Adapting the Trials of Improved Practices (TIPs) approach to explore the acceptability and feasibility of nutrition and parenting recommendations: what works for low-income families?

Child food portion sizes in the home environment: how do parents decide?

The consumption of larger portion sizes (PS) of food has been implicated in the increased prevalence of childhood obesity. The home is usually the first place children learn about food, however, little is known about how parents determine child PS in the home environment. This narrative review aimed to explore parental beliefs, decisions, strategies and barriers to the provision of appropriate food PS for children in the home environment. Results indicate that parental decisions on child food PS are based on the amounts they serve themselves, personal intuition and knowledge of child appetite. Owing to the habitual nature of food provision, parental decisions on child PS may be taken without conscious thought and/or could be part of a complex decision-making process influenced by several interlinked factors, including parental childhood mealtime experiences, other family members and child weight status. Strategies to determine child-appropriate PS include modelling the desired PS behaviour, use of unit-based food packaging and PS estimation aids, and providing the child with a degree of autonomy to rely on their own appetite cues. A lack of knowledge/awareness of PS guidance is a key barrier identified by parents to the provision of age-appropriate PS, warranting the inclusion of salient child-appropriate PS guidance within national dietary recommendations. Further home-based interventions to improve the provision of appropriate child PS are required, leveraged on parental strategies already in use, as outlined in this review.

Food-based nutrition counselling and education intervention for improved diets of pregnant women in rural Malawi: a qualitative study of factors influencing dietary behaviour change

OBJECTIVE

We wanted to identify factors related to dietary behavioural change among impoverished pregnant women in the face of nutrition education and counselling, describing what creates an enabling environment and barriers for dietary change.

DESIGN

We used qualitative data from a cluster-randomised maternal education trial and conducted a thematic analysis using a social ecological framework to describe the factors that influenced dietary adherence.

SETTING

Mangochi district in rural Malawi.

PARTICIPANTS

We interviewed ten pregnant women and conducted four sets of focus group discussions with twenty-two significant family members (husbands and mothers-in-law) and twelve counsellors.

RESULTS

The participants' experiences showed that the main barriers of adherence to the intervention were taste, affordability and poverty. The use of powders and one-pot dishes, inclusion of both women and significant family members and a harmonisation with local food practices enabled adherence to the intervention. We found it crucial to focus the dietary education and counselling intervention on locally available ingredients and food processing methods.

CONCLUSIONS

Use of contextualised food-based solutions to combat maternal malnutrition was observed to be relatively cheap and sustainable. However, there is need for more research on local foods used as nutrition supplements. We suggest that investments need to be directed not only to nutrition education and counselling but also to the enabling factors that enhance adherence. The original cluster-randomised controlled trial was registered with Clinical trials.gov ID: NCT03136393.

Engaging fathers to improve complementary feeding is acceptable and feasible in the Lake Zone, Tanzania

In Tanzania, suboptimal complementary feeding practices contribute to high stunting rates. Fathers influence complementary feeding practices, and effective strategies are needed to engage them. The objectives of this research were to examine the acceptability and feasibility of (1) tailored complementary feeding recommendations and (2) engaging fathers in complementary feeding. We conducted trials of improved practices with 50 mothers and 40 fathers with children 6-18 months. At visit 1, mothers reported current feeding practices and fathers participated in focus group discussions. At visit 2, mothers and fathers received individual, tailored counselling and chose new practices to try. After 2 weeks, at visit 3, parents were interviewed individually about their experiences. Interview transcripts were analysed thematically. The most frequent feeding issues at visit 1 were the need to thicken porridge, increase dietary diversity, replace sugary snacks and drinks and feed responsively. After counselling, most mothers agreed to try practices to improve diets and fathers agreed to provide informational and instrumental support for complementary feeding, but few agreed to try feeding the child. At follow-up, mothers reported improved child feeding and confirmed fathers' reports of increased involvement. Most fathers purchased or provided funds for recommended foods; some helped with domestic tasks or fed children. Many participants reported improved spousal communication and cooperation. Families were able to practice recommendations to feed family foods, but high food costs and seasonal unavailability were challenges. It was feasible and acceptable to engage fathers in complementary feeding, but additional strategies are needed to address economic and environmental barriers.

