Photo credit: Kimberly Flowers/USAID

The U.S. Agency for International Development (USAID) Multi-Sectoral Nutrition Strategy sets an ambitious goal for the next decade (2014–2025) to improve nutrition in order to save lives, build resilience, increase economic productivity, and advance development. To reach the goal and vision, USAID will help reduce the number of stunted children by a minimum of 2 million, reflecting a 20 percent reduction over 5 years; reach 10s of millions of nutritionally vulnerable people with nutrition information and services; mitigate increases in acute malnutrition during humanitarian crisis, with the goal of maintaining global acute malnutrition rates below 15 percent; and track nutrition contributions to maternal and under-5 mortality reductions in programs aiming to end preventable child and maternal deaths (EPCMD).¹ In order to achieve these targets, USAID missions and our partners will leverage every opportunity to increase the nutrition impacts of their development and humanitarian programs, using multiple delivery platforms (see box) to support nutrition activities. The wide array of platforms reflects a greater commitment to program both nutrition-specific and nutrition-sensitive activities to lead to improved nutrition outcomes.² The new USAID Multi-Sectoral Nutrition Conceptual Framework in the Strategy provides a visual depiction of how the Agency plans to reach improved outcomes using integrated approaches.

What Is Intensive Nutrition Programming?

Intensive Nutrition Programming (INP) packages are proven and promising interventions and approaches. They are informed and driven by data – incorporating formative research, regular monitoring, and impact evaluation – to address context-specific determinants of behavior and social norms and barriers to effective health systems. In addition to nutrition-specific components, INP includes nutrition-sensitive activities to address the multi-sectoral nature of undernutrition. Finally, intensive nutrition programming includes activities that support government plans and policies at the national (e.g., Scaling Up Nutrition Efforts, National Integrated Nutrition Plans, etc.), regional and sub-regional levels, while leveraging existing opportunities to achieve maximum coverage including investments by host government, other U.S. Government, U.N., and other donors' investments, and civil society. This will be achieved with the aim of achieving impact at scale, utilizing a systems approach.

INP consists of the following key elements:

• Regular, quality contact for nutrition-specific services with mothers/direct caregivers and their families
• Social and behavior change communication (SBCC) messaging reinforced by community mobilization and mass media
• Nutrition-sensitive health, agriculture, water, sanitation and hygiene (WASH)
• Improve quality and expand data collection and use

1) Regular, quality contact with mothers/direct caregivers and their families is necessary in order to ensure use of quality health services and optimal maternal, infant and young child nutrition practices during critical periods, especially the first 1,000 days from pregnancy to a child's 2^nd birthday. Evidence suggests that simply increasing knowledge and awareness of good nutrition practices, especially via “one-off’ activities, rarely leads to sustained behavior change. To influence feeding practices and care decision-making, service providers at the community and facility levels must foster dialogue with mothers, other caregivers, and their influencers in order to address barriers to optimal maternal, infant and young child nutrition practices, as well as WASH, family planning, and other healthy practices. Frequent, effective interpersonal communication with mothers, caregivers, and other family members is necessary to understand and address underlying determinants of and barriers to change and to identify positive practices to reinforce. For example, an increasing number of USAID partners are implementing the Care Group Model, a peer educator model focused on the 1,000 days, which emphasizes fortnightly individual home visits by intensively trained lead mothers. In successful Alive and Thrive activities in Bangladesh, health workers conduct monthly home visits and counseling sessions with mothers and other caregivers during pregnancy and until the child is 9 months old and make quarterly visits thereafter. In addition to exclusive breastfeeding and adequate complementary feeding, routine care should include other nutrition-specific services: micronutrient supplementation and fortification according to international standards, prenatal and postnatal nutritional care, appropriate care and feeding of sick children, assessment of growth and development, and management of acute malnutrition.

2) Social and behavior change communication reinforced by community mobilization and mass media will further lead to individual change while addressing broader social norms. Evidence suggests that using multiple SBCC approaches and channels to influence behaviors is more effective than using one single approach. In addition to quality interpersonal interaction described above, two other core SBCC components to behavior change communication, namely community mobilization and media, target whole communities including caregivers, family members, community leaders and change agents, in order to reinforce consistent messaging and promote optimal maternal, infant and young child nutrition, and other nutrition-specific and nutrition-sensitive practices. Social mobilization activities should be frequent and targeted, involving community members in monitoring, including data collection, which will increase accountability, sustainability and ownership. Messaging can be delivered in a variety of ways, such as through informal means (e.g., community theater and songs), videos, posters and leaflets, targeted mass media (e.g., community radio), mass media (e.g., television and social media), and short messaging service. All forms of media and community and social mobilization should be thoroughly tested and use harmonized messaging in order to complement efforts of host government and other actors.

