Drivers of stunting reduction in Peru: a country case study

Drivers of success in global health outcomes: A content analysis of Exemplar studies

Applying a positive outlier lens is one effective approach for generating evidence to inform global health policy, program, and funding decisions. Exemplars in Global Health (EGH) is a program that studies positive outlier countries that have made extraordinary progress in health outcomes (despite limited resources) and disseminates their successes through multiple types of outputs. To date, EGH has studied, or is studying, 14 global health topics in 28 countries. This paper aims to identify findings, summarized as themes and sub-themes, that appear among all completed EGH studies. We developed a conceptual framework and used a content analysis approach to identify the top thematic areas that appear as drivers for programmatic success across EGH studies that were completed between June 2020-May 2023. The EGH studies (N = 31) spanned six topics including under-five child mortality (n = 6), childhood stunting (n = 5), community health workers (CHW) (n = 4), vaccine delivery (n = 3), COVID-19 response (n = 6), and newborn and maternal mortality reduction (n = 7) across 19 countries in sub-Saharan Africa, Latin America, South and Central Asia, and the Caribbean regions. Top drivers of success were defined as those critical or catalytic in achieving the intended outcome. Eight key drivers were identified: (1) efficient data collection and use for decision-making, (2) strong political commitment and health leadership, (3) effective stakeholder coordination, (4) a local, connected, and capacitated workforce, (5) intentional women's empowerment and engagement, (6) effective adoption and implementation of national policies, (7) effective and sustainable financing, and (8) equitable, efficient outreach and targeting. These cross-cutting drivers span a broad range of development outcomes, sectors, and populations, and indicate a need to effectively integrate people, systems, and sectors to improve global health outcomes. Findings from this study aim to support peer learning among countries and support evidence-based decision-making for funders, policymakers, and other key stakeholders.

Concurrence of anemia and stunting and associated factors among children aged 6 to 59 months in Peru

Anemia and stunting are two health problems in the child population; therefore, their concurrence needs to be quantified. We estimated the prevalence of concurrent anemia and stunting (CAS) in children aged 6-59 months and identified the factors associated with this condition. The data came from the Demographic and Health Survey of Peru (DHS), 2022. The study design was cross-sectional and included 19,191 children. Height and hemoglobin measurement followed the specifications of National Health Institute of Peru. To reduce error in measures, the anthropometry personnel was training, the quality of measuring equipment was ensuring, and protocolized techniques and procedures was applying. Hemoglobin concentration was measured in capillary blood using the Hemocue model Hb 201+. Stunting was defined as a height-for-age Z-score less than minus two standard deviations (SD) from the median, following the 2006 WHO child growth standard. Anemia was classified into mild (10.0 to 10.9 g/dL), moderate (7.0 to 9.9 g/dL), severe (< 7.0 g/dL), and no anemia (11.0 to 14.0 g/dL). We performed a bivariate analysis to evaluate factors associated with CAS. To include variables in the multivariate analysis, we applied a statistical criterion (p < 0.10 in the crude analysis) and an epidemiological criterion. We used a binary logistic hierarchical regression model. The prevalence of CAS was 5.6% (95%CI: 5.2 to 5.9). The modifiable factors associated with higher odds of CAS were: "poorest" (aOR: 3.87, 95%CI: 1.99 to 7.5) and "poorer" (aOR: 2.07, 95%CI: 1.08 to 3.98) wealth quintiles, mother with no formal education or primary (aOR: 2.03, 95%CI: 1.46 to 2. 81), father with no formal education or primary (aOR: 1.55, 95%CI: 1.16 to 2.07), no improved water source (aOR: 1.36, 95%CI: 1.10 to 1.68), no roof with improved material (aOR: 1.49, 95%CI: 1.12 to 1.98) and low birth weight (aOR: 7.31, 95%CI: 4.26 to 12.54). In Peru, five out of every 100 children suffer from anemia and stunting simultaneously; there are modifiable factors that, if addressed, could reduce their prevalence.

