diarrhea during the first 3 years of life. To determine whether a factor conferred benefit, the statistical significance of the interaction between this factor and the intervention was tested. Data from the Institute of Nutrition of Central America and Panama (INCAP) supplementation trial in Guatemala and from the follow-up of the same subjects at adolescence were used. In women differences between the groups were significant only for length at 36 months and height at adolescence. In males length at 36 months was statistically greater among the Atole group, but height in adolescence was not. Ordinary least squares (OLS) showed that high rates of diarrhea in males and poor SES in females were significant determinants of benefit from supplementation at adolescence, and that the effects were mediated by length at 3 years old. Male children who benefited from the supplementation were those with more diarrhea in early infancy. The difference in length at 36 months was 3.03 cm in favor of the Atole group compared to 0.98 cm for the groups with less diarrhea. 2-stage least squares analysis showed that length at 36 months, maturation, and maternal height were significant determinants of height at adolescence but SES was not. Nutrition supplementation in early childhood has long-lasting effects on body size, and the larger benefits acquired by some groups of children remain throughout early adulthood.

Prenatal multiple micronutrients (UNIMMAP) improve fetal growth only moderately compared to iron and folic acid alone (IFA). Whether this is due to insufficient amounts of UNIMMAP or to IFA being in reality an active control is unknown. We assessed the association between cumulative micronutrient intake (CMI) and fetal growth by secondary analysis of a randomized controlled trial in Burkina Faso where tablet intake was directly observed. We applied 2-part residual regression models adjusted for main confounders. Among the 1056 single pregnancies included, the mean CMI (+/- SD) was 124 +/- 54 tablets. The odds of delivering a small-for-gestational-age baby was reduced by 21% [(95%CI: 5, 35); P = 0.013] for each additional tertile of CMI. The association between CMI and birth weight was positively modified by gestational age at enrollment (P-interaction = 0.001). Each unit of CMI was associated with a 1.6-g [(95%CI: 0.3, 3.1); P = 0.019] higher birth weight at a mean-centered gestational age at enrollment, with a higher gradient observed later in pregnancy. Maternal BMI at enrollment was also a positive modifying factor (P-interaction = 0.02), with no association of CMI with birth weight for low BMI. There was no evidence of an effect modification by group allocation; i.e., we observed the same change in birth weight per unit of CMI with either IFA or UNIMMAP. Yet UNIMMAP increased birth weight by 69 g [(95%CI: 58, 81); P < 0.001] relative to IFA. We found similar results for thoracic and cephalic circumferences. In conclusion, for both IFA and UNIMMAP, the effect on fetal growth is cumulative. The supplementation should therefore begin as early as possible in pregnancy, even if the growth increment per CMI is higher in late than in early pregnancy. Women with a low BMI should also receive extra energy.

There are five broad categories of food-related public health problems in the U.S. for which survey data on food consumption are needed. These relate to reproduction, growth and development, chronic disease, food safety, food insecurity and problems specific to the elderly. The collection and analysis of food consumption data has become increasingly difficult for three major reasons. First, broad societal trends (e.g., ethnicity and use of food away from home) and changes in the food production, processing and marketing sectors have complicated the task. Second, the traditional concerns of monitoring (tracking population means and prevalences) are no longer the only objectives; there is a growing demand for data on habitual intake of individuals and variability in habitual intakes (e.g., to estimate the frequency of acute exposures). Third, data are required at several levels of aggregation (e.g., nutrients, food categories, commodities and name-brand foods) and a high frequency of non-consumption at lower levels of aggregation places high demands on sample size. It is suggested that the current large national surveys be supplemented with special purpose surveys that meet individual agency needs, and that principles and methods of state and local monitoring be further developed and implemented.

Mixed-methods research investigated the work motivation of paraprofessional community nutrition educators (CNEs) delivering a long-running public health nutrition program. In interviews, CNEs (n = 9) emphasized "freedom," supportive supervision, and "making a difference" as key sources of motivation. Community nutrition educator surveys (n = 115) confirmed high levels of autonomy, which was associated with supervisors' delegation and support, CNE decision-making on scheduling and curricula, and job satisfaction. Supervisors (n = 32) rated CNEs' job design as having inherently motivating characteristics comparable to professional jobs. Supervisory strategies can complement job design to create structured, supportive contexts that maintain fidelity, while granting autonomy to paraprofessionals to enhance intrinsic work motivation.