Columbia University Analysis for the Scaling Up Nutrition (SUN) Secretariat - PowerPoint Presentation

Columbia University Analysis for the Scaling Up Nutrition (SUN) Secretariat Simulating Potential of Nutrition Sensitive Investments Slide Deck to Accompany the Technical Report January 2014

The Lives Saved Tool ( LiST ) Visualizer Five outcome areas, intermediary to stunting, served as key starting point for our study Source: http://list.cherg.org/ FAMILY PLANNING MATERNAL NUTRITION Lancet, 2013

Health Environment and Water Social Protection Agriculture Maternal Nutrition [low birth weight and dietary patterns] Family Planning [Contraceptive use] Exclusive Breastfeeding [EBF for 0-6 months} Complementary Feeding [minimum acceptable diet] Selected outcomes delivered through nutrition sensitive channels for literature search. Used data available at the national level to model associations of outcomes with contextual factors. Used data available at the national level and in the literature review to model associations of interventions with outcomes. Strong or Weak Associations for decision making Nutrition Sensitive Sector Literature Review And Modeling Outcome Areas Predictors Diarrhea incidence [diarrhea rate] Education Theoretical Framework

Public Health Model: Theoretical Framework Public Health Maternal Nutrition [Low-birth weight] Strong or Weak Associations for decision making Nutrition Sensitive Sector Interventions/ Delivery Channels Outcome Areas Predictors Peer counseling Commercial packets Facility based education Maternal education Health professional training Supplement provision Community Health Workers School promotion Media campaign Iron/ Folic Acid Supplementation Multiple Micronutrient Supp Calcium Supplementation Balanced Energy Protein Supp Contextual Factors Done by LIST: GNI per capita Adult literacy rate Adolescent birth rate Female labor participation Sec. School Enrollment Maternity leave Family Planning [Contraceptive use] Exclusive Breastfeeding [EBF for 0-6 months} Complementary Feeding [minimum acceptable diet]

Environment Model: Theoretical Framework Environment and Water Strong or Weak Associations for decision making Nutrition Sensitive Sector Interventions/ Delivery Channels Outcome Areas Predictors Reduced diarrhea [diarrhea rate] Promotion of access to water and sanitation Safety of complementary foods Contextual Factors % Rural Population Adult Literacy Rates Vaccination Rates

Agriculture Model: Theoretical framework Agriculture Complementary feeding (minimum acceptable diet) Maternal nutrition [low birth weight; dietary patterns: % energy from non staples, calories per capita, micronutrient availability] Strong or Weak Associations for decision making Nutrition Sensitive Sector Agricultural Investments Outcome areas Predictors Inputs Ag biodiversity Fertilizer Land available for agriculture Water available for agriculture Mechanization Rural Infrastructure Irrigation Crop storage facilities Road infrastructure Port infrastructure Mobile networkInstitutions and governanceAccess to finance Policy and legal frameworkAccountability and transparancyAllocation of pub resourcesMarkets Ag imports and exportsAg import tarifsResearchAg R&D Contextual factors Economic setting and agricultural role in society GNI per capita GINI index % rural population% Ag value added% Ag employment Health settingLife expectancy # physicians per 1000GenderGirls/boys ratio in secondary school EducationLiteracy

We investigate the estimated effect of interventions in these two sectors on the following key outcomes: exclusive breastfeeding, complementary feeding, maternal diet and family planning (public health sector), and promotion of access to improved water and sanitation (environment and water sector). Contextual models we used country level data from The State of World Children (SOWC) 2013 report, and most recent data available from International Labor Organization, World Bank or other sources . The available data ranges from period 2006-2010 for adolescent birth rate to year 2011 for vaccination data.   we ran cross country multiple regression analysis with 1000 simulations to investigate the predictors of the outcome measures. We estimated the 95% confidence interval Intervention models: Interventions in these two sectors were assessed via meta-analysis, as following: we conducted an extensive literature review on intervention impacts on the following outcome measures: exclusive breastfeeding, minimum acceptable diet, contraceptive use, percent of low births and diarrhea rate. we selected relevant studies and formatted the results as needed for meta regressions we estimated the pooled relative risks (RR) and their respective confidence intervals (CI) using a restricted maximum likelihood estimator (REML) on a random effect model. The pooled estimates were calculated using the natural logarithms of the RRs and their standard errors from the individual studies. w e explored sources of heterogeneity using sub-group analysis. The sub-groups (moderators) were identified based on participant or study characteristics. For moderators that were not systematically available at the study level, we used country level data that was matched to the country of the study. Significant moderator were identified using contextual models – described below. Public Health and Environment: Methodology

Agriculture model: Methodology We focused on two intermediary outcome areas for the agriculture model including: maternal nutrition and complementary feeding. For both outcome areas, we developed a national-level contextual model that allows us to identify associations rather than causal relationships between agricultural and nutrition variables. Quantitative model: National level data from seven publicly available databases were collated and organized to populate the model integrating agriculture (FAO, IFAD, EIU), socio-economic (World Bank), human nutrition and health (WHO NILS, WHO IYCF) data using the country as the unitwe first identified model indicators for maternal nutrition and complementary feeding that are significantly related to stunting, while controlling for income levelStarting from these results we fit the agricultural factors into multivariate regressions against each of these indicators while taking into account a set of contextual factors Additional literature review:Starting from the results of the quantitative model, we revisited the literature to identify specific programs/ interventions and delivery channels that contribute to the implementation of the agricultural investments that were identified as significantly related to nutrition specific indicators.

