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.

Micronutrient intakes among women of reproductive age in Vietnam

BACKGROUND

Micronutrient deficiencies are a public health concern worldwide negatively affecting maternal and child health outcomes. The primary underlying causes of micronutrient deficiencies are insufficient intake and poor bioavailability of micronutrients. However, reliable data on micronutrient intakes are sparse. The objectives of this study were to identify the key local food sources providing the majority of micronutrients and assess the adequacy and determinants of micronutrient intakes.

METHODS

The study used data from a survey of 4,983 rural women of reproductive age (WRA) participating in a preconception micronutrient supplementation trial in Vietnam. Micronutrient intakes were assessed using a validated 107-item semi-quantitative food-frequency questionnaire. Multivariate linear and logistic regression analyses were used to examine the association between socioeconomic status and micronutrient intakes.

RESULTS

Starchy staples were the main source of iron and zinc (37% and 54%, respectively) with only a small proportion from meat (10% and 18%, respectively). The primary source of folate and vitamin A were vegetables; vitamin B12 came from meat and eggs. The proportion of the population with intakes below the estimated average requirement was 25% for iron, 16% for zinc, 54% for folate, 64% for vitamin B12 and 27% for vitamin A. Socioeconomic status was the main determinant of micronutrient intakes. WRA in the highest quintile consumed 26% more iron, 19% more zinc, 36% more folate, 82% more vitamin B12 and 47% more vitamin A compared to those in the lowest quintile. Women in the upper quintiles of SES were more likely to obtain nutrients from more nutritious and higher bioavailable foods than those in the lowest quintile.

CONCLUSIONS

Underprivileged women were at increased risk for insufficient micronutrient intakes due to poor diet quality. Targeted efforts to promote the consumption of local nutrient rich foods along with educational programs and social development are needed.

The positive deviance/hearth approach to reducing child malnutrition: systematic review

OBJECTIVES

The Positive Deviance/Hearth approach aims to rehabilitate malnourished children using practices from mothers in the community who have well-nourished children despite living in poverty. This study assesses its effectiveness in a range of settings.

METHODS

Systematic review of peer reviewed intervention trials and grey literature evaluation reports of child malnutrition programs using the Positive Deviance/Hearth approach.

RESULTS

Ten peer reviewed studies and 14 grey literature reports met the inclusion criteria. These described results for 17 unique Positive Deviance/Hearth programs in 12 countries. Nine programs used a pre- and post-test design without a control, which limited the conclusions that could be drawn. Eight used more robust designs such as non-randomized trials, non-randomized cross-sectional sibling studies and randomized controlled trials (RCTs). Of the eight programs that reported nutritional outcomes, five reported some type of positive result in terms of nutritional status - although the improvement was not always as large as predicted, or across the entire target population. Both the two RCTs demonstrated improvements in carer feeding practices. Qualitative results unanimously reported high levels of satisfaction from participants and recipient communities.

CONCLUSIONS

Overall this study shows mixed results in terms of program effectiveness, although some Positive Deviance/Hearth programs have clearly been successful in particular settings. Sibling studies suggest that the Positive Deviance/Hearth approach may have a role in preventing malnutrition, not just rehabilitation. Further research is needed using more robust study designs and larger sample sizes. Issues related to community participation and consistency in reporting results need to be addressed.

Using programme theory to assess the feasibility of delivering micronutrient Sprinkles through a food-assisted maternal and child health and nutrition programme in rural Haiti

This paper uses programme theory to assess, in the context of an effectiveness evaluation, the feasibility and acceptability of distributing micronutrient Sprinkles through a food-assisted maternal and child health and nutrition programme in rural Haiti. We laid out the steps related to programme delivery and household utilization of Sprinkles and used qualitative and quantitative methods to gather data on these steps. Methods included structured observations, checks of beneficiary ration cards, exit interviews, focus group discussions (FGD), individual interviews and survey data from the effectiveness evaluation. Results are as follows: (1) information on use of Sprinkles was provided before mothers first received them, as planned; (2) Sprinkles were re-packaged and distributed as planned and in the appropriate amount; (3) almost all mothers (96%) received two monthly rations of Sprinkles and received timely information on their use; (4) mothers understood instructions about use of Sprinkles and acceptance was high, and no selling of the product was reported or observed; and (5) mothers reported using Sprinkles as instructed, every day (63% in survey; 86% at exit interviews), and for the child only (99%). FGD with staff highlighted the acceptance of the intervention, with a reported 'modest' increase in workload. Within this well-established programme, it proved feasible to distribute Sprinkles and to ensure appropriate use by beneficiary mothers. Existing programme venues were suitable for distributing Sprinkles and educating mothers about their use. Use of programme theory helped to assess feasibility and acceptability of the Sprinkles intervention and provided useful information for programme replication or scale-up.