Applying focused ethnographic methods: examining implications of intracultural diversity for nutrition interventions

This paper examines the implications of intracultural difference for the design and implementation of nutrition interventions. It raises the question of whether small-sample, mixed-method implementation research, using a focused ethnographic approach, has sufficient power to detect meaningful differences in cultural beliefs, values, perceptions, and attitudes that are important for the design and implementation of nutrition interventions. It first presents the theoretical framework that was used to guide the research, followed by a description of the methodology of the Focused Ethnographic Study for Infant and Young Child Feeding. It then uses the findings from recent research in Ghana to address the central question. The findings document strong elements of shared cultural consensus, but intracultural differences of importance, in relation to the planning and content of behavior change communication.

Integrating Calcium Into Antenatal Iron-Folic Acid Supplementation in Ethiopia: Women's Experiences, Perceptions of Acceptability, and Strategies to Support Calcium Supplement Adherence

Recommendations for antenatal calcium supplementation to prevent preeclampsia could substantially reduce maternal mortality, but adherence to multiple daily doses may constrain effectiveness. World Health Organization guidelines recommend 3 daily calcium supplements (1.5-2 g/d), taken separately from 1 iron-folic acid (IFA) supplement; however, limited data suggest lower calcium doses may also be effective. We conducted mixed-methods household trials to identify strategies for supporting adherence and integrating calcium into antenatal IFA supplementation programming in Ethiopia. Participants were randomly assigned to 3 regimens varying in dose and timing and were later given a choice of regimens. Semistructured interviews conducted over 6 weeks explored acceptability, barriers, and facilitators and offered opportunities to choose calcium pill type. Interviews were transcribed, translated, and analyzed thematically. Calcium adherence was measured using medication event monitoring. All participants (N=48) agreed to try supplementation. Adherence barriers included forgetting to take pills when busy or travelling and perceived side effects. Midday doses were the most challenging because of farming, market, and social events; women avoided taking supplements in public due to fear of being perceived as HIV positive. Social support from families, visual reminders, and anticipated benefits motivated adherence. More participants (75%) selected chewable versus conventional supplements due to organoleptic properties, but this preference declined over time. Adherence rates did not substantially differ across regimens with 2 (81.1%), 3 (83.4%), or 4 (77.1%) pill-taking events. Women indicated that the 2-event regimen was more acceptable than 3- and 4-event regimens, but this acceptability was not associated with higher adherence. Consequently, mean daily calcium consumption (811.3 mg) was lower than for 3-event (1,251.1 mg) and 4-event (1,156.4 mg) regimens. Integrating calcium into antenatal IFA supplementation is acceptable to Ethiopian women, with a 3-event regimen yielding the highest consumption rates. Despite women experiencing challenges with midday dosing and stigma, using simple home-based strategies and being counseled on the purpose of supplementation were more effective than reducing dosage for mitigating barriers and improving adherence.

Development of Parent and Adolescent Questionnaires to Assess Food Parenting Practices That Address Adolescent Consumption During Independent Eating Occasions

OBJECTIVE

To develop and test parent and early adolescent questionnaires to assess food parenting practices that influence early adolescent food consumption during independent eating occasions (iEOs).

METHODS

Cross-sectional online questionnaires were completed by 206 and 62 low-income parent/early adolescent (11-14 years) dyads at Time 1 and 2, respectively, recruited via a Qualtrics (Provo, UT) US national panel database. Principal component analyses, internal consistency, and test-retest reliability checks were performed.

RESULTS

Six parallel components were identified for parents and early adolescents with acceptable internal consistency and test-retest reliability. Scales included autonomy support, monitoring, availability, indulgence, expectations, and modeling. All except indulgence were positively correlated with importance of helping early adolescents make healthy choices during iEOs.

