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Value chains to improve diets: Diagnostics to support intervention design in Malawi
Gelli, Aulo; Donovan, Jason; Margolies, Amy; Aberman, Noora-Lisa; Santacroce, Marco; Chirwa, Ephraim W.; Henson, Spencer; Hawkes, Corinna. Article in press

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Governments and development partners looking to accelerate progress in addressing malnutrition have been examining how to use interventions in value-chains to improve diets. However, the links between interventions in value chains and diets involve a range of direct and indirect effects that are not yet well understood. We apply a mixed-method multisectoral diagnostic to examine potential interventions in food systems to improve diets of smallholder farmers in Malawi. We examine entry points for interventions involving public and private-sectors, and explore the methodological requirements for undertaking this type of multisectoral analysis. We find that although food consumption is dominated by maize, a range of nutritious foods are also being consumed; including leafy greens, fruits, chicken, dried fish, dried beans and peas, and groundnuts. Yet important deficits in nutrient intake remain prevalent in low-income households due to inadequate quantity of consumption. While increasing consumption through own-production is one potentially important channel to increase quantity of nutritious foods available (particularly fruits and leafy green vegetables), markets also play a potentially important role. Nutritious foods are available on markets year-round, although strong seasonality impacts the availability and price of perishable products. For beans, peas and groundnuts, supply appears to be available throughout the year, with price fluctuations relatively controlled due to storage capacity and imports. The capacity of markets to supply safe and nutritious food is limited by a number of issues, including poor hygiene; lack of infrastructure for storage and selling; limited information on nutrition, and weak coordination among sellers and producers. Other bottlenecks include: on-farm constraints for expanded production, consumers with limited purchasing capacity, intense competition among sellers and few services for sellers to increase volume of product sold during peak demand. The diagnostics identify the role of information-related interventions to optimize decisions related to food choices, involving a range of different foods and value-chains, that could potentially lead to short- and medium-term improvements in diets. Longer-term and more resource-intensive interventions are also identified, such as improving capacity for product differentiation, processing, storage, and market infrastructure across a different range of food chains, so as to maximise coherence between short- and long-term planning. The findings highlight the benefits of applying a strategic, food systems-based approach of identifying specific and complementary actions for both the public and private sectors that can improve the diets of low-income populations.
The prominent role of informal medicine vendors despite health insurance: A weekly diaries study in rural Nigeria
Nelissen, Heleen E.; Brals, Daniëlla; Ameen, Hafsat A.; van der List, Marijn; Kramer, Berber; Akande, Tanimola M.; Janssens, Wendy; van’t Hoog, Anja H.. Oxford Article in press

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In sub-Saharan Africa, accessibility to affordable quality care is often poor and health expenditures are mostly paid out of pocket. Health insurance, protecting individuals from out-of-pocket health expenses, has been put forward as a means of enhancing universal health coverage. We explored the utilization of different types of healthcare providers and the factors associated with provider choice by insurance status in rural Nigeria. We analysed year-long weekly health diaries on illnesses and injuries (health episodes) for a sample of 920 individuals with access to a private subsidized health insurance programme. The weekly diaries capture not only catastrophic events but also less severe events that are likely underreported in surveys with longer recall periods. Individuals had insurance coverage during 34% of the 1761 reported health episodes, and they consulted a healthcare provider in 90% of the episodes. Multivariable multinomial logistic regression analyses showed that insurance coverage was associated with significantly higher utilization of formal health care: individuals consulted upgraded insurance programme facilities in 20% of insured episodes compared with 3% of uninsured episodes. Nonetheless, regardless of insurance status, most consultations involved an informal provider visit, with informal providers encompassing 73 and 78% of all consultations among insured and uninsured episodes, respectively, and individuals spending 54% of total annual out-of-pocket health expenditures at such providers. Given the high frequency at which individuals consult informal providers, their position within both the primary healthcare system and health insurance schemes should be reconsidered to reach universal health coverage.
Nutrition intervention using behavioral change communication without additional material inputs increased expenditures on key food groups in Bangladesh
Warren, Andrea M.; Frongillo, Edward A.; Nguyen, Phuong Hong; Menon, Purnima. Article in press

