Integrated Nutrition Project Research Articles

A graphical method for causal program attribution in theory-based evaluation

We describe a simple yet rigorous graphical method for eliminating bias in theory-based program evaluation. The method is an application to social and international development program evaluation of the graphical causal models used to test medical treatments. We implement a graphical causal model for the World Bank’s well-known Bangladesh Integrated Nutrition Project. We show how to construct the graphical causal model to represent program theory in context in explicitly causal terms. We then show how to visually inspect the graphical causal model to distinguish causal from non-causal associations between variables in evaluation data. Finally, we show how to select a set of adjustment variables to neutralize non-causal associations, eliminating bias in all forms of causal inference—qualitative and quantitative, linear and non-linear.

Hungry for Change

The World Bank has become the largest financial contributor to health-related and nutrition projects, committing more than $1 billion annually towards the health, nutrition and population sector. This article examines how the World Bank addressed malnutrition in Tamil Nadu and discusses the consequences of this approach for the Bank's projects and target communities. Using the case study of the Tamil Nadu Integrated Nutrition Project (TINP), it is argued that the World Bank nutrition package, now implemented in several countries, might not be effective in extremely poor and destitute communities because it does not address the underlying social causes of malnutrition. The final section of the article goes ‘inside’ the Bank to examine two institutional drivers that could explain the promotion of the TINP approach to undernutrition.

The Role of Structure and Agency in Hunger Reduction in India

This article investigates the role of structure and agency in hunger reduction in India using the case study of the Tamil Nadu Integrated Nutrition Project (TINP). The TINP was a World Bank-funded, state-run project that was initiated in 1980 to improve the nutritional and health status of preschool children, and pregnant and nursing women. Its primary purpose was behavioural change of mothers using the educational tools of growth monitoring, nutrition counselling and supplementary feeding. This paper argues that the predominant cause of undernutrition is not ignorance, but structural factors such as poverty and gender inequality that constrain women's agency. In addition, it examines the representation of the feminised ‘mind’ which is the point of interface between the state and the body.

Prevention of Malnutrition among Young Children in Rural Bangladesh by a Food-Health-Care Educational Intervention: A Randomized, Controlled Trial

As a result of inappropriate feeding, poor health and hygiene, and poor caring practices, the nutritional status of many young infants deteriorates with advancing age. To explore the effectiveness of a nutrition education package to prevent malnutrition among young children. A community-based, randomized, controlled trial was conducted among 605 normal and mildly malnourished children aged 6 to 9 months in 121 Community Nutrition Centers (CNCs) of the Bangladesh Integrated Nutrition Project (BINP) in four regions of Bangladesh from 2000 to 2002. The intervention group received weekly nutrition education based on the nutrition triangle concept of UNICEF for 6 months, whereas the control group received regular BINP services. Both groups were observed for a further 6 months to assess the sustainability of the effects. Information on socioeconomic status, feeding patterns, morbidity, and anthropometric features was collected. A significant increase in the frequency of complementary feeding was observed in the intervention group as compared with the control group, and the increase was sustained throughout the observation period. The intervention group had a higher weight gain than the control group after the end of the intervention (0.86 vs. 0.77 kg, p = 0.053) and after the end of the observation period (1.81 vs. 1.39 kg, p < .001). The proportion of normal and mildly malnourished children was greater in the intervention group than in the control group after the end of the observations (88.9% vs. 61.5%, p < .001). Nutrition education successfully prevented malnutrition in all the areas. Variation in the outcome of nutrition education among the regions was observed. This culturally appropriate nutrition education package based on the nutrition triangle model effectively prevented growth faltering and malnutrition among young children.

Assessing interventions to improve child nutrition: a theory‐based impact evaluation of the Bangladesh Integrated Nutrition Project

AbstractThe Community‐Based Nutrition Component of the Bangladesh Integrated Nutrition Project sought to improve nutritional status through nutritional counselling and supplementary feeding for malnourished children and pregnant women. This paper presents a theory‐based impact evaluation of this programme. Both counselling and feeding suffered from problems of inappropriate targeting strategies and a failure to reach intended groups. While counselling has changed women's knowledge it has had less of an impact on behaviour. There is a knowledge‐practice gap, which is explained by resource constraints faced by women, including lack of time, which prevent them from putting the advice into practice. The impact of the project on anthropometric outcomes of infants, children and mothers has not been large. Copyright © 2006 John Wiley &amp; Sons, Ltd.

