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Medical Nutrition Therapy: A Case Based Approach

• Kathryn M. Kolasa, PhD, RDN, LDN Kathryn M. Kolasa Affiliations Brody School of Medicine at East Carolina University, 3080 Dartmouth Dr, Greenville, NC 27858 Search for articles by this author

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DOI: https://doi.org/10.1016/j.jneb.2022.02.003

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Dietetic and Nutrition: Case Studies

ISBN: 978-1-118-89824-6

February 2016

Wiley-Blackwell

Digital Evaluation Copy

Judy Lawrence , Pauline Douglas , Joan Gandy

The ideal companion resource to ‘Manual of Dietetic Practice’, this book takes a problem-based learning approach to dietetics and nutrition with cases written and peer reviewed by registered dietitians, drawing on their own experiences and specialist knowledge

• Each case study follows the Process for Nutrition and Dietetic Practice published by the British Dietetic Association in 2012
• Includes case studies in public health, an increasingly important area of practice

Judy Lawrence is a Research Officer, BDA & Visiting Researcher at King's College London, England

Joan Gandy is a Freelance Dietitian & Visiting Researcher, Nutrition & Dietetics, University of Hertfordshire, Englan.

Pauline Douglas is Senior Lecturer & Clinical Dietetic Facilitator, Northern Ireland Centre for Food and Health (NICHE), Ulster University, Northern Ireland.

Nutrition resources made for RDs, by an RD

Clinical Nutrition Case Study: 3 must-ask questions

If you’re struggling to figure out answers to your clinical nutrition case study or if you’re having trouble working through patient care in real life, keep reading. These 3 questions are for you.

Clinical nutrition case studies are hard.

They have a lot of moving parts and (if they’re anything like patients you’ll see in the real world), don’t always have obvious answers to simple questions.

If you’re struggling to figure out answers to your clinical case studies or if you’re having trouble working through patient care in real life, keep reading.

You’re going to start with these 3 questions every time you’re handed a new patient.

What are the 3 steps in a nutrition intervention

Before we talk about the 3 questions you’ll use every time you start a new clinical nutrition case study, let’s talk about the standard nutrition intervention format.

You probably already know the 3 steps to use in a nutrition intervention. They look like this:

• Intervention

However I’ve found that taking the words assessment, diagnosis and intervention at face value, can be kind of confusing.

And if you aren’t sure where different patient issues fall into these categories, it’s going to be much harder to work through clinical nutrition case studies.

So you’re going to stop trying to figuring out if what you’re looking at falls into the assessment, diagnosis or intervention category, we’re going to make it much easier.

Instead, you’re going to ask yourself 3 simple questions that will make sure you’re thinking clearly about all the available information you have.

How to do a clinical nutrition case study with 3 question

These are the 3 questions you’ll answer during every clinical nutrition case study you’re given. These are also the same questions you should be asking with any patient you see in the real world.

Here are the 3 questions to ask yourself every time you’re looking at patient in clinical nutrition for the first time :

• What do you know?
• What are you most concerned about?
• What are your next steps?

Each of these questions will focus your attention on what information you have, what is most important and what you’re missing.

If these 3 questions sound a lot like the way you do a nutrition intervention, you’re right.

What do you know is the assessment . What are you most concerned about is the diagnosis . And what are your next steps is the intervention .

Thinking about each of the 3 parts of the nutrition intervention this way make it much easier to understand figure out the most acute nutritional issue of your patient.

And from there, understand how you can support them in improving their nutritional health.

The point of doing a clinical nutrition case study

Ultimately your goal is always to answer a single question:

What’s the one thing I can do right now to improve this person’s health as quickly as possible?

The answer to that is  your patient’s most acute nutritional issue.

And once you know their most acute nutritional issue, you’ll know how to form your PES statement and what to focus on in your nutrition note or care plan.

So let’s talk specifics.

What do each of these questions mean? And how are you going to use them to determine the most acute nutritional issue as you think through your clinical nutrition case study?

The 3 questions to answer in during a clinical nutrition case study

Question #1: what do you know.

This is the first question you’re going to ask yourself when you’re handed a clinical nutrition case study. But keep in mind, these work for real life patients too.

Write down every piece of information that seems nutritionally relevant. That includes:

• Diagnoses: admitting and PMH
• Weight status

Question #2: What are you most concerned about?

This is where you filter that list into the things that impacting your patient’s health status. 

Some of the things on this list will be not worry you at all. The lab work might be normal. Your patient’s weight status might be within normal limits. Maybe they have no significant past medical history.

On the other hand, you might be worried about everything on the list. Clinical nutrition case studies can be either overly simple or ridiculously complex.

Whatever stands out to you, highlight it. All of it.

These are the items that will form the basis of your nutrition assessment and intervention.

Question #3: What are your next steps?

There are 2 possible ways the answer to this question can go.

• You have all the information you need.
• You are missing information.

If you have everything you need and you have no more questions, you’re done. Wrap up your clinical nutrition case study by summarizing the important points that you’ve pulled together with questions 1 and 2.

Write you nutrition note and move on.

But if you need to find out more information, it’s time to make a list of what you just learned. Then start reviewing these 3 questions again, from the top. 

More information might need to come from a doctor , looking up something new in the medical chart or by asking your patient a direct question. 

Each of these sources have the power to dramatically shift the way you support your patient. And if that happens, you want to take the time to revise your nutrition care plan to better meet those new needs.

And That’s It!

Clinical nutrition in the real world, just like clinical nutrition case studies, is all about using all available information to give your patient the best possible chance at positive health outcomes. 

To make that happen these are the 3 questions you’re going to ask yourself. On repeat. Until you are confident of you can help them get discharged as quickly as possible.

Feel like this was cool, but you’ve got specific questions? I got you. Clinical Text Support is your chance to ask every question you have, as they come up in real time. Maybe it’s working through a crazy case study. It could also be real patients you’re assigned in your clinical rotations. In Clinical Text Support, you get immediate answers to the questions you might not want to ask a preceptor or teacher.

Need even more? I hear you. Clinical Bootcamp is everything you need to do clinical nutrition in the real world. It’s exactly the clinical nutrition course you thought you’d get in school, but never did. After Bootcamp, you’ll know how to not only work through every patient care situation — but you’ll be doing it confidently. Every time.

Want even more to help in clinical? Check out The Nutrition Cheat Sheets Shop for all the nutrition education and clinical resources that will make your life easier.

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Creative Steps to Write a Nutrition Case Study

Table of Contents

Nutrition plays a vital role in improving a patient’s health. However, each patient has unique nutritional needs requiring a personalized healthcare approach. That’s where nutrition case studies come in. These case studies comprehensively assess a patient’s nutritional status and help develop an individualized nutrition plan. They also help to monitor and evaluate the patient’s progress toward their health goals over time. In this article, we will provide a step-by-step guide on  how to write a nutrition case study . This post will help you understand the importance of nutrition case studies, whether you are a healthcare professional or a student.

What Is a Nutrition Case Study?

A nutrition case study comprehensively reports an individual’s nutritional status, dietary habits, and health outcomes . Healthcare professionals typically use these case studies to evaluate and treat patients. This is with various nutritional concerns, such as obesity, malnutrition, or chronic diseases. If you are a nutrition student or practitioner, learning how to write a nutrition case study is an essential skill to have. 

Importance of Nutrition Case Study

Nutrition case studies are a crucial tool for healthcare professionals in nutrition and dietetics. Here are some of the reasons why nutrition case studies are essential:

Provides a Comprehensive Assessment of a Patient’s Nutritional Status

 Nutrition case studies involve a detailed analysis of a patient’s dietary intake, medical history, and lifestyle factors that may impact their nutritional status. This information is used to develop a personalized nutrition plan tailored to the patient’s needs.

Develops an Individualized Nutrition Plan

A nutrition case study’s personalized approach to healthcare leads to an individualized nutrition plan. This approach can lead to better patient outcomes, improved health outcomes, and a higher quality of life for the patient.

Monitors and Evaluates Progress Over Time

Nutrition case studies track a patient’s food intake, weight, body composition, and other health outcomes over time. This enables healthcare professionals to monitor and evaluate the patient’s progress toward their health goals and adjust the nutrition plan as needed.

Provides Education About Healthy Eating Habits and Lifestyle Changes

Nutrition case studies can help educate patients about healthy eating habits and lifestyle changes. By providing a detailed assessment of a patient’s nutritional status, healthcare professionals can help patients make sustainable changes to their diet and lifestyle.

Supports Evidence-Based Practice

Nutrition case studies are based on evidence-based practice, meaning the nutrition plan is grounded in scientific research and clinical expertise. This approach ensures that the patient receives the best care based on the latest research and clinical knowledge.

Steps on How to Write a Nutrition Case Study

Selecting the patient.

The first step in writing a nutrition case study is selecting the patient. Typically, the patient has sought out nutritional counseling or treatment for a specific reason. These reasons include weight management, a chronic disease, or a food allergy. The patient should be willing to participate in the case study and provide detailed information about their diet, health history, and lifestyle habits. When selecting a patient, obtaining their written consent to participate in the case study is essential. This should include an explanation of the purpose of the case study and how their information will be used. It should also add any potential risks or benefits of participating. The patient should know that they can stop participating in the research at any moment if they don’t want to.

