An adequacy evaluation of a 10-year, four-country nutrition and health programme

Before and after study of a national complementary and supplementary feeding programme in Rwanda, 2017-2021

To address high rates of malnutrition among children from vulnerable households in Rwanda, the government initiated a national food supplementation programme. A before and after evaluation, using repeat cross-sectional surveys in randomly selected villages was conducted; aimed at assessing the effectiveness of providing fortified blended food (FBF) to children 18-23 months of age, pregnant and lactating women in the lowest tier of Rwanda's social support system. Data were collected in 2017, 2018 and 2021 through interviews with caregivers; anthropometric measurements and a capillary blood sample were obtained from children. The primary statistical analysis compared the nutritional status of children before and after the introduction of FBF. We enroled 724 children during each survey. The prevalence of stunting declined from 47% to 35% between 2017 and 2021; in 2018, the prevalence of stunting was 43%. Children had a 42% reduction in the odds of being stunted (adjusted odds ratio [AOR]: 0.58, 95% confidence interval [CI]: 0.47-0.74, p < 0.001) from 2017 to 2021 even after adjusting for inherent, distal, proximal, and intermediate covariates. The reduction in stunting observed within the first year of the programme was not statistically significant (AOR: 0.83, 95% CI: 0.67-1.03, p < 0.091). We observed meaningful reductions in the prevalence of stunting among children which coincided with the introduction of Government-led initiative to reduce malnutrition. The Rwandan Government has committed to improving the living conditions of vulnerable households and has made strong investments in reducing malnutrition. The impact of these investments can be seen in the overall trend towards improved nutritional status highlighted in this evaluation.

Anaemia among women of reproductive age in selected sub-Saharan African countries: multivariate decomposition analyses of the demographic and health surveys data 2008-2018

Objectives

The burden and highest regional prevalence of anaemia is reported in sub-Saharan Africa (SSA). The study evaluated changes in anaemia prevalence across the Demographic Health Surveys (DHS) periods in SSA and reported factors influencing observed changes in the trend.

Method

The study was implemented by a two-stage cross-sectional stratified sampling approach. The study involved women of reproductive age (15-49 years) in sub-Saharan Africa countries (Ghana, Sierra Leone, Mali, and Benin) using two different periods of their demographic health surveys (DHS) data. The study adopted both descriptive and inferential statistical methods. The chi-square test was used to determine the existence of a statistically significant relationship between the outcome and predictor variables and test the observed changes in anaemia. Multivariable logistic regression analyses were conducted on each survey year and the pooled dataset for eligible study countries. Multivariate decomposition analysis was performed to explain how compositional changes and behavioural effects of women characteristics affected the changes in anaemia prevalence. The study reported frequencies, percentages and odds ratios along with their 95% confidence intervals (CI).

Results

Ghana and Sierra Leone experienced 17.07% [95% CI: 14.76-19.37, p < 0.001] and 1% [95% CI: 1.0-2.9, p > 0.05] of anaemia decrease from period 1 to period 2, respectively, while Mali and Benin experienced 11% [95% CI: 9.14-12.90, p < 0.001] and 16.7% [95% CI: 14.99-18.5, p < 0.001] of increase in anaemia prevalence from period 1 to period 2, respectively. Behavioural effects explained the decrease in Ghana and the increase in Benin and Mali while endowments or compositional changes explained the decrease in Sierra Leone.

Conclusion

Anaemia continues to pose a significant challenge in sub-Saharan Africa. Therefore, there is an imperative need to scale up the implementation of nutrition-related programmes and advocacies to ensure optimum changes in women nutrition-related behaviours.

Interventions to improve infant and young child feeding practices in Ethiopia: a systematic review

OBJECTIVE

In Ethiopia, despite the implementation of several interventions to improve infant and young child feeding (IYCF) practices, no published studies have highlighted the most effective IYCF interventions in the country. This systematic review investigated the impacts of various interventions on IYCF in Ethiopia.

SOURCE OF INFORMATION

A systematic search was conducted on seven computerised bibliographic databases (Embase, ProQuest Central, Scopus, PsycINFO, Web of Science, MEDLINE/PubMed and CINAHL) to locate experimental or quasi-experimental studies published between the year 2000 and May 2021.

