Manual for Country-Level Nutrition Advocacy Using PROFILES and Nutrition Costing Presentation Slides Stakeholder Meeting on Nutrition Advocacy [Slides.

Manual for Country-Level Nutrition Advocacy Using PROFILES and Nutrition Costing
Presentation Slides Stakeholder Meeting on Nutrition Advocacy [Slides 3 – 102] PROFILES Workshop [Slides 103 – 252] Preliminary Results [Slides 253 – 282] Nutrition Advocacy Planning Workshop [Slides 283 – 378]

Instructions As part of the Manual for Country-Level Nutrition Advocacy Using PROFILES and Nutrition Costing, this compilation of slides can be used throughout the process: for the stakeholder meeting (slides 3–101); the PROFILES workshop (slides 102–250); preliminary results (slides 251–280); and nutrition advocacy (slides 281–375). Please consult the manual for detailed instructions and accompanying handouts. This tool is made possible by the generous support of the American people through the support of the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, U.S. Agency for International Development (USAID), under terms of Cooperative Agreement No. AID-OAA-A , through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID or the United States Government.

Stakeholder Meeting on Nutrition Advocacy Using PROFILES and Nutrition Costing
Presentation Slides

Welcoming Remarks

Purpose of Meeting To discuss:
The current nutrition situation in [insert country] and government priorities Time period for PROFILES Data sources for information and targets to be used as input for PROFILES Nutrition advocacy needs in [insert country] [Possible nutrition interventions to be costed]

Nutrition Situation in Country
Note to Facilitators: Slide 6 to 21 needs to be shared with experts in country to prepare this presentation and present these slides

Presentation Outline Nutrition situation in country
Consequences of prevailing situation Government priorities Current initiatives Policy environment Commitments 28 9 14 Percent of children under 5

Malnutrition in [Insert Country]
Sources:

Underweight

Stunting

Wasting

Iodine deficiency

Iron deficiency

Anemia

Infant and young child feeding

Consequences of Prevailing Situation

Government Priorities

Current Initiatives

Policy Environment

Commitments

Thank you

Global Progress on Nutrition

Presentation Outline What is the problem and why does it matter?
Why invest in nutrition and why now? What are the benefits of improved nutrition? How many children are affected? What are the types of malnutrition? What are the causes of malnutrition? What has been the global progress on nutrition?

What Is the Problem and Why Does It Matter?
Malnutrition still affects an estimated 155 million preschool children in developing countries. Malnourished children have an increased risk of: Illness and infections Delayed development and cognitive deficits Poorer school performance Mortality Nearly 50 percent of all child mortality is directly or indirectly a result of malnutrition. Over time and at an aggregate level, this undermines human capital and economic productivity and can limit progressin achieving the Sustainable Development Goals and the World Health Assembly targets.

Why Invest in Nutrition and Why Now?
Nutrition is a foundation for health and as such is a human right. Nutrition is an essential building block to achieve the Sustainable Development Goals and the World Health Assembly Targets. Nutrition is a best investment— every US$1 spent on reducing malnutrition has at least a $16 return (Global Nutrition Report 2015) Nutrition interventions are highly cost-effective for a resource-poor country. Nutrition is central to development—in essence it is not only a human right, but a necessary and essential building block for a country to achieve health and development goals. It has also been identified as a best investment and as one of the most cost-effective interventions for a resource-poor country.

What Are the Benefits of Improved Nutrition?
Improved nutrition will… Reduce infection and illness in children Improve growth and development, cognitive function, and school performance in children Reduce mortality in infants, children, and mothers Increase economic productivity There are several important benefits of improved nutrition, including reduced mortality, improved child growth, cognitive development, and school performance in children, reduced infections, and increased economic productivity.

Under-5 Child Mortality
Malnutrition ~45% The yellow portion of the graph shows the neonatal mortality and the blue area shows the causes of under 5 mortality after the neonatal period of 0-27 days. Neonatal (0-27 days) Under 5 deaths after the neonatal period (1-59 months) Source: Under-5 mortality: WHO-MCEE Methods and Data Sources for Child Cases of Death (Global Health Estimates Technical Paper. WHO/HIS/IER/GHE/2016.1; Malnutrition: Black et al “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” The Lancet. Vol. 382.

Under-5 Child Mortality Attributed to Malnutrition (%)
Under 5 child mortality is attributed to different forms of malnutrition. The different forms of malnutrition that affect under 5 child mortality are shown and the proportion of deaths attributed to that malnutrition problem is shown. Source: Black et al “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” The Lancet. Vol. 382.

How Many Children Are Affected?
Globally, nearly 165 million children under 5 are chronically malnourished (World Bank/WHO/UNICEF 2011 estimates) 124 million of these children are in sub-Saharan Africa (56 million) and South Asia (68 million)

Children Under 5 Affected by Moderate and Severe Stunting
Prevalence Estimate (%) Number Affected (Million) Region 2000 2016 East Asia & Pacific 25 12 36 19 Latin America & Caribbean 18 11 6 Middle East & North Africa 23 15 9 8 South Asia 51 89 62 Sub-Saharan Africa 43 34 50 57 Global 33 198 155 Joint estimates from the World Bank, UNICEF, and the World Health Organization show that chronic malnutrition affects 40 and 37 percent of children under 5 years of age in sub-Saharan Africa and South Asia, respectively. In fact, the prevalence of chronic malnutrition in sub-Saharan Africa is rising relative to other regions. Importantly these are the two regions with the greatest number of children affected by moderate and severe stunting, 56 million children in sub-Saharan Africa and 68 million in South Asia. Source: United Nations Children’s Fund, World Health Organization, World Bank. UNICEF, WHO-World Bank Joint Child Malnutrition Estimates. UNICEF, New York; WHO, Geneva; World Bank, Washington, DC; 2017.

Types of Malnutrition Malnutrition can take many forms, which can co-exist. These include: Underweight (low weight-for-age) Stunting (low height-for-age) Wasting (low weight-for-height) Overweight and obesity Low birth weight (birth weight of less than 2.5 kg) Iron deficiency anemia Vitamin A deficiency Iodine deficiency Multiple micronutrient deficiencies All forms of malnutrition, except iodine deficiency, carry an increased risk of death. But the increased risk of death is different for each type of malnutrition.

Malnutrition Starts Early: Within 1,000 Days
Global average for healthy children Wasting (weight-for-height) Z-score Underweight (weight-for-age) Stunting (height-for-age) As shown in this figure, malnutrition often begins early—within the first 1,000 days (pregnancy through a child’s second birthday). Even when children are born with normal birth weight, they quickly become malnourished due to infections, poor infant and young child feeding and hygiene practices, and lack of water and sanitation. It is well established that action to address prevent and reduce malnutrition needs to begin during this critical window of opportunity. Age in months (data shown for developing countries) Source: Victora et al. Pediatrics. 2010

The Consequences of Malnutrition
Undernutrition often begins in the womb and its consequences can carry through to infancy, childhood, adolescence, adulthood, and the next generation. Undernutrition during pregnancy can lead to the birth of low birth-weight babies and continued childhood undernutrition. It is well established that preventing malnutrition among children under 2 should be the focus of nutrition interventions, but that there are other critical times within the life cycle when intervention is also critical including: under 5 years of age and during adolescence, pregnancy, and the postpartum period.

What Are the Causes of Malnutrition?
Source: UNICEF Multi-sectoral approaches to nutrition: Nutrition-specific and Nutrition-sensitive interventions to accelerate progress.

Global Progress on Stunting
This graph shows global progress on reducing stunting (chronic malnutrition). The highest burden of chronic malnutrition is in South Asia and the numbers of stunted children is actually increasing in sub-Saharan Africa, while it is decreasing in all other regions.

Global Progress on Scaling Up Nutrition
Prioritizing nutrition Repositioning nutrition (2006) Building alliances Scaling Up Nutrition movement Advocacy for nutrition Global, regional, national alliances for advocacy on scaling up nutrition

Overview of Nutrition Advocacy Process

Presentation Outline Nutrition Advocacy Terms and Approach
PROFILES and Nutrition Costing for [insert country]: Why and Why Now? Way Forward

Nutrition Advocacy Terms and Approach

What Is Nutrition Advocacy?
Planned process to ignite social change for movement toward greater political and social commitment to improve the nutrition situation Promotes accountability for nutrition and strengthens nutrition governance Defined and shaped by specific country context Can support a country at any stage of commitment

What Is PROFILES? An evidence-based tool to support nutrition advocacy
Consists of a set of computer-based models that calculate consequences if malnutrition does not improve over a defined time period and the benefits of improved nutrition over the same time period, including lives saved, disabilities averted, human capital gains, and economic productivity gains (or, put another way, economic productivity losses averted) PROFILES also includes a section where estimates are calculated for two risk factors of stunting – inadequate dietary diversity and teenage pregnancy Based on reduction in the prevalence of several nutrition problems, such as iron deficiency anemia; low birth weight; vitamin A deficiency; iodine deficiency; suboptimal breastfeeding practices; and childhood stunting, underweight, and wasting Requires current country-specific nutrition data that are identified and agreed upon in collaboration with stakeholders in country Results can be used to engage government and other high-level stakeholders in a collaborative process to identify, prioritize, and advocate evidence-based actions to reduce malnutrition Refer to slide.

What Need Was it Meant to Address?
“Before we had PROFILES, all we had were pictures of malnourished children” – PROFILES workshop participant

Nutrition Problems Addressed in PROFILES and the Benefits of Their Reduction
This slide shows that for a specific nutrition indicator, PROFILES calculates an estimate for a specific outcome. So a reduction in maternal iron deficiency anemia would result in a reduction in maternal and perinatal mortality (this is what we know from the scientific literature). If iron status improves, there would be fewer maternal and perinatal deaths as a result. Similarly, a reduction in low birth weight would reduce infant mortality. A reduction in vitamin A deficiency in children would reduce child mortality. A reduction in iodine deficiency during pregnancy would reduce permanent disabilities in children. A reduction in stunting, underweight, wasting, and sub-optimal breastfeeding practices would reduce child mortality. A reduction in sub-optimal breastfeeding practices can also help to reduce childhood overweight/obesity. Similarly, a reduction in stunting would increase human capital through improved learning potential in childhood. And lastly, a reduction in stunting, low birth weight, anemia, and iodine deficiency would increase economic productivity. PROFILES also estimates economic productivity losses if there is no change in the nutrition situation.

What Needs to Be Determined for PROFILES?
Data Sources (What sources of information do we use?) Period (What period should we use for the estimates? Does it need to correspond to national vision documents? How much time do we need to see real change?) Targets (What is our goal for prevalence during this period?) Refer to slide.

What Is Nutrition Costing?
Estimates the costs of implementing a comprehensive set of nutrition programs in a country or prioritized geographic area over a specified period Involves a collaborative exercise to: Identify an appropriate structure for the nutrition program Select interventions and activities Determine a management structure Select an approach for service provision Identify inputs and obtain unit costs

How Are PROFILES and Nutrition Costing Used?
PROFILES and nutrition costing estimates are the cornerstones of this nutrition advocacy planning process Using a consensus-building approach coupled with systematic planning with government and nongovernment stakeholders, country teams develop nutrition advocacy plans and targeted materials to disseminate PROFILES results to key audiences

Nutrition Advocacy Process in Summary

Nutrition Advocacy Process in Summary
PROFILES and nutrition costing are helpful in situations where: Advocacy processes for nutrition need to be: Tools such as PROFILES and nutrition costing provide: The prevalence of many forms of malnutrition are high Investment, commitment, governance, and accountability for nutrition is low Nutrition services are fragmented and not holistic Based on a sound understanding of the current country context for nutrition (scale of problem, visibility, commitment, investment, and accountability) Systematic, planned, and deliberate, involving key stakeholders and targeting key audiences Part of a collaborative effort at the country level including multiple stakeholders (government and nongovernment) Multisectoral—obtaining buy-in of stakeholders across sectors Targeted at key audience segments that are influential and that can promote accountability and good governance Insight for action Consensus building and a shared vision for nutrition (“one voice”) Accountability and goal setting for investment in nutrition across the lifecycle, including services along a continuum of care for the prevention and treatment of malnutrition

PROFILES and Nutrition Costing for [insert country]: Why and Why Now?

[Tailor text to each country: example text below] PROFILES and Nutrition Costing for [insert country]: Why and Why Now? Although some progress has been made to reduce malnutrition, the number of children who suffer from chronic and acute malnutrition in this country is unacceptable A lack of coordination in nutrition programming continues to exist despite concerted efforts This process would assist the Government of [insert country] and partners to promote accountability and governance for nutrition in support of existing efforts to reduce malnutrition The process of developing estimates uses a consensus-building approach, which engages stakeholders to consider the benefits of improved nutrition and the cost of providing nutrition services at scale

Way Forward

Illustrative Timeline for Nutrition Advocacy Planning Process and Implementation

Approach Used in PROFILES

What Approach Is Used in PROFILES to Calculate Estimates?
The basic approach of PROFILES is to provide two scenarios: Status quo scenario Assumes there will be no change from the current situation throughout a specified period (aside from projected changes in population size and structure) The consequences are expressed as lives lost and economic productivity losses Improved scenario Assumes that the nutrition situation improves and the stated targets are reached for the various forms of undernutrition for the same specified period The benefits are expressed as lives saved and economic productivity gains PROFILES calculates estimates based on two scenarios: the status quo scenario and the improved scenario. The status quo scenario assumes that over a selected time period for which we want PROFILES to calculate estimates (for example, 10 years), that the prevalence of undernutrition will remain the same (unchanged) throughout. This helps us calculate the number of deaths or the economic losses that would occur during the selected time period if the nutrition situation did not improve. In contrast, in the improved scenario, we assume that the nutrition situation does improve over the selected time period, and in the PROFILES spreadsheet we input the target prevalence that we assume will be reached by the end of the selected time period. While PROFILES itself does not use interventions or coverage information in calculating the estimates, we assume that the improvement in nutrition indicators in the improved scenario will be a result of effective interventions that will be implemented at scale and that they achieve the chosen targets. With the reduced prevalence by the end of the time period in the improved scenario, the PROFILES spreadsheets calculate the number of deaths and the magnitude of economic losses that would occur during the selected time period if the nutrition situation does improve. Finally, PROFILES calculates the difference between the status quo scenario and improved scenario; this difference between the two scenarios is the lives saved or deaths averted—or in terms of economic productivity is the economic gains or economic losses averted.

Approach Used in PROFILES to Calculate Estimates (Example)
Figure C. Improved Scenario and Status Quo Scenario Figure A. Status Quo Scenario Figure B. Improved Scenario Annual number of under-5 deaths This slide provides an illustrative example of the approach used in PROFILES to calculate estimates for child deaths (and lives saved) related to stunting. Figures a–c provide an illustrative example of the approach used in PROFILES to calculate estimates for child deaths (and lives saved) related to stunting. (Information shown in these graphs is not from [insert country] PROFILES [insert year].) For the purpose of providing an example of how PROFILES calculates the estimates for the status quo and the improved scenario, the number of children under 5 has been kept constant. But, in the actual PROFILES model, there is usually an increase in the number of children under 5 each year based on population projections. The graphs show how the status quo scenario (Figure a) vs. the improved scenario (Figure b) is used to provide estimates of lives saved (or deaths averted) related to stunting among children under 5 years during a 10-year period. Figure c shows the number of lives saved, calculated by subtracting the number of deaths in the improved scenario from the number of deaths in the status quo scenario. A comparable approach is used in PROFILES to estimate the number of lives saved (or deaths averted) related to other nutrition indicators and to estimate economic productivity gains related to selected nutrition indicators.

What Are the Assumptions in PROFILES?
The estimates that PROFILES calculates are based on several assumptions: Assumption 1 The periods are the same in the two scenarios Assumption 2 In the status quo scenario, the prevalence of various forms of undernutrition remain unchanged, and consequently there is no improvement in health or economic outcomes. This is presented as lives lost for the health outcomes, and economic productivity losses for the economic outcomes The estimates that PROFILES calculates are based on a few key assumptions. For example in PROFILES, we assume that if undernutrition is reduced that over time this would lead to improvements in health and economic outcomes. In the status quo scenario, we assume that the prevalence of various forms of undernutrition does not improve over time and this results in no improvements in health and economic outcomes. The status quo scenario assumes there will be no change from the current situation throughout the chosen time period (the number of years for which estimates are calculated), aside from projected changes in population size and structure. The prevalence of each nutrition problem remains the same every year in the status quo scenario. PROFILES assumes no other changes aside from changes in population size and structure.

If different forms of undernutrition are reduced, health and economic outcomes will improve over time. Assumption 4 In the improved scenario, reducing the prevalence of different forms of undernutrition has corresponding improvements in specific health and economic productivity outcomes. This is presented as lives saved for the health outcomes and economic productivity gains for the economic outcomes. In order to calculate estimates in PROFILES we need to agree on the time period for which estimates will be calculated (for example, 10 years). We also make assumptions to calculate estimates in the improved scenario; for example we assume that over the selected time period if undernutrition were reduced by a certain amount, that lives would be saved and there would be economic productivity gains. In this regard we make an assumption about how much nutrition will improve over the selected time period. As such, to calculate estimates in the improved scenario we need to set targets for the reduction of various forms of undernutrition.

Assumption 4 (continued) To calculate the estimates in the improved scenario, there is a need to set targets for the reduction of each of the various forms of undernutrition. In consultation with stakeholders and PROFILES workshop participants, there is a need to discuss and agree on the size of the reduction for each form of undernutrition. These targets consider national commitments/vision and planning to determine the size of the reduction and the period required to improve the nutrition indicators (or other international guidance standards). For setting the targets, participants in this workshop will provide inputs so decisions can be reached regarding by how much undernutrition will be reduced by the end of the selected time period. Setting the targets should be guided to an extent by the existing vision in the country, national and international commitments, and should also consider the secular trend in the reduction of undernutrition that is anticipated over the selected time period.

For the improved scenario, the nutrition situation improves and the stated targets are reached for the various forms of undernutrition. For example: Assumption 6 In the improved scenario, there is a linear reduction in the prevalence of the different forms of undernutrition. (A linear increase is expected for optimal breastfeeding). The prevalence at the beginning of the period is the same for the status quo and the improved scenarios. Prevalence at start of time period Target for reduction Target prevalence by the end of the time period 32.0% 0.3 (or 30 percent) 22.4% While PROFILES itself does not use interventions or coverage information in calculating the estimates, we expect that the improvement in nutrition indicators in the improved scenario will be a result of effective interventions that will be implemented at scale and that they achieve the chosen targets. Specific nutrition interventions (i.e. optimal breastfeeding counseling) are not input into the model to develop the PROFILES estimates. Rather, the improvement in the nutrition situation is based on the assumption that if nutrition interventions that are known to be effective are implemented at scale they will succeed in reaching the stated targets. Finally PROFILES also assumes a linear reduction in the prevalence of different forms of undernutrition.

