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Objective: To evaluate whether maternal and child nutrition activities provided through the Indian Integrated Child Development Services scheme in India were associated with improved nutritional knowledge and practices among beneficiary women. Methods: We used a multistage sampling design to randomly select 4400 pregnant women or mothers of children younger than 2 years for a cross-sectional telephone survey. The respondents were beneficiaries of the scheme from across 11 Indian states. We used multivariate regression models controlling for sociodemographic factors to estimate the association between: scheme activities and nutrition messages heard; and scheme activities and nutrition practices. We also estimated the proportion of the total association with nutrition practices which was mediated by nutrition messages. Results: Among 110 regression models testing unique pairs of seven activities and 18 nutrition messages, 103 showed a statistically significant positive relationship (median risk ratio, RR: 1.14). For activities and nine nutrition practices, 39 out of 54 tested pairs were significantly associated (median RR: 1.16). We observed statistically significant mediation through nutrition messages for 28 out of 42 tested pairs of activities and nutrition practices. Conclusion: Receipt of the scheme's activities was associated with improved nutrition knowledge and practices. Improvements in practices were statistically mediated by improvements in knowledge. These findings suggest that a large-scale nutrition scheme with a strong counselling component could successfully change beneficiary behaviours.

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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. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-021-01252-x.

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The objective of this study was to assess public financing for nutrition in Bhutan, Nepal and Sri Lanka to identify limitations of available data and to discuss policy implications. A variant of the Scaling Up Nutrition Movement methodology was used. Budget allocations and expenditures for relevant government ministries during 2012-2018 were identified. Nutrition-related line items were tagged using definitions of nutrition-specific and nutrition-sensitive interventions. Data were aggregated by year and calculated in constant United States dollars (USD). Expenditures by year were presented as a proportion of gross domestic product and general government expenditures. The percent utilization of budget allocations and proportion of funding from central government sources were determined. Per capita expenditures on nutrition-specific interventions varied from USD 1.08-8.76 and for nutrition-sensitive interventions varied from USD 20.22-51.20. Nutrition-specific expenditures as a percent of gross domestic product ranged from 0.08% in Sri Lanka in 2017% to 0.34% in Nepal in 2016. The median utilization rate was 64% for nutrition-specific and 84% for nutrition-sensitive interventions. Nutrition-specific funding financed by the central government was 90.7% in Bhutan and 99.4% in Sri Lanka. This study revealed the need to prioritize and invest in evidence-based interventions, including balancing investments in nutrition-specific versus -sensitive interventions. Challenges in estimation of nutrition expenditures and cross-country comparison were also observed, highlighting the need for appropriate nutrition line item tagging and standardized systems for data collection.

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An amendment to this paper has been published and can be accessed via the original article.

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BACKGROUND: The disproportionately high burden of mental disorders in low- and middle-income countries, coupled with the overwhelming lack of resources, requires an innovative approach to intervention and response. This study evaluated the feasibility of delivering a maternal mental health service in a severely-resource constrained setting as part of routine service delivery. METHODS: This exploratory feasibility study was undertaken at two health facilities in Afghanistan that did not have specialist mental health workers. Women who had given birth in the past 12 months were screened for depressive symptoms with the PHQ9 and invited to participate in a psychological intervention which was offered through an infant feeding scheme. RESULTS: Of the 215 women screened, 131 (60.9%) met the PHQ9 criteria for referral to the intervention. The screening prevalence of postnatal depression was 61%, using a PHQ9 cut-off score of 12. Additionally, 29% of women registered as suicidal on the PHQ9. Several demographic and psychosocial variables were associated with depressive symptoms in this sample, including nutritional status of the infant, anxiety symptoms, vegetative and mood symptoms, marital difficulties, intimate partner violence, social isolation, acute stress and experience of trauma. Of the 47 (65%) women who attended all six sessions of the intervention, all had significantly decreased PHQ9 scores post-intervention. CONCLUSION: In poorly resourced environments, where the prevalence of postnatal depression is high, a shift in response from specialist-based to primary health care-level intervention may be a viable way to provide maternal mental health care. It is recommended that such programmes also consider home-visiting components and be integrated into existing infant and child health programmes. Manualised, evidence-based psychological interventions, delivered by non-specialist health workers, can improve outcomes where resources are scarce.

