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Changes in socio-economic patterns of energy consumption and insufficient energy intake across India from 1993–94 to 2011–12
Perkins, Jessica M.; Chakrabarti, Suman; Joe, William; Lee, Hwa-Young; Heo, Jongho
. Article in press

A community-based early childhood development center platform promoting diversified diets and food production increases the mean probability of adequacy of intake of preschoolers in Malawi: A cluster randomized trial
Gelli, Aulo; Nguyen, Phuong Hong; Santacroce, Marco; Twalibu, Aisha; Margolies, Amy; Katundu, Mangani. Article in press

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Background: Young children in Malawi consume low-quality diets lacking micronutrients critical for their development.
Objective: To evaluate the impact of an agriculture and nutrition behavior change communication (BCC) intervention implemented through community-based childcare centers on the nutrient adequacy of diets of children living in food-insecure settings in Malawi.
A double edged sword? Improvements in economic conditions over a decade in India led to declines in undernutrition as well as increases in overweight among adolescents and women
Young, Melissa; Nguyen, Phuong Hong; Tran, Lan Mai; Avula, Rasmi; Menon, Purnima. Article in press

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This study examined the national and state trends for BMI and identified the determinants of underweight and overweight/obesity among adolescent girls and women.
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.
Different combination of behavior change interventions and frequency of interpersonal contacts are associated with infant and young child feeding practices in Bangladesh, Ethiopia, and Viet Nam
Kim, Sunny S.; Nguyen, Phuong Hong; Tran, Lan Mai; Alayon, Silvia; Menon, Purnima; Frongillo, Edward A.. Article in press

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Background
Social and behavior change communication interventions are integral to improving dietary and care practices, but evidence on the impact of the combination and intensity of these interventions in different contexts is scarce.
Objective
We examined the extent of and factors associated with intervention exposure: interpersonal communication (IPC) alone or with other interventions (i.e., mass media, community mobilization, or nutrition-sensitive agricultural activities); number of and factors associated with IPC contacts; and combinations of intervention components and number of contacts associated with infant and young child feeding (IYCF) practices.
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.
Different cooking styles enhance antioxidant properties and carotenoids of biofortified pumpkin (Cucurbita moschata Duch) genotypes
Moreira, Lara de Azevedo Sarmet; Carvalho, Lucia Maria Jaeger de; Cardoso, Flávio da Silva e Souza Neves; Ortiz, Gisela Maria Dellamora; Finco, Fernanda Dias Bartolomeu Abadio; Carvalho, José Luiz Viana de . Article in press

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Biofortification is an important technique where the nutritional quality of food crops is enriched through the increase of nutrient content. Provitamin A deficiency is still a public health concern mainly in developing countries. Since beta-carotene is a vitamin A precursor, the increase of this compound in foods through biofortification is a manner to reach people under hidden hunger condition. This work aimed to evaluate the effect of different cooking styles on carotenoids content and antioxidant activity of two different genotypes of biofortified Cucurbita moschata. In the present study, biofortified pumpkins submitted to different cooking conditions were assessed for antioxidant activity by ABTS, DPPH, β-carotene/linoleic acid systems and have polyphenols and carotenoids content compared. The cooking style affected the antioxidant activity. Pumpkins from genotype 1 showed high levels of carotenoids, α-carotene and all-E-β-carotene compared to samples from genotype 2. There was an increase of all carotenoids in both cooked pumpkins, and steam cooking showed the highest retention percentages. Steam cooking presented a higher percentage of carotenoid retention. Pumpkin consumption in developing countries, especially in the Northeast Brazil may be promoted to combat vitamin A deficiency.
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.
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

The cost of improving nutritional outcomes through food‐assisted maternal and child health and nutrition programs in Burundi and Guatemala
Heckert, Jessica; Leroy, Jef L.; Olney, Deanna K.; Ritcher, Susan; Iruhiriye, Elyse; Ruel, Marie T.. 2020

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Evidence on the cost‐effectiveness of multisectoral maternal and child health and nutrition programmes is scarce. We conducted a prospective costing study of two food‐assisted maternal and child health and nutrition programmes targeted to pregnant women and children during the first 1,000 days (pregnancy to 2 years). Each was paired with a cluster‐randomized controlled trial to evaluate impact and compare the optimal quantity and composition of food rations (Guatemala, five treatment arms) and their optimal timing and duration (Burundi, three treatment arms). We calculated the total and per beneficiary cost, conducted cost consequence analyses, and estimated the cost savings from extending the programme for 2 years. In Guatemala, the programme model with the lowest cost per percentage point reduction in stunting provided the full‐size family ration with an individual ration of corn–soy blend or micronutrient powder. Reducing family ration size lowered costs but failed to reduce stunting. In Burundi, providing food assistance for the full 1,000 days led to the lowest cost per percentage point reduction in stunting. Reducing the duration of ration eligibility reduced per beneficiary costs but was less effective. A 2‐year extension could have saved 11% per beneficiary in Guatemala and 18% in Burundi. We found that investments in multisectoral nutrition programmes do not scale linearly. Programmes providing smaller rations or rations for shorter durations, although less expensive per beneficiary, may not provide the necessary dose to improve (biological) outcomes. Lastly, delivering effective programmes for longer periods can generate cost savings by dispersing start‐up costs and lengthening peak operating capacity.
Cognitive interviewing to improve women's empowerment questions in surveys: Application to the health and nutrition and intrahousehold relationships modules for the project‐level Women's Empowerment in Agriculture Index
Hannan, Anika; Heckert, Jessica; James-Hawkins, Laurie; Yount, Kathryn M.. 2020

