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Abstract
Objectives The scaling-up nutrition (SUN) initiative, which was launched in 2010 to eradicate malnutrition in all its forms by 2030, collaborates with a diverse range of stakeholders, such as governments, non-governmental organisations (NGOs), donors, businesses and academia. Given the widespread adoption of this multisectoral approach, it is crucial to explore methods for evaluating the perspectives of multiple stakeholders in child undernutrition topics.
Design This scoping review was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.
Data sources Six peer-reviewed databases, including PubMed, Web of Science, Cochrane, Embase, CINAHL and PROQUEST ASSIA, were systematically searched.
Eligibility criteria Original English studies published between 1 January 2010 and 1 June 2023, focusing on undernutrition in SUN countries.
Data extraction and synthesis Two reviewers independently screened titles, abstracts and full texts for inclusion and extracted data using Rayyan.
Results Out of the 4533 articles, 19 met the inclusion criteria for the review, and 5 more were added through manual searches. These studies were conducted in 14 SUN countries, with 62% using mixed methods and the remaining using qualitative methods. Six methods were used to gather stakeholder perspectives, including in-depth interviews, focus group discussions, Net-Map, organisational network analysis and Q methodology. Most studies focused on government, development partners and NGOs, while only two studies involved the business network.
Conclusions Our study indicates that study on stakeholder perspectives in SUN countries focuses mainly on those showing progress in malnutrition/undernutrition reduction. Future research should explore countries with less progress to improve partnership frameworks. The SUN movement should establish a standard method for evaluating stakeholder perspectives, considering both outcomes and processes.
Trial registration number The final protocol was registered prospectively with the Open Science Framework in July 2023 (https://osf.io/te7cb).
- Child
- NUTRITION & DIETETICS
- Health policy
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The scoping review compiles all existing literature on multistakeholder perspective analysis in scaling-up nutrition (SUN) countries published in peer-reviewed journals.
This review misses out on non-peer-reviewed sources, including reviewing SUN movement-related documents that attempted to include stakeholder perspectives in the annual review process.
This review is limited to child undernutrition.
Non-English-language articles were excluded.
Introduction
Undernutrition is a widespread issue globally, impacting a significant number of all deaths among children under 5 years old.1 According to the latest estimates, 22.3% of children are affected by stunting, while 6.8% are affected by wasting.2 Although there has been a noticeable improvement in reducing stunting rates since 2000, the 2030 global target of 13.5% remains out of reach.2 Wasting rates have only slightly improved, with a minor reduction of 1.9% between 2000 and 2020.2 Undernutrition can have detrimental effects on a child’s physical and cognitive development, with stunting being a persistent condition often linked to poor socioeconomic conditions and overall health during pregnancy and early life.3
Scaling-up nutrition (SUN) is a global initiative launched in 2010 with the goal of reducing malnutrition.4 The SUN Movement Secretariat, led by the SUN Coordinator appointed by the UN Secretary General, facilitates the global movement. It includes 66 low- and middle-income countries and 4 Indian states and aims to create a world free of malnutrition by 2030.4 SUN aims to address the root cause of malnutrition through nutrition-sensitive interventions from actors outside the health sector while also ensuring continuity of nutrition-specific interventions.4 As of now, SUN countries are divided into five regions: East and Southern Africa, Latin America and the Caribbean, South and Southeast Asia and the Pacific, West and Central Africa and West and Central Asia. The SUN 3.0 Movement for 2021–2025 continues to prioritise nutrition as a universal agenda aligned with the sustainable development goals.5 The initiative is driven by a multistakeholder platform consisting of government, civil society organisation (CSO)/non-governmental organisations (NGOs), donors, businesses and academia.6 The country-driven and country-led approach involves multisectoral and multistakeholder actions, with a SUN Government Focal Point serving as the key driving force for the national movement.6
In the nutrition domain, a multisector approach has gained widespread use since The Lancet’s series in 2008 emphasised the importance of preventing undernutrition during the first 1000 days, from pregnancy to a child’s second birthday.7 In 2013, The Lancet called for a collective effort from all stakeholders within a multisector framework to solve undernutrition problems.8 Since then, this approach has been implemented on a scale in member countries of the SUN initiative.
