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Michaud-Létourneau I, Gayard M, Wassef J, Likhite N, Tharaney M, Cissé AS, Le Dain AS, Laillou A, Zafimanjaka MG, Kiburente M, Bambara E, Kim SS, Menon P. "Stronger with Breastmilk Only" Initiative in 5 African Countries: Case Study on the Implementation Process and Contribution to the Enabling Environment for Breastfeeding. Curr Dev Nutr 2023; 7:101988. [PMID: 37736401 PMCID: PMC10509664 DOI: 10.1016/j.cdnut.2023.101988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 09/23/2023] Open
Abstract
Background The practice of giving water before 6 mo of age is the biggest barrier to exclusive breastfeeding in West and Central Africa. To address this challenge, a regional initiative, "Stronger with Breastmilk Only" (SWBO), was rolled out at country level in several countries of the region. Objective We examined the implementation process of the SWBO initiative and the contribution of its advocacy component to a more supportive environment for breastfeeding policies and programs. Methods This study was based on 2 assessments at the national level carried out in 5 countries (Burkina Faso, Chad, Democratic Republic of the Congo, Senegal, and Sierra Leone) using qualitative methods. We combined 2 evaluative approaches (contribution analysis and outcome harvesting) and applied 2 theoretical lenses (Breastfeeding Gear Model and Consolidated Framework for Implementation Research) to examine the implementation process and the enabling environment for breastfeeding. Data sources included ∼300 documents related to the initiative and 43 key informant interviews collected between early 2021 and mid-2022. Results First, we show how a broad initiative composed of a set of combined interventions targeting multiple levels of determinants of breastfeeding was set up and implemented. All countries went through a similar pattern of activities for the implementation process. Second, we illustrate that the initiative was able to foster an enabling environment for breastfeeding. Progress was achieved notably on legislation and policies, coordination, funding, training and program delivery, and research and evaluation. Third, through a detailed contribution story of the case of Burkina Faso, we illustrate more precisely how the initiative, specifically its advocacy component, contributed to this progress. Conclusion This study shed light on how an initiative combining a set of interventions to address determinants of breastfeeding at multiple levels can be implemented regionally and contributes to fostering an enabling environment for breastfeeding at scale.
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Affiliation(s)
- Isabelle Michaud-Létourneau
- Society for Implementation Science in Nutrition, Washington DC, USA
- Département de médecine sociale et préventive, École de santé publique, Université de Montréal, Montréal, Québec, Canada
| | - Marion Gayard
- Society for Implementation Science in Nutrition, Washington DC, USA
| | - Jacqueline Wassef
- Society for Implementation Science in Nutrition, Washington DC, USA
- Département de médecine sociale et préventive, École de santé publique, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | | | | | | | | | - Estelle Bambara
- Direction de la Nutrition, Ministère de la santé, Ouagadougou, Burkina Faso
| | - Sunny S. Kim
- International Food Policy Research Institute, Washington DC, USA
| | - Purnima Menon
- International Food Policy Research Institute, Washington DC, USA
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Prost A, Harris‐Fry H, Mohanty S, Parida M, Krishnan S, Fivian E, Rath S, Nair N, Mishra NK, Padhan S, Pradhan R, Sahu S, Skordis J, Danton H, Koniz‐Booher P, Beaumont E, James P, Allen E, Elbourne D, Kadiyala S. Understanding the effects of nutrition‐sensitive agriculture interventions with participatory videos and women's group meetings on maternal and child nutrition in rural Odisha, India: A mixed‐methods process evaluation. MATERNAL & CHILD NUTRITION 2022; 18:e13398. [PMID: 35851750 PMCID: PMC9480959 DOI: 10.1111/mcn.13398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 05/14/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022]
Abstract
A trial of three nutrition‐sensitive agriculture interventions with participatory videos and women's group meetings in rural Odisha, India, found improvements in maternal and child dietary diversity, limited effects on agricultural production, and no effects on women and children's nutritional status. Our process evaluation explored fidelity, reach, and mechanisms behind interventions' effects. We also examined how context affected implementation, mechanisms, and outcomes. We used data from intervention monitoring systems, review notes, trial surveys, 32 case studies with families (n = 91 family members), and 20 group discussions with women's group members and intervention workers (n = 181 and 32, respectively). We found that interventions were implemented with high fidelity. Groups reached around half of the mothers of children under 2 years. Videos and meetings increased women's knowledge, motivation and confidence to suggest or make changes to their diets and agricultural production. Families responded in diverse ways. Many adopted or improved rainfed homestead garden cultivation for consumption, which could explain gains in maternal and child dietary diversity seen in the impact evaluation. Cultivation for income was less common. This was often due to small landholdings, poor access to irrigation and decision‐making dominated by men. Interventions helped change norms about heavy work during pregnancy, but young women with little family support still did considerable work. Women's ability to shape cultivation, income and workload decisions was strongly influenced by support from male relatives. Future nutrition‐sensitive agriculture interventions could include additional flexibility to address families’ land, water, labour and time constraints, as well as actively engage with spouses and in‐laws. In rural eastern India, participatory videos and women's group meetings on agriculture and maternal and child nutrition increased women's knowledge, motivation and confidence to improve their and their children's diets. Given strong constraints linked to small landholdings, poor access to water and gender norms which meant that in‐laws' and husbands' assent or support were often required for cultivation decisions, many women responded to interventions by increasing rainfed homestead garden cultivation for consumption rather than cultivating for income. Women's and children's diets may have improved because of discussions about nutrition and an increase in homestead garden cultivation. These dietary changes alone were likely insufficient to improve women's and children's nutritional status. The interventions’ ability to influence the adoption of nutrition‐sensitive agriculture practices could be improved by being family‐centric: understanding women's decision‐making power in a family context, using tailored problem‐solving to address households' individual constraints to cultivation, and including women's husbands and in‐laws.
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Affiliation(s)
- Audrey Prost
- Institute for Global Health University College London London UK
| | - Helen Harris‐Fry
- Department of Population Health London School of Hygiene & Tropical Medicine London UK
| | | | | | - Sneha Krishnan
- Jindal School of Environment and Sustainability Jindal Global University Haryana India
| | - Emily Fivian
- Department of Population Health London School of Hygiene & Tropical Medicine London UK
| | | | | | - Naba K. Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT) Kendrapara India
| | - Shibanath Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT) Kendrapara India
| | | | | | - Jolene Skordis
- Institute for Global Health University College London London UK
| | - Heather Danton
- JSI Research & Training Institute, Inc. Arlington Virginia USA
| | | | - Emma Beaumont
- Department of Medical Statistics London School of Hygiene & Tropical Medicine London UK
| | - Philip James
- Department of Population Health London School of Hygiene & Tropical Medicine London UK
| | - Elizabeth Allen
- Department of Medical Statistics London School of Hygiene & Tropical Medicine London UK
| | - Diana Elbourne
- Department of Medical Statistics London School of Hygiene & Tropical Medicine London UK
| | - Suneetha Kadiyala
- Department of Population Health London School of Hygiene & Tropical Medicine London UK
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3
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Mihrshahi S, Ara G, Khanam M, Rasheed S, Agho KE, Kabir AI, Roy SK, Haider R, Derakhshani Hamadani J, Tofail F, Alam A, Dibley MJ. The Shishu Pushti Trial-Extended Peer Counseling for Improving Feeding Practices and Reducing Undernutrition in Children Aged 0-48 Months in Urban Bangladesh: Protocol for a Cluster-Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e31475. [PMID: 35129457 PMCID: PMC8861872 DOI: 10.2196/31475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/08/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The aim of this study is to assess if peer counseling of women improves breastfeeding, complementary feeding practices, and child growth, and thus reduces the prevalence of undernutrition in children up to 4 years of age. OBJECTIVE Lack of exclusive breastfeeding and inappropriate complementary feeding are critical factors in reducing child undernutrition, morbidity, and mortality. There are reported trials of peer counseling to improve breastfeeding; however, they did not examine the efficacy of peer counseling to improve complementary feeding or the long-term impacts on child growth and development. METHODS This study has used a community-based, cluster-randomized controlled trial with a superiority design and 2 parallel treatment arms. It is assessing the impact of peer counseling, starting in late pregnancy up to 1 year after delivery, on child feeding practices, growth, and development with follow-up until 48 months of age. The study site was Mirpur, a densely populated area in Dhaka. Using satellite maps and geographic information system mapping, we constructed 36 clusters with an average population of 5000 people. We recruited pregnant women in the third trimester aged 16-40 years, with no more than 3 living children. Trained peer counselors visited women at home twice before delivery, 4 times in the first month, monthly from 2 to 6 months, and again at 9 and 12 months. Trained research assistants collected anthropometric measurements. The primary outcome will be differences in child stunting and mean length for age at 6, 12, 15, and 18 months. Secondary outcomes will be differences in the percentage of women exclusively breastfeeding in the mean duration of any breastfeeding and in the percentage of children at 6 and 9 months of age who receive solid, semisolid, or soft foods; and the percentage of children consuming foods from 4 or more food groups at 9, 12, 15, and 18 months. We will assess the mean cognitive function scores from the Ages and Stages Questionnaire (9 and 18 months) and Bayley tests (24 and 36 months). RESULTS We identified 65,535 people in mapped residences, from which we defined 36 clusters and randomly allocated them equally to intervention or control groups stratified by cluster socioeconomic status. From July 2011 to May 2013, we identified 1056 pregnant women and 993 births in the intervention group and 994 pregnancies and 890 births in the control group. At 18 months, 692 children remained in the intervention group and 551 in the control group. From January 2015 to February 2017, we conducted the long-term follow-up of the cohort. We have now completed the data collection and processing and have started analyses. CONCLUSIONS This study will help fill the evidence gap about the short- and long-term impact of peer counseling on improving infant feeding, preventing childhood undernutrition, and enhancing child cognitive development. TRIAL REGISTRATION ClinicalTrials.gov NCT01333995; https://clinicaltrials.gov/ct2/show/NCT01333995. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/31475.
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Affiliation(s)
- Seema Mihrshahi
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, Australia.,Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Gulshan Ara
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mansura Khanam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sabrina Rasheed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | | | - S K Roy
- Bangladesh Breastfeeding Foundation, Institute of Public Health, Dhaka, Bangladesh
| | - Rukhsana Haider
- Training and Assistance for Health and Nutrition Foundation, Dhaka, Bangladesh
| | - Jena Derakhshani Hamadani
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Fahmida Tofail
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Ashraful Alam
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Michael J Dibley
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
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4
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Moucheraud C, Epstein A, Sarma H, Kim SS, Nguyen PH, Rahman M, Tariquijaman M, Glenn J, Payán DD, Menon P, Bossert TJ. Assessing sustainment of health worker outcomes beyond program end: Evaluation results from an infant and young child feeding intervention in Bangladesh. FRONTIERS IN HEALTH SERVICES 2022; 2:1005986. [PMID: 36925817 PMCID: PMC10012630 DOI: 10.3389/frhs.2022.1005986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/15/2022] [Indexed: 01/11/2023]
Abstract
Introduction Alive and Thrive (A&T) implemented infant and young child feeding (IYCF) interventions in Bangladesh. We examine the sustained impacts on health workers' IYCF knowledge, service delivery, job satisfaction, and job readiness three years after the program's conclusion. Methods We use data from a cluster-randomized controlled trial design, including repeated cross-sectional surveys with health workers in 2010 (baseline, n = 290), 2014 (endline, n = 511) and 2017 (post-endline, n = 600). Health workers in 10 sub-districts were trained and incentivized to deliver intensified IYCF counseling, and participated in social mobilization activities, while health workers in 10 comparison sub-districts delivered standard counseling activities. Accompanying mass media and policy change activities occurred at the national level. The primary outcome is quality of IYCF service delivery (number of IYCF messages reportedly communicated during counseling); intermediate outcomes are IYCF knowledge, job satisfaction, and job readiness. We also assess the role of hypothesized modifiers of program sustainment, i.e. activities of the program: comprehensiveness of refresher trainings and receipt of financial incentives. Multivariable difference-in-difference linear regression models, including worker characteristic covariates and adjusted for clustering at the survey sampling level, are used to compare differences between groups (intervention vs. comparison areas) and over time (baseline, endline, post-endline). Results At endline, health workers in intervention areas discussed significantly more IYCF topics than those in comparison areas (4.9 vs. 4.0 topics, p < 0.001), but levels decreased and the post-endline gap was no longer significant (4.0 vs. 3.3 topics, p = 0.067). Comprehensive refresher trainings were protective against deterioration in service delivery. Between baseline and endline, the intervention increased health workers' knowledge (3.5-point increase in knowledge scores in intervention areas, vs. 1.5-point increase in comparison areas, p < 0.0001); and this improvement persisted to post-endline, suggesting a sustained program effect on knowledge. Job satisfaction and readiness both saw improvements among workers in intervention areas during the project period (baseline to endline) but regressed to a similar level as comparison areas by post-endline. Discussion Our study showed sustained impact of IYCF interventions on health workers' knowledge, but not job satisfaction or job readiness-and, critically, no sustained program effect on service delivery. Programs of limited duration may seek to assess the status of and invest in protective factors identified in this study (e.g., refresher trainings) to encourage sustained impact of improved service delivery. Studies should also prioritize collecting post-endline data to empirically test and refine concepts of sustainment.