Discussion of Time Period for Estimates

Time Period Discussion Questions
What time period should we use for the estimates? What time period corresponds to the national vision documents? How much time do we need to see real change? Examples from other countries include: Uganda (2013–2025) Ghana (2011–2020) Bangladesh (2011–2021)

Introduction to Group Work

Discussion Groups After Lunch
Group #1a: Anthropometry—data sources for PROFILES, current prevalence, and targets Group #1b: Proportion reduction in prevalence of micronutrient deficiencies—data sources for PROFILES, current prevalence and targets Group #1c: Breastfeeding and low birth weight—data sources for PROFILES, current prevalence and targets Group #1d: Stunting risk factors – data sources for PROFILES, current prevalence, and targets Group #1e: Other information (including employment and education)—data sources for PROFILES and targets Group #2: Advocacy needs Group #3: Nutrition costing

Group #1a: Information Needed for PROFILES Nutrition Problems
Undernutrition (mild, moderate, and severe): Stunting among children under 5 years Stunting among children 24–35 months Wasting among children under 5 years Underweight among children under 5 years

Group #1b: Information Needed for PROFILES Nutrition Problems
Vitamin A deficiency (including subclinical) among children under 5 years Iodine deficiency (% with goiter) Anemia among: Pregnant women Women (15–49 years) Children 6-59 months Children 5–14 years (if available) Men (15–64 years)

Group #1c: Information Needed for PROFILES Nutrition Problems
Percentage of children who weigh < 2,500 grams at birth Breastfeeding practices among children 0–5 months of age (% in each category): Early initiation of breastfeeding (within 1 hour of birth) Exclusive breastfeeding Predominant breastfeeding Partial breastfeeding No breastfeeding Breastfeeding practices among children 6–23 months of age (% in each category): Any breastfeeding

Group #1d: Risk Factors of Stunting
Inadequate dietary diversity (fewer than 4 foods groups) among children 6–23 months of age (%) Proportion of children born to a mother less than 20 years of age (%)

Group #1e: Other Information Needed for PROFILES
Total population (most recent official estimate/projection) Mortality Maternal mortality ratio Neonatal mortality rate Infant mortality rate Under-5 mortality rate Perinatal mortality rate Education Primary school starting age Years of schooling (duration of universal primary schooling)

Group #1e: Other Information Needed for PROFILES (continued)
Employment in all sectors: Employed/population (%) (economic activity rate) Employment in manual labor: Employed/population (%) Females employed/population (%) Males employed/population (%) Proportion of manual labor that is “heavy” (around 10% is often used in PROFILES) Average annual wage for manual labor and all sectors (national currency) Exchange rate (per US$1); gross domestic product per capita

Group #2: Advocacy Needs
Overarching problem with the state of nutrition in the country Changes that need to occur (at the enabling environment level) to improve the situation

Group #3: Nutrition Costing
Nutrition interventions based on the current policy environment, the national goals and commitments for nutrition, and the evidence base in the nutrition literature Target groups for these interventions, level of coverage, and intensity of interventions

Nutrition Advocacy Needs Discussion Group

Objectives of the Session
Discuss the overarching problem with the state of nutrition in the country Discuss the changes that need to occur (at the enabling environment level) to improve the situation

How This Activity Fits into the Approach
This is the first step in the development of a national nutrition advocacy plan that will be developed in the nutrition advocacy planning workshop (dates to be determined)

How Advocacy, Social Mobilization, and BCC Support Each Other
Analysis of audiences determines the mix of strategies: Advocacy to raise resources and political/social commitment for change goals Social mobilization for wider participation, collective action, and ownership, including community mobilization Behavior change communication (BCC) for changes in knowledge, attitudes, and practices of specific audiences Here you will see how the three components of a successful social and behavior change program support each other. Advocacy raises resources and political/social commitment for change goals Social mobilization creates wider participation, collective action, and ownership at the community level Behavior change communication creates changes in knowledge, attitudes, and practices of specific audiences, specifically at the household level What we know works to change social norms are sustained communication programs that work at multiple levels with multiple channels. Strong policies, champions at national, state, and local levels, and strong civil society involvement, in addition to work at the household and community levels using counseling, school programs, and earned and paid media, for example, are all important components in a successful SBC program. These three components need to be planned for, and often advocacy needs to happen first to create the enabling environment for change to happen in the other levels. For example, policies may need to be put into place or, if services or products are being promoted through communication at the household level, it’s essential that those services or products be available and accessible; otherwise, your communication will lose credibility.

Socio-Ecological Model
Levels of analysis: Where is the tipping point for change? Self: Who is directly affected? Partners, Family, Peers: Who is directly influencing “self”? Local Community, Services, Products, and Leaders and Providers: Who or what is directly influencing “self” at the local level? National Enabling Environment and Leaders: Who or what is indirectly affecting “self” at the national level? Crosscutting Factors: Information, Motivation, Ability to Act, and Norms: How are these factors addressed across all levels? For interventions aimed at improving the nutritional status of the population in the country to be successful, especially that of nutritionally vulnerable groups within the household, they must include a comprehensive strategy to improve knowledge, attitudes, beliefs and behaviors related to nutrition. Such changes are often difficult to change and require more than providing correct information about prevention of undernutrition. For individuals to be able to change behavior, key factors affecting the individuals themselves and those directly or indirectly influencing them need to be addressed, including motivation, the ability to act (including self-efficacy), and social/gender norms. This model of behavior change, known as the socio-ecological model supports the theory that individual behavior is a product of multiple overlapping individual, social, and environmental influences, and combines individual change with the aim to influence the social context in which the individual operates. The socio-ecological model for change is based on a synthesis of theories and approaches from disciplines such as psychology, sociology, communication, and political science. The model allows practitioners to examine and address several levels of influence to find opportunities for change. Each of those audiences fit within the categories in this model. Advocacy audiences fit within the enabling environment; social mobilization audiences fit within the community; and behavior change audiences fit within the areas of interpersonal and self.

Activity #1: Why Are We Here?
In groups of 2–3, discuss what the overarching problem is in [insert country] with regard to nutrition. Each group should write down one thought per card. (15 minutes)

Visualization in Participatory Programs (VIPP) Rules
One thought per card Write with a marker, not a pen Write with broad side of marker No more than three lines per card

Activity #2: What Changes Need to Occur?
In groups of 2–3, discuss what changes would need to occur at the enabling environment level to improve the situation. Each group should write down one thought per card. (15 minutes)

Data Sources and Targets Discussion Group

Discuss potential data sources and targets for five topic areas: Anthropometry Micronutrients Breastfeeding and low birth weight Risk factors of stunting Other information (e.g. demographic, employment information)

This is one of the first steps in developing PROFILES estimates During the PROFILES workshop, a small task team will work with the PROFILES spreadsheets to develop PROFILES results Preliminary PROFILES results will be presented immediately after the PROFILES workshop The results will be used to develop advocacy materials and conduct advocacy activities

Activity Split up into five groups: Anthropometry Micronutrients
Low birth weight and Breastfeeding Risk factors of stunting Other information (e.g. demographic, employment information)

Activity Address these questions in each subgroup (35 minutes):
What sources of information should we use? What is the current prevalence of the problem? What targets should we set for the end of the period? What interventions are currently being implemented to alleviate the problems? What assumptions can we make about the interventions by the end of the period?

Activity On each [insert color] card, write down one data source. On each [insert color] card, write down one target. Place the cards on a flipchart for discussion.

Visualization in Participatory Programs (VIPP) Rules
One thought per card Write with a marker, not a pen Write with the broad side of the marker No more than three lines per card

Nutrition Costing Discussion Group

Discuss nutrition interventions based on the current policy environment, the national goals and commitments for nutrition, and the evidence base in the nutrition literature Discuss nutrition-specific and nutrition-sensitive interventions Discuss what could be realistically costed given potential data limitations Vote on the interventions that should be costed Discuss the target groups for these interventions, the level of coverage, and the prevalence and forms of malnutrition in different parts of the country to determine whether interventions should be implemented equally everywhere

This will be the first step for costing a national nutrition program in [insert country] A costing team is being assembled that will work on the costs of developing and scaling up a nutrition program in the country The initial results will be presented in the next few months This is the first opportunity for stakeholders to contribute to what needs to be considered in costing a national nutrition program

Activity #1: Review the National Policy and List Interventions for Costing
The group will discuss the following questions and the facilitator will make a list of interventions to be costed by writing each on a card (40 minutes): Is the policy clear on which interventions should be included in a national nutrition program? What are they? Are any interventions missing? What are the challenges? Can any nutrition-sensitive interventions be added? What could be realistically costed given potential data limitations?

Activity #2: Voting on Interventions to Cost
Each person can cast five “votes” by placing a dot on the card of the intervention they would like to prioritize.

Activity #3: Deciding Which Interventions Can Be Costed
As a group, discuss the following topics for each prioritized intervention or set of interventions (40 minutes): Target groups for interventions Level of coverage Prevalence and forms of malnutrition across the country and within regions to determine whether interventions would be implemented with the same intensity everywhere

Plenary Discussion by the Groups

Group #1a: Data Sources and Targets
Anthropometry Data sources: Prevalence: Targets:

Group #1b: Data Sources and Targets
Micronutrients Data sources: Prevalence: Targets:

Group #1c: Data Sources and Targets
Breastfeeding and low birth weight Data sources: Prevalence: Targets:

Group #1d: Data Sources and Targets
Risk factors of stunting Data sources: Prevalence: Targets:

Group #1e: Data Sources and Targets
Other information Data sources: Prevalence: Targets:

Group #2: Nutrition Advocacy Needs
Discussion question: What is the overarching problem with the status of nutrition in the country?

Group #2: Nutrition Advocacy Needs
Discussion question: What are the changes that need to occur (at the enabling environment level) in order to improve the situation?

Interventions to be costed:

Target groups for interventions: Level of coverage: Intensity of interventions:

The PROFILES Workshop to Generate Estimates for Nutrition Advocacy
Presentation Slides

Session 1: Welcome and Introduction to the PROFILES Workshop

Welcoming Remarks

Session Objectives By the end of the session, participants will have:
Introduced themselves and their organization and shared their expectations for the workshop Set ground rules for the workshop Understood the purpose of the workshop in relation to the broader nutrition advocacy planning process Reviewed the workshop agenda

Introductions Please introduce yourself, including: Your name
Your organization Your role in your organization

Introductions (continued)
Pair up with someone near you and ask each other: “What is your interest in nutrition advocacy?” (Take 3 minutes) In plenary, share your expectations for the workshop.

Visualization in Participatory Programs (VIPP)—So Everyone’s Voice Is Heard
Rules: One thought per card Use a marker, not a pen Write with broad side of marker No more than three lines per card Print legibly “The purpose of using the Visualization in Participatory Programs (VIPP) process is to promote participation throughout the workshop. In essence, VIPP is a participatory process to ensure that everyone’s voice in the workshop is heard as everyone is allowed time to write down and then share their thoughts. Because everyone shares their thoughts and then eventually votes on decisions (depending on the activity), this process also helps the group reach consensus on important topics.”

Ground Rules To establish ground rules for the workshop, set up one flipchart paper with a vertical line down the middle. Start the game “Topsy Turvy” by asking the question: “If you wanted to make this workshop not successful, what would you do? For example, talk on the phone during sessions, come in late, sleep, etc.” Write each idea down on a VIPP card and tape them on the left side of the flipchart. Then ask: “So, what will make this workshop successful?” (e.g., turn our phones on silent, be on time, and be engaged). Write each idea on a VIPP card and tape them on the right side of the flipchart. Ask the participants if they agree that the ideas on the right side of the flipchart are the ground rules.

Purpose of the Workshop
To complete the PROFILES spreadsheets and generate preliminary results that, once finalized, will be used in nutrition advocacy

Review of Agenda How this workshop fits into the nutrition advocacy planning process … Ask participants to briefly review the agenda. Note how this workshop is one step in the nutrition advocacy planning process. Note this process may differ from country to country and workshop to workshop. Revise as needed. This nutrition advocacy planning process usually takes the following form: First the stakeholder meeting is held where participants first discuss information needed to input into the PROFILES spreadsheet and current nutrition advocacy needs. Next the PROFILES workshop is held where participants input information into the PROFILES spreadsheet and preliminary estimates to be used in nutrition advocacy materials are created. Then the preliminary results meeting is held to disseminate the results of the workshop. Finally the advocacy workshop is held to create advocacy materials based on the needs of the country. Nutrition costing may be done in parallel to the other nutrition advocacy steps.

You Are Here Refer to slide. Adapt as necessary.

Questions?

Session 2: Review of the Nutrition Advocacy Approach and Overview of the Stakeholder Meeting
Note: If a stakeholder meeting was not held, hide the slides in this session that appear after “What Needs to Be Determined for PROFILES?” to provide only information on the PROFILES process and approach. If a stakeholder meeting was held, explain that a group of stakeholders from multiple sectors (including many of you) met to discuss nutrition advocacy using PROFILES and nutrition costing. We’d like to recap the discussions that took place during the stakeholder meeting, walk through the process for nutrition advocacy, and share some definitions of what we mean by some of the terms we’ll be using in this workshop. Note: If a stakeholder meeting was not held, hide the slides in this session that appear after “What Needs to Be Determined for PROFILES?” to provide only information on the PROFILES process and approach.

Reviewed the causes of malnutrition and the benefits of improved nutritional status Reviewed the nutrition advocacy planning process, what PROFILES is, and how it can be used to support nutrition advocacy Reviewed the outcomes of the nutrition advocacy stakeholder meeting held on [XXX] Discussed the country’s nutrition advocacy needs This slide shows the learning objectives for this session. Call upon participants who were present at the stakeholder meeting and ask them to share their observations, thoughts, and the take away from the stakeholder meeting. Note: The facilitator should be prepared with his/her notes from the stakeholder meting in case any important points are not mentioned by participants. The facilitator should then bring up these points for discussion.

What Is the Problem and Why Does It Matter?
Malnutrition affects an estimated 155 million preschool children in developing countries Malnourished children have an increased risk of: Illness and infections Delayed development and cognitive deficits Poorer school performance Mortality Globally, nearly 50% of all child mortality is directly or indirectly a result of malnutrition Over time and at an aggregate level, this undermines human capital and economic productivity and can limit progress in achieving at least 8 of the 17 Sustainable Development Goals and the World Health Assembly Targets

Why Invest in Nutrition and Why Now?
Nutrition is a foundation for health and as such is a human right Nutrition is a best investment—for every US$1 spent on nutrition, there is a US$16 return in health and economic benefits (IFPRI 2015) Nutrition interventions are highly cost-effective interventions for a resource- poor country Nutrition is central to development—in essence it is not only a human right, but a necessary and essential building block for a country to achieve health and development goals. It has also been identified as a best investment and as one of the most cost-effective interventions for a resource-poor country. International Food Policy Research Institute Global Nutrition Report 2015: Actions and Accountability to Advance Nutrition and Sustainable Development. Washington, DC. Available at

What Are the Benefits of Improved Nutrition?
Improved nutrition will: Reduce infection and illness in children Improve child growth and development, cognitive function, learning ability, and school performance in children Reduce mortality in infants, children, and mothers Increase economic productivity There are several important benefits of improved nutrition, including reduced mortality; improved child growth, cognitive development, and school performance in children; reduced infections; and increased economic productivity.

Under-5 Child Mortality
Malnutrition ~45% The yellow portion of the graph shows the neonatal mortality and the blue area shows the causes of under 5 mortality after the neonatal period of 0-27 days. Neonatal (0-27 days) Under 5 deaths after the neonatal period(1-59 months) Source: Under-5 mortality: WHO-MCEE Methods and Data Sources for Child Cases of Death (Global Health Estimates Technical Paper. WHO/HIS/IER/GHE/2016.1; Malnutrition: Black et al “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” The Lancet. Vol. 382.

Under-5 Child Mortality Attributed to Malnutrition (%)
Under 5 child mortality is attributed to different forms of malnutrition. The different forms of malnutrition that affect under 5 child mortality are shown and the proportion of deaths attributed to that malnutrition problem is shown. Source: Black et al “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” The Lancet. Vol. 382.

Children Under 5 Affected by Moderate and Severe Stunting
Prevalence Estimate (%) Number Affected (Million) Region 2000 2016 East Asia & Pacific 25 12 36 19 Latin America & Caribbean 18 11 6 Middle East & North Africa 23 15 9 8 South Asia 51 89 62 Sub-Saharan Africa 43 34 50 57 Global 33 198 155 Joint estimates from the World Bank, UNICEF, and the World Health Organization show that chronic malnutrition affects 40 and 37 percent of children under 5 years of age in sub-Saharan Africa and South Asia, respectively. In fact, the prevalence of chronic malnutrition in sub-Saharan Africa is rising relative to other regions. Importantly these are the two regions with the greatest number of children affected by moderate and severe stunting, 56 million children in sub-Saharan Africa and 68 million in South Asia. Source: United Nations Children’s Fund, World Health Organization, World Bank. UNICEF, WHO-World Bank Joint Child Malnutrition Estimates. UNICEF, New York; WHO, Geneva; World Bank, Washington, DC; 2017.

Most forms of malnutrition carry an increased risk of death.
Types of Malnutrition Malnutrition can take many forms, and different forms of malnutrition can co-exist. These include: Underweight (low weight-for-age) Stunting (low height-for-age) Wasting (low weight-for-height) Overweight and obesity (high weight-for-height) Low birth weight (birth weight of less than 2.5 kg) Iron deficiency anemia Vitamin A deficiency Iodine deficiency Micronutrient deficiencies Most forms of malnutrition carry an increased risk of death. But the increased risk of death is different for each type of malnutrition.

Malnutrition Starts Early: Within 1,000 Days
Global average for healthy children Wasting (weight-for-height) Z-score Underweight (weight-for-age) Stunting (height-for-age) As shown in this figure, malnutrition often begins early—within the first 1,000 days (pregnancy through a child’s second birthday). Even when children are born with normal birth weight, they quickly become malnourished due to infections, poor infant and young child feeding and hygiene practices, and lack of water and sanitation. It is well established that action to address prevent and reduce malnutrition needs to begin during this critical window of opportunity. Age in months (Data shown for developing countries) Source: Victora et al "Worldwide Timing of Growth Faltering: Revisiting Implications for Interventions." Pediatrics. Vol. 125 (3) e473-e480.

The Consequences of Malnutrition
Undernutrition often begins in the womb and its consequences can carry through to infancy, childhood, adolescence, adulthood, and the next generation. Undernutrition during pregnancy can lead to the birth of low birth-weight babies and continued childhood undernutrition. It is well established that preventing malnutrition among children under 2 should be the focus of nutrition interventions, but that there are other critical times within the life cycle when intervention is also critical including: under 5 years of age and during adolescence, pregnancy, and the postpartum period. Source: Adapted from ACC/SCN Fourth Report on the World Nutrition Situation. Geneva: ACC/SCN in collaboration with IFPRI.