Gathering Information

The next step in writing a nutrition case study is gathering information about the patient. This includes a comprehensive assessment of their dietary habits, health status, medical history, and lifestyle factors that may impact their nutrition. To gather this information, you may need to conduct a nutrition assessment, which typically includes the following components:

Anthropometric Measurements

This involves measuring the patient’s height, weight, body mass index (BMI), and other body composition measures.

Dietary Intake Assessment

This involves collecting information about the patient’s dietary habits, including food preferences, allergies, and cultural or religious dietary restrictions.

Biochemical Assessment

This involves analyzing the patient’s blood, urine, or other biological samples to assess their nutritional status.

Medical History

This involves collecting information about the patient’s past and current medical conditions, medications, and surgeries.

Lifestyle Assessment

This involves collecting information about the patient’s physical activity, stress, and other lifestyle factors that may impact their nutrition status. Gathering as much information as possible is essential to create a comprehensive nutrition case study. This information will help you develop an individualized nutrition plan addressing the patient’s needs and concerns.

Developing a Nutrition Plan

Once you have gathered all the necessary information, the next step is to develop a nutrition plan for the patient. The nutrition plan should be based on the patient’s dietary needs, health goals, and lifestyle factors. It should also consider any medical conditions or medications that may impact the patient’s nutritional status. The nutrition plan should include the following components:

Macronutrient and Micronutrient Recommendations

This involves recommending specific amounts of carbohydrates, protein, fat, and other essential nutrients the patient should consume daily.

Food Group Recommendations

This involves recommending specific food groups for the patient, such as fruits, vegetables, whole grains, and lean proteins.

Meal and Snack Recommendations

This involves recommending specific meals and snacks for the patient to meet their nutritional needs throughout the day.

Nutritional Supplements

This involves recommending specific nutritional supplements, such as vitamins, minerals, or protein powders, that may help patients meet their nutritional needs.

Behavioral Recommendations

This involves recommending specific behavioral changes that may impact the patient’s nutrition status, such as increasing physical activity or reducing stress. The nutrition plan should be individualized to the patient’s needs and preferences. It should also be realistic and achievable, considering any barriers the patient may face in following the plan.

Implementing the Nutrition Plan

Once the nutrition plan has been developed, the next step is implementing it with the patient. This may involve educating the patient about healthy eating habits and strategies for making dietary changes. The patient should also be encouraged to track their food intake and monitor their progress toward their health goals. Working collaboratively with the patient throughout the implementation process is essential, as ongoing support and guidance are needed. This may involve regular follow-up appointments or communication via phone or email. The patient should be encouraged to ask questions and share any concerns or challenges they may be experiencing.

Monitoring and Evaluating Progress

The final step in writing a nutrition case study is monitoring and evaluating the patient’s progress. This involves tracking the patient’s food intake, weight, body composition, and other health outcomes. The patient’s progress should be regularly assessed, and adjustments made to the nutrition plan as needed. Objective measures such as laboratory values or body composition assessments are essential to evaluate the patient’s progress. This can help ensure that the nutrition plan is effective and that the patient is progressing toward their health goals.

How to Write a Nutrition Case Study

Once the nutrition plan has been implemented and the patient’s progress has been evaluated, it is time to write the case study. The case study should be organized in a logical and easy-to-read format, and should include the following sections:

Introduction

This should provide an overview of the patient’s case and outline the purpose of the case study.

Patient History

You should provide a comprehensive overview of the patient’s medical history, dietary habits, and lifestyle factors that may impact their nutritional status.

Nutrition Assessment

This should provide a detailed assessment of the patient’s nutritional status, including anthropometric measurements, dietary intake, biochemical markers, and medical history.

Nutrition Plan

This should provide a comprehensive overview of the patient’s individualized nutrition plan. They include macronutrient and micronutrient recommendations, food group recommendations, meal and snack recommendations, nutritional supplement recommendations, and behavioral recommendations.

Implementation and Follow-Up

This should provide an overview of the patient’s progress in implementing the nutrition plan, including any challenges or barriers encountered. It should also outline the follow-up appointments or communication that took place between the patient and healthcare provider.

This should provide an overview of the patient’s progress towards their health goals, including any changes in weight, body composition, or laboratory values.

This should provide an interpretation of the patient’s results, including any limitations or strengths of the case study. It should also provide a summary of the key takeaways and implications for future practice.

Writing a nutrition case study may not be the most exciting task in the world, but it is a crucial one. By following these steps and using a bit of wit and creativity, healthcare professionals can effectively communicate their patient’s nutritional needs . This shows progress toward their health goals. Who knows, maybe writing a nutrition case study will be more fun than you thought!

Abir Ghenaiet

Abir is a data analyst and researcher. Among her interests are artificial intelligence, machine learning, and natural language processing. As a humanitarian and educator, she actively supports women in tech and promotes diversity.

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Dietetic and Nutrition Case Studies

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Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition. Geneva: World Health Organization; 2013.

Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition.

Annex 3 nutrition programme case studies.

The Bangladesh Integrated Nutrition Programme (BINP) ran from 1995 to 2002, with about 15% coverage by area (59/464 thanas ). This led into the National Nutrition Program, 2004–2007, whose intended coverage was 105/464 thanas . Both of these programmes were supported by the World Bank. Various issues inhibited activities, which appear to have been absorbed into the Health and Nutrition Population Sector Programme (HNPSP), 2007–2010 (25% nutrition and food security; about $4300 million, 37% external funding).

HNPSP has no available evaluation data, and disbursement up to July 2010 was about 5%, so the progamme appears to have been slow in starting activities. Components are described in the project appraisal document. The World Bank implementation completion report ( 1 ) on National Nutrition Program was critical of the plan and the ineffective implementation. This followed considerable earlier debate on the effectiveness of the BINP, and most of the available data on process and outcome stem from this earlier programme. It is not clear whether support to community nutrition promoters continued under the HNPSP.

During BINP internal evaluations were commissioned ( 2 ), then challenged by Save the Children ( 3 ) based on a retrospective cross-sectional survey. White and Massett ( 4 ) concluded that the reduction in malnutrition (underweight or stunting) which could be ascribed to BINP activities was about 2 ppt (about 0.3 ppt/year). However, early data did show an initial substantial reduction in severe underweight, as in other projects, and about 20 g improvement in birth weight was attributed to BINP activities.

Programme design was similar to that for TINP, involving growth monitoring, with supplementary feeding for children with growth faltering and nutrition counselling. Reasons for low effectiveness may include:

• targeting for supplementary feeding was fairly ineffective, and food was shared;
• community nutrition promoters were of low intensity (approximately 1:150 households) and worked out of community nutrition centres rather than making home visits;
• while there was some effect on knowledge and to a lesser degree on practices, these did not translate into nutritional impact.

BINP itself was of low effectiveness and did not lead to a sustainable set of actions. In part this was due to the project design and inadequate intensity, and in part to complexities in implementation (institutional and otherwise). Under the HNPSP there appears to be less emphasis on community-based actions and services.

The Child Pastorate Programme was implemented in 1983 by the Catholic Church of Brazil. It remains in operation to the time of writing and is funded by multiple sources, including the MoH (80%), Electric Company, Ministry of Education, the GLOBO television network and UNICEF. In 2001 Child Pastorate Programme coverage by area was about 63% (5140/8159 parishes), providing services to 32 265 communities. Coverage by population for the same year was about 1.6 million children less than 6 years of age (9.8% of total population for age group), in addition to more than 77 000 pregnant women. Resource intensity for the Child Pastorate Programme is US$ 4/person per year and personnel intensity is 1 community worker:37 children less than 6 years of age. Total funding for the programme for 1999–2000 was US$ 6.9 million.

Internal evaluations were conducted from 1988–2001 with reported decreases in malnourished children (from 18% to 4%) and pregnant women (from 20% to 4%), as well as low birth weight (from 14% to 6%). An increase in EBF during the first 4 months was also reported (from 60% to 80%). External evaluation data are unavailable.

The Integrated Management of Childhood Illness (IMCI) was implemented in Brazil in 1997 and by 2002 had begun in all states, within the context of the Family Health Programme, which is supported by the World Bank and the MoH. Coverage reported for the Family Health Programme is variable since municipalities must apply to the federal government and make a financial contribution to join the programme. Teams are trained in both Family Health Programme and IMCI principles though IMCI training is lagging behind that of FHP. Intensity of CHWs is reported as 1 per 100–200 families ( 5 ). The impact of IMCI on nutritional status in Brazil has not been reported.

Bolsa Alimentacão was a CCT programme from 2001–2003, when it merged with several programmes to form the current Bolsa Familia Programme (BFP). Coverage of Bolsa Alimentacão in 2003 was 1.5 million persons (about 1% of the population) supported by the World Bank and managed by the MoH. Families with pregnant or lactating women and/or children less than 7 years of age with a monthly per capita income below US$ 42 received US$ 7 per child monthly, for up to 3 children. Conditions for receipt of the transfer included regular pre- and postnatal care, growth monitoring, immunization, and participation in nutrition education seminars ( 6 ).

Initial evaluation data from Bolsa Alimentacão showed worsening height-for-age z-scores (HAZ) and weight-for-age z-scores (WAZ) for beneficiaries compared to non-beneficiaries, though results were not statistically significant ( 7 ). This result was despite a reported increase in food consumption, which may have been due to beneficiary mothers assuming they would be ineligible for benefits if children were healthy.