Stop stunting-A misguided campaign by well-meaning nutritionists

OBJECTIVE

"Stop stunting" is the central focus of the national Indonesian campaign to improve child health. We provide an autoethnographic statement on the currently practiced strategy that commits 23 ministries and an estimated $3.9 billion per year to coordinating nutrition interventions that are supposed to address the underlying causes of stunting.

METHODS

We visited six community health posts (posyandus) in West Timor and in Java and participated in routine child health examinations. We documented our impressions and discussed them with Indonesian colleagues, health officials, and local physicians.

RESULTS

Routine health checks for children include anthropometry (height, weight, head, and mid-upper arm circumference), immunizations, and documentation in the children's health records. The examinations do not include a physical examination, vision and hearing tests of the child, health questionnaires, or information on nutrition. No specific information or recommendations are given to the mothers.

CONCLUSION

Stunting is highly prevalent in Indonesia and "Stop-stunting" campaigns have become a national issue. Yet, their impact is disillusioning. Stunting is associated with a way of life that differs from that in developed Western countries today and was prevalent in feudal and other nondemocratic societies. We do not want to throw away policies that try to improve growth in children, but instead of spending money for dubious interventions as we have encountered in Indonesia, we rather suggest spending thoughts on the political and emotional causes of poor growth in otherwise healthy Indonesian children.

Decomposing the Intraurban Malnutrition Gap Between Poor and Non-poor Children in Colombia : Decomposing the Intraurban Malnutrition Gap Between Poor and Non-poor Children in Colombia

In Colombia, although it can be said that, on average children living in urban areas have better quality of life than their rural peers, it is also true that within cities, there are high levels of socioeconomic inequality. Our objective is to identify the contribution of the factors that explain the gap in stunting and excess weight between poor and non-poor children under 5 years of age in urban areas of Colombia. We use data from the 2015 National Nutritional Status Survey, and two nonlinear decomposition techniques based on the classical decomposition method developed by Blinder-Oaxaca. With a sample of 6877 observations, the results show that the intraurban gap of stunting between poor and non-poor children in urban areas is 4.8 percentage points. Its main determinants are the mother's educational level (46.5%), affiliation to the health system by the mother (19.4%), and assisted delivery in a medical institution (16.6%). For excess weight, the gap is - 2.1 percentage points, and its main determinants are the mother's educational level (39.2%) and birth attended by a physician (21.8%). This study suggests the coexistence of a double burden of malnutrition (DBM) in children under 5 years of age living in urban areas of Colombia. Stunting is associated with low-income levels while excess weight is associated with higher income levels. The identification of the main determinants of DBM and its relative importance, constitutes a contribution for public policy makers aimed at reducing socioeconomic gaps.

Geographic inequalities in health intervention coverage – mapping the composite coverage index in Peru using geospatial modelling

Background

The composite coverage index (CCI) provides an integrated perspective towards universal health coverage in the context of reproductive, maternal, newborn and child health. Given the sample design of most household surveys does not provide coverage estimates below the first administrative level, approaches for achieving more granular estimates are needed. We used a model-based geostatistical approach to estimate the CCI at multiple resolutions in Peru.

Methods

We generated estimates for the eight indicators on which the CCI is based for the departments, provinces, and areas of 5 × 5 km of Peru using data from two national household surveys carried out in 2018 and 2019 plus geospatial covariates. Bayesian geostatistical models were fit using the INLA-SPDE approach. We assessed model fit using cross-validation at the survey cluster level and by comparing modelled and direct survey estimates at the department-level.

Results

CCI coverage in the provinces along the coast was consistently higher than in the remainder of the country. Jungle areas in the north and east presented the lowest coverage levels and the largest gaps between and within provinces. The greatest inequalities were found, unsurprisingly, in the largest provinces where populations are scattered in jungle territory and are difficult to reach.