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Background
Behavioral change communication (BCC) promotes skills and knowledge to improve infant and young child feeding, but without additional material inputs, recipients must develop strategies to translate knowledge into action. Using data from the Alive & Thrive initiative in Bangladesh (2010–2014), we aimed to test whether households receiving the intensive intervention (opposed to the nonintensive intervention) increased expenditures on key foods for mothers and children (e.g., foods that were promoted by the intervention and also changed in maternal and child diets).
Methods
The intensive intervention provided interpersonal counseling, community mobilization, and mass media campaigns to promote breastfeeding and complementary feeding. A cluster-randomized design compared 20 subdistricts randomly assigned to the intensive (4281 households) or nonintensive (4284 households) intervention. Measures included food and nonfood expenditures, dietary diversity, and women's economic resources. Linear and logistic regression tested difference-in-differences (DD) in expenditures and dietary diversity, accounting for subdistricts as clusters, and the association between maternal and child consumption of specific food groups and corresponding food expenditures.
Food access and nutritional status of rural adolescents in India: Pune maternal nutrition study
Ganpule-Pao, Anjani V.; Roy, Devesh; Karandikar, Bhushana; Yajnik, Chittaranjan S.; Rush, Elaine C.. Article in press

Increased iron status during a feeding trial of iron-biofortified beans increases physical work efficiency in Rwandan women
Luna, Sarah V.; Pompano, Laura M.; Lung'aho, Mercy; Gahutu, Jean Bosco; Haas, Jere D.. Article in press

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Background
Iron-biofortified staple foods can improve iron status and resolve iron deficiency. However, whether improved iron status from iron biofortification can improve physical performance remains unclear.
Objective
This study aimed to examine whether changes in iron status from an iron-biofortified bean intervention affect work efficiency.
Methods
A total of 125 iron-depleted (ferritin <20 μg/L) female Rwandan university students (18–26 y) were selected from a larger sample randomly assigned to consume iron-biofortified beans (Fe-Bean; 86.1 mg Fe/kg) or conventional beans (control: 50.6 mg Fe/kg) twice daily for 18 wk (average of 314 g beans consumed/d). Blood biomarkers of iron status (primary outcome) and physical work efficiency (secondary outcome) were measured before and after the intervention. Work performed was assessed during 5-min steady-state periods at 0-, 25-, and 40-W workloads using a mechanically braked cycle ergometer. Work efficiency was calculated at 25 W and 40 W as the work accomplished divided by the energy expended at that workload above that expended at 0 W. General linear models were used to evaluate the relation between changes in iron status biomarkers and work efficiency. Results The Fe-Bean intervention had significant positive effects on hemoglobin, serum ferritin, and body iron stores but did not affect work efficiency. However, 18-wk change in hemoglobin was positively related to work efficiency at 40 W in the full sample (n = 119; estimate: 0.24 g/L; 95% CI: 0.01, 0.48 g/L; P = 0.044) and among women who were anemic (hemoglobin <120 g/L) at baseline (n = 43; estimate: 0.64 g/L; 95% CI: 0.05, 1.23 g/L; P = 0.036). Among women who were nonanemic at baseline, change in serum ferritin was positively related to change in work efficiency at 40 W (n = 60; estimate: 0.50 μg/L; 95% CI: 0.06, 0.95 μg/L; P = 0.027). Conclusions Increasing iron status during an iron-biofortified bean feeding trial improves work efficiency in iron-depleted, sedentary women. This trial was registered at clinicaltrials.gov as NCT01594359.
Diet quality over time is associated with better development in rural Nepali children
Miller, Laurie C.; Neupane, Sumanta; Joshi, Neena; Shrestha, Merina; Neupane, Shailes; Lohani, Mahendra; Thorne‐Lyman, Andrew L.. Oxford, UK Article in press

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Developmental delays affect between 150 and 200 million children <5 years of age worldwide. Outside of diet supplement studies, relatively little is known about the relationships between diet quality and developmental status in resource‐poor settings. We examined associations between different aspects of dietary quality (dietary diversity score [DDS] and animal‐source food [ASF] consumption) and child development (assessed using the Ages and Stages Questionnaire‐3 [ASQ‐3]) among children whose families were enrolled in a community development intervention trial (implemented by Heifer Nepal) in western Nepal. Two sets of analyses were performed: (a) cross‐sectional Sample (N = 629) seen at the endline survey and (b) longitudinal sample (N = 269) with complete dietary records (six surveys over 48 months). In both samples, child development was significantly related to household wealth, maternal education, and especially home environmental quality. In the cross‐sectional sample, greater consumption of eggs (adjusted odds ratio [aOR] 0.80, p = .04) or dairy products (aOR 0.95, p = .05) over the previous 7 days significantly reduced odds of low total ASQ score, by logistic regression analysis. In the longitudinal sample, only egg consumption and cumulative DDS and ASF scores were associated with significantly reduced odds of low total ASQ score (aORs 0.59–0.89). In adjusted linear regression analysis, both cumulative DDS (β [CI]: 1.92 [0.4, 3.5]) and ASF scores (2.46 [0.3, 4.7]) were significantly associated with greater continuous total child development. Programmes targeting child development must address home environmental quality as well as long‐term diet quality.
Stunting and wasting among Indian preschoolers have moderate but significant associations with the vegetarian status of their mothers
Headey, Derek D.; Palloni, Giordano. Article in press