Growth monitoring and promotion: review of evidence of impact

Table of Contents Summary 86  1. Background 88  1.1 History and development of growth monitoring programmes 88  1.2 Objectives of growth monitoring 89  2. Expected benefits of growth monitoring and growth promotion 90  3. Objectives of this review 91  4. Methodology 91  5. Evidence of effectiveness of growth monitoring programmes 91  5.1 Nutritional status and mortality of young children 91   5.1.1 Studies before 1990 91   5.1.2 Studies since 1990 96  5.2 Utilization of primary health services 103  6. Quality of implementation 104  7. Caregivers' knowledge and understanding of growth charts 105  8. Empowerment and community mobilization 106  9. Coverage and attendance 107 10. Potential consequences if withdrawn 108 11. Feasibility and conditions under which growth monitoring and promotion can be expected to work 108 12. Cost‐effectiveness 109 13. Potential adverse consequences 109 14. Policy considerations and recommendations 110 References 113

Summary

The rationale for growth monitoring and promotion is persuasive but even in the 1980s the appropriateness of growth monitoring programmes was being questioned. The concerns centred largely around low participation rates, poor health worker performance and inadequacies in health system infrastructure that constrained effective growth‐promoting action. More recently there has been a call for a general review of the impact of large‐scale growth monitoring and promotion programmes to determine if the investments are justified. The launch of the new World Health Organization growth standard and charts has been a timely reminder of this debate. It is within this context that this review has been undertaken: the main purpose is to analyse the evidence that growth monitoring programmes are effective in conferring measurable benefits to the children for whom growth charts are kept. The benefits considered here are improved nutritional status, increased utilization of health services and reductions in mortality.

There is evidence from small‐scale studies in Nigeria, Jamaica, India (Narangwal and Jamkhed), and from large programmes in Tanzania (Iringa), India (Tamil Nadu Integrated Nutrition Project), Madagascar and Senegal that children whose growth is monitored and whose mothers receive nutrition and health education and have access to basic child health services have a better nutritional status and/or survival than children who do not. There is tentative evidence from a large‐scale programme in Brazil (Ceara) that participation in growth monitoring confers a significant benefit on nutritional status independent of immunization and socio‐economic status. There is evidence from India (Integrated Child Development Services) and Bangladesh (Bangladesh Rural Advancement Committee and Bangladesh Integrated Nutrition Project) that growth monitoring has little or no effect on nutritional status in large‐scale programmes with weak nutrition counselling. There is evidence from Tamil Nadu in a randomized trial that when mothers are visited fortnightly at home and have unhurried counselling, no additional benefit accrues from the visual depiction of growth on a chart. There is some evidence that growth monitoring can improve utilization of health services.

Although there is no unequivocal evidence that growth monitoring is beneficial per se , it was perceived to be beneficial by the investigators of several of the studies described in this review. Growth monitoring can provide an entry point to preventive and curative health care and was an integral part of programmes that were associated with significant reductions in malnutrition and mortality. Good nutrition counselling is paramount for growth promotion and is often done badly. Effort must be made to improve this and provide age‐appropriate advice to achieve exclusive breastfeeding and appropriate complementary feeding, irrespective of decisions about growth monitoring. This review highlights the paucity of rigorous trials to determine the impact of growth monitoring separately from the impact of growth promotion. There is no controversy about the need for growth‐promotion activities, and weighing children is desirable to assess health and nutrition status. The debatable question is whether weights need to be monitored monthly and plotted on a chart. Even if there is a policy for growth monitoring, if a child has grown well in the first year of life then it would appear that little is gained by monitoring weight beyond the age of 12 months, and that the time spent monitoring older children might be better spent improving the counselling given to caregivers of infants.