Conclusions

Our study highlighted provinces with high levels of inequality in CCI coverage indicating areas, mostly low-populated jungle areas, where more attention is needed. We also uncovered other areas, such as the border with Bolivia, where coverage is lower than the coastal provinces and should receive increased efforts. More generally, our results make the case for high-resolution estimates to unveil geographic inequities otherwise hidden by the usual levels of survey representativeness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14371-7.

Double burden of malnutrition as a risk factor for overweight and obesity

OBJECTIVE

To assess the longitudinal effect of double burden of malnutrition (DBM) on the risk of developing child and adolescent overweight or obesity.

METHODS

Analysis of the Peruvian Young Lives Study, younger cohort: baseline (2002) and 4 follow-ups (2006-2007, 2009-2010, 2013-2014, and 2016-2017). Outcomes were the incidence of overweight and obesity as defined by the World Health Organization standards. The exposure comprised a variable with 4 categories: non-stunted child with a non-overweight mother (reference group), non-stunted child with an overweight mother, stunted child with a non-overweight mother, and stunted child with an overweight mother (i.e., DBM). Poisson regression models were built to assess the association of interest, and relative risks (RR) and 95%CI were reported.

RESULTS

Data from 2,034 children; 50.0% were girls and the mean age was 12.0 (3.6) months at baseline. Non-stunted children with an overweight mother had greater risk (RR = 1.64; 95%CI: 1.35-1.99) of developing overweight, compared with the risk for stunted children with a non-overweight mother (RR = 1.38; 95%CI: 1.10-1.72), and for those with DBM (RR = 1.28; 95%CI: 1.02-1.61). When compared with the reference group, obesity risk was greater among non-stunted children with an overweight mother (RR = 2.33; 95%CI: 1.68-3.22), greater among stunted children with a non-overweight mother (RR = 2.59; 95%CI: 1.75-3.84), and greater among those with DBM (RR = 2.14; 95%CI: 1.39-3.28).

CONCLUSIONS

DBM is a risk factor for childhood overweight and obesity in Peru. Dual-duty policies tackling both undernutrition in children and overweight in mothers are needed to reduce DBM and its future effects in Peru.

Implementation Outcomes of National Convergence Action Policy to Accelerate Stunting Prevention and Reduction at the Local Level in Indonesia: A Qualitative Study

The study aims to explore the implementation outcome variables of Indonesia's national policy convergence action in the stunting reduction intervention at district, sub-district, and village levels. The study design was qualitative with an implementation research approach at District Cirebon, Indonesia. Data were collected through in-depth interviews, focus group discussions, study documents, and 6 months of participant observation. We recruited 172 respondents. The assessment instrument used was formed on was implementation outcomes variables. Data were analyzed through coding, categorizing and thematic content analysis based on a predetermined theme. Comparative cross district activity-site analysis was applied between sub-districts and villages. The implementation outcome variables for the convergence action policy were performed well at the district level, in line with the central government's adequate regulation, control, and budget. Meanwhile, the sub-district and village levels only performed aspects of acceptability, appropriateness, and coverage for specific interventions. The acceptability level in the village was only partially running. The barriers at the sub-district and village levels were issues of commitment, staff capacity, and poor coordination. Superficial understanding and capacity weaknesses drove the convergence of the stunting reduction responsibility back into the burden of the health sector at the forefront. Local politics also colored the implementation in the village.

Diet and food insecurity among mothers, infants, and young children in Peru before and during COVID‐19: A panel survey