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Background: India has high rates of child undernutrition and widespread lactovegetarianism. Objectives: The objective of this study was to examine how nutrition outcomes varied among Indian preschool children in relation to the vegetarian status of their parents. Methods: The 2015–2016 National Family Health Survey (NFHS) and the 2011–2012 National Sample Survey (NSS) were used to explore associations between parental vegetarian status and child stunting and wasting at ages 0–59 mo and anemia at ages 6–59 mo. In the NFHS, self-reports on usual consumption of foods were used to classify maternal diets, whereas in the NSS lactovegetarianism was defined at the household level. Results: Compared with children of nonvegetarian mothers, children aged 24–59 mo of lactovegetarian mothers were 2.9 percentage points (95% CI: −4.0, −1.9) less likely to be stunted and children aged 6–23 mo were 1.6 points less likely to be wasted (95% CI: −3.0, −0.03), whereas children aged 6–23 mo with vegan mothers were 5.2 points more likely to be stunted (95% CI: 0.1, 9.4). When compared with nonvegetarian households, lactovegetarian households had better socioeconomic status and were more likely to consume dairy frequently. Children in nonvegetarian households consumed nondairy animal-sourced foods (ASFs) with relatively low frequency. The frequency of maternal dairy consumption was significantly associated with lower risks of child stunting and wasting. Conclusions: Anthropometric outcomes differed by maternal vegetarian status, which is itself strongly associated with socioeconomic position, location, religion, and caste.
What is the role of civil society in multisectoral nutrition governance systems? A multicountry review
Busse, Heidi; Covic, Namukolo; Aakesson, Ashley; Jogo, Wellington. Article in press

Associations of maternal resources with care behaviours differ by resource and behaviour
Basnet, Sulochana; Frongillo, Edward A.; Nguyen, Phuong Hong; Moore, Spencer; Arabi, Mandana. Article in press

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Care is important for children's growth and development, but lack or inadequacy of resources for care can constrain appropriate caregiving. The objectives of this study were to examine whether maternal resources for care are associated with care behaviours specifically infant and young child feeding, hygiene, health‐seeking, and family care behaviours. The study also examined if some resources for care are more important than others. This study used baseline Alive & Thrive household surveys from Bangladesh, Vietnam, and Ethiopia. Measures of resources for care were maternal education, knowledge, height, nourishment, mental well‐being, decision‐making autonomy, employment, support in chores, and perceived instrumental support. Multiple regression analyses were conducted to examine the associations of resources for care with child‐feeding practices (exclusive breastfeeding, minimum meal frequency, dietary and diversity), hygiene practices (improved drinking water source, improved sanitation, and cleanliness), health‐seeking (full immunization), and family care (psychosocial stimulation and availability of adequate caregiver). The models were adjusted for covariates at child, parents, and household levels and accounted for geographic clustering. All measures of resources for care had positive associations with care behaviours; in a few instances, however, the associations between the resources for care and care behaviours were in the negative direction. Improving education, knowledge, nutritional status, mental well‐being, autonomy, and social support among mothers would facilitate provision of optimal care for children.
Willingness to pay of Nigerian poultry producers and feed millers for aflatoxin‐safe maize
Johnson, Andrew M.; Abdoulaye, Tahirou; Ayedun, Bamikole; Fulton, Joan R.; Widmar, Nicole J. Olynk; Adebowale, Akande; Bandyopadhyay, Ranajit; Bandyopadhyay, Ranajit. Article in press