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Affiliation(s)
- Corrina Moucheraud
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States
| | - Adrienne Epstein
- Department of Vector Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Haribondhu Sarma
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Sunny S Kim
- International Food Policy Research Institute, Washington, DC, United States
| | - Phuong Hong Nguyen
- International Food Policy Research Institute, Washington, DC, United States
| | - Mahfuzur Rahman
- International Centre for Diarrhoeal Disease Research (ICDDR), Dhaka, Bangladesh
| | - Md Tariquijaman
- International Centre for Diarrhoeal Disease Research (ICDDR), Dhaka, Bangladesh
| | - Jeffrey Glenn
- Department of Public Health, Brigham Young University, Provo, UT, United States
| | - Denise D Payán
- Department of Health, Society, and Behavior, University of California, Irvine, CA, United States
| | - Purnima Menon
- International Food Policy Research Institute, New Delhi, India
| | - Thomas J Bossert
- School of Public Health, Harvard University, Boston, MA, United States
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5
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Payán DD, Zahid N, Glenn J, Tran HTT, Huong TTT, Moucheraud C. Implementation of two policies to extend maternity leave and further restrict marketing of breast milk substitutes in Vietnam: a qualitative study. Health Policy Plan 2021; 37:472-482. [PMID: 34536274 PMCID: PMC9006067 DOI: 10.1093/heapol/czab116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 02/03/2023] Open
Abstract
Policy research can reveal gaps and opportunities to enhance policy impact and implementation. In this study, we use a theoretically informed qualitative approach to investigate the implementation of two policies to promote breastfeeding in Vietnam. We conducted semi-structured interviews with national and local policy stakeholders (n = 26) in 2017. Interviews were audio-recorded, transcribed verbatim and then translated to English by certified translators. Transcript data were analysed using an integrated conceptual framework of policy implementation. Respondents identified several positive outcomes resulting from implementation of an extended maternity leave policy (Labour Code No. 10/2012/QH13) and further restrictions on marketing of breast milk substitutes (Decree No. 100/2014/ND-CP). Decree No. 100, in particular, was said to have reduced advertising of breast milk substitutes in mass media outlets and healthcare settings. Key implementation actors were national-level bureaucratic actors, local organizations and international partners. Findings reveal the importance of policy precedence and a broader set of policies to promote the rights of women and children to support implementation. Other facilitators were involvement from national-level implementing agencies and healthcare personnel and strength of government relationships and coordination with non-governmental and international organizations. Implementation challenges included insufficient funding, limited training to report violations, a cumbersome reporting process and pervasive misinformation about breast milk and breast milk substitutes. Limited reach for women employed in the informal labour sector and in rural communities was said to be a compatibility issue for the extended maternity leave policy in addition to the lack of impact on non-parental guardians and caretakers. Recommendations to improve policy implementation include designating a role for international organizations in supporting implementation, expanding maternity protections for all working women, building local-level policy knowledge to support enforcement, simplifying Decree No. 100 violation reporting processes and continuing to invest in interventions to facilitate a supportive policy environment in Vietnam.
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Affiliation(s)
- Denise Diaz Payán
- *Corresponding author. Department of Public Health, Social Sciences, Humanities and Arts (SSHA), University of California Merced, 5200 N Lake Road, Merced, CA 95343, USA. E-mail:
| | - Neha Zahid
- Department of Public Health, School of Social Sciences, Humanities and Arts, University of California Merced, 5200 N Lake Road, Merced, CA 95343, USA
| | - Jeffrey Glenn
- Department of Public Health, College of Life Sciences, Brigham Young University, 4103 LSB, Provo, UT 84602, USA
| | - Ha TT Tran
- Research and Training Centre for Community Development (RTCCD), No 39 Lane 255, Vong Street, Hai Ba Trung District, Hanoi, Vietnam
| | - Tran Thi Thu Huong
- Research and Training Centre for Community Development (RTCCD), No 39 Lane 255, Vong Street, Hai Ba Trung District, Hanoi, Vietnam
| | - Corrina Moucheraud
- Department of Health Policy and Management, University of California Los Angeles, Fielding School of Public Health, 650 Charles E. Young Dr. South, Los Angeles, CA 90095-1772, USA
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6
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Frongillo EA. Designing and implementing at-scale programs to improve complementary feeding. Nutr Rev 2021; 78:62-70. [PMID: 33196087 DOI: 10.1093/nutrit/nuz043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Advancing knowledge about how to improve complementary feeding at large scale is a high priority. This article identifies strategies for designing and implementing programs to improve complementary feeding at large scale, drawing on lessons learned from three initiatives: Alive & Thrive, which implemented large-scale programs in 3 countries; a low-burden intervention in Mexico that used scripted messages; and Estrategia Integral de Atención a la Nutrición, which is introducing large-scale programs tied to Mexico's conditional cash transfer program. These initiatives illustrate different ways of designing and implementing large-scale programs, with lessons about the importance of having partnerships and alliances; well-grounded understanding from research; a public health strategy; scalable program modes and elements; using existing systems where possible; monitoring, learning, and evaluating; and adopting a model aimed at successfully implementing programs at scale. Improving complementary feeding globally is challenging because of the complex behaviors involved, and the development of specific programs geared to complementary feeding is necessary. Designing and implementing such specific programs at large scale is achievable with the intention, commitment, appropriate strategies, and financial support to do so from the outset.
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Affiliation(s)
- Edward A Frongillo
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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7
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Moucheraud C, Sarma H, Ha TTT, Ahmed T, Epstein A, Glenn J, Hanh HH, Huong TTT, Luies SK, Moitry AN, Nhung DP, Payán DD, Rahman M, Tariqujjaman M, Thuy TT, Tuan T, Bossert TJ, Kruk ME. Can complex programs be sustained? A mixed methods sustainability evaluation of a national infant and young child feeding program in Bangladesh and Vietnam. BMC Public Health 2020; 20:1361. [PMID: 32887601 PMCID: PMC7487916 DOI: 10.1186/s12889-020-09438-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 08/24/2020] [Indexed: 12/05/2022] Open
Abstract
Background Poor early-life nutrition is a major barrier to good health and cognitive development, and is a global health priority. Alive & Thrive (A&T) was a multi-pronged initiative to improve infant and young child feeding behaviors. It aimed to achieve at-scale child health and nutrition improvements via a comprehensive approach that included nutrition counseling by health workers, policy change, social mobilization and mass media activities. This study evaluated the sustainability of activities introduced during A&T implementation (2009–2014) in Bangladesh and Vietnam. Methods This was a mixed methods study that used a quasi-experimental design. Quantitative data (surveys with 668 health workers, and 269 service observations) were collected in 2017; and analysis compared outcomes (primarily dose and fidelity of activities, and capacity) in former A&T intervention areas versus areas that did not receive the full A&T intervention. Additionally, we conducted interviews and focus groups with 218 stakeholders to explore their impressions about the determinants of sustainability, based on a multi-level conceptual framework. Results After program conclusion, stakeholders perceive declines in mass media campaigns, policy and advocacy activities, and social mobilization activities – but counseling activities were institutionalized and continued in both countries. Quantitative data show a persisting modest intervention effect: health workers in intervention areas had significantly higher child feeding knowledge, and in Bangladesh greater self-efficacy and job satisfaction, compared to their counterparts who did not receive the full package of A&T activities. While elements of the program were integrated into routine services, stakeholders noted dilution of the program focus due to competing priorities. Qualitative data suggest that some elements, such as training, monitoring, and evaluation, which were seen as essential to A&T’s success, have declined in frequency, quality, coverage, or were eliminated altogether. Conclusions The inclusion of multiple activities in A&T and efforts to integrate the program into existing institutions were seen as crucial to its success but also made it difficult to sustain, particularly given unstable financial support and human resource constraints. Future complex programs should carefully plan for institutionalization in advance of the program by cultivating champions across the health system, and designing unique and complementary roles for all stakeholders including donors.
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Affiliation(s)
- Corrina Moucheraud
- University of California Los Angeles, Fielding School of Public Health, 650 Charles E. Young Dr. S, Los Angeles, CA, 90095, USA.
| | - Haribondhu Sarma
- icddr,b, Nutrition and Clinical Services Division, Dhaka, Bangladesh
| | - Tran Thi Thu Ha
- Research and Training Centre for Community Development (RTCCD), Hanoi, Vietnam
| | - Tahmeed Ahmed
- icddr,b, Nutrition and Clinical Services Division, Dhaka, Bangladesh
| | - Adrienne Epstein
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Present Address: University of California San Francisco School of Medicine, San Francisco, USA
| | - Jeffrey Glenn
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Present Address: Brigham Young University College of Life Sciences, Provo, USA
| | - Hoang Hong Hanh
- Research and Training Centre for Community Development (RTCCD), Hanoi, Vietnam
| | - Tran Thi Thu Huong
- Research and Training Centre for Community Development (RTCCD), Hanoi, Vietnam
| | | | | | - Doan Phuong Nhung
- Research and Training Centre for Community Development (RTCCD), Hanoi, Vietnam
| | - Denise Diaz Payán
- University of California Los Angeles, Fielding School of Public Health, 650 Charles E. Young Dr. S, Los Angeles, CA, 90095, USA.,Present Address: University of California Merced, Department of Public Health, San Francisco, USA
| | - Mahfuzur Rahman
- icddr,b, Nutrition and Clinical Services Division, Dhaka, Bangladesh
| | - Md Tariqujjaman
- icddr,b, Nutrition and Clinical Services Division, Dhaka, Bangladesh
| | - Tran Thi Thuy
- Research and Training Centre for Community Development (RTCCD), Hanoi, Vietnam
| | - Tran Tuan
- Research and Training Centre for Community Development (RTCCD), Hanoi, Vietnam
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8
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Ambikapathi R, Passarelli S, Madzorera I, Canavan CR, Noor RA, Abdelmenan S, Tewahido D, Tadesse AW, Sibanda L, Sibanda S, Munthali B, Madzivhandila T, Berhane Y, Fawzi W, Gunaratna NS. Men's nutrition knowledge is important for women's and children's nutrition in Ethiopia. MATERNAL AND CHILD NUTRITION 2020; 17:e13062. [PMID: 32755057 PMCID: PMC7729551 DOI: 10.1111/mcn.13062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 12/12/2022]
Abstract
In an effort to address undernutrition among women and children in rural areas of low‐income countries, nutrition‐sensitive agriculture (NSA) and behaviour change communication (BCC) projects heavily focus on women as an entry point to effect nutritional outcomes. There is limited evidence on the role of men's contribution in improving household diets. In this Agriculture to Nutrition trial (Clinicaltrials.gov identifier: NCT03152227), we explored associations between men's and women's nutritional knowledge on households', children's and women's dietary diversity. At the midline evaluation conducted in July 2017, FAO's nutrition knowledge questionnaire was administered to male and female partners in 1396 households. There was a high degree of agreement (88%) on knowledge about exclusive breastfeeding between parents; however, only 56–66% of the households had agreement when comparing knowledge of dietary sources of vitamin A or iron. Factor analysis of knowledge dimensions resulted in identifying two domains, namely, ‘dietary’ and ‘vitamin’ knowledge. Dietary knowledge had a larger effect on women's and children's dietary diversities than vitamin knowledge. Men's dietary knowledge had strong positive associations with households' dietary diversity scores (0.24, P value = 0.001), children's dietary diversity (0.19, P value = 0.008) and women's dietary diversity (0.18, P value < 0.001). Distance to markets and men's education levels modified the effects of nutrition knowledge on dietary diversity. While previous NSA and BCC interventions predominantly focused on uptake among women, there is a large gap and strong potential for men’s engagement in improving household nutrition. Interventions that expand the role of men in NSA may synergistically improve household nutrition outcomes.
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Affiliation(s)
- Ramya Ambikapathi
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA.,Department of Public Health, Purdue University, West Lafayette, Indiana, USA
| | - Simone Passarelli
- Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Isabel Madzorera
- Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Chelsey R Canavan
- Departments of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ramadhani A Noor
- Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | | | - Lindiwe Sibanda
- Food, Agriculture and Natural Resources Policy Analysis Network, Pretoria, South Africa
| | - Simbarashe Sibanda
- Food, Agriculture and Natural Resources Policy Analysis Network, Pretoria, South Africa
| | - Bertha Munthali
- Food, Agriculture and Natural Resources Policy Analysis Network, Pretoria, South Africa
| | | | - Yemane Berhane
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Wafaie Fawzi
- Departments of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Departments of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Departments of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nilupa S Gunaratna
- Department of Public Health, Purdue University, West Lafayette, Indiana, USA
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Savy M, Briaux J, Seye M, Douti MP, Perrotin G, Martin-Prevel Y. Tailoring Process and Impact Evaluation of a "Cash-Plus" Program: The Value of Using a Participatory Program Impact Pathway Analysis. Curr Dev Nutr 2020; 4:nzaa099. [PMID: 32666032 PMCID: PMC7326474 DOI: 10.1093/cdn/nzaa099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/15/2020] [Accepted: 05/22/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Evaluations are often limited to affirming what impact health and nutrition interventions have, without providing enough insights into "how/why" impacts are achieved. OBJECTIVES This article describes how a Program Impact Pathway (PIP) analysis was used to tailor theory-driven impact and process evaluation of a "Cash-Plus" program combining unconditional cash transfers with behavior change communication (BCC) activities, which was implemented to improve children's growth in Togo. METHODS A theoretical PIP diagram was developed using existing literature, program documentation, and interviews with the program's stakeholders at the central level. Next, the PIP diagram was refined through 2 regional participatory workshops, 6 mo after the program began. Workshop participants were multilevel field implementers and were asked to 1) discuss their vision of the program's objectives; 2) describe the "inputs-process-outputs-outcomes-impacts" flow; 3) reflect on modifiers that may arise along the PIP; and 4) report bottlenecks in the program's conception or implementation and suggest corrective actions. The PIP was used to determine research questions that should be investigated during impact or process evaluation and guided the choice of data collection methods and tools. RESULTS The PIP analysis identified 3 impact pathways, all based on the synergy between cash and raised women's knowledge. Along these pathways, the motivation and workload of frontline workers, along with issues in cash flow, were identified as factors that may affect the delivery of activities, whereas women's control over resources, time availability, support from relatives, and the presence of markets and health and school services were recognized as factors that may influence the uptake of activities. Improved communication between stakeholders and increased involvement of husbands were suggested for better impact achievement. CONCLUSIONS The participatory PIP analysis helped implementers and evaluators to share a common vision of the program's objective and logic, encouraged communication across sectors, and facilitated course-adjustments of the program.
