Key principles to improve programmes and interventions in complementary feeding

Formulation and acceptability of local nutrient-dense foods for young children: A formative study for the Child Health, Agriculture and Integrated Nutrition (CHAIN) Trial in rural Zimbabwe

Stunting affects almost one-quarter of children globally, leading to reduced human capacity and increased long-term risk of chronic disease. Despite intensive infant and young child feeding (IYCF) interventions, many children do not meet their requirements for essential nutrients. This study aimed to assess the feasibility of implementing an IYCF intervention utilizing nutrient-dense powders from egg, biofortified sugar beans and Moringa oleifera leaf in rural Zimbabwe. A mixed-methods formative study was conducted comprising the following: (i) a recipe formulation trial, (ii) trials of improved practices to assess acceptability of the intervention, and (iii) a participatory message formulation process to develop counselling modules for the IYCF-plus intervention. Twenty-seven mother-baby pairs were recruited between November 2019 and April 2020. Key domains affecting IYCF practices that emerged were time, emotional and physical space, cultural and religious beliefs, indigenous knowledge systems and gender dynamics. Household observations and sensory evaluation indicated high acceptability of the new ingredients. Recipe formulation and participatory message formulation by participants instilled community ownership and served to demystify existing misconceptions about the new food products. Families noted the potential for intervention sustainability because the foods could be grown locally. Supplementing complementary foods with nutrient-dense local food ingredients as powders has the potential to sustainably address nutrient-gaps in the diets of young children living in rural lower- and middle-income countries. Comprehensive IYCF counselling utilizing a gender-lens approach, family support and indigenous knowledge systems or resources are key elements to support positive behaviour change in complementary feeding interventions.

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.

Evaluating the coverage and quality of nutrition programs via a bottom-up approach: A secondary analysis of real-time data from an end-user monitoring system in Ethiopia

Over the last two decades, great efforts and investments have been made in Ethiopia to ensure that all children have equal access to nutrition services in health facilities. While quality health systems are a prerequisite for quality nutrition services, little attention has been given to the evaluation of the supply and delivery services. The purpose of the study was to evaluate the coverage and quality of the nutrition-specific interventions delivered through the health system. Using an end-user monitoring (EUM) system, we monitored the delivery of nutrition-specific interventions in 500 districts, having 2514 health facilities distributed throughout Ethiopia. Data were collected through third-party monitors between August 2020 and 2021. Roughly 90% of health facilities were performing severe acute malnutrition management in line with the national guideline/protocol, and 2/3 of the assessed facilities were delivering iron and folic acid, vitamin A supplementation and deworming. A third of the messages on AMIYCN were retained by beneficiaries. Warehouse conditions were good in 64.3% of the facilities, but only 22% had good recording practices and about half had problems related to the quality and availability of nutrition supplies. Most beneficiaries were satisfied with the nutrition supplies and service delivered at the health facility level. This study also suggests the relevance of an EUM system to assess the quality of nutrition service delivery and its related supply management, as well as to improve the implementation of nutrition interventions as a decision-making tool.

Improving knowledge, attitude, and practices of complementary feeding using practical intervention training for parents living in central Lombok, Indonesia: A community-based study

BACKGROUND

Stunting remains a major public health concern in Indonesia despite many interventions. This study aimed to assess the effectiveness of interventions in the form of education and demonstration on preparing complementary feeding (CF) to increase knowledge, attitude, and practices (KAP) of CF among parents living in villages with high stunting prevalence in Central Lombok, Indonesia.

MATERIALS AND METHODS

This is a quasi-experimental community-based study, conducted from June to August 2019. Three villages were divided into three groups, i.e., control group (CG), education alone (EA) group, and education-cum-demonstration (ED) group. We assessed KAP before and after intervention with a 4-week interval.

RESULTS

A total of 205 participants were enrolled in this study, consisting of 67, 70, and 68 participants in the CG, EA, and ED groups, respectively. In within-group analysis, parents' attitudes (P = 0.015) and practices (P = 0.014) improved in the ED group while only parents' practices (P = 0.034) improved in the EA group. In between-group analysis, parental attitude (P = 0.039) and practices (P = 0.008) improved in the ED group when compared to the CG. In the EA group, only parents' practices improved when compared to the CG (P = 0.006). There was no significant difference in KAP score in the EA and ED groups.

CONCLUSION

A combined approach of education and demonstration works better to promote healthy CF practices among mothers.