While the SUN member countries regularly conduct annual self-assessments about the undernutrition reduction progress and how the process of mainstreaming nutrition issues at a country level, little is known about the multistakeholder perspective on this network in each country. The SUN secretariat at the global level has mainstreamed the stages of action every 5 years and has published the reporting recommendation in stage 1 (2010–2015) and stage 2 (2016–2020) to capture the process at the country level: enabling environment, policies and legislation, implementation and finance. However, the publication in peer-reviewed journals as the basis of evidence remains scarce. We are looking especially at the method that can be employed for the whole SUN countries to allow for cross-country learning in strengthening the nutrition commitment. Identifying how the network of nutrition plays and their dynamics could draw a common understanding of how to push the nutrition agenda forward. Therefore, this study aimed to synthesise methods that have been used to assess the stakeholder perspectives in the context of child undernutrition. By synthesising the existing methods used to assess stakeholder perspectives in the context of child undernutrition, this study provides valuable insights into the effectiveness, strengths and limitations of various assessment approaches.
Methods
Our scoping review was built on the five methodological frameworks by Arksey and O’Malley,9 with enhancements by Levac et al.10 The five frameworks include identifying research questions, identifying relevant studies, selecting studies, charting data and collating and summarising data. Our review also adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews for appropriate reporting.11 The protocol for this scoping review was registered with Open Science Framework in July 2023 prior to the abstract and title review (https://osf.io/te7cb). This study analyses the existing research studies and, therefore, involves no patients or members of the public involved and, therefore, no patient consent was sought for publication.
Identifying studies and search strategy
Following the identification of the research question, the electronic search strategy was developed with the assistance of a librarian from the University of Heidelberg to identify Medical Subject Headings (MeSH) and non-MeSH terms to ensure that an appropriate search strategy was used. The research question was then translated into a population, concept and context (PCC) framework to make the search strategy more systematic. The search string was formulated as follows: ‘nutrition’, ‘malnutrition’, ‘undernutrition’, ‘stunt’, ‘underweight’, ‘deficienc*’, ‘Scaling Up Nutrition’, ‘SUN networks’, ‘multisector’ and ‘child undernutrition’. We applied appropriate Boolean operators (ie, ‘AND’ and ‘OR’) for the appropriate permutation of the search string. The complete list of specific terms that were used can be found in online supplemental material 1.
Supplemental material
The refined search strings were used to identify relevant studies. Original research articles were identified by searching across six databases (PubMed, Web of Science, Cochrane, Embase, CINAHL and PROQUEST ASSIA). The search duration was limited to studies that were published between 1 January 2010 and 1 June 2023. The timeframe was chosen because the SUN movement started on 1 January 2010 until June 2023, which constitutes the project period ending. Furthermore, we limited our searches to articles that were published in English to reduce the risk of misinterpretation. The inclusion and exclusion criteria used in the study are shown in table 1.
Inclusion and exclusion criteria of the review
Selecting studies
The retrieved articles from each database were inserted into endnote for an initial duplicate check, followed by uploading the files to Rayyan for the title and abstract screening process.
Rayyan is a free, web-based platform that allows researchers to manage a collaborative systematic review.12 Two reviewers independently evaluated the eligibility of titles, abstracts and full texts for inclusion. Any disagreements were discussed between the pair of reviewers and a third-party reviewer was consulted if consensus was not reached. Articles were included in the review if they were full-text papers, published at least in 2010, and met the PCC criteria. Studies were excluded if they were not original research studies, were conference abstracts, editorials, letters to the editor, commentaries, opinions, reviews and research protocol, did not assess multistakeholder perspective on a national level, were studies of health topics other than child undernutrition or were published in a non-English language.
Extracting data, summarising and synthesis
The quality of the included studies was assessed critically using the mixed method appraisal tool (MMAT) 2018.13 MMAT is an instrument designed to enable researchers to evaluate the methodological quality of five study categories: qualitative research, randomised controlled trials, non-randomised studies, quantitative descriptive studies and mixed methods studies.14 Two independent reviewers extracted specific data from the selected full-text articles through an Excel spreadsheet. The information extracted includes the details of the authors, publication years, countries, methods, and a list of stakeholders involved. In case of any disagreements between the reviewers, they resolved the issue through consensus. On the completion of the extraction, major findings from the included studies were summarised and mapped into a framework of methods.
Results
The initial search of five databases yielded 4533 articles. Following the elimination of duplicates and the completion of title and abstract screening, a total of 67 articles were selected for full-text review. Among these, 19 articles fulfilled all the inclusion criteria and were ultimately included in the final review. Additionally, five articles were added to the final review from a manual search. The PRISMA flow diagram demonstrating the study selection process is shown in figure 1.
PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Study characteristics
Among the 24 studies analysed in table 2, 15 (62%) employed mixed methods, while 9 (38%) used qualitative methods. Three prominent study groups emerged: ‘Stories of Change’ (n=7), the South Asia Infant Feeding Research Network (SAIFRN) (n=5) and the Exemplars study (n=5). The study group referenced in the review refers to the funding organisation. Although the study may be conducted by different researchers, there is an interrelation in terms of funding and research objectives, despite not all studies addressing the same topics. The analysis of the records revealed six distinct methods for collecting stakeholder perspectives data. In-depth interviews (IDIs) were the most used method (n=11), followed closely by Net-Map (n=8). The countries represented in the review include studies from 14 different nations. Of these, Nepal has the largest number of records (n=4), followed by Ethiopia (n=3) and Senegal (n=3).
Characteristics of included studies
In all the studies, participants from government and CSOs/NGO were included in the data collection process. In some studies, Donor and UN organisations were often interchanged. To maintain consistency, these two categories have been combined and referred to as development partners. Therefore, the five core networks within the SUN framework consist of the government, development partners, CSO/NGO sector, business community and academia. Excluding these five categories, one study (N2) additionally included parliamentary institutions in the national-level data collection. Only one study (N18) comprised all five main SUN networks, while the majority (n=17) included four out of the five types of SUN networks. Business networks were the least represented, appearing in only two studies.
The 14 countries from the five regions of the SUN movement represent only 20% of the total 65 SUN member countries included in the review. In September 2023, Panama joined the movement as the 66th member country; however, this is outside the data collection timeframe, which ended in June 2023. Certain studies, such as the Exemplars and Stories of Change, specifically targeted countries based on their success. The Exemplars study focused on countries that achieved a significant reduction in stunting prevalence between 2000 and 2015 despite having a smaller Gross Domestic Product (GDP) per capita.15 Similarly, the Stories of Change studies were conducted in countries with high levels of undernutrition, a commitment to address the issue and positive trends in nutrition outcomes.16
The Exemplars study seeks to conduct a comprehensive and systematic evaluation of the factors that have contributed to the reduction of stunting in Nepal,17 Senegal,18 Ethiopia,19 Peru20 and the Kyrgyz Republic21 by interviewing key national-level stakeholders. This approach is designed to identify contextual factors and interventions that have played a role in the reduction of stunting. The Exemplars study employed IDIs as the primary method of data collection, except for Peru,20 where focus group discussions (FGDs) were initially used, followed by IDI for clarification and additional insights.
The SAIFRN aims to conduct studies that assess infant and young child feeding (IYCF) policy situations and identify areas for improvement in five countries: Bangladesh,22 Nepal,23 Sri Lanka,24 Pakistan15 and India.16 These studies used Net-Map, an interview-based mapping tool, to analyse the relationships, influence and objectives of the stakeholders involved in the IYCF situation.24 In all SAIFRN studies, the focus lies on actors influencing two main categories: funding and technical information.22–26 Specifically, they seek to identify key policy actors, actors providing funding and technical assistance, and the influence of various stakeholders in shaping IYCF policies.
The ‘Stories of Change in Nutrition’ studies had diverse objectives; however, they all focused on understanding how nutrition became a top priority in each country and the factors that contributed to significant achievements in nutrition. For instance, the study conducted in Zambia27 analysed the process of incorporating international frameworks into national policies, while other studies examined the factors that led to rapid reductions in specific nutrition issues, such as child stunting and anaemia in Ghana,28 stunting in Bangladesh29 and overall malnutrition in Nigeria.30 Moreover, additional studies in Burkina Faso,31 Senegal32 and Zambia33 assessed the broader picture of nutrition policy at the national level. The domains of question in ‘Stories of Change’ studies differ based on the data collection tool that is being used. Four studies used IDI,29 30 32 33 while three studies used Net-Map.27 28 31
Furthermore, IDI was used as the data collection tool in three studies out of the seven that were not a part of a larger group.34–36 One study was conducted in Senegal, where stakeholders were interviewed to identify the factors that contribute to successful collaboration and the challenges faced in the process.18 The leaders of each organisation were then asked to provide a list of all nutrition-related projects they were working on in Senegal, along with a list of partners.18 These data were used to create an affiliation network that revealed patterns of influence between organisations and indicated the degree of reachability of an organisation based on the number of collaborations they had in nutrition programmes.34 The most reachable actors served as metagovernors within the network.34 In Ethiopia, interview questions focused on five dimensions: coordination and structural accountability, political commitment, financing, human resources and data monitoring and transparency.35 Earlier studies in the same country examined four dimensions: the nature of the nutrition problem, decision making and ownership, programme design and implementation and challenges in implementing the national nutrition strategy and plan.19 35 36