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Affiliation(s)
- Mathilde Savy
- UMR NUTRIPASS, French Research Institute for Sustainable Development, University of Montpellier/SupAgro, Montpellier, France
| | - Justine Briaux
- UMR NUTRIPASS, French Research Institute for Sustainable Development, University of Montpellier/SupAgro, Montpellier, France
- UMR 1219 Bordeaux Population Health Research Center, team IDLIC, French Institute of Health and Medical Research, University of Bordeaux, Bordeaux, France
| | - Moustapha Seye
- Laboratoire de Recherche sur les Transformations Economiques et Sociales, Laboratoires de l'Institut Fondamental d'Afrique Noire, University of Dakar, Dakar, Senegal
| | - Mireille P Douti
- School of Advanced Studies in the Social Sciences, Centre Norbert Elias, Marseille, France
| | - Gautier Perrotin
- UMR NUTRIPASS, French Research Institute for Sustainable Development, University of Montpellier/SupAgro, Montpellier, France
| | - Yves Martin-Prevel
- UMR NUTRIPASS, French Research Institute for Sustainable Development, University of Montpellier/SupAgro, Montpellier, France
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Choudhury N, Raihan MJ, Ahmed SMT, Islam KE, Self V, Rahman S, Schofield L, Hall A, Ahmed T. The evaluation of Suchana, a large-scale development program to prevent chronic undernutrition in north-eastern Bangladesh. BMC Public Health 2020; 20:744. [PMID: 32443977 PMCID: PMC7245033 DOI: 10.1186/s12889-020-08769-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/23/2020] [Indexed: 11/27/2022] Open
Abstract
Evidence of the impact of community-based nutrition programs is uncommon for two main reasons: the lack of untreated controls, and implementation does not account for the evaluation design. Suchana is a large-scale program to prevent malnutrition in children in Sylhet division, Bangladesh by improving the livelihoods and nutrition knowledge of poor and very poor households. Suchana is being implemented in 157 unions, the smallest administrative unit of government, in two districts of Sylhet. Suchana will deliver a package of interventions to poor people in about 40 randomly selected new unions annually over 4 years, until all are covered. All beneficiaries will receive the normal government nutrition services. For evaluation purposes the last 40 unions will act as a control for the first 40 intervention unions. The remaining unions will receive the program but will not take part in the evaluation. A baseline survey was conducted in both intervention and control unions; it will be repeated after 3 years to estimate the impact on the prevalence of stunted children and other indicators. This stepped wedge design has several advantages for both the implementation and evaluation of services, as well as some disadvantages. The units of delivery are randomized, which controls for other influences on outcomes; the program supports government service delivery systems, so it is replicable and scalable; and the program can be improved over time as lessons are learned. The main disadvantages are the difficulty of estimating the impact of each component of the program, and the geographical distribution of unions, which increases program delivery costs. Stepped implementation allows a cluster randomized trial to be achieved within a large-scale poverty alleviation program and phased-in and scaled-up over a period of time. This paper may encourage evaluators to consider how to estimate attributable impact by using stepped implementation, which allows the counterfactual group eventually to be treated.
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Affiliation(s)
- Nuzhat Choudhury
- Nutrition and Clinical Services Division, icddrb, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
- Department of Anthropology, Durham University, Durham, UK.
| | - Mohammad Jyoti Raihan
- Nutrition and Clinical Services Division, icddrb, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - S M Tanvir Ahmed
- Save the Children Bangladesh, House CWN (A) 35, Road 43, Gulshan, Dhaka, Bangladesh
| | - Kazi Eliza Islam
- Save the Children Bangladesh, House CWN (A) 35, Road 43, Gulshan, Dhaka, Bangladesh
| | - Vanessa Self
- Save the Children U.K., 1 St John's Lane, London, EC1M 4AR, UK
| | - Shahed Rahman
- Save the Children Bangladesh, House CWN (A) 35, Road 43, Gulshan, Dhaka, Bangladesh
| | - Lilly Schofield
- Save the Children U.K., 1 St John's Lane, London, EC1M 4AR, UK
| | - Andrew Hall
- Save the Children U.K., 1 St John's Lane, London, EC1M 4AR, UK
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddrb, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
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11
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Warren AM, Frongillo EA, Nguyen PH, Menon P. Nutrition Intervention Using Behavioral Change Communication without Additional Material Inputs Increased Expenditures on Key Food Groups in Bangladesh. J Nutr 2020; 150:1284-1290. [PMID: 31943055 PMCID: PMC7198287 DOI: 10.1093/jn/nxz339] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/20/2019] [Accepted: 12/20/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Behavioral change communication (BCC) promotes skills and knowledge to improve infant and young child feeding, but without additional material inputs, recipients must develop strategies to translate knowledge into action. Using data from the Alive & Thrive initiative in Bangladesh (2010-2014), we aimed to test whether households receiving the intensive intervention (opposed to the nonintensive intervention) increased expenditures on key foods for mothers and children (e.g., foods that were promoted by the intervention and also changed in maternal and child diets). METHODS The intensive intervention provided interpersonal counseling, community mobilization, and mass media campaigns to promote breastfeeding and complementary feeding. A cluster-randomized design compared 20 subdistricts randomly assigned to the intensive (4281 households) or nonintensive (4284 households) intervention. Measures included food and nonfood expenditures, dietary diversity, and women's economic resources. Linear and logistic regression tested difference-in-differences (DD) in expenditures and dietary diversity, accounting for subdistricts as clusters, and the association between maternal and child consumption of specific food groups and corresponding food expenditures. RESULTS Expenditures on eggs and flesh foods increased more in intensive areas than in nonintensive areas by 53 (P < 0.01) and 471 (P < 0.01) taka/mo, respectively. Household food expenditures increased more in intensive areas by 832 taka (P = 0.02), whereas changes in nonfood expenditures did not differ. Women's employment and control of income increased more in intensive areas by 12 (P = 0.03) and 13 (P < 0.01) percentage points, respectively, while jewelry ownership decreased more by 23 percentage points (P < 0.01). Higher expenditures on food groups were reflected in higher consumption by women and children. CONCLUSIONS Recipients in the intensive intervention mobilized additional resources to improve diets, reflected in increased expenditures and consumption of promoted foods. BCC interventions should document how recipients produce desired results without additional material inputs, particularly for behaviors that likely require additional resources. This trial was registered at clinicaltrials.gov as NCT01678716.
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Affiliation(s)
- Andrea M Warren
- University of South Carolina, Columbia, SC, USA,Address correspondence to AMW (e-mail: )
| | | | - Phuong H Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
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12
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Nguyen PH, Kim SS, Tran LM, Menon P, Frongillo EA. Early breastfeeding practices contribute to exclusive breastfeeding in Bangladesh, Vietnam and Ethiopia. MATERNAL AND CHILD NUTRITION 2020; 16:e13012. [PMID: 32319177 PMCID: PMC7507484 DOI: 10.1111/mcn.13012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 03/27/2020] [Accepted: 04/06/2020] [Indexed: 11/30/2022]
Abstract
Limited evidence exists on the complex relationship among interventions, early initiation of breastfeeding (EIBF), prelacteal feeding and exclusive breastfeeding (EBF). We examined whether early breastfeeding practices are associated with EBF and how much improving EIBF and non‐prelacteal feeding contributes to increased prevalence of EBF. Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh, Vietnam and Ethiopia. Multivariable logistic regression analyses were used to examine effects of interventions and early breastfeeding practices on EBF. Structural equation modelling quantified the direct and indirect effects of interventions (via improving EIBF and non‐prelacteal feeding) on EBF. Although breastfeeding is nearly universal in all three countries (≥98%), delayed initiation of breastfeeding is prevalent (>60%) and prelacteal feeding is common. EIBF alone was not associated with EBF, whereas non‐prelacteal feeding was associated with 1.6–3.5 higher odds of EBF. Intervention exposure affected breastfeeding practices in all three countries; these impacts were amplified among those who practiced EIBF or non‐prelacteal feeding [odds ratio (OR) = 11 and 27.5 in Bangladesh and 6.5 and 11.5 in Vietnam, respectively]. The paths through EIBF and non‐prelacteal feeding explained 13%–18% of the effect of the interventions on EBF. Early breastfeeding practices influence EBF, but interventions aimed only at the initiation and early days of breastfeeding will be inadequate to promote EBF. Social and behaviour change interventions should simultaneously target EIBF, non‐prelacteal feeding and EBF to support optimal breastfeeding practices.
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Sunny S Kim
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | | | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Edward A Frongillo
- Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, USA
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13
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Kim SS, Nguyen PH, Tran LM, Alayon S, Menon P, Frongillo EA. Different Combinations of Behavior Change Interventions and Frequencies of Interpersonal Contacts Are Associated with Infant and Young Child Feeding Practices in Bangladesh, Ethiopia, and Vietnam. Curr Dev Nutr 2020; 4:nzz140. [PMID: 31976385 PMCID: PMC6964730 DOI: 10.1093/cdn/nzz140] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/25/2019] [Accepted: 12/06/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Social and behavior change communication interventions are integral to improving dietary and care practices, but evidence on the impact of the combination and intensity of these interventions in different contexts is scarce. OBJECTIVES We examined the extent of and factors associated with intervention exposure: interpersonal communication (IPC) alone or with other interventions (i.e., mass media, community mobilization, or nutrition-sensitive agricultural activities), number of and factors associated with IPC contacts, and combinations of intervention components and number of contacts associated with infant and young child feeding (IYCF) practices. METHODS We used endline survey data from impact evaluations in Bangladesh, Ethiopia, and Vietnam (n = 1001, 1720, and 1001 mothers with children aged <2 y, respectively). Multivariable regression models were used for analyses. RESULTS Exposure to the interventions varied in all 3 countries. On average, mothers received 8 visits in the last 6 mo in Bangladesh, 2 visits in the last 3 mo in Ethiopia, and 1 visit in the last 6 mo in Vietnam. Across countries, the factors associated with intervention exposure and number of IPC contacts differed. In Ethiopia, exposure to IPC with other interventions was associated with higher odds of achieving minimum meal frequency (OR: 1.6), minimum dietary diversity (OR: 1.8), and consumption of iron-rich foods (OR: 4.7). In Vietnam, exposure to IPC alone or with mass media was associated with higher odds of exclusive breastfeeding (EBF; OR: 2.8-3.7). Near-monthly visits were associated with 2-3 times higher odds of IYCF practices in Bangladesh and Ethiopia. In Vietnam, even 1 IPC visit was associated with 2 times higher odds of EBF. CONCLUSIONS Exposure matters for impact, but the combination of behavior change interventions and number of IPC contacts required to support IYCF behavior change are context specific. This trial was registered at www.clinicaltrials.gov as NCT01678716 (Bangladesh), NCT02775552 (Ethiopia), and NCT01676623 (Vietnam).
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Affiliation(s)
- Sunny S Kim
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Phuong Hong Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | | | | | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
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14
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Choufani J, Jamaluddine Z, Cunningham K. A Multisectoral Nutrition Program in Nepal Improves Knowledge of Dietary Diversity, Sick Child Feeding, and Handwashing, but Not All Practices: a Program Impact Pathways Mediation Analysis. Curr Dev Nutr 2020; 4:nzz135. [PMID: 32258988 PMCID: PMC7101495 DOI: 10.1093/cdn/nzz135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/10/2019] [Accepted: 11/14/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Few intervention studies have focused on how inputs link with outcomes. OBJECTIVES This study tested whether Suaahara I program inputs translated into intended outcomes and identified gaps along the theorized program impact pathway to improved nutrition, care, and water, sanitation, and hygiene behaviors. METHODS We used household-level, cross-sectional survey data from a process evaluation of Suaahara I conducted in 2014. A total of 480 households with a pregnant woman or child aged <2 y were selected with an equal split between intervention and comparison arms. We used regression models to test associations between exposure to Suaahara I and 3 primary outcomes and 3 parallel knowledge mediators: child minimum dietary diversity, child feeding during illness, and proper handwashing during child care. We used generalized structural equation modeling using full information maximum likelihood to test whether knowledge mediated associations between exposure and outcomes. RESULTS In the adjusted regression models between maternal exposure to Suaahara I and 3 behavioral outcomes, we found a small positive association for handwashing (β: 0.21; 95% CI: 0.10, 0.31), but no association with the other 2 outcomes. In the mediation analysis, maternal exposure to Suaahara I, however, was associated with the mediator (knowledge) for all 3 outcomes: handwashing with soap and water (β: 0.05 ± 0.02), child minimum dietary diversity (logit = 0.06; P = 0.03), and child feeding during illness (logit = 0.09 ± 0.02). We found a positive, significant association for the full indirect pathway of program input to output via knowledge for child feeding during illness (logit = 0.07 ± 0.03) only. CONCLUSIONS Exposure to Suaahara I behavior change interventions improved knowledge, but this did not always translate into improved practices. It is important to address barriers to optimal practices beyond knowledge in future nutrition programs in Nepal.