What Are the Causes of Malnutrition?
Source: UNICEF Multi-sectoral approaches to nutrition: Nutrition-specific and Nutrition-sensitive interventions to accelerate progress.

What Is Nutrition Advocacy?
Planned process to ignite social change for movement toward greater political and social commitment to improve the nutrition situation Promotes accountability for nutrition and strengthens nutrition governance Defined and shaped by specific country context Can support a country at any stage of commitment Give participants the Handout: Advocacy to Reduce Malnutrition: Using PROFILES and Nutrition Costing. Note: After presentation of this slide, inform participants that examples of work FANTA has supported in other countries, including reports and other products, are available on a table in the room for them to browse.

Analysis of audiences determines the mix of strategies: Advocacy to raise resources and political/social commitment for change goals Social mobilization for wider participation, collective action, and ownership, including community mobilization Behavior change communication (BCC) for changes in knowledge, attitudes, and practices of specific audiences What we know that works to change social norms are sustained communication programs that work at multiple levels with multiple channels. Initiatives that have been most successful at changing social norms over the past few decades have used advocacy, social mobilization, and behavior change communication channels to reinforce messages and create an environment conducive to change. This construct is based on the socio-ecological model of change which emphasizes that people are influenced by the world in which they live, including the political, religious, economic, policy, and natural environment. We define advocacy as the efforts to raise resources and political and social commitment for change goals. Social mobilization is defined as actions for wider participation, collective action, and ownership, which includes community mobilization. And, behavior change communication is defined as efforts to change knowledge, attitudes, and practices of specific audiences.

Socio-Ecological Model
Levels of analysis: Where is the tipping point for change? Self: Who is directly affected? Partners, Family, Peers: Who is directly influencing “self”? Local Community, Services, Products, and Leaders and Providers: Who or what is directly influencing “self” at the local level? National Enabling Environment and Leaders: Who or what is indirectly affecting “self” at the national level? Crosscutting Factors: Information, Motivation, Ability to Act, and Norms: How are these factors addressed across all levels? For individuals to be able to change behavior, key factors affecting the individuals themselves and those directly or indirectly influencing them need to be addressed, including motivation, the ability to act (including self-efficacy), and social/gender norms. This model of behavior change, known as the socio-ecological model supports the theory that individual behavior is a product of multiple overlapping individual, social, and environmental influences, and combines individual change with the aim to influence the social context in which the individual operates. The socio-ecological model for change is based on a synthesis of theories and approaches from disciplines such as psychology, sociology, communication, and political science. The model allows practitioners to examine and address several levels of influence to find opportunities for change. Each of the audiences shown on the previous slide fits within the categories in this model. Advocacy audiences fit within the enabling environment; social mobilization audiences fit within the community; and BCC audiences fit within the areas of interpersonal and self.

Consists of a set of computer-based models that calculate consequences if malnutrition does not improve over a defined time period (e.g., 10 years) and the benefits of improved nutrition over the same time period, including lives saved, disabilities averted, human capital gains, reduced risk of childhood overweight/obesity, and economic productivity gains Based on reduction in the prevalence of several nutrition problems, such as anemia; low birth weight; vitamin A deficiency; iodine deficiency; suboptimal breastfeeding practices; and childhood stunting, underweight, and wasting PROFILES also includes estimates for two risk factors of stunting (inadequate dietary diversity and teenage pregnancy) Requires current country-specific nutrition data that are identified and agreed upon in collaboration with stakeholders in country Results can be used to engage government and other high-level stakeholders in a collaborative nutrition advocacy planning process Works to identify, prioritize, and advocate for evidence-based actions to reduce malnutrition

What Need Was it Meant to Address?
“Before we had PROFILES, all we had were pictures of malnourished children” – PROFILES workshop participant

This slide shows that for a specific nutrition indicator, PROFILES calculates an estimate for a specific outcome. So a reduction in maternal iron deficiency anemia would result in a reduction in maternal and perinatal mortality (this is what we know from the scientific literature). If iron status improves, there would be fewer maternal and perinatal deaths as a result. Similarly, a reduction in low birth weight would reduce infant mortality. A reduction in vitamin A deficiency in children would reduce child mortality. A reduction in iodine deficiency during pregnancy would reduce permanent disabilities in children. A reduction in stunting, underweight, wasting, and sub-optimal breastfeeding practices would reduce child mortality. A reduction in sub-optimal breastfeeding practices can also help to reduce childhood overweight/obesity. Similarly, a reduction in stunting would increase human capital through improved learning potential in childhood. And lastly, a reduction in stunting, low birth weight, anemia, and iodine deficiency would increase economic productivity. PROFILES also estimates economic productivity losses if there is no change in the nutrition situation.

The basic approach in PROFILES is to provide two scenarios: Status quo scenario Assumes there will be no change from the current situation throughout the chosen time period (aside from projected changes in population size and structure) The consequences are expressed, for example, as lives lost and economic productivity losses Improved scenario Assumes that the nutrition situation improves and that the stated targets are reached for the various forms of undernutrition by the end of the same time period The benefits are expressed, for example, as lives saved and economic productivity gains The basic approach in PROFILES is to provide two scenarios: a “status quo” scenario and an “improved” scenario. The status quo scenario assumes there will be no change from the current situation throughout the chosen time period (the number of years for which estimates are calculated), aside from projected changes in population size and structure. The prevalence of each nutrition problem remains the same every year in the status quo scenario. In contrast, in the improved scenario—with results estimated for the same time period—it is expected that nutrition interventions that are known to be effective are implemented at scale and succeed in reaching the stated targets in terms of improvements in the prevalence of the various nutrition problems. The targets reflect the proportion by which nutrition problems will be reduced by the end of the chosen time period and are determined and agreed upon through stakeholder meetings and a PROFILES workshop. In the status quo scenario, the negative consequences are expressed, for example, in terms of lives lost, disabilities, human capital lost, and economic productivity losses. When contrasting the results between the status quo and the improved scenarios, the differences reflect the benefits of improved nutrition, expressed as lives saved, disabilities averted, human capital gains, and economic productivity gains.

How Are PROFILES Estimates Used?
PROFILES estimates are the cornerstone of this nutrition advocacy planning process Using a consensus-building approach coupled with systematic planning with government and nongovernment stakeholders, country teams develop nutrition advocacy plans and targeted materials to disseminate PROFILES results to key audiences Note: only use this slide if you feel it is helpful, as this information is mentioned in an earlier slide.

What Needs to Be Determined for PROFILES?
Data Sources (What sources of information are used?) Time Period (What time period should the estimated be based on? Does it need to correspond to national vision documents? How much time is needed to see real change?) Targets (What should be the goal with regard to prevalence at the end of the given time period?) Each of these were discussed during the stakeholder meeting held on (insert date).

Recap of Information Discussed During the Stakeholder Meeting
During this session the facilitator should review the objective for the stakeholder meeting and how the discussions from that meeting will inform and enrich the discussions to be held during this current workshop. Present the following points: The stakeholder meeting brought together experts from multiple sectors (such as nutrition, health, agriculture, education, finance, information, and policy). Participants discussed the following during the meeting: Data sources to use in the spreadsheets for PROFILES A time period for the estimates calculated using PROFILES Targets for improvements in nutrition at the end of the chosen time period Nutrition advocacy needs Let participants know how far the stakeholders got in terms of identifying this information and if further discussion during the current workshop is required.

Stakeholder Meeting Time period for PROFILES [insert country, year, and time period decided upon] This is the time period that was agreed upon during the stakeholder meeting. [Here the facilitator or one of the participants from the stakeholder meeting should note the reasons why the time period was selected.]

Information Sources and Prevalence
Nutrition Indicators Source (Year) Prevalence Stunting among under-5 children [facilitator add information] Wasting among under-5 children Underweight among under-5 children Overweight/obesity among under-5 children Low birth weight Breastfeeding practices Late initiation of breastfeeding (≥ 1 hour after birth) Exclusive breastfeeding (0-5 months) No breastfeeding (0-5 months and 6-23 months) Vitamin A deficiency (0-59 months) Anemia Children <5 years of age Children 5-14 years of age Woman years of age Pregnant women Men Iodine deficiency (goiter) “Now we will review the data source and the prevalence that were agreed upon during the stakeholders meeting for each of the key nutrition indicators needed to input into the PROFILES spreadsheet. If it is necessary to complement the work done during the stakeholder meeting on sources of information and prevalence of nutrition problems, this can be discussed later in the following sessions.” Note: If many of the participants at the workshop were also at the stakeholder meeting, instead of reading this slide, the facilitator may choose to review this information in a more interactive manner by asking participants who were at the stakeholder meeting to provide the information for each indicator, revealing the answer after their response. The PPT has been set up to facilitate participation in this manner. Reminder: Write “not available” if data for anemia among men or children are not available.

Information Sources and Prevalence
Mortality, Education, and Economic Indicators Source (Year) Data Education information [facilitator add information] Employment information Maternal mortality ratio Mortality in the first 5 years of life Addressing Risk Factors of Stunting Source (Year) Data Inadequate dietary diversity [facilitator add information] Teenage pregnancy Ask participants to recall the main information sources discussed and potentially agreed upon for each of these indicator categories during the stakeholder meeting. Note: Similar to the previous slide, if many of the participants at the workshop were also at the stakeholder meeting, instead of reading this slide, the facilitator may choose to review this information in a more interactive manner by asking participants who were at the stakeholder meeting to provide the information for each indicator, revealing the answer after their response. The PPT has been set up to facilitate participation in this manner. Note that some of this information may not have been fully discussed or agreed upon during the stakeholder meeting and additional discussion may need to take place during the PROFILES workshop.

Target Setting Indicator
Current prevalence (used for status quo scenario) (%) Target prevalence [insert target final year] (%) Stunting among under-5 children Wasting among under-5 children Underweight among under-5 children Overweight/obesity among under-5 children Low birth weight Breastfeeding practices Early initiation of breastfeeding (within 1 hour) Exclusive breastfeeding (0-5 months and 4-5 months) No breastfeeding (0-5 months and 6-23 months) [facilitator add information] Vitamin A deficiency (0-59 months) Anemia Children <5 years of age Children 5-14 years of age Woman years of age Pregnant women Men Iodine deficiency (goiter) “Now we will discuss the targets that were set for each of the key nutrition indicators. If it is necessary to complement the work done during the stakeholder meeting on sources of information and prevalence of nutrition problems, this can be discussed later on in the following sessions.” Note: The facilitator will fill in this slide between the stakeholder meeting and the start of the workshop. Here the facilitator should briefly note the reasons why each target was selected (but leave it blank if it is still undecided or contentious). This should be done using notes from the stakeholder meeting. The facilitator may also choose to ask participants to provide input on each indicator, revealing the answer after their response. The PPT has been set up to facilitate participation in this manner. Reminder: Write “not available” if data for anemia among men or children are not available.

Target Setting – Risk Factors of Stunting
Indicator Current prevalence (used for status quo scenario) (%) Target prevalence [insert target final year] (%) Inadequate dietary diversity [facilitator add information] Teenage pregnancy “Now we will discuss the targets that were set for each of the stunting risk factors indicators. If it is necessary to complement the work done during the stakeholder meeting on sources of information and prevalence of nutrition problems, this can be discussed later on in the following sessions.” Note: The facilitator will fill in this slide between the stakeholder meeting and the start of the workshop. Here the facilitator should briefly note the reasons why each target was selected (but leave it blank if it is still undecided or contentious). This should be done using notes from the stakeholder meeting. The facilitator may also choose to ask participants to provide input on each indicator, revealing the answer after their response. The PPT has been set up to facilitate participation in this manner.

Activity: Recap of Stakeholder Meeting/Advocacy Needs Discussion
What is the problem? Why are we here? What changes does the problem call for? Note: This is where the facilitator will ask the group to look at the flipcharts from the stakeholder meeting and review and discuss the advocacy needs identified during the stakeholder meeting, including the problem and changes the problem calls for. The facilitator will ask participants to use VIPP cards to state what should be added or modified and stick these cards on the flipchart.

Flipchart in the Back of the Room
Please list any questions or comments you have on the nutrition advocacy planning process throughout the workshop. They will be addressed at the beginning of each day. “There is a flipchart located in the back of the room. Please list any questions or comments you have on any aspect of the nutrition advocacy planning process there, and your questions will be addressed at the beginning of each day.” Facilitator will now provide participants with the handout: Advocacy to Reduce Malnutrition: Using PROFILES and Nutrition Costing.

Session 3: Scientific Basis for PROFILES

Explored key relationships between nutrition and health and development outcomes Explored the scientific basis for PROFILES

Activity 1 In pairs, take 5 minutes to discuss:
Your thoughts about the nutrition problems in your country Your ideas on how you could use data to make the case for improved nutrition interventions/programs/services Conduct activity.

How Can We Use Evidence-Based Data to Make the Case for Greater Investment and Commitment to Nutrition? Research has established that various forms of malnutrition have a range of adverse impacts on health, education, human capital, and economic productivity. We can use these relationships to estimate the benefits of improved nutrition. PROFILES is a tool that helps make these connections to develop estimates of how improved nutrition benefits health and development outcomes. We know from scientific literature that malnutrition in its many forms has adverse impacts on various health and development outcomes. For example we know that different forms of malnutrition carry a different risk of mortality. Stunting, underweight, and wasting each carry a different risk of mortality risk. Building on this evidence, we can calculate the benefits of improved nutrition. PROFILES is a tool that does just this—it helps us calculate estimates of the benefits of nutrition in terms of health and development outcomes.

What Is the Scientific Basis from Which We Can Make This Case?
Economic outcomes Human capital outcomes Malnutrition Child stunting, underweight, and wasting Low birth weight Iron deficiency anemia Iodine deficiency Vitamin A deficiency Stunting Reduced cognitive function Lower economic productivity Lower physical capability results in lower wages Poorer school performance results in lower wages Suboptimal breastfeeding Reduced learning Health outcomes Increased child mortality Increased infant mortality Increased maternal and perinatal mortality Permanent brain damage and reduced IQ Increased risk of child overweight/ obesity This framework presents the main relationships for which PROFILES calculates estimates. For example, the prevalence of stunting, underweight, and wasting is entered into the PROFILES spreadsheet to calculate the number of child deaths at a population level—and this is presented in terms of lives saved and lives lost. Similarly, PROFILES calculates the number of infant deaths given the prevalence of low birth weight, the number of maternal and perinatal deaths related to iron deficiency anemia, the number of permanent disabilities in children (reduced IQ and brain damage) related to maternal iodine deficiency during pregnancy, the number of child deaths related to vitamin A deficiency, and the number of child deaths and increased risk of child overweight/obesity related to suboptimal breastfeeding practices. So, on the far right (under health outcomes), PROFILES calculates estimates of lives saved or lives lost from these various forms of malnutrition. Similarly PROFILES also calculates estimates for the relationship between stunting and learning, which falls under human capital. PROFILES also uses the prevalence of stunting, low birth weight, iron deficiency anemia, and iodine deficiency to calculate the impact on economic productivity gains or losses. The dark blue boxes with bolded text reflect the specific estimates that PROFILES calculates.

Malnutrition and Child Mortality
Note for facilitators: Listed in the upcoming slides is scientific evidence to support relationships examined in the PROFILES spreadsheet. Not all of the evidence presented is used in the actual spreadsheet and formulas, but have been included in this presentation as they provide additional context and clarity to the relationships examined by PROFILES. For a full list of references used in this presentation and the PROFILES spreadsheet, see the facilitator guide, which includes a PROFILES reference list and an additional reading list.

Malnutrition and Child Mortality
2013 Lancet studies provide further evidence of proportion of total deaths attributable to nutrition disorders 2008 Meta-analysis of 8 datasets from low-income countries showed underweight, wasting, and stunting all had significant associations with increased child disease and child mortality 1994 Meta-analysis estimates consequences of malnutrition (underweight and stunting) on child mortality based on 8 studies in 5 countries Consistent relationship between the two Increasing severity of malnutrition = increased risk of mortality; relationship is exponential The next few slides focus on the evidence behind each of these relationships. For example, over time we have learned that childhood malnutrition is a risk factor in child mortality. The first set of studies that showed this relationship date back to the 1980s, and a first meta-analysis of this data that looked at the relationship between underweight and child mortality was published by Pelletier et al. in Since then, there has been more recent analyses in the Lancet 2008 series that establish the relative risks or odds ratios of stunting, underweight, and wasting on child mortality. These later studies further reinforce this relationship. The Lancet 2013 studies provide an updated review of the risk of various forms of malnutrition on child mortality and provide a breakdown of the distribution of child deaths by types of nutrition disorders. Until the analyses published by Pelletier in 1994, an association between child malnutrition and mortality had been suspected, but strong evidence supporting that relationship had been lacking. Even though malnutrition prevalence, morbidity, and mortality rates vary across countries, the same exponential relationship is consistently observed. This same exponential relationship with death was shown in the Lancet 2008 studies. The study reaffirmed that stunting, wasting, and underweight, from mild to severe, each carried an independent risk of mortality: mild forms of stunting, wasting, and underweight carried the lowest risk of death, while severe forms of stunting, wasting, and underweight carried an exponential increased risk of death—with severe wasting carrying the highest risk of death. It is important to note that although more severe forms of malnutrition carry an increased risk of death, at a population level, there are often fewer severe cases, so a substantial number of deaths may be a result of moderate malnutrition as there are more children affected by moderate forms of malnutrition. 1980s Studies show relationship between malnutrition (underweight) and child mortality

Stunted Children This graph provides a simplified example. The green curve reflects the normal population in a context where the majority of the population is healthy. The curve in the red, however, illustrates a developing country population where the curve is shifted and a substantial percentage of children under five is moderately stunted. The percentage severely stunted is smaller, and—although the risk of dying is higher for children with severe stunting—a substantial proportion of child deaths attributable to stunting is related to moderate stunting.

Iron Deficiency Anemia and Maternal and Perinatal Mortality
Anemia during pregnancy is a contributor to: Maternal mortality through increased risk of death from postpartum hemorrhage Perinatal mortality, e.g., through increasing the risk of preterm delivery Stoltzfus et al. (2004) meta-analysis of 6 studies showed: Lower perinatal mortality is associated with a 1 g/dL increase in hemoglobin: OR 0.72 (95% CI: 0.65–0.81) Black et al. (2013) showed: Lower maternal mortality is associated with a 1 g/dL increase in hemoglobin: OR 0.71 Anemia during pregnancy is an important contributor to maternal mortality, including through an increased risk of death from postpartum hemorrhage. Anemia during pregnancy also contributes to perinatal mortality, e.g., through increasing the risk of preterm delivery. A recent effort to quantify this contribution (Stoltzfus et al. 2004) draws on a meta-analysis of six studies, using logistic regression to calculate, for each study, an estimate of the risk ratio associated with a one-unit difference in hemoglobin. (An overall risk ratio for the six studies was calculated in a random effects model [after testing for heterogeneity], weighting the individual estimates by the inverse of their within-study variances.) Perinatal mortality is associated with a 1 g/dL increase in hemoglobin: OR 0.72. In addition, the 2013 Lancet Series on maternal and child nutrition found that maternal mortality is associated with a 1 g/dL increase in hemoglobin: OR 0.71 (Black et al. 2013). For more specifics on how the models are calculated in the PROFILES spreadsheet please see the facilitator guide. Estimated decrease in maternal mortality risk for each 1 g/dL increase in hemoglobin during pregnancy.