Exclusive Breastfeeding [EBF for 0-6 months} Complementary Feeding [ M inimum acceptable diet] Family Planning [Contraceptive use] Maternal Nutrition[Low-birth weight] GNI per capita 0.01*** [ 0.0001, 1.84] 8.60***[0.022,3295] Adolescent birth rate - 0.10 [ -0.21,0.03 ] 0.28 ** * [ 0.07,0.71] F emale to male labor participation * maternity leave -6.13** [-10.79,-1.60] Female to male labor participation -64.31*** [-95.5,-35.0] Adult literacy: females as a % of males 0.24* [ 0.004, 0.48] Ethnicity African -17.90* [ -32.16, -3.39] Asian -14.41* [ -28.89, 1.09] Asian 19.10 *, [ 0.64, 37.66] Mixed 24.59 * [ 4.98, 44.50] % urban -0.56 * * [ -0.90,- 0.19] -0.18 * [ 0.02,0.33] Secondary school enrollment female/male ratio 0.47** * [ 0.26,0.69] Latino/Hispanic 12.46* ,95% CI [1.48, 23.75 ] Access to improved rural sanitation 0.21* * [ 0.09,0.34] Public Health M odel: Results Contextual model

Exclusive Breastfeeding [EBF for 0-6 months} Peer counseling Contextual factors influencing the intervention effect RR 2.46*** Public Health M odel: Results Intervention model EBF Non provision of commercial packets RR 1.55*** Facility based education RR 1.33*** Duration of BF Adult literacy rate % rural population Female labor participation Maternity leave Adolescent birth rate For interpretation: Relative Risk (RR) = 1 indicates that the outcome in intervention and control groups are equally likely to occur; RR<1 outcome in intervention is less likely to occur compared with control; RR>1 outcome in intervention is more likely to occur compared with RR>control. E.g. RR 0.6 is usually interpreted in the following way ( exp for RR=0.6). (1-0.6)*100=40%, the outcome in intervention is 40% less likely to occur. If RR is 1.5, the outcome is 1.5 times more likely to occur in the intervention compared with control (or 50% increased risk.

Results of meta-regressions for the effect of peer counseling on exclusive breastfeeding in randomized controlled trials and quasi-experimental studies

Results of meta-regressions for the effect of facility based education on exclusive breastfeeding in randomized controlled trials and quasi-experimental studies

Public Health Model: ResultsIntervention model Family planning Family Planning [Contraceptive use] School promotion, media campaign, community-based education RR 1.15*

Environment model: Results Contextual model Diarrhea treatment [% treatment with ORS ] Adult literacy rate: females as % of males Vaccination rate 0.31* [ 0.07, 0.56] 0.34* [0.03, 0.68]

Environment Model: Results Intervention model Diarrhea incidence [Diarrhea rate ] Hand washing RR 0.76*** Water treatment Contextual factors controlled for Adult literacy % rural population Vaccination rate GNI per capita RR 0.71**

Agriculture Model Identification of model indicators for nutrition-related intermediary outcomes Stunting Dietary patterns (proxy for maternal nutrition) % Energy from non staples in supply (-4.75***) Calories per capita (-6.86***) Fe availability from animal-products (-4.15*) Low-birth weight (proxy for maternal nutrition) % Low-birth weight(2.82***) Complementary feeding % Minimum acceptable diet (-6.51***) CONTEXT - SPECIFICITY Log GNI per capita Adj R 2 0.84 Adj R 2 0.73 Adj R 2 0.32 Adj R 2 0.43% energy from non staples in national food supply significantly related to % low birth weight (-1.91**) Adj R 2 0.63 Fe availability from animal based products significantly related to % minimum acceptable diet (9.93*)

Agriculture Model Agricultural investments related to dietary patterns Dietary patterns (proxy for maternal nutrition) % Energy from non staples in supply Calories per capita Fe availability from animal-products Contextual factors influencing outcomes 6.88*** to -1.81 dependent on income level % Energy from non staples in production -0.39 *** Access to finance for farmers 0.14** # tractors per land unit -0.34 ** Road infrastructure Exports as % of GDP Log GNI per capita Fertilizer use per land unit 0.48** % land for agriculture 0.15** Ag R&D as % of GDP Ag import tariffs 0.47** -0.48 **

Agriculture Model Supply diversity as a function of production diversity The relationship between food supply diversity and food production diversity depends on the income level of a country . For low-income countries the diversity of agricultural goods produced by a country is a strong predictor for food supply diversity; for middle- and high-income countries national income and trade are better predictors.