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Affiliation(s)
- Jowel Choufani
- International Food Policy Research Institute, Washington, DC, USA
| | - Zeina Jamaluddine
- Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
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15
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Ruel-Bergeron JC, Hurley KM, Buckland A, Mlambo T, Kang Y, Chirwa E, Farhikhtah A, Aburto N, Christian P. Process Evaluation of a Large-Scale Community-Based Nutrition Program in Malawi. Curr Dev Nutr 2020; 4:nzz131. [PMID: 32258986 PMCID: PMC7101488 DOI: 10.1093/cdn/nzz131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Global attention to the study of nutrition program implementation has been inadequate yet is critical for effective delivery and impact at scale. OBJECTIVES The objective of this mixed-methods process evaluation study was to measure the recruitment, fidelity, and reach of a large-scale, community-based nutrition program in Malawi. METHODS The nutrition program delivered a small-quantity lipid-based nutrient supplement (SQ-LNS) and social and behavior change communication (SBCC) to improve infant and young child feeding (IYCF) and water, sanitation, and hygiene (WASH) practices in households with children aged 6-23 mo. Program monitoring and evaluation data were used to measure program recruitment, reach, and fidelity. Structured direct observations and knowledge questionnaires with program volunteers measured quality aspects of program fidelity. The number of times activities were done correctly was used to tabulate proportions used to represent program functioning. RESULTS Half (49.5%) of eligible children redeemed program benefits by 8 mo of age during the first 4 y of program implementation. Implementation of training activities for SBCC cadres exceeded program targets (100.6%), but the completion of certain modules (breastfeeding and complementary feeding) was lower (22.9% and 18.6%, respectively). Knowledge of IYCF, WASH, and SQ-LNS messages by volunteers was >85% for most messages, except ability to list the 6 food groups (35.7%). Structured direct observations of SQ-LNS distributions indicated high fidelity to program design, whereas those of household-level counseling sessions revealed lack of age-appropriate messaging. Program reach showed participation in monthly distribution sessions of 81.0%, group counseling of 93.3%, and individual-level counseling of 36.9%. CONCLUSIONS This community-based nutrition program was implemented with high fidelity and quality, with specific interventions requiring further attention. The documentation of implementation contributes to our understanding about how program impacts were achieved.
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Affiliation(s)
| | - Kristen M Hurley
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Audrey Buckland
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Yunhee Kang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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16
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Nguyen PH, Frongillo EA, Kim SS, Zongrone AA, Jilani A, Tran LM, Sanghvi T, Menon P. Information Diffusion and Social Norms Are Associated with Infant and Young Child Feeding Practices in Bangladesh. J Nutr 2019; 149:2034-2045. [PMID: 31396621 PMCID: PMC6825823 DOI: 10.1093/jn/nxz167] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/12/2019] [Accepted: 06/20/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Interaction within mothers' social networks can theoretically diffuse messages from interventions and campaigns into norms and practices for infant and young child feeding (IYCF). OBJECTIVES We hypothesized that mothers' social networks, diffusion of information, and social norms differed in intensive [intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM)] compared with nonintensive (standard IPC and less-intensive CM and MM) intervention areas, were associated with IYCF practices, and partly explained practice improvement. METHODS We conducted household surveys at endline in 2014 and follow-up in 2016 (n = ∼2000 each round). We used multiple regression to test differences and changes in networks, diffusion, and norms within intervention areas. We analyzed paths from intervention exposure to IYCF practices through networks, diffusion, and norms. RESULTS Mothers' networks were larger in intensive than in nonintensive areas in 2014 and increased in both areas over time [25-38 percentage points (pp)]. The prevalence of receipt of IYCF information was high, with no changes over time in intensive areas but an increase in nonintensive areas (8-16 pp). In both areas, more family members and health workers provided IYCF information over time. Sharing of information increased 17-23 pp in intensive and 11-41 pp in nonintensive areas over time. Perceived descriptive norms improved 8-16 pp in intensive and 17-28 pp in nonintensive areas. Perceived injunctive norms were high in both areas. Breastfeeding practices were associated with networks, diffusion, and norms (OR: 1.6-4.4 times larger comparing highest with lowest quartile). Minimum dietary diversity was associated with larger networks and diffusion (OR: 1.5-2.2) but not with social norms. Indirect paths from intervention exposure to practices explained 34-78% of total effects. CONCLUSIONS Diffusion of IYCF information through social networks, reinforced by positive social norms for messages promoted over time, will contribute to positive changes in IYCF practices that may be achieved and sustained through large-scale social and behavior change interventions. This trial was registered at clinicaltrials.gov as NCT0274084.
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Affiliation(s)
- Phuong H Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA,Address correspondence to PHN (e-mail: )
| | | | - Sunny S Kim
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Amanda A Zongrone
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Amir Jilani
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | | | | | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
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17
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Lanou HB, Osendarp SJ, Argaw A, De Polnay K, Ouédraogo C, Kouanda S, Kolsteren P. Micronutrient powder supplements combined with nutrition education marginally improve growth amongst children aged 6-23 months in rural Burkina Faso: A cluster randomized controlled trial. MATERNAL & CHILD NUTRITION 2019; 15:e12820. [PMID: 30941887 PMCID: PMC6859995 DOI: 10.1111/mcn.12820] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 03/07/2019] [Accepted: 03/19/2019] [Indexed: 01/18/2023]
Abstract
Micronutrients powder (MNP) can prevent anaemia amongst children 6-23 months old. However, evidence of an effect on growth is limited and concerns about the safety of iron-containing MNP interventions limits their applicability. In a cluster randomized controlled intervention, we evaluated the effectiveness of a nutritional package including counselling and provision of MNP to improve the nutritional status of children aged 6-23 months and the effect of sustained use of MNP on morbidity in a malaria-endemic area. Child feeding practises and nutritional status were assessed through cross-sectional surveys. Biweekly morbidity surveillance and anthropometry measurements were carried out in a nested cohort study. No significant differences in the prevalence of wasting (-0.7% [-6.8, 5.3] points; p = .805), stunting (+4.6% [-2.9, 12.0] points; p = .201), or mean length-for-age z-score and weight-for-length z-score scores were found between study groups. The proportion of children with a minimum dietary diversity score and those with a minimum acceptable diet significantly increased in the intervention group compared with the control by 6.5% points (p = .043) and 5.8% points (p = .037), respectively. There were no significant differences in the risk of diarrhoea (RR: 1.68, 95% CI [0.94, 3.08]), fever (RR: 1.20 [0.82, 1.77]), and malaria (RR: 0.68 [0.37, 1.26]) between study groups. In the nested study, the rate of linear growth was higher in the intervention than in the control group by 0.013 SD/month (p = .027). In a programmatic intervention, MNP and nutrition education marginally improved child feeding practises and growth, without increasing morbidity from malaria or fever.
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Affiliation(s)
- Hermann B. Lanou
- Ministry of Higher Education, Scientific Research and InnovationInstitut de Recherche en Sciences de la SantéOuagadougouBurkina Faso
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
| | | | - Alemayehu Argaw
- Nutrition InternationalOttawaOntarioCanada
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
- Department of Population and Family HealthJimma UniversityJimmaEthiopia
| | - Kirrily De Polnay
- Child Health and Nutrition Unit, Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | | | - Seni Kouanda
- Ministry of Higher Education, Scientific Research and InnovationInstitut de Recherche en Sciences de la SantéOuagadougouBurkina Faso
| | - Patrick Kolsteren
- Child Health and Nutrition Unit, Department of Public HealthInstitute of Tropical MedicineAntwerpBelgium
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
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18
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Olney DK, Marshall Q, Honton G, Ogden K, Hambayi M, Piccini S, Go A, Gelli A, Bliznashka L. Leveraging an Implementation– Research Partnership to Improve Effectiveness of Nutrition-Sensitive Programs at the World Food Programme. Food Nutr Bull 2019; 41:18-37. [DOI: 10.1177/0379572119874273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Nutrition-sensitive programs can accelerate progress in addressing malnutrition. However, evidence gaps exist related to their effectiveness and how to optimize program design and implementation. Objective: We present the process the International Food Policy Research Institute and the World Food Programme (WFP) used to develop nutrition-sensitive program guidance and plans for improving program effectiveness and contributing to the evidence base through rigorous evaluations. Methods: A 5-step process, using principles of design thinking (a systematic, iterative analytical approach to problem solving), was used to develop, test, and refine WFP’s nutrition-sensitive guidance. The guidance focuses on improving nutrition outcomes for nutritionally vulnerable groups across the life cycle: women and children in the first 1000 days, preschoolers, schoolchildren, and adolescents. Results: Through iterative consultations, we created WFP’s nutrition-sensitive guidance that includes harmonized theories of change across WFP’s programs; 7 opportunities to enhance the programs’ nutrition-sensitivity; and mapping of these opportunities to WFP programs and key evidence gaps. This guidance has been rolled out to WFP’s offices worldwide to support improved nutrition outcomes. Finally, several evaluation designs have been proposed to fill identified evidence gaps. Conclusions: By leveraging our implementation–research partnership, we expect that WFP’s programs will be more effective and cost effective for improving nutrition. This can be assessed through coupling newly designed nutrition-sensitive programs with rigorous evaluations. Evaluation results will be used to refine WFP’s nutrition-sensitive guidance and improve their programs globally. This guidance, and creation process, could be useful for others interested in designing nutrition-sensitive programs and increasing program effectiveness for nutrition.
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Affiliation(s)
- Deanna K. Olney
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Quinn Marshall
- Nutrition Division, World Food Programme (WFP), Rome, Italy
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Kathryn Ogden
- Nutrition Division, World Food Programme (WFP), Rome, Italy
| | | | - Sarah Piccini
- Nutrition Division, World Food Programme (WFP), Rome, Italy
| | - Ara Go
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Aulo Gelli
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Lilia Bliznashka
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Le Port A, Zongrone A, Savy M, Fortin S, Kameli Y, Sessou E, Diatta AD, Koulidiati JL, Kodjo NE, Kamayera F, Mahamadou T, Martin-Prevel Y, Ruel MT. Program Impact Pathway Analysis Reveals Implementation Challenges that Limited the Incentive Value of Conditional Cash Transfers Aimed at Improving Maternal and Child Health Care Use in Mali. Curr Dev Nutr 2019; 3:nzz084. [PMID: 31528837 PMCID: PMC6735791 DOI: 10.1093/cdn/nzz084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The program "Santé Nutritionnelle à Assise Communautaire à Kayes" (SNACK) in Mali aimed to improve child linear growth through a set of interventions targeted to mothers and children during pregnancy and up to the child's second birthday. Distributions of cash to mothers and/or lipid-based nutrient supplement to children 6-23 mo of age were added to SNACK to increase attendance at community health centers (CHCs). OBJECTIVES The aim of this study, which was embedded in a cluster-randomized impact evaluation of the program, was to assess the incentive value of the cash in relation to CHC attendance. METHODS We used a mixed-methods approach. We collected quantitative data on cash receipt and CHC attendance in a midline survey of mother-child pairs (n = 3443). A program impact pathway analysis guided qualitative data collection and analysis. Twelve CHCs were purposively selected in study groups that received cash. We conducted semistructured continuous observations of cash distributions in 11 CHCs (n = 22) and semistructured qualitative interviews with frontline workers (FLWs) (n = 71) and mothers (n = 22) who were purposively selected from the midline survey. RESULTS FLWs' knowledge of the objective and implementation plan of the cash program component was limited. A challenging physical environment and insufficient cash available for each distribution were identified as causes of irregularities in cash distributions. Most mothers mentioned having to return several times to receive their cash. Child health was identified as the main motivation to attend CHCs and cash was described as an additional benefit. CONCLUSION Implementation constraints related to remoteness and inaccessibility may have undermined the incentive value of the cash transfers in the SNACK program. Additional research is needed to identify interventions that not only incentivize mothers to participate but that can be implemented effectively and with high quality in challenging contexts such as rural areas of Mali.
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Affiliation(s)
- Agnes Le Port
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
| | - Amanda Zongrone
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
| | - Mathilde Savy
- UMR204 “Nutripass” (IRD-UM-SupAgro), French National Research Institute for Sustainable Development, Montpellier, France
| | - Sonia Fortin
- UMR204 “Nutripass” (IRD-UM-SupAgro), French National Research Institute for Sustainable Development, Montpellier, France
| | - Yves Kameli
- UMR204 “Nutripass” (IRD-UM-SupAgro), French National Research Institute for Sustainable Development, Montpellier, France
| | - Eric Sessou
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
| | - Ampa Dogui Diatta
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
| | | | | | | | | | - Yves Martin-Prevel
- UMR204 “Nutripass” (IRD-UM-SupAgro), French National Research Institute for Sustainable Development, Montpellier, France
| | - Marie T Ruel
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
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20
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Nguyen PH, Kim SS, Tran LM, Menon P, Frongillo EA. Intervention Design Elements Are Associated with Frontline Health Workers' Performance to Deliver Infant and Young Child Nutrition Services in Bangladesh and Vietnam. Curr Dev Nutr 2019; 3:nzz070. [PMID: 31346584 PMCID: PMC6642067 DOI: 10.1093/cdn/nzz070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/30/2019] [Accepted: 06/10/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Frontline health workers (FLWs) are needed for delivering interventions at scale to reduce maternal and child undernutrition, but low- and middle-income countries often face inadequate FLW performance. OBJECTIVES We examined whether and how intervention design elements such as training, supervision, and mass media improved FLW performance in delivering nutrition services. METHODS Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh and Vietnam. FLWs in A&T intensive (A&T-I) areas received specialized IYCF training, job aids, and regular supportive supervision. Those in non-intensive (A&T-NI) areas received standard government training and supervision. There was mass media exposure in both areas. Multiple regression was used to test differences in exposure to intervention design elements and performance outcomes between the 2 program areas. Path analyses were conducted to examine the paths from exposure to performance outcomes measured at FLW and end-user levels. RESULTS Compared to FLWs in A&T-NI areas, those in A&T-I areas had higher scores in training (by 1.3-3.6 of 10 points), supportive supervision (0.3-3.5 points), and mass media exposure (0.3-3.5 points). These intervention design elements were significantly associated with FLW knowledge and motivation, which in turn improved service delivery. FLW-level performance outcomes contributed to improving end-user-level outcomes such as higher service received (β = 0.12-1.04 in Bangladesh and 0.11-0.96 in Vietnam) and maternal knowledge (β = 0.12-0.17 in Bangladesh and 0.04-0.21 in Vietnam). CONCLUSIONS Training, supervision, and mass media exposure can be implemented at large scale and contribute to improved FLW service delivery by enhancing knowledge and motivation, which in turn positively influence mother's service utilization and IYCF knowledge. Training, supervision, and mass media to enhance service provision should be considered when designing interventions. This trial was registered at clinicaltrials.gov as NCT01678716 (Bangladesh) and NCT01676623 (Vietnam).