CONCLUSIONS AND IMPLICATIONS

Additional research is needed to test the questionnaires' validity regarding relationships between parenting practices and early adolescent consumption during iEOs. Findings could inform development of interventions to improve consumption during these occasions.

Implementation of Parental Strategies to Improve Child Vegetable Intake: Barriers and Facilitators

Purpose. To qualitatively assess barriers and facilitators to implementing specific behavioral strategies to increase child vegetable intake during home dinner meals by low-income parents. Method. Parents (n = 49) of children (9-12 years) were asked to implement 1 behavioral strategy following each of 6 weekly cooking classes at community centers. Example strategies included serving vegetables first, serving 2 vegetables, and using a bigger spoon to serve vegetables. The following week, parents discussed how they used the strategy and barriers and facilitators to its use. Discussions were recorded, transcribed verbatim, and coded separately by strategy using NVivo Pro 11 software. Inductive, comparative thematic analyses were used to identify themes by strategy. Results. Most participants were multiethnic women aged 30 to 39 years with low food security. Time and scheduling conflicts limited involvement of children in vegetable preparation (Child Help strategy). The type of foods served and an unfamiliar serving style inhibited use of the MyPlate and Available/Visible strategies, respectively. Children's dislike of vegetables limited use of the Serve Vegetables First and Serve 2 Vegetables strategies. Ease of use promoted use of the Bigger Spoon strategy. Conclusion. Educators could tailor application of specific parent strategies for low-income families based on child and environmental characteristics.

Using Trials of Improved Practices to identify practices to address the double burden of malnutrition among Rwandan children

OBJECTIVE

Low- and middle-income countries (LMIC) are increasingly experiencing the double burden of malnutrition. Studies to identify 'double-duty' actions that address both undernutrition and overweight in sub-Saharan Africa are needed. We aimed to identify acceptable behaviours to achieve more optimal feeding and physical activity practices among both under- and overweight children in Rwanda, a sub-Saharan LMIC with one of the largest recent increases in child overweight.

DESIGN

We used the Trials of Improved Practices (TIPs) method. During three household visits over 1·5 weeks, we used structured interviews and unstructured observations to collect data on infant and young child feeding practices and caregivers' experiences with testing recommended practices.

SETTING

An urban district and a rural district in Rwanda.

PARTICIPANTS

Caregivers with an under- or overweight child from 6 to 59 months of age (n 136).

RESULTS

We identified twenty-five specific recommended practices that caregivers of both under- and overweight children agreed to try. The most frequently recommended practices were related to dietary diversity, food quantity, and hygiene and food handling. The most commonly cited reason for trying a new practice was its benefits to the child's health and growth. Financial constraints and limited food availability were common barriers. Nearly all caregivers said they were willing to continue the practices and recommend them to others.

CONCLUSIONS

These practices show potential for addressing the double burden as part of a broader intervention. Still, further research is needed to determine whether caregivers can maintain the behaviours and their direct impact on both under- and overweight.

Context-specific complementary feeding recommendations developed using Optifood could improve the diets of breast-fed infants and young children from diverse livelihood groups in northern Kenya

OBJECTIVE

To formulate age- and context-specific complementary feeding recommendations (CFR) for infants and young children (IYC) and to compare the potential of filling population-level nutrient gaps using common sets of CFR across age groups.

DESIGN

Linear programming was used to develop CFR using locally available and acceptable foods based on livelihood- and age-group-specific dietary patterns observed through 24 h dietary recalls. Within each livelihood group, the nutrient potential of age-group-specific v. consolidated CFR across the three age groups was tested.

SETTING

Three food-insecure counties in northern Kenya; namely, settled communities from Isiolo (n 300), pastoralist communities from Marsabit (n 283) and agro-pastoralist communities from Turkana (n 299).

SUBJECTS

Breast-fed IYC aged 6-23 months (n 882).