The Bolsa Alimentacão programme was incorporated into the BFP in 2003. BFP coverage in 2006 was 11.1 million families (46 million persons), approximately 100% of the poor and 25% of the total Brazilian population. Public expenditure for the BFP in 2005 was US$ 3.2 billion, equivalent to 0.36% of GDP ( 6 ). World Bank support for the programme was about US$ 562 million from 2003–2009, or approximately US$ 93.7 million/year ( 8 ). The entire BFP is overseen by the Ministry of Social Development, while the health component is managed by the MoH. Monthly cash transfers range from US$ 7–US$ 45 per family depending upon eligibility as determined by monthly per capita income ceilings of US$ 57 (moderately poor) and US$ 29 (extremely poor). Targeting of pregnant and lactating mothers and children less than 7 years of age and health conditions for receipt of the transfer remain as they did in Bolsa Alimentacão .

Evaluation data from the BFP is limited, but a positive impact has been reported; stunting among beneficiary children aged 6–11 months was 3.3 ppt lower (2 versus 5.3) than non-beneficiary children. However, the results are questionable due to selection bias. Study results may also be limited (especially for children aged 12–36 months) by supply-side constraints restricting health services, irregular growth monitoring despite the conditionality, and lack of information on timing of enrollment ( 7 ).

Hogares Comunitarios is a national community nursery programme that started in 1986 and at the time of writing is still in operation. It is funded principally by the Colombian government but also to a very small part by the parents of the children who participate through a monthly fee (US$ 4) used to provide a small salary to the community mother who runs the nursery. Funding for the programme is US$ 250 million annually. Children six years of age and younger in poor neighborhoods are targeted. In 2004, approximately 80 000 Hogares Comunitarios were in operation nationally, with an average of 12 children attending each (maximum 15); about 1 million children 6 years of age and younger attend. Supplementary feeding is a major programme component, as children are provided lunch and two snacks daily in addition to a supplemental beverage; in total 70% of daily caloric needs are provided ( 9 ).

Evaluation data for Hogares Comunitarios reported an increase in HAZ in children 0–72 months based on variables of programme attendance/participation (0.486), of number of months in the programme (0.013), and of the exposure (number of months adjusted by age of child) to Hogares Comunitarios (0.78). Changes in WAZ were not significant.

Familias en Acción is a large-scale CCT programme that began in 2002 and remains in operation at the time of writing. It is implemented by the Colombian government and supported by both the World Bank and the Inter-American Development Bank; total annual funding in 2004 was US$ 95 million. Coverage of Familias en Acción in 2005 was 66% of municipalities (700/1060) and 5% of the population, roughly 400 000 households or 2.1 million persons ( 10 ). Children 7 years of age and younger in the lowest income category are targeted for the programme, which includes roughly the poorest 20% of households ( 11 ). The nutrition/health component transfer for Familias en Acción is US$ 17/month per mother, independent of the number of children in the household, which is equivalent to approximately 24% of total household expenditure ( 12 ). Conditions for receipt of the transfer include regular health visits and growth monitoring.

Evaluation data of Familias en Acción has demonstrated an increase in HAZ score of 0.161 in children less than 24 months of age; though this increase is not significant, it translates to a 6.9% decrease in the risk of being chronically undernourished ( 11 ). In addition, Familias en Acción participants in urban areas experienced an increase in newborn weight of 57.8 g. This finding should be interpreted with caution since the programme was targeted to children, not mothers.

Key strategies to address malnutrition in Ethiopia include the National Nutrition Programme (NNP), which has many relevant components, and the Productive Safety Net Programme. The Government of Ethiopia launched the programme (2008–present) to reduce the magnitude of malnutrition in Ethiopia by reorienting the focus away from emergency and food security interventions and mainstreaming nutrition into community-based health and development programmes. Key nutrition activities of the NNP include:

• Health Extension Programme (HEP)
• Promotion of Essential Nutrition Actions
• Community-based Nutrition (CBN)
• Therapeutic Feeding Programme (TFP)
• Enhanced Outreach Strategy (EOS)/ Extended Enhanced Outreach Strategy (EEOS) and Targeted Supplementary Feeding (TSF).

The HEP (2005–time of writing) is the core strategy for universal primary health service coverage. The programme, operating with multi-donor support, aims to improve family health status through disease prevention and control at the community level. Under the HEP, the Government of Ethiopia aimed for a ratio of 1 health extension worker (HEW):2500 persons and 1 health post:5000 persons. After year-long training, HEWs deliver preventive, promotive and selected curative activities according to 16 modules. These incorporated IMCI (from 2002) and Essential Nutrition Actions (from 2004). As of 2009, 83% of target kebeles (sub-districts) had health post coverage, and 100% of the target HEWs (30 000) had been trained and deployed. However, resource intensity for the programme remains low: Government of Ethiopia spending on health is only 7.5% of the total government budget, and total per capita public health expenditure was US$ 3.00 in 2008, below the target expenditure of US$ 4.80 per capita estimated for full implementation of the HEP ( 13 ).

The CBN (2008 –present) was launched in 2008 and will expand to cover 35% of Ethiopia's total population (228 woredas 1 ) by the first half of 2011. CBN is focused on children under two and uses monthly growth monitoring and promotion to involve families and community members in assessing health and nutrition-related problems, analysing causes of these problems, taking action and monitoring progress. Other important processes in CBN include strengthened referral of severely underweight children to TFPs and/or TSFs as required; control of micronutrient deficiencies through biannual vitamin A supplementation and deworming; and quarterly screening for acute malnutrition through Community Health Days. CBN activities are facilitated by HEWs and voluntary CHWs (1:30–50 households). Per capita costs are not available. Initial analysis of routine programme data from 1.5 million under-2 children weighed in 4 regions showed a decline in underweight from 30% in January 2009 to 20% in March 2010 (8 ppt/year). 2

In TFPs (2008–present), children with complicated SAM receive care through therapeutic feeding units, and children with uncomplicated SAM are managed in the community through Outpatient Therapeutic Programmes (OTP) at decentralized sites. There are more than 5000 OTP sites across 200 woredas .

EOS/TSF Programmes (2004–present) are jointly operated by the MoH with UNICEF support and the Disaster Risk Management and Food Security Sector with World Food Programme support. The EOS targets children 6–59 months for vitamin A supplementation, measles vaccination, insecticide-treated bednets in malarial areas, health messages and deworming. Children 6–59 months and pregnant and lactating women (PLW) are also screened using mid-upper arm circumference (MUAC). Those identified as moderately malnourished are referred to TSF for 3-month supplementary food rations, where available ( 14 ). The EOS/TSF programme began in 2004 as a pilot, and quickly scaled up to cover 6.8 million children in 365 drought-prone woredas . In 2005/6, the programme was expanded through the EEOS, which covers additional woredas with a reduced package of only vitamin A supplementation and deworming. National coverage by EOS and EEOS has expanded to reach around 95% of children under 5, at an estimated cost of US$ 1.14 per child. 3 In 2008, the programme covered 163 food-insecure woredas (2.9 million children 6–59 months and 600 000 PLW), provided targeted supplementary food to 720 000 children and 420 000 PLW, and cost about US$ 43 million. Under HEP, the EOS programme is currently phasing out and being replaced by Community Health Days. These events will offer the same inputs as EOS but will move away from the regionally-supported biannual mobilizations and instead be carried out quarterly, supported by the district health structures and HEWs ( 15 ).

The PSNP (2005–present) is a partnership between the GoE and a group of donors providing direct budgetary support through a multi-donor trust fund. Outside of South Africa, PSNP is the largest social protection programme in sub-Saharan Africa. In 2009, PSNP reached nearly 10% of the country (7.6 million people), covering more than 40% of the woredas . The annual budget is around US$ 360 million. Per capita, cash and food transfers totaled US$ 32.8 for male-headed households and US$ 37.1 for female-headed households in 2007 ( 16 ). PSNP employs geographic, administrative and community-based targeting to identify chronically food-insecure populations. The objective of the programme is to improve food security and prevent vulnerable households from having to sell assets (nutrition is not explicitly addressed). Cash and/or in-kind support is provided to targeted households in exchange for labour-intensive public works to build community assets. Labour-poor households (i.e. female-headed households with young children, the elderly, PLWs) receive unconditional transfers. An impact evaluation in 2008 found no significant change in anthropometric status of children in PSNP households compared to non-PSNP households. However, participation had positive effects on use of education and health services and household food security, caloric acquisition, and asset protection ( 17 ).

The national Atención Integral a la Niñez en la Comunidad (AIN-C) began in the mid-1990s and remains in operation at the time of writing as a community-based expansion from the original AIN programme. AIN-C is supported by the Honduran MoH, and received major funding from United States Agency for International Development from 1998–2005 (initial planning and support began in 1991). Coverage of the programme by area was 24 of 42 health areas (>50%) in 2006 ( 18 ), and by population was 90% of children less than 24 months of age. Intensity as measured by CHNWs:children is 3:25, where CHNWs work part-time for 3.5 hours weekly. Financial resource intensity is US$ 6.43/child per year ( 18 ).

The programme is targeted at children less than 24 months of age and sick children 24–60 months of age. Activities of the AIN-C are carried out at monthly growth monitoring and promotion sessions at the community centre, although home visits are provided for children who do not attend. Components of the programme include nutrition counselling for EBF less than 6 months of age, complementary feeding less than 24 months of age, and hygienic practices; micronutrient distribution for children (iron and vitamin A); medication distribution for illness; antenatal care (newborn visits); and referral to the health facility as needed ( 19 ).