Leveraging the Scaling Up Nutrition Movement to Operationalize Stunting Prevention Activities: Implementation Lessons From Rural Malawi

BACKGROUND

The rural district of Ntchisi is in the central region of Malawi. Among children aged 6 to 23 months, the stunting prevalence is 40% to 50%. To address this high prevalence, the World Food Programme, with cooperating partners, supported the Government of Malawi to implement an integrated stunting prevention program entitled The Right Foods at the Right Time from 2013 to 2018.

OBJECTIVE

To provide implementation lessons learned from systematic documentation of how the Scaling Up Nutrition (SUN) movement, combined with other international and national initiatives and policies, was translated into tailored programming.

METHODS

During program conception, early design, and implementation, this descriptive study systematically documented the process of translating SUN principles and government policies into an operational stunting prevention program in rural Malawi.

RESULTS

We identified 8 factors that contributed to successful translation of policy into program activities: (1) well-structured National SUN framework, (2) reliable coordination platforms and district ownership, (3) systematic and evidence-informed program design, (4) multiple forms of data used to inform program planning, (5) multisectoral implementation approaches to stunting prevention, (6) innovation in technology to improve overall program efficiency, (7) systematic collaboration among diverse stakeholders, and (8) strong public health nutrition capacity of program team members.

CONCLUSIONS

Lessons from this nutrition program in Ntchisi, Malawi, provide one case illustrating how the SUN movement, government policies, and global evidence base can be operationalized into tailored programming for improving nutrition.

Impact of Nutrition Education on the Nutrition Capacity of Caregivers and Nutrition Outcomes of Indigenous Mbororo Children in the West Region of Cameroon: Protocol for a Cluster Randomized Controlled Trial

Background

Inadequate diets and life-threatening infections have profound adverse implications for child growth, development, and survival, particularly among indigenous peoples. Evidence of the effectiveness of community-based nutrition education interventions in improving child feeding and nutrition outcomes among indigenous Mbororo population in Cameroon is scarce.

Objective

This study aims to investigate the impact of culturally tailored community-based nutrition education intervention on caregivers’ knowledge, attitude, and practice regarding complementary feeding and on nutrition outcomes of indigenous Mbororo children (aged 3-59 months) in the Foumban and Galim health districts of the West Region of Cameroon.

Methods

A two-arm cluster randomized controlled trial will be conducted in the Foumban Health District and Galim Health District. The intervention and control arms will each comprise 5 clusters with 121 child–caregiver pairs. Participants in the intervention arm will be organized into 5 caregivers’ peer-support platforms. A total of 12 educational sessions will be assigned to the intervention group by trained female Mbororo nutrition volunteers (n=6) and community health workers (n=6). The control arm will receive routine facility-based nutrition education. Data will be collected at 3-month and 6-month follow-up. Both descriptive statistics and multivariate logistic models will be used to estimate the effect of culturally tailored community-based nutrition education intervention (independent variable) on outcome variables (caregivers’ knowledge, attitude, and practice), child growth (weight, height/length, weight for age), and morbidity status (diarrhea, cough, and fever) between both arms. Data assessors will be blinded to the group allocation. Ethical approval (reference no. 2019/1002-07/UB/SG/IRB/FHS) was obtained from the Faculty of Health Sciences Institutional Review Board at the University of Buea.

Results

Baseline data were collected in September 2019. In February 2020, 10 Mbororo communities (clusters) with 242 child–caregiver pairs were selected and allocated to the experimental and control arm in a 1:1 ratio. Community nutrition volunteers (n=6) and community health workers (n=6) were selected and trained. Data collection and analysis are ongoing, and results are not available for this manuscript.

Conclusions

The findings of this study will provide evidence on the impact of culturally tailored and health belief model–based nutrition education on behavior change as a complementary strategy for strengthening health facility–based approaches in the reduction of malnutrition burden among the study population

International Registered Report Identifier (IRRID)

DERR1-10.2196/23115

Drivers of stunting reduction in Peru: a country case study

BACKGROUND

Peru reduced its under-5 child stunting prevalence notably from 31.3% in 2000 to 13.1% in 2016.

OBJECTIVES

We aimed to study factors and key enablers of child stunting reduction in Peru from 2000-2016.

METHODS

Demographic and Health Surveys were used to conduct descriptive analyses [height-for-age z scores (HAZ) means and distributions, equity analysis, predicted child growth curves through polynomial regressions] and advanced regression analyses. An ecological (at department level) multilevel regression analysis was conducted to identify the major predictors of stunting decline from 2000 to 2016, and Oaxaca-Blinder decomposition was conducted to identify the relative contribution of each factor to child HAZ change. A systematic literature review, policy and program analysis, and interviews with relevant stakeholders were conducted to understand key drivers of stunting decline in Peru.