The COVID‐19 pandemic may impact diet and nutrition through increased household food insecurity, lack of access to health services, and poorer quality diets. The primary aim of this study is to assess the impact of the pandemic on dietary outcomes of mothers and their infants and young children (IYC) in low‐income urban areas of Peru. We conducted a panel study, with one survey prepandemic (n = 244) and one survey 9 months after the onset of COVID‐19 (n = 254). We assessed breastfeeding and complementary feeding indicators and maternal dietary diversity in both surveys. During COVID‐19, we assessed household food insecurity experience and economic impacts of the pandemic on livelihoods; receipt of financial or food assistance, and uptake of health services. Almost all respondents (98.0%) reported adverse economic impacts due to the pandemic and 46.9% of households were at risk of moderate or severe household food insecurity. The proportion of households receiving government food assistance nearly doubled between the two surveys (36.5%–59.5%). Dietary indicators, however, did not worsen in mothers or IYC. Positive changes included an increase in exclusive breastfeeding <6 months (24.2%–39.0%, p < 0.008) and a decrease in sweet food consumption by IYC (33.1%–18.1%, p = 0.001) and mothers (34.0%–14.6%, p < 0.001). The prevalence of sugar‐sweetened beverage consumption remained high in both mothers (97%) and IYC (78%). In sum, we found dietary indicators had not significantly worsened 9 months into the COVID‐19 pandemic. However, several indicators remain suboptimal and should be targeted in future interventions.

Almost all respondents (98.0%) reported negative economic impacts on their households from the pandemic.

During the pandemic, almost half of households (46.9%) were at risk of moderate or severe household food insecurity.

During the pandemic, 66.9% of households received cash transfers, and 59.4% received food assistance from the government.

Nine months into the pandemic, positive changes included an increased prevalence of exclusive breastfeeding <6 months, a decreased proportion of mothers and infants and young children (IYC) consuming sweet foods, and stable dietary indicators for IYC and women.

Consumption of sugar‐sweetened beverages and unhealthy foods remained high across the two time periods for mothers and IYC and should be targeted in future interventions.

Association between maternal depression and emotion and behavior regulation in Peruvian children: a population-based study

Depression is more frequent in women, affecting the early stages of child development. This study aimed to determine the association between maternal depression and self-regulation of emotions and behaviors in Peruvian children under five years. A cross-sectional analytical study of data collected by the 2019 Demographic and Family Health Survey (ENDES) was conducted. The outcome variable was emotion and behavior regulation in children aged 24 to 59 months, and exposure was the presence of depression in women aged 15 to 49 years during the 14 days prior to the survey using the Patient Health Questionnaire (PHQ-9). A generalized linear model of the binomial family was used for reporting crude prevalence ratios and adjusted. The overall prevalence of children who did not self-regulate their emotions and behaviors was 68.8%, while 3.8% of the mothers had moderate depressive symptoms and 2.2% severe symptoms. Regarding the association of interest, moderate and severe depressive symptoms of mothers decreased the probability of children regulating emotions and behaviors in the first model, whereas in the second model, an association was only found with severe depressive symptoms. In conclusion, children of mothers with moderate and severe depressive symptoms had a lower probability of self-regulating their emotions and behaviors. Therefore, it is necessary to develop maternal education, nutritional and social support programs and mental health strategies from the first level of care aimed at reducing social, economic and child factors to reduce the risk of depression in mothers and low early childhood development, which could reduce the risk of developing mental health disorders in adolescence and adulthood.

Ethnic differences in adverse iron status in early pregnancy: a cross-sectional population-based study

We studied ethnic differences in terms of iron status during pregnancy between Dutch women and other ethnicities and explore to what extent these differences can be explained by environmental factors. This cross-sectional population-based study (2002-2006) was embedded in the Generation R study and included a total of 4737 pregnant women from seven ethnic groups (Dutch, Turkish, Moroccan, Cape Verdean, Surinamese-Hindustani, Surinamese-Creole and Antillean). Ethnicity was defined according to the Dutch classification of ethnic background. Ferritin, iron and transferrin were measured in early pregnancy. The overall prevalence of iron deficiency was 7 %, ranging from 4 % in both Dutch and Surinamese-Creoles, to 18 % in Turkish, Moroccan and Surinamese-Hindustani women. Iron overload was most prevalent in Surinamese-Creole (11 %) and Dutch (9 %) women. Socioeconomic factors accounted for 5-36 % of the differences. Income was the strongest socioeconomic factor in the Cape Verdean and Surinamese-Hindustani groups and parity for the Turkish and Moroccan groups. Lifestyle determinants accounted for 8-14 % of the differences. In all groups, the strongest lifestyle factor was folic acid use, being associated with higher iron status. In conclusion, in our population, both iron deficiency and iron overload were common in early pregnancy. Our data suggest that ethnic differences in terms of socioeconomic and lifestyle factors only partly drive the large ethnic differences in iron status. Our data support the development of more specific prevention programmes based on further exploration of socioeconomic inequities, modifiable risk and genetic factors in specific ethnic subgroups, as well as the need for individual screening of iron status before supplementation.