Low Birth Weight and Infant Mortality
Low birth weight (LBW) is defined as less than 2,500 g LBW can be caused by preterm birth and/or intrauterine growth restriction LBW rate in a population is a good indicator of public health problems that include long-term maternal malnutrition, ill health, and poor health care. For individuals, LBW is an important predictor of newborn health and survival (UNICEF/WHO 2004). LBW infants are at higher risk of neonatal death: Term infants weighing 2,000–2,499 g at birth face four times the risk of neonatal death and twice the risk of post-neonatal death than do term infants weighing 2,500–2,999 g (Alderman and Behrman 2004) Low birth weight (LBW) is defined as less than 2,500 g (up to and including 2,499 g) LBW can be caused by preterm birth and/or intrauterine growth restriction LBW rate in a population is a good indicator of a public health problem that includes long-term maternal malnutrition, ill health, and poor health care. “The probability of infant mortality is estimated to be significantly higher for LBW than for non-LBW infants.” Additional information—use if needed: For term infants weighing 2,000-2,499 grams at birth the risk of neonatal death is four times as high and the risk of post-neonatal death is two times as high as for term infants weighing 2,500-2,999 grams and implies that the probability of an infant death (either neonatal or post-neonatal) drops by about for each birth in the 2,500-2,999 grams range instead of in the 2,000-2,499 gram range (Alderman and Behrman 2004).” PROFILES calculates the population attributable fraction and excess number of deaths related to LBW. PROFILES uses the values cited in Alderman and Behrman These values can be reviewed in the handout on the scientific basis. PROFILES uses relative risks together with the country-specific prevalence of LBW to calculate the population-attributable risk of neonatal and postneonatal infant mortality due to low birth weight. These are then applied to the country-specific levels of neonatal and postneonatal infant mortality to calculate the excess deaths due to low birth weight.

Suboptimal Breastfeeding
Suboptimal breastfeeding practices are related to increased neonatal, infant, and young child mortality (due to increased risk of infection). Late initiation of breastfeeding (after the first hour of birth) increases the risk of death in the neonatal period (first 28 days) (Khan et al. 2015; NEOVITA 2016), particularly in low resource, high-mortality contexts where infection causes a large proportion of newborn deaths. Suboptimal breastfeeding is related to increased neonatal, infant, and young child mortality (due to increased risk of infection). Late initiation of breastfeeding (after the first hour) increases the risk of death in the neonatal period (first 28 days), which is particularly evident in low-resource, high-mortality settings where infection is a main cause of newborn deaths. With recent declines in infant and child mortality globally, the prevention of neonatal mortality has become a higher priority, beginning with risk factors that are most easily addressed. PROFILES uses a relative risk (RR) of death on days 3-27 among “ever breastfed” infants of 1.53, derived by pooling the analyses of Khan et al. (2015 ) and NEOVITA (2016).

Suboptimal Breastfeeding
According to the 2013 Lancet Series on Nutrition, suboptimal breastfeeding results in more than 800,000 child deaths annually, which is 11.6% of deaths among that age group (Black et al. 2013). Two articles (Lamberti et al and Black et al. 2008) found that a lack of exclusive breastfeeding among infants 0–5 months and no breastfeeding among children 6–23 months are associated with increased risk of mortality. Suboptimal breastfeeding is related to increased infant and young child mortality (due to increased risk of infection). According to the 2013 Lancet Series on Nutrition suboptimal breastfeeding results in more than 800,000 child deaths annually, which is 11.6% of deaths of children younger than five years of age (Black et al. 2013). The Lamberti et al article found among infants 0-5 months of age, risk of all-cause mortality was almost three times higher in children who were partially breastfed and 14 times higher in children not breastfed as compared to children who were exclusively breastfed. Lamberti et al also found an increased risk of all-cause mortality (RR 3.69) for children 6-23 months who were not breastfed as compared to children who received any breastfeeding. Additional information: Two articles (Lamberti et al and 2013) found that a lack of exclusive breastfeeding among infants 0-5 months of age and no breastfeeding among children 6-23 months of age are associated with increased diarrhea morbidity and mortality and that suboptimal breastfeeding elevated the risk of pneumonia morbidity and mortality outcomes across age groups (0-23 months). In particular, pneumonia mortality was higher among not breastfed compared to exclusively breastfed infants 0-5 months of age (RR: 14.97; 95% CI: 0.67–332.74) and among not breastfed compared to breastfed infants and young children 6-23 months of age (RR: 1.92; 95% CI: 0.79–4.68).

Vitamin A Deficiency and Child Mortality
Vitamin A deficiency (VAD) reduces immunity to infections and increases both the severity and duration of illness. Vitamin A supplements in vitamin A-deficient populations significantly reduce child mortality (Beaton et al. 1992; Humphrey et al. 1992). A meta-analysis of vitamin A supplementation trials concluded that children 6–59 months living in vitamin A-deficient areas who received vitamin A supplements were, on average, 23% less likely to die than children not receiving supplements (Beaton et al. 1993). Children with VAD are at risk of blindness resulting from xerophthalmia, including corneal ulceration, and have a higher risk of dying from diarrhea, measles, and other diseases. The relationship between vitamin A deficiency and child mortality was shown in 1992 through a meta-analysis of several studies on vitamin A and child mortality. The meta-analysis found that supplementation with vitamin A resulted in a 23% mortality reduction. Vitamin A-deficient children are at risk of blindness resulting from xerophthalmia, including corneal ulceration, and have a higher risk of dying, from, e.g., diarrhea and measles.

Malnutrition, Disability, Childhood Overweight/Obesity, and Education Outcomes

Suboptimal Breastfeeding Practices and Overweight/Obesity
Suboptimal breastfeeding practices are associated with an increased risk of childhood overweight/obesity. Several meta-analyses have found that breastfeeding can help to reduce the future risk of overweight/obesity (Horta and Victora 2013; Horta et al. 2015; Yan et al. 2014; Harder et al ). There is a dose-response related to increased quality (exclusivity) and duration of breastfeeding Exclusive breastfeeding for the full 6 months confers the greatest benefit For more information on this model see the facilitator guide as well as the brief by Oot et al titled “The Effect of Suboptimal Breastfeeding on Preschool Overweight/Obesity: A Model in PROFILES for Country-Level Advocacy” on the FANTA project website.

Iodine Deficiency and Mental Disability
Iodine deficiency is the main cause of preventable brain damage worldwide. Iodine deficiency during pregnancy and the first few months of infancy leads to irreversible brain damage. The severity ranges from mild to moderate to severe in infants (including a severe form called cretinism). Iodine deficiency can lead to a reduction in IQ of up to points on average (Black et al. 2013). Several types of nutritional deficiencies can influence learning performance and mental development. The most important is iodine deficiency during pregnancy, which is known to hinder development of the fetus and can result in the birth of infants with cretinism (severe mental and physical impairment), or milder forms of congenital iodine deficiency with clinical (or subclinical) mental impairment. Published literature finds an average reduction of up to 13.5 IQ points (Black et al. 2013).

Stunting and Education Outcomes
Studies show that stunted children: Learn to sit, stand, and walk later Have poorer cognitive function Enroll in school later Perform worse in school Miss more days of school due to illness Are more likely to drop out of school than well-nourished children (Grantham- McGregor et al. 2007). Stunted children complete fewer years in school—the total deficit (both in terms of learning capabilities and years in school) in school grade equivalents is estimated to be 2.91 years (Grantham-McGregor et al. 2007). Among stunted children who are also poor, this rises to 4 years of schooling lost. Lost years of schooling may have a direct impact on a person’s income potential. A study in Central America found that 1 additional year of schooling is associated with a 12–14% increase in lifetime earnings (Psacharopoulos and Patrinos 2004). PROFILES uses 0.8 of a grade equivalent lost per school year per 1 SD unit reduction in the height-for-age z-score. Over the years studies have shown that stunting is associated with delayed child development milestones and poor education outcomes, in terms of fewer years in school and poorer performance in school. In more recent years this relationship has been quantified to a degree, and this has formed the basis of calculating estimates in PROFILES. Although the impact of stunting on economic productivity is covered in more depth later on in the presentation, there is a study that found a direct impact of education on a person’s income potential. The study in Central America found that 1 additional year of schooling is associated with a 12-14% increase in lifetime earnings (Psacharopoulos and Patrinos 2004). For more information on this model see the facilitator guide and/or the brief by Oot et al titled “The Effect of Chronic Malnutrition (Stunting) on Learning Ability, a Measure of Human Capital: A Model in PROFILES for Country-Level Advocacy” on the FANTA project website.

Malnutrition and Economic Productivity

Stunting and Economic Productivity
Growth deficits early in life are related to productivity loss in adulthood (Behrman 1992; Pinstrup-Andersen et al. 1993): 1.0% height deficit in adulthood = 1.38% drop in productivity Using coefficients based on published scientific literature, PROFILES estimates reduced adult productivity related to both decreased physical capacity and impaired intellectual ability (affecting school achievement and resulting in lower wages in the future). Improved early nutrition and a reduction in stunting can improve economic productivity and wages. Reduced adult stature due to stunting is a proxy indicator for various nutritional and other insults that can affect physical and mental development (the issue is not short stature per se). The PROFILES workbook estimates the impact of growth deficit in children on future labor productivity based on the fact that stunting developed during the first 2 years of life is generally maintained throughout life and that the productivity of adults is related to their stature. FACILITATOR: STOP HERE (use additional information below only if needed) Using coefficients based on published scientific literature, PROFILES estimates reduced adult productivity related to both decreased physical capacity and reduced intellectual ability (affecting school achievement). The calculations use the “economic activity rate” (the population actually working) discounting future wages at 3% per year, and adjusts for normal mortality. The lifetime discount factor is the sum of all the adjusted annual discounted years from age 15 through age 64. The lifetime discount factor is used to calculate the present day value of future economic productivity losses related to childhood stunting, based on the proportion of children 24–35 months of age that were classified as stunted. The percentage of children classified as having severe, moderate, and mild stunting are considered, after subtracting the proportion of children expected in each of these categories (according to reference population values). Assumptions: Elasticity of productivity with respect to height = 1.38 Only affects two-thirds of manual labor Stunting at age 2 is permanent Moderate stunting (−2 to −3 SD below median height-for-age) = average height deficit of 4.375% Severe stunting (less than −3 SD below median height-for-age) = average height deficit of 6.25% Height deficit in adulthood: Moderate stunting 7 cm = 4.4% Severe stunting 10 cm = 6.3% (Pinstrup-Andersen et al. 1993) This equation has come out of two studies: Behrman, 1992, The economic rationale for investing in nutrition in developing countries Pinstrup-Andersen et al., 1993, Protein-Energy Malnutrition A study conducted in the Philippines showed that wages earned by sugar cane workers were higher by 1.38% for every 1% increase in their height (Haddad and Bouis, 1991, The Impact of Nutritional Status on Agricultural Productivity: Wage Evidence from the Philippines). Default estimate for the proportion of manual labor affected by stunting is two thirds; it should be recognized that this is a rough guess that should be scrutinized in the light of local knowledge. Within manual labor occupations, not all tasks are assumed to be affected. Lifetime discounting factor: ages 15 to 64. Wages are discounted at 3% per year after adjusting for normal mortality at each year of life. The Pinstrup-Andersen models predict the productivity effects of moderate and severe stunting in the current population of 2 year olds. After the age of 2, very little further stunting or catch-up growth occurs (Martorell et al. 1994). Therefore the prevalence at this time is taken to reflect the cumulative deficit that will be carried into adulthood. Percentage reduction in adult height is taken as 4.375% and 6.25% for moderate and severe stunting, respectively, and for each percentage point reduction in adult height there is a 1.38% reduction in wages. Note that the effects of mild stunting (with a height-for-age z-score between -1 and -2) fall within the normal range. Although technically normal, given better nutrition they would be at the higher rather than lower end of the normal distribution and would accordingly become more productive adults. These figures have been found in the Pinstrup-Andersen 1993 study, “Protein-Energy Malnutrition.”

Stunting and Economic Productivity
A large-scale randomized longitudinal supplementation trial in Guatemala where mothers and children were given either atole (micronutrients, energy, protein) or fresco (micronutrients, low energy, no protein) showed that improved early nutrition can positively impact a child’s cognitive development and consequently their educational attainment and productivity. Habicht (2010) linked the provision of atole to children ≤ 3 years to increased height. Hoddinott et al. (2008) found that atole exposure during but not after the first 3 years of life was associated with higher hourly wages among men 26–42 years of age. Exposure to atole from 0–2 years was associated with an increased wage of US$0.67 per hour (95% CI 0.16–1.17), equal to a 46% increase in average wages. Multiple studies from a large-scale randomized longitudinal supplementation trial in Guatemala indicate improved early nutrition can have a positive impact on a child’s cognitive development, and thus their educational attainment and productivity. During this trial both mothers and children were given either atole (which provided micronutrients, energy, and protein) or fresco (which contained micronutrients and low amounts of energy but not protein). An analysis by Habicht (2010) found that a causal effect of atole on children ≤ 3 years of age on increased height. A study by Hoddinott et al. (2008), when the cohort was 26–42 years of age, found that atole exposure, during but not after 3 years of age, was associated with higher hourly wages for men. Exposure to atole from 0–2 years was associated with an increased wage of US$0.67 per hour (95% CI 0.16—1.17), which meant a 46% increase in average wages.

Effects of LBW on Productivity (Stunting and Cognitive Loss)
Low birth weight infants (< 2,500 grams) are more likely to become stunted and have reduced cognitive ability as they grow and develop. LBW reduces productivity through its impact on stunting and cognitive development. Preventing LBW can lead to productivity gains (Alderman and Behrman 2004). Because LBW contributes to stunting, and stunting results in productivity losses, the productivity losses attributable to LBW and stunting overlap. These estimates cannot be added as this would result in double-counting productivity losses. Infants born with low birth weight (LBW) (< 2,500 grams) are more likely to become stunted and this has an impact on a child’s cognitive abilities and their economic productivity. Both of these effects independently have consequences for lifetime economic productivity. The impact of LBW on stunting as described here cannot be added to the stunting effects calculated in other PROFILES models because the productivity implications of short stature at age 2 should already include the effects of LBW as estimated here. Productivity is also affected by cognitive losses attributable to low birth weight. In their review of the magnitude of this effect, Alderman and Behrman (2004) conclude that total productivity gain from preventing LBW is 5–10% of lifetime earnings, or a point estimate of 7.5%, divided between 2.2% from reduced stunting and 5.3% from improved cognitive development (directly and through its effect on schooling). A 7.5% increase in productivity from preventing LBW is equivalent to a proportional reduction in productivity (from LBW) of 7.5/107.5 or 0.07.

Iodine Deficiency and Productivity
Iodine deficiency during pregnancy is known to hinder the development of the fetus and result in mental and physical impairment which impacts a person’s future productivity. Levin et al. (1993) estimate that: People with cretinism have no productivity (100% reduction in productivity) Severely mentally impaired persons are 25% less productive than individuals who are not impaired Mildly mentally impaired individuals are 5% less productive than people who are not impaired IQ is highly correlated with school achievement (r=0.92), and high IQ is associated with high per capita GDP and fast economic growth (Meisenberg and Lynn 2011) Assumptions of productivity losses: Iodine deficiency is the main cause of preventable brain damage worldwide. Iodine deficiency during pregnancy is known to hinder the development of the fetus and result in mental and physical impairment which impacts a person’s future productivity. Although no studies have measured the productivity losses resulting from mental impairment due to iodine deficiency during pregnancy, Levin et al. (1993) estimates that cretins have no productivity and that the other severely mentally impaired persons are 25% less productive relative to unaffected individuals and that mildly mental retarded individuals have a 5% reduction in productivity. In addition, studies have shown IQ point differentials between iodine deficient and replete populations of up 13.5 points, and since IQ is highly correlated with school achievement and high per capital GDP, the impact of iodine deficiency on economic productivity can be quite substantial.

Anemia and Productivity
Hemoglobin, an iron-containing protein, is the oxygen-carrying component of the blood. Anemia (low blood hemoglobin concentration) indicates reduced oxygen-carrying capacity and can be an indicator of poor iron status. Adequate blood oxygen levels are important for mental function, fetal development, and physical activity. There is a direct relationship between hemoglobin (Hb) levels and productivity: Hb reduction 1% = Productivity reduction 1.5% Horton and Ross (2003) found that iron supplementation in anemic adults resulted in: 5% increase in “blue collar” labor productivity 17% increase in heavy manual labor productivity Anemia also significantly impacts a child’s cognitive development and future economic productivity. Hemoglobin, an iron-containing protein, is the oxygen-carrying component of the blood. Anemia (that is, low blood hemoglobin concentration) indicates reduced oxygen-carrying capacity and can be an indicator of poor iron status. Because of the importance of adequate blood oxygen levels for mental function, fetal development, and physical activity, iron deficiency anemia has a range of consequences on health, performance, and survival. Here we only look at the effect of anemia on labor productivity. Studies in the literature establish that iron deficiency anemia (IDA) has an adverse impact on economic productivity, most likely as a result of lowered physical capability. As such, PROFILES can use this association to calculate economic productivity losses as a result of IDA. Horton and Ross (2003) estimate that iron supplementation in anemic adults results in a 5% increase in “blue collar” labor productivity and an additional 17% increase in heavy manual labor productivity. This information is used in the PROFILES model to calculate the estimates on IDA and productivity. Additional information: PROFILES uses the following assumptions in the model in the spreadsheet Assumptions for adults: Applies to working age men and women with anemia Average reductions in productivity: Manual labor: 5% “Heavy” manual labor: 17% Wages and employment rates from national statistics Assumptions for children: Applies to future manual labor productivity of current children 0–14 with anemia All sectors: 2.5%

Addressing the Risk Factors of Stunting
Of all the nutrition problems facing developing countries, stunting is perhaps the most important long-term nutrition problem. In most countries, stunting is a complex problem that is the result of a wide range of context-specific risk factors. For example, as shown in the figure here, one analysis identified 18 different risk factors associated with stunting in children months of age, indicating that a specific focus on maternal and infant health was too narrow, as a more broad approach addressing improvements in the general living conditions of mothers and families was necessary. Addressing stunting is also complicated by the country context, as different risk factors may vary across regions and countries. Even if there are common risk factors that affect many countries in a similar way, in some countries the impact of a risk factor may be high, in others it may be moderate or low, and in some cases those same risk factors may not be related to stunting at all. For the purposes of nutrition advocacy, it is therefore important to convey the complexity of reducing stunting and consider how addressing each risk factor could contribute to reducing the prevalence. For this reason, two additional models have been developed and included in the PROFILES workbook to quantify the reduction in stunting if dietary diversity in children under age two were improved and if the proportion of births to mothers below the age of twenty were reduced. These two models focus on two common risk factors for stunting for which we have both an adequate body of research to develop the models and sufficient country-level survey data to calculate the impact on stunting prevalence. Importantly, although these two models illustrate how stunting could be reduced by addressing these two risk factors, unless the many other risk factors for stunting are also addressed, prevalence would likely remain high. (Danaei et al. 2016)

Inadequate Dietary Diversity and Stunting
Among the many factors thought to influence child health and nutrition, optimal complementary feeding (when the child transitions from exclusive breastfeeding to family foods, beginning at 6 months) is among the most important. Complementary feeding is a complex behavior, where timeliness, quantity, and quality are all important. However, research indicates that an adequately diverse diet during a child’s first years of life (6–23 months) is most consistently correlated with child growth (Marriot et al. 2012). Among the many factors thought to influence child health and nutrition, complementary feeding (after 6 months, when breast milk alone is no longer sufficient) is among the most important. Although complementary feeding is a complex behavior with many dimensions, dietary diversity (DD) during the critical period from 6-23 months has proven to be the aspect most consistently correlated with child growth. Although DD may be difficult to define in practice, given wide variations in foods and feeding practices across cultures, a tested and globally accepted indicator of minimum DD has been adopted by DHS and international agencies for household surveys. PROFILES uses a RR of stunting related to not meeting minimum DD of 1.22, derived from information provided by Marriot et al. (2012).