RESULTS

The distribution of HAZ scores showed a slight rightward shift from 2000 to 2007/2008, and a greater shift from 2007/2008 to 2016. Stunting reduction was higher in the lowest wealth quintile, in rural areas, and among children with the least educated mothers. Decomposing predicted changes showed that the most important factors were increased maternal BMI and maternal height, improved maternal and newborn health care, increased parental education, migration to urban areas, and reduced fertility. Key drivers included the advocacy role of civil society and political leadership around poverty and stunting reduction since the early 2000s. Key enablers included the economic growth and the consolidation of democracy since the early 2000s, and the acknowledgement that stunting reduction needs much more than food supplementation.

CONCLUSIONS

Peru reduced child stunting owing to improved socioeconomic determinants, sustained implementation of out-of-health-sector and within-health-sector changes, and implementation of health interventions. These efforts were driven through a multisectoral approach, strong civil society advocacy, and keen political leadership. Peru's experience offers useful lessons on how to tackle the problem of stunting under differing scenarios, with the participation of multiple sectors.

Designing integrated interventions to improve nutrition and WASH behaviors in Kenya

Background

Child stunting, an indicator of chronic malnutrition, is a global public health problem. Malnutrition during pregnancy and the first 2 years of life undermines the survival, growth, and development of children. Exposure to fecal pathogens vis-à-vis inadequate water, sanitation, and hygiene (WASH) has been implicated in the etiology of child stunting, highlighting the need to integrate WASH with nutrition-sensitive interventions to comprehensively address this complex problem. The aim of this study was to describe a systematic, theoretically informed approach (that drew from the Starr and Fornoff approach to the Theory of Change development and the Behavior Change Wheel approach) to design a multi-component and integrated social and behavior change intervention to improve WASH and nutrition-related behaviors in western Kenya.

Methods

This intervention was developed to be integrated into an existing project that utilized the care group model and aimed to create a culture of care and support for HIV/AIDS-affected children under two and their caregivers and was executed by local partners. We tested the newly created intervention packages in user-testing trials using an adapted Trials of Improved Practices approach to pilot acceptability and feasibility.

Results

Using authentic stakeholder engagement and relevant theories, we conducted an 8-step process: (1) conduct mixed methods formative research, (2) prioritize target behaviors, (3) use causal analysis to create problem trees, (4) develop solution trees and articulate assumptions and rationales for change, (5) link solution trees to intervention functions, (6) develop the intervention plan, (7) create the intervention packages, and (8) test and refine the intervention packages.

Conclusions

This study highlights the need to take a multi-sectorial, integrated approach that integrates contextually relevant behavior change theories with the experiential knowledge gleaned from stakeholders into the design of interventions that seek to reduce child stunting. This process resulted in the creation of intervention packages that grouped behaviors thematically to be most relevant and responsive to the population context. This work has the potential to make important contributions towards achievement of the United Nations’ sustainable development goals.

Factors associated with dietary diversity and length-for-age z-score in rural Ethiopian children aged 6-23 months: A novel approach to the analysis of baseline data from the Sustainable Undernutrition Reduction in Ethiopia evaluation

Infants and young children need diets high in nutrient density and diversity to meet the requirements of rapid growth and development. Our aim was to evaluate sociodemographic, agricultural diversity, and women's empowerment factors associated with child dietary diversity and length-for-age z-score (LAZ) in children 6-23 months using data collected as part of the Sustainable Undernutrition Reduction in Ethiopia (SURE) evaluation study baseline survey in May-June 2016. We here present a novel analysis using directed acyclic graphs (DAGs) to represent our assumptions about the causal influences between the factors of interest and the outcomes. The causal diagrams enabled the identification of variables to be included in multivariable analysis to estimate the total effects of factors of interest using ordinal logistic/linear regression models. We found that child dietary diversity was positively associated with LAZ with children consuming 4 or more food groups having on average an LAZ score 0.42 (95% CI [0.08, 0.77]) higher than those consuming no complementary foods. Household production of fruits and vegetables was associated with both increased child dietary diversity (adjusted OR 1.16; 95% CI [1.09, 1.24]) and LAZ (adjusted mean difference 0.05; 95% CI [0.005, 0.10]). Other factors positively associated with child dietary diversity included age in months, socio-economic status, maternal education, women's empowerment and dietary diversity, paternal childcare support, household food security, fruit and vegetable cultivation, and land ownership. LAZ was positively associated with age, socio-economic status, maternal education, fruit and vegetable production, and land ownership.

