implementation science and research in nutrition...
TRANSCRIPT
Purnima Menon, PhD Senior Research Fellow and Theme Leader for South Asia Nutrition Programs Kathmandu | May 17, 2017
Implementation science and research in nutrition scale up efforts
Acknowledgements
§ Research collaborators o Rahul Rawat, Marie Ruel, Phuong Nguyen, Sunny Kim, Rasmi Avula, Kuntal Saha
(Alive & Thrive , POSHAN) o Shams El Arifeen and Masum Billah (icddr,b) & Stuart Gillespie and Andrew Kennedy
for work on Transform Nutrition § Funding
o Bill & Melinda Gates Foundation for work on Alive & Thrive and POSHAN o DFID UK for work on Transform Nutrition
§ Other o David Pelletier and other members of the Society for Implementation Science in
Nutrition
Presentation objectives
§ Connect nutrition interventions to delivery platforms and define implementation research
§ Showcase examples of implementation research in nutrition § Reflect on challenges and opportunities in the context of addressing
wasting in South Asia
1. Definitions: Implementation research in nutrition
§ Interventions: Things we want to get out there o Iron-folic acid supplements o Zinc tablets with oral rehydration
salts o Information o Nutritional counseling o Food supplements o RUTF o Treatment protocols
§ Delivery platforms: Ways in which we can get things out there o Primary health center, well-child
check-up o Primary health center, antenatal
care o Community outreach program with
home visits by health workers o Mass media campaign o Facility-based platforms for
treatment
Defining terms
THE SITUATION IN SOUTH ASIA
Akseer et al., BMJ 2017
No standard coverage indicator related to screening or treatment for severe was3ng
0
10
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40
50
60
70
80
90
100
%
Sources: NFHS-4. RSoC data was used for indicators on pregnancy registration, food supplementation during pregnancy, lactating and for children, visits by health worker, pediatric IFA and deworming for children.
SUBNATIONAL ANALYSES SHOW FURTHER VARIABILITY (COVERAGE BY STATE IN INDIA)
Menon et al 2017
Data from coverage indicator related to screening/growth monitoring not available yet
Characteris3cs, Capaci3es and Dynamics
Nutritional
Status
Enabling Environment: Government, funders, civil
society, private sector
ImplemenDng organizaDons
Clients, households
and communiDes
Frontline workers,
supervisors and
managers
Nutrition Interventions
Nutrition Outcomes
But, why this gap?
The Black Box of
Implementation
Vitamin & Mineral Powder
Slide credit: D. PelleDer and the Society for ImplementaDon Science in NutriDon
Opening the Black Box of Implementation (Five Domains)
Nutritional Status
Adapted from Damschroeder et al., Implementation Science 4:50, 2009
1. Objects of Implementation
2. Implementing Organization(s) Frontline workers,
supervisors and managers
4. Individuals, households and communities
3. Enabling Environment: Government, funders, civil society, private
sector • Nutrition-specific
interventions
• Nutrition-sensitive interventions
• National multisectoral agendas
• NGO projects (usually sub-national)
• Implementation innovations
5.
Implementation Processes
Initiation, Planning&Design, Implementation,
Sustaining
Slide credit: D. PelleDer and the Society for ImplementaDon Science in NutriDon
Adapted from Damschroeder et al.,Implementation Science 4:50, 2009
Implementation Outcomes
Client
Outcomes
2. Implementing Organizations
Objects (adapted) • Core components • Peripheral components
3. Enabling Environment and Stakeholder Dynamics:
Perceived and Actual: source, evidence, advantage, adaptability, trialability, complexity, design quality and packaging, cost
5. Implementation Processes
Staff (frontline, supervisors and managers): • Knowledge, skills, beliefs, motivation
and incentives, workload, self-efficacy, stage of change, values, intellect, competence, learning style, openness, access to materials and resources, accountabilities
SISN’s Five Domains of Implementation: Black Boxes Within Black Boxes
Needs, resources, capacities, social, cultural, behavioral, economic, political factors
1. Objects of Implementation
Organizational Characteristics: • Leadership, commitment, readiness,
management, competing pressures and priorities, incentives, compatibility with mission, capacity and resources to adopt, adapt, implement, support, monitor and adjust, accountabilities
Government and donor policies, practices, resources & regulations, peer/ network influences, national, societal & cultural influences, accountabilities
4. Individuals, households and communities:
