Malnutrition in all its forms has risen on global and national agendas in recent years because of the recognition of its magnitude and its consequences for a wide range of human, social, and economic outcomes. Although the WHO, national governments, and other organizations have endorsed targets and identified appropriate policies, programs, and interventions, a major challenge lies in implementing these with the scale and quality needed to achieve population impact. This paper presents an approach to implementation science in nutrition (ISN) that builds upon concepts developed in other policy domains and addresses critical gaps in linking knowledge to effective action. ISN is defined here as an interdisciplinary body of theory, knowledge, frameworks, tools, and approaches whose purpose is to strengthen implementation quality and impact. It includes a wide range of methods and approaches to identify and address implementation bottlenecks; means to identify, evaluate, and scale up implementation innovations; and strategies to enhance the utilization of existing knowledge, tools, and frameworks based on the evolving science of implementation. The ISN framework recognizes that quality implementation requires alignment across 5 domains: the intervention, policy, or innovation being implemented; the implementing organization(s); the enabling environment of policies and stakeholders; the individuals, households, and communities of interest; and the strategies and decision processes used at various stages of the implementation process. The success of aligning these domains through implementation research requires a culture of inquiry, evaluation, learning, and response among program implementers; an action-oriented mission among the research partners; continuity of funding for implementation research; and resolving inherent tensions between program implementation and research. The Society for Implementation Science in Nutrition is a recently established membership society to advance the science and practice of nutrition implementation at various scales and in varied contexts.
The positive deviance (PD) approach offers an alternative to needs-based approaches for development. The “traditional” application of the PD approach for childhood malnutrition involves studying children who grow well despite adversity, identifying uncommon, model practices among PD families, and designing an intervention to transfer these behaviors to the mothers of malnourished children. A common intervention for child malnutrition, the so-called “hearth,” brings mothers together to practice new feeding and caring behaviors under the encouragement of a village volunteer. Hearths probably work because they modify unmeasured behavioral determinants and unmonitored behaviors, which, in turn, result in better child growth. Some health outcomes require a better understanding of behavioral determinants and are not best served by hearth-like facilitated group skills-building. We propose testing “booster PD inquiries” during implementation to confirm behavioral determinants and efficiently focus interventions. We share early experience with the PD approach for HIV/AIDS and food security. The attributable benefit of the PD approach within a program has not been quantified, but we suspect that it is a catalyst that accelerates change through the processes of community attention getting, awareness raising, problem-solving, motivating for behavior change, advocacy, and actual adopting new behaviors. Program-learners should consider identifying and explicitly attempting to modify the determinants of critical behavior(s), even if the desired outcome is a change in health status that depends on multiple behaviors; measure and maintain program quality, especially at scale; and creatively expand and test additional roles for PD within a given program.
Background. Global interest in scaling up nutrition outcomes has focused attention on the need for more effective programs to improve infant and young child feeding (IYCF
Improved understanding of how to advance national nutrition policy is critical to ensure greater policy investments in nutrition. We used a participant-observer, change-agent model to prospectively study why and how national nutrition policy advanced in Vietnam between 2006 and 2008. Our goal was to understand strategies used, factors that shaped policy advancement, and the interaction of strategies with factors in this context. Data were collected using questionnaires, informant interviews, programme visits, document reviews and documentation of key events. For analysis, we created a chronology of events, examined strategies and actions used and their results by event, coded interviews and summarized findings using a well-known framework for policy analysis. Our analysis shows that the following elements were critical to bring greater attention to nutrition policy in this context: (1) building a cohesive nutrition policy community through creation and support of an alliance; (2) clearly defining internal and external frames for the nutrition problem; (3) using and creating high-profile internal and external policy windows; and (4) capitalizing on cultural motivations and values. Findings indicate that that rapid nutrition policy advancement is possible if purposeful, contextually sensitive strategies are used where favourable conditions exist, or can be created. The participant-observer, change-agent model was successful in both contributing to policy advancement and documenting it.
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