Women's bargaining power and child feeding in Nepal: Linkages through nutrition information

Women's intra-household bargaining power is an important determinant of child nutritional status, but there is limited evidence on how it relates to infant and young child feeding (IYCF) practices. We conducted a cross-sectional analysis using 2012 baseline data from the impact evaluation of Suaahara, a multisectoral programme in Nepal, focusing on households with children 0-23 months (n = 1787). We examined if women's bargaining power was related to exposure to IYCF information and if exposure to IYCF information was in turn associated with improved IYCF practices: early initiation of breastfeeding, exclusive breastfeeding, minimum meal frequency and dietary diversity. Bargaining power consisted of four domains: (i) ownership and control of assets; (ii) social participation; (iii) workload; and (iv) household decision-making control and were primarily measured using additive scales. We used generalized structural equation modelling to examine if exposure to IYCF information mediated the relationship between the bargaining domains and the four IYCF practices, separately. Social participation was positively associated with exposure to IYCF information (β = 0.266, P < .001), which in turn was related to early initiation (β = 0.241, P = .001). We obtained similar results for the relationship between social participation and dietary diversity. Decision-making control was directly associated with exclusive breastfeeding (β = 0.350, P = .036). No domains were associated with minimum meal frequency. Different domains of women's bargaining power may relate to exposure to nutrition information and IYCF behaviours. Understanding specific domains of bargaining power is critical to developing interventions that can effectively address gender-related issues that underlie child nutrition outcomes.

An Iterative Process for Training Design and Implementation Increased Health Workers' Knowledge for Taking Nutrition Behavior Change to Scale

BACKGROUND

The shortage of skilled, motivated, and well-supported health workers is a major barrier to scaling up nutrition interventions and services.

OBJECTIVE

The objective of this study is to describe the process for developing and implementing a training of health personnel for the delivery of the Integrated Strategy for Attention to Nutrition (EsIAN), an evidence-based strategy for promoting infant and young child feeding through primary health care in Mexico. The specific objective is to provide a case study and highlight challenges, as well as elements to successfully mitigate these, and discuss potential applications of findings beyond the Mexican context.

METHODS

The design and implementation of training followed a 5-phase process: situation analysis, formative research, large-scale feasibility study, redesign and scale up, and evaluation. We conducted document reviews, surveys, and focus groups during the first phases to inform and refine the training, as well as a pre- and posttraining telephone survey to evaluate change in knowledge.

RESULTS

The initial phases of the design provided a clear understanding of the opportunities and challenges for promoting infant and young child feeding, as well as health workers' routines and practices, which informed training design. The feasibility study allowed tailoring and refinement of training. The vertical coherence and coordination between the federal and state levels during redesign and scale up facilitated compliance with training timeline and process. Evaluation results showed significant improvement in knowledge posttraining of up to 19 percentage points.

CONCLUSIONS

The EsIAN training component for health providers was developed using a systematic approach to consolidate and generate relevant evidence, following an iterative process to test, learn, and improve both design and implementation. This process allowed for flexibility to take advantage of new opportunities and respond to findings from iterations. Garnering and ensuring political support allowed for continuity and sustainability of actions.

Government information systems to monitor complementary feeding programs for young children

Accelerating progress to improve complementary feeding of young children is a global priority. Strengthening monitoring through government information systems may increase the quality and implementation of infant and young child feeding (IYCF) programs. Monitoring is necessary for the effective implementation of programs as it allows program managers to assess program performance, identify problems, and take corrective action. Program descriptions and conceptual models explain how program inputs and activities should lead to outputs and outcomes, and ultimately public health impact; thus, they are critical tools when designing effective IYCF programs and monitoring systems as these descriptions and conceptual models form the basis for the program and are key for developing the monitoring system, indicators, and tools. Despite their importance, many programs do not have these documented, nor monitoring plans, limiting their ability to design effective programs and monitoring systems. Once in place, it is important to periodically review the monitoring system to confirm it still appropriately meets stakeholder needs and the data are being used to inform decision-making, and to make program adjustments as the monitoring focus, resources, or capacity may change during the program lifecycle. Including priority indicators of IYCF practices and counseling indicators in the government information systems may strengthen IYCF programs when the indicators are contextualized to the government IYCF program, capacity, and setting, and the indicators are used for decision-making and program improvement.