3) Nutrition sensitive agriculture, health, and WASH increase the impact and improve cost-effectiveness by better integrating nutrition efforts across multiple sectors. Agriculture interventions may become nutrition-sensitive through many different pathways across food systems, leading to a more direct impact on nutritional status. Most prominent are investments that target poorer households, increase nutrient-dense food production for consumption, and increase women’s empowerment, especially through control of assets, income and time use, and reduction in women’s energy expenditure. Promotion of dietary diversity is an important contribution of agriculture to improve the nutrient quality of food available to rural and urban consumers.

Nutrition-sensitive health includes several sectors such as family planning and WASH. Under family planning, healthy timing and spacing of pregnancy, and promotion of the lactational amenorrhea method are critical to achieving nutrition objectives. WASH includes safe water supply, sanitation, food safety, personal and environmental hygiene, access to essential WASH commodities and multiple water use systems. Other sectors, such as early childhood development and social protection, should also be included, where appropriate.

4) Improved quality and expanded collection and use of data. USAID’s nutrition programs will expand the availability of high-quality, timely data at the output and outcome levels for monitoring and evaluating the quality and coverage of interventions. Data-driven programming implies strategic use of data throughout the program cycle and at the various levels of decision-making allowing for programmatic adjustments in response to data. Missions and their implementing partners will collect, use and report appropriate process and output measures, as described in mission and performance monitoring plans. This includes:

• Strategic development and management of an effective monitoring and evaluation plan, e.g., inclusion of indicators to measure coverage of interventions and quality of visits
• Identification and collection of high-priority output indicators, e.g., use of registers for community health and nutrition workers, service delivery forms at facility level
• Determination of desired outcomes and identification and collection of clear outcome indicators³
• Ensuring inclusion of performance indicators that are both useful and applicable for project management
• Continued monitoring of high-level indicators⁴ generally collected through the Demographic and Health Surveys or other large-scale population-based surveys
• Regular data collection to track nutrition contacts and progress in changes in behavior during critical times in the life cycle, e.g., at critical times during pregnancy and the child's life from 0–6 months, 6–12 months and 13–24 months; strategic use of data will allow for programmatic shifts, as needed.

The USAID Multi-Sectoral Nutrition Strategy 2014–2025 lays out a vision to reduce chronic malnutrition by focusing on high impact actions, setting and monitoring nutrition targets and managing nutrition funds and programs in a rigorous manner. The Strategy’s multi-sectoral approach incorporates both nutrition specific and nutrition sensitive interventions. This guidance is intended to highlight some essential elements of effective nutrition programming that Missions and their partners must include in order to reach USAID’s targets. These actions are fully described in the Strategy and summarized in this Intensive Nutrition Programming brief.

References and Resources

• Evidence of Effective Approaches to Social and Behavior Change Communication for Preventing and Reducing Stunting and Anemia: Findings from a Systematic Literature Review (SPRING – August, 2014) [PDF, 1.4MB]
• Alive & Thrive Program Brief: Strategic Use of Data as a Component of a Comprehensive Program to Achieve IYCF at Scale (Alive & Thrive – Nov. 2014)
• Examples of Performance Checklists, Registers and Other Data Forms from Alive & Thrive Implementation Manual for BRAC's Community-based Alive & Thrive Infant and Young Child Feeding Program in Bangladesh (Alive & Thrive Bangladesh – updated Nov. 2013)

This technical brief will be periodically updated. Comments from readers are welcome to Leslie Koo (lkoo@usaid.gov), especially comments to help clarify the information provided or where additional information may be useful (last updated October 16, 2015).

• View the PDF [PDF, 262KB].

Footnotes

1. Greater attention to reducing undernutrition is a critical factor for success for Ending Preventable Child and Maternal Deaths efforts; undernutrition is an underlying cause of 45 percent of child mortality.
2. MULTI-SECTORAL NUTRITION STRATEGY 2014-2025 Outcome Level Indicators:
   • Prevalence of low birth weight in USAID-assisted countries
   • Prevalence of exclusive breastfeeding of infants 0–5 months in USAID-assisted countries
   • Prevalence of minimum acceptable diet of children 6–23 months in USAID-assisted countries
   • Women’s dietary diversity score in USAID-assisted countries
   • Prevalence of moderate and severe hunger in USAID-assisted countries
   • Number of HIV-positive, clinically malnourished clients who received therapeutic and supplementary feeding in USAID-assisted countries
3. MULTI-SECTORAL NUTRITION STRATEGY 2014-2025 Impact Level Indicators:
   • Prevalence of stunting among children under 5 in USAID-assisted countries
   • Prevalence of wasting among children under 5 in USAID-assisted countries
   • Prevalence of overweight among children under 5 in USAID-assisted countries
   • Prevalence of anemia among children 6–59 months in USAID-assisted countries
   • Prevalence of healthy weight among women of reproductive age in USAID-assisted countries
   • Prevalence of anemia among women of reproductive age in USAID-assisted countries