Reducing childhood stunting in India: Insights from four subnational success cases

Global success case analyses have identified factors supporting reductions in stunting across countries; less is known about successes at the subnational levels. We studied four states in India, assessing contributors to reductions in stunting between 2006 and 2016. Using public datasets, literature review, policy analyses and stakeholder interviews, we interpreted changes in the context of policies, programs and enabling environment. Primary contributors to stunting reduction were improvements in coverage of health and nutrition interventions (ranged between 11 to 23% among different states), household conditions (22–47%), and maternal factors (15–30%). Political and bureaucratic leadership engaged civil society and development partners facilitated change. Policy and program actions to address the multidimensional determinants of stunting reduction occur in sectors addressing poverty, food security, education, health services and nutrition programs. Therefore, for stunting reduction, focus should be on implementing multisectoral actions with equity, quality, and intensity with assured convergence on the same geographies and households.

Peru - Progress in health and sciences in 200 years of independence

Peru celebrates 200 years of independence in 2021. Over this period of independent life, and despite the turbulent socio-political scenarios, from internal armed conflict to economic crisis to political instability over the last 40 years, Peru has experienced major changes on its epidemiological and population health profile. Major advancements in maternal and child health as well as in communicable diseases have been achieved in recent decades, and today Peru faces an increasing burden of non-communicable diseases including mental health conditions. In terms of the configuration of the public health system, Peru has also strived to secure country-wide optimal health care, struggling in particular to improve primary health care and intercultural services. The science and technology infrastructure has also evolved, although the need for substantial investments remains if advancing science is to be a national priority. Climate change will also bring significant challenges to population health given Peru's geographical and microclimates diversity. Looking back over the 200-years of independence, we present a summary of key advances in selected health-related fields, thus serving as the basis for reflections on pending agendas and future challenges, in order to look forward to ensuring the future health and wellbeing of the Peruvian population.

Resumen translated abstract

El Perú cumple 200 años de independencia en 2021. Durante estos dos siglos de vida independiente, junto con periodos sociales y políticos turbulentos, incluyendo un conflicto armado interno, hiperinflación y la inestabilidad política de los últimos 40 años, el Perú ha experimentado importantes cambios en su perfil epidemiológico con repercusiones directas en la salud de la población. En las últimas décadas, los indicadores de salud materno-infantil y de las enfermedades transmisibles muestran mejoría importante, pero el país se enfrenta de manera simultánea a una carga cada vez mayor de enfermedades no transmisibles y de salud mental. En cuanto a los sistemas de salud pública, se han realizado esfuerzos por aumentar la cobertura y calidad de la atención de salud en todo el país, apostándose en particular por mejorar la atención primaria. La ciencia y tecnología relacionadas con la salud también han mejorado, aunque si se quiere que la ciencia sea una prioridad nacional, son necesarias inversiones sustanciales. El cambio climático traerá importantes desafíos para la salud de la población, dada la diversidad geográfica y de microclimas del país. Para conmemorar los 200 años de vida independiente del Perú, presentamos un resumen de avances clave en diversas áreas y temas relacionados con la salud. Este repaso sirve como base para reflexionar sobre agendas y desafíos pendientes y futuros, con el fin de asegurar la salud y el bienestar de la población peruana en las próximas décadas.

Maternal internal migration and child growth and nutritional health in Peru: an analysis of the demographic and health surveys from 1991 to 2017

BACKGROUND

Peru has historically experienced high rural-to-urban migration. Despite large reductions in undernutrition, overweight is increasing. Elsewhere, internal migration has been associated with differences in children's growth and nutritional health. We investigated how child growth and nutritional status in Peru varied over time and in association with maternal internal migration.