Evaluation of the AIN-C was planned as a pre- and post-intervention, project and control comparison study, but the design was altered due to extensive contamination of control communities, non-equivalent groups, and reduced intensity of programme implementation due to changes in funding. A cross-sectional study using baseline data compared AIN-C participants to non-participants. Improved caring practices were reported among AIN-C mothers. A 15.8 ppt difference in EBF at 6 months was found (55.8% AIN-C, 40% non-AIN-C). With regard to receiving iron and vitamin A supplementation, differences of 36.1 ppt (65.6% AIN-C, 29.5% non-AIN-C) and 6.8 ppt (94.3% AIN-C, 87.5% non-AIN-C) respectively, were reported for children. Mean height-for-age was lower in the AIN-C group as compared to non-participants at less than six months of age. At 6–11 months and 12–23 months of age, there was no difference between AIN-C children and non-participants, suggesting a protective effect of AIN-C against growth faltering. Since a pre-/post- comparison was not possible, this conclusion cannot be certain ( 20 ). Intensity of participation in the programme was based on percentage of possible weighings attended by the child; after controlling for household assets and age of child, for every 1% increase in participation intensity, weight-for-age increased 0.005 z-score ( 20 ).

Two major health and nutrition programmes were evaluated: Integrated Child Development Scheme (ICDS) and Tamil Nadu Integrated Nutrition Programme (TINP). TINP 1, funded by the World Bank, operated from 1980 to 1989 and TINP II operated from 1990 to 1997. ICDS was initiated by the Government of India (GoI) in 1975 and continues today. From 1990 to 1997, the World Bank supported ICDS I in Orissa and Andhra Pradesh, and from 1993 to 2001, supported ICDS II in Madhya Pradesh and Bihar.

An important conclusion to draw from this analysis of large-scale nutrition programmes in India is that a lack of proper evaluation is a major constraint to the development of evidence-based nutrition policies.

TINP I (1980–1989)

Among TINP participants, there was an approximate 1.25 to 2.40 ppt/ year decline in underweight prevalence. In TINP areas, there was an approximate 0.83 to 1.12 ppt/year decline in underweight prevalence as compared with non-TINP areas where an approximate 0.26 to 1.12 ppt/year decrease in underweight prevalence was observed. The estimated underlying trend for the whole of India during this time was a 0.7 ppt/year decrease in underweight prevalence. Thus an estimated one quarter to one half of the decrease in underweight prevalence is attributable to the project.

There are important issues related to data sources. Data on residents in TINP and non-TINP areas (rather than on TINP participants) come from the National Nutrition Monitoring Bureau (NNMB) while data on TINP participants comes from programme monitoring records. NNMB estimates are from an 11-year period (1979–1990) while TINP estimates are from an 8-year period (1982–1990). Furthermore, NNMB surveys consistently produce higher estimated underweight prevalence than TINP surveys because NNMB surveys cover entire areas rather than only programme participants. This may reveal differences between participants and non-participants.

TINP II (1990–1997)

TINP II built off the lessons learned during TINP I. The components of TINP II remained the same as those in TINP II, although additional components were added.

Among TINP II participants, there was an approximate 6.0 ppt/year decrease in underweight prevalence. In TINP areas, there was an average 1.1 ppt/year decline in underweight prevalence. The underlying trend in Tamil Nadu at that time was estimated by the World Bank to be 5.0–7.0 ppt/year, which is most certainly an overestimate. In its 1998 Implementation Completion Report for TNIP I, the World Bank suggests 2.0 ppt/year as a more realistic estimate of the underlying nutritional trend in Tamil Nadu.

Overall, TINP II was found to be successful in achieving its objective to decrease severe malnutrition but not successful in achieving its objective for moderate malnutrition. The latter objective may have been too ambitious, and underlying trends may have been overestimated.

ICDS (1975–present)

In 1998, ICDS was implemented in approximately 45% of the poorest villages and 60% of the richest villages in India. Universal coverage is a major goal of the programme, although it has proven difficult to reach certain remote areas and vulnerable groups. A major issue related to the effectiveness of the programme is the fact that coverage is much higher in areas with lower underweight prevalence. The intensity also tends to be significantly higher in areas that are wealthier.

An evaluation by Lokshin and colleagues ( 21 ) found no statistically significant differences between the “treatment” group (children living in areas with ICDS) and the “control” group (children living in areas without ICDS). Using propensity score matching, the difference between HAZ scores among “cases” and “controls” was found to be only 0.056 in 1992 and 0.024 in 1998. Similarly, the difference between WAZ scores among “cases” and “controls” was found to be -0.044 (in the opposite direction expected) in 1992 and 0.001 in 1998. None of the differences was statistically significant. These figures (derived from National Family Health Surveys) can be used only to investigate differences at one point in time, rather than to examine trends year to year, and thus provide for only weak attribution of changes to programme activities.

ICDS I (1990–1997)

Between 1990 and 1997, the World Bank supported ICDS activities in Andhra Pradesh and Orissa.

According to programme monitoring data, the decrease in underweight prevalence was found to be approximately 3.2 ppt/year in Andhra Pradesh and 0.05 ppt/year in Orissa. This data represents changes among programme participants rather than among community members as a whole. The underlying trend in underweight prevalence was estimated to be 2.8 ppt/year in Orissa and 4.2 ppt/year in Andhra Pradesh. Overestimation of the underlying trend may have caused an underestimation of the effectiveness of ICDS I in Andhra Pradesh.

According to the World Bank, definitive judgments on the effectiveness of ICDS I cannot be made due to a lack of high-quality data. Measham & Chatterjee ( 22 ) attribute the ineffectiveness of the project, particularly in Orissa, to issues related to proper implementation of programme activities:

• inadequate coverage of children < 3 years
• irregular food supply
• poor nutrition education
• inadequate health worker training
• anganwadi work “overload”
• poor linkages between ICDS and the health system.

ICDS II (1993–2001)

Between 1993 and 2001, the World Bank supported ICDS activities in Madhya Pradesh and Bihar. Components of the programme were identical to those in ICDS I. ICDS II was found to be unsuccessful in improving the nutritional status of children in Madhya Pradesh and Bihar. In Madhya Pradesh, there was found to be a 0.62 ppt/year increase in severe underweight prevalence and a 0.18 ppt/year increase in moderate underweight prevalence ( 23 , 24 ). In Bihar, a 0.93 ppt/year decrease in severe underweight prevalence and a 1.37 ppt/year decrease in moderate underweight prevalence were found. The World Bank did not provide information on the estimated underlying trend during this period.

The Family Nutrition Improvement Programme (UPGK) ran from 1975 to 1990, followed by the Third Community Health and Nutrition Project (CHN3) from 1993 to 2000. They were supported by the World Bank and combined participation and inputs from the MoH as well as from the community.

The UPGK (centred on Posyandus ) projects were based on the strategy of consistent monthly weight gain in healthy children targeting children under five and their mothers. The activities included weighing, education, micronutrient supplementation and supplementary feeding in combination with other health interventions through weighing posts managed by community leaders and volunteers ( 25 ). The cost per beneficiary was US$ 2 for weighing-screening and US$ 11 per beneficiary for weighing-feeding. In all regions, 58 355 villages received access to weighing posts, and coverage reached 17 million children or 80% of the under-5 population. Of those 80%, 77% received services and 47% were weighed monthly. Of those weighed monthly, 54% showed consistent weight gain, but active long-term participation ranged from only 34%–69% ( 26 ). The level of severe protein-energy malnutrition declined from 3%–5% to 1%.

Both process and impact evaluations were performed on UPGK. A longitudinal study showed positive changes in health practices. However the degree to which these changes, or any change in nutritional status of the programme target population, can be attributed to the programme cannot be defined. Inclusion of too many other health issues may have diluted the nutrition interventions ( 27 ). Other evaluation results indicate high programme access and initial coverage above 80% but reduced active participation over time. A lack of baseline data makes impact difficult to assess.

CHN3 picked up where UPGK left off, running from 1993 to 2001 with a US$ 3.6 million investment in improving nutritional status by the World Bank and US$ 0.6 million by the Government of Indonesia. This project focused on capacity building, health information systems, education and service delivery in a province-based model in five provinces. From 1989 to 2003 underweight (<-2 SD WAZ) decreased from 37.5% to 27.5% (0.71 ppt/year) despite the financial crisis of the early 1990s. This decrease may be partially attributed to a reduction in birthrate in the lowest quintile of the population ( 28 ). A World Bank evaluation of the project determined that design made the project difficult to supervise and that poor monitoring and evaluation of performance made assessment of project effectiveness difficult to determine ( 29 ).

Improvements in childhood malnutrition have been seen from the early 1980s. National level programmes such as UPGK achieved strong access and initial coverage but met significant problems of sustained results, in part due to dilution of focus. Attempts to decentralize health interventions to the provincial level with CHN3 faced challenges of implementation and monitoring. Lack of baseline and surveillance data made effectiveness of these projects difficult to define.