Tools to improve planning, implementation, monitoring, and evaluation of complementary feeding programmes

Adequate nutrient intake is a prerequisite for achieving good nutrition status. Suboptimal complementary feeding practices are a main risk factor for stunting. The need for systematic and user-friendly tools to guide the planning, implementation, monitoring, and evaluation of dietary interventions for children aged 6-23 months has been recognized. This paper describes five tools, namely, ProPAN, Optifood, Cost of the Diet, Fill the Nutrient Gap, and Monitoring Results for Equity System that can be used in different combinations to improve situation analysis, planning, implementation, monitoring, or evaluation approaches for complementary feeding in a particular context. ProPAN helps with development of strategies and activities designed to change the behaviours of the target population. Optifood provides guidance for developing food-based recommendations. The Cost of the Diet can provide insight on economic barriers to accessing a nutritious and balanced diet. The Fill the Nutrient Gap facilitates formulation of context-specific policies and programmatic approaches to improve nutrient intake, through a multistakeholder process that uses insights from linear programming and secondary data. The Monitoring Results for Equity System helps with analysis of gaps, constraints, and determinants of complementary feeding interventions and adoption of recommended practices especially in the most vulnerable and deprived populations. These tools, and support for their use, are readily available and can be used either alone and/or complementarily throughout the programme cycle to improve infant and young child-feeding programmes at subnational and national levels.

First foods: Why improving young children's diets matter

Globally, only 52% of children aged 6-23 months meet the minimum meal frequency and a mere 29% meet the minimum dietary diversity, with large disparities across and within regions. With most of the stunting occurring during the first thousand days-from conception to age 2 years-improving complementary feeding in children 6-23 months old is an urgent priority. With this evidence in mind, UNICEF collaborated with the governments of India and Maharashtra to convene a global meeting in Mumbai, India, under the theme: First Foods: A Global Meeting to Accelerate Progress on Complementary Feeding in Young Children (November 17-18, 2015). The global meeting provided a platform that aimed to (a) synthesize the biological and implementation science on complementary feeding; (b) review the practice and experience in improving access to nutritious complementary foods and good complementary feeding practices; and (c) consolidate a strong evidence base that can inform the development of strategies and approaches to improve complementary feeding that are fit to context. This overview paper summarizes the rationale on why improving complementary foods and feeding for infants and young children matters and what it takes to improve them. It builds on the papers presented at the First Foods Global Meeting and those commissioned as a follow on to it.

[Promoting a healthy diet in childhood: weaknesses in the context of Primary Health Care]

This paper reports the experience of the incorporation of perceptions of social actors in the investigation of the weaknesses of the process of implementation of programs that aim to promote a healthy diet in childhood. It involves qualitative research carried out in a medium-sized Brazilian municipality in which the participants were nurses and community health agents. The data were collected through semi-structured questionnaires as well as focus groups. The findings indicated that the quality and continuity of actions to promote a healthy diet were limited due to the precarious working conditions, hence the strong demand for adequate orientation due to the unfavorable context where child health is concerned. Although the reality of peripheral countries points to an incipience in program evaluation, the incorporation of qualitative investigation broadened by the perspective of the participants may constitute an important tool of participation and social responsibility. This minimizes political effects and verticalized and discontinuous actions, helping the generation of opportune and adequate information for the understanding of the different local contexts and social experiences.

Achieving behaviour change at scale: Alive & Thrive's infant and young child feeding programme in Bangladesh

Abstract

The Alive & Thrive programme scaled up infant and young child feeding interventions in Bangladesh from 2010 to 2014. In all, 8.5 million mothers benefited. Approaches – including improved counselling by frontline health workers during home visits; community mobilization; mass media campaigns reaching mothers, fathers and opinion leaders; and policy advocacy – led to rapid and significant improvements in key practices related to breastfeeding and complementary feeding. (Evaluation results are forthcoming.) Intervention design was based on extensive formative research and behaviour change theory and principles and was tailored to the local context. The programme focused on small, achievable actions for key audience segments identified through rigorous testing. Promotion strategies took into account underlying behavioural determinants and reached a high per cent of the priority groups through repeated contacts. Community volunteers received monetary incentives for mothers in their areas who practised recommended behaviours. Programme monitoring, midterm surveys and additional small studies to answer questions led to ongoing adjustments. Scale‐up was achieved through streamlining of tools and strategies, government branding, phased expansion through BRAC – a local non‐governmental implementing partner with an extensive community‐based platform – and nationwide mainstreaming through multiple non‐governmental organization and government programmes.