STUDY ELIGIBILITY CRITERIA

Interventional studies that measured IYCF indicators (early initiation of breast feeding (EIBF), exclusive breast feeding (EBF), the introduction of complementary foods, minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet) as outcome variables were included.

STUDY APPRAISAL AND SYNTHESIS

All included studies were examined for biases related to interventional studies (ie, selection bias, performance bias, attrition bias, detection bias and reporting bias). Author reports of effect size measures were used to narratively report the findings of each study.

RESULTS

Of the 23 eligible studies, 14 studies were quasi-experimental and 9 studies were cluster randomised trials (CRTs). Eight quasi-experimental studies had a serious risk of bias, while two CRTs had a high risk of bias. Four studies for EBF and six studies for EIBF showed significant impacts of policy advocacy, health service strengthening, interpersonal communication, community mobilisation and mass media campaigns. Six studies for MDD and three studies for MMF indicated significant effects of community-level and health facility complementary feeding promotions on infants and young children. Interventions that delivered in combination increased the impacts in improving EIBF, MDD and MMF compared with a single intervention.

CONCLUSION

Our review showed that 12 out of 21 eligible studies that implemented in the form of community-level and health facility interventions improved EIBF, EBF, and/or MDD in Ethiopia.

PROTOCOL REGISTRATION NUMBER

PROSPERO, CRD42020155519.

Best practices and opportunities for integrating nutrition specific into nutrition sensitive interventions in fragile contexts: a systematic review

Background

Annually, undernutrition contributes globally to 45% (3.1 million) of preventable deaths in children under 5. Effect following undernutrition i.e. physical growth & cognitive development etc. can be prevented during the first 1000 days also called window of opportunity. There is substantial evidence of positive nutrition outcomes resulting from integrating nutrition-specific interventions into nutrition specific program. However, there is paucity of knowledge on establishing and sustaining effective integration of nutrition intervention in fragile context. The objective of this review is to map and review the integration of nutrition-specific intervention to nutrition sensitive program and its impacts on nutrition outcomes.

Methods

In the study, we systematically searched the literature on integrated nutrition intervention into multi-sectoral programme in PUBMED, Google’s Scholar, the Cochrane Library, World Health Organisation (WHO), United Nations Children’s Fund (UNICEF), World Bank and trial registers from their inception until Oct 30, 2020 for up-to-date published and grey resources. We screened records, extracted data, and assessed risk of bias in duplicates. This study is registered with PROSPERO (CRD42020209730).

Result

Forty-four studies were included in this review, outlining the integration of nutrition-specific interventions among children 0–59 months with various existing programme. Most common integration platform in the study included integrated community case management and Integrated Management of Childhood Illness, Child Health Days, immunization, early child development, and cash transfers. Limited quantitative data were suggestive of some positive impact on nutrition and non-nutrition outcomes with a number of model of integration which varies according to the context and demands of the particular setting in which integration occurs.

Conclusion

Overall, existing evidence for nutrition sensitive and specific interventions is not robust and remains limited. It’s worthwhile to note, for future studies/interventions should be based on the context key criteria like relevance, political support, effectiveness, feasibility, expected contribution to health system strengthening, local capacities, ease of integration and targeting for sustainability, cost effectiveness and financial availability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-021-00443-1.

Repurposing NGO data for better research outcomes: a scoping review of the use and secondary analysis of NGO data in health policy and systems research

Background

Non-governmental organisations (NGOs) collect and generate vast amounts of potentially rich data, most of which are not used for research purposes. Secondary analysis of NGO data (their use and analysis in a study for which they were not originally collected) presents an important but largely unrealised opportunity to provide new research insights in critical areas, including the evaluation of health policy and programmes.

Methods

A scoping review of the published literature was performed to identify the extent to which secondary analysis of NGO data has been used in health policy and systems research (HPSR). A tiered analytical approach provided a comprehensive overview and descriptive analyses of the studies that (1) used data produced or collected by or about NGOs; (2) performed secondary analysis of the NGO data (beyond the use of an NGO report as a supporting reference); and (3) analysed NGO-collected clinical data.

