An Innovative Grandmother-Inclusive Approach for Addressing Suboptimal Infant and Young Child Feeding Practices in Sierra Leone

Effectiveness of Elements of Social Behavior Change Activities in Nutrition-Sensitive Agriculture Programs: A Systematic Review

Background

Limited research exists on the specific approaches and behavior change techniques (BCT) used in nutrition-sensitive agriculture (NSA) programs and their effects on diet diversity.

Objectives

We aimed to describe nutrition-related social behavior change (SBC) in the context of NSA and quantify the effectiveness of different SBC components of NSA programs in improving diet diversity.

Methods

We searched PubMed, Embase, Web of Science, the International Food Policy and Research Institute repository, and Agricola for articles published between 2000 and 2023. We identified the agricultural activities each project used as a pathway to improved nutrition (ag-nutrition pathways), identified SBC approaches used by each project, and coded BCTs using validated coding protocols. Effectiveness ratios (ERs) were calculated to assess pathways, approaches, and BCTs in relation to dietary diversity outcomes (minimum diet diversity for children, child dietary diversity score, and women's dietary diversity).

Results

Of 65 included NSA interventions, the most used agriculture-to-nutrition pathways included 1) agricultural production for home consumption (n = 61); 2) women's empowerment (n = 36); and 3) agricultural income (n = 37) pathways. The most used SBC approaches were interpersonal communication (IPC, n = 59) and community-based approaches (n = 53). Frequently used BCTs included "instructions on how to perform the behavior" (n = 65), "social support (unspecified)" (n = 43), and using a "credible source" (n = 43). The increased production for the home consumption pathway, IPC approach, and the BCT "behavioral practice" had high ERs for diet diversity outcomes.

Conclusions

Although the agricultural production for home consumption pathway to improved nutrition had the highest ERs for diet diversity, other pathways, such as income generation and reducing wastage, hold promise and require additional investigation. The most commonly applied BCTs focused on information dissemination; however, participatory BCTs related to behavioral demonstration, and behavioral practice had higher ERs. Findings indicate a need to test less frequently utilized SBC components to determine effectiveness.This trial was registered at PROSPERO (=https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=179016) as CRD42020179016.

Application of the Capabilities, Opportunities, Motivations, and Behavior (COM-B) Change Model to Formative Research for Child Nutrition in Western Kenya

Background

Interventions aimed at improving dietary intake and feeding practices have alone proven insufficient for combatting stunting resulting from poor nutrition and repeated infections.

Objectives

To support the development of an integrated water, sanitation, and hygiene (WASH) and nutrition, social, and behavior change strategy aimed at reducing stunting, formative research was conducted in 2 program sites in western Kenya.

Methods

Twenty-nine key informant interviews were conducted with community leaders, health workers, and project staff, and 24 focus group discussions with caregivers of children under 2 y on topics related to feeding, sanitation, and hygiene behaviors. Three frameworks informed the study design and analysis of our formative research: the Capabilities, Opportunities, and Motivations model for behavior change, which identifies what needs to change in order for behavior change interventions to be effective; the Grandmother Project's Change Through Culture Approach, which values the important role of influential household and community members in producing household health; and Starr and Fornoff's approach to Theory of Change development.

Results

Caregivers exhibited sufficient psychological capabilities (knowledge and skills) for many of the key maternal and infant nutrition behaviors. However, reflective motivation to perform optimal behaviors was undermined by limitations in physical and social opportunities, including limited time and competing priorities for mothers, limited accessibility and availability of diverse foods, low self-efficacy for exclusive breastfeeding, and fears of negative consequences related to specific foods and recommended practices.

Conclusions

Interventions that aim to improve maternal and child diets should address the underlying social, cultural, and environmental determinants that contribute to motivations and opportunities to perform recommended practices.

Experiences Engaging Family Members in Maternal, Child, and Adolescent Nutrition: A Survey of Global Health Professionals

BACKGROUND

Family members influence maternal, child, and adolescent nutrition and are increasingly engaged in nutrition interventions and research. However, there remain gaps in the literature related to programmatic experiences and lessons learned from engaging these key influencers in nutrition activities.

OBJECTIVES

This research aimed to document global health professionals' experiences engaging family members in nutrition activities, and their perceived barriers, facilitators, and recommendations for nutrition activities that engage family members.

METHODS

Global health and nutrition professionals were invited to complete an online survey about their experiences engaging family members in nutrition activities. The survey included 42 multiple-choice questions tabulated by frequency and 4 open-response questions, which were analyzed thematically.