Freedom from want: the human right to adequate food

List of Tables and Figures Foreword by Jean Ziegler Acknowledgments Introduction: Taking Rights Seriously Part I. Foundations Chapter 1. Food and Nutrition Malnutrition Causes of Malnutrition Growth Measurement Numbers of Malnourished People Malnutrition and Mortality Comparative Morality Food and Nutrition Security Varieties of Government Action Chapter 2. The International Human Rights System Historical Foundations International Humanitarian Law The International Bill of Human Rights Children's Rights Regional Human Rights Agreements Human Rights Agencies United Nations Charter Bodies United Nations Treaty Bodies Civil Society Organizations Informal Civil Society Chapter 3. Adequate Food is a Human Right Economic, Social, and Cultural RightsFood in International Human Rights Law Food in International Humanitarian Law Global Declarations and Commitments General Comment 12The Special RapporteurThe Voluntary Guidelines Part II. Human Rights Systems Chapter 4. Human Rights, Governance, and Law Human Rights and Governance Studying Human Rights in National Governance The Role of National LawUniversal Human Rights and the Role of International Law Chapter 5. Rights/Entitlements DefinitionMoral versus Legal RightsSoft versus Hard RightsRights as Goals Rights Imply EntitlementsDetermining Local EntitlementsHaving versus Realizing Rights Chapter 6. Obligations and Commitments Moral Responsibilities When Do Governments Do Human Rights Work? Levels of Government ObligationEconomic Rights The Obligation of Good Governance Obligations of Nonstate Actors Questionable Charity Chapter 7. Accountability MechanismsVarieties of Accountability Justiciability Remedies for Rights Holders National and Local Human Rights AgenciesAccountability through Public Action Chapter 8. India The Supreme Court Case Starvation is Not the Problem The Missing Piece in India's Rights SystemThe Tamil Nadu Integrated Nutrition Project Chapter 9. Brazil Chapter 10. The United States Chapter 11. Feeding InfantsBreast-Feeding RightsInfants' Human Right to Adequate Food Principles Women's Right to Breast-Feed versus Infants' Right to be Breast-Fed Chapter 12. Feeding Infants of HIV-Positive Mothers Official Guidance on HIV/AIDS and Infant Feeding Issues A Court Case Informed Choice Principles Chapter 13. Water The Household Water Problem Water Rights are DifferentGeneral Comment 15 Chapter 14. TradeIssues The Human Right to Adequate Food in Relation to Trade Reconciling Different Frameworks Food Sovereignty Chapter 15. RefugeesIssues in Refugee NutritionExplanations and Justifications for Uneven ServicesThe Human Right to Adequate FoodThe Adequacy QuestionSpecifying the ObligationsLimiting the ObligationsThe Work Ahead Chapter 16. International Humanitarian AssistanceIssuesRights to AssistanceThe Provider's Motivation Implementation Chapter 17. Global Human RightsGlobal Rights and Global ObligationsGlobal Accountability Strategic Planning Sources ReferencesIndex

Intensive nutrition education with or without supplementary feeding improves the nutritional status of moderately-malnourished children in Bangladesh.

This prospective randomized trial was carried out to test the efficacy of a specific intervention for reducing the extent of their malnutrition and to change behaviour of mothers relating to child-feeding practices, care-giving, and health-seeking practices under the Bangladesh Integrated Nutrition Project (BINP). The study was conducted in rural Bangladesh among 282 moderately-malnourished (weight-for-age between 61% and 75% of median of the National Center for Health Statistics standard) children aged 6-24 months. Mothers of the first intervention group received intensive nutrition education (INE group) twice a week for three months. The second intervention group received the same nutrition education, and their children received additional supplementary feeding (INE+SF group). The comparison group received nutrition education from the community nutrition promoters twice a month according to the standard routine service of BINP. The children were observed for a further six months. After three months of interventions, a significantly higher proportion of children in the INE and INE+SF groups improved (37% and 47% respectively) from moderate to mild or normal nutrition compared to the comparison group (18%) (p < 0.001). At the end of six months of observation, the nutritional status of children in the intervention groups improved further from moderate to mild or normal nutrition compared to the comparison group (59% and 86% vs 30%, p < 0.0001). As the intensive nutrition education and supplementation given were highly effective, more children improved from moderate malnutrition to mild or normal nutritional status despite a higher incidence of morbidity. The frequency of child feeding and home-based complementary feeding improved significantly (p < 0.001) in both the intervention groups after three months of interventions and six months of observation. Body-weight gain was positively associated with age, length-for-age, weight-for-length, frequency of feeding of khichuri, egg, and potato (p < 0.05). Ability of mothers to identify malnutrition improved from 15% to 99% in the INE group and from 15% to 100% in the INE+SF group, but reduced from 24% to 21% in the comparison group. Use of separate feed pots, frequency of feeding, and cooking of additional complementary feeds improved significantly in the INE and INE+SF groups compared to the comparison group after three months of interventions and six months of observation. It can be concluded from the findings of the study that intensive nutrition education significantly improves the status of moderately-malnourished children with or without supplementary feeding.