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Dietary aflatoxin exposure is a widespread problem in the developing world and causes severe negative health consequences to humans and livestock animals. A new biological control product, called Aflasafe, has been introduced in Nigeria to mitigate aflatoxin contamination of maize in the field and in storage. No known prior work has estimated how much African agribusinesses using maize for animal feed will pay for aflatoxin‐safe maize. This study measured the levels of Aflasafe awareness, surveyed current aflatoxin management practices, and estimated, using choice experiments, willingness to pay (WTP) for aflatoxin‐safe maize by Nigerian poultry producers and feed millers. Data was gathered from 272 orally administered surveys, which included discrete choice experiments examining maize purchasing decisions. Results suggest that the proportion of enterprises that were aware of aflatoxin was found to vary across states. Two latent classes of Nigerian poultry producers and feed millers were identified that were willing to pay average premiums of 4.9% and 30.9%, respectively for maize with 10 parts per billion (ppb) aflatoxin concentration relative to maize with 20 ppb aflatoxin concentration. Both latent classes were, on average, willing to pay larger premiums for maize with 4 ppb aflatoxin concentration. There was evidence that latent class membership, and hence WTP, varied based on awareness of aflatoxin and across geographies.
Quantitatively evaluating the cross-sectoral and one health impact of interventions: A scoping review and application to antibiotic resistance
Naylor, Nichola R.; Lines, Jo; Waage, Jeff; Wieland, Barbara; Knight, Gwenan M.. Article in press

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Current published guidance on how to evaluate antibiotic resistance (ABR) from a One Health perspective has focussed on the evaluation of intervention design and of the implementation process. For efficient resource allocation, it is also important to consider quantitative measures of intervention impact. In particular, there has been little discussion of how to practically evaluate ABR-related agri- and aquaculture interventions from a public health perspective. Lessons can be learned from other One Health and cross-sectoral intervention impact evaluations. WebofScience, EconLit, PubMed and grey literature were searched for literature quantitatively evaluating interventions across humans, animals and/or the environment. The review included 90 studies: 73 individual evaluations (from 72 papers) and 18 reviews, all including some measure of human impact, but only 29 papers covered all three One Health perspectives (human, animal and environmental). To provide decision makers with expected outcome estimates that are related to their objective, evaluations should provide outcome estimates from multiple different perspectives; individual, microeconomic and/or macroeconomic perspectives across the One Health system should be taken into account. Based on the methods found in this review, a multi-level compartmental modelling approach for ABR-related intervention evaluation is proposed. The outcomes of such models can then feed into multi-criteria-decision analyses that weigh outcomes alongside other chosen outcome estimates (for example equity or uncertainty). It is key that future quantitative evaluation models on ABR-related interventions are shared (for example through open source code sharing websites) to avoid duplication of effort and to enable more comprehensive estimates of intervention impact to be modelled in the future.
Genetic variability, diversity and interrelationship for twelve grain minerals in 122 commercial pearl millet cultivars in India
Govindaraj, Mahalingam; Yadav, O. P.; Rajpurohit, B. S.; Kanatti, A.; Rai, Kedar N.; Dwivedi, Sangam L.. Article in press

Leveraging an implementation–research partnership to improve effectiveness of nutrition-sensitive programs at the World Food Programme
Olney, Deanna K.; Marshall, Quinn; Honton, Geraldine; Ogden, Kathryn; Hambayi, Mutinta; Piccini, Sarah; Go, Ara; Gelli, Aulo; Bliznashka, Lilia. Article in Press

Pradhan Mantri Kisan Samman Nidhi (PM-KISAN) and the adoption of modern agricultural technologies in Uttar Pradesh, India
Varshney, Deepak; Joshi, Pramod Kumar; Roy, Devesh; Kumar, Anjani. Washington, DC 2020

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The Pradhan Mantri Kisan Samman Nidhi (PM-KISAN) scheme aims to provide income support to farmers to facilitate timely access to inputs by easing their liquidity needs. This study, based on 1,406 farmers of Uttar Pradesh and using a binary choice model, examines the scheme’s targeting accuracy and the correlates of farmers’ spending patterns. Triple difference with matching estimators are used to identify the differential impact of PM-KISAN on Krishi Vigyan Kendras (farm science centers, or KVKs) beneficiaries. Results show that PM-KISAN reached to one-third of all the farmers in the first three months of its implementation. Moreover, the study finds no selection bias based on social, economic and agricultural characteristics. The scheme has significantly helped those who are relatively more dependent on agriculture and have poor access to credit. Moreover, scheme has significantly stimulated the KVK ’s impact on the adoption of modern cultivars.
Poultry production in Burkina Faso: Potential for poverty reduction and women’s empowerment
Hoffmann, Vivian; Awonon, Josue; Gelli, Aulo. Washington, DC 2020