SECALINE (1993–1997)

SECALINE (Surveillance and Education for Schools and Communities on Food and General Nutrition) was implemented in two provinces of Madagascar, Antananarivo and Toliary, starting in 1993. Nongovernmental organizations (NGOs) were contracted to provide services to beneficiaries and supervision for community nutrition workers (CNWs) in target areas. CNWs provided services at community nutrition centers and were paid in rice by SECALINE for working on the project five days each week. The ratio of beneficiaries to nutrition workers was approximately 400 to 1200 children and 200 women for each worker. The cost per child beneficiary was approximately US$ 7.31 per year. The programme objective was to reduce food insecurity and malnutrition in Madagascar's two most food-insecure provinces through income generating projects and targeted nutrition programmes.

According to interim findings by the World Bank ( 30 ), there was a 14 ppt decrease in underweight prevalence among child participants in Antananarivo and a 10 ppt decrease in underweight prevalence among child participants in Toliary between January 1994 and June 1996. This amounted to a 5.6 ppt/year decrease in malnutrition in Antananarivo and a 4 ppt/year decrease in malnutrition in Toliary. The programme was deemed successful and was subsequently scaled up to cover all regions in the country through SEECALINE (see below).

SEECALINE (1999–2003)

The SEECALINE (Second Surveillance and Education for Schools and Communities on Food and General Nutrition) programme began in 1999 and was gradually scaled-up until 2002. Upon completion of scale-up activities, there were 3600 project sites in half the districts in Madagascar. SEECALINE targeted communities with poorer nutritional status as sites for implementation. Thus, communities with the programme had higher baseline levels of malnutrition than communities that did not have the programme. A key feature is that services are contracted out and provided by local NGOs in the target area. Activities were coordinated by a paid CNW in each programme site. Each site (and each CNW) serves between 200 and 500 women and children. There is a coverage rate of approximately 50% of children under the age of 3 years in each target area. The programme objective was to improve the nutritional status of children under three, PLW, and school-aged children

SEECALINE was evaluated by the World Bank in two different ways:

First, Galasso and Yau ( 31 ) utilized monitoring data to estimate improvements in the nutritional status of child participants. Over the course of 3 years, there was approximately a 7–9 ppt decrease in underweight prevalence among programme participants (2.33–3.0 ppt/year). Galasso and Yau ( 31 ) found that “the returns are decreasing as time and duration increase, though they do not dissipate to zero.” Results also showed higher differential returns in poorer areas and areas more vulnerable to disease.

Second, Galasso and Umapathi ( 32 ) utilized two nationally representative surveys to calculate the improvements in child nutritional status in programme areas rather than among programme participants. Between the 1997/98 and 2004 surveys, they found a 5.2–7.5 ppt decrease in underweight prevalence in programme areas (0.86–1.25 ppt/year).

Oportunidades (known as Progresa from 1997–2002) is a CCT programme in operation at the time of writing. The programme is funded by the government of Mexico with support from the World Bank (US$ 1.5 billion in 2009). It was initiated in rural areas and expanded to include urban areas beginning in 2002, although approximately 70% of programme participants reside in rural areas. Total coverage in 2007 was 5 million families, or 20% of the population. Targeting for Oportunidades is based on both geography, through identification of localities with high marginality indices, and socioeconomic status, through proxy means testing. Approximately 60% of households in the bottom decile of per capita expenditures are participants, suggesting effective targeting of the poorest ( 33 ).

The health and nutrition transfer component of Oportunidades is US$ 15/household per month, about 20% of average monthly household expenditures ( 7 ), and is intended for PLW, all children less than 2 years of age, and children less than 5 years of age with low WAZ scores. Receipt of transfer is conditional upon regular health visits for all children in which growth monitoring is included, pre- and postnatal care for women, and adult (greater than 15 years of age) participation in health and nutrition education sessions. Iron supplementation and nutrition supplements are provided as well. The nutrition supplement is intended to provide 20% of daily caloric and 100% of daily micronutrient requirements.

Multiple evaluations of Oportunidades have been conducted with data demonstrating significant improvements in nutritional outcomes. In 2004, Rivera and colleagues ( 34 ) reported an increase in height in children 0–6 months of 1.1 cm (26.4 cm versus 25.3 cm) in programme beneficiaries compared to a control group ( 35 ). In rural children ages 12–24 months, a significant increase in mean hemoglobin of 0.37 g/dl was found after 12 months in the programme; 11.12 g/dl in the treatment group compared to 10.75 g/dl in the controls. Corresponding anaemia prevalence among beneficiary children was 44.3% compared to 54.9% among control children, a significant 10.6 ppt decrease. Even with improvement, nearly half of beneficiary children were still anaemic ( 34 ).

Gertler ( 36 ) reported a significant increase in height of 0.96 cm in children 12–36 months in the treatment as compared to the control group, though there was no significant impact on the odds of being stunted. Treatment was defined as living in a locality covered by Progresa , therefore including children in households that were not receiving Progresa benefits. Thus, the estimates obtained from the study may be conservative ( 7 ). Anaemia prevalence was evaluated in rural children aged 12–48 months after 12 months in the programme; a significant difference of 48.3% in beneficiary children compared to 41.1% in comparison children was found ( 36 ).

A 2005 evaluation by Behrman and Hoddinott, as reviewed by Lagarde and colleagues ( 37 ), found a significant increase in height of 1.016 cm in children 12–36 months, although this occurred in children whose mothers had greater than 5 years of schooling.

Leroy and colleagues ( 12 ) found a significant impact on height in children 0–6 months; an increase of 1.53 cm was seen in treatment children compared to control children. The mean HAZ gain of 0.41 cm in this age group was also significant. When income/poverty tertiles were considered, a significant increase in height of 0.27 cm in the poorest tertile was found ( 35 ).

Barber and Gertler ( 38 ) also reported positive impact of Oportunidades on nutritional outcomes in 2008. They found a significantly higher birthweight of 127.3 g in programme beneficiaries and a 4.6 ppt reduction in LBW. When evaluated based on average beneficiary time, programme impact was 68.3 g, which was significant. Programme impact from cash received was not significant at 78.2 g ( 35 ).

The Red de Protección Social Programme (RPS) ran from 2000–2005. It was a small-scale CCT programme funded mainly by the Inter-American Development Bank, with contributions from the Government of Nicaragua and the World Bank. Total funding was US$ 38 million. The RPS provided transfers for both nutrition/health and education upon meeting of certain conditions by programme beneficiaries, although the education component will not be discussed here. Coverage of the RPS in 2005 was about 165 000 persons, or 3% of the population. Both geographical and household targeting was used for implementation in departments and municipalities with high rates of extreme poverty. Intended beneficiaries were children 5 years of age and younger ( 7 ).

RPS participants received a nutrition/food security transfer equivalent to US$ 18/month upon confirmation that conditions were met, although it has been reported that this was not strictly monitored. The transfer was equivalent to approximately 18% average monthly household expenditure. Conditions for receipt of the transfer included: monthly growth monitoring for children less than 24 months (every other month for children ages 2–5 years), participation in nutrition and health education sessions on topics such as breastfeeding, hygiene and feeding practices, regular vaccinations for children, and routine care for pregnant women. Antiparastic medications and iron supplements were also provided, though problems with delivery and noncompliance for iron have been reported ( 7 ). Supply-side enhancements to ensure access to health care and ability to meet conditions were implemented as well by providing funding to private providers (mostly NGOs).

Available evaluation data from the RPS report a 19% improvement in per capita consumption in beneficiary households versus control households. Beneficiary household consumption was unchanged despite an economic crisis and drought while control household consumption decreased; the cash transfer may be beneficial in protecting nutritional intake during times of crisis. An increase in HAZ of 0.17 was reported for beneficiary children and stunting decreased in RPS versus control groups by 5.5 ppt ( 39 ). A significant change in underweight was also reported; it decreased in RPS areas (13.7% to 9.8%) while it increased in control areas (14.3% to 16.6%). Compared to national averages for this time period, the prevalence of underweight was much higher in both RPS and control areas. The cash transfer may have a greater impact in these rural, poor areas in times of economic and environmental hardship.

Atención a Crisis ran from 2005–2006 as a pilot/experimental CCT programme designed to help poor households in drought-affected regions of Nicaragua. Total funding was US$ 1.8 million, provided by the Ministry of Family. About 3000 households (approximately 16 500 persons) in 6 municipalities that were affected by drought during the previous year were targeted by the programme. The food transfer amount was US$ 145/household per year (US$ 24/every 2 months). Conditions for receipt of transfer included growth monitoring, nutrition education and pre- and postnatal care for women. Supply-side benefits were planned for the programme but not implemented.

Evaluation data for Atención a Crisis show no impact on HAZ, WAZ or LBW. Due to the short duration of the programme and evaluation just after its completion, the lack of results is understandable.

The Lady Health Worker (LHW) programme started in 1994, expanding to 100 000 LHWs by 2002/3 ( 40 ), at about 1:1000 people, or about 1:150 households; the aim was 1:200 households. An evaluation found that they worked approximately 30 hours/week, with about 25 household visits per week ( 41 ). LHW supervisors were at a ratio of about 1:20–25. Coverage rose to about 70% of households. The programme targets children under five and women of reproductive age. Components are village committees, water/sanitation, referral/links to the health system, health education, essential drugs provision, immunization, growth monitoring and antenatal care/safe motherhood including iron supplements. Cost data ( 40 ) estimate about US$ 500 per LHW/year, of which US$ 240 is stipend/salaries, about US$ 2.50/household per year, which may be too low to expect measurable impact. Social exclusion is a key factor, not specifically addressed in the reports.