Seeking optimal means to address micronutrient deficiencies in food supplements: A case study from the Bangladesh Integrated Nutrition Project.

In seeking to improve the micronutrient contents of a food supplement used in a major community-based nutrition project in Bangladesh, operations research was conducted to compare the provision of needed micronutrients through additional food sources (fresh or dried fruits or vegetables), a micronutrient multi-mix, and a combination of the two. Micronutrient gaps (the difference between micronutrient requirements and actual micronutrient intake) were estimated for four groups of project beneficiaries, with target intakes defined as requirements for iron, calcium, zinc, vitamin A, vitamin C, riboflavin, niacin, and vitamin B12 recommended by the Food and Agriculture Organization/World Health Organization. Primary focus was placed on iron and vitamin A. Cost and bulk constraint analyses, based on cost of supplement, feasibility of delivery, and serving volume needed to achieve micronutrient targets, were used for comparing the supplement options. In terms of these analyses, the micronutrient multimix proved, by far, to be the most advantageous. Food options, however, are arguably desirable in that they provide dietary benefits additional to that of known micronutrients and may increase demand to boost production of domestic fruits and vegetables for the population as a whole. The study concludes that it is cost-effective to use powdered micronutrient mixes for such specific purposes as enrichment of supplementary food and food fortification, but encourages production and consumption of micronutrient-rich foods through programme messages and activities.

Increased Food Intake after the Addition of Amylase-Rich Flour to Supplementary Food for Malnourished Children in Rural Communities of Bangladesh

In Bangladesh, as in other developing countries, protein-energy malnutrition is mostprevalent among children during weaning. After weaning, children are often fed cereal-based diluted low-calorie porridge, resulting in growth-faltering. To assess the effect on food intake of adding amylase-rich flour (ARF) from germinated wheat to supplementary food among children in nine rural Community Nutrition Centers under the Bangladesh Integrated Nutrition Project (BINP). A total of 166 malnourished children of either sex, aged 6 to 24 months, received one of three diets randomly allocated to the Community Nutrition Centers. The composition of the diets was the same; however, the consistency and calorie density were altered by adding either ARF or water. Thirty-five children received the standard supplementary food of the BINP (S-SF), 65 received supplementaryfood with added ARF (ARF-SF), and 66 received supplementary food with added water (W-SF). The children were studied for six weeks. Results. The mean +/- SD intake of supplementaryfood from a single meal by children completing six weeks on the diets was higher for children receiving ARF-SF (33.91 +/- 8.25 g) than for those receiving S-SF (25.66 +/- 6.73 g) or W-SF (30.26 +/- 8.39g) (p < .05 for both comparisons). The weight of vomited food was significantly higher for children receiving W-SF than for children in the other two groups. Weight gain and increments in length and weight-for-height were higher for children who received ARF-SF than for children in the other two groups, but the differences were not statistically significant. The acceptability ofARF-SF was higher than that of the two other diets. The additional cost of adding 2 g of ARF to the diet was about Taka 0.25 (U.S. dollar 1 = Taka 48). Addition of ARF to existing standard supplementary food, as used under the BINP program, is a simple and effective means to increase the intake of food by changing its consistency, thus making it easier for malnourished children to ingest.

Comment on contributions regarding the impact of the Bangladesh Integrated Nutrition Project

The Bangladesh Integrated Nutrition Project (BINP) started in 1995 sought to reduce child malnutrition through growth monitoring and supplementary feeding of children aged 6-24 months and supplementary feeding for pregnant women so as to increase pregnancy weight gain and hence reduce the incidence of low birth weight. The paper by Hossain et al. (2005) in the January issue of this journal laid out the workings of the programme more fully and presented evidence of limited impact based on a survey undertaken by Save the Children UK (SC). Two letters received in response to that paper published in this issue draw on other data sources to argue that the BINP has in fact been a success to be replicated. But the need to address the issue of malnutrition in Bangladesh and the undoubted commitment of the NGO workers who are implementing the BINP at field level should not deflect us from the need to make a rigorous assessment of the available evidence as to how well the programme is working. (excerpt)