Four remaining studies37–40 used unique data collection methods. For example, a 2022 study in Nepal used organisational network analysis (ONA) to identify working relationships between organisations related to the development of the multisector nutrition plan (MSNP).39 Stakeholders completed a questionnaire and sorted these relationships into three categories based on the MSNP development stage: policy dialogue and development, strategic planning and implementing the scale-up plan. Finally, they were asked open-ended questions about barriers and facilitators of MSNP development in Nepal.39 Another study that was conducted in 2019 on multisector approaches to improve food security, nutrition and population health in Nepal used a workshop-based approach gathered insights from stakeholders.38 In their study, participants were divided into five focus groups based on five topics guide. The study identified current practices, key institutions, key interventions, implementation procedures, key achievements and existing gaps in multisector programmes related to food security, nutrition, environment and health in Nepal.38 Galaurchi et al. in their study on stakeholder perspectives on barriers and facilitators to the implementation of 1000 days plus nutrition policy activities in Ghana used a combination of IDI and FGD to gather information on the 1000 days plus programme.37 Questions in their study related to current activities, priorities, best entry points, key players, challenges and research support were asked.37 Finally, one study in Mozambique used the Q methodology to gather subjective statements from stakeholders during meetings, documents and interviews related to the multisector nutrition programme.40
Discussion
Our study explored the existing methods used to assess stakeholder perspectives in the context of child undernutrition. Findings from our review show that over two-thirds (62%) of our included studies employed mixed methods, while the remaining used qualitative methods across 14 SUN countries. The six methods used in our included studies include IDIs, FGDs, Net-Map, ONA and Q methodology. Among these methods, IDIs stand out as the most widely used (n=11), followed closely by Net-Map (n=8). Furthermore, the majority of the studies focused on government, development partners and NGOs, while only two studies involved the business network.
IDI and FGD were the most common methods employed in qualitative research. The IDI, as used in our included studies, seeks to know individual perspectives of the issue, while FGDs were employed to generate a collective view or consensus. Previous studies in India and Malawi have shown how combining IDI and FGD represents a form of qualitative method triangulation for nutrition-based intervention.41 42 Researchers often use this approach to enrich and deepen the data they collect.23 However, careful consideration is necessary when combining IDI and FGD, especially when integrating the data. According to a previous study, five possibilities can emerge from the process: (1) similar interpretations; (2) similar answers but different interpretations; (3) missing information; (4) unique information and (5) different data that are not contradictory.24 However, rigorous integration of IDI and FGD data can result in an enhanced description and analysis of the phenomenon under study.23
Furthermore, the Net-Map was used among eight (n=8) of our included studies. According to the previous studies in Ghana and Ecuador, Net-Map serves as an interview-based mapping technique that integrates social network analysis, stakeholder mapping and power mapping.43–45 Furthermore, it allows researchers to understand the stakeholder influence networks that go beyond the formal relationship that can be inferred from policy document.44 Specifically, Net-Map is built on four questions: identifying actors involved in an issue, understanding their interconnections, assessing their level of influence and discerning their goals.46 47 The process can be conducted as a group exercise or through individual interviews, depending on the research goals.46 Net-Map has proven to be an intuitive and effective method for participatory research. By using a combination of qualitative and quantitative data, it simplifies analysis compared with relying solely on qualitative interview data. However, researchers have argued that it does require researchers or facilitators to possess contextual knowledge to interpret the resulting map accurately.48 Net-Map may also not be suitable in a setting with a high degree of hierarchy, as some stakeholders might not feel comfortable evaluating others in the networks.48
Our findings further highlighted how ONA was used in the included studies. For instance, ONA is a research approach that seeks to understand the relational aspect of a topic, focusing on the connections between different entities rather than the attributes or variables of those entities. Similar to our study, previous literature in Hawaii USA, Australia and Canada has highlighted that ONA focuses on networks among agencies or organisations rather than individuals.49–51 The strength of ONA lies in the visual representation of network data, making it easily understandable for a general audience.52 Network analysis has four characteristics: (1) focuses on patterns of linkages between actors; (2) grounding in empirical data; (3) utilisation of mathematical and computational models and (4) reliance on graphical illustrations.52 However, a potential limitation of network analysis is the tendency to oversimplify the complexities of network relationships in practice.53 Moreover, it also risks omitting some actors in the process of network abstraction for the sake of coherence.53
Q methodology is a valuable approach to extract the subjective opinions of respondents. Its main technique, Q sorting guided by the research question and coming from previous individual or group interviews, literature reviews or other documentation, involves asking respondents to rank statements in a forced normal distribution model in the form of a Likert scale ranging from strongly agree to strongly disagree.54 However, critics of Q methodology in a study in Thailand reported concerns about the use of preset statements, which may limit the range of respondents' opinions.55 Additionally, the forced normal distributions may prompt respondents to choose uncertain responses in the middle of normal distributions, although the risk is lower compared with the normal Likert scale.54
The findings from our included studies suggest that the use of existence of various assessment methods highlights the absence of a definitive gold standard for evaluating stakeholder perspectives on SUN frameworks at the national level. At the global level, the SUN movement secretariat has introduced diverse tools, such as dashboards to monitor progress indicators, for pushing the MSNP agenda in countries. However, these tools do not explain how progress occurs.45 Therefore, process-oriented research is essential, and one approach to achieving this is through assessing stakeholder perspectives.