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Poultry rearing is widespread in rural Burkina Faso, and contributes to both the food security and cash income of smallholders farmers. The landlocked status of the country, coupled with increasing demand for poultry in urban areas implies an opportunity for significant, pro-poor growth through this sector. We use data from a survey of 1800 poultry producers to characterize smallholder poultry producers and their practices. We find that 88% of households in program areas raised poultry. While access to vaccination services and veterinary medicines at the village level is high, uptake of these services is limited, especially among smaller producers. Fewer women than men own poultry, but most women report that they control the proceeds from sales of their own birds, indicating the potential for development of the poultry sector to generate relatively equitable gains in terms of gender. Access to credit appears to increase women’s poultry ownership, but remains limited, as does women’s access to poultry output markets.
What does empowerment mean to women in northern Ghana? Insights from research around a small-scale irrigation intervention
Bryan, Elizabeth; Garner, Elisabeth. Washington, DC 2020

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Women’s empowerment is important to improve the status of women and achieve greater gender equity. It is also an important vehicle for achieving other development goals related to food security, nutrition, health, and economic growth. Increasingly, researchers seek ways to measure women’s empowerment, trace the pathways through which women’s empowerment is achieved, and provide guidance for policymakers and practitioners aiming to facilitate women’s empowerment through their interventions. This paper explores local perceptions of empowerment in the Upper East Region of Ghana in the context of a small-scale irrigation intervention targeted to men and women farmers. Using data collected through qualitative interviews and focus groups, the paper traces the linkages between small-scale irrigation and aspects of women’s empowerment, identified as important to men and women farmers themselves. The relationship between the components of empowerment and small-scale irrigation are placed within a larger context of social change underlying these relationships. Finally, this paper explores the ways that the introduction of modern technologies for small-scale irrigation may contribute to women’s empowerment.
Food systems resource center
CGIAR Research Program on Agriculture for Nutrition and Health (A4NH). Washington, DC 2020

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Food systems in low- and middle-income countries are changing rapidly, with serious consequences for the nutritional health and wellbeing of billions of people. A4NH’s Research Flagship on Food Systems for Healthier Diets provides research and support to countries working to ensure their food systems develop in a way that ensures people have equitable access to nutritious and sustainable diets.
The Food Systems Resource Center provides access to research, tools, ideas, and people conducting work in this important area.
Regressing forward: Agriculture mechanization subsidy modalities in Bihar and Odisha
Saini, Smriti; Kishore, Avinash; Alvi, Muzna. 2020

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Farm mechanization is indispensable for enhancing agricultural productivity across the country. Over the years, the Indian government has instituted several schemes and programs to promote agricultural mechanization in the country. Until recently, state and central government schemes took the form of price subsidies, especially targeting critical farm equipment. More recently, the government has shifted to direct benefit transfers (DBT) for all agricultural inputs, including farm implements. While the central government instituted the broader schemes and programs, the specifics concerning subsidy disbursement have been left to state governments, with flexibility on which implements to promote and how much and when to disburse subsidy payments. These broad guidelines have been enshrined in several programs, chief among which is the National Mission on Agriculture Extension and Technology (NMAET).
POSHAN's abstract digest on maternal and child nutrition research - Issue 32
Avula, Rasmi, ed.. New Delhi, India 2020

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We are delighted to present the first issue of Abstract Digest for this year. It has a collection of articles on various outcomes, determinants and interventions related to maternal and child nutrition, from around the world and India, in particular. In this issue, we feature a special series on the double burden of malnutrition from The Lancet journals and three systematic reviews – 1. Micronutrient supplementation and fortification interventions and health and developmental outcomes; 2. Effectiveness of interventions for managing acute malnutrition among children below five years; and 3. Preventive interventions among adolescents. In addition, there are two unique global articles relevant for multiple contexts – the first one generates lessons about nutrition behaviour change from cluster-randomized evaluations in three countries, Bangladesh, Vietnam, and Ethiopia; and the second is based on research to improve nutrition in the context of an at-scale social protection program in Mexico, which has learnings for many developing countries. Given below is the list of articles included in this issue. Please click on the title if you wish to go straight to the article or scroll down to explore the abstract in the pages that follow.