Implementation and scale-up of nutrition-sensitive agriculture in low- and middle-income countries: a systematic review of what works, what doesn't work and why

Evidence is rapidly growing on the impact pathways through which nutrition-sensitive agriculture (NSA) con-tributes to improving nutritional outcomes. However, to harness NSA's full potential, it is equally important to understand why impacts are achieved (or not) and which factors play a role. Evidence on success and failure factors as well as external barriers and facilitators that influence the implementation and scale-up of NSA in low-and middle-income countries (LMICs) is still limited. To address this gap, we reviewed empirical evidence (since 2000) on factors influencing NSA implementation and scale-up. The Consolidated Framework for Implementa-tion Research (CFIR) guided the analysis and synthesis of this systematic review. Eighty-five studies that met the inclusion criteria were extracted and synthesized across the five domains of the CFIR; here we report findings from three of the domains: NSA interventions, inner setting and outer setting. Many factors related to each of the domains were identified: intervention-specific factors (clustered in seven sub-domains and 23 themes), local contextual factors (in six sub-domains and 23 themes), and factors related to the broader enabling environment (in five sub-domains and 12 themes). A strong interplay among factors across the three domains was observed. This review highlights key areas for attention to enhance the success of NSA programs: learning from past successes and failures; appropriateness and acceptability based on context knowledge; project flexibility in addressing design limitations and coping with unforeseen hindrances; strengthening local structures, community empowerment and increasing resilience; supportive policy and governance. Our findings can help decision-makers at multiple levels to strengthen on-going/future NSA programs and anticipate possible pitfalls to maximise NSA's potential to reduce undernutrition in LMICs.