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Sunny S Kim
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Lan Mai Tran
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, USA
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Edward A Frongillo
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, USA
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21
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Epstein A, Moucheraud C, Sarma H, Rahman M, Tariqujjaman M, Ahmed T, Glenn J, Bossert T, Kruk ME. Does health worker performance affect clients' health behaviors? A multilevel analysis from Bangladesh. BMC Health Serv Res 2019; 19:516. [PMID: 31340809 PMCID: PMC6657138 DOI: 10.1186/s12913-019-4205-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 05/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background Suboptimal healthcare quality may be a barrier to achieving child health improvements, yet little is known about the relationship between provider compliance with evidence-based practices and client behavior change. We assess provider compliance in the context of infant and young child feeding (IYCF) counseling, its relationship with client IYCF behaviors in Bangladesh, and explore its potential determinants. Methods We use data from a 2017 evaluation of an IYCF program that includes a health worker survey (n = 74), caregiver survey (n = 232), and direct service observation checklists of counseling sessions (n = 232 observations of 74 health workers). We assess the relationship between provider compliance with recommended IYCF counseling topics and behaviors (standardized to a 100-point scale) and three reported IYCF behaviors among clients using multi-level models with random effects at the health worker and sub-district (sampling) levels. We also evaluate whether health worker self-efficacy, satisfaction, and technical knowledge are associated with provider compliance. Results Health worker compliance was significantly associated with reported exclusive breastfeeding for children under 6 months of age (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.06, 95% CI 1.01, 1.12) and marginally associated with minimum dietary diversity (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.05, 95% CI 1.00, 1.11). Counseling compliance was significantly and positively associated with both health worker self-efficacy and technical knowledge. Conclusions We find evidence for an association between health worker compliance and client health behaviors; however, small effect sizes suggest that behavior change is multifactorial and affected by factors beyond care quality. Improvements to technical quality of care may contribute to desired health outcomes; but policies and programs seeking to change health behaviors through counseling may also wish to target upstream factors such as self-efficacy, alongside technical skill-building and knowledge, for maximum impact. Electronic supplementary material The online version of this article (10.1186/s12913-019-4205-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adrienne Epstein
- Department of Epidemiology and Biostatistics, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA.
| | - Corrina Moucheraud
- Department of Health Policy and Management, University of California Los Angeles, Fielding School of Public Health, Los Angeles, CA, USA
| | - Haribondhu Sarma
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh.,Research School of Population Health, Australian National University, Acton, ACT, 2601, Australia
| | - Mahfuzur Rahman
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Md Tariqujjaman
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Jeffrey Glenn
- Department of Public Health, Brigham Young University, Provo, UT, USA
| | - Thomas Bossert
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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22
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Ruel-Bergeron JC, Hurley KM, Kang Y, Aburto N, Farhikhtah A, Dinucci A, Molinas L, Lee Shu Fune W, Mitra M, Phuka J, Klemm R, West K, Christian P. Monitoring and evaluation design of Malawi's Right Foods at the Right Time nutrition program. EVALUATION AND PROGRAM PLANNING 2019; 73:1-9. [PMID: 30453182 DOI: 10.1016/j.evalprogplan.2018.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 10/19/2018] [Accepted: 11/06/2018] [Indexed: 06/09/2023]
Abstract
Child stunting is a public health problem in Malawi. In 2014, the Government of Malawi launched the Right Foods at the Right Time (RFRT) program in Ntchisi district delivering nutrition social and behavior change communication, a small-quantity lipid-based nutrient supplement to children 6-23 months, and nutrition sensitive activities. Monitoring and evaluation (M&E) systems are key aspects of successful program implementation. We describe these and the methodology for an impact evaluation that was conducted for this program. Two monitoring systems using traditional and electronic platforms were established to register and track program delivery and processes including number of eligible beneficiaries, worker performance, program participation, and to monitor input, output, and outcome indicators. The impact evaluation used comparative cross-sectional and longitudinal designs to assess impact on anthropometric and infant and young child feeding outcomes. Three cross-sectional surveys (base-, mid-, and end-line) and two longitudinal cohorts of children followed in 6-month intervals from 6 to 24 months of age, were conducted in sampled households in the program and a neighboring comparison district. Additional M&E included qualitative studies, a process evaluation, and a cost-effectiveness study. The current paper describes lessons from this program's M&E, and demonstrates how multiple implementation research activities can inform course-correction and program scale-up.
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Affiliation(s)
- Julie C Ruel-Bergeron
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Program in Human Nutrition, 615 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Kristen M Hurley
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Program in Human Nutrition, 615 N. Wolfe St., Baltimore, MD, 21205, USA.
| | - Yunhee Kang
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Program in Human Nutrition, 615 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Nancy Aburto
- United Nations World Food Programme, Nutrition Division, Via Cesare Guilio Viola 68, Parco dei Medici, Rome, 00148, Italy
| | - Arghanoon Farhikhtah
- United Nations World Food Programme, Nutrition Division, Via Cesare Guilio Viola 68, Parco dei Medici, Rome, 00148, Italy
| | - Alessandro Dinucci
- United Nations World Food Programme, Nutrition Division, Via Cesare Guilio Viola 68, Parco dei Medici, Rome, 00148, Italy
| | - Luca Molinas
- United Nations World Food Programme, Nutrition Division, Via Cesare Guilio Viola 68, Parco dei Medici, Rome, 00148, Italy
| | - Wu Lee Shu Fune
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Program in Human Nutrition, 615 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Maithilee Mitra
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Program in Human Nutrition, 615 N. Wolfe St., Baltimore, MD, 21205, USA
| | - John Phuka
- College of Medicine, University of Malawi, Private Bag 360, Blantyre, Malawi
| | - Rolf Klemm
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Program in Human Nutrition, 615 N. Wolfe St., Baltimore, MD, 21205, USA; Helen Keller International, 352 Park Avenue South, 12th floor, New York, NY, 10010, USA
| | - Keith West
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Program in Human Nutrition, 615 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Parul Christian
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Program in Human Nutrition, 615 N. Wolfe St., Baltimore, MD, 21205, USA; The Bill & Melinda Gates Foundation, Women's Nutrition, 500 Fifth Avenue North, Seattle, WA, 98109, USA
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23
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Michaud‐Létourneau I, Gayard M, Pelletier DL. Translating the International Code of Marketing of Breast-milk Substitutes into national measures in nine countries. MATERNAL & CHILD NUTRITION 2019; 15 Suppl 2:e12730. [PMID: 30793543 PMCID: PMC6519018 DOI: 10.1111/mcn.12730] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/26/2018] [Accepted: 08/14/2018] [Indexed: 01/13/2023]
Abstract
The International Code of Marketing of Breast-milk Substitutes (the Code) adopted by the World Health Assembly (WHA) in 1981 and regularly updated through subsequent WHA resolutions, represents the international policy framework for protecting breastfeeding against inappropriate marketing practices. By March 2016, at least 135 countries had some measures covering provisions of the Code in their legislation. The translation of the International Code into national measures was investigated in the context of the advocacy efforts undertaken by the Alive & Thrive (A&T) initiative with UNICEF and partners. A real-time evaluation was carried out over 22 months in seven Southeast Asian countries (Cambodia, Indonesia, Lao People's Democratic Republic [Lao PDR], Myanmar, Thailand, Vietnam, and Timor-Leste) and two African countries (Burkina Faso and Ethiopia). Drivers of policy change and progress were examined. Two theory-based approaches were used: developmental evaluation and contribution analysis. Data collection methods included participant observation, key informant meetings, in-depth interviews, reflective practice, and desk review. Overall, countries made significant progress in translating the International Code into national measures and in moving forward throughout the policy cycle. The main driver of policy change was the creation of a strategic group, which engaged key relevant actors and supported the government in the performance of 15 critical tasks, which the analysis reveals is a second driver. Those critical tasks are described in this paper and could help public health advocates to anticipate the stages and challenges of policy change and develop more effective strategies to translate the Code into their legal framework.
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Affiliation(s)
- Isabelle Michaud‐Létourneau
- Department of Social and Preventive Medicine, School of Public HealthUniversité de MontréalMontrealQuebecCanada
- Department of Family Medicine and Emergency MedicineUniversité de SherbrookeLongueuilQuebecCanada
| | - Marion Gayard
- Department of Family Medicine and Emergency MedicineUniversité de SherbrookeLongueuilQuebecCanada
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24
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Kung'u JK, Pendame R, Ndiaye MB, Gerbaba M, Ochola S, Faye A, Basnet S, Frongillo EA, Wuehler S, De-Regil LM. Integrating nutrition into health systems at community level: Impact evaluation of the community-based maternal and neonatal health and nutrition projects in Ethiopia, Kenya, and Senegal. MATERNAL AND CHILD NUTRITION 2019; 14 Suppl 1. [PMID: 29493902 DOI: 10.1111/mcn.12577] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 11/08/2017] [Accepted: 11/13/2017] [Indexed: 11/28/2022]
Abstract
Maternal undernutrition and mortality remain high in several African countries. Key nutrition and health interventions improve maternal and birth outcomes. Evidence is scarce on how to strengthen health systems to ensure pregnant women and newborns are reached with these interventions. We conducted three quasi-experimental nonrandomized Community Based Maternal and Neonatal Health and Nutrition projects in regions of Ethiopia, Senegal, and Kenya to demonstrate how proven nutrition interventions could be integrated into health programs to improve knowledge and practices during pregnancy, birth, and postpartum. We evaluated impact on knowledge and practices related to maternal and neonatal care using logistic regression and repeated-measures models with districts as a fixed variable and adjusted for covariates. Combined country analyses show significant positive effects of the intervention on women receiving first antenatal care visit (ANC) during first trimester (OR = 1.44; p < .001), those consuming any iron and folic acid supplement during their latest pregnancy (OR = 1.60; p = .005), those whose <6 months infants were exclusively breastfed (OR = 2.01; p=.003), those whose delivery was facility based (OR = 1.48; p=.031), and those whose postnatal care was facility based (OR = 2.15; p<.001). There was no significant differences between intervention and control groups regarding one or more and four or more ANC visits, women consuming iron and folic acid for ≥90 days, and early initiation of breastfeeding. We conclude that integrating proven nutrition interventions into health programs at community level improved components of access to and use of ANC, delivery services, and postnatal care by women in three African countries.
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Affiliation(s)
| | - Richard Pendame
- Africa Regional Office, Nutrition International, Nairobi, Kenya
| | | | - Mulusew Gerbaba
- Population and Family Health, Jimma University, Jimma, Ethiopia
| | - Sophie Ochola
- Foods, Nutrition and Dietetics, Kenyatta University, Nairobi, Kenya
| | - Adama Faye
- Institut de Santé et Développement, Université Cheikh Anta Diop de Dakar, Dakar, Senegal
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25
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Buccini G, Harding KL, Hromi-Fiedler A, Pérez-Escamilla R. How does "Becoming Breastfeeding Friendly" work? A Programme Impact Pathways Analysis. MATERNAL AND CHILD NUTRITION 2019; 15:e12766. [PMID: 30536582 DOI: 10.1111/mcn.12766] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/23/2018] [Accepted: 11/29/2018] [Indexed: 12/16/2022]
Abstract
Becoming Breastfeeding Friendly (BBF) is an initiative designed to track country readiness and progress to effectively scale up breastfeeding programmes. BBF includes a policy toolbox that has three components: the BBF Index (BBFI), case studies, and a five-meeting process. Mapping pathways of how BBF was implemented and utilized enables contextually grounded interpretation of its impact on breastfeeding outcomes. We conducted a programme impact pathways (PIP) analysis to identify pathways and critical quality control points (CCPs) by which BBF can enable changes in policy, legislation, and implementation of breastfeeding programmes. A BBF PIP diagram was developed, and CCPs were identified through a literature review and an iterative interviewing process with BBF investigators. The PIP was revised after feedback from BBF's Technical Advisory Group. BBF pretesting in Ghana and Mexico informed the formative evaluation of the PIP. PIP analysis identified relevant pathways between BBF activities and outcomes. Eight CCPs that could facilitate or attenuate BBF to fully impact the scaling up of the breastfeeding programmes were identified: (a) committee formed and trained; (b) committee understands BBF and BBFI; (c) committee's ability to acquire data; (d) BBFI scores; (e) criteria used for prioritizing recommendations; (f) dissemination of recommendations; (g) policymaker's reactions and media coverage; (h) committee's motivation and effective teamwork throughout BBF. Ghana and Mexico's pretesting of BBF confirmed the CCPs and provided valuable insights on potential mechanisms of BBF impacts at the country level. To further validate the PIP, a policy analysis framework is being tested in Ghana and Mexico.
