How to design a complex behaviour change intervention: experiences from a nutrition-sensitive agriculture trial in rural India

Many public health interventions aim to promote healthful behaviours, with varying degrees of success. With a lack of existing empirical evidence on the optimal number or combination of behaviours to promote to achieve a given health outcome, a key challenge in intervention design lies in deciding what behaviours to prioritise, and how best to promote them. We describe how key behaviours were selected and promoted within a multisectoral nutrition-sensitive agriculture intervention that aimed to address maternal and child undernutrition in rural India. First, we formulated a Theory of Change, which outlined our hypothesised impact pathways. To do this, we used the following inputs: existing conceptual frameworks, published empirical evidence, a feasibility study, formative research and the intervention team’s local knowledge. Then, we selected specific behaviours to address within each impact pathway, based on our formative research, behaviour change models, local knowledge and community feedback. As the intervention progressed, we mapped each of the behaviours against our impact pathways and the transtheoretical model of behaviour change, to monitor the balance of behaviours across pathways and along stages of behaviour change. By collectively agreeing on definitions of complex concepts and hypothesised impact pathways, implementing partners were able to communicate clearly between each other and with intervention participants. Our intervention was iteratively informed by continuous review, by monitoring implementation against targets and by integrating community feedback. Impact and process evaluations will reveal whether these approaches are effective for improving maternal and child nutrition, and what the effects are on each hypothesised impact pathway

Center Size and Glycemic Control: An International Study With 504 Centers From Seven Countries

The variance in glycemic control between different childhood diabetes centers is not fully understood. Although the International Society for Pediatric and Adolescent Diabetes guidelines from 2014 recommended center sizes of more than 150 patients (1), it has not been thoroughly investigated whether glycemic control is associated with center size (2–4). We have data from more than 500 childhood diabetes centers from seven different countries and thereby a unique opportunity to elaborate further on this association. Therefore, this study aims to investigate the relationship between center size and glycemic control in children with type 1 diabetes (T1D). Patient data have been described previously (5). Briefly, the population comprised children with T1D in the age-group 3 months from seven high-income countries during 2013–2014: Austria, Denmark, England, Germany, Norway, Sweden, and Wales. Data were anonymized and obtained from five national registries/audits on children with T1D (Austria and Germany use the same electronic health record and England and Wales have a common National Paediatric Diabetes Audit, while Denmark, Norway, and Sweden have national registries). Mean HbA1c was compared between groups after adjusting for sex, age (<6 years, 6 to <12 years, and 12–18 years), duration of diabetes (<2 years, 2 to <5 years, and ≥5 years), and minority status (yes/no) (HbA1c adj) before and after stratifying for treatment modality (insulin injection/pump). Center size was defined as the number of patients with diabetes reported to be cared for in a center. Center size groupings were 1) <20, 2) 20 to <50, 3) 50 to <100, 4) 100 to <200, and 5) ≥200 patients. In total 54,494 children (48% females) with T1D across 504 centers in seven countries were included in the study. The number of centers per country varied between 14 (Wales) and 219 (Germany). Mean (SD) for age was 12.5 (3.9) years, mean age at T1D onset was 7.5 (4.0) years, and mean T1D duration was 5.0 (3.7) years. A total of 21% of patients had minority status, which varied between 5% (Wales) and 28% (Austria). A total of 38.1% of patients were on pump treatment, and the percentage varied between 25% (England) and 69% (Denmark). National coverage of T1D patients was >95% in all countries, apart from Austria, which had ∼80% data coverage. Included patients had 100% data coverage for all of the following variables: sex, age, diabetes duration, minority status, and HbA1c. Data on treatment modality were not available for 2,428 patients (4.5%); of these, 2,130 were from England and 154 were from Sweden. A total of 23.2% of centers had 200 patients, representing 12.3% of all centers. The distribution of small and large centers in the seven countries varied. England and Sweden had few small centers (34%). HbA1c adj was significantly higher in the centers with 50 patients, in both pen users (P 50 patients managed equally well; therefore, centralizing to very-high-volume diabetes centers may not necessarily be an advantage. Future research should focus on identifying reasons leading to differences in glycemic control in T1D patients cared for in small and large centers, e.g., the lack or presence of an updated multidisciplinary diabetes team

What is the role of civil society in multisectoral nutrition governance systems? A multicountry review

Objectives: To review attributes of civic engagement in multisectoral nutrition governance systems and to provide recommendations to increase CSO participation. Methods: We reviewed 7 national case studies of Civil Society Networks involved with the Scaling Up Nutrition movement and characterized 6 functional attributes of CSOs in multisectoral nutrition governance: identify needs of all community members, mobilize and build civic capacity, advocate for political commitments, inform program design and evaluation, ensure accountability mechanisms in public institutions, and report challenges and successes using broad media campaigns. Results: All studies described government agencies involved with multisectoral nutrition governance systems, at national and subnational levels; however, there was limited evidence of subnational platforms for CSO engagement. Although countries increased investments in public institutions for nutrition, it was unclear whether nutrition service quality improved and none reported corresponding investments in civil society

A New Water Oxidation Catalyst: Lithium Manganese Pyrophosphate with Tunable Mn Valency

The development of a water oxidation catalyst has been a demanding challenge for the realization of overall water-splitting systems. Although intensive studies have explored the role of Mn element in water oxidation catalysis, it has been difficult to understand whether the catalytic capability originates mainly from either the Mn arrangement or the Mn valency. In this study, to decouple these two factors and to investigate the role of Mn valency on catalysis, we selected a new pyrophosphate-based Mn compound (Li2MnP2O7), which has not been utilized for water oxidation catalysis to date, as a model system. Due to the monophasic behavior of Li2MnP2O7 with delithiation, the Mn valency of Li2-xMnP2O7 (x = 0.3, 0.5, 1) can be controlled with negligible change in the crystal framework (e.g., volume change similar to 1%). Moreover, inductively coupled plasma mass spectrometry, X-ray photoelectron spectroscopy, ex-situ X-ray absorption near-edge structure, galvanostatic charging discharging, and cyclic voltammetry analysis indicate that Li2-xMnP2O7 (x = 0.3, 0.5, 1) exhibits high catalytic stability without additional delithiation or phase transformation. Notably, we observed that, as the averaged oxidation state of Mn in Li2-xMnP2O7 increases from 2 to 3, the catalytic performance is enhanced in the series Li2MnP2O7 &lt; Li1.7MnP2O7 &lt; Li1.5MnP2O7 &lt; LiMnP2O7. Moreover, Li2MnP2O7 itself exhibits superior catalytic performance compared with MnO or MnO2. Our study provides valuable guidelines for developing an efficient Mn-based catalyst under neutral conditions with controlled Mn valency and atomic arrangement.N