Results

Of the 156 studies that performed secondary analysis of NGO-produced or collected data, 64% (n = 100) used NGO-produced reports (mostly to a limited extent, as a contextual reference or to critique NGO activities) and 8% (n = 13) analysed NGO-collected clinical data. Of these studies, 55% (n = 86) investigated service delivery research topics and 48% (n = 51) were undertaken in developing countries and 17% (n = 27) in both developing and developed countries. NGOs were authors or co-authors of 26% of the studies. NGO-collected clinical data enabled HPSR within marginalised groups (e.g. migrants, people in conflict-affected areas), albeit with some limitations such as inconsistent and missing data.

Conclusion

We found evidence that NGO-collected and produced data are most commonly perceived as a source of supporting evidence for HPSR and not as primary source data. However, these data can facilitate research in under-researched marginalised groups and in contexts that are hard to reach by academics such as conflict-affected areas. NGO–academic collaboration could help address issues of NGO data quality to facilitate their more widespread use in research. The use of NGO data use could enable relevant and timely research in the areas of programme evaluation and health policy and advocacy to improve health and reduce health inequalities, especially in marginalised groups and developing countries.

A scoping review of social-behaviour change techniques applied in complementary feeding interventions

Education and other strategies to promote optimal complementary feeding can significantly improve practices, but little is known about the specific techniques successful interventions use to achieve behaviour change. We reviewed the literature for complementary feeding interventions in low‐/middle‐income countries (LMIC) published since 2000. We systematically applied a validated taxonomy mapping process to code specific behaviour change techniques (BCTs) used in each intervention; effectiveness ratios for each BCT were estimated. Sixty‐four interventions met inclusion criteria, were abstracted, BCTs identified, and coded. Dietary diversity was the most commonly assessed component of complementary feeding, and interpersonal communication, either individually or in groups, was the most commonly used delivery platform. Of the 93 BCTs available for mapping, the 64 interventions included in this review applied a total of 28 BCTs. Interventions used a median of six techniques (max = 13; min = 2). All interventions used “instruction on how to perform the behaviour.” Other commonly applied BCTs included “use of a credible source” (n = 46), “demonstration of the behaviour” (n = 35), and “providing information about health consequences” (n = 30). Forty‐three interventions reported strategies to shift the physical or social environment. Among BCTs used in >20 interventions, five had effectiveness ratios >0.8: “provision of/enabling social support”; “providing information about health consequences”; “demonstration of the behaviour”; and “adding objects to the environment” namely, food, supplements, or agricultural inputs. The limited reporting of theory‐based BCTs in complementary feeding interventions may impede efforts to improve and scale effective programs and reduce the global burden of malnutrition.

Integrating nutrition into health systems: What the evidence advocates

There is considerable evidence of positive health and nutrition outcomes resulting from integrating nutrition-specific interventions into health systems; however, current knowledge on establishing and sustaining effective integration of nutrition into health systems is limited. The objective of this review is to map the existing types of integration platforms and review the evidence on integrated health and nutrition programmes' impacts on specific nutrition outcomes. A literature search was conducted, and integrated nutrition programmes were examined through the lens of the six World Health Organization (WHO) building blocks, including the demand side. Forty-five studies were included in this review, outlining the integration of nutrition-specific interventions with various programmes, including integrated community case management and Integrated Management of Childhood Illness, Child Health Days, immunization, early child development, and cash transfers. Limited quantitative data were suggestive of some positive impact on nutrition and non-nutrition outcomes with no adverse effects on primary programme delivery. Through the lens of the six WHO building blocks, service delivery and health workforce were found to be well-integrated, but governance, information systems, finance and supplies and technology were less well-integrated. Integrating nutrition-specific interventions into health systems may ensure efficient service delivery while having an impact on nutrition outcomes. There is no single successful model of integration; it varies according to the context and demands of the particular setting in which integration occurs. There is a need for more well-planned programmes considering all the health systems building blocks to ensure compliance and sustainability.

