PROTOCOL: The effectiveness of community, financial, and technology platforms for delivering nutrition‐specific interventions in low‐ and middle‐income countries: A systematic review

About half of global under-5 child mortality, or about 3 million deaths, are linked to poor nutrition (UN Inter-agency Group for Child Mortality, 2017; UNICEF, 2018). The effects of compromised nutrition at an early age are evident throughout the life course, with physical and cognitive impairments affecting health, learning, and economic potential (Martins, Toledo Florêncio, & Grillo, 2011). Good nutrition is also important beyond the childhood years, with adolescent girls being especially vulnerable to undernutrition because of their higher nutritional requirements, particularly those who might become pregnant. Therefore, a focus on adolescent girls’ nutrition is important to ensure adequate prepregnancy nutrition for maternal, fetal, and infant health. Evidence suggests under-5 child mortality can be reduced by 15% with 90% coverage of 10 evidence-based nutrition interventions (Bhutta, Das, & Rizvi, 2013). However, despite evidence of efficacy generated from controlled settings, the potential impacts of what are considered “proven” nutrition interventions are often not realized in real-world environments due to ineffective delivery channels for achieving high and equitable coverage. A review by Ramakrishnan et al. (2014) noted that while prenatal protein-energy and iron folic acid supplementation have been shown to reduce low birth weight by 20–30% in trial settings, variable implementation has led to uncertain effectiveness. Menon et al. (2014) also acknowledge evidence supporting effective delivery platforms for nutrition-specific interventions remains limited. Of particular concern are gaps in how to successfully reach adolescents with evidence-based nutrition interventions in low- and middle-income countries (LMIC) (Bhutta, Lassi, & Bergeron, 2017; Salam, Hooda and Das, 2016). Our review considers delivery platforms that can improve coverage of nutrition-specific interventions at all stages of the life course from preconception to pregnancy, infancy, childhood, and adolescence. The review is part of a series of concurrent reviews to produce up-to-date evidence on preventive and curative nutrition interventions across the lifecycle. The review will consider platforms for interventions to address a variety of nutrition-specific conditions. We will examine the effects of using community, financial, and technology platforms for delivering evidence-based nutrition-specific interventions to improve nutrition behaviors and outcomes for women, children, and adolescents in LMICs. For the purpose of our review, a “platform” is defined as a modality through which a service is made available to target beneficiaries. In this review, we have chosen to limit our focus to community, financial, and technology-based platforms for providing direct nutrition interventions to populations in LMICs. These platforms are widely used globally and were reviewed previously (Bhutta et al., 2013). While acknowledging the existence of other health delivery platforms, we have limited our review to those that integrate a direct nutrition component for feasibility reasons. Community delivery platforms have shown potential for increasing coverage of evidence-based nutrition interventions and improving equity of service delivery (Bhutta et al., 2013). In LMICs, these platforms include community health workers (CHWs), peer groups (women and mothers), and community outreach events (e.g., Child Health Days [CHD]) that provide health and nutrition services at the community level. In many countries, extending the reach of the health system has involved training CHWs to deliver essential low-cost health and nutrition interventions such as counseling on prenatal nutrition and appropriate breastfeeding and complementary feeding practices, micronutrient supplementation, and child growth monitoring, with evidence indicating properly trained CHWs can improve key maternal, infant, and child nutrition practices (Bhutta, Lassi, Pariyo, & Huicho, 2009; Perry, Zulliger, & Rogers, 2014; Shakir, 2010). Community platforms are also important channels for reaching adolescent girls who are less likely to seek preventive care at health care facilities. CHD are a widely used community platform in Sub-Saharan Africa (SSA) and involve semiannual provision of an integrated package of child and family health and nutrition interventions such as micronutrient supplementation, immunization, deworming, and insecticide-treated bednets (UNICEF, 2017). CHDs have been particularly successful for increasing coverage of vitamin A supplementation for children <5 years in SSA (Oliphant, Mason, & Doherty, 2010). We will review the evidence for CHWs, CHDs, and similar events, as well as peer group models (and other community platforms identified in our search) as a means to increase coverage and impact of nutrition interventions targeted to women, children, and adolescents in LMICs. Nutrition-sensitive programs can improve the coverage and effectiveness of nutrition-specific interventions (Ruel, Alderman, Maternal, & Child Nutrition Study Group, 2013). Financial incentive platforms are increasingly being used in LMICs as part of poverty-reduction/social protection programs to reduce economic barriers to achieving better health and nutrition outcomes through enabling higher quality diets, increased access to health services, and improved living environments (de Groot, Palermo, Handa, Ragno, & Peterman, 2015). These mainly consist of cash payments or vouchers targeted to poor households, and commonly to mothers of young children. While evidence suggests the potential positive impact of conditional cash transfers, where cash is provided to beneficiaries upon compliance with health and/or nutrition-promoting services (e.g., child growth monitoring, nutrition education sessions), for improving coverage of child health interventions such as breastfeeding practices, the quality of available evidence