Rahul Rawat

It has recently been hypothesized that exposure to livestock constitutes a significant risk factor for diarrhea and environmental enteric disorder in young children, which may significantly contribute to undernutrition. To date, though, very little research has documented the extent of exposure to animal feces and whether this exposure is associated with child anthropometry in large samples and diverse settings. This study investigates these issues using data from the Alive and Thrive study conducted in rural areas of Ethiopia, Bangladesh, and Vietnam. These surveys used spot-checks to collect data on proxies of hygiene behaviors such as the cleanliness of mothers, young children, and the homestead environment, including the presence of animal feces. Animal feces were visible in 38–42% of household compounds across the three countries and were positively associated with household livestock ownership and negatively associated with maternal and child cleanliness. One-sided tests from multivariate least squares models for children 6–24 months of age indicate that the presence of animal feces is significantly and negatively associated with child height-for-age z scores in Ethiopia (β = −0.22), Bangladesh (β = −0.13), and in a pooled sample (β = −0.11), but not in Vietnam. There is also suggestive evidence that animal feces may be positively associated with diarrhea symptoms in Bangladesh. The results in this article, therefore, contribute to a growing body of evidence suggesting that animal ownership may pose a significant risk to child nutrition and health outcomes in developing countries.

Program effectiveness is influenced by the degree and quality of implementation, thus requiring careful examination of delivery processes and how the program is or is not being implemented as intended. Implementation fidelity is defined by adherence to intervention design, exposure or dose, quality of delivery, and participant responsiveness. As part of the process evaluation (PE) of Alive & Thrive in Ethiopia, a large-scale initiative to improve infant and young child feeding (IYCF), we assessed these four fidelity elements along three components of its community-based intervention: training of frontline workers (FLWs), delivery of program tools and messages, and supportive supervision. Data from a qualitative study among three levels of FLWs (n = 54), i.e. supervisors, health extension workers (HEWs), and community volunteers, and among mothers with children under two years of age (n = 60); and cross-sectional PE surveys with FLWs (n = 504) and mothers (n = 750) in two regions (Tigray and SNNPR) were analyzed to examine program fidelity. There was strong adherence to the intended cascading design (i.e. transfer of knowledge and information from higher to lower FLW levels) and high exposure to training (95% HEWs and 94% volunteers in Tigray, 68% and 81% respectively in SNNPR). Training quality, assessed by IYCF knowledge and self-reported capacity, was high and increased since baseline. Job aids were used regularly by most supervisors and HEWs, but only 54% of volunteers in Tigray and 39% in SNNPR received them. Quality of program message delivery was lower among volunteers, and aided recall of key messages among mothers was also low. Although FLW supervision exposure was high, content and frequency were irregular. There is evidence of strong fidelity in training and delivery of program tools and messages at higher FLW levels, but gaps in the reach of these to community volunteers and mothers and variability between regions could limit the potential for impact. Strengthening the linkages between HEWs and volunteers further can help to reach the target households and deliver IYCF results at scale.

Objectives: Little is known about how different delivery platforms can be used to reach at-risk populations with micronutrient-powders (MNPs). We conducted a process-evaluation of a market-based model where frontline-workers (FLW) sell MNPs at home visits, and provide IYCF-counseling. We sought to understand factors influencing sales of MNPs, household awareness, purchase, and use.

Background: Traditionally, impact evaluations have focused primarily on answering what impact programs or interventions have, with less attention to how or why impacts are achieved, or not achieved. The Alive & Thrive initiative, a 6-year program that aims to improve infant and young child feeding (IYCF) practices and reduce stunting in Bangladesh, Ethiopia, and Vietnam, has a specific objective to generate learning on how to achieve and replicate Alive & Thrive's impact. Objective: In Alive & Thrive, theory-driven process evaluation methods are the primary mechanism through which data are generated to address this objective. This paper focuses on the different methodological approaches that are being utilized, to answer the critical “how”; questions, and to generate information on the many processes and pathways to program impact. Methods: We identify four key principles in our methodological approach that guides all process evaluation activities: 1) developing detailed program impact pathway (PIP) models, 2) linking data collection to PIPs utilizing mixed methods and multiple data sources, 3) linking evaluation activities with program implementation timelines, and 4) engaging with the program implementation and management teams. Results: Beginning with the launch of the program, we outline the steps that have been taken in the design and implementation of the process evaluations of Alive & Thrive, and provide examples of how these steps have been operationalized in different country contexts. Conclusions: This theory-driven and country- and component-specific approach, centered on careful analysis of PIPs, is intended to generate information on implementation and utilization pathways of Alive & Thrive's interventions, thereby answering the questions of how impacts are achieved, or why not. This evaluation approach is not without challenges, and we highlight some of these key challenges.

The evidence evaluating the benefits of programmatic nutrition interventions to HIV-infected individuals in developing countries, where there is a large overlap between HIV prevalence and malnutrition, is limited. This study evaluates the impact of food assistance (FA) on change in weight and disease progression as measured by WHO staging.

The authors assessed whether livelihood interventions integrated with HIV and AIDS care and treatment programmes share a clearly elucidated causal pathway to impact, and examined their service delivery and utilisation plans to realise intended impacts on food security. They conducted multiple in-depth key informant interviews, along the livelihood programme chain, with staff from the AIDS Support Organisation and 16 collaborating partners implementing livelihood programmes in eastern and northern Uganda. They present their results using a programme theory framework, highlighting the quality of conceptualisation of programme impact pathways by programme staff, and identify key steps along the process pathway as they relate to successful delivery of interventions, programme participation, and uptake of services by beneficiaries. Key research questions include the following: Do programmes possess coherent, consistent and plausible objectives and approaches to attaining them? Are the impact and process theories clearly defined and logical? Through analysis of programme staff interviews, the authors highlight critical gaps in conceptualisation of causal pathways and programme processes that need to be addressed in order to maximise programme impact.

Objectives: The relationship between Fe status and HIV infection is complex and poorly understood. While anaemia is a major complication of HIV infection, higher Fe stores may be associated with disease progression. There is limited and conflicting data available from Africa.Design: Cross-sectional and prospective cohort study.Setting, subjects and methods: We examined the association between postpartum Fe status (Hb, serum ferritin (SF) and transferrin receptor (TfR)) and viral load (VL) and HIV-related mortality in 643 HIV-positive Zimbabwean women over a period of 12 months.Results: In non-anaemic women a log₁₀increase in SF was associated with a 2·3-fold increase in VL (P= 0·019); this association was absent in anaemic women. In prospective analyses, a log₁₀increase in SF was associated with a 4-fold increase in mortality by 12 months (P= 0·002). Hb was negatively associated with VL (P= 0·001) and mortality (P= 0·047). The adverse associations between SF and both VL and mortality were found at SF concentrations >45 μg/l (P< 0·05). Controlling for α₁acid glycoprotein, a marker of inflammation, attenuated the association between both SF and VL and mortality, but these remained significant.Conclusions: These results are consistent with the hypothesis that high Fe stores have adverse consequences in HIV infection. If adverse consequences are real, our data suggest that they occur at SF concentrations exceeding those consistent with adequate Fe nutriture.