Needs and Barriers of Teen Mothers in Rural Eastern Uganda: Stakeholders' Perceptions Regarding Maternal/Child Nutrition and Health

For adolescent mothers in rural Eastern Uganda, nutrition and health may be compromised by many factors. Identifying individual and environmental needs and barriers at local levels is important to inform community-based interventions. This qualitative study used interviews based on constructs from social cognitive theory. 101 adolescent mothers, family members, health-related personnel and community workers in Budondo sub-county (Jinja district), eastern Uganda were interviewed. Young mothers had needs, related to going back to school, home-based small businesses; social needs, care support and belonging to their families, employment, shelter, clothing, personal land and animals, medical care and delivery materials. Barriers to meeting their needs included: lack of skills in income generation and food preparation, harsh treatment, pregnancy and childcare costs, lack of academic qualifications, lack of adequate shelter and land, lack of foods to make complementary feeds for infants, insufficient access to medicines, tailored health care and appropriate communications. Using the social cognitive framework, this study identified myriad needs of young mothers and barriers to improving maternal/child nutrition and health. Adolescent-mother-and-child-friendly environments are needed at local levels while continuing to reduce broader socio-cultural and economic barriers to health equity. Findings may help direct future interventions for improved adolescent maternal/child nutrition and health.

Milk Other Than Breast Milk and the Development of Asthma in Children 3 Years of Age. A Birth Cohort Study (2006⁻2011)

Prevalence of asthma in Australian children is amongst the highest in the world. Although breastfeeding positively influences infant immunity, early introduction of Milk Other than Breast Milk (MOTBM) may also play an important role in the development of Asthma. The aim of this study was to investigate the association between the introduction of MOTBM in the first six months after birth and the development of reported persistent asthma in 3-year olds. A sample of 1121 children was extracted from the Environments for Healthy Living longitudinal birth cohort study. Introduction of MOTBM during the first six months after birth increased almost two-fold the risk of development of persistent asthma after adjusting for other covariates (Adjusted Relative Risk (ARR): 1.71, 95% CI: 1.03⁻2.83, p = 0.038). This study indicates that the introduction of MOTBM in the first six months of life is a risk factor for asthma incidence among 3-year old children. This result is important in explaining the benefits of breastfeeding as part of public health interventions to encourage mothers to increase breastfeeding initiation and duration, and avoid the introduction of MOTBM in the first six months after childbirth.

Multiple-micronutrient supplementation: Evidence from large-scale prenatal programmes on coverage, compliance and impact

Micronutrient deficiencies during pregnancy pose important challenges for public-health, given the potential adverse outcomes not only during pregnancy but across the life-course. Provision of iron-folic acid (IFA) supplements is the strategy most commonly practiced and recommended globally. How to successfully implement IFA and multiple micronutrient supplementation interventions among pregnant women and to achieve sustainable/permanent solutions to prenatal micronutrient deficiencies remain unresolved issues in many countries. This paper aims to analyse available experiences of prenatal IFA and multiple micronutrient interventions to distil learning for their effective planning and large-scale implementation. Relevant articles and programme-documentation were comprehensively identified from electronic databases, websites of major-agencies and through hand-searching of relevant documents. Retrieved documents were screened and potentially relevant reports were critically examined by the authors with the aim of identifying a set of case studies reflecting regional variation, a mix of implementation successes and failures, and a mix of programmes and large-scale experimental studies. Information on implementation, coverage, compliance, and impact was extracted from reports of large-scale interventions in Central America, Southeast Asia, South Asia, and Sub-Saharan Africa. The WHO/CDC Logic-Model for Micronutrient Interventions in Public Health was used as an organizing framework for analysing and presenting the evidence. Our findings suggest that to successfully implement supplementation interventions and achieve sustainable-permanent solutions efforts must focus on factors and processes related to quality, cost-effectiveness, coverage, utilization, demand, outcomes, impacts, and sustainability of programmes including strategic analysis, management, collaborations to pilot a project, and careful monitoring, midcourse corrections, supervision and logistical-support to gradually scaling it up.