Assessing and Improving Childhood Nutrition and Growth Globally

Improving maternal and child nutrition is central to global development goals and reducing the noncommunicable disease burden. Although the process of becoming malnourished starts in utero, the consequences of poor nutrition extend across the life cycle and into future generations. The global nutrition targets for 2025 include reducing infant and young child growth faltering, halting the increase of overweight children, improving breastfeeding practices, and reducing maternal anemia. In this review, we address nutritional assessment, discuss nonnutritive factors that affect growth, and endorse the evidence-based interventions that should be scaled up to improve maternal and child nutrition.

Adherence to dietary recommendations for preschoolers: clinical trial with teenage mothers

OBJECTIVE

To assess the effect of educational dietary intervention offered in the child’s first year of life, as well as teenage mothers and grandmothers in carrying out the dietary recommendations at four to seven years.

METHODS

Randomized clinical trial initiated in 2006, in Porto Alegre, RS, involving 323 teenage mothers and grandmothers who cohabited. The intervention consisted of six counseling sessions on breastfeeding and healthy complementary feeding. The first session occurred in the maternity ward and the other ones in the households of mothers at seven, 15, 30, 60, and 120 days of the child’s life. The information about the child’s diet were obtained on a monthly basis in the first six months, every two months in the second half-year, and at four to seven years, using a food frequency questionnaire. To assess the adequacy of food consumption to the recommendations from the Ministry of Health, we elaborated a score system that would reflect the compliance with the Ten Steps for Healthy Toddlers from 2 to 10 Years. The average scores of intervention and control groups were compared using the t-test.

RESULTS

Low adherence to recommendations on child nutrition was found in the study population, with no difference in implementation the steps between the groups. The score on the compliance with the steps was similar in both groups (9.6 [SD = 1.63] and 9.3 [SD = 1.60] in the intervention and control groups, respectively) and no influence of the cohabitation with the grandmother was found.

CONCLUSIONS

Educational dietary intervention in the first four months of the child’s life for teenage mothers and grandmothers had no effect on the compliance with the recommendations at four to seven years of the child’s life.

Minimum Acceptable Diet at 9 Months but Not Exclusive Breastfeeding at 3 Months or Timely Complementary Feeding Initiation Is Predictive of Infant Growth in Rural Bangladesh

The association between suboptimal infant feeding practices and growth faltering is well-established. However, most of this evidence comes from cross-sectional studies. To prospectively assess the association between suboptimal infant feeding practices and growth faltering, we interviewed pregnant women at 28–32 weeks’ gestation and followed-up their offspring at postnatal months 3, 9, 16 and 24 months in rural Bangladesh. Using maternal recall over the past 24 hours, exclusive breastfeeding (EBF) status at 3 months, age at complementary feeding (CF) initiation, and receipt of minimum acceptable diet (MAD; as defined by WHO) at 9 months were assessed. Infant length and weight measurements were used to produce length-for-age (LAZ) and weight-for-length (WLZ) z-scores at each follow-up. Generalized estimating equations were used to estimate associations of LAZ and WLZ with infant feeding practices. All models were adjusted for baseline SES, infant sex, maternal height, age, literacy and parity. Follow-up was completed by 2189, 2074, 1969 and 1885 mother-child dyads at 3, 9, 16 and 24 months, respectively. Stunting prevalence increased from 28% to 57% between infant age 3 and 24 months. EBF at 3 months and age at CF initiation were not associated with linear infant growth, but receipt of MAD at 9 months was. By age 24 months, infants receiving MAD had attained a higher LAZ compared to infants who did not receive MAD (adjusted β = 0.25, 95% CI: 0.13–0.37). Although prevalence of stunting was already high at age 3 months, ensuring infants receive a diverse, high quality diet from 6 months onwards may reduce rates of stunting in the second year of life.

Health Extension Workers’ Knowledge and Knowledge-Sharing Effectiveness of Optimal Infant and Young Child Feeding Are Associated With Mothers’ Knowledge and Child Stunting in Rural Ethiopia

Background:

Little is known about how the knowledge and the knowledge-sharing effectiveness (KSE) of health extension workers (HEWs) affect maternal knowledge of optimal infant and young child feeding (IYCF) and their child’s nutritional status.