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Affiliation(s)
- Gabriela Buccini
- Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Kassandra L Harding
- Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Amber Hromi-Fiedler
- Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut
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26
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Ruel-Bergeron J, Hurley K, Kapadia-Kundu N, Oemcke R, Chirwa E, Hambayi M, Aburto N, Christian P. Physical and sociocultural facilitators and barriers to access and utilization of a nutrition program in rural Malawi: a qualitative study. Ecol Food Nutr 2018; 57:405-424. [DOI: 10.1080/03670244.2018.1518221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Julie Ruel-Bergeron
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kristen Hurley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Rachel Oemcke
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Mutinta Hambayi
- Nutrition Division, The World Food Programme, Roma, RM, Italy
| | - Nancy Aburto
- Nutrition Division, The World Food Programme, Roma, RM, Italy
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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27
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Kim SS, Roopnaraine T, Nguyen PH, Saha KK, Bhuiyan MI, Menon P. Factors influencing the uptake of a mass media intervention to improve child feeding in Bangladesh. MATERNAL & CHILD NUTRITION 2018; 14:e12603. [PMID: 29644807 PMCID: PMC6055868 DOI: 10.1111/mcn.12603] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 12/22/2017] [Accepted: 02/04/2018] [Indexed: 11/29/2022]
Abstract
Mass media are increasingly used to deliver health messages to promote social and behaviour change, but there has been little evidence of mass media use for improving a set of child feeding practices, other than campaigns to promote breastfeeding. This study aimed to examine the factors influencing the uptake of infant and young child feeding messages promoted in TV spots that were launched and aired nationwide in Bangladesh. We conducted a mixed-methods study, using household surveys (n = 2,000) and semistructured interviews (n = 251) with mothers of children 0-23.9 months and other household members. Factors associated with TV spot viewing and comprehension were analysed using multivariable logistic regression models, and interview transcripts were analysed by systematic coding and iterative summaries. Exposure ranged from 36% to 62% across 6 TV spots, with comprehension ranging from 33% to 96% among those who viewed the spots. Factors associated with comprehension of TV spot messages included younger maternal age and receipt of home visits by frontline health workers. Three direct narrative spots showed correct message recall and strong believability, identification, and feasibility of practicing the recommended behaviours. Two spots that used a metaphorical and indirect narrative style were not well understood by respondents. Understanding the differences in the uptake factors may help to explain variability of impacts and ways to improve the design and implementation of mass media strategies.
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Affiliation(s)
- Sunny S. Kim
- Poverty, Health, and Nutrition DivisionInternational Food Policy Research InstituteWashingtonDistrict of ColumbiaUSA
| | | | - Phuong H. Nguyen
- Poverty, Health, and Nutrition DivisionInternational Food Policy Research InstituteWashingtonDistrict of ColumbiaUSA
| | - Kuntal K. Saha
- Department of Nutrition for Health and DevelopmentWorld Health OrganizationGenevaSwitzerland
| | - Mahbubul I. Bhuiyan
- Poverty, Health, and Nutrition DivisionInternational Food Policy Research InstituteDhakaBangladesh
| | - Purnima Menon
- Poverty, Health, and Nutrition DivisionInternational Food Policy Research InstituteNew DelhiIndia
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28
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Frongillo EA. Evaluation of programs to improve complementary feeding in infants and young children. MATERNAL AND CHILD NUTRITION 2018; 13 Suppl 2. [PMID: 29032620 DOI: 10.1111/mcn.12436] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/13/2016] [Accepted: 01/09/2017] [Indexed: 11/29/2022]
Abstract
Evaluation of complementary feeding programs is needed to enhance knowledge on what works, to document responsible use of resources, and for advocacy. Evaluation is done during program conceptualization and design, implementation, and determination of effectiveness. This paper explains the role of evaluation in the advancement of complementary feeding programs, presenting concepts and methods and illustrating them through examples. Planning and investments for evaluations should occur from the beginning of the project life cycle. Essential to evaluation is articulation of a program theory on how change would occur and what program actions are required for change. Analysis of program impact pathways makes explicit the dynamic connections in the program theory and accounts for contextual factors that could influence program effectiveness. Evaluating implementation functioning is done through addressing questions about needs, coverage, provision, and utilization using information obtained from process evaluation, operations research, and monitoring. Evaluating effectiveness is done through assessing impact, efficiency, coverage, process, and causality. Plausibility designs ask whether the program seemed to have an effect above and beyond external influences, often using a nonrandomized control group and baseline and end line measures. Probability designs ask whether there was an effect using a randomized control group. Evaluations may not be able to use randomization, particularly for programs implemented at a large scale. Plausibility designs, innovative designs, or innovative combinations of designs sometimes are best able to provide useful information. Further work is needed to develop practical designs for evaluation of large-scale country programs on complementary feeding.
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Affiliation(s)
- Edward A Frongillo
- Department of Health Promotion, Education, and Behavior Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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29
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Vossenaar M, Tumilowicz A, D'Agostino A, Bonvecchio A, Grajeda R, Imanalieva C, Irizarry L, Mulokozi G, Sudardjo MN, Tsevegsuren N, Neufeld LM. Experiences and lessons learned for programme improvement of micronutrient powders interventions. MATERNAL AND CHILD NUTRITION 2018; 13 Suppl 1. [PMID: 28960877 PMCID: PMC5656835 DOI: 10.1111/mcn.12496] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/25/2017] [Accepted: 07/06/2017] [Indexed: 01/24/2023]
Abstract
Continual course correction during implementation of nutrition programmes is critical to address factors that might limit coverage and potential for impact. Programme improvement requires rigorous scientific inquiry to identify and address implementation pathways and the factors that affect them. Under the auspices of “The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance,” 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powder (MNP) interventions for young children. This paper focuses on how MNP interventions undertook key elements of programme improvement, specifically, the use of programme theory, monitoring, process evaluation, and supportive supervision. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that although much has been written and published about the use of monitoring and process evaluation to inform MNP interventions at small scale, there has been little formal documentation of lessons for the transition from pilot to scaled implementation. Supervision processes and experiences are not documented, and to our knowledge, there is no evidence of whether they have been effective to improve implementation. Improving the efficiency and effectiveness of interventions requires identification of critical indicators for detecting implementation challenges and drivers of impact, integration with existing programmes and systems, strengthened technical capacity, and financing for implementation of effective monitoring systems. Our understanding of programme improvement for MNP interventions is still incomplete, especially outside of the pilot stage, and we propose a set of implementation research questions that require further investigation.
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Affiliation(s)
| | | | - Alexis D'Agostino
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, Arlington, Virginia, USA.,John Snow Inc., Arlington, Virginia, USA
| | | | - Ruben Grajeda
- Pan-American Health Organization, Washington, District of Columbia, USA
| | | | | | - Generose Mulokozi
- Tanzania Food and Nutrition Center, Dar es Salaam, Tanzania.,IMA World Health, Dar es Salaam, Tanzania
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Alderman H, Headey D. The timing of growth faltering has important implications for observational analyses of the underlying determinants of nutrition outcomes. PLoS One 2018; 13:e0195904. [PMID: 29694431 PMCID: PMC5919068 DOI: 10.1371/journal.pone.0195904] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/02/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Growth faltering largely occurs in the first 23 months after birth and is thought to be largely determined by various harmful or protective socioeconomic conditions. Children 23 months or younger, however, have only been partially exposed to these conditions, implying that statistical associations between these conditions and child growth may be substantially smaller in samples that include younger children. OBJECTIVES To test the prediction that associations between child anthropometric outcomes and various socioeconomic conditions are systematically different for older and younger children. METHODS We analyzed data for 699,421 children aged 0-59 months, drawn from 125 DHS implemented between 1992 and 2014 in 57 countries. The outcome variables were height-for-age Z scores (HAZ) and stunting (HAZ<-2), and weight-for-height z scores (WHZ) and wasting (WHZ<-2). Independent variables included household wealth, parental education, maternal height, demographic factors, and exposure to WASH and health services. We used age-disaggregated regressions to examine how the associations between dependent and independent variables vary across different child age ranges. RESULTS Non-parametric regression results reaffirmed that most linear growth faltering and wasting takes place prior to 23 months of age. Estimates of the magnitude of association with wealth, education and improved toilet use from HAZ regressions are systematically larger in the sample of children 24-59 months than in the 0-23 month or 0-59 month samples; the reverse is true for WHZ regressions. CONCLUSIONS Previous observational analyses appear to substantially underestimate the protective impacts of a wide range of underlying determinants on stunting. Conversely, wasting rates are typically low for children 24-59 months, implying that associations between underlying conditions and wasting may be stronger for children 0-23 months of age. Such analyses should pay closer attention to age disaggregation; researchers should be aware of the age effect reported in the current study and present analysis stratified by age.
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Affiliation(s)
- Harold Alderman
- International Food Policy Research Institute, Washington, District of Columbia, United States of America
| | - Derek Headey
- International Food Policy Research Institute, Washington, District of Columbia, United States of America
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Zongrone AA, Menon P, Pelto GH, Habicht JP, Rasmussen KM, Constas MA, Vermeylen F, Khaled A, Saha KK, Stoltzfus RJ. The Pathways from a Behavior Change Communication Intervention to Infant and Young Child Feeding in Bangladesh Are Mediated and Potentiated by Maternal Self-Efficacy. J Nutr 2018; 148:259-266. [PMID: 29490102 PMCID: PMC6299133 DOI: 10.1093/jn/nxx048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/11/2017] [Accepted: 11/17/2017] [Indexed: 11/23/2022] Open
Abstract
Background Although self-efficacy is a potential determinant of feeding and care behaviors, there is limited empirical analysis of the role of maternal self-efficacy in low- and middle-income countries. In the context of behavior change interventions (BCIs) addressing complementary feeding (CF), it is possible that maternal self-efficacy can mediate or enhance intervention impacts. Objective In the context of a BCI in Bangladesh, we studied the role of maternal self-efficacy for CF (MSE-CF) for 2 CF behaviors with the use of a theoretically grounded empirical model of determinants to illustrate the potential roles of MSE-CF. Methods We developed and tested a locally relevant scale for MSE-CF and included it in a survey (n = 457 mothers of children aged 6-24 mo) conducted as part of a cluster-randomized evaluation. Qualitative research was used to inform the selection of 2 intervention-targeted behaviors: feeding green leafy vegetables in the last 24 h (GLV) and on-time introduction of egg (EGG) between 6 and 8 mo of age. We then examined direct, mediated, and potentiated paths of MSE-CF in relation to the impacts of the BCI on these behaviors with the use of regression and structural equation modeling. Results GLV and EGG were higher in the intensive group than in the nonintensive control group (16.0 percentage points for GLV; P < 0.001; 11.2 percentage points for EGG; P = 0.037). For GLV, MSE-CF mediated (β = 0.345, P = 0.010) and potentiated (β = 0.390, P = 0.038) the effect of the intensive group. In contrast, MSE-CF did not mediate or potentiate the effect of the intervention on EGG. Conclusions MSE-CF was a significant mediator and potentiator for GLV but not for EGG. The divergent findings highlight the complex determinants of individual specific infant and young child feeding behaviors. The study shows the value of measuring behavioral determinants, such as MSE-CF, that affect a caregiver's capability to adopt intervention-targeted behaviors.
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Affiliation(s)
- Amanda A Zongrone
- Poverty, Health, and Nutrition Division, International Food Policy Research
Institute, Washington, DC
| | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research
Institute, Washington, DC
| | - Gretel H Pelto
- Division of Nutritional Sciences, Charles H Dyson School of Applied Economics
and Management, and Cornell Statistical Consulting Unit, Cornell University, Ithaca,
NY
| | - Jean-Pierre Habicht
- Division of Nutritional Sciences, Charles H Dyson School of Applied Economics
and Management, and Cornell Statistical Consulting Unit, Cornell University, Ithaca,
NY
| | - Kathleen M Rasmussen
- Division of Nutritional Sciences, Charles H Dyson School of Applied Economics
and Management, and Cornell Statistical Consulting Unit, Cornell University, Ithaca,
NY
| | - Mark A Constas
- Division of Charles H Dyson School of Applied Economics and Management, and
Cornell Statistical Consulting Unit, Cornell University, Ithaca, NY
| | - Francoise Vermeylen
- Division of Cornell Statistical Consulting Unit, Cornell University, Ithaca,
NY
| | - Adiba Khaled
- Poverty, Health, and Nutrition Division, International Food Policy Research
Institute, Washington, DC
| | - Kuntal K Saha
- Department of Nutrition for Health and Development, WHO, Geneva,
Switzerland
| | - Rebecca J Stoltzfus
- Division of Nutritional Sciences, Charles H Dyson School of Applied Economics
and Management, and Cornell Statistical Consulting Unit, Cornell University, Ithaca,
NY
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Alderman H, Headey D. The timing of growth faltering has important implications for observational analyses of the underlying determinants of nutrition outcomes. PLoS One 2018. [PMID: 29694431 DOI: 10.1371/journalpone.0195904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Growth faltering largely occurs in the first 23 months after birth and is thought to be largely determined by various harmful or protective socioeconomic conditions. Children 23 months or younger, however, have only been partially exposed to these conditions, implying that statistical associations between these conditions and child growth may be substantially smaller in samples that include younger children. OBJECTIVES To test the prediction that associations between child anthropometric outcomes and various socioeconomic conditions are systematically different for older and younger children. METHODS We analyzed data for 699,421 children aged 0-59 months, drawn from 125 DHS implemented between 1992 and 2014 in 57 countries. The outcome variables were height-for-age Z scores (HAZ) and stunting (HAZ<-2), and weight-for-height z scores (WHZ) and wasting (WHZ<-2). Independent variables included household wealth, parental education, maternal height, demographic factors, and exposure to WASH and health services. We used age-disaggregated regressions to examine how the associations between dependent and independent variables vary across different child age ranges. RESULTS Non-parametric regression results reaffirmed that most linear growth faltering and wasting takes place prior to 23 months of age. Estimates of the magnitude of association with wealth, education and improved toilet use from HAZ regressions are systematically larger in the sample of children 24-59 months than in the 0-23 month or 0-59 month samples; the reverse is true for WHZ regressions. CONCLUSIONS Previous observational analyses appear to substantially underestimate the protective impacts of a wide range of underlying determinants on stunting. Conversely, wasting rates are typically low for children 24-59 months, implying that associations between underlying conditions and wasting may be stronger for children 0-23 months of age. Such analyses should pay closer attention to age disaggregation; researchers should be aware of the age effect reported in the current study and present analysis stratified by age.