Can an integrated approach reduce child vulnerability to anaemia? Evidence from three African countries

Addressing the complex, multi-factorial causes of childhood anaemia is best done through integrated packages of interventions. We hypothesized that due to reduced child vulnerability, a "buffering" of risk associated with known causes of anaemia would be observed among children living in areas benefiting from a community-based health and nutrition program intervention. Cross-sectional data on the nutrition and health status of children 24-59 mo (N=2405) were obtained in 2000 and 2004 from program evaluation surveys in Ghana, Malawi and Tanzania. Linear regression models estimated the association between haemoglobin and immediate, underlying and basic causes of child anaemia and variation in this association between years. Lower haemoglobin levels were observed in children assessed in 2000 compared to 2004 (difference -3.30 g/L), children from Tanzania (-9.15 g/L) and Malawi (-2.96 g/L) compared to Ghana, and the youngest (24-35 mo) compared to oldest age group (48-59 mo; -5.43 g/L). Children who were stunted, malaria positive and recently ill also had lower haemoglobin, independent of age, sex and other underlying and basic causes of anaemia. Despite ongoing morbidity, risk of lower haemoglobin decreased for children with malaria and recent illness, suggesting decreased vulnerability to their anaemia-producing effects. Stunting remained an independent and unbuffered risk factor. Reducing chronic undernutrition is required in order to further reduce child vulnerability and ensure maximum impact of anaemia control programs. Buffering the impact of child morbidity on haemoglobin levels, including malaria, may be achieved in certain settings.

The effects of household food production strategies on the health and nutrition outcomes of women and young children: a systematic review

The objective of this review is to systematically examine and summarise the effects of agricultural interventions to increase household food production on the nutrition and health outcomes of women and young children and provide recommendations for future research and programming. Data from all studies meeting inclusion/exclusion criteria were abstracted into a standardised form. The quality of the evidence was assessed and graded using a modified version of the Child Health Epidemiology Reference Group adaptation of the Grading of Recommendations, Assessment, Development and Evaluation technique. Thirty-six articles, representing 27 unique projects were identified. Of these 32 and 17 reported on the health and nutrition outcomes of children and women, respectively. Although studies were too heterogeneous to conduct meta-analysis, agricultural strategies consistently reported significantly improved diet patterns and vitamin A intakes for both women and children. Although some individual studies reported significant reductions in child malnutrition, summary estimates for effects on stunting [relative risk (RR) 0.93 [95% confidence interval (CI) 0.84, 1.04]], underweight (RR 0.80 [95% CI 0.60, 1.07]) and wasting (RR 0.91 [95% CI 0.60, 1.38]) were not significant. Findings for an effect on vitamin A status, anaemia and morbidity were inconsistent. Overall the evidence base for the potential of agricultural strategies to improve the nutrition and health of women and young children is largely grounded in a limited number of highly heterogeneous, quasi-experimental studies, most of which have significant methodological limitations. While household food production strategies hold promise for improving the nutrition of women and children, the evidence base would be strengthened by additional research that is methodologically robust and adequately powered for biological and dietary indicators of nutrition.

Multisector intervention to accelerate reductions in child stunting: an observational study from 9 sub-Saharan African countries

BACKGROUND

In sub-Saharan Africa, ~ 40% of children <5 y old are stunted, with levels that have remained largely unchanged over the past 2 decades. Although the complex determinants of undernutrition are well recognized, few studies have evaluated strategies that combine nutrition-specific, health-based approaches with food system- and livelihood-based interventions.

OBJECTIVE

We examined changes in childhood stunting and its determinants after 3 y of exposure to an integrated, multisector intervention and compared these changes with national trends.

DESIGN

A prospective observational trial was conducted across rural sites in 9 sub-Saharan African countries with baseline levels of childhood stunting >20%. A stratified random sample of households and resident children <2 y old from villages exposed to the program were enrolled in the study. Main outcome measures included principal determinants of undernutrition and childhood stunting, which was defined as a height-for-age z score less than -2. National trends in stunting were generated from demographic and health surveys.

RESULTS

Three years after the start of the program in 2005-2006, consistent improvements were observed in household food security and diet diversity, whereas coverage with child care and disease-control interventions improved for most outcomes. The prevalence of stunting in children <2 y old at year 3 of the program (2008-2009) was 43% lower (adjusted OR: 0.57; 95% CI: 0.38, 0.83) than at baseline. The average national stunting prevalence for the countries included in the study had remained largely unchanged over the past 2 decades.

CONCLUSION

These findings provide encouraging evidence that a package of multisector interventions has the potential to produce reductions in childhood stunting.