Intervention/ Innovation / Guideline/ Practice / Policy (unadapted) • Core
components • Peripheral
components
Initiating, Scoping & Engaging • assessing fit and readiness with
opinion leaders, formal leaders, champions, facilitators, partners
Planning • Theory of Change / PIP • Formative research • Design & adaptation • Implementation strategy Implementation, Iterative Improvements & Scaling Up • components, sequence, intensity • duration, quality improvement, • process evaluation, operations • research, special studies • decisions and adjustments Commitment, Support, Financing & Sustainability • continuous advocacy, networking,
engagement, strategizing, vigilance, reporting and documentation
AAA
Pathway to impact for nutriDon intervenDons
INPUTS (Domain 1) PROCESSES OUTCOMES IMPACTS
IntervenDon design &
implementaDon plans, training
content, training plans
Choice of food/MN
intervenDons, ProducDon/ procurement
(Domains 2,3) Upstream Processes
Management capaciDes Training processes, moDvaDons
ProducDon capaciDes
(Domains 2,3) Midstream Processes
Supervision & management processes
Supply chain for foods/MNS
(Domain 4) Downstream Processes
Frontline capaciDes, work loads
Local supply chain/stock
issues Local product promoDon
(Domain 5) Quality, scale
equity of service delivery, access to products and
food
Contextual factors at community and household levels affecDng demand, uDlizaDon, adherence and sustainability, including
individual capaciDes of user communiDes
(Domain 6) UDlizaDon/ demand of
services, foods and products
(Domain 7) IMPROVED NUTRITION BEHAVIORS
IMPROVED
NUTRITIONAL STATUS
(Dom
ains 5,6)
Coverage / Ad
herence
BCC Foods/M
Ns
ENABLING POLICY ENVIRONMENTS & GOVERNANCE
Strategies for demand creaDon ,
sensiDzaDon, advocacy,
sustainability
Contextual factors at naDonal and organizaDonal level affecDng implementaDon and sustainability, including
stakeholders
* Domains 1-‐7 are defined below. Menon et al. gAnnals of the NYAS, 2014
“Implementation research is the systematic approach to understanding and addressing barriers to effective and quality implementation of nutrition interventions, strategies and policies (typically in specific contexts)”
(WHO/TDR Implementation Research Toolkit, 2014)
Implementation Research (IR)
What do implementation research studies on look like?
§ Formative research studies § Process evaluations nested in impact evaluations § Experimental studies with operational end-points § Stand-alone operational assessments § Responsive rapid studies/analytics § Costing studies § Creative routine monitoring § Implementation-focused analyses of secondary data?
Scaling up : nine key elements
1) Clear vision and goal for impact
2) IntervenDon characterisDcs 3) Enabling operaDonal
context 4) Catalysts, champions,
ownership 5) Relevant pathways
6) OperaDonal and strategic capaciDes 7) Adequacy, stability and flexibility of funding 8) Enabling policy and governance system 9) Mechanisms for learning & accountability
Gillespie, Menon and Kennedy, Advances in Nutri/on, 2015
Scaling up is highly dependent on operational contexts and implementation research needs to help shed light on the intersection Intervention complexity with implementation context complexity Simpler interven3on Complex interven3on Simpler context
Vit A supplementaDon through campaign. DistribuDon of micronutrient powders to homes through NGO plahorm
Complex (mulD-‐component) behavioral change communicaDon intervenDon through community-‐based nutriDon-‐focused NGO program plahorm. Agricultural diversificaDon intervenDon through nutriDon-‐focused NGO program plahorm
Complex context
Vit A/iron-‐folate/calcium supplementaDon, nutriDon counseling through mulD-‐purpose, mulD-‐Dered government health system
Integrated complex behavioral change communicaDon, micronutrient supplementaDon and agricultural extension intervenDon through women’s self-‐help groups and links with government health systems. Integrated con3nuum of care (community to facility and back to community) for screening, iden3fica3on, referral, treatment and follow-‐up and management, of severe acute malnutri3on through mul3-‐purpose, mul3-‐3ered government system
Some challenges with implementation research
§ The best place to do this research is within and with programs being implemented.
§ Requires reconciling research objectives and values with program implementation objectives and values
§ Requires adequate funding for research on implementation and utilization of programs
§ Funding and publication bias can discourage relevant research.