is low and evidence gaps remain (Bassani et al., 2013; Bastagli, Hagen-Zanker, & Harman, 2016; Lagarde, Haines, & Palmer, 2009). We will review the evidence on the nutritional effects of financial incentive platforms (involving a nutrition-related conditionality) that are targeted to women and children in LMICs. The review will include technology platforms, given their increasing relevance for nutrition interventions in LMICs. Though there is broad clinical application for technology to improve health in these settings through telemedicine and other telehealth services for diagnosis and treatment, we focus on key technology platforms for nutrition promotion, including mass and social media and mobile health. The use of mobile phone technologies, such as SMS messaging, has shown to be effective for improving health-related behaviors through facilitating greater connectivity between providers and communities in remote areas (Barnett, Yosellina, & Sulistyo, 2016; Källander, Tibenderana, & Akpogheneta, 2013). Mass media involves dissemination of health information through traditional radio spots, print material, and television broadcasts. Social media utilizes internet-based applications such as websites, blogs, and so forth, to promote healthy practices and behaviors and has great potential for reaching adolescents. Given the growing penetration of mobile phones in low-resource settings and increased global connectivity via the Internet, these platforms are increasingly being leveraged for nutrition programming in LMICs (Tamrat & Kachnowski, 2012). We will review the evidence for these platforms as means to deliver interventions targeted to women, children, and adolescents in LMICs. Health and nutrition gains are contingent on how well interventions are targeted, implemented, and utilized in a particular context. To guide our review, we use Menon et al. (2014) Nutrition Implementation Framework (Figure 1) as our theory of change model. The framework considers core implementation domains affecting quality of service delivery, coverage, utilization, and impact with a view to scaling-up prioritized nutrition interventions. Though a range of nutrition-specific interventions can potentially be delivered through our included platforms, common interventions include counseling and education for women and mothers on good maternal nutrition and optimal infant and young child feeding practices through community outreach efforts such as home visits and peer group sessions, as well as media events and other community mobilization activities. Nutrition implementation framework [Color figure can be viewed at wileyonlinelibrary.com] Improving nutrition in LMICs requires investments in “proven” interventions, as well as knowledge of effective mechanisms for delivering high-impact interventions to those most in need as, without good coverage, even the most efficacious interventions will not achieve impact at scale. Though the merits of using specific platforms (e.g., CHWs, cash transfers) for health and nutrition are well-described in the literature and have been shown through efficacy studies, the effectiveness of nutrition interventions is likely to vary depending on the delivery platform. Our review aims to review and synthesize evidence on key delivery platforms that are effective for improving coverage, utilization, and or impact (nutrition benefit gained) from nutrition-specific interventions targeted to women, children, and adolescents in LMICs. In combination, coverage, utilization, and impact are considered “effective” coverage (Ng, Fullman, & Dieleman, 2014). Where possible, we will assess effective coverage, but will also examine components of effective coverage separately depending on data available. A key focus of the review will build on prior evidence suggesting CHWs are important agents to improving uptake of child nutrition interventions in hard-to reach populations. The 2013 Lancet nutrition series (Bhutta et al., 2013) concluded community delivery strategies that reach poor at-risk segments of the population have potential to increase population-level coverage of nutrition interventions through demand creation and household service delivery. Further, in a review of 82 studies, Lewin et al. (2010) showed positive effects of lay health workers for promoting the initiation of breastfeeding (risk ratio [RR], 1.36; 95% confidence interval [CI]: 1.14–1.61) and exclusive breastfeeding (RR, 2.78; 95% CI: 1.74–4·44), when compared with the standard of care. Our review will provide up-to-date evidence to help inform policy and programming for delivery of nutrition-specific interventions to promote health and well-being through improved nutrition behaviors and practices in LMICs, while also highlighting gaps in the existing evidence surrounding the effectiveness of community, financial, and technology platforms requiring further study. To assess the coverage of nutrition-specific interventions delivered using community, financial, and technology platforms To assess the utilization of nutrition-specific interventions delivered using community, financial, and technology platforms To assess the nutritional impact of nutrition-specific interventions delivered using community, financial, and technology platforms Randomized controlled trials (RCTs) where participants were randomly assigned, individually or in clusters, to intervention and comparison groups (includes cluster and stepped-wedge RCTs). Quasiexperimental studies in which nonrandom assignment to intervention and comparison groups was based on other known allocation rules, including a threshold on a continuous variable (regression discontinuity designs) or exogenous geographical variation in the treatment allocation (natural experiments) Controlled before-after studies in which allocation to intervention and control groups was not made by study investigators, but outcomes were measured in both intervention and control groups pre- and post-intervention and appropriate methods were used to control for selection bias and confounding such as statistical matching (e.g., propensity score matching, covariate matching) or regression adjustment (e.g., difference-in-differences, instrumental variables). Pre-post studies without a control group will not be included. Interrupted time series studies in which outcomes were measured in the intervention group at a minimum of three time points before and after the intervention. The target populations for this review are pregnant women, mothers of children <5 years, children <5 years, children 5–9 years, and female adolescents 10–19 years living in a LMIC as defined by the World Bank (see below). Studies including both eligible and noneligible participants will only be included if we can disaggregate relevant data. We will include experimental studies and program evaluations that report coverage, utilization, and/or impact of nutrition-specific interventions. Interventions to be examined in our review are based on evidence-informed recommendations to reduce poverty and knowledge barriers. Many of these interventions are behavioral, such as education and support to mothers to promote early and exclusive breastfeeding and appropriate complementary feeding practices, and can be delivered through multiple platforms. For example, interventions that include an education component could be delivered within the context of community-based nutrition promotion programs or through large mass media campaigns. However, each platform-intervention combination will be synthesized separately. Interventions will be compared against the standard of care in respective settings and we will exclude studies that do not have a control group. If a study includes multiple intervention arms, we will only include those meeting our eligibility criteria. Interventions to be included for each platform are presented in Table 2. The primary outcomes are coverage, utilization, and impact of nutrition interventions. Eligible outcome measures by platform are summarized in Table 2. All outcomes will be measured separately by target group and platform. For example, a breastfeeding promotion intervention may be provided to both adolescent mothers and women of reproductive age (WRA) using different platforms. Further, in the context of a breastfeeding promotion intervention, we are interested in studies that report the percentage of mothers reached with breastfeeding counseling, the uptake of improved breastfeeding practices, and if available, the effect of the improved practice on the child's nutritional status (e.g., infant growth as assessed by weight gain, height gain, Z scores for height-for-age (HAZ), weight-for-height (WHZ), weight-for-age (WAZ), stunting, wasting, underweight). Definitions for primary outcomes are presented below. Coverage: the proportion of a population that is eligible to benefit from an intervention that actually receives it. Outcome example 1: proportion of targeted mothers of children <5 years receiving at least one monthly home visit from a CHW. Outcome example 2: proportion of targeted women receiving at least 90 iron folic acid tablets during pregnancy. Utilization: the proportion of the eligible population that receives and adopts an intervention (i.e., uptake, intended change in behavior observed) Outcome example 1: proportion of targeted infants breastfed within one hour of birth. Outcome example 2: proportion of targeted children 6–23 months of age receiving minimum meal frequency. Impact: the health benefit/gain experienced by the target population as a result of the intervention; here we will focus on anthropometric and micronutrient status outcomes for all groups. Outcome example 1: proportion of targeted infants wasted (WHZ < −2SD) at 12 months of age. Outcome example 2: Average hemoglobin measurement in adolescent girls pre- and postintervention. Table 2 includes the primary outcome indicators to be measured by platform, intervention, and target population. There will be no restrictions based on duration of exposure or timing of outcome measurement. For studies that have varying time points for outcome measurement, we will include and report all time points, using the time point that is most similar across studies for data synthesis. We do not expect adverse outcomes given the nature of the nutrition-specific interventions delivered through community, financial, and technology platforms (e.g., education). We will not examine secondary outcomes in the review. There will be no restrictions regarding duration of follow-up. Included studies will have been conducted in a LMIC, as defined by the World Bank (2018), at the time of publication. Low-income economies are defined as those with a gross national income (GNI) per capita of USD 1,005 or less in 2016 and lower middle-income economies are countries with a GNI per capita between USD 1,006 and 3,955 in 2016. Local settings will comprise urban, rural, or mixed environments. Depending on the study context, an intervention may be delivered in a micro-level environment (e.g., community village education) or a macro-level environment (e.g., provincial cash transfer program). Our search strategy is guided by our PICO model Table 1 and will not be restricted by outcome. For indexed databases, the search will be conducted using medical subject headings and free text key words. The search strategy specific to each database is provided in Appendix 1. We will also review reference lists of included papers and relevant reviews for eligible studies. Studies published during 1997 to June 2018 will be included and studies published in languages other than English will be excluded due to resource limitations. Clinicaltrials.gov and WHO's ICRTP will be searched for ongoing trials. ClinicalTrials.gov Embase MEDLINE Scopus Web of Science WHO e-Library of Evidence for Nutrition Actions (eLENA) WHO Global Database on the Implementation of Nutrition Action (GINA) WHO International Clinical Trials Registry Platform WHO library database (WHOLIS) Our search will include studies outside the peer-reviewed literature (e.g., nonindexed program evaluations). 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