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In 2015, the United Nations adopted the Sustainable Development Goals, which include fostering gender equality and women's empowerment and ending hunger and malnutrition. To monitor progress and evaluate programmes that aim to achieve these goals, survey instruments are needed that can accurately assess related indicators. The project‐level Women's Empowerment in Agriculture Index (pro‐WEAI) is being developed to address the need for an instrument that is sensitive to changes in empowerment over the duration of an intervention. The pro‐WEAI includes new modules with previously untested survey questions, including a health and nutrition module (focused on women's agency in this area) and an intrahousehold relationships module. This study uses cognitive interviewing to identify how new survey questions might be misinterpreted and to understand what experiences women are referencing when they respond to these questions. This was undertaken with the goal of informing revision to the modules. The study was conducted in Bangladesh with women from nuclear, extended, and migrant‐sending households and from two regions of the country to identify difficulties with interpretation and response formulation across these groups. Findings revealed that questions were generally understood, but participants occasionally responded to the wrong part of the question, did not understand key phrases, or were uncomfortable with questions. The findings also suggested ways to revise the modules and strengthen the pro‐WEAI. The revised pro‐WEAI health and nutrition and intrahousehold relationships modules will advance the ability to measure changes in these domains and their relationship with the health and nutritional status of women and their children.
Using structural equation modelling to understand the contributors to anemia among young Burkinabe children
Bliznashka, Lilia; Arsenault, Joanne E.; Becquey, Elodie; Ruel, Marie T.; Olney, Deanna K.. 2020

Ask me why: Patterns of intrahousehold decision-making
Bernard, Tanguy; Doss, Cheryl R.; Hidrobo, Melissa; Hoel, Jessica B.; Kieran, Caitlin. 2020

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Households are sites of both cooperation and contestation. With more data available at the intrahousehold level, development researchers and practitioners have increasingly focused on household dynamics and decision-making and how these relate to outcomes of interest across many domains such as health and agriculture. Many researchers who wish to better understand power dynamics within households have focused on the question of who makes decisions in the household. A woman’s participation in household decision-making is often used both as a proxy for empowerment, an end in its own right, and as a means to achieve better production and consumption outcomes. However, research on this topic pays less attention to why different household members may make different decisions, and whether this matters for individual or household welfare. In this paper, we use an innovative methodology to look beyond the identity of the decision-maker to explore the reasons that may drive patterns of household decision-making. We then assess whether the rationale behind who makes household decisions helps explain variation in household outcomes, above and beyond what is explained by the identity of the decision-maker. Our approach uses vignettes, which are survey instruments used to measure concepts that are more easily defined by examples.1 Vignettes have been used to measure subjective well-being (Ravallion, Himelein, & Beegle, 2016), women’s agency (see Donald, Koolwal, Annan, Falb, & Goldstein, 2017 for a review), bias against women politicians (Beaman, Chattopadhyay, Duflo, Pande, & Topalova, 2009), as well as risk aversion (Barter & Renold, 1999). However, this is the first time that they have been used to analyze the processes of household decision-making.
Multisectoral community development in Nepal has greater effects on child growth and diet than nutrition education alone
Miller, Laurie C.; Neupane, Sumanta; Joshi, Neena; Lohani, Mahendra; Rogers, Beatrice L.; Neupane, Shailes
. 2020

Experimental evidence on post-program effects and spillovers from an agriculture-nutrition program
Dillon, Andrew; Bliznashka, Lilia; Olney, Deanna K.. 2020

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Integrated agricultural-nutrition programs are often implemented under the premise that program effects are durable and spillover. This paper estimates one year post-program effects, three-year aggregate program effects and spillover effects using treated and untreated household cohorts. Two treatment interventions implemented agricultural interventions with behavior change communication strategies varying implementers using either village health committees or older female leaders. In the post-program period, program effects deteriorated relative to program period impacts documented in Olney et al. (2015), but the three-year agricultural, nutrition knowledge, health care practices and severe anemia impacts remained statistically significant. Despite the non-rival nature of nutrition education and promoted production techniques, there is little evidence of agricultural technology or health knowledge spillovers to non-treated households within treatment communities. Spillover effects measured for appropriate treatment of diarrhea (10 pp increase in giving rehydration salts rather than traditional medicine), wasting (20 pp lower probability of wasting) and children’s anemia status (7 pp reduction in severe anemia) significantly improve in later cohorts. The aggregate program effects and spillovers are generally robust to multiple hypothesis testing.
Lipid-based nutrient supplements and all-cause mortality in children 6–24 months of age: A meta-analysis of randomized controlled trials
Stewart, Christine P.; Wessells, K. Ryan; Arnold, Charles D.; Huybregts, Lieven; Ashorn, Per; Becquey, Elodie. Oxford, UK 2020

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Background: Undernutrition is associated with an elevated risk of mortality among children in low- and middle-income countries. Small-quantity lipid-based nutrient supplements (LNS) have been evaluated as a method to prevent undernutrition and improve infant development, but the effects on mortality are unknown.
Affordability of the EAT–Lancet reference diet: A global analysis
Hirvonen, Kalle; Bai, Yan; Headey, Derek D.; Masters, William A.. 2020

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The EAT–Lancet Commission drew on all available nutritional and environmental evidence to construct the first global benchmark diet capable of sustaining health and protecting the planet, but it did not assess dietary affordability. We used food price and household income data to estimate affordability of EAT–Lancet benchmark diets, as a first step to guiding interventions to improve diets around the world.