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Affiliation(s)
- Harold Alderman
- International Food Policy Research Institute, Washington, District of Columbia, United States of America
| | - Derek Headey
- International Food Policy Research Institute, Washington, District of Columbia, United States of America
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Nielsen JN, Olney DK, Ouedraogo M, Pedehombga A, Rouamba H, Yago-Wienne F. Process evaluation improves delivery of a nutrition-sensitive agriculture programme in Burkina Faso. MATERNAL AND CHILD NUTRITION 2017; 14:e12573. [PMID: 29278449 DOI: 10.1111/mcn.12573] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 10/25/2017] [Accepted: 11/06/2017] [Indexed: 11/29/2022]
Abstract
Evidence is emerging from rigorous evaluations about the effectiveness of nutrition-sensitive agriculture programmes in improving nutritional outcomes. Additional evidence can elucidate how different programme components and pathways contribute and can be optimized for impact. The International Food Policy Research Institute, with Helen Keller International, designed a comprehensive framework to evaluate the delivery, utilization, and impact of Helen Keller International's enhanced homestead food production programme in Burkina Faso. After 18 months of implementation, a process evaluation was conducted to examine programme impact pathways, using key informant and semistructured interviews with implementing agents and beneficiaries, and with residents of control communities. Data were analyzed by International Food Policy Research Institute and reviewed with project managers and partners through multiple workshops to identify opportunities to strengthen implementation. Findings illuminated gaps between intended and actual delivery schemes, including input constraints, knowledge gaps among community agents in agriculture and young child nutrition practices, and lower than expected activity by community volunteers. In response, staff developed measures to overcome water constraints and expand vegetable and poultry production, retrained volunteers in certain techniques of food production and counselling for nutrition behaviour change, added small incentives to motivate volunteers, and shaped both immediate and long-term changes to the programme model. Working closely with International Food Policy Research Institute on the evaluation activities also expanded the repertoire of research methods and skills of Helen Keller International staff. Process evaluation can strengthen programme delivery, utilization, and design. Collaboration between researchers and implementers can improve programme effectiveness, project staff capacity, and advance delivery science.
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Affiliation(s)
| | - Deanna K Olney
- International Food Policy Research Institute, Washington, D.C., District of Columbia, USA
| | | | - Abdoulaye Pedehombga
- Helen Keller International, Ouagadougou, Burkina Faso.,Agence de Formation, de Recherche, et d'Expertise en Santé pour l'Afrique, Ouagadougou, Burkina Faso
| | - Hippolyte Rouamba
- Helen Keller International, Ouagadougou, Burkina Faso.,Center for Human Services, University Research Co., Ouagadougou, Burkina Faso
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Kabunga NS, Ghosh S, Webb P. Does ownership of improved dairy cow breeds improve child nutrition? A pathway analysis for Uganda. PLoS One 2017; 12:e0187816. [PMID: 29125871 PMCID: PMC5681260 DOI: 10.1371/journal.pone.0187816] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 10/26/2017] [Indexed: 11/22/2022] Open
Abstract
The promotion of livestock production is widely believed to support enhanced diet quality and child nutrition, but the empirical evidence for this causal linkage remains narrow and ambiguous. This study examines whether adoption of improved dairy cow breeds is linked to farm-level outcomes that translate into household-level benefits including improved child nutrition outcomes in Uganda. Using nationwide data from Uganda’s National Panel Survey, propensity score matching is used to create an unbiased counterfactual, based on observed characteristics, to assess the net impacts of improved dairy cow adoption. All estimates were tested for robustness and sensitivity to variations in observable and unobservable confounders. Results based on the matched samples showed that households adopting improved dairy cows significantly increased milk yield—by over 200% on average. This resulted in higher milk sales and milk intakes, demonstrating the potential of this agricultural technology to both integrate households into modern value chains and increase households’ access to animal source foods. Use of improved dairy cows increased household food expenditures by about 16%. Although undernutrition was widely prevalent in the study sample and in matched households, the adoption of improved dairy cows was associated with lower child stunting in adopter household. In scale terms, results also showed that holding larger farms tends to support adoption, but that this also stimulates the household’s ability to achieve gains from adoption, which can translate into enhanced nutrition.
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Affiliation(s)
- Nassul S. Kabunga
- International Food Policy Research Institute (IFPRI), Kampala, Uganda
- * E-mail:
| | - Shibani Ghosh
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States of America
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States of America
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Qualitative Studies of Infant and Young Child Feeding in Lower-Income Countries: A Systematic Review and Synthesis of Dietary Patterns. Nutrients 2017; 9:nu9101140. [PMID: 29057842 PMCID: PMC5691756 DOI: 10.3390/nu9101140] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/06/2017] [Accepted: 10/12/2017] [Indexed: 11/16/2022] Open
Abstract
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.
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Grain legume cultivation and children's dietary diversity in smallholder farming households in rural Ghana and Kenya. Food Secur 2017; 9:1053-1071. [PMID: 32952744 PMCID: PMC7473086 DOI: 10.1007/s12571-017-0720-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Boosting smallholder food production can potentially improve children’s nutrition in rural Sub-Saharan Africa through a production-own consumption pathway and an income-food purchase pathway. Rigorously designed studies are needed to provide evidence for nutrition impact, but are often difficult to implement in agricultural projects.Within the framework of a large agricultural development project supporting legume production (N2Africa), we studied the potential to improve children’s dietary diversity by comparing N2Africa and non-N2Africa households in a cross-sectional quasi-experimental design, followed by structural equation modelling (SEM) and focus group discussions in rural Ghana and Kenya. Comparing N2Africa and non-N2Africa households, we found that participating in N2Africa was not associated with improved dietary diversity of children. However, for soybean, SEM indicated a relatively good fit to the posteriori model in Kenya but not in Ghana, and in Kenya only the production-own consumption pathway was fully supported, with no effect through the income-food purchase pathway. Results are possibly related to differences in the food environment between the two countries, related to attribution of positive characteristics to soybean, the variety of local soybean-based dishes, being a new crop or not, women’s involvement in soybean cultivation, the presence of markets, and being treated as a food or cash crop. These findings confirm the importance of the food environment for translation of enhanced crop production into improved human nutrition. This study also shows that in a situation where rigorous study designs cannot be implemented, SEM is a useful option to analyse whether agriculture projects have the potential to improve nutrition.
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Cunningham K, Singh A, Pandey Rana P, Brye L, Alayon S, Lapping K, Gautam B, Underwood C, Klemm RDW. Suaahara in Nepal: An at-scale, multi-sectoral nutrition program influences knowledge and practices while enhancing equity. MATERNAL & CHILD NUTRITION 2017; 13:e12415. [PMID: 28058772 PMCID: PMC6866152 DOI: 10.1111/mcn.12415] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/25/2016] [Accepted: 11/14/2016] [Indexed: 12/30/2022]
Abstract
The burden of undernutrition in South Asia is greater than anywhere else. Policies and programmatic efforts increasingly address health and non-health determinants of undernutrition. In Nepal, one large-scale integrated nutrition program, Suaahara, aimed to reduce undernutrition among women and children in the 1,000-day period, while simultaneously addressing inequities. In this study, we use household-level process evaluation data (N = 480) to assess levels of exposure to program inputs and levels of knowledge and practices related to health, nutrition, and water, sanitation, and hygiene (WASH). We also assess Suaahara's effect on the differences between disadvantaged (DAG) and non-disadvantaged households in exposure, knowledge, and practice indicators. All regression models were adjusted for potential confounders at the child-, maternal-, and household levels, as well as clustering. We found a higher prevalence of almost all exposure and knowledge indicators and some practice indicators in Suaahara areas versus comparison areas. A higher proportion of DAG households in Suaahara areas reported exposure, were knowledgeable, and practiced optimal behaviors related to nearly all maternal and child health, nutrition, and WASH indicators than DAG households in non-Suaahara areas and sometimes even than non-DAG households in Suaahara areas. Moreover, differences in some of these indicators between DAG and non-DAG households were significantly smaller in Suaahara areas than in comparison areas. These results indicate that large-scale integrated interventions can influence nutrition-related knowledge and practices, while simultaneously reducing inequities.
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Affiliation(s)
| | | | | | - Laura Brye
- Suaahara/Helen Keller InternationalKathmanduNepal
| | | | | | | | - Carol Underwood
- Johns Hopkins Bloomberg School of Public HealthBaltimore, MarylandUSA
| | - Rolf D. W. Klemm
- Johns Hopkins Bloomberg School of Public HealthBaltimore, MarylandUSA
- Helen Keller InternationalWashington, D.C.USA
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Krebs NF, Lozoff B, Georgieff MK. Neurodevelopment: The Impact of Nutrition and Inflammation During Infancy in Low-Resource Settings. Pediatrics 2017; 139:S50-S58. [PMID: 28562248 DOI: 10.1542/peds.2016-2828g] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 11/24/2022] Open
Abstract
Infancy and early childhood (ie, birth through age 24 months) represent a period of life with both exquisite opportunity and vulnerability for neurodevelopment. This is due to rapid brain development, both anatomic and functional, as well as to high nutrient requirements during a time of dependence on human milk and complementary foods. Complex interactions exist among nutrition, social, and physical environments and exposures. The newborn brain also reflects maternal exposures that occurred as the product of many interacting forces during gestation. Connections between nutrient use and acute and chronic inflammation are increasingly recognized, but the evidence base linking both nutrition and inflammation to neurodevelopment is relatively modest and quite limited for this young age group specifically. This article provides an overview of key interactions of nutritional requirements relevant to brain development and function; nutritional vulnerabilities related to maternal nutritional status and function; and the impact of environmental exposures and inflammation on nutrient homeostasis and neurodevelopment during this critical developmental window.
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Affiliation(s)
- Nancy F Krebs
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado;
| | - Betsy Lozoff
- Center for Human Growth and Development and.,Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan; and
| | - Michael K Georgieff
- Division of Neonatology, University of Minnesota School of Medicine, Minneapolis, Minnesota
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Rawat R, Nguyen PH, Tran LM, Hajeebhoy N, Nguyen HV, Baker J, Frongillo EA, Ruel MT, Menon P. Social Franchising and a Nationwide Mass Media Campaign Increased the Prevalence of Adequate Complementary Feeding in Vietnam: A Cluster-Randomized Program Evaluation. J Nutr 2017; 147:670-679. [PMID: 28179488 PMCID: PMC5368587 DOI: 10.3945/jn.116.243907] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/13/2016] [Accepted: 01/13/2017] [Indexed: 01/25/2023] Open
Abstract
Background: Rigorous evaluations of health system-based interventions in large-scale programs to improve complementary feeding (CF) practices are limited. Alive & Thrive applied principles of social franchising within the government health system in Vietnam to improve the quality of interpersonal counseling (IPC) for infant and young child feeding combined with a national mass media (MM) campaign and community mobilization (CM).Objective: We evaluated the impact of enhanced IPC + MM + CM (intensive) compared with standard IPC + less-intensive MM and CM (nonintensive) on CF practices and anthropometric indicators.Methods: A cluster-randomized, nonblinded evaluation design with cross-sectional surveys (n = ∼500 children aged 6-23.9 mo and ∼1000 children aged 24-59.9 mo/group) implemented at baseline (2010) and endline (2014) was used. Difference-in-difference estimates (DDEs) of impact were calculated for intent-to-treat (ITT) analyses and modified per-protocol analyses (MPAs; mothers who attended the social franchising at least once: 62%).Results: Groups were similar at baseline. In ITT analyses, there were no significant differences between groups in changes in CF practices over time. In the MPAs, greater improvements in the intensive than in the nonintensive group were seen for minimum dietary diversity [DDE: 6.4 percentage points (pps); P < 0.05] and minimum acceptable diet (8.0 pps; P < 0.05). Significant stunting declines occurred in both intensive (7.1 pps) and nonintensive (5.4 pps) groups among children aged 24-59.9 mo, with no differential decline.Conclusions: When combined with MM and CM, an at-scale social franchising approach to improve IPC, delivered through the existing health care system, significantly improved CF practices, but not child growth, among mothers who used counseling services at least once. A greater impact may be achieved with strategies designed to increase service utilization. This trial was registered at clinicaltrials.gov as NCT01676623.
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Affiliation(s)
- Rahul Rawat
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Phuong Hong Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC;
| | | | | | | | | | | | - Marie T Ruel
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
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41
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Frongillo EA, Nguyen PH, Saha KK, Sanghvi T, Afsana K, Haque R, Baker J, Ruel MT, Rawat R, Menon P. Large-Scale Behavior-Change Initiative for Infant and Young Child Feeding Advanced Language and Motor Development in a Cluster-Randomized Program Evaluation in Bangladesh. J Nutr 2017; 147:256-263. [PMID: 28031374 DOI: 10.3945/jn.116.240861] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 09/14/2016] [Accepted: 12/05/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Promoting adequate nutrition through interventions to improve infant and young child feeding (IYCF) has the potential to contribute to child development. OBJECTIVE We examined whether an intensive intervention package that was aimed at improving IYCF at scale through the Alive & Thrive initiative in Bangladesh also advanced language and gross motor development, and whether advancements in language and gross motor development were explained through improved complementary feeding. METHODS A cluster-randomized design compared 2 intervention packages: intensive interpersonal counseling on IYCF, mass media campaign, and community mobilization (intensive) compared with usual nutrition counseling and mass media campaign (nonintensive). Twenty subdistricts were randomly assigned to receive either the intensive or the nonintensive intervention. Household surveys were conducted at baseline (2010) and at endline (2014) in the same communities (n = ∼4000 children aged 0-47.9 mo for each round). Child development was measured by asking mothers if their child had reached each of multiple milestones, with some observed. Linear regression accounting for clustering was used to derive difference-in-differences (DID) impact estimates, and path analysis was used to examine developmental advancement through indicators of improved IYCF and other factors. RESULTS The DID in language development between intensive and nonintensive groups was 1.05 milestones (P = 0.001) among children aged 6-23.9 mo and 0.76 milestones (P = 0.038) among children aged 24-47.9 mo. For gross motor development, the DID was 0.85 milestones (P = 0.035) among children aged 6-23.9 mo. The differences observed corresponded to age- and sex-adjusted effect sizes of 0.35 for language and 0.23 for gross motor development. Developmental advancement at 6-23.9 mo was partially explained through improved minimum dietary diversity and the consumption of iron-rich food. CONCLUSIONS Intensive IYCF intervention differentially advanced language and gross motor development, which was partially explained through improved complementary feeding. Measuring a diverse set of child outcomes, including functional outcomes such as child development, is important when evaluating integrated nutrition programs. This trial was registered at clinicaltrials.gov as NCT01678716.