Objective:

The objective of this study was to evaluate mothers’ and HEWs’ knowledge of key IYCF practices and to investigate whether mothers’ knowledge and HEWs’ KSE are associated with stunting in young children (aged 12-23 months).

Methods:

This cross-sectional study used face-to-face interviews to assess the IYCF knowledge of HEWs (n = 96) and mothers of 12- to 23-month-old children (n = 122) in Mecha district, West Gojam, Ethiopia. The association between HEWs’ KSE and children’s length-for-age z scores (LAZ) was investigated.

Results:

Stunting (50%), underweight (34%), and wasting (10%) were highly prevalent. Less than half (45%) of the mothers had access to nutrition education through the health extension program, but those who had, had better knowledge of IYCF practices and thus lower rates of stunting ( P < .001). However, key IYCF practices were not well understood by the HEWs and this affected their KSE. The gap in KSE was negatively associated with LAZ ( r = −.475, P < .001) and remained significant even after adjusting for maternal height, socioeconomic status, and maternal education ( r = −.423, P = .002).

Conclusion:

Health extension workers’ KSE is associated with child stunting. Future training of HEWs would benefit from emphasis on not only the content of the IYCF messages but also the process of delivery while increasing their counseling skills.

Strengthening health services to deliver nutrition education to promote complementary feeding and healthy growth of infants and young children: formative research for a successful intervention in peri-urban Trujillo, Peru

Formative research is critical for developing effective nutrition-specific interventions to improve infant and young child (IYC) feeding practices and promote healthy growth. Health workers interact with caregivers during health facility visits, yet there is limited research about how to optimize delivery of such interventions during these visits. The extensive reach of IYC health services globally calls for research to address this gap. In Trujillo, Peru, formative research was conducted to explore complementary feeding practices with caregivers as well as health worker routines and interactions with caregivers related to feeding and healthy growth; results informed the development and delivery of an educational intervention. Multiple qualitative methods were used to collect data on a purposive sample of health workers and caregivers from three health facilities and communities: household trials followed. Complementary feeding messages with doable behaviours were developed, and three were selected as key to promote based on their nutritional impact and cultural acceptability. In the health facilities, medical consultation, well-child visits and nutrition consultation all dealt with aspects of IYC nutrition/growth during their interactions with caregivers but were independent and inconsistent in approach. A nutrition education strategy was developed based on consistency, quality and coverage in the IYC health services. We conclude that formative research undertaken in the community and IYC health services was critical to developing a successful and culturally relevant intervention to promote optimal complementary feeding practices and healthy growth during interactions between health workers and caregivers at routine health facility visits. © 2016 John Wiley & Sons Ltd.

Feeding practices for infants and young children during and after common illness. Evidence from South Asia

Global evidence shows that children's growth deteriorates rapidly during/after illness if foods and feeding practices do not meet the additional nutrient requirements associated with illness/convalescence. To inform policies and programmes, we conducted a review of the literature published from 1990 to 2014 to document how children 0–23 months old are fed during/after common childhood illnesses. The review indicates that infant and young child feeding (IYCF) during common childhood illnesses is far from optimal. When sick, most children continue to be breastfed, but few are breastfed more frequently, as recommended. Restriction/withdrawal of complementary foods during illness is frequent because of children's anorexia (perceived/real), poor awareness of caregivers' about the feeding needs of sick children, traditional beliefs/behaviours and/or suboptimal counselling and support by health workers. As a result, many children are fed lower quantities of complementary foods and/or are fed less frequently when they are sick. Mothers/caregivers often turn to family/community elders and traditional/non‐qualified practitioners to seek advice on how to feed their sick children. Thus, traditional beliefs and behaviours guide the use of ‘special’ feeding practices, foods and diets for sick children. A significant proportion of mothers/caregivers turn to the primary health care system for support but receive little or no advice. Building the knowledge, skills and capacity of community health workers and primary health care practitioners to provide mothers/caregivers with accurate and timely information, counselling and support on IYCF during and after common childhood illnesses, combined with large‐scale communication programmes to address traditional beliefs and norms that may be harmful, is an urgent priority to reduce the high burden of child stunting in South Asia.