METHODS

Using data from Demographic & Health Surveys from 1991 to 2017, we assessed trends in child growth (height-for-age [HAZ], weight-for-age [WAZ], weight-for-height [WHZ] z scores) and nutritional health (stunting, underweight, overweight) by maternal adult internal migration (urban [UNM] or rural non-migrant [RNM], or urban-urban [UUM], rural-urban [RUM], rural-rural [RRM], or urban-rural migrant [URM]). Using 2017 data, we ran regression analyses, adjusting for confounders, to investigate associations of maternal migration with child outcomes and the maternal and child double burden of malnutrition. We further stratified by timing of migration, child timing of birth and, for urban residents, type of area of residence. Results are given as adjusted predictive margins (mean z score or %) and associated regression p-values [p].

RESULTS

In 1991-2017, child growth improved, and undernutrition decreased, but large differences by maternal migration persisted. In 2017, within urban areas, being the child of a migrant woman was associated with lower WHZ (UUM = 0.6/RUM = 0.5 vs UNM = 0.7; p = 0.009 and p < 0.001 respectively) and overweight prevalence ((RUM 7% vs UNM = 11% [p = 0.002]). Results however varied both by child timing of birth (birth after migration meant greater overweight prevalence) and type of area of residence (better linear growth in children of migrants [vs non-migrants] in capital/large cities and towns but not small cities). In rural areas, compared to RNM, children of URM had higher HAZ (- 1.0 vs - 1.2; p < 0.001) and WAZ (- 0.3 vs - 0.4; p = 0.001) and lower stunting (14% vs 21%; [p < 0.001]). There were no differences by timing of birth in rural children, nor by time since migration across all children. The mother and child double burden of malnutrition was higher in rural than urban areas but no differences were found by maternal internal migration.

CONCLUSIONS

Migration creates a unique profile of child nutritional health that is not explained by maternal ethnic and early life factors, but which varies depending on the pathway of migration, the child timing of birth in relation to migration and, for urban dwellers, the size of the place of destination. Interventions to improve child nutritional health should take into consideration maternal health and migration history.

National and subnational trends of birthweight in Peru: Pooled analysis of 2,927,761 births between 2012 and 2019 from the national birth registry

Background

National and subnational characterization of birthweight profiles lacks in low- and middle-income countries, yet these are needed for monitoring the progress of national and global nutritional targets. We aimed to describe birthweight indicators at the national and subnational levels in Peru (2012-2019), and by selected correlates.

Methods

We studied mean birthweight (g), low birthweight (<2,500 g) and small for gestational age (according to international growth curves) prevalences. We analysed the national birth registry and summarized the three birthweight indicators at the national, regional, and province level, also by geographic area (Coast, Highlands, and Amazon). With individual-level data from the mother, we described the birthweight indicators by age, educational level and healthcare provider. Following an ecological approach (province level), we described the birthweight indicators by human development index (HDI), altitude above sea level, proportion of the population living in poverty and proportion of rural population.

Findings

Mean birthweight was always the lowest in the Highlands (2,954 g in 2019) yet the highest in the Coast (3,516 g in 2019). The same was observed for low birthweight and small for gestational age. In regions with Coast and Highlands, the birthweight indicators worsen from the Coast to the Highlands; the largest absolute difference in mean birthweight between Coast and Highlands in the same region was 367 g. All birthweight indicators were the worst in mothers with none/initial education, while they improved with higher HDI.

Interpretation

This analysis suggests that interventions are needed at the province level, given the large differences observed between Coast and Highlands even in the same region.

Funding

Wellcome Trust (214185/Z/18/Z).

