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

Multisectoral interventions for urban health in Africa: a mixed-methods systematic review

Increasing evidence suggests that urban health objectives are best achieved through a multisectoral approach. This approach requires multiple sectors to consider health and well-being as a central aspect of their policy development and implementation, recognising that numerous determinants of health lie outside (or beyond the confines of) the health sector. However, collaboration across sectors remains scarce and multisectoral interventions to support health are lacking in Africa. To address this gap in research, we conducted a mixed-method systematic review of multisectoral interventions aimed at enhancing health, with a particular focus on non-communicable diseases in urban African settings. Africa is the world's fastest urbanising region, making it a critical context in which to examine the impact of multisectoral approaches to improve health. This systematic review provides a valuable overview of current knowledge on multisectoral urban health interventions and enables the identification of existing knowledge gaps, and consequently, avenues for future research. We searched four academic databases (PubMed, Scopus, Web of Science, Global Health) for evidence dated 1989-2019 and identified grey literature from expert input. We identified 53 articles (17 quantitative, 20 qualitative, 12 mixed methods) involving collaborations across 22 sectors and 16 African countries. The principle guiding the majority of the multisectoral interventions was community health equity (39.6%), followed by healthy cities and healthy urban governance principles (32.1%). Targeted health outcomes were diverse, spanning behaviour, environmental and active participation from communities. With only 2% of all studies focusing on health equity as an outcome and with 47% of studies published by first authors located outside Africa, this review underlines the need for future research to prioritise equity both in terms of research outcomes and processes. A synthesised framework of seven interconnected components showcases an ecosystem on multisectoral interventions for urban health that can be examined in the future research in African urban settings that can benefit the health of people and the planet.Paper ContextMain findings: Multisectoral interventions were identified in 27.8% of African countries in the African Union, targeted at major cities with five sectors present at all intervention stages: academia or research, agriculture, government, health, and non-governmental.Added knowledge: We propose a synthesised framework showcasing an ecosystem on multisectoral interventions for urban health that can guide future research in African urban settings.Global health impact for policy and action: This study reveals a crucial gap in evidence on evaluating the long-term impact of multisectoral interventions and calls for partnerships involving various sectors and robust community engagement to effectively deliver and sustain health-promoting policies and actions.

Beneficiary and Local Stakeholder Participation in Community-Based Nutrition Interventions

Beneficiary and local stakeholder participation is an essential element to the success of community-based nutrition interventions. We sought to define active participation and review the available evidence on beneficiary and local stakeholder participation in community-based nutrition interventions in Africa. From reviewing the literature, we provide a reflective assessment on the process and findings. Participation falls on a continuum of community involvement from passive (no real involvement) to empowerment and community ownership (full active involvement). However, we found a clear gap in the research on defining active participation and identifying what constitutes active participation on behalf of beneficiaries and local stakeholders. However, progress was found; evidence included the use of participatory methods to engage beneficiaries and local stakeholders in the assessment and design phase. Beneficiary and local stakeholder participation in delivering interventions has moved forward with quantitative measures from process evaluation and implementation science. Research has started on the extent of beneficiary engagement (as recipients) and connecting this to outcomes. Evaluation has benefited from qualitative inquiry with insights from participants on engagement itself, and the barriers and facilitators to engagement. Yet questions remain in each study phase around defining and quantifying active participation and in understanding the personal, social, and motivational elements of active participation. We offer a simple framework to stimulate thought and commitment to research on participation in community-based nutrition interventions.

Home-Grown School Feeding: Implementation Lessons From a Pilot in a Poor Ethnic Minority Community in Vietnam

Background:

Undernutrition threatens the health and future of preschool children in disadvantaged remote communities. Home-grown school feeding (HGSF) in nursery schools could positively impact children’s nutrition while creating multiple benefits for the whole community. However, evidence is lacking on implementation of HGSF within multi-sectoral programs in remote areas.

Objective:

This study assessed an HGSF pilot intervention, part of a nutrition-sensitive agriculture (NSA) program, in a mountain ethnic minority community in Vietnam. It aimed to identify the changes brought about by the intervention, in particular diversity of children’s food, food sources, barriers and facilitators to change, and future challenges and strategies.

Methods:

Mixed-methods assessment covered school meal diversity, cost, and food sources but the key focus was on observed changes resulting from the HGSF intervention and perceived barriers and facilitators to its implementation. Data were collected mainly through semi-structured interviews (n = 30) and seven focus group discussions (n = 76).

