Supportive Evidence for Program Impact Pathways: Food-Assisted Maternal and Child Health and Nutrition Programs Can Produce Sustained Dietary Improvements

Following the end of a 15-y civil war in 2005, Burundi has experienced political instability, persistent poverty, and rapid population growth punctuated with some economic growth and peace. In 2014, Burundi had the worst Global Hunger Index score of any country in the world (1). In 2019, Burundi had the second highest prevalence of stunting of all countries assessed in the most recent Global Nutrition Report (2). Half of the 11 million population live in extreme poverty (3). Public health care expenditure is just 2.9% of the gross domestic product, and less than half of the national population have health care coverage (3).

For >60 y, the United States Agency for International Development (USAID) has operated the Food for Peace program to reduce hunger and malnutrition worldwide. Food-assisted maternal and child health and nutrition (FA-MCHN) programs are a principal strategy used by Food for Peace to reduce malnutrition through a combination of food rations, behavior change communication (BCC), and strengthening of health systems (4).

FA-MCHN programs require routine reporting of undernutrition indicators in endline reports. However, rigorous evaluation of programs that combine household and individual food rations with BCC and health interventions on food consumption patterns within households and maternal and child diets is limited. Identifying if and how dietary intermediates (e.g., energy intake, dietary diversity) are affected by multicomponent FA-MCHN programs provides essential evidence for understanding the impact pathway of programs—how FA-MCHN programs achieve, or fail to achieve, their goals for improving nutritional status and health outcomes. Many nutrition programs still fail to conduct evaluations using a program impact pathway approach that links program logic model frameworks to evaluation designs. Thus, the measurement of intermediate impacts such as food security, energy intake, and indicators of diversity provides critical information for future program planning and implementation.

In this issue of the Journal, Leroy et al. (5) evaluate the Tubaramure (“Let's help them grow” in Kirundi) program in rural Burundi that provided a combination of food rations (corn-soy blend and micronutrient-fortified vegetable oil), education on nutrition, hygiene, and health, and strengthening and promotion of health services. The Tubaramure program was a USAID Title II Development and Food Assistance Program designed to target the underlying causes of hunger and malnutrition, and operated from 2010 to 2014 (6). Using a cluster-randomized design, the program evaluation was administered over 3 intervention arms that provided the same 3 components, but differed in their timing: 1) pregnancy to 23.9 mo (1000 d); 2) pregnancy to 17.9 mo; and 3) birth to 23.9 mo. Households in the fourth control arm received only access to improved health services, and were not provided with any food rations or education. Using a repeated cross-sectional design, the evaluation conducted surveys with 4960 households in 2012, and 6946 households in 2014 across 60 geographically defined clusters (“collines”).

Whereas positive impacts of the Tubaramure have been previously reported on nutrition status outcomes of stunting and anemia (7), the impact on dietary intermediates has not yet been evaluated. The program accomplished a number of notable impacts: improvements in maternal and child dietary diversity, an increase in the proportion of food-secure households within clusters, and an increase in household energy and micronutrient consumption. The impact of some of these indicators persisted 6–8 mo after the completion of the program and after food rations were discontinued: household food security, maternal dietary diversity, and the complementary feeding practices of younger siblings were all improved over baseline values.

The chronic malnutrition and food security context of the program is critical to interpreting the impact of Tubaramure: >55% of children are stunted—the second highest of any country. In 2018, among the population of 11 million, 15.5% experienced crisis or emergency levels of food insecurity (8). The proportion of food-secure households in the intervention arms was 4.5 to 7.3 percentage points higher across intervention arms compared with the control group. These differences were sustained 6–8 mo after the program's completion. The program was not credited with significant impacts on household hunger. There were small and mixed results on children's dietary diversity. Moreover, the timing of the intervention according to the period of pregnancy or early childhood did not produce consistent results. This evaluation leaves unanswered questions about the optimal timing of combined nutrition education and supplemental feeding programs.

Large-scale approaches to reduce undernutrition among children in food-insecure settings are frequently challenged by the leakage of intended food rations such as ready-to-use food supplements and fortified blended flours—away from children to other household members (9). USAID's Preventing Malnutrition in Children under 2 approach addresses this reality by providing household rations alongside corn-soy blend and oil to pregnant and lactating women and children aged 6–23 mo. The evaluation of Tubaramure demonstrates the success of this strategy through documenting improvements in both maternal and child diets and child nutritional status. The authors applied a novel method to estimate the amount of household ration received by mothers and children using 3 probable allocation scenarios.

Evaluations from large-scale programs like Tubaramure provide meaningful evidence of how programs achieve impact. These results underscore not only the potential impact of Title II programs on reducing undernutrition and the importance of their sustained support, but also highlight the need to fund rigorous evaluations on intermediate dietary indicators and impacts after the conclusion of programs. This evaluation documents the particular benefit of including BCC into maternal and child nutrition and health programming. It was noteworthy that maternal and child diets were improved after program completion in spite of delays in the implementation of the complementary feeding education component. Moreover, the participation in the BCC sessions was lower than anticipated, even in spite of a relatively low-dose (2 sessions per month) education and demonstration intervention. Despite this relatively low dose of BCC exposure, program-attributable impacts on maternal and child diets were sustained 8 mo after program completion. Evidence of prolonged impacts is only possible through funding that appreciates the value of this type of postprogram dietary intake data for both households and individuals. This evaluation also underscores the need for up-to-date nutrient databases throughout low- and middle-income countries to conduct accurate dietary analysis research in regions of the world where evidence-based nutrition interventions are implemented.

Notes

The author reported no funding received for this study.

Author disclosures: The author reports no conflicts of interest.

Abbreviations used: BCC, behavior change communication; FA-MCHN, food-assisted maternal and child health and nutrition; USAID, United States Agency for International Development.