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Affiliation(s)
| | - Phuong H Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Kuntal K Saha
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | | | | | | | | | - Marie T Ruel
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Rahul Rawat
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
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Nguyen PH, Headey D, Frongillo EA, Tran LM, Rawat R, Ruel MT, Menon P. Changes in Underlying Determinants Explain Rapid Increases in Child Linear Growth in Alive & Thrive Study Areas between 2010 and 2014 in Bangladesh and Vietnam. J Nutr 2017; 147:462-469. [PMID: 28122930 PMCID: PMC5320405 DOI: 10.3945/jn.116.243949] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/07/2016] [Accepted: 01/03/2017] [Indexed: 12/01/2022] Open
Abstract
Background: Child linear growth sometimes improves in both intervention and comparison groups in evaluations of nutrition interventions, possibly because of spillover intervention effects to nonintervention areas or improvements in underlying determinants of nutritional change in both areas. Objective: We aimed to understand what changes in underlying socioeconomic characteristics and behavioral factors are important in explaining improvements in child linear growth. Methods: Baseline (2010) and endline (2014) surveys from the Alive & Thrive impact evaluation were used to identify the underlying determinants of height-for-age z scores (HAZs) among children aged 24–48 mo in Bangladesh (n = 4311) and 24–59 mo in Vietnam (n = 4002). Oaxaca-Blinder regression decompositions were used to examine which underlying determinants contributed to HAZ changes over time. Results: HAZs improved significantly between 2010 and 2014 in Bangladesh (∼0.18 SDs) and Vietnam (0.25 SDs). Underlying determinants improved substantially over time and were larger in Vietnam than in Bangladesh. Multiple regression models revealed significant associations between changes in HAZs and socioeconomic status (SES), food security, maternal education, hygiene, and birth weight in both countries. Changes in HAZs were significantly associated with maternal nutrition knowledge and child dietary diversity in Bangladesh, and with prenatal visits in Vietnam. Improvements in maternal nutrition knowledge in Bangladesh accounted for 20% of the total HAZ change, followed by maternal education (13%), SES (12%), hygiene (10%), and food security (9%). HAZ improvements in Vietnam were accounted for by changes in SES (26%), prenatal visits (25%), hygiene (19%), child birth weight (10%), and maternal education (7%). The decomposition models in both countries performed well, explaining >75% of the HAZ changes. Conclusions: Decomposition is a useful and simple technique for analyzing nonintervention drivers of nutritional change in intervention and comparison areas. Improvements in underlying determinants explained rapid improvements in HAZs between 2010 and 2014 in Bangladesh and Vietnam.
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC;
| | - Derek Headey
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Edward A Frongillo
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC; and
| | | | - Rahul Rawat
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Marie T Ruel
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
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Kim SS, Rawat R, Mwangi EM, Tesfaye R, Abebe Y, Baker J, Frongillo EA, Ruel MT, Menon P. Exposure to Large-Scale Social and Behavior Change Communication Interventions Is Associated with Improvements in Infant and Young Child Feeding Practices in Ethiopia. PLoS One 2016; 11:e0164800. [PMID: 27755586 PMCID: PMC5068829 DOI: 10.1371/journal.pone.0164800] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 10/01/2016] [Indexed: 11/18/2022] Open
Abstract
Optimal breastfeeding (BF) practices in Ethiopia are far below the government’s targets, and complementary feeding practices are poor. The Alive & Thrive initiative aimed to improve infant and young child feeding (IYCF) practices through large-scale implementation of social and behavior change communication interventions in four regions of Ethiopia. The study assessed the effects of the interventions on IYCF practices and anthropometry over time in two regions–Southern Nations, Nationalities and Peoples Region and Tigray. A pre- and post-intervention adequacy evaluation design was used; repeated cross-sectional surveys of households with children aged 0–23.9 mo (n = 1481 and n = 1494) and with children aged 24–59.9 mo (n = 1481 and n = 1475) were conducted at baseline (2010) and endline (2014), respectively. Differences in outcomes over time were estimated using regression models, accounting for clustering and covariates. Plausibility analyses included tracing recall of key messages and promoted foods and dose-response analyses. We observed improvements in most WHO-recommended IYCF indicators. Early BF initiation and exclusive BF increased by 13.7 and 9.4 percentage points (pp), respectively. Differences for timely introduction of complementary foods, minimum dietary diversity (MDD), minimum meal frequency (MMF), minimum acceptable diet (MAD), and consumption of iron-rich foods were 22.2, 3.3, 26.2, 3.5, and 2.7 pp, respectively. Timely introduction and intake of foods promoted by the interventions improved significantly, but anthropometric outcomes did not. We also observed a dose-response association between health post visits and early initiation of BF (OR: 1.8); higher numbers of home visits by community volunteers and key messages recalled were associated with 1.8–4.4 times greater odds of achieving MDD, MMF, and MAD, and higher numbers of radio spots heard were associated with 3 times greater odds of achieving MDD and MAD. The interventions were associated with plausible improvements in IYCF practices, but large gaps in improving children’s diets in Ethiopia remain, particularly during complementary feeding.
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Affiliation(s)
- Sunny S. Kim
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, D.C., United States of America
- * E-mail:
| | - Rahul Rawat
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
| | - Edina M. Mwangi
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, D.C., United States of America
| | - Roman Tesfaye
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Addis Ababa, Ethiopia
| | | | - Jean Baker
- Alive & Thrive, FHI 360, Washington, D.C., United States of America
| | - Edward A. Frongillo
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, United States of America
| | - Marie T. Ruel
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, D.C., United States of America
| | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, New Delhi, India
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Menon P, Nguyen PH, Saha KK, Khaled A, Kennedy A, Tran LM, Sanghvi T, Hajeebhoy N, Baker J, Alayon S, Afsana K, Haque R, Frongillo EA, Ruel MT, Rawat R. Impacts on Breastfeeding Practices of At-Scale Strategies That Combine Intensive Interpersonal Counseling, Mass Media, and Community Mobilization: Results of Cluster-Randomized Program Evaluations in Bangladesh and Viet Nam. PLoS Med 2016; 13:e1002159. [PMID: 27780198 PMCID: PMC5079648 DOI: 10.1371/journal.pmed.1002159] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 09/19/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite recommendations supporting optimal breastfeeding, the number of women practicing exclusive breastfeeding (EBF) remains low, and few interventions have demonstrated implementation and impact at scale. Alive & Thrive was implemented over a period of 6 y (2009-2014) and aimed to improve breastfeeding practices through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM) intervention components delivered at scale in the context of policy advocacy (PA) in Bangladesh and Viet Nam. In Bangladesh, IPC was delivered through a large non-governmental health program; in Viet Nam, it was integrated into government health facilities. This study evaluated the population-level impact of intensified IPC, MM, CM, and PA (intensive) compared to standard nutrition counseling and less intensive MM, CM, and PA (non-intensive) on breastfeeding practices in these two countries. METHODS AND FINDINGS A cluster-randomized evaluation design was employed in each country. For the evaluation sample, 20 sub-districts in Bangladesh and 40 communes in Viet Nam were randomized to either the intensive or the non-intensive group. Cross-sectional surveys (n ~ 500 children 0-5.9 mo old per group per country) were implemented at baseline (June 7-August 29, 2010, in Viet Nam; April 28-June 26, 2010, in Bangladesh) and endline (June 16-August 30, 2014, in Viet Nam; April 20-June 23, 2014, in Bangladesh). Difference-in-differences estimates (DDEs) of impact were calculated, adjusting for clustering. In Bangladesh, improvements were significantly greater in the intensive compared to the non-intensive group for the proportion of women who reported practicing EBF in the previous 24 h (DDE 36.2 percentage points [pp], 95% CI 21.0-51.5, p < 0.001; prevalence in intensive group rose from 48.5% to 87.6%) and engaging in early initiation of breastfeeding (EIBF) (16.7 pp, 95% CI 2.8-30.6, p = 0.021; 63.7% to 94.2%). In Viet Nam, EBF increases were greater in the intensive group (27.9 pp, 95% CI 17.7-38.1, p < 0.001; 18.9% to 57.8%); EIBF declined (60.0% to 53.2%) in the intensive group, but less than in the non-intensive group (57.4% to 40.6%; DDE 10.0 pp, 95% CI -1.3 to 21.4, p = 0.072). Our impact estimates may underestimate the full potential of such a multipronged intervention because the evaluation lacked a "pure control" area with no MM or national/provincial PA. CONCLUSIONS At-scale interventions combining intensive IPC with MM, CM, and PA had greater positive impacts on breastfeeding practices in Bangladesh and Viet Nam than standard counseling with less intensive MM, CM, and PA. To our knowledge, this study is the first to document implementation and impacts of breastfeeding promotion at scale using rigorous evaluation designs. Strategies to design and deliver similar programs could improve breastfeeding practices in other contexts. TRIAL REGISTRATION ClinicalTrials.gov NCT01678716 (Bangladesh) and NCT01676623 (Viet Nam).
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Affiliation(s)
- Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America
| | - Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America
| | - Kuntal Kumar Saha
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America
| | - Adiba Khaled
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America
| | - Andrew Kennedy
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America
| | - Lan Mai Tran
- Alive & Thrive, FHI360, Washington, District of Columbia, United States of America
| | - Tina Sanghvi
- Alive & Thrive, FHI360, Washington, District of Columbia, United States of America
| | - Nemat Hajeebhoy
- Alive & Thrive, FHI360, Washington, District of Columbia, United States of America
| | - Jean Baker
- Alive & Thrive, FHI360, Washington, District of Columbia, United States of America
| | - Silvia Alayon
- Save the Children, Washington, District of Columbia, United States of America
| | | | | | - Edward A. Frongillo
- University of South Carolina, Columbia, South Carolina, United States of America
| | - Marie T. Ruel
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America
| | - Rahul Rawat
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America
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Walters D, Horton S, Siregar AYM, Pitriyan P, Hajeebhoy N, Mathisen R, Phan LTH, Rudert C. The cost of not breastfeeding in Southeast Asia. Health Policy Plan 2016; 31:1107-16. [PMID: 27107295 PMCID: PMC5013784 DOI: 10.1093/heapol/czw044] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2016] [Indexed: 01/25/2023] Open
Abstract
Rates of exclusive breastfeeding are slowly increasing, but remain suboptimal globally despite the health and economic benefits. This study estimates the costs of not breastfeeding across seven countries in Southeast Asia and presents a cost-benefit analysis of a modeled comprehensive breastfeeding strategy in Viet Nam, based on a large programme. There have been very few such studies previously for low- and middle-income countries. The estimates used published data on disease prevalence and breastfeeding patterns for the seven countries, supplemented by information on healthcare costs from representative institutions. Modelling of costs of not breastfeeding used estimated effects obtained from systematic reviews and meta-analyses. Modelling of cost-benefit for Viet Nam used programme data on costs combined with effects from a large-scale cluster randomized breastfeeding promotion intervention with controls. This study found that over 12 400 preventable child and maternal deaths per year in the seven countries could be attributed to inadequate breastfeeding. The economic benefits associated with potential improvements in cognition alone, through higher IQ and earnings, total $1.6 billion annually. The loss exceeds 0.5% of Gross National Income in the country with the lowest exclusive breastfeeding rate (Thailand). The potential savings in health care treatment costs ($0.3 billion annually) from reducing the incidence of diarrhoea and pneumonia could help offset the cost of breastfeeding promotion. Based on the data available and authors' assumptions, investing in a national breastfeeding promotion strategy in Viet Nam could result in preventing 200 child deaths per year and generate monetary benefits of US$2.39 for every US$1, or a 139% return on investment. These encouraging results suggest that there are feasible and affordable opportunities to accelerate progress towards achieving the Global Nutrition Target for exclusive breastfeeding by 2025.
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Affiliation(s)
- Dylan Walters
- Canadian Centre for Health Economics, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Susan Horton
- Department of Economics, University of Waterloo, Waterloo, Ontario, Canada
| | | | - Pipit Pitriyan
- Department of Economics, Padjadjaran University, Badung, Indonesia
| | | | | | | | - Christiane Rudert
- Department of Nutrition, UNICEF East Asia and the Pacific Regional Office, Bangkok, Thailand
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Menon P, Nguyen PH, Saha KK, Khaled A, Sanghvi T, Baker J, Afsana K, Haque R, Frongillo EA, Ruel MT, Rawat R. Combining Intensive Counseling by Frontline Workers with a Nationwide Mass Media Campaign Has Large Differential Impacts on Complementary Feeding Practices but Not on Child Growth: Results of a Cluster-Randomized Program Evaluation in Bangladesh. J Nutr 2016; 146:2075-2084. [PMID: 27581575 PMCID: PMC5037872 DOI: 10.3945/jn.116.232314] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/27/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Complementary feeding (CF) contributes to child growth and development, but few CF programs are delivered at scale. Alive & Thrive addressed this in Bangladesh through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM). OBJECTIVE The objective was to evaluate the impact of providing IPC + MM + CM (intensive) compared with standard nutrition counseling + less intensive MM + CM (nonintensive) on CF practices and anthropometric measurements. METHODS We used a cluster-randomized, nonblinded evaluation with cross-sectional surveys [n = ∼600 and 1090 children 6-23.9 mo and 24-47.9 mo/group, respectively, at baseline