RESULTS

Age-specific CFR could achieve adequacy for seven to nine of eleven modelled micronutrients, except among 12-23-month-old children in agro-pastoralist communities. Contribution of Fe, Zn and niacin remained low for most groups, and thiamin, vitamin B6 and folate for some groups. Age-group-consolidated CFR could not reach the same level of nutrient adequacy as age-specific sets among the settled and pastoralist communities.

CONCLUSIONS

Context- and age-specific CFR could ensure adequate levels of more modelled nutrients among settled and pastoralist IYC than among agro-pastoralist communities where use of nutrient-dense foods was limited. Adequacy of all eleven modelled micronutrients was not achievable and additional approaches to ensure adequate diets are required. Consolidated messages should be easier to implement as part of a behaviour change strategy; however, they would likely not achieve the same improvements in population-level dietary adequacy as age-specific CFR.

Adherence partners are an acceptable behaviour change strategy to support calcium and iron-folic acid supplementation among pregnant women in Ethiopia and Kenya

Antenatal calcium and iron-folic acid (IFA) supplementation can reduce maternal mortality and morbidity. Yet, even when pregnant women have a stable supply of supplements, forgetting is often a barrier to adherence. We assessed the acceptability of adherence partners to support calcium and IFA supplementation among pregnant women in Kenya and Ethiopia. Adherence partners are a behaviour change strategy to improve adherence, where pregnant women are counselled to select a partner (e.g. spouse, relative) to remind them to take their supplements. We conducted trials of improved practices, a formative research method that follows participants over time as they try a new behaviour. We provided pregnant women in Ethiopia (n = 50) and Kenya (n = 35) with calcium and IFA supplements and counselling, and suggested selecting an adherence partner. For each participant, we conducted semi-structured interviews about acceptability and adherence during four interviews over six weeks. We analysed interview transcripts thematically and tallied numerical data. In Kenya, 28 of 35 women agreed to try an adherence partner; almost all selected their husbands. In Ethiopia, 42 of 50 women agreed to try an adherence partner; half asked their husbands, others asked children or relatives. Most women who did not select adherence partners reported not needing help or not having anyone to ask. Participants reported adherence partners reminded and encouraged them, brought supplements, provided food and helped address side-effects. Almost all women with adherence partners would recommend this strategy to others. Adherence partners are an acceptable, low-cost strategy with the potential to support antenatal micronutrient supplementation adherence.

Adapting the Trials of Improved Practices (TIPs) approach to explore the acceptability and feasibility of nutrition and parenting recommendations: what works for low-income families?

Interventions to prevent childhood obesity must consider not only how child feeding behaviours are related to child weight status but also which behaviours parents are willing and able to change. This study adapted Trials of Improved Practices (TIPs) to assess acceptability and feasibility of nutrition and parenting recommendations, using in-depth interviews and household trials to explore families' experiences over time. A diverse sample of 23 low-income parents of 3-11-year-olds was recruited following participation in nutrition and parenting education. Parents chose nutrition and parenting practices to try at home and were interviewed 2 weeks and 4-6 months later about behaviour change efforts. Qualitative analysis identified emergent themes, and acceptability and feasibility were rated based on parents' willingness and ability to try new practices. The nutrition goal parents chose most frequently was increasing children's vegetable intake, followed by replacing sweetened beverages with water or milk, and limiting energy-dense foods. Parents were less inclined to reduce serving sizes. The parenting practices most often selected as applicable to nutrition goals were role-modelling; shaping home environments, often with other adults; involving children in decisions; and providing positive feedback. Most recommendations were viewed as acceptable by meaningful numbers of parents, many of whom tried and sustained new behaviours. Food preferences, habits and time were common barriers; family resistance or food costs also constrained some parents. Despite challenges, TIPs was successfully adapted to evaluate complex nutrition and parenting practices. Information on parents' willingness and ability to try practices provides valuable guidance for childhood obesity prevention programmes.