Results:

School meals contributed to increasing diversity of food consumed by children. Above 30% of foods used were home-grown. Respondents reported increased school attendance; children’s food preferences and hygiene practices improved as did parents’ caring and feeding practices. Local food systems became less cash-crop-oriented and more self-reliant, contributing to household food security and income generation. Social capital increased. Positive changes were attributed to HGSF and synergy among NSA program components. Poverty and limited resilience to external shocks threatened sustainability.

Conclusions:

Implementing HGSF within an NSA program in a mountainous ethnic minority area with a high prevalence of undernutrition benefitted children and their communities.

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.

Determinants of adherence to micronutrient powder use among young children in Ethiopia

In Ethiopia, home fortification of complementary foods with micronutrient powders (MNPs) was introduced in 2015 as a new approach to improve micronutrient intakes. The objective of this study was to assess factors associated with intake adherence and drivers for correct MNP use over time to inform scale‐up of MNP interventions. Mixed methods including questionnaires, interviews and focus group discussions were used. Participants, 1,185 children (6–11 months), received bimonthly 30 MNP sachets for 8 months, with instruction to consume 15 sachets/month, that is, a sachet every other day and maximum of one sachet per day. Adherence to distribution (if child receives ≥14 sachets/month) and adherence to instruction (if child receives exactly 15[±1] sachets/month) were assessed monthly by counting used sachets. Factors associated with adherence were examined using generalized estimating equations. Adherence fluctuated over time, an average of 58% adherence to distribution and 28% for adherence to instruction. Average MNP consumption was 79% out of the total sachets provided. Factors positively associated with adherence included ease of use (instruction), child liking MNP and support from community (distribution and instruction) and mother's age >25 years (distribution). Distance to health post, knowledge of correct use (OR = 0.74, 95% CI = 0.66–0.81), perceived negative effects (OR = 0.73, 95% CI = 0.54–0.99) and living in Southern Nations, Nationalities and People Region (OR = 0.59, 95% CI = 0.52–0.67) were inversely associated with adherence to distribution. Free MNP provision, trust in the government and field staff played a role in successful implementation. MNP is promising to be scaled‐up, by taking into account factors that positively and negatively determine adherence.

Nutrition-Sensitive Agriculture: A Systematic Review of Impact Pathways to Nutrition Outcomes

The role of agriculture in reducing undernutrition is widely recognized, yet there is also consensus on the need to make the sector nutrition-sensitive. Evidence on the impact pathways from nutrition-sensitive agriculture (NSA) interventions, agricultural interventions with specific nutrition objectives, and actions detailing each temporal stage to reach nutrition outcomes is limited, however. We thus synthesized study results regarding impact of NSA interventions on nutrition outcomes relating to undernutrition, and constructed an impact pathway by mapping the evidence on each temporal stage from interventions to nutrition outcomes. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses to conduct and report our systematic review of studies on NSA interventions implemented in low- and lower-middle-income countries. Forty-three studies that met the inclusion criteria were extracted and synthesized across impact and pathways analyses. We carried out a thematic analysis of the effect of NSA interventions using evidence-based indicators and constructed the pathways by adopting a published framework on agriculture to nutrition pathways. Our findings reveal that NSA interventions can significantly improve dietary practices, and have the potential to enhance care practices and reduce occurrence of diseases, indicating their effectiveness in simultaneously addressing multiple determinants of undernutrition. However, NSA interventions have a lesser impact on nutritional status. NSA interventions lead to nutrition outcomes through 5 key pathways: food production, nutrition-related knowledge, agricultural income, women's empowerment, and strengthening of local institutions. We emphasize the need to carefully design, implement, and evaluate interventions with consideration for factors affecting impact pathways. Future research should focus on the effect of interventions combining multisector components, and pathways through non-food-production-related income, women's empowerment, strengthening of local institutions, food prices at intervention level, and expenditure on health care.

Effectiveness of a Program Intervention with Reduced-Iron Multiple Micronutrient Powders on Iron Status, Morbidity and Growth in Young Children in Ethiopia

Despite the potential for improving iron status and child growth in low- and middle-income settings, concerns on the safety of high iron dosages of Micronutrient Powders (MNP currently limit their applicability in programs. We examined the effectiveness and risks of an integrated complementary feeding program with low iron dose (6 mg/serving) MNP among 6–23-month-old Ethiopian children using a quasi-experimental study design comparing children from five intervention districts (n = 1172) to those from four matched non-intervention districts (n = 1137). Haemoglobin concentrations increased in intervention and decreased in non-intervention children (group-difference +3.17 g/L), but without improvement in iron stores. Intervention children were 2.31 times more likely to have diarrhoea and 2.08 times more likely to have common cold and flu, but these differences decreased towards the end of the intervention. At end line, intervention children had higher mean Height-for-Age Zscore (HAZ) and a 51% reduced odds of being stunted compared to non-intervention children. MNP with low iron dose, when provided combined with other Infant and Young Child Feeding (IYCF) interventions, marginally improved haemoglobin status and resulted in a remarkable improvement in linear growth in 6–23-month-old children. These benefits likely outweigh the relatively small increase in the risk of diarrhoea.