RESULTS

More than 180 respondents (n = 183) in 49 countries with experience engaging fathers, grandmothers, and other family members in nutrition activities participated in the survey. Participants highlighted the importance of conducting formative research with all members of the family system and using participatory processes in intervention design and implementation. Respondents reported engaging family members increases support for recommended behaviors, improves program sustainability, and facilitates family and community ownership. Some respondents also shared experiences with positive and negative unintended consequences when engaging family members; for example, one-fifth of participants reported that mothers were uncomfortable with involving men in discussions. Common challenges centered on limited resources for program delivery, not involving all influential family members, and traditional gender norms. Recommendations included incorporating family members in the project design phase and ensuring sufficient project resources to engage family members throughout the project lifecycle.

CONCLUSIONS

Surveying global health professionals provides an opportunity to learn from their experiences and fill gaps in the peer-reviewed literature to strengthen intervention design and implementation. Community ownership and sustainability emerged as key benefits of family engagement not previously reported in the literature, but responses also highlighted potential negative unintended consequences.

Introduction: A family systems approach to promote maternal, child and adolescent nutrition

In all cultures, women and children are embedded in family systems that determine roles, relationships, patterns of communication and authority between family members. Especially in non-western societies, maternal and child nutrition practices are determined not only by the biological parents but also by other influential family members. Most maternal and child nutrition research and interventions do not consider the constellation of family roles and influence on women and children and continue to focus on the mother-child dyad and individual knowledge, attitudes and practices. There is growing agreement on the need to adopt an ecological framework to address public health issues, including those dealing with maternal and child nutrition. This special issue presents examples of research from a variety of settings that employed an ecological, family systems approach either to investigate maternal, child or adolescent nutrition issues or to design interventions that engaged various actors within family settings. These 11 articles contribute to a growing body of evidence supporting the relevance of a wider family systems perspective for nutrition research and interventions. Key themes across studies include the limitations of using a nuclear family model for research and intervention design, the need for formative research that comprehensively explores family systems, increasing recognition of the extensive involvement and support provided by grandmothers, and the importance of engaging men in culturally appropriate ways based on community dialogue and women's perspectives. Future maternal and child nutrition research and interventions can be strengthened by systems thinking that acknowledges that individuals are situated within family and community systems.

Engaging family members in maternal, infant and young child nutrition activities in low- and middle-income countries: A systematic scoping review

The influence of fathers, grandmothers and other family members on maternal, infant and young child nutrition practices has been well documented for decades, yet many social and behavioural interventions continue to reach only mothers. While recent guidelines recommend involving fathers, grandmothers and other family members in maternal and child nutrition, we lack a comprehensive review of interventions that have engaged them. This scoping review aimed to address this gap by describing social and behavioural interventions to engage family members in maternal and child nutrition in low- and middle-income countries. We systematically searched PubMed, Scopus, Web of Science, Global Health and CINAHL for peer-reviewed studies meeting inclusion criteria. We screened 6,570 abstracts, evaluated 179 full-text articles, and included 87 articles from 63 studies. Studies reported a broad range of approaches to engage fathers, grandmothers and other family members to support maternal nutrition (n = 6); breastfeeding (n = 32); complementary feeding (n = 6) and multiple maternal and child nutrition practices (n = 19). Interventions were facility and community based; included individual and group-based interpersonal communication, community mobilization, mass media and mHealth; and reached mothers and family members together or separately. Most interventions were located within the health sector; rare exceptions included nutrition-sensitive agriculture, social protection, early child development and community development interventions. Few interventions addressed gender norms, decision-making, and family dynamics or described formative research or theories informing intervention design. These diverse studies can shed light on innovative programme approaches to increase family support for maternal and child nutrition.

The male breadwinner nuclear family is not the 'traditional' human family, and promotion of this myth may have adverse health consequences

The importance of social support for parental and child health and wellbeing is not yet sufficiently widely recognized. The widespread myth in Western contexts that the male breadwinner-female homemaker nuclear family is the 'traditional' family structure leads to a focus on mothers alone as the individuals with responsibility for child wellbeing. Inaccurate perceptions about the family have the potential to distort academic research and public perceptions, and hamper attempts to improve parental and child health. These perceptions may have arisen partly from academic research in disciplines that focus on the Western middle classes, where this particular family form was idealized in the mid-twentieth century, when many of these disciplines were developing their foundational research. By contrast, evidence from disciplines that take a cross-cultural or historical perspective shows that in most human societies, multiple individuals beyond the mother are typically involved in raising children: in evolutionary anthropology, it is now widely accepted that we have evolved a strategy of cooperative reproduction. Expecting mothers to care for children with little support, while expecting fathers to provide for their families with little support, is, therefore, likely to lead to adverse health consequences for mothers, fathers and children. Incorporating evidence-based evolutionary, and anthropological, perspectives into research on health is vital if we are to ensure the wellbeing of individuals across a wide range of contexts. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.