Community-based grain banks using local foods for improved infant and young child feeding in Ethiopia

The first thousand days of a child's life are critical for ensuring adequate nutrition to enable optimal health, development and growth. Inadequate infant and young child feeding (IYCF) practices likely contribute to Ethiopia's concerning malnutrition situation. Development partners in four regions of Ethiopia implemented community production of complementary food with women's groups processing local grains and legumes at grain banks to improve availability, accessibility, dietary diversity and timely introduction of complementary foods. The objective of this study was to establish the acceptability, perceived impact, feasibility and required inputs to sustain local grain bank interventions to improve IYCF. A subsidized barter system was used by mothers in the rural communities, and flour was sold in the semi-urban context. Purposive sampling guided the qualitative study design and selection of project stakeholders. A total of 51 key informant interviews and 33 focus group discussions (n = 237) were conducted. The grain bank flour was valued for its perceived diverse local ingredients; while the project was perceived as creating labour savings for women. The grain bank flour offered the potential to contribute to improved IYCF; however, further dietary modification or fortification is needed to improve the micronutrient content. Dependence upon external inputs to subsidize the barter model and the reliance on volunteer labour from women's groups in the rural context are the greatest risks to sustainability. This intervention illustrates how integrated agricultural and health interventions leveraging local production can appeal to diverse stakeholders as an acceptable approach to improve IYCF.

Identifying determinants of effective complementary feeding behaviour change interventions in developing countries

As stunting moves to the forefront of the global agenda, there is substantial evidence that behaviour change interventions (BCI) can improve infant feeding practices and growth. However, this evidence has not been translated into improved outcomes on a national level because we do not know enough about what makes these interventions work, for whom, when, why, at what cost and for how long. Our objective was to examine the design and implementation of complementary feeding BCI, from the peer-reviewed literature, to identify generalisable key determinants. We identified 29 studies that evaluated BCI efficacy or effectiveness, were conducted in developing countries, and reported outcomes on infant and young children aged 6-24 months. Two potential determinants emerged: (1) effective studies used formative research to identify cultural barriers and enablers to optimal feeding practices, to shape the intervention strategy, and to formulate appropriate messages and mediums for delivery; (2) effective studies delineated the programme impact pathway to the target behaviour change and assessed intermediary behaviour changes to learn what worked. We found that BCI that used these developmental and implementation processes could be effective despite heterogeneous approaches and design components. Our analysis was constrained, however, by the limited published data on how design and implementation were carried out, perhaps because of publishing space limits. Information on cost-effectiveness, sustainability and scalability was also very limited. We suggest a more comprehensive reporting process and a more strategic research agenda to enable generalisable evidence to accumulate.

The World Health Organization's global target for reducing childhood stunting by 2025: rationale and proposed actions

In 2012, the World Health Organization adopted a resolution on maternal, infant and young child nutrition that included a global target to reduce by 40% the number of stunted under-five children by 2025. The target was based on analyses of time series data from 148 countries and national success stories in tackling undernutrition. The global target translates to a 3.9% reduction per year and implies decreasing the number of stunted children from 171 million in 2010 to about 100 million in 2025. However, at current rates of progress, there will be 127 million stunted children by 2025, that is, 27 million more than the target or a reduction of only 26%. The translation of the global target into national targets needs to consider nutrition profiles, risk factor trends, demographic changes, experience with developing and implementing nutrition policies, and health system development. This paper presents a methodology to set individual country targets, without precluding the use of others. Any method applied will be influenced by country-specific population growth rates. A key question is what countries should do to meet the target. Nutrition interventions alone are almost certainly insufficient, hence the importance of ongoing efforts to foster nutrition-sensitive development and encourage development of evidence-based, multisectoral plans to address stunting at national scale, combining direct nutrition interventions with strategies concerning health, family planning, water and sanitation, and other factors that affect the risk of stunting. In addition, an accountability framework needs to be developed and surveillance systems strengthened to monitor the achievement of commitments and targets.

Multi-sectoral interventions for healthy growth

The risk of stunted growth and development is affected by the context in which a child is born and grows. This includes such interdependent influences as the political economy, health and health care, education, society and culture, agriculture and food systems, water and sanitation, and the environment. Here, we briefly review how factors linked with the key sectors can contribute to healthy growth and reduced childhood stunting. Emphasis is placed on the role of agriculture/food security, especially family farming; education, particularly of girls and women; water, sanitation, and hygiene and their integration in stunting reduction strategies; social protection including cash transfers, bearing in mind that success in this regard is linked to reducing the gap between rich and poor; economic investment in stunting reduction including the work with the for-profit commercial sector balancing risks linked to marketing foods that can displace affordable and more sustainable alternatives; health with emphasis on implementing comprehensive and effective health care interventions and building the capacity of health care providers. We complete the review with examples of national and subnational multi-sectoral interventions that illustrate how critical it is for sectors to work together to reduce stunting.