Teenage Pregnancy and Stunting
Young maternal age (<20 years) is associated with poor maternal health and has a variety of consequences for the child, including poor birth outcomes and growth deficits, including stunting (Fink et al. 2014). Although the relationship between teenage pregnancy and stunting may depend on the context (e.g., relationship is stronger in urban settings and can depend on socioeconomic status), there is a need in all countries to appreciate the potential impact of improvements in the timing of pregnancy and childbirth. Young maternal age is associated with poor maternal health and a variety of consequences for the child such as poor birth outcomes and growth deficits, including stunting. Child stunting, in turn, is a risk factor for mortality and a variety of health and developmental problems that can reduce learning ability and economic potential throughout the life span. The relationship between teenage pregnancy and child stunting can depend on socioeconomic status and tends to be stronger in urban settings. It also varies across countries and regions (Fink et al. 2014). Although the relationship between teenage pregnancy and child stunting may depend on the context, there is a need in all countries to appreciate the potential impact of improvements in the timing of pregnancy and childbirth. PROFILES uses a RR of stunting related to teenage pregnancy of 1.20, derived by pooling RRs provided by Fink et al. (2014) for children of different birth orders born to mothers in different age strata (<18 vs years).

Session 4: Approach and Assumptions Used in PROFILES Spreadsheet Models

Reviewed the approach used in PROFILES Discussed the assumptions made to calculate estimates Discussed the challenges and limitations of this approach Refer to slide

Activity 1 Group activity: Do you have experience with models that generate estimates or projections? Ask participants if they have any experience with models that generate estimates or projections. If so, ask them to share their experiences. Note: This activity should take no more than 10 minutes.

Approach Used in PROFILES to Calculate Estimates (Illustrative Example for Stunting)
Figure C. Improved Scenario and Status Quo Scenario Figure A. Status Quo Scenario Figure B. Improved Scenario Annual number of under-5 deaths Figures A–C provide an illustrative example of the approach used in PROFILES to calculate estimates for child deaths (and lives saved) related to stunting. (Information shown in these graphs is not from this country.) For the purpose of providing an example of how PROFILES calculates the estimates for the status quo and the improved scenario, the number of children under 5 has been kept constant. But, in the actual PROFILES model, there is usually an increase in the number of children under 5 each year based on population projections. The graphs show how the status quo scenario (Figure A) vs. the improved scenario (Figure B) is used to provide estimates of lives saved (or deaths averted) related to stunting among children under 5 years of age during a 10-year period. Figure C shows the number of lives saved, calculated by subtracting the number of deaths in the improved scenario from the number of deaths in the status quo scenario. A comparable approach is used in PROFILES to estimate the number of lives saved (or deaths averted) related to other nutrition indicators and to estimate economic productivity gains related to selected nutrition indicators.

The estimates that PROFILES calculates are based on several assumptions: Assumption 1 To calculate estimates for the two scenarios, the time period to be used to calculate estimates must be agreed upon. Assumption 2 In the status quo scenario, it is assumed that the prevalence of various forms of undernutrition do not improve and remain unchanged, and consequently there is no improvement in health and economic outcomes. This is presented as lives lost for the health outcomes, and economic productivity losses for the economic outcomes. The estimates that PROFILES calculates are based on a few key assumptions. For example, in PROFILES, we assume that if undernutrition is reduced that over time this would lead to improvements in health and economic outcomes. In the status quo scenario, we assume that the prevalence of various forms of undernutrition does not improve over time and this results in no improvements in health and economic outcomes. The status quo scenario assumes there will be no change from the current situation throughout the chosen time period (the number of years for which estimates are calculated), aside from projected changes in population size and structure. The prevalence of each nutrition problem remains the same every year in the status quo scenario. PROFILES assumes no other changes aside from changes in population size and structure.

If different forms of undernutrition are reduced, over time there would be improvements in health and economic outcomes. Assumption 4 In the improved scenario, it is assumed that the prevalence of the different forms of undernutrition is reduced and for each of these indicators there is a corresponding improvement in specific health and economic productivity outcomes. This is presented as lives saved for the health outcomes and economic productivity gains for the economic outcomes. In order to calculate estimates in PROFILES we need to agree on the time period for which estimates will be calculated (for example, 10 years). We also make assumptions to calculate estimates in the improved scenario; for example we assume that over the selected time period if undernutrition were reduced by a certain amount, that lives would be saved and there would be economic productivity gains. In this regard, we make an assumption about how much nutrition will improve over the selected time period. As such, to calculate estimates in the improved scenario we need to set targets for the reduction of various forms of undernutrition.

Assumption 4 (continued) To calculate the estimates in the improved scenario, targets must be set for the reduction of each form of undernutrition; the targets must be discussed and agreed upon in consultation with stakeholders and PROFILES workshop participants. The targets for reducing the forms of undernutrition can take into account various considerations, such as national commitments/vision and planning documents (stating how much and by when the country aims to improve the nutrition indicators) and/or other international guidance. For setting the targets, participants in this workshop will provide inputs so decisions can be reached regarding by how much undernutrition will be reduced by the end of the selected time period. Setting the targets should be guided to an extent by the existing vision in the country, national and international commitments, and should also consider the secular trend in the reduction of undernutrition that is anticipated over the selected time period.

For the improved scenario, it is expected that effective nutrition interventions are implemented at scale and achieve the target prevalence for the various forms of undernutrition by the end of the chosen time period. For example: Assumption 6 PROFILES assumes that for the improved scenario, there is a linear reduction in the prevalence of the different forms of undernutrition (except for optimal breastfeeding, where an increase is expected). The prevalence at the beginning of the time period is the same for both the status quo and improved scenarios. Prevalence at beginning of time period Target for reduction Target prevalence by the end of the chosen time period 32.0% 0.3 (or 30%) 22.4% While PROFILES itself does not use interventions or coverage information in calculating the estimates, we expect that the improvement in nutrition indicators in the improved scenario will be a result of effective interventions that will be implemented at scale and that they achieve the chosen targets. Specific nutrition interventions (e.g., optimal breastfeeding counseling) are not input into the model to develop the PROFILES estimates. Rather, the improvement in the nutrition situation is based on the assumption that if nutrition interventions that are known to be effective are implemented at scale they will succeed in reaching the stated targets. Finally PROFILES also assumes a linear reduction in the prevalence of different forms of undernutrition.

Limitations of PROFILES
Because different malnutrition problems can co-exist in the same person (for example, a child can be stunted, wasted, and vitamin A deficient at the same time), it is difficult to effectively account for co-existing forms of undernutrition. PROFILES calculates estimates for individual nutrition problems. While nutrition interventions are discussed through the broader advocacy process, the estimates that PROFILES calculates are not linked to nutrition interventions. Refer to slide

What Are the Advantages of This Approach?
Addresses a range of nutrition problems Generates country-specific evidence-based estimates related to various nutrition problems Flexibility to advocate for specific nutrition issues in addition to being able to advocate for action to address malnutrition overall Embedded in a broader advocacy approach Refer to slide.

Session 5: Considerations for Setting the Time Period for PROFILES Estimates
Only use this session if no stakeholder meeting was held where time periods could be discussed or if the discussion on the time period during the stakeholder meeting was limited and additional discussion is necessary. (Only use this session if no stakeholder meeting was held where time periods could be discussed or if the discussion on the time period during the stakeholder meeting was limited and additional discussion is necessary.)

Discussed the time period for the estimates Finalized and agreed upon the time period for the estimates Refer to slide

Activity 1: National Commitment to Nutrition
Is there a national vision statement or commitment to nutrition within your country? If so, what are your thoughts on this vision/commitment? Ask participants to share their point of view on the following question: Is there a national vision statement or commitment to nutrition within your country? If so, what are your thoughts on this vision/commitment? This activity should take no more than 5 minutes.

Setting the Time Period
The time period for which PROFILES will calculate estimates must be discussed and decided. Often, the selected time period is 10 years; time periods shorter than 7 years or longer than 15 years are not recommended. Setting the time period is often guided by existing national vision documents and/or commitments to global goals and targets (such as the World Health Assembly 2025 nutrition targets). A longer time period (e.g., 10 years) is slightly preferable as: New nationally representative survey data are not available every year but more commonly every 5 years. A longer period allows for advocacy that can present a longer term vision and potentially make the case for sustained investment in the nutrition sector. Often a time period of about 10 years is chosen, but it is not recommended to select a time period that is shorter than 7 or longer than 15 years. The time period for which PROFILES estimates are calculated depends on what people in country feel is appropriate to considered, based on the country’s current nutrition situation, the government’s commitments and goals for improved nutrition, and when these goals need to be achieved. The time period should also take into consideration the fact that we do not always have access to new nationally representative survey data, and as this type of data is only available every few years, preparing estimates for a short time frame can be a challenge. At the same time, preparing estimates for a very long time can also be a challenge as there may be important improvements in nutrition, health, or development outcomes over the long term. These are points to consider when deliberating about the time period.

Activity 2: Plenary Discussion of the Time Period
Discuss the time period for the estimates Review, discuss, and list on a flipchart the current national vision and/or government commitment for improved nutrition in your country. Based on this discussion, determine the following: What would be most useful for advocating for greater investment in nutrition? What should the time period for the estimates be? Record the time period on the PROFILES scoreboard Activity should take 35 minutes. Ask participants to discuss in plenary the current vision documents, national commitments, and targets for nutrition, and based on this review, consider the following two questions: What would be most useful for advocating for greater investment in nutrition? What should the time period for the estimates be? Give the participants about minutes to discuss in a group the two questions. Toward the end of this time, facilitate the session by reflecting and summarizing the various points of view on a possible time period and ask participants if they agree on one time period. Propose a time period that aligns with what was discussed. Then introduce the PROFILES scoreboard to the participants and inform them that the group will use this scoreboard throughout the workshop to record their work in developing the estimates. Indicate that the first piece of information to be added to the scoreboard is the time period that was just discussed and agreed upon. Ask for a volunteer to write the time period on a long strip (long VIPP card) and stick it at the top of the PROFILES scoreboard.

Session 6: Time Period, Available Information Sources, and Targets
If a stakeholder meeting has not taken place, the tone and some of the activities within this session will need to be altered since no previous discussions on the information sources or targets would have occurred. (If no stakeholder meeting was held, this PPT will need to be revised.)

Recalled the time period agreed upon for the PROFILES estimates Finalized the discussion on the information sources required for the PROFILES spreadsheets Finalized the prevalence(s) that will be used for each key indicator Finalized the target reductions and the target prevalence for the different forms of malnutrition by the end of the time period Refer to slide

Activity 1: Sources of Nutrition Information
What are the most recent national sources of nutrition information? Ask participants to share their point of view on the following question: What are the most recent national sources of nutrition information? This activity should take no more than 10 minutes to discuss.

Type of Information Required for PROFILES
Recent nationally representative survey information for key indicators, including: Stunting Iodine deficiency Underweight Breastfeeding and complementary feeding practices Wasting Overweight Teenage pregnancy Low birth weight Vitamin A deficiency Anemia As presented earlier, for PROFILES to calculate estimates, key nutrition and other data need to be included in the spreadsheets. In particular—given the specific estimates PROFILES calculates—we need data for the following indicators. Note: If nationally representative survey information is not available, other sources of information could be considered as input information for PROFILES. See the facilitator guide for more information.

Information Sources Various information sources should be considered for the various nutrition indicators to help ensure that PROFILES uses the most recent prevalence to calculate estimates in the status quo scenario. Information sources often include recent nationally representative surveys such as the DHS. Some information (such as micronutrient deficiencies or low birth weight) may not be available in the DHS, so other national sources, such as the most recent micronutrient survey, may be used instead. It is important for all participants to discuss, consider, and agree upon which sources of information you would like to use that you feel best represent the country context. In many instances, it takes time to consider the options and agree on which sources of information to use in PROFILES. During the upcoming activity, you will have an opportunity to discuss information sources in small groups.

Current Nutrition Situation
Note: This slide should be based on information from a presentation by an in-country expert during the stakeholder meeting. However, if no stakeholder meeting was held, the facilitator will need to assign a representative to develop the slide or develop the slide themselves and share it with in-country stakeholders to ensure the information reflects the national/government understanding of the nutrition situation. This slide is also linked to an Excel spreadsheet within PPT so the data can easily be updated to reflect the country context based on national data sources or a nationally representative survey. “This slide presents the country’s current nutrition situation, based on the data we have been able to gather and review prior to this workshop. But as was presented this morning, and in our discussions this afternoon, we will surely be able to update this information based on recent data or better suited surveys to be used in PROFILES.”

Setting Targets Targets for reducing the prevalence of different forms of malnutrition are needed to calculate estimates in PROFILES for the improved scenario. The question of setting targets in the PROFILES spreadsheets centers on asking: By the end of a specified time period, by how much do the workshop participants assume that selected nutrition indicators will improve? Setting the target prevalence for the reduction of various forms of undernutrition is important in order for PROFILES to be able to calculate estimates in the improved scenario. In setting the targets, it is important to consider by how much the group anticipates being able to improve nutrition by in the future. Note to the facilitator: Targets are for the sake of advocacy, not for program planning, and no one will be held accountable for reaching the targets.

Setting Targets In setting targets, a few points to consider:
If the target prevalence is very conservative (with only small improvement from the status quo prevalence), the decisions may end up conveying that it is acceptable for nutrition problems to persist If the targets are overly optimistic, it may convey that they are unachievable A balanced approach in which the targets are visionary, optimistic, and ambitious, but also fairly realistic is often helpful Here again it is important to consider the country context when determining what the target for improvement should be for each of the nutrition indicators considered in PROFILES. A balanced approach in setting targets is important. Sometimes there is a desire to be conservative (with only small improvement compared to the status quo prevalence) and sometimes there is a desire to be optimistic. But as this is a tool for advocacy, what this finally conveys to the audiences you will advocate to is important to consider. If we are very conservative, we may convey that it is ok for nutrition problems to persist. On the other hand, if we are too optimistic, we may show estimates that are unachievable. A balanced approach in which we are visionary, optimistic, and ambitious, but also realistic is often helpful. To arrive at the target prevalence for each of the nutrition indicators, it might be helpful for participants in the PROFILES workshop to keep in mind various considerations. Information on statements in official government documents could inform the targets for the time period selected for PROFILES (for example, national vision documents or strategies). Such documents could help guide discussions on target setting for some of the indicators. Other sources of information that could stimulate the discussion and provide insights on setting targets, include (a) documents from the 2012 World Health Assembly (some governments have committed to the targets in these documents), and (b) WHO’s Nutrition Landscape Information System, which provides insights on various prevalence cut-off values and the extent to which malnutrition is of public health significance.

Activity 2: Discussion on Nutrition Information and Targets
Join one of four groups: (1) anthropometry, (2) micronutrients, (3) low birth weight and breastfeeding, and 4) risk factors of stunting. Each group should do the following: Review and discuss the flipchart with the prevalence, information source, and targets discussed for your group’s topic in the stakeholder meeting Based on the information discussed in the stakeholder meeting, review and finally agree upon: The nutrition information that is available for your country The prevalence for each indicator (with information sources) Targets for reducing prevalence by the end of the time period (or increasing prevalence for certain feeding behaviors) for each of the nutrition indicators Refer to slide.

Activity 3: Discuss and Agree Upon Indicators and Targets
Discuss each group’s decisions in the larger plenary group Agree upon each indicator and target Record your decisions and put them on the PROFILES scoreboard Note to facilitator: Introduce the use and purpose of the PROFILES scoreboards (if not done previously). They are intended to record and track the progress the group is making throughout the workshop to develop the estimates and serve as a visual reminder of the information that was agreed upon as the workshop progresses. Activity 3: The groups should now come back together for a larger plenary discussion. One person per group should share their decisions with the larger plenary, which can be discussed and a final decision made. The discussion will continue until all three groups have presented and their indicators/targets discussed. Once the information is agreed upon, have one representative from each group do the following: Write on VIPP cards the current prevalence for each of the nutrition indicators for their group Write on VIPP cards the target prevalence for reduction for each of the nutrition indicators for their group Place their VIPP cards on the PROFILES scoreboard Note: facilitators should check the flipchart of questions at the end of each day and respond if necessary.

Session 7: Recap of Day One and Scoreboard Updates

Activity 1 Cabbage ball game: Let’s recall what we discussed yesterday. Conduct activity—see session plan for more information on how to do this activity. It should take 15 minutes.

Activity 2 Review of the PROFILES scoreboard
Conduct activity—see session plan for more information on how to do this activity. It should take 10 minutes.

Session 8: Demography and Other Indicators Needed for PROFILES

Discussed and reviewed the information sources required to fill in the PROFILES spreadsheets Discussed information gaps and approaches to address them Agreed on the demographic, mortality, education, and economic indicators that will be used in the PROFILES spreadsheets

Activity 1: Discuss Other Information Needed
Discuss other types of information that are needed to calculate estimates from PROFILES Ask participants to share their views on the other types of information that may be needed to calculate estimates (other than nutrition data), such as recent population projections, labor surveys, national surveys, international surveys, or assessments. (10 minutes)

Demographic, Fertility, Mortality, Economic, and Education Indicators Needed for PROFILES
Rationale: Why is this needed? Demographic Total Population To help calculate population-level estimates for the full time period selected. Mortality MMR IMR CMR NMR PMR Change or lack of change in the different nutrition indicators are calculated in terms of deaths and lives saved. Calculations for each nutrition indicator relate to one or more of the following: infant, child, neonatal, maternal, and perinatal deaths and lives saved. Economic Exchange rate GDP per capita Employment Wages These are needed to calculate economic productivity gains or losses in currency amounts, and this is based on wage and employment data, in addition to the exchange rate and GDP per capita. Education Age at school entry Number years of school (duration of schooling) These are needed to calculate the human capital gains or losses related to stunting expressed in equivalent school years of learning. You have already identified some of the different types of data that PROFILES might need to calculate estimates. Here are some of the types of data that are needed and why these are needed.