An evaluation of the impact of a US$60 million nutrition programme in Bangladesh

To compare levels of childhood malnutrition in areas where the Bangladesh Integrated Nutrition Project had been operational for over 5 years with matched non-project areas, with the purpose of evaluating whether the project had achieved its objective of reducing the prevalence of underweight among children <24 months. The study involved an ex-post cross-sectional survey in six thanas (a locality with a population of approximately 200,000-450,000 people) in Bangladesh. Participants were 6,820 households (4,554 in the project areas and 2,266 in the non-project areas) including 7183 children aged 6-59 months selected using a two-stage stratified cluster sampling frame. Main outcome measures were moderate and severe underweight, wasting and stunting reported using z scores, and indicators of mothers' reported nutritional knowledge and practice. 2,388 children aged 6-23 months and 6815 children aged 6-59 months had clean anthropometric data. No significant difference was found between the socio-economic variables of households in the project and non-project areas. No significant difference was found in the prevalence of either severe or moderate underweight (weight-for-age) in children aged 6-23 months in the project and non-project areas: 183 (11.4%, 95% confidence interval 9.9-13.2%) children in project areas and 96 (12.2%, 95% confidence interval 9.9-14.8%) children in non-project areas. Mothers in project areas reported significantly better caring practices than in non-project areas. There is no evidence that the Bangladesh Integrated Nutrition Project has achieved its objectives to reduce severe underweight by 40% if project areas are compared ex-post with non-project areas. There is urgent need to review the evidence behind investments based on growth monitoring and promotion.

Monitoring and Evaluation of the Bangladesh Integrated Nutrition Project

Monitoring and Evaluation of the Bangladesh Integrated Nutrition Project

Effect of targeted food supplementation and services in the Bangladesh Integrated Nutrition Project on women and their pregnancy outcomes.

Monitoring data from the Bangladesh Integrated Nutrition Project and new data collected for this purpose were analyzed to assess the effects of targeted project services, including supplementation of food, on malnourished pregnant women (women with a body mass index [BMI] of < or = 18.5 in early pregnancy). Monitoring data on 456 women--195 receiving food supplement and 261 not receiving supplement--were collected from 17 upazilas (sub-districts) in four districts of Bangladesh. The assessment found that, despite lower economic status, the women with low BMI receiving supplementation of food and intensified services were more likely to have adequate pregnancy-related weight gain than the more economically-advantaged women with higher BMI. Primigravidae receiving supplementation were also more likely to have adequate pregnancy-related weight gain than the better-off non-supplemented primigravidae (85.7% vs 51.9%, p = 0.044). The mean birth-weights of infants of the supplemented women with low BMI were comparable to those of the better-off, non-supplemented women.

Empowerment in Rural Viet Nam: Exploring Changes in Mothers and Health Volunteers in the Context of an Integrated Nutrition Project

Empowerment is often cited as a fundamental component of health promotion strategies. Anecdotes suggest that Save the Children's integrated nutrition project empowers local women and health volunteers. The aim of this research was to document the degree to which this is being accomplished. Using qualitative methodologies, we conducted a cross-sectional assessment to compare self-reported changes in identified empowerment domains among 17 program health volunteers and 20 mothers involved in a child nutrition intervention and among five Women's Union leaders and five mothers in a non-intervention comparison commune. Intervention mothers reported increased knowledge, confidence, and information sharing about child-care and feeding, while non-intervention mothers reported minimal changes in these domains. Both intervention health volunteers and non-intervention Women's Union leaders expressed improvements in knowledge, confidence, and relationships with community members. In this study we found that the relative increases in empowerment were greater for mothers than for health volunteers. Intervention mothers reported more sharing of information on child care with neighbors. Health volunteers developed closer relationships with community members than Women's Union leaders. The increased information sharing has positive implications for spread of key messages to families that did not directly participate in intensive feeding and the sustainability of the intervention's impact. Future research should focus on developing culturally specific concepts of empowerment to better understand the effects of empowerment efforts. This study's identification of empowerment domains will inform future empowerment studies in Vietnam.