Mothers' groups enrich diet and culture through promoting traditional Quichua foods

Indigenous Peoples in Latin America bear a disproportionate burden of undernutrition, yet traditional foods, including wild leafy greens, can contribute nutritional value to diets. As part of a community nutrition intervention using local foods in highland Tungurahua, Ecuador, mothers' groups promoted the consumption of wild leafy greens through community cooking clubs and recipe competitions at local fairs. The objective was to assess the social, cultural, and nutritional potential of a mothers' club intervention that promoted 2 indigenous greens (stinging nettle/Urtica dioica L. and round-leaved dock/Rumex obtusifolius L.) into children's diets. Key informant interviews and focus groups were conducted with 54 mothers and 16 elders to identify perceptions of the intervention and traditional foods. Social and cultural dimensions were identified through content analysis. The nutritional contribution of the leafy greens was estimated through semiquantitative food frequency questionnaires conducted with 160 participant mothers and 98 mothers living in comparison communities who had not been exposed to the intervention. The use of local foods generated pride for mothers and elders. Nonfood uses of the nettle proved an initial barrier to acceptance; however, peer support within mothers' groups enabled increased consumption. The greens were estimated to contribute an additional 8% vitamin A, 7% iron, 12% vitamin C, and 27% folate to children's recommended dietary intakes. By promoting wild leafy greens, mothers' groups improved food security and the cultural and nutritional value of their diets. Additionally, mothers' cooking clubs increased self-efficacy and cultural identity for Quichua women, offering a highly acceptable nutrition intervention model.

Exploring barriers and enablers for scaling up a community-based grain bank intervention for improved infant and young child feeding in Ethiopia: A qualitative process evaluation

Child malnutrition remains high in Ethiopia, and inadequate complementary feeding is a contributing factor. In this context, a community‐based intervention was designed to provide locally made complementary food for children 6–23 months, using a bartering system, in four Ethiopian regions. After a pilot phase, the intervention was scaled up from 8 to 180 localities. We conducted a process evaluation to determine enablers and barriers for the scaling up of this intervention. Eight study sites were selected to perform 52 key informant interviews and 31 focus group discussions with purposely selected informants. For analysis, we used a framework describing six elements of successful scaling up: socio‐political context, attributes of the intervention, attributes of the implementers, appropriate delivery strategy, the adopting community, and use of research to inform the scale‐up process. A strong political will, alignment of the intervention with national priorities, and integration with the health care system were instrumental in the scaling up. The participatory approach in decision‐making reinforced ownership at community level, and training about complementary feeding motivated mothers and women's groups to participate. However, the management of the complex intervention, limited human resources, and lack of incentives for female volunteers proved challenging. In the bartering model, the barter rate was accepted, but the bartering was hindered by unavailability of cereals and limited financial and material resources to contribute, threatening the project's sustainability. Scaling up strategies for nutrition interventions require sufficient time, thorough planning, and assessment of the community's capacity to contribute human, financial, and material resources.

Qualitative Studies of Infant and Young Child Feeding in Lower-Income Countries: A Systematic Review and Synthesis of Dietary Patterns

Continued high rates of both under- and over-nutrition in low- and low-middle-income countries highlight the importance of understanding dietary practices such as early and exclusive breastfeeding, and dietary patterns such as timely, appropriate complementary feeding-these behaviors are rooted in complex cultural ecologies. A systematic review and synthesis of available qualitative research related to infant and young child dietary patterns and practices from the perspective of parents and families in low income settings is presented, with a focus on barriers and facilitators to achieving international recommendations. Data from both published and grey literature from 2006 to 2016 was included in the review. Quality assessment consisted of two phases (Critical Appraisal Skills Program (CASP) guidelines and assessment using GRADE-CERQual), followed by synthesis of the studies identified, and subsequent thematic analysis and interpretation. The findings indicated several categories of both barriers and facilitators, spanning individual and system level factors. The review informs efforts aimed at improving child health and nutrition, and represents the first such comprehensive review of the qualitative literature, uniquely suited to understanding complex behaviors leading to infant and young child dietary patterns.

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.