Activity 2: Discuss and Agree on the Other Information Needed for PROFILES
Join one of two groups: (1) total population estimate and mortality, and (2) employment, economic, and education information. Each group should do the following: Identify the source(s) of information Note the values to be used in PROFILES on the worksheet List gaps or challenges Give a brief report on your group’s decisions Record the information from the other groups to complete the worksheet Designate a person in each group to follow up on identified gaps Activity 2 is a small group discussion by thematic area in which groups recommend which information source and what numbers should be used. This is followed by an opportunity for participants to note what else needs to be researched or discussed further during the week (30 minutes).

Session 9: Introduction to PROFILES Spreadsheets: How They Work

Reviewed the structure of the PROFILES Spreadsheet Workbook Reviewed the “flow” within the PROFILES Spreadsheet Workbook Explored how to use the spreadsheet Refer to slide.

Activity 1 What are some challenges and limitations with estimates calculated using models? Take a few moments to note that as with other models, PROFILES is not a perfect tool, but that we are doing the best we can with PROFILES at this time, however, some challenges remain (5 minutes). This should be done in pairs that can then report out to the group as a whole.

PROFILES Spreadsheet Scenario 1 (status quo/not improved)
No change in prevalence of nutrition problems Scenario 2 (improved) Improvement (reduced prevalence of nutrition problems) Net Gains Difference between the two scenarios The following is a general overview of PROFILES; often there is more nuanced information in the actual model. The net gains are expressed as, for example, lives saved or economic productivity gains

Schematic Summary of Flow in PROFILES Spreadsheet Workbook
FrontPage Input: Prevalence of nutrition problems, targets (improved scenario); information on employment and income/wages, education, mortality, and estimated total population Output: Estimates of deaths/lives saved; economic productivity losses/gains; human capital losses/gains (related to learning potential); child overweight/obesity Input: Nutrition problems—prevalence Status quo scenario, improved scenario (targets) Input: Time period; demography (population size and structure, mortality); information on education, employment, etc. Relational information (coefficients, calculators, formulas, etc.) Output: Status quo scenario estimates of: Number of deaths Human capital losses—poorer learning potential Economic productivity losses Child overweight/obesity The PROFILES spreadsheet workbook is a series of spreadsheets. Note: The main sheet in which participants will work is called the “FrontPage.” It is where all of the information will be input by the workshop participants. The FrontPage was created to ease the use of the spreadsheet (as most of the work done by participants is done in this sheet) and to significantly reduce mistakes as errors can be easily introduced, which are difficult to then catch and fix. Information to be input is: Country-specific prevalence of nutrition problems Proportion to reduce the nutrition problems (to reach the target prevalence) Other country-specific variables: total population, mortality, education, and employment Information from the FrontPage flows into other sheets where the information is used by various sheets to calculate the outputs. This includes taking demographic information from a sheet designated for population size and structure, and other inputs and coefficients from other sheets. The calculated outputs, which we also refer to as results or estimates, are then sent back to the FrontPage where they provide a summary of the results to the user. Note: The two stunting risk factor models follow the same approach discussed in this diagram. Output: Improved scenario estimates of: Number of lives saved Human capital—increased learning potential Economic productivity gains Reduced child overweight/obesity FANTA Project, FHI 360

Session 10: Introduction to Nutrition and Health in PROFILES Concurrent Sessions

Reviewed the approach used in PROFILES for calculating estimates for health outcomes Reviewed source(s) of information, prevalence of indicators, and targets Entered the status quo scenario information and examined the results/estimates Entered the improved scenario information and examined the results/estimates Recorded the estimates on the PROFILES scoreboard Discussed what the numbers mean for nutrition advocacy Refer to slide.

Activity 1 What types of estimates could be calculated for health and survival based on nutrition prevalence data? Ask one or two participants what types of estimates could be calculated for health and survival based on nutrition prevalence data. Answers can be general, such as child deaths, maternal deaths, etc. (5 minutes)

Estimates that PROFILES Can Calculate: Health Outcomes
Economic outcomes Human capital outcomes Malnutrition Child stunting, underweight, and wasting Low birth weight Iron deficiency anemia Iodine deficiency Vitamin A deficiency Stunting Reduced cognitive function Lower economic productivity Lower physical capability results in lower wages Poorer school performance results in lower wages Suboptimal breastfeeding Reduced learning Health outcomes Increased child mortality Increased infant mortality Increased maternal and perinatal mortality Permanent brain damage and reduced IQ Increased risk of child overweight/ obesity This framework presents the main relationships for which PROFILES calculates estimates. For example, the prevalence of stunting, underweight, and wasting is entered into the PROFILES spreadsheet to calculate the number of child deaths at a population level, and this is presented in terms of lives saved and lives lost. Similarly PROFILES calculates: The number of infant deaths given the prevalence of low birth weight The number of maternal and perinatal deaths related to iron deficiency anemia The number of permanent disabilities in children (reduced IQ and brain damage) related to maternal iodine deficiency during pregnancy The number of child deaths related to vitamin A deficiency The number of child deaths related to suboptimal breastfeeding practices The increased risk of child overweight/obesity due to suboptimal breastfeeding practices So on the far right, under the column health outcomes, PROFILES calculates estimates of lives saved or lives lost from these various forms of malnutrition. Similarly PROFILES also calculates estimates for the relationship between stunting and learning, which falls under human capital. PROFILES also uses the prevalence of stunting, low birth weight, iron deficiency anemia, and iodine deficiency to calculate the impact on economic productivity gains or losses. The dark blue boxes with bolded text reflect the specific estimates that PROFILES calculates.

Nutrition and Health Outcomes (Mortality) Concurrent Sessions (Activity 2)
As a group, review the spreadsheet, enter demographic/education information and click on the macros, and complete one model as an example Break into three groups: (1) anthropometry, (2) micronutrients, (3) low birth weight/breastfeeding Begin entering the required information into the PROFILES spreadsheet: Review source(s) of information, prevalence of indicators, and targets Enter the relational information: demographic and economic information Enter status quo scenario information and review the results/estimates Enter improved scenario information and review the results/estimates Record your estimates on the PROFILES scoreboard Discuss what these estimates mean for advocacy Before you have participants begin working in their own groups, it is recommended that the facilitator click through the sheet named FrontPage and describe how the data flows through other sheets and feeds into the FrontPage, as described in session 9. Then begin working in the spreadsheet all together, inform participants how to save the file, and walk participants through entering the demographic, education, and economic information at the bottom of the FrontPage, and clicking on the macros. It is also suggested that the facilitator walk the participants through an example model to make sure everyone understands how to enter and read the information. Since vitamin A is one of the easier models to enter, it is suggested that the facilitator begin with vitamin A. Also note, for the anthropometric indicators—stunting, underweight, and wasting—the spreadsheet will calculate an estimate for the status quo percentage in the mild category. For the improved scenario, the spreadsheet calculates the percentage in each category—mild, moderate, and severe (after the user has specified the target improvement for each indicator).

Report Out, Record Additional Estimates, and Q&A
See session plans for more information on how to do this activity. Facilitators should check the flipchart of questions at the end of each day and respond if necessary.

Session 11: Introduction to Nutrition’s Impact on Human Capital (Learning) and Economic Productivity Outcomes

Session Objectives By the end of the session participants will have:
Generate estimates using the PROFILES spreadsheet related to human capital and economic outcomes Reviewed the approach used in PROFILES for calculating nutrition estimates for human capital and economic outcomes Reviewed source(s) of information, prevalence of indicators, and targets Entered the status quo scenario information and examined the results/estimates Entered the improved scenario information and examined the results/estimates Recorded the estimates on the PROFILES scoreboard Discussed what the numbers mean for nutrition advocacy Refer to slide.

Activity 1 What types of estimates could be calculated for economic productivity and education based on nutrition prevalence information? Ask one or two participants what types of estimates could be calculated for economic productivity and education based on nutrition prevalence information? Answers can be general: years of learning, economic productivity, etc. (5 minutes)

Estimates that PROFILES Can Calculate: Economic and Human Capital Outcomes
Economic outcomes Human capital outcomes Malnutrition Child stunting, underweight, and wasting Low birth weight Iron deficiency anemia Iodine deficiency Vitamin A deficiency Stunting Reduced cognitive function Lower economic productivity Lower physical capability results in lower wages Poorer school performance results in lower wages Suboptimal breastfeeding Reduced learning Health outcomes Increased child mortality Increased infant mortality Increased maternal and perinatal mortality Permanent brain damage and reduced IQ Increased risk of child overweight/ obesity PROFILES calculates estimates for the relationship between stunting and learning, which falls under human capital. PROFILES also uses the prevalence of stunting, low birth weight, iron deficiency anemia, and iodine deficiency to calculate the impact on economic productivity gains or losses. The dark blue boxes with bolded text reflect the specific estimates that PROFILES calculates.

Nutrition and Economic Productivity/Human Capital Concurrent Sessions (Activity 2)
Break into two groups: (1) stunting and low birth weight and (2) anemia and iodine deficiency Begin entering the required information into the PROFILES spreadsheet: Review source(s) of information, prevalence of indicators, and targets Enter status quo scenario information and review the results/estimates Enter improved scenario information and review the results/estimates Record your estimates on the PROFILES scoreboard Discuss what these estimates mean for advocacy Refer to slide.

Q&A End the session by asking if the participants have any final questions or concerns for the day. If a question cannot be addressed immediately, have participants put their question on the flipchart in the back of the room to discuss later in the workshop. Then ask for two volunteers to come up with a game/way to recap the day’s events tomorrow morning. Inform them they will have about 20 minutes for an activity. (10 minutes)

Session 12: Introduction to Addressing Risk Factors to Reduce Stunting

Generated estimates using the PROFILES spreadsheet related to addressing two risk factors of stunting Reviewed the approach used in PROFILES for calculating estimates related to addressing two risk factors of stunting Reviewed source(s) of information, prevalence of indicators, and targets Entered the status quo scenario information and examined the results/estimates Entered the improved scenario information and examined the estimates Recorded the estimates on the PROFILES scoreboard Discussed what the numbers mean for nutrition advocacy Refer to slide.

Activity 1 What activities in your country are currently being implemented to address stunting? Ask one or two participants to briefly discuss current activities in country to address stunting? (5 minutes)

Addressing the Risk Factors of Stunting
Briefly review this slide again, noting the complexity of addressing stunting and providing a reminder of what the two risk factor models are. The models quantify the reduction in stunting if dietary diversity in children under age two were improved and if the proportion of births to mothers below the age of twenty were reduced. Additional text if needed: Of all the nutrition problems facing developing countries, stunting is perhaps the most important long-term nutrition problem. In most countries, stunting is a complex problem that is the result of a wide range of context-specific risk factors. For example, as shown in the figure here, one analysis identified 18 different risk factors associated with stunting in children months of age, indicating that a specific focus on maternal and infant health was too narrow, as a more broad approach addressing improvements in the general living conditions of mothers and families was necessary. Addressing stunting is also complicated by the country context, as different risk factors may vary across regions and countries. Even if there are common risk factors that affect many countries in a similar way, in some countries the impact of a risk factor may be high, in others it may be moderate or low, and in some cases those same risk factors may not be related to stunting at all. For the purposes of nutrition advocacy, it is therefore important to convey the complexity of reducing stunting and consider how addressing each risk factor could contribute to reducing the prevalence. For this reason, two additional models have been developed and included in the PROFILES workbook to quantify the reduction in stunting if dietary diversity in children under age two were improved and if the proportion of births to mothers below the age of twenty were reduced. These two models focus on two common risk factors for stunting for which we have both an adequate body of research to develop the models and sufficient country-level survey data to calculate the impact on stunting prevalence. Importantly, although these two models illustrate how stunting could be reduced by addressing these two risk factors, unless the many other risk factors for stunting are also addressed, prevalence would likely remain high. (Danaei et al. 2016)

Risk Factors of Stunting—Concurrent Sessions (Activity 2)
Break into two groups: (1) inadequate dietary diversity and (2) teenage pregnancy Begin entering the required information into the PROFILES spreadsheet: Review source(s) of information, prevalence of indicators, and targets Enter status quo scenario information and review the estimates Enter improved scenario information and review the estimates Record your estimates on the PROFILES scoreboard Discuss what these numbers mean for advocacy Refer to slide.

Q&A End the session by asking if the participants have any final questions or concerns for the day. If a question cannot be addressed immediately, have participants put their question on the flipchart in the back of the room to discuss later in the workshop. Then ask for two volunteers to come up with a game/way to recap the day’s events tomorrow morning. Inform them they will have about 20 minutes for an activity. (10 minutes)

Session 13: Recap of Day Two

Activity 1 Recap game—Let’s recall what we discussed yesterday
Conduct activity—see session plan for more information. Led by volunteer participants. (25 minutes)

Activity 2 Review of the PROFILES scoreboard
Conduct activity—see session plan for more information on how to do this activity. It should take 10 minutes.

Session 14: Gallery Walk—Review of Preliminary Estimates from PROFILES

Discussed and reviewed the preliminary estimates from PROFILES Discussed these results in terms of: General implications Recommendations to be included in the report Next steps for advocacy Refer to slide.

Activity 1: Gallery Walk
What are key highlights of these results? Is this what you expected? Does anything surprise you? What and why? How do you envision these results will help your advocacy efforts? Conduct activity—see session plan for more information on how to conduct activity (approximately 55 minutes).

Activity 2: PROFILES Preliminary Results
Review of the PROFILES preliminary results PowerPoint. Conduct activity – see session plan for more information. (Approximately 20 minutes)

Activity 3: Recommendations for the PROFILES Report
Group work: What recommendations should be included in the report that complement these results and strengthen the case for nutrition in the country? Conduct activity – see session plan for more information (approximately 10 minutes).

Session 15: Discussion of Advocacy Needs

Thought through their nutrition advocacy goals and shared their ideas of how the PROFILES estimates can be used to support nutrition advocacy efforts Discussed the overarching problem with regard to nutrition in the country Discussed the changes that need to occur (at the enabling environment level) to improve the situation Discussed how the estimates developed during this workshop can be used in nutrition advocacy Refer to slide.

Activity 1 What prior experience do you have with using evidence-based data for nutrition advocacy in your country? Ask participants to share their prior experience with using evidence-based data for nutrition advocacy in their country. (5 minutes).

This is the first step toward developing a national nutrition advocacy plan that will be developed in the next workshop (dates to be decided). Refer to slide. Note, this slide may need to be adapted to reflect the country context and the next steps that are taking place in the nutrition advocacy process.

Analysis of audiences determines the mix of strategies: Advocacy to raise resources and political/ social commitment for change goals Social mobilization for wider participation, collective action, and ownership, including community mobilization Behavior change communication (BCC) for changes in knowledge, attitudes, and practices of specific audiences “Here you will see how the three components of a successful social and behavior change program support each other. Advocacy raises resources and political/social commitment for change goals Social mobilization creates wider participation, collective action, and ownership at the community level Behavior change communication creates changes in knowledge, attitudes, and practices of specific audiences, specifically at the household level These three components need to be planned for, and often advocacy needs to happen first to create the enabling environment for change to happen in the other levels. For example, policies may need to be put into place or, if services or products are being promoted through communication at the household level, it’s essential that those services or products be available and accessible; otherwise, your communication will lose credibility.” What we know works to change social norms are sustained communication programs that work at multiple levels with multiple channels. Strong policy and law enforcement elements, champions at national, state, and local levels, and strong civil society involvement, in addition to work at the household and community levels using counseling, school programs, and earned and paid media are key components in programs that help to change norms.”

Using the Socio-Ecological Model to Determine Key Audiences
Levels of Analysis: Where is the tipping point for change? Self: Who is directly affected? Partners, Family, Peers: Who is directly influencing “self”? Local Community, Services, Products, and Leaders and Providers: Who or what is directly influencing “self” at the local level? National Enabling Environment and Leaders: Who or what is indirectly affecting “self” at the national level? Cross-Cutting Factors: Information, Motivation, Ability to Act, and Norms: How are these factors addressed across all levels? For interventions aimed at improving the nutritional status of the population in the country to be successful, especially that of nutritionally vulnerable groups within the household, they must include a comprehensive strategy to improve knowledge, attitudes, beliefs and behaviors related to nutrition. Such changes are often difficult to change and require more than providing correct information about prevention of undernutrition. For individuals to be able to change behavior, key factors affecting the individuals themselves and those directly or indirectly influencing them need to be addressed, including motivation, the ability to act (including self-efficacy), and social/gender norms. This model of behavior change, known as the socio-ecological model supports the theory that individual behavior is a product of multiple overlapping individual, social, and environmental influences, and combines individual change with the aim to influence the social context in which the individual operates. The socio-ecological model for change is based on a synthesis of theories and approaches from disciplines such as psychology, sociology, communication, and political science. The model allows practitioners to examine and address several levels of influence to find opportunities for change. Think back to the slide we discussed earlier on advocacy, social mobilization, and behavior change communication. Each of those audiences fit within the categories in this model. Advocacy audiences fit within the enabling environment; social mobilization audiences fit within the community; and behavior change audiences fit within the areas of interpersonal and self.

Recall Questions Asked Earlier in Workshop
What is the problem: Why are we here? What changes does the problem call for? How can the estimates be used for nutrition advocacy? During the stakeholder meeting and Session 2 of the PROFILES workshop, the following questions on nutrition advocacy were discussed: What is the problem? What changes does the problem call for? and How can the estimates be used for nutrition advocacy? Note: If there was no time for a discussion on the questions above, the facilitator may need to take time to discuss these topics and not just recall them.

What Is the Problem? Summary of Discussion
[Add summary from earlier discussions] This slide will need to be filled in from previous advocacy discussions that took place during the PROFILES workshop—see session plan for more information.

What Changes Does the Problem Call For? Summary of Discussion
[Add summary from earlier discussions] This slide will need to be filled in from previous discussions—see session plan for more information.

How Can the Health and Nutrition Estimates Be Used for Nutrition Advocacy? Summary of Discussion
[Add summary from earlier discussions] Summarize the key points from the discussion earlier in the workshop. This slide will need to be filled in from previous discussions—see session plan for more information.

How Can the Human Capital and Economic Estimates Be Used for Nutrition Advocacy? Summary of Discussion [Summary from earlier discussions] Summarize the key points of the discussion earlier in the workshop. This slide will need to be filled in from previous discussions—see session plan for more information.