Evaluations showed good impact on some process indicators – e.g. immunization and growth monitoring – although none on EBF ( 42 ). Child nutritional status was not measured; the only outcome seems to have been infant/child mortality rates. No impact was found, but it could be due to lack of statistical power in the evaluation designs.

There seem to be no child underweight estimates since 2001 – the 2006/2007 Demographic and Health Survey did not include anthropometry. Most estimates up to 2001 indicate about 0.6 ppt/year improvement at national level. The programme may have been successfully implemented, but had too low intensity (e.g. resources/household) for a major impact on nutritional status.

• Philippines

The Barangay Integrated Development Approach for Nutrition Improvement (BIDANI) programme ran in the Philippines from 1978 to 1989 with support from UNICEF and the World Bank. It achieved 70% coverage of children under 5 with inputs at US$ 2/child per year in 136 villages primarily in the areas of supplementary feeding, nutrition education, growth monitoring and home food production ( 43 ). There was a reduction in underweight from 28.3% (1983) to 18.7% (1985) (3.2 ppt/year), However, during the height of the programme a 1997 broad evaluation by UNICEF found implementation to be a consistent restraint ( 44 ).

The Early Childhood Development (ECD) Project ran from 1998 to 2005 and achieved 86% national coverage with US$19 million support from the World Bank (approximately 30% of total budget) and additional funding from the Asian Development Bank. The intervention used CHWs based in health centres and schools, as well as home visits. Programme components focused primarily on supplementary feeding, micronutrient supplementation and fortification, and nutrition education. Area coverage for feeding programmes reached 25/36 municipalities and nutrition education 36/36 municipalities. A World Bank evaluation of ECD in 2006 and an Asian Development Bank evaluation in 2007 found predominantly positive programme impacts on weight-for-height and wasting. From 2001 to 2003 in programme areas, underweight for age decreased 1.33 ppt/year and wasting decreased 1.56 ppt/year. No positive impact was found on stunting. An evaluation concluded that there were positive results on acute malnutrition due to the feeding programme but negative impact on chronic malnutrition as addressed by the nutrition education and behaviour change components ( 45 ). The programme might have been more successful with better coordination of the CHWs. During ECD, from 1993 to 2003, prevalence of underweight for age declined from 28.3% to 20.7% (1.52 ppt/year).

The BIDANI programme showed positive impact on weight for age, though there were some issues with implementation. The ECD programme has had some significant effectiveness and could have potentially had even better results with improved implementation. The ECD programme showed positive evidence for the influence of community-based programmes on improved nutrition status with solid results in reducing prevalence of weight-for-height and wasting through feeding programmes. Long-term behaviour change was less effective due to poor coordination of CHWs.

Community Nutrition Programme (CNP) (1995–2001)

The Senegal CNP was implemented from 1995 to 2001 in poor urban and peri-urban areas. Activities were coordinated by the NGO Agence d'Exécution des Travaux d'Intérêt Public contre le sous-emploi (AGETIP), and other local NGOs were contracted out to provide services. Services were provided at community nutrition centres (CNC) in target areas. At the time of programme completion, there were 292 centres serving approximately 457 000 beneficiaries in 37 communes. According to interim data collected early in the programme cycle (June 1996), there were approximately 465 beneficiaries being served at each CNC. Services were provided by micro-enterprises composed of four young people from the target community. These groups were supervised by maîtres d'oeuvre communautaires employed by AGETIP. Each supervisor was responsible for five micro-enterprises. Members of micro-enterprises were paid salaries and worked on the project six days per week.

The programme objectives were to:

• halt further deterioration in the nutritional status of the most vulnerable groups (children under three and PLW) in targeted poor urban neighborhoods;
• provide potable water to under-serviced neighborhoods targeted under the nutrition programme; and
• enhance household food security among the poor urban population and in targeted poor rural areas during critical periods of vulnerability.

Nutrition Enhancement Programme

The Nutrition Enhancement Programme was designed to extend nutrition and growth promotion interventions into rural areas in Senegal through NGO service providers. The programme targeted 3 regions and contracted 12 NGOs to provide services through 34 district-level subprojects. By June 2005, 15% of the age cohort was receiving services.

The Tanzania Iringa Joint Nutrition Support Programme (JNSP) ran from 1984–1991, and was supported by WHO and UNICEF. The JNSP operated in 6/7 districts covering about 250 000 persons, 46 000 of whom were children (73% participation). Children less than 5 years of age and women were targeted, and selection was not based on socioeconomic status. Resource intensity of the JNSP ranged from US$ 8–US$ 17/child per year (US$ 30/child per year total cost, equivalent to US$ 6 million). Intensity as measured by personnel was 2 village health workers/village (1220 total) or 1:40 children.

JNSP evaluation data demonstrated a decrease in underweight from 50% to 35% (1984–1988), or 4.5 ppt/year for the first 4 years of the programme. The decrease occurring in the first 2 years of the programme was even greater at 8 ppt/year, although the sustained decline in underweight in the population was 0.8 ppt/year (for years 2–7). The JNSP had components such as systems development and support, health services and water facilities, but these were not in place when the initial improvements in nutritional outcomes were seen. The reduction in malnutrition was attributed to increased feeding frequency, especially of severely underweight children at established child feeding posts, improved health care in families and communities and provision of information.

Following the success of the JNSP, the Child Survival and Development (CSD) Programme was initiated in 1985 and ran until 1995 with support from the World Bank. The programme aimed for complete coverage, although ultimately it was about 45% (9/20 regions), with approximately 12 million beneficiaries, 2 million of whom were children. Resource intensity of the CSD programme was US$ 2–US$ 3/child per year ( 46 ).

Although coverage of the CSD programme was much greater than the JNSP and resource intensity was less, evaluation demonstrates comparable results to those of the JNSP; an initial reduction in malnutrition of about 8 ppt/year for 1–2 years, then a continued decrease of 1–2 ppt/year following the initial rapid decline. The difference in resource intensity may be due to the fact that supplementary feeding was not a component of the CSD programme.

IMCI was initiated in 1995 and is presently in operation with a goal of national coverage. It is both facility- and community-based and supported by WHO and UNICEF. Coverage at the time of writing is varied. All 114 districts have received orientation and the majority (83% in 2005) had carried out at least initial training. Resource intensity of IMCI is approximately US$ 11/child/year (US$ 1.70/child per year for routine care). IMCI has various components ( 47 ).

Evaluation data from IMCI show a decrease in stunting, as measured by improvement in concentration indices in children aged 24–59 months in IMCI districts (-0.102 to -0.032) in relation to comparison districts (-0.122 to -0.133) from 1999–2002 ( 48 ). Overall stunting decreased from 59% to 43% in IMCI districts versus 51% to 40% in comparison districts. Improvement in underweight was also seen in IMCI districts (-0.071 to -0.057) as compared to non-IMCI districts (-0.136 to -0.166). Corresponding percentage changes for underweight were 30%–23% in IMCI districts versus 27%–10% in comparison districts ( 49 ). Further studies demonstrating effectiveness of the programme have not yet been conducted. Several reported challenges in implementation have occurred, as the main activity remains training of health care workers without significant expansion to community-based practices.

Child Health Days (CHDs) were implemented in Tanzania beginning in 2000. Coverage for each component of CHDs has been reported as follows: measles immunization, 97% per population total (2005); vitamin A supplementation, 81% per population total (2005); deworming, 80% -100% per target area population (2004–2006). Intensity and impact evaluation data are not available for CHDs; however, based on coverage and known efficacy of these interventions, positive effects are plausible ( 50 ).

From 1999 to 2004/05, during operation of both IMCI and CHDs, overall stunting in Tanzania decreased from 48.3% to 44.4%, which is equivalent to approximately 0.7 ppt/year. Underweight in this time period decreased from 25.3% to 16.7%, which corresponds to approximately 1.6 ppt/year.

The Health Sector Development Project II (HSDP II) was launched in 2003 with support from the World Bank and pooled funds from development partners. Total project funding was US$ 1.83 billion, 14% of which was designated for nutrition and food security (US$ 256 million). The project was extended through 2009 to support completion of the Second Health Sector Strategic Plan (HSSP II), which was also launched in 2003 with the same scope as HSDP II. As reported in a World Bank project paper, funding for the original project has been expanded for 2009–2011 under the Third Health Sector Strategic Plan (HSSP III), with the same scope and planned activities as the original project. Additional funding disbursed was US$ 30.9 million in pooled funds and US$ 9.1 million in non-pooled World Bank funds. Proposed use for the additional non-pooled funds is implementation of a comprehensive food fortification programme to decrease micronutrient deficiencies in Tanzania.

In the past, programmes in Tanzania that were multi-component, community-based, and adequate in intensity resulted in reductions in malnutrition among children less than 5 years of age. Improvements in both stunting and underweight have been seen during more recent years of implementation of both IMCI and CHDs, though effectiveness studies for CHDs are unavailable. Evaluation of effectiveness of IMCI may be limited by a continued focus on training of facility-based health care workers, rather than implementation of community-based practices.

Thailand's nutrition interventions, which have provided an important model for community-based programmes in general, contributed to a reduction in child underweight from around 30% (converted to WHO standards) in 1987 to 7% in 2005, averaging 1.3 ppt/year. However, in the early stages this rate was probably 2–3 ppt/year for the population and above 4 ppt/year for participants in the various interventions. In fact the rates from 1982 – the first growth monitoring data – and the recent national survey (2005/06) are somewhat vague, but the overall major improvement is clear.