Growth monitoring may not be the best use of limited resources in countries with weak economies and inadequate health budgets: a limited package of health and nutrition interventions including good nutrition counselling may be preferable, aiming for good coverage and effective health worker performance, and prioritizing infants and children <18 months of age. Two of the potential strengths of growth monitoring are that it provides frequent contact with health workers and a conduit to child health interventions. Taking into account the evidence from recent nutrition education interventions in India and Peru that used multiple delivery channels within routine health services, possible options to consider for the future are:

• If growth monitoring is not in place, then focus efforts on growth‐promotion activities and consider counselling caregivers intensively at all child health contacts and through home visits by community health workers or volunteers. Where possible chart weights at birth, immunization (6, 10, 14 weeks and 9 months), vitamin A distribution and sick‐child visits. Follow up and counsel any whose weight is faltering and those with a weight‐for‐age <−2 SD. • Where growth monitoring exists but the coverage is low or there is little potential for improvement, then consider abandoning it and re‐focus efforts on growth‐promotion activities as described above. • Where growth monitoring and promotion programmes currently exist and there is potential for improvement, then maximize their potential, strengthen the nutrition counselling elements, combine growth monitoring with other health intervention channels such as immunization for the convenience of caregivers, and ensure consistent message delivery. Target younger children and use the time gained to improve services. Monitor weight until 12 months of age. If there are episodes of growth faltering, continue to monitor until 18 months. Where cultural traditions and conditions are favourable, use growth monitoring additionally for community mobilization to address underlying socio‐economic and other causes of poor nutrition and health.

Scaling up from successful small‐scale growth monitoring and promotion programmes to effective national programmes will require political commitment, investment, extensive capacity building and strengthening of health systems. Training, supervision and support will need to be improved if health workers are to be equipped with the necessary knowledge and communication skills to promote healthy growth. Impact will be related to coverage, intensity of contact, health worker performance, adequacy of resources and the ability and motivation of families to follow advice.

A longitudinal assessment of the diet and growth of malnourished children participating in nutrition rehabilitation centres in Accra, Ghana

Objective:

To examine the adoption of feeding recommendations among caregivers of children recuperating from malnutrition and assess the determinants of growth of children attending a nutrition rehabilitation centre (NRC) in Accra, Ghana.

Design:

Longitudinal study in which attendance and maternal programme participation were recorded daily and children's anthropometry and dietary intake were measured at four time points (admission, interim, exit, post-exit) at the NRC and participants' homes.

Setting:

NRCs at four polyclinics and participants' homes in Accra, Ghana.

Subjects:

One hundred and eight caregivers and their 116 children referred to an NRC between November 1999 and July 2000.

Results:

Most caregivers attended the NRC sporadically (effective length of stay was 1.4 ± 0.1 months). Use of NRC-promoted foods in the home after discharge was low due to inaccessibility of the food items, lack of preparation knowledge or money, child preferences and the common practice of purchasing ready-to-eat foods. Although there were significant increases in children's weight-for-age (P = 0.048) and weight-for-height (P = 0.002) Z-scores between enrolment and discharge, most children discontinued programme participation before adequate recuperation.

Conclusions:

The NRC education did not address the use of street foods for child feeding and was unsuccessful in changing in-home feeding behaviour. The prominence of street foods in children's diets warrants re-evaluation of the NRC's educational approaches to enhance their responsiveness to caregivers' needs and effectiveness for the continued recuperation of malnourished children at home. NRC feeding strategies need improvement to ensure adequate provision of energy and nutrients to support catch-up growth in children.

Process evaluation determines the pathway of success for a health center-delivered, nutrition education intervention for infants in Trujillo, Peru

Process evaluation was used to explain the success of a randomized, controlled trial of an educational intervention to improve the feeding behaviors of caregivers and the nutritional status of infants in Trujillo, Peru. Health personnel delivered a multicomponent intervention within the environment of usual care at government health centers. We created a model of the expected intervention pathway to successful outcomes. Process data were then collected on health center implementation of the intervention and caregiver reception to it. Using multivariate models, we found that variables of health center implementation, caregiver exposure, and caregiver message recall were all significant determinants in the pathway leading to improved feeding behaviors. These outcomes were consistent with our original intervention model. Further support for our model arose from the differences in caregiver reception between intervention and control centers. Process data allowed us to characterize the pathway through which an effective nutrition intervention operated. This study underscores the importance of including process evaluation, which will lead to the development and implementation of more effective nutrition interventions.