Activity 2 Do you agree with the previous discussions?
What would you add to or change in this discussion? What key points would you like participants in the upcoming nutrition advocacy planning workshop to know?

Session 16: Next Steps/Wrap-Up

Reviewed next steps in the nutrition advocacy planning process Discussed how to talk about the nutrition advocacy planning process including PROFILES Refer to slide.

Activity 1 Share one or two impressions of the workshop and share what you have learned and how you would like to use the information from this workshop for nutrition advocacy purposes. Ask participants in plenary to share one or two impressions of the workshop, stating what they have learned and how they would like to use the information from this workshop for nutrition advocacy purposes. (5 minutes)

You Are Here Refer to slide. Adapt as necessary.

Activity 2 How to discuss nutrition advocacy using PROFILES
Conduct activity—see session plan for more guidance. The PROFILES technical brief should be used for the activity. (approximately 20 minutes)

Thank You! Questions, comments?

Preliminary Results: [COUNTRY] PROFILES [Year] Results
STEP 2 Preliminary Results: [COUNTRY] PROFILES [Year] Results Presentation Slides Note that ideally a participant from the PROFLES workshop should make this presentation. “Good morning. I would like to present to you the preliminary results of the [country] PROFILES [year] workshop. As a group, around [insert # of participants of workshop] of us worked to create estimates using PROFILES to use in nutrition advocacy materials. Here are our results.”

Purpose of Presentation
During a consultative stakeholder meeting and 2.5-day workshop, participants developed PROFILES estimates for the time period [insert years] for [insert country] The purpose of this presentation is to share the initial estimates that have been developed Purpose of Presentation

Uses computer-based models and current country-specific data to estimate the benefits of improved nutrition on health and development outcomes, and the negative consequences if malnutrition continues over a defined time period PROFILES estimates are intended to support nutrition advocacy efforts targeting multiple audiences (e.g., communities, local government authorities, parliamentarians) “First, let me briefly review what PROFILES is. PROFILES is a computer-based model that serves as a tool to support nutrition advocacy. It consists of a set of spreadsheet models reflecting current scientific nutrition knowledge and is designed to estimate the functional consequences of malnutrition to support advocacy and communication with policymakers, program implementers, and other stakeholders. The basic approach in PROFILES is to provide two scenarios, contrasting a status quo scenario that assumes there will be no change from the current situation throughout the chosen time period (aside from projected changes in population size) to an improved scenario. The improved scenario—with results estimated for the same time period—assumes that nutrition interventions that are known to be effective are implemented at scale and succeed in reaching the specified targets in terms of reductions in the prevalence of the various nutrition problems. In the status quo scenario, consequences are expressed in terms of lives lost or economic productivity losses, for example. When contrasting the results from the status quo and the improved scenarios, the differences reflect benefits expressed as lives saved or economic productivity gains. Although nutrition interventions are not included in the PROFILES models, the subsequent steps in the nutrition advocacy process can address the need for various nutrition services, interventions, programs, or issues related to the nutrition policy environment.”

General Assumptions of PROFILES
PROFILES requires: Current prevalence of nutrition indicators Mortality rates Demographic, economic, and education information Assumptions about targets for improvement in nutrition Time period for the estimates The PROFILES model assumes a steady linear reduction in the prevalence of nutrition problems from the starting point until the end of the specified time period “In order to utilize the PROFILES process, the PROFILES spreadsheet requires information on the current prevalence of various nutrition indicators, mortality rates, and projected population growth, and assumptions are made about what the targets for improvement in nutrition should be. The other steps in the nutrition advocacy process can address the need for various nutrition services, interventions, and programs. The PROFILES model assumes a steady linear reduction in the prevalence of nutrition problems from the starting point until the end of the specified selected time period.”

This slide shows that for a specific nutrition indicator, PROFILES calculates an estimate for a specific outcome. So a reduction in maternal iron deficiency anemia would result in a reduction in maternal and perinatal mortality (this is what we know from the scientific literature). If iron status improves, there would be fewer maternal and perinatal deaths as a result. Similarly, a reduction in low birth weight would reduce infant mortality. A reduction in vitamin A deficiency in children would reduce child mortality. A reduction in iodine deficiency during pregnancy would reduce permanent disabilities in children. A reduction is stunting, underweight, and wasting would reduce child mortality, as would a reduction in sub-optimal breastfeeding practices. A reduction in sub-optimal breastfeeding practices can also help to reduce childhood overweight/obesity. Similarly, a reduction in stunting would increase human capital through improved learning potential in childhood. And lastly, a reduction in stunting, low birth weight, iron deficiency anemia, and iodine deficiency would increase economic productivity.

The basic approach in PROFILES is to provide two scenarios: Status quo scenario Assumes there will be no change from the current situation throughout the chosen time period (aside from projected changes in population size and structure) The consequences are expressed, for example, as lives lost and economic productivity losses Improved scenario Assumes that the nutrition situation improves and that the stated targets are reached for the various forms of undernutrition by the end of the same time period The benefits are expressed, for example, as lives saved and economic productivity gains The basic approach in PROFILES is to provide two scenarios: a “status quo” scenario and an “improved” scenario. The status quo scenario assumes there will be no change from the current situation throughout the chosen time period (the number of years for which estimates are calculated), aside from projected changes in population size and structure. The prevalence of each nutrition problem remains the same every year in the status quo scenario. In contrast, in the improved scenario—with results estimated for the same time period—it is expected that nutrition interventions that are known to be effective are implemented at scale and succeed in reaching the stated targets in terms of improvements in the prevalence of the various nutrition problems. The targets reflect the proportion by which nutrition problems will be reduced by the end of the chosen time period and are determined and agreed upon through stakeholder meetings and a PROFILES workshop. In the status quo scenario, the negative consequences are expressed, for example, in terms of lives lost, disabilities, human capital lost, and economic productivity losses. When contrasting the results between the status quo and the improved scenarios, the differences reflect the benefits of improved nutrition, expressed as lives saved, disabilities averted, human capital gains, and economic productivity gains.

Steps to Develop the PROFILES Estimates
Stakeholder Meeting Participants identified advocacy needs and discussed the sources of information for the nutrition indicators required in PROFILES PROFILES Workshop Participants selected the best source of information for each nutrition indicator to generate the estimates in PROFILES The following steps were undertaken to develop the PROFILES estimates.

Initial and Target Prevalence for Time Period [YEAR–YEAR]
Indicator Status quo prevalence (%) Source (status quo prevalence) Rationale for selecting data source Target prevalence (%) Wasting—moderate and severe (0–59 months) Underweight—moderate and severe (0–59 months) Stunting—moderate and severe (24–35 months) Stunting—moderate and severe (0–59 months) Child overweight/ obesity—moderate and severe (48–59 months) NA “Our first step was to set a time period. After careful consideration of several timelines, [insert time period] was selected. This slide shows prevalence for nutrition indicators in the status quo scenario, their source, and the targets that we set.” Note: Delete indicators if estimates were not generated during the workshop. Note: A target prevalence is not selected for child overweight/obesity, as the model looks at the impact of exclusive breastfeeding on a reduction in overweight/obesity prevalence, so a target for exclusive breastfeeding is set, not overweight/obesity.

Indicator Status quo prevalence (%) Source (status quo prevalence) Rationale for selecting data source Target prevalence (%) Vitamin A deficiency (6–59 months) Iodine deficiency Anemia—children (< 5 years of age) Anemia—school-age children (5–14 years) Anemia—pregnant women Anemia—women (15–49 years) Anemia—men (15–64 years) Refer to slide

Indicator Status quo prevalence (%) Source (status quo prevalence) Rationale for selecting data source Target prevalence (%) Low birth weight Early initiation of breastfeeding (within 1 hr of birth) Ever breastfed Exclusive breastfeeding (0–5 months) Exclusive breastfeeding (4–5 months) Predominant breastfeeding (0–5 months) Partial breastfeeding (0–5 months) No breastfeeding (0–5 months) Any breastfeeding (6–23 months) No breastfeeding (6–23 months) “We also looked at low birth weight and breastfeeding indicators.” Refer to slide.

If There is No Change in Stunting Prevalence: Annual Number of Deaths Related to Stunting will Rise Because of Increase in the Population of Children Under 5 “As you will see in this slide, if stunting levels remain unchanged until [end of time period], the annual number of under-5 deaths related to stunting in children can be expected to increase over time because of an increase in the size of the population of children under 5 due to changes in population size and structure. Although, [country] has made some progress in reducing stunting, these reductions may not be continued without significant commitments of both resources and political support.” Note: This slide/graphic will need to be adjusted for country context. See tables and figures tab of the PROFILES Spreadsheet Workbook to edit slide.

If Nutrition Improves and Stunting Prevalence Is Reduced: Annual Number of Deaths Related to Stunting Will Decrease and Children’s Lives Will Be Saved In the period [insert time period], [xxxx] deaths related to stunting could be averted. “However, this slide shows that if high coverage of effective nutrition interventions are implemented and succeed in reducing stunting levels to their assumed targets, in the [xxxx] time period, assuming a steady decrease in stunting levels, the lives of about [xxx] children under 5 years will be saved.” Note: This slide/graphic will need to be adjusted for country context. See tables and figures tab of the PROFILES Spreadsheet Workbook to edit slide.

If There Is No Change in Wasting Prevalence: Annual Number of Deaths Related to Wasting Will Rise Because of Increase in the Population of Children Under 5 “As you will see in this slide, if wasting levels remain unchanged until [end of time period], the annual number of under-5 deaths related to wasting in children can be expected to increase over time because of an increase in the size of the population of children under 5 due to changes in population size and structure. Although, [country] has made some progress in reducing wasting, these reductions may not be continued without significant commitments of both resources and political support.” Note: This slide/graphic will need to be adjusted for country context. See tables and figures tab of the PROFILES Spreadsheet Workbook to edit slide.

If Nutrition Improves and Wasting Prevalence Is Reduced: Annual Number of Deaths Related to Wasting Will Decrease and Children’s Lives Will Be Saved In the period [insert time period], [xxxx] deaths related to wasting could be averted. “However, this slide shows that if high coverage of effective nutrition interventions are implemented and succeed in reducing wasting levels to their assumed targets, in the [xxxx] time period, assuming a steady decrease in wasting levels, the lives of about [xxx] children under 5 years will be saved.” Note: This slide/graphic will need to be adjusted for country context. See tables and figures tab of the PROFILES Spreadsheet Workbook to edit slide.

Child development & disability*
Number of Deaths That Would Result If the Current Nutrition Situation Continues: Status Quo Scenario for the Time Period [YEAR–YEAR] Maternal deaths Perinatal deaths Infant deaths Child deaths Child development & disability* IDA IDA LBW VAD IDD This slide indicates the number of lives lost that would result if the current nutrition situation in [country] continues—the status quo scenario. “As you can see, if there is no change in malnutrition levels over the time period up to [final year in time period], the lives of [xxx] women will be lost due to maternal anemia related to iron deficiency, [xxx] lives will be lost during the perinatal period due to maternal anemia, the lives of [xxx] infants will be lost to low birth weight, the lives of [xxx] children will be lost to vitamin A deficiency. Similarly, if maternal iodine deficiency is not reduced by [final year in time period], then over [xxx] million children will suffer from permanent disabilities. Globally, brain damage from intrauterine iodine deficiency is the leading cause of preventable brain damage. Note: Do not feel you need to go over every number—judge based on time and interest from the group. Delete any indicator for which estimates were not generated. [XXX] [XXX] [XXX] [XXX] [XXX] * Cretinism and mild to severe permanent brain damage. IDA: iron deficiency anemia; LBW: low birth weight; VAD: vitamin A deficiency; IDD: iodine deficiency disorder

Child overweight/ obesity
Number of Deaths That Would Result If the Current Nutrition Situation Continues: Status Quo Scenario for the Time Period [YEAR–YEAR] Neonatal deaths Young child deaths Child overweight/ obesity Late initiation of BF Sub-optimal BF Sub-optimal BF This slide indicates the number of lives lost that would result if the current nutrition situation in [country] continues—the status quo scenario. “As you can see, if there is no change in breastfeeding practices over the time period, the lives of {xxx} infants will be lost related to late initiation of breastfeeding, the lives of [xxx] young children will be lost to suboptimal breastfeeding practices, and {xxx} children aged months will become overweight/obese related to suboptimal breastfeeding practices Note: Do not feel you need to go over every number—judge based on time and interest from the group. Delete any indicator for which estimates were not generated. [XXX] [XXX] [XXX] BF: breastfeeding

Number of Lives That Could Be Saved If the Nutrition Situation Improves: Improved Scenario for the Time Period [YEAR–YEAR] Maternal deaths averted Perinatal deaths averted Infant deaths averted Child deaths averted Child development & disability* averted IDA IDA LBW VAD IDD “Here you see that reductions in prevalence of maternal iron deficiency anemia by [insert end of time period] could save about [xxx] women’s lives and avert about [xxx] perinatal deaths over the [xxxx–xxxx] time period. Maternal anemia increases the risk of maternal deaths related to pregnancy and delivery. In addition, in the [xxxx-xxxx] time period, [xxx] infant deaths could be averted by reductions in low birth weight, and [xxx] child deaths could be averted by reducing vitamin A deficiency. Finally, the reduction of maternal iodine deficiency by [insert final year of timer period] could result in preventing permanent brain damage in about [xxx] children.” Note: Do not feel you need to go over every number—judge based on time and interest from the group. Delete any indicator for which estimates were not generated. [XXX] [XXX] [XXX] [XXX] [XXX] * Cretinism and mild to severe permanent brain damage. IDA: iron deficiency anemia; LBW: low birth weight; VAD: vitamin A deficiency; IDD: iodine deficiency disorder

Number of Lives That Could Be Saved If the Nutrition Situation Improves: Improved Scenario for the Time Period [YEAR–YEAR] Neonatal deaths averted Young child deaths averted Child overweight/ obesity prevented Late initiation of BF Sub-optimal BF Sub-optimal BF “Here you see that improvements in breastfeeding practices by [insert end of time period] could save about [xxx] young child deaths could be averted by improving breastfeeding practices, [xxx] infant deaths could be averted by improving the early initiation of breastfeeding practice, and [xxx] number of children aged months could be prevented from becoming overweight/obese by improving breastfeeding practices”. Note: Do not feel you need to go over every number—judge based on time and interest from the group. Delete any indicator for which estimates were not generated. [XXX] [XXX] [XXX] BF: breastfeeding

Equivalent school years of learning
Human Capital Losses in Learning Related to Stunting for the Time Period [YEAR–YEAR] Status Quo Scenario Equivalent school years of learning “We also calculated the impact of stunting on human capital, and in particular learning. Here is the status quo scenario if the stunting situation does not improve.” [xxx] million years

Equivalent school years of learning
Human Capital Gains in Learning Related to Stunting for the Time Period [YEAR–YEAR] Improved Scenario Average number of equivalent school years of learning gained among children 2 years of age in final year of the time period: {xxx}, related to a reduction in stunting Equivalent school years of learning Here is the improved scenario. Stunting has an impact on human capital, and learning in particular, as stunting compromises learning in multiple ways. Losses in learning are not only related to fewer overall years in school and therefore lost learning potential, but once children are actually in school they have reduced capacity to learn; meaning they learn less per school year. If stunting prevalence is reduced, then more than [xxx] million years of school equivalent learning will be gained.” Note, the model also assumes that children who are not in school also have learning losses related to stunting. Average number of equivalent school years of learning gained among children 2 years of age in final year of the time period by the time they reach the age corresponding to the end of the primary school years: {xxx} Note: you may use both this slide and the following to display the human capital gains or you may chose just one. [xxx] million years

Human Capital Gains in Learning Related to Stunting for the Time Period [YEAR–YEAR]
In the period 2017–2026, million equivalent school years of learning gained related to a reduction in stunting. For those in the 24–35- month age group in the year 2026, 1.7 equivalent school years of learning gained per child related to a reduction in stunting. See the tables and figures tab of the PROFILES Spreadsheet Workbook to edit slide.

Economic Productivity Losses That Would Result If the Current Nutrition Situation Continues: Status Quo Scenario for the Time Period 2018–2030 Economic productivity losses Economic productivity losses Economic productivity losses Economic productivity losses Stunting* Iodine deficiency Child anemia Adult anemia Note: One way to write the numbers, using Malawi as an example, is: 3,730,599,360,000 or trillion MWK (US$6.618 billion). “We also examined the economic loses related to various nutrition problems in the status quo scenario, which is if there is no improvement or no change in these various nutrition problems (stunting, iron deficiency anemia, and iodine deficiency). If there is no change, the country will suffer [xxx] million US dollars worth of economic losses related to stunting, [xxx] million US dollars related to iron deficiency anemia, and [xxx] million US dollars related to iodine deficiency." [xxx] [xxx] [xxx] [xxx] * Productivity losses from stunting include losses that would result from no change or no improvement in stunting related to no change or no improvement in low birth weight.

Economic Productivity Gains That Would Result If the Current Nutrition Situation Improves: Improved Scenario for the Time Period 2018–2030 Economic productivity gains Economic productivity gains Economic productivity gains Economic productivity gains Stunting* Child anemia Adult anemia Iodine deficiency Note: A way to write out the numbers, using Malawi as an example, is: 3,730,599,360,000 or trillion MWK (US$ billion). “However, if the nutrition situation were to improve, the country would save around [xxx] related to reductions in stunting and [xxx] related to reduced adult anemia and improved productivity, and [xxx] million US dollars related to reductions in iodine deficiency.".” [XXX] [XXX] [XXX] [XXX] * Productivity gains from stunting include gains that would result from reductions in stunting related to reduced low birth weight.

Economic Productivity Gains That Would Result If the Current Nutrition Situation Improves: Improved Scenario for the Time Period [YEAR–YEAR] See the tables and figures tab of the PROFILES Spreadsheet Workbook to edit slide. Here is a summary of the economic productivity gains in the improved scenario.

Inadequate dietary diversity
Cases of Stunting That Would Result If the Current Nutrition Situation Continues: Status Quo Scenario for the Time Period [YEAR–YEAR] Stunting Cases Stunting Cases Inadequate dietary diversity Teenage pregnancy Number of children age months who are stunted related to inadequate dietary diversity Number of children age months who are stunted related to teenage pregnancy [xxx] [xxx]

Stunting cases averted Stunting cases averted
Stunting Cases That Would be Averted If the Current Nutrition Situation Improves: Improved Scenario for the Time Period [YEAR–YEAR] Stunting cases averted Stunting cases averted Improved dietary diversity Reduced teenage pregnancy Number of children aged month for whom stunting is averted related to improved dietary diversity Number of children aged month for whom stunting is averted related to a reduction in teenage pregnancy [xxx] [xxx]

Inadequate Dietary Diversity as a Risk Factor for Stunting: Status Quo vs. Improved Scenario
See the tables and figures tab of the PROFILES Spreadsheet Workbook to edit slide. Number of children with stunting related to inadequate dietary diversity and the number of children for whom stunting is averted.