The attribution of improved child nutrition to programme activities has not been made through formal evaluations. Nutrition improvement started (1982–85) before rapid economic growth ( 51 , 52 ), and while no-one doubts the success and contribution of the Thai nutrition programme (e.g. 53, 54) no attempt can be found in the literature to actually ascribe the improvement to the programme.

The programme gave high priority to training village health volunteers and village health communicators, at ratios of 1:100 and 1:10–20 to households ( 54 ). Coverage was reported to reach nearly 100% of villages and 90% of children by 1990 ( 51 ). Cost estimates of around US$ 10/household per year come from average budget figures. The components were seen as a menu from which villages could select priorities. These included antenatal care, breastfeeding support, growth monitoring and counselling, micronutrient provision, limited supplementary foods (including use of vouchers) plus group feeding, hygiene, basic health services and others. Social mobilization, awareness and community participation were the key features, linked to evolving primary health care, while lessening reliance on direct top-down service delivery. A set of Basic Minimum Needs indicators, self-assessed by communities, helped prioritize and monitor activities through a structure of facilitators (local officers in health or other sectors), community leaders, and ‘mobilizers’ (village health communicators and village health volunteers).

Child underweight improved at 1.5 to 2 ppt/year from around 1994 to 2008 according to repeated surveys and from the weighing programme (1999–2005 data). The Protein-Energy Malnutrition (PEM) Control Programme operated in all 64 provinces of the country, covering 100% of communes with more than 10 000 health stations. About 100 000 nutritional collaborators were in place by 2005, a ratio of about 1:70 children at a cost of about US$ 0.70/child per year.

The components were counselling for breastfeeding and complementary feeding; vitamin A campaigns; iron in pregnancy; hygiene, sanitation and deworming for kindergartens; growth monitoring; and nutrition products for malnourished children. During this period there were also rapid economic growth and poverty alleviation programmes, and iodized salt was adopted. Stunting reduction began at least by 1985. The portion of the recent nutrition improvement that can be ascribed to the PEM Control Programme has not been evaluated. A small-scale trial ( 55 ) indicated minor effects on child anthropometry.

Overall, this is an example of a widely-implemented community-based programme, with probable impact that has not been evaluated. An estimate of 1.5 ppt/year improvement from the programme seems reasonable from the data published by year and province by the MoH-National Institute of Nutrition ( 56 ).

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UNICEF Ethiopia. personal communication. 2010.

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• Published: 21 August 2024

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• Amirhossein Ataei Kachouei   ORCID: orcid.org/0000-0003-0834-3609 1   na1 ,
• Noushin Mohammadifard 1   na1 ,
• Fahimeh Haghighatdoost   ORCID: orcid.org/0000-0003-4766-6267 2 ,
• Parisa Hajihashemi 3 ,
• Ehsan Zarepur 1 , 4 ,
• Fereydoon Nouhi 5 , 6 ,
• Tooba Kazemi 7 , 8 ,
• Nahid Salehi 9 ,
• Kamal Solati 10 ,
• Samad Ghaffari 11 ,
• Mahboobeh Gholipour 12 ,
• Habib Heybar 13 ,
• Hassan Alikhasi 14 &
• Nizal Sarrafzadegan 2 , 15  

In 2019, a globally sustainable dietary pattern that primarily emphasizes the consumption of plant-based foods was proposed by the EAT-Lancet Commission. However, there is limited evidence regarding the association of this diet with coronary events.

To determine the association between the EAT-Lancet Reference Diet (ELD) and premature coronary artery disease (PCAD) risk and its severity.

This multi-center, case-control study was conducted within the framework of the Iran premature coronary artery disease (I-PAD). A total of 3185 participants aged under 70 years in women and 60 years in men were included. Cases were those whose coronary angiography showed stenosis ≥ 75% in at least one vessel or ≥ 50% in the left main artery ( n  = 2033), while the controls had normal angiography results ( n  = 1152). Dietary intake was assessed using a validated food frequency questionnaire. Logistic regression was utilized to examine the association between ELD and presence of PCAD.

Compared with individuals in the first quartile, those in the highest quartile of ELD (OR = 0.29, 95% CI: 0.21, 0.39; P for trend < 0.001) and ELD calculated with minimum intake (OR = 0.39, 95% CI: 0.29, 0.52; P  < 0.001) had lower risk of PCAD. Individuals in the highest quartile of adherence to the ELD and ELD with minimum intake had 78% and 72% lower risk of having severe PCAD compared with those in the lowest quartile, respectively.

An inverse association was observed between adherence to the ELD and PCAD risk and its severity. Large-scale prospective cohort studies are required to confirm these findings.

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Acknowledgements

Authors would like to acknowledge participants who took part in the study. Also, they thank the staff of Isfahan Cardiovascular Research Institute and all coordinators and their team members in different cities.

This study was supported by the Ministry of Health and Medical Education of Iran and Isfahan University of Medical Sciences (grant number: 96110).

Author information

Amirhossein Ataei Kachouei and Noushin Mohammadifard contributed equally as co-first authors.

Authors and Affiliations

Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

Amirhossein Ataei Kachouei, Noushin Mohammadifard & Ehsan Zarepur

Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

Fahimeh Haghighatdoost & Nizal Sarrafzadegan

Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Parisa Hajihashemi

Department of Cardiology, Medicine School, Isfahan University of Medical Sciences, Isfahan, Iran

Ehsan Zarepur

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran

Fereydoon Nouhi

Iranian Network of Cardiovascular Research (INCVR), Tehran, Iran

Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran

Tooba Kazemi

Clinical Research Development Unit, Razi Hospital, Birjand University of Medical Sciences, Birjand, Iran

Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

Nahid Salehi

Department of Psychiatry, Shahrekord University of Medical Sciences, Shahrekord, Iran

Kamal Solati

Cardiovascular Research Center, Tabriz University of Medical sciences, Tabriz, Iran

Samad Ghaffari

Department of Cardiology, Healthy Heart Research Center, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran

Mahboobeh Gholipour

Atherosclerosis Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

Habib Heybar

Heart Failure Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

Hassan Alikhasi

Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, Canada

Nizal Sarrafzadegan

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Contributions

N.M., E.Z. and N.S. conceived and designed the study. P.H., F.N., T.K., N.S., K.S., S.G., M.G., H.H., and H.A. contributed to data collection and database construction. F.H. performed statistical analysis. A.A.K. and F.H. interpreted the results and drafted the manuscript. All authors have reviewed and accepted the final manuscript.

Corresponding author

Correspondence to Fahimeh Haghighatdoost .

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Ataei Kachouei, A., Mohammadifard, N., Haghighatdoost, F. et al. Adherence to EAT-Lancet reference diet and risk of premature coronary artery diseases: a multi-center case-control study. Eur J Nutr (2024). https://doi.org/10.1007/s00394-024-03475-y

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DOI : https://doi.org/10.1007/s00394-024-03475-y

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Framework for identifying research and innovation impact case studies from south african universities.

• African Population and Health Research Center

1. Introduction and Background

The African Population and Health Research Center (APHRC) is a premier research-to-policy institution, generating evidence, strengthening research and related capacity in the African research and development ecosystem, and engaging policy to inform action on health and development. The Center is Africa-based and African-led, with its headquarters in Nairobi, Kenya, and a West Africa Regional Office (WARO), in Dakar, Senegal. APHRC seeks to drive change by developing strong African research leadership and promoting evidence-informed decision-making (EIDM) across sub-Saharan Africa.

The Center is collaborating with the Southern African Research and Innovation Management Association (SARIMA) on its project on Building it Forward for Research (Management) Leadership in Southern Africa, in which the Center is leading a specific workstream to carry out impact case studies arising out of university research. This collaborative approach ensures effective execution and maximizes the value of the research impact assessment.

2. Project Scope and Focus

University research plays a critical role in improving wellbeing, informing policy decisions, and driving innovation. However, the impact of this research often remains under-communicated, hindering efforts to secure sustained funding and public support. While quantitative data is essential, compelling case studies go beyond mere numbers. They weave narratives that capture the human stories behind the research, highlighting the challenges addressed, the innovative solutions developed, and the real-world impact on societal outcomes. These narratives resonate with audiences, generating greater understanding and appreciation for the value of research. The case studies produced in this workstream target a diverse audience, including:

• Funders: Highlighting the transformative power of research investments.
• Policymakers: Demonstrating the research-policy nexus and influencing policy decisions.
• Public: Raising awareness about the impact of research on their lives.
• Media: Generating media interest and amplifying the research's impact.

Led by APHRC, the workstream aims to identify, analyse and document four case studies showcasing the impact of research and innovation projects conducted by South African universities. The case studies will highlight the tangible contributions of university research and innovation to national priorities and broader societal well-being.