§ Contextual factors are critically important, especially social, organizational and political contexts
2. Some examples of implementation research in nutrition
73.7
90.9
75.8 87.9
32.1
63.8
30.0
45.5
6.3 12.4
0
20
40
60
80
100
Baseline 2010 Endline 2014 % Achieving m
inim
um diet d
iversity
VN -‐ Intensive VN -‐ Non intensive BD -‐ Intensive BD -‐ Non intensive ET
Example 1. Results from behavior change intervention evaluations targeting infant feeding in Bangladesh, Ethiopia and Vietnam (children 6-23 months)
Bangladesh context: outreach program, household food diversity & resources
Vietnam context: facility-‐based program à lower reach to women with children >6 mo of age; high at baseline, low potenDal to benefit; economic constraints on food purchase were low
Ethiopia context: outreach program, low household food diversity and resources
18.9
57.8
17.8
28.4
48.5
87.6
51.2 53.5
72.4 82.8
0
20
40
60
80
100
Baseline 2010 Endline 2014
% Exclusiv
ely breashed
VN -‐ Intensive VN -‐ Non intensive BD -‐ Intensive BD -‐ Non intensive ET
Results from breastfeeding behavior change intervention evaluations in Bangladesh, Ethiopia and Vietnam (children 0-6 months)
Bangladesh context: outreach program, low levels of women in work force
Vietnam context: facility-‐based program, lower reach, high parDcipaDon of women in work force, formula markeDng rampant
Ethiopia context: outreach program, low parDcipaDon of women in workforce
45.1
24.3
11.3
5.8
13.5 No visit < 50% recommended visits 50 -‐ 74% recommended visits 75 -‐ 99% recommended visits ≥ 100% recommended visits
Utilization of nutrition counseling at health facilities in Vietnam was less than optimal despite availability and quality [demand side constraints]
0-‐5.9 months
6-‐23.9 months
(n=502) (n=506) Ever seen MTBT logo 91.2 96.8 Ever heard the name of MTBT
77.3 88.1
Ever seen an invitaDon card
49.4 63.2
Ever received an invitaDon card
39.0 50.3
Have been to MTBT 47.6 62.1 Number of Dme visited MTBT in the last 6 mos
1.7±1.4 1.3±0.1
Nguyen et al., 2015
Example 3: Multiple interventions, across the continuum of care, 2 major delivery platforms, (Odisha, India)
0 10 20 30 40 50 60 70 80 90 100
Pregnancy 0-‐6 months 6-‐24 months
Avula et al., 2015
INDIA NFHS-3 – had a question on weight measurements in the ICDS! Eighteen percent of children age 0-59 months in areas served by an anganwadi centre have had their weight measured in an AWC. Orissa is the only state where more than half of the children under age five were weighed in an anganwadi centre. There are 11 states where not even 10 percent of children in areas covered by an anganwadi centre were weighed in an AWC. With the exception of Bihar and Uttar Pradesh, all these states belong to the North and Northeastern regions. With 24 percent of children under age 5 being weighed, Himachal Pradesh is an exception in the northern region. Similarly, Meghalaya, Mizoram and Sikkim are exceptions in the northeastern region, as at least 23 percent children under age five are weighed in each of these three states.
Example 4: Integrating nutrition interventions in routine health systems in Bangladesh: sick child visits
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ObservaDon of service delivery
Weighed and recorded weight
Measured and recorded height
Clinically diagnosed for SAM
Demonstrate IYCF pracDce using visual job aids
Checked child's weight against a growth chart
Counselled on ensuring Vitamin A capsule
Give age specific advice on inclusion of salt in complemetary food Used BCC materials to raise awareness on nutriDon
Counselled mothers on food and care required for underweight children
NutriDonal assessment
NutriDon counseling
N=>500 sick child case management observaDons
Saha et al., 2015; Billah et al., BMC Public Health, forthcoming
§ Interventions o Challenges vary
tremendously by intervention type
o Even seemingly simple interventions have significant systems and capacity needs
o People must want the intervention (e.g., facility-based counseling is not usually demanded)
§ Delivery platforms o Reach and maturity of
the platform is critical o Ability to assure quality
and intensity differs by context, even for same type of platform
o Assuring intervention coverage even within “at-scale” delivery platforms require investments in monitoring, incentives and systems capacities
Reflections from implementation research I have been involved in
3. Approaching implementation research in the context of preventing and treating wasting
ISSUES TO CONSIDER IN IMPLEMENTATION RESEARCH ON WASTING PREVENTION AND TREATMENT
Con3nuum of preven3on and treatment for was3ng
PrevenDon IdenDficaDon Treatment PrevenDon of relapse
How to effecDvely deliver prevenDve acDons to address undernutriDon – at scale? What plahorms work best to reach children with prevenDve services?
What plahorms and approaches integrated into plahorms are most effecDve to support screening and iden/fica/on? What metrics (W/H vs. MUAC) are more feasible to integrate?
How to match treatment modaliDes to context? How best to integrate treatment with prevenDon? How to moDvate and support staff who deliver these programs?
How best can we set up supporDve systems to prevent relapse? What are the most feasible “graduaDon criteria”?
COSTING STUDIES!
Illustra/ve ques/ons
Closing thoughts § Tremendous opportunities and a great
need to invest in understanding how to support effective interventions both for prevention and treatment of malnutrition.
§ Implementation research, embedded in the systems of intervention delivery, can help identify ways to strengthen delivery
§ Key areas for wasting-focused implementation research are on integration with prevention, screening and identification, development and validation of coverage measurements, uptake and adherence, prevention of relapse, and more.
Photo: P. Menon, 2013, Uzar Pradesh
An implementation research framework and agenda (2014)
FURTHER READING ON LINKING WASTING AND STUNTING