In conclusion, while considering the available methods for gathering stakeholder perspectives on a large scale across SUN countries, one key consideration is the integration of both qualitative and quantitative methods to ensure comparability across different contexts. Among the methods reviewed, Q methodology, Net-Map and ONA stood out as particularly relevant. Net-Map emerged as the most widely used method, particularly in studies, such as the SAIFRN, that sought to understand the power dynamics of nutrition policy across different countries, specifically in relation to funding and technical assistance. Despite its strengths, Net-Map also has its limitations, particularly because it relies on predetermined questions, which sometimes restricts novelty, and the scope of insights gathered. Q methodology, on the other hand, offers greater flexibility, as it captures stakeholders' perceptions through a scorecard system. However, drawing cross-country comparisons using Q methodology can be challenging due to variations in stakeholder responses and contextual differences.55
These methodological limitations and contextual variations in different methods highlight the ongoing challenge of integrating stakeholder perspectives into formal assessments across all SUN countries. Addressing this challenge requires interdisciplinary collaboration beyond the health sector. A study from public administration field34 underscores the need for the health sector to collaborate with social sciences to critically address the partnership in the health sector. By acknowledging these factors, the progress achieved in reducing malnutrition can be better understood and effectively scaled up.
Strengths and limitations of the review
The main strength of this study lies in its comprehensive approach to mapping out stakeholder analyses conducted in SUN countries that have been published in peer-reviewed journals. By gathering various records from different big studies, such as Stories of Change, Exemplars and SAIFRN, the study has been able to present a rich collection of methods. Furthermore, based on our knowledge, our review was the first review to synthesise methods used to gather multistakeholder perspectives in the SUN initiative. However, the study does face certain weaknesses, primarily stemming from the complex nature of assessing stakeholder perspectives, which complicates the extraction and analysis of data. Additionally, the study focused solely on peer-reviewed articles, which could potentially result in the exclusion of valuable insights from non-peer-reviewed sources or grey literature. Finally, our review only incorporates articles published in English, which potentially omits significant research in other languages.
Conclusion
In conclusion, our scoping review reveals that studies that have been published and assessed stakeholder perspectives in SUN countries exclusively concentrate on nations that have achieved significant progress in reducing malnutrition. Therefore, a future study that demonstrates less significant progress will enable researchers to enhance current partnership frameworks. There is currently no standardised method for consistently evaluating stakeholder perspectives. From the available methods, we conclude that Net-Maps were the most visible method to use on a large scale because of their approach to combining quantitative and qualitative methods. Nonetheless, it is pertinent that the SUN movement secretariat at the international level develops a recommended, interdisciplinary and contextually relevant approach for assessing stakeholder perspectives, which not only measures the accomplishments of SUN countries but also examines the processes through which these outcomes are achieved.
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The lead author would like to thank Joscha Stadler from the University of Heidelberg Library for their assistance and guidance in refining the search strategy. Also, to the Deutscher Akademischer Austauschdienst (DAAD) for providing the scholarship that supported the lead author's study in Germany. For the publication fee we acknowledge financial support by Heidelberg University.
References
Footnotes
Contributors OQP conceived the idea. OQP and TA wrote the first draft of the manuscript. ALK supervised, edited and reviewed the manuscript. ALK acted as guarantor. All authors approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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