3. Criteria for Selecting Case Studies

The preferred sectors for cases include:

• Agriculture
• Inclusive financial systems

The case studies will demonstrate one or more of the following impact pathways:

• Reductions in mortality or morbidity rates for specific diseases.
• Increased access to services, particularly for underserved populations.
• Improved behaviors through effective interventions.
• Economic benefits (e.g., cost savings in systems).
• Development of new diagnostic tools or treatments.
• Innovative approaches to health promotion or disease prevention.
• New technologies that improve quality of life, create jobs and/or uplift communities.
• Culturally sensitive interventions addressing specific needs within South Africa.
• Research informing policy changes.
• Studies influencing policy decisions on public health and other public good interventions.
• Research contributing to the development of national legislation, policy or guidelines.
• Addressing the needs of underserved and vulnerable populations.
• Ensuring research findings can be applied in diverse settings across South Africa and beyond.
• Promoting long-term benefits and sustainable impact.
• Potential for Scale-Up: The case study should demonstrate the scalability of the research findings, potentially impacting a broader population or region. This can be achieved through:
• Adapting the intervention for broader implementation.
• Developing clear dissemination strategies for research outputs.
• Building partnerships with stakeholders to facilitate scale-up.
• Stakeholder Involvement: Evidence of collaboration with diverse stakeholders who contributed to the research impact. These may include:
• External enablers: Role of and interactions with ecosystem players – e.g. collaborative research partners, funding from local/national governments and international funders, private sector, civil society, role of regulators and regulatory process, national policies that aided impact (e.g. IP policy), commercialization routes, infrastructure, manufacturing or value delivery (services/processes)
• Internal Enablers: The case study should highlight the role of university support structures and policies that facilitated the research's translation into impact. E.g. role of Research Management Office and Technology Transfer Office and the conditions internally that allowed for impact (this could go as far as looking at institutional policies, systems etc.)
• Diversity: The case studies will aim to represent a variety of research disciplines, universities, and types of impacts.

4. Call for Submission of Qualifying Projects for Case Studies

South African Universities are invited to submit examples of research and innovation projects conducted by their institutions that could be suitable subjects for impact case studies predicated on the criteria outlined in paragraph 3 above.

5. Role of the Consultant

The APHRC wishes to appoint a qualified and experienced Consultant in case study analysis and development, for the production and dissemination of knowledge products to lead APHRC’s effort to deliver on this workstream. The Consultant will be required to perform the following tasks:

5.1 Selection of Case Studies

A Consultant in collaboration with APHRC will review submissions and select promising research projects for case study development. Selected universities will be contacted by the dedicated consultant to collaborate on developing a comprehensive case study report.

• Evaluation and selection of Case Studies: The Consultant will develop the criteria for scoring and selection of potential case studies submitted by South African universities for further analysis, development and documentation.
• **Collaboration with Universities:**If necessary, the Consultant will collaborate with the relevant research and support departments and units at South African universities to identify and select potential case studies for consideration.
• **Desktop Research:**The Consultant will conduct a literature review of published research from South African universities in relevant fields in order to identify suitable projects. This will involve searching academic databases, government reports, media articles and online resources (e.g. Databases such as ResearchGate and institutional websites of universities canbe explored by the Consultant to find relevant research projects.)
• **Expert Consultation:**The Consultant will consult with relevant experts and stakeholders to identify/further refine impactful research projects. Working with APHRC, the Consultant will further determine and implement simple criteria to review potential case studies submitted by South African universities and/or identified by the Consultant. This may include:
• Scientific merit and methodological rigor of the research.
• Potential for broader impact and scalability of the findings.
• Alignment of the research with national policy priorities and the funder's interests.

5.2 Developing Strong Case Studies

The Consultant will identify a short list of case studies and will collaborate with the qualifying universities to conduct a detailed analysis of each case study to further elaborate on how each case study addresses the criteria set out in paragraph 3. In terms of methodology, the Consultant will use the Theory of Change framework and employ – without limitation - the following techniques:

• In-depth Interviews: The Consultant will conduct interviews with researchers and other role players and stakeholders to capture a detailed narrative of the research journey, key role players, the research outcomes, the impact of the research, and future potential.
• Data Analysis and Storytelling: The Consultant will assist with analyzing data and crafting a compelling narrative that showcases the research's significance and impact.
• Identifying Visuals: Working with the selected universities, the Consultant will identify relevant visuals (charts, photos) to enhance the case study report.

5.2.1. Focus on Storytelling

Crafting a captivating narrative is central to a strong case study. This narrative should:

• Research focus and objectives
• Measurable impact on relevant areas (sector e.g. health, agriculture, inclusive financial systems; economy; society)
• Alignment with national/provincial priorities
• Set the Stage: Introduce the challenge addressed by the research and highlight its significance for South Africa's population.
• Describe the Research Journey: Explain the research approach, methodology, and key findings in clear and concise language.
• Showcase Innovation: Emphasize the novel aspects of the research and how it addressed existing limitations or offered new solutions.
• Demonstrate Impact: Quantify the impact of the research on societal outcomes using relevant data (e.g. surveys, statistics).
• Highlight Policy Influence: If applicable, detail how the research findings informed policy changes or national guidelines.
• Focus on Equity and Sustainability: Explain how the research addressed the needs of underserved populations and how its impact can be sustained over time.
• Showcase Potential for Scale-Up: Describe plans or ongoing efforts to scale-up the intervention and reach a wider population.

5.2.2. Data and Evidence:

Strong narratives are bolstered by robust evidence. Case studies should incorporate a combination of:

• Reductions in mortality or morbidity rates.
• Increased access to services (e.g. number of people reached).
• Improved health behaviors (e.g. changes in dietary habits, vaccination rates).
• Economic benefits (e.g. cost savings).
• Creation of jobs.
• Improved efficiency.
• Interviews with researchers, policymakers, healthcare providers, and community members impacted by the research.
• Focus group discussions to understand perceptions and experiences.
• Case studies of individual beneficiaries who have demonstrably benefited from the research.
• Policy Documents: Documents such as policy briefs, white papers, or government reports showcasing how research findings influenced policy decisions.

5.2.3. Engaging Visuals and Multimedia

Incorporating visuals can significantly enhance the case study's impact and accessibility. Examples include:

• Charts and Infographics: Visualize data and trends to make complex information more easily understood by the audience.
• Photographs: Images of researchers, healthcare providers, community members, or interventions in action can personalize the narrative.
• Short Video Clips: Short videos can capture the essence of the research and its impact in a compelling way.

5.2.4. Stakeholder Testimonials

Including testimonials from key stakeholders adds credibility and authenticity to the case studies. This could include:

• Researchers: Sharing their insights into the research process and the significance of the findings.
• Policymakers: Describing how the research influenced policy decisions.
• Healthcare Providers: Highlighting how the research improved their practice or patient care.
• Community Members: Sharing their experiences and how the research impacted their health and well-being.

5.2.5. Showcase the Enabling Factors that Contributed to the Research's Success :

• External stakeholder collaboration (research partners, funders, regulators)
• University support structures (including Research Management Offices, Technology Transfer Offices)
• Internal policies and systems promoting research impact.

6. Deliverables

• A set of four well-written, compelling case studies demonstrating impactful research and innovation from South African universities.

7. Dissemination and Advocacy Strategies

The final stage involves disseminating the case studies to a wide audience and leveraging them for advocacy and informational purposes.

7.1. Dissemination Channels:

• APHRC Website and Social Media: A dedicated webpage will be created on the APHRC website to showcase the case studies. This webpage will be promoted through social media platforms like X, Facebook, and LinkedIn
• SARIMA Website and Social Media: The case studies will be showcased on the SARIMA website, and promoted through social media platforms like X and LinkedIn
• Other channels and platforms will be discussed and agreed between the funder, APHRC and SARIMA.

7. Reporting and Communication

The Consultant will provide the case studies and periodic progress reports to APHRC as required.

8. Timeline

8.1 Submission of Case Studies: By September 30, 2024 .

8.2 Recruitment of Consultant: By August 31, 2024

8.3 The case study development will be conducted in two phases. It is expected that the first two case studies will be developed by November 30, 2024 and the other two case studies will be developed by June 30, 2025 .

9. Submission of Potential Research for Case Study Development

If you know of any research which aligns with the criteria above, you are encouraged to submit it to be considered for case study development. Follow the following guidelines for submitting your research:

Prepare a Short Summary (2 Pages Maximum):

• Briefly describe the research project and its objectives.
• Highlight the specific challenge the research addressed.
• Summarize the research approach and key findings.
• Explain how the research made impact and quantify this impact (if possible).
• Include any evidence of policy influence or potential for scale-up.

Provide Supporting Materials (To the Extent Applicable):

• Include relevant publications, reports, or presentations related to your research.
• Share any data (quantitative or qualitative) that demonstrates impact.
• Offer contact details for key individuals involved in the project eg researchers, funders, end-users, beneficiaries and others who played a role in ensuring that impact was achieved (including – without limitation the institutional Research Support Office).

How to apply

Submission Process for Universities Wishing to submit Potential Projects for Case Study Consideration:

• Submit your research summary and supporting materials electronically to [email protected] with a copy to [email protected] and [email protected] . Please use “ South Africa University Research Case Study Development ” as subject title in your email submission.
• Indicate your university affiliation and the lead researcher/contact person contact information.

Submission Process for Consultancy Bids:

• Submit your consultancy bids and supporting materials demonstrating your expertise and qualifications for the assignment electronically to [email protected] with a copy to [email protected] and [email protected]
• This should include a detailed proposal addressing all areas identified in the Term of Reference, a detailed budget and evidence of related previous work.
• Indicate subject title as “ Consultancy for South Africa University Research Impact Case Study ”.

12. For Further Queries: [email protected]

Special Notice

APHRC is an equal opportunity employer committed to creating a diverse and inclusive workplace. All employment decisions are made based on qualifications and organizational needs. Reasonable accommodation may be provided to applicants with disabilities upon request to support their participation in the recruitment process.

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