Empowerment in Rural Viet Nam: Exploring Changes in Mothers and Health Volunteers in the Context of an Integrated Nutrition Project

Empowerment is often cited as a fundamental component of health promotion strategies. Anecdotes suggest that Save the Children's integrated nutrition project empowers local women and health volunteers. The aim of this research was to document the degree to which this is being accomplished. Using qualitative methodologies, we conducted a cross-sectional assessment to compare self-reported changes in identified empowerment domains among 17 program health volunteers and 20 mothers involved in a child nutrition intervention and among five Women's Union leaders and five mothers in a non-intervention comparison commune. Intervention mothers reported increased knowledge, confidence, and information sharing about child-care and feeding, while non-intervention mothers reported minimal changes in these domains. Both intervention health volunteers and non-intervention Women's Union leaders expressed improvements in knowledge, confidence, and relationships with community members. In this study we found that the relative increases in empowerment were greater for mothers than for health volunteers. Intervention mothers reported more sharing of information on child relationships with community members than Women's Union leaders. The increased information sharing has positive implications for spread of key messages to families that did not directly participate in intensive feeding and the sustainability of the intervention's impact. Future research should focus on developing culturally specific concepts of empowerment to better understand the effects of empowerment efforts. This study's identification of empowerment domains will inform future empowerment studies in Vietnam.

Authors’ Response

Romaniello and her colleagues emphasize in their letter that nutrition intervention programs require 2 important features: they must be intensive enough to yield behavior change, and they must be designed so that teachers can readily use them to enhance their existing curricula. The Integrated Nutrition Project seems to be successful in meeting both of these objectives, and the use of the special-resource teacher makes this program unique and especially valuable.

Outcomes from a School-based Nutrition Education Program Using Resource Teachers and Cross-disciplinary Models

The Integrated Nutrition Project is an ongoing comprehensive elementary school-based program focused on increasing consumption of whole grains, fruits, and vegetables in children and establishing nutrition education in the schools through local partnerships. This paper reports on years three and four outcomes. It was hypothesized that blending Social Cognitive Theory with the educational philosophies of Piaget and Dewey would enhance behavior change. The primary intervention consisted of (1) 24 weekly hands-on activities taught by a resource teacher and (2) six parent-taught lunchroom “mini-lessons.” Classroom activities were designed to reinforce concepts in math, science, literacy, and social studies. The quasi-experimental design used classrooms in matched schools; 20 and 17 classes were in treatment and comparison conditions, respectively, in year four. Surveys, interviews, and lunchroom plate waste were used to assess children; teachers were interviewed. Students in treatment classrooms achieved significantly greater gains in knowledge and self-efficacy regarding food preparation and fruit and vegetable consumption and consumed 0.4 more National Cancer Institute equivalent servings of fruits and vegetables in the lunchroom. Teachers responded favorably to the resource teacher model and the hands-on approach. The project's outcomes were attributed to the intervention's theory-based behavior change focus and the use of a resource teacher who ensured consistent delivery of the intervention. Program implications include the need to explore variations of the resource teacher model and the potential for implementation on a larger scale.

Growth monitoring can and does work! An example from the Tamil Nadu Integrated Nutrition Project in rural south India.

Growth monitoring can and does work! An example from the Tamil Nadu Integrated Nutrition Project in rural south India.

Use of positive-negative deviant analyses to improve programme targeting and services: example from the TamilNadu Integrated Nutrition Project.

This paper describes the characteristics of southern rural Indian children who grow best (positive deviants) and worst (negative deviants) as compared to median growers. A 100 each of positive and negative deviants and 120 median growers were selected after analysing the 12-month growth patterns (weight-for-age) of 2954 children enrolled in the TamilNadu Integrated Nutrition Project (TINP), a major health and nutrition intervention project covering nearly one million children in rural south India. The determinants of poor growth that have been left unaddressed by 6 years of TINP exposure are delineated to address the question of what more needs to be done. Further, the rationale for differential targeting of services to negative deviants and to median growers is discussed, as are the implications for programme evaluation. Data indicate that the next generation of projects targeted at the most needy (negative deviants) should address the issues of gender discrimination in childcare, of breastfeeding, of diarrhoeal disease, and of maternal empowerment. Such interventions will, however, not improve the growth of median growers in the direction of positive deviance. Instead, programmes targeted at the median growers need to support the hygienic use of nonbreast milk supplements. Improving family wealth will also improve the nutritional status of the median growers, but less so than for the negative deviants.

The Bubble Chart: An Update on its Development

The bubble chart is a method of monthly growth monitoring by means of circles representing 100 gm units on the vertical axis and the childs age in months on the horizontal axis. The chart is a more accurate growth monitoring mechanism than the nutritional status index and is easier for health workers to use. It can also be used to measure the nutritional level of a community. The bubble chart was initially tested and used by the Indian governments Integrated Child Development Scheme in Gujarat and Maharashtra states where 80% of the health workers could plot weight gain accurately and mothers understood the implications of the chart. The bubble chart has been successfully used by the Tamil Nadu Integrated Nutrition Project in India by the National Institute Salvador Zubiran in Mexico (where tortillas are substituted for bubbles) and in Lesotho.