Agriculture Model Agricultural investments related to complementary feeding Complementary feeding % Minimum acceptable diet Fe availability from animal-products Contextual factors influencing outcomes 9.02* % Energy from non staples in production -4.85* Exports as % of GDP Log GNI per capita % land for agriculture 9.93* Ag R&D as % of GDP Ag import tariffs 0.47** -0.48 **

Summary Table of Model Results Intervention Outcome Impact Peer counselling EBF The likelihood of EBF is 2.46 higher for mothers who received peer counseling than for mothers who weren’t counseled (95% CI: 1.99 to 3.04, p<0.001). Facility based promotion EBFThe likelihood of EBF is 1.55 times higher for mothers receiving the facility based intervention than for mothers who didn’t (95% CI: 1.31 to 1.84, p<0.001). Commercial packets of infant formula EBFThe likelihood of EBF for mothers who were not given commercial packets is 1.34 higher than for mothers who received the packets (95% CI: 1.12 to 1.59, p=0.0011). Combined health interventions (minus mass media campaigns which was assessed qualitatively) EBF The results show that the likelihood of exclusive breastfeeding for mothers that received the public health interventions is 2.02 higher than mothers who did not (95% CI: 1.74 to 2.34, p<0.001)

Summary Table of Model Results Intervention Outcome Impact Family Planning Promotion Contraceptive Use Contraceptive use for participants who were exposed to school promotions, media campaigns and community based education is 1.16 higher than for the control groups (95% CI: 1.01 to 1.35, p<0.0425). Hand washing Diarrhea ratesThe likelihood of diarrhea for those who were exposed to hand washing interventions is 24% less likely than for those in the control group (RR= 0.76% CI: 0.62 to 0.93, p=0.0074)Water treatment Diarrhea ratesThe likelihood of diarrhea those who were exposed to water treatment intervention is 29% less likely than for those in control group (RR= 0.7073% CI: 0.56 to 0.90, p=0.0043).

Summary Table of Model Results Investment Examples s pecific interventions Outcome Association Agricultural diversification Promotion of animal-based products, homegardens, irrigation, legume intercropping, agro-forestryDietary patternsComplementary feeding Increased food supply diversity in low-income countriesPotential trade-off with calories available per capita Increased % of children meeting minimum acceptable dietAgricultural intensificationIncreased fertilizer use per land unit (e.g. subsidy program)Increased number of tractors per land unitDietary patternsIncreased amount of calories available per capita Potential trade-off with food supply diversityAgricultural extensification Increased % land for agriculture Dietary patterns Complementary feeding Increased amount of calories available per capita Potential trade-off with % children meeting minimum acceptable diet Rural development Increased access to finance for farmers (e.g. microcredits)Road infrastructureDietary patternsIncreased food supply diversityTrade policies/ strategies Ag import tariffsExport cropsDietary patternsPotential trade-off with food supply diversity and micronutrient availability Ag R&D e.g. biofortification, livestock health programs Dietary patternsComplementary feeding Increased micronutrient availability

Implications With limited evidence, the evidence at hand suggests that public health, environment and agriculture investments could support nutrition specific interventions that address undernutrition.A country’s contextual factors (relating to income, social, education and governance) are important to consider in their impact on nutrition outcomes with nutrition sensitive approaches.Examining agriculture through large scale investments, rather than nutrition interventions, can provide insight for MoA on impact for nutrition, indirectly. Alternative delivery channels for public health and environment, through marketing, commercialization, food safety, and social protection, are less clear in their evidence of impact. Evidence published in the literature remains scant and varied for nutrition sensitive interventions, and more implementation science should be published.Using a quantitative statistical simulation model can only go so far as with the current literature and data. This has resulted in some interesting insights but unfortunately it is not a tool that is user friendly for countries looking to scale up nutrition. Costing tools and perhaps game tools could provide an entry point for decision making in which this quantitative modeling could be used as a first step resource. Implications

Maternal Nutrition Complementary feeding Diarrhea incidence Family planning Exclusive breastfeeding PUBLIC HEALTH Peer counseling Facility-based education Non provision of commercial packages Maternal counseling Health worker training School promotionMedia campaignsCommunity-based education AGRICULTURE Agriculture diversification Animal products Homegardens Legumes Agroforestry Small scale irrigation Access to Finance Fertilizer use Agriculture research and development Biofortification Rural infrastructure Women empowerment ENVIRONMENT AND WATER Water treatment, Handwashing Food safety measures SOCIAL PROTECTION Conditional cash transfers CONTEXT- SPECIFICITY Income, Education, Urbanization, Geographic Location, Employment Policy, Schematic Summary of Findings ( LiST results)