A framework for identifying and learning from countries that demonstrated exemplary performance in improving health outcomes and systems

This paper introduces a framework for conducting and disseminating mixed methods research on positive outlier countries that successfully improved their health outcomes and systems. We provide guidance on identifying exemplar countries, assembling multidisciplinary teams, collecting and synthesising pre-existing evidence, undertaking qualitative and quantitative analyses, and preparing dissemination products for various target audiences. Through a range of ongoing research studies, we illustrate application of each step of the framework while highlighting key considerations and lessons learnt. We hope uptake of this comprehensive framework by diverse stakeholders will increase the availability and utilisation of rigorous and comparable insights from global health success stories.

Understanding multifactorial drivers of child stunting reduction in Exemplar countries: a mixed-methods approach

BACKGROUND

Several countries have notably reduced childhood stunting relative to economic growth over the past 15-20 y. The Exemplars in Stunting Reduction project, or "Exemplars," studies success factors among these countries with a lens toward replicability.

OBJECTIVES

This paper details the standardized mixed-methods framework for studying determinants of childhood stunting reduction applied in Exemplars studies.

METHODS

An expert technical advisory group (TAG), criteria for identifying Exemplar countries, evidence-based frameworks, mixed methodologies (quantitative, qualitative, policy, literature review), effective research partnerships, case study process and timeline, and data triangulation and corroboration are presented.

RESULTS

Experts in health, nutrition, and evaluation methods were selected at the study outset to provide technical support to all phases of research (TAG). Exemplar countries were selected by the TAG, who considered quantitative data (e.g., annual rates of stunting change compared with economic growth, country population size) and qualitative insights (e.g., logistics of country work, political stability). Experienced country research partners were selected and an inception meeting with stakeholder consultations was held to launch research and garner support. Evidence-based conceptual frameworks underpinned all Exemplars research activities. A systematic review of published peer-reviewed and grey literature was undertaken, along with in-depth policy and program analysis of nutrition-specific and -sensitive investments. Both descriptive and advanced quantitative analysis was undertaken (e.g., equity analyses, difference-in-difference regression, Oaxaca-Blinder decomposition). Qualitative data collection using in-depth interviews and focus groups was conducted with national and community stakeholders (i.e., child care workers and mothers) to understand country experiences. The case study process was iterative, and all research outputs were triangulated to develop the stunting reduction narrative for each country. Findings were shared with country experts for weigh-in and corroboration through dissemination events.

CONCLUSIONS

Exemplars research uses a mixed-methods framework for studying positive outliers that can be applied across diverse health and development outcomes.

COVID-19 pandemic and mitigation strategies: implications for maternal and child health and nutrition

Coronavirus disease 2019 (COVID-19) continues to ravage health and economic metrics globally, including progress in maternal and child nutrition. Although there has been focus on rising rates of childhood wasting in the short term, maternal and child undernutrition rates are also likely to increase as a consequence of COVID-19 and its impacts on poverty, coverage of essential interventions, and access to appropriate nutritious foods. Key sectors at particular risk of collapse or reduced efficiency in the wake of COVID-19 include food systems, incomes, and social protection, health care services for women and children, and services and access to clean water and sanitation. This review highlights key areas of concern for maternal and child nutrition during and in the aftermath of COVID-19 while providing strategic guidance for countries in their efforts to reduce maternal and child undernutrition. Rooted in learnings from the exemplars in Global Health's Stunting Reduction Exemplars project, we provide a set of recommendations that span investments in sectors that have sustained direct and indirect impact on nutrition. These include interventions to strengthen the food-supply chain and reducing food insecurity to assist those at immediate risk of food shortages. Other strategies could include targeted social safety net programs, payment deferrals, or tax breaks as well as suitable cash-support programs for the most vulnerable. Targeting the most marginalized households in rural populations and urban slums could be achieved through deploying community health workers and supporting women and community members. Community-led sanitation programs could be key to ensuring healthy household environments and reducing undernutrition. Additionally, several COVID-19 response measures such as contact tracing and self-isolation could also be exploited for nutrition protection. Global health and improvements in undernutrition will require governments, donors, and development partners to restrategize and reprioritize investments for the COVID-19 era, and will necessitate data-driven decision making, political will and commitment, and international unity.