Being Born to a Teenage Mother as a Risk Factor for Stunting: Status Quo vs. Improved Scenario
See the tables and figures tab of the PROFILES Spreadsheet Workbook to edit slide. Number of children with stunting related to being born to a teenage mother and number of children for whom stunting is averted.

Conclusion Nutrition is critical for national development in [country]
Nutrition is still a chronic, hidden issue that is often overshadowed Investment in nutrition is imperative to achieve further gains in health and economic growth and the 2012 World Health Assembly targets for 2025 committed to by [country] Investing in nutrition offers some of the highest development returns on investment and is critical because implementation of evidence-based, effective nutrition interventions can: Improve child development, cognitive function, and educational outcomes Increase economic productivity Save the lives of women and children

Questions and Answers

Nutrition Advocacy Planning Workshop
STEP 4 Nutrition Advocacy Planning Workshop Presentation Slides

Nutrition Advocacy Planning Workshop Day One

Welcoming Remarks

Session 1: Purpose of the Workshop: Why Advocacy and Why Now?

Purpose of the Workshop
Develop an initial harmonized, multisectoral strategic nutrition advocacy plan that includes a prioritized list of advocacy materials, a timeline for advocacy activities and development/dissemination of materials, and M&E indicators Review initial draft of nutrition advocacy material Use the material planning tool for selected prioritized nutrition advocacy materials

Key Steps in the Process
Government of [insert country] requested support in nutrition advocacy efforts Core working group supervised the process and convened key stakeholders from multiple sectors, donors, and implementing agencies Stakeholder meeting was held to discuss advocacy approach and sources for advocacy materials, including PROFILES PROFILES workshop was held to develop PROFILES estimates

Why Advocacy and Why Now?
Using the term “advocacy” to mean raising resources and political/social commitment for nutrition Advocacy is a key component that supports all future communication efforts Advocacy is essential now to: Create awareness and understanding of the importance of nutrition among the public and within government Ensure adequate resources and structures for nutrition services at national, regional, and district levels Increase political action and accountability among government and stakeholders “Advocacy is a planned, deliberate, systematic and coordinated process, so stakeholders can speak in one harmonized voice. The aim of this workshop is to create an advocacy plan, and to do this, the work you will do is to: Prioritize who you want to communicate with (audience) What you want to communicate about/on (desired change and advocacy objectives) How you want to communicate (activities and materials) How you will measure your success (indicators and means of verification) By when you will complete these activities (timeline) Who will be responsible (responsible parties)”

Introductions Please introduce yourself: Your name Your organization
Your expectations for the workshop

Visualization in Participatory Programs (VIPP)
Allows everyone’s voice to be heard Rules: One thought per card Use a marker, not a pen Write with broad side of marker No more than three lines per card Print legibly

Review of Agenda

Session 2: The Nutrition Situation in [insert country]

Session 3: Review of Existing Nutrition Advocacy Activities and Materials

Discussion Question Are you currently using nutrition advocacy materials? Or have used such materials in the past?

Session 4: Components of a Nutrition Advocacy Plan; Review of the Problem and Possible Solutions

Analysis of audiences determines the mix of strategies: Advocacy to raise resources and political/ social commitment for change goals Social mobilization for wider participation, collective action, and ownership, including community mobilization Behavior change communication (BCC) for changes in knowledge, attitudes, and practices of specific audiences “Here you will see how the three components of a successful social and behavior change program support each other. Advocacy raises resources and political/social commitment for change goals Social mobilization creates wider participation, collective action, and ownership at the community level Behavior change communication creates changes in knowledge, attitudes, and practices of specific audiences, specifically at the household level These three components need to be planned for, and often advocacy needs to happen first to create the enabling environment for change to happen in the other levels. For example, policies may need to be put into place or, if services or products are being promoted through communication at the household level, it’s essential that those services or products be available and accessible; otherwise, your communication will lose credibility.” What we know works to change social norms are sustained communication programs that work at multiple levels with multiple channels. Strong policy and law enforcement elements, champions at national, state, and local levels, and strong civil society involvement, in addition to work at the household and community levels using counseling, school programs, and earned and paid media are key components in programs that help to change norms.”

Step-by-Step Process to Develop an Advocacy Plan
Using a 4-day participatory workshop: Identify the problem Discuss the changes the problem calls for Identify target audiences Identify the advocacy intent for each audience Determine the barriers to achieving that change for each audience Determine the desired change for each audience Identify channels, activities and materials for each audience Identify by when activities will be completed and by whom Identify how change will be measured “This slide shows you the participatory step-by-step process used during nutrition advocacy plan development.” “During the 4-day workshop, stakeholders identify the problems, discuss the changes the problem calls for, identify the target audiences, determine what needs to change for each audience, what the barriers to change are by audience, and identify the intent of advocating to that audience. For each audience, workshop participants also identify what activities will be undertaken, and what materials will be needed, and by when activities will be completed and how change and progress will be measured. A national guiding framework such as this is crucial to coordinate and harmonize advocacy efforts across many implementers.”

Components of an Advocacy Plan
1. Problem Statement 6. Advocacy Intent for Each Audience 2. Changes Needed to Solve the Problem 7. Strategic Approach 3. Final Audience Segmentation 8. Channels, Activities, and Materials for Each Audience 4. Desired Changes for Each Audience 9. Draft Implementation Plan with M&E indicators 5. Barriers for Each Audience “By the end of the workshop, these are the components that will have been developed by participants to constitute the nutrition advocacy plan.”

Discussion from Stakeholder Meeting and PROFILES Workshop on Nutrition Advocacy
“For our advocacy efforts and for the materials we will begin to develop this week, we should use as many resources as we have available to make the case for improved nutrition. This includes PROFILES estimates. A workshop was held to develop estimates using PROFILES. Some of you participated in that workshop; for those of you who did not, PROFILES results provide comprehensive information for nutrition advocacy purposes on the economic and health consequences of not adequately addressing a country’s nutrition problems, and the benefits of improved nutrition, including lives improved and saved, human capital gains and economic productivity losses averted. We will be sharing PROFILES results later today. Participants at the workshop began to discuss how PROFILES results could be used for advocacy purposes. We’ll start our work there to get your feedback and build off of those discussions.”

Questions Addressed at Stakeholder Meeting and PROFILES Workshop
What is the problem? Why are we here? What changes could solve the problem?

The Problem: Why Are We Here?

Summary of Discussion from Stakeholder Meeting and PROFILES Workshop: The Problem
[Insert text after Stakeholder Meeting and PROFILES Workshop. Consider this example:] Despite continued efforts, these problems exist: Nutrition is not prioritized at all levels A lack of coordination of nutrition activities at all levels Little understanding of nutrition and nutrition’s impact on other development outcomes No clear institutional framework for nutrition, and no multisectoral action plan for nutrition with defined roles and responsibilities A lack of resources for nutrition (specifically at the local government level) A lack of nutrition data at the district level Nutritious foods not available or accessible for many Weak management of multisectoral action on nutrition at the local government level Confusion on reporting lines for nutrition

Feedback Session Do you agree?
What would you add or change on this list?

What Changes Might Solve the Problem?
What changes—policies, services, products, social norms, individual behaviors, etc.—could help to reduce or solve the problem?

Summary of Discussion from Stakeholder Meeting and PROFILES Workshop: The Solutions
[Insert text after the Stakeholder Meeting and PROFILES Workshop. Consider this example:] Nutrition advocacy at all levels with a harmonized call to action for target audiences Increased resources for nutrition (particularly at the local government level) Increased ability to pool funding and work together Incorporation of nutrition into political agendas and manifestos Clear institutional frameworks and a multisectoral action plan for nutrition with defined roles and responsibilities Strengthened multisectoral coordination committees at national, regional, district, and community levels Centralization of the reporting mechanism Improved affordability and access to nutritious foods (through food fortification and subsidies)

Feedback Session Do you agree?
What would you add to or change on this list?

Flipchart in the Back of the Room
Please list any questions or comments you have on the nutrition advocacy process throughout the workshop. They will be addressed at the beginning of each day.

Session 5: Summary of PROFILES Estimates [Insert Preliminary Results Slides from Step 2]
“Now we will look at a summary of the PROFILES estimates, which were arrived at through a collaborative PROFILES workshop with participants from various sectors of the government and nutrition experts, including [insert government sectors and partners].”

Session 6: Audience Analysis and Segmentation Using the Socio-Ecological Model

Using the Socio-Ecological Model to Determine Key Audiences
Levels of Analysis: Where is the tipping point for change? Self: Who is directly affected? Partners, Family, Peers: Who is directly influencing “self”? Local Community, Services, Products, and Leaders and Providers: Who or what is directly influencing “self” at the local level? National Enabling Environment and Leaders: Who or what is indirectly affecting “self” at the national level? Cross-Cutting Factors: Information, Motivation, Ability to Act, and Norms: How are these factors addressed across all levels? For interventions aimed at improving the nutritional status of the population in the country to be successful, especially that of nutritionally vulnerable groups within the household, they must include a comprehensive strategy to improve knowledge, attitudes, beliefs and behaviors related to nutrition. Such changes are often difficult to change and require more than providing correct information about prevention of undernutrition. For individuals to be able to change behavior, key factors affecting the individuals themselves and those directly or indirectly influencing them need to be addressed, including motivation, the ability to act (including self-efficacy), and social/gender norms. This model of behavior change, known as the socio-ecological model supports the theory that individual behavior is a product of multiple overlapping individual, social, and environmental influences, and combines individual change with the aim to influence the social context in which the individual operates. The socio-ecological model for change is based on a synthesis of theories and approaches from disciplines such as psychology, sociology, communication, and political science. The model allows practitioners to examine and address several levels of influence to find opportunities for change. Think back to the slide we discussed earlier on advocacy, social mobilization, and behavior change communication. Each of those audiences fit within the categories in this model. Advocacy audiences fit within the enabling environment; social mobilization audiences fit within the community; and behavior change audiences fit within the areas of interpersonal and self.

Audience Analysis Exercise

Session 6 (Continued): Audience Analysis and Segmentation Using the Socio-Ecological Model

Voting on Audiences Each person gets 5 votes.

Session 7: Context Analysis

Context Analysis Information: What in formation does the audience receive about the issue? From whom? What is the format? (For example: Do the news media receive press releases from nutrition organizations?) Motivation: What motivates the audience? (For example: Are newspaper publishers motivated by a need to write stories that will appeal to their readers, sell more papers, or keep elected officials accountable?) Ability to Act: What power and resources does the audience have? (For example: Editors and news producers can decide what to cover, but their resources for investigative reporting may be limited.) Norms: What are the underlying values of the audience? How do these values affect their attitudes, beliefs, and behaviors? (For example: Politics and sports may have more prestige than public health reporting among journalists.) “The purpose of this exercise is to begin thinking about the context in which each target audience lives and works. Working in groups to think through these questions will help us begin thinking like our target audience and putting ourselves in their shoes.”

Session 8: Desired Changes, Barriers, and Advocacy Intent for Each Audience

Advocacy Intent What is an “advocacy intent”?
How you plan to address the barriers you identified, so that you can achieve the desired change For example: An advocacy intent could involve improving the audience’s understanding of an issue or building their skills What is not an “advocacy intent”? It is not a program objective “It is important to emphasize that the advocacy intent is NOT your program objective. You have already addressed that through your desired change. The question here is HOW are you planning on addressing the barriers—using advocacy—to get to your desired change? Do you need to change attitudes? Or build skills? Or both? This is your advocacy intent.”

Barriers (Why are we still dealing with this problem?)
The advocacy intent must address the reasons that people ignore, fear, or resist change Barriers “Communication programs have been working on many of the same problems for decades, because people have reasons for ignoring, fearing or resisting change. I want to focus on barriers for a moment because I feel like people talk about barriers a lot, we know we need to address them but when once we start designing our programs, we have a hard time focusing on them. It’s important that the advocacy intent you set address one or more of the barriers you’ve identified.” Desired change Advocacy intent

Desired Changes, Barriers, and Advocacy Intent for Each Audience
For each audience, discuss: Desired changes Barriers Advocacy intent, which should have these qualities: Specific Measurable Attainable Realistic Time-bound

Example from Ethiopia Target Audience: Media Desired Change Barriers
Increase the amount and accuracy of media coverage on nutrition issues Barriers Priority is given to politics and sports A lack of journalists who specialize in health, especially nutrition A lack of journalists trained in nutrition issues Advocacy Intent By the end of the time period, media gatekeepers will have an increased understanding of the benefits of reporting on nutrition, and journalists will have an increased capacity to report on nutrition.

Wrap-Up and Closing of Day 1

Nutrition Advocacy Planning Workshop:
Day Two

Recap of Day One

Session 9: Discussion of Desired Changes, Barriers, and Advocacy Intent for Each Audience

Session 10: Revision of Desired Changes, Barriers, and Advocacy Intent for Each Audience

Session 11: Advocacy Activities and Materials for Each Audience

Discussion Questions Have you participated in any advocacy activities?
What was your experience? What was effective? What was not effective?

Communication Channels
Benefit Interpersonal: One-on-one meetings, roundtables, etc. Tailored communication Interactive Good for complex information Collective: Collective meetings with leaders, etc. Provides social support Can motivate collective solutions Mass Media: Radio and TV ads and programs, newspaper articles, posters, brochures, etc. Extensive reach Efficient and consistent repetition of messages “While interpersonal channels are often shown to have the most impact in terms of behavior change, it’s often the most costly and time and resource intensive, so it’s more difficult to reach large audiences. Community-based meetings provide a forum for collective solutions and ownership of a problem. Mass media can have extensive reach with repetition of messages, but can never be a replacement for interpersonal communication. It’s really the range of tools that makes a communication initiative successful.”

Factors that Influence the Choice of Channels
Complexity of the issue Sensitivity of the issue Desired reach Cost Literacy Audience preference for formats, languages, and media habits “There are many factors that influence the choice of communication channels. Issues that are particularly complex and/or sensitive will benefit from using interpersonal channels. While this channel has been shown to be the most effective at behavior change, it does not have nearly as large of a reach as mass media and is more expensive with regard to how many households are reached, which is why these are done in tandem to complement each other. Literacy levels also play a role in choice of channels. Reaching audiences that have a lower level of literacy, for example, may require the use of mediums such as radio, TV, community theatre or interpersonal counseling. It’s important to know your audience and determine before you begin any communication initiative, their preferences about which formats, language and media habits will be most effective.”

Deciding on Activities and Materials
What channels/activities are the best for your audience? For example: What formats do they prefer? What has worked in the past? Identify specific newspapers, and TV or radio programs. What language do they prefer? Does your content suit the channel/activity? For example: Sensitive or complex content may require interpersonal contact, rather than a poster. Do you have the resources to support your approach? How does your approach align with the national vision documents and plans?

Example from Ethiopia Target Audience: Media Activities
Conduct baseline media monitoring and continuous media monitoring every quarter Meet with press associations and media gatekeepers to increase understanding of reporting on nutrition issues Hold roundtables with select media houses in capital and other cities Conduct training sessions for journalists on nutrition issues Materials Training modules for journalist training Media kit, including fact sheet, a contact list for specific issues on nutrition, and a “Frequently Asked Questions” document

Session 12: Discussion of Advocacy Activities and Materials for Each Audience

Session 13: Revision of Advocacy Activities and Materials for Each Audience

Session 14: Indicators and Means of Verification

Indicators and Means of Verification
Monitoring and evaluation is needed throughout an SBCC program: Baseline research Process evaluation Output evaluation Outcome evaluation “Monitoring and evaluation is useful at all stages of an advocacy program. Baseline evaluation occurs at the very beginning of the program to determine the starting point. Process evaluation occurs throughout implementation. Output and outcome evaluation take place after the activity is finished but must be planned from the beginning. Of course, all evaluation results are used to plan, adapt, and conduct activities again using the lessons learned.”

How do we judge the success of our advocacy efforts? Outcome indicators: Can be used to measure if the desired changes were achieved Are stated in terms of percentage of target audience reached

How do we judge the success of our advocacy efforts? Output indicators: Can be used to measure if the advocacy intents were achieved Stated in terms of numbers of target audience reached

How do we judge the success of our advocacy efforts? Process indicators: Can be used to measure if activities were accomplished Stated in terms of activities held such as number of trainings, number of household visits, etc.

Means of verification are what you use to monitor and verify the indicator such as meeting minutes, pre- and post-tests for trainings, workshop reports, program quarterly reports, etc.

Example from Ethiopia Target Audience: Media
Indicators and Means of Verification At the desired change level: % of media coverage on nutrition issues (outcome indicator) At the advocacy intent level: # of media gatekeepers with increased understanding of benefits of reporting on nutrition (output indicator) At the activity level: # of trainings with media (process indicator) Media monitoring reports Training reports

Session 15: Discussion of Indicators and Means of Verification

Day Three

Recap of Day 2

Session 16: Revision of Indicators and Means of Verification

Session 17: Timeline and Responsible/Supporting Organizations

Example from Ethiopia Target Audience: Media [For each activity...]
Timeline Year 2 Q2–Q3 Responsible Organization Ministry of Health Supporting Organization FANTA

Session 18: Discussion of Timeline and Responsible/Supporting Organizations

Session 19: Revision of Timeline and Responsible/Supporting Organizations

Session 20: Introduction to Material Planning Tool and Review of Draft Material

What is a Material Planning Tool?
A material planning tool helps you plan and develop materials Also called a “creative brief,” a material planning tool is used by advertising agencies and communications firms to develop their strategies A material planning tool can help groups of people who are working on the same material to coordinate their efforts

Discuss the Material Is the target audience clearly defined? Who is it? Is the call to action clearly defined? What is it? Does the material convey a strong benefit? What is it? Does the information in the material support the benefits? Is information missing from the material? Should any information be changed?

Session 21: Discussion and Revision of Draft Material

Day Four

Session 22: Review of the Completed Nutrition Advocacy Plan

Session 23: Material Planning Tool—Key Promise, Support Statement, and Call to Action

Session 24: Material Planning Tool—Discussion of Key Promise, Support Statement, and Call to Action

Session 25: Material Planning Tool—Revision of Key Promise, Support Statement, and Call to Action

Session 26: Material Planning Tool—Key Content (Detailed Outline of Document) and How it Fits the Mix/Creative Considerations

Session 27: Material Planning Tool—Discussion of Key Content (Detailed Outline of Document) and How it Fits the Mix/Creative Considerations

Session 28: Material Planning Tool—Revision of Key Content (Detailed Outline of Document) and How it Fits the Mix/Creative Considerations

Closing and the Way Forward

Manual for Country-Level Nutrition Advocacy Using PROFILES and Nutrition Costing Presentation Slides Stakeholder Meeting on Nutrition Advocacy [Slides.

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Manual for Country-Level Nutrition Advocacy Using PROFILES and Nutrition Costing Presentation Slides Stakeholder Meeting on Nutrition Advocacy [Slides.

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