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BACKGROUND: Integrated nutrition and health programs seek to reduce undernutrition by educating child caregivers about infant feeding and care. Data on the quality of program implementation and consequent effects on infant feeding practices are limited. This study evaluated the effectiveness of enhancing a nutrition and health program on breastfeeding and complementary-feeding practices in rural India. METHODS: Utilizing a quasi-experimental design, one of the implementing districts of a Cooperative for Assistance and Relief Everywhere (CARE) nutrition and health program was randomly selected for enhanced services and compared with a district receiving the Government of India's standard nutrition and health package alone. A cohort of 942 mother-child dyads was longitudinally followed from birth to 18 months. In both districts, the evaluation focused on responses to services delivered by community-based nutrition and health care providers [anganwadi workers (AWWs) and auxiliary nurse midwives (ANMs)]. FINDINGS: The CARE enhanced program district showed an improvement in program coverage indicators (e.g., contacts, advice) through outreach visits by both AWWs (28.8-59.8% vs. 0.7-12.4%; all p<0.05) and ANMs (8.6-46.2% vs. 6.1-44.2%; <0.05 for ages ≥6 months). A significantly higher percentage of child caregivers reported being contacted by the AWWs in the CARE program district (20.5-45.6% vs. 0.3-21.6%; p<0.05 for all ages except at 6months). No differences in ANM household contacts were reported. Overall, coverage remained low in both areas. Less than a quarter of women received any infant feeding advice in the intervention district. Earlier and exclusive breastfeeding improved with increasing number or quality of visits by either level of health care provider (OR: 2.04-3.08, p = <0.001), after adjusting for potentially confounding factors. Socio-demographic indicators were the major determinants of exclusive breastfeeding up to 6 month and age-appropriate complementary-feeding practices thereafter in the program-enhanced but not comparison district. INTERPRETATION: An enhanced nutrition and health intervention package improved program exposure and associated breastfeeding but not complementary-feeding practices, compared to standard government package. TRIAL REGISTRATION: ClinicalTrials.gov NCT00198835.

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An effective delivery strategy coupled with relevant social and behaviour change communication (SBCC) have been identified as central to the implementation of micronutrient powders (MNP) interventions, but there has been limited documentation of what works. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," three working groups were formed to summarize experiences and lessons across countries regarding MNP interventions for young children. This paper focuses on programmatic experiences related to MNP delivery (models, platforms, and channels), SBCC, and training. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that most countries distributed MNP free of charge via the health sector, although distribution through other platforms and using subsidized fee for product or mixed payment models have also been used. Community-based distribution channels have generally shown higher coverage and when part of an infant and young child feeding approach, may provide additional benefit given their complementarity. SBCC for MNP has worked best when focused on meeting the MNP behavioural objectives (appropriate use, intake adherence, and related infant and young child feeding behaviours). Programmers have learned that reincorporating SBCC and training throughout the intervention life cycle has allowed for much needed adaptations. Diverse experiences delivering MNP exist, and although no one-size-fits-all approach emerged, well-established delivery platforms, community involvement, and SBCC-centred designs tended to have more success. Much still needs to be learned on MNP delivery, and we propose a set of implementation research questions that require further investigation.

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BACKGROUND: Undernutrition below two years of age remains a major public health problem in India. We conducted an evaluation of an integrated nutrition and health program that aimed to improve nutritional status of young children by improving breast and complementary feeding practices over that offered by the Government of India's standard nutrition and health care program. METHODS: In Uttar Pradesh state, through multi-stage cluster random sampling, 81 villages in an intervention district and 84 villages in a comparison district were selected. A cohort of 957 third trimester pregnant women identified during house-to-house surveys was enrolled and, following childbirth, mother-child dyads were followed every three months from birth to 18 months of age. The primary outcomes were improvements in weight-for-age and length-for-age z scores, with improved breastfeeding and complementary feeding practices as intermediate outcomes. FINDINGS: Optimal breastfeeding practices were higher among women in intervention than comparison areas, including initiating breastfeeding within one hour of delivery (17.4% vs. 2.7%, p<0.001), feeding colostrum (34.7% vs. 8.4%, p<0.001), avoiding pre-lacteals (19.6% vs. 2.1%, p<0.001) and exclusively breastfeeding up to 6 months (24.1% vs. 15.3%, p = 0.001). However, differences were few and mixed between study arms with respect to complementary feeding practices. The mean weight-for-age z-score was higher at 9 months (-2.1 vs. -2.4, p = 0.0026) and the prevalence of underweight status was lower at 12 months (58.5% vs. 69.3%, p = 0.047) among intervention children. The prevalence of stunting was similar between study arms at all ages. Coefficients to show the differences between the intervention and comparison districts (0.13 cm/mo) suggested significant faster linear growth among intervention district infants at earlier ages (0-5 months). INTERPRETATION: Mothers participating in the intervention district were more likely to follow optimal breast, although not complementary feeding practices. The program modestly improved linear growth in earlier age and weight gain in late infancy. Comprehensive nutrition and health interventions are complex; the implementation strategies need careful examination to improve feeding practices and thus impact growth. TRIAL REGISTRATION: The trial was registered with ClinicalTrials.gov, NCT00198835.

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