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      A Brief History of Evidence-Informed Decision Making for Nutrition in Mexico

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          ABSTRACT

          The Progresa Conditional Cash Transfer program in Mexico began in 1997, with a strong evidence-based design. The program's ultimate objective was to foster the development of human capital through 3 components—education, health, and food. Rigorous impact evaluation generated evidence of impact on several outcomes, including child growth, but also aspects of program design and implementation challenges that may have limited impact. The objective of this supplement is to present research that led to the redesign of the health component, its implementation and evaluation at pilot scale, and its scale-up to national level, representing >15 y of collaboration among evaluators, program implementers, and funders. The studies used various methodologies, including process evaluation, cohort studies, ethnographic assessments, and a cluster-randomized trial, among others. The articles report previously unpublished results and citations of published literature. Article 1 uses an impact pathway to highlight gaps and bottlenecks that limited potential for greater impact, the original recognition of which was the impetus for this long collaboration. Article 2 explores the social and cultural factors that influence decisions to participate in programs and to adopt the actions proposed by them. Article 3 presents a cluster-randomized trial implemented to inform the choice of nutritional supplements for pregnant and lactating women and children 6–59 mo of age and how this and other evidence from the studies were used to redesign the health component of the program. Articles 4 and 5 present results of the development and pilot testing of the modified health component, the Integrated Strategy for Attention to Nutrition (abbreviated to EsIAN from its name in Spanish) (article 4), and the process and challenges of training and supervision in taking the EsIAN to scale (article 5). The final article provides reflections on the relevance of this body of work for implementation research in nutrition.

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          Most cited references 17

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          Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study.

          Malnutrition causes death and impaired health in millions of children. Existing interventions are effective under controlled conditions; however, little information is available on their effectiveness in large-scale programs. To document the short-term nutritional impact of a large-scale, incentive-based development program in Mexico (Progresa), which included a nutritional component. A randomized effectiveness study of 347 communities randomly assigned to immediate incorporation to the program in 1998 (intervention group; n = 205) or to incorporation in 1999 (crossover intervention group; n = 142). A random sample of children in those communities was surveyed at baseline and at 1 and 2 years afterward. Participants were from low-income households in poor rural communities in 6 central Mexican states. Children (N = 650) 12 months of age or younger (n = 373 intervention group; n = 277 crossover intervention group) were included in the analyses. Children and pregnant and lactating women in participating households received fortified nutrition supplements, and the families received nutrition education, health care, and cash transfers. Two-year height increments and anemia rates as measured by blood hemoglobin levels in participating children. Progresa was associated with better growth in height among the poorest and younger infants. Age- and length-adjusted height was greater by 1.1 cm (26.4 cm in the intervention group vs 25.3 cm in the crossover intervention group) among infants younger than 6 months at baseline and who lived in the poorest households. After 1 year, mean hemoglobin values were higher in the intervention group (11.12 g/dL; 95% confidence interval [CI], 10.9-11.3 g/dL) than in the crossover intervention group (10.75 g/dL; 95% CI, 10.5-11.0 g/dL) who had not yet received the benefits of the intervention (P =.01). There were no differences in hemoglobin levels between the 2 groups at year 2 after both groups were receiving the intervention. The age-adjusted rate of anemia (hemoglobin level <11 g/dL) in 1999 was higher in the crossover intervention group than in the intervention group (54.9% vs 44.3%; P =.03), whereas in 2000 the difference was not significant (23.0% vs 25.8%, respectively; P =.40). Progresa, a large-scale, incentive-based development program with a nutritional intervention, is associated with better growth and lower rates of anemia in low-income, rural infants and children in Mexico.
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            Do Conditional Cash Transfers Improve Child Health? Evidence from PROGRESA′s Control Randomized Experiment

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              The Oportunidades program increases the linear growth of children enrolled at young ages in urban Mexico.

              The goal of this study was to evaluate the impact of Mexico's conditional cash transfer program, Oportunidades, on the growth of children <24 mo of age living in urban areas. Beneficiary families received cash transfers, a fortified food (targeted to pregnant and lactating women, children 6-23 mo, and children with low weight 2-4 y), and curative health services, among other benefits. Program benefits were conditional on preventative health care utilization and attendance of health and nutrition education sessions. We estimated the impact of the program after 2 y of operation in a panel of 432 children <24 mo of age at baseline (2002). We used difference-in-difference propensity score matching, which takes into account nonrandom program participation and the effects of unobserved fixed characteristics on outcomes. All models controlled for child age, sex, baseline anthropometry, and maternal height. Anthropometric Z-scores were calculated using the new WHO growth reference standards. There was no overall association between program participation and growth in children 6 to 24 mo of age. Children in intervention families younger than 6 mo of age at baseline grew 1.5 cm (P < 0.05) more than children in comparison families, corresponding to 0.41 height-for-age Z-scores (HAZ) (P < 0.05). They also gained an additional 0.76 kg (P < 0.01) or 0.47 weight-for-height Z-scores (P < 0.05). Children living in the poorest intervention households tended (0.05 < P < 0.10) to be taller than comparison children (0.9 cm, 0.27 HAZ). Oportunidades, with its strong nutrition component, is an effective tool to improve the growth of infants in poor urban households.
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                Author and article information

                Journal
                J Nutr
                J. Nutr
                jn
                The Journal of Nutrition
                Oxford University Press
                0022-3166
                1541-6100
                December 2019
                03 December 2019
                03 December 2019
                : 149
                : Suppl 1
                : 2277S-2280S
                Affiliations
                [1 ] Global Alliance for Improved Nutrition , Geneva, Switzerland
                [2 ] National Coordination of the Prospera Program of Social Inclusion , Mexico City, Mexico
                [3 ] National Commission for Social Protection in Health, Secretary of Health , Mexico City, Mexico
                [4 ] Department of Social Protection and Jobs, Latin America and Caribbean, The World Bank , Washington, DC, USA
                [5 ] Social Protection and Health Division, Inter-American Development Bank , Washington, DC, USA
                [6 ] National Institute of Public Health of Mexico , Cuernavaca, Mexico
                Author notes
                Address correspondence to LMN (e-mail: lneufeld@ 123456gainhealth.org ).
                Article
                nxz188
                10.1093/jn/nxz188
                6887934
                31793646
                Copyright © American Society for Nutrition 2019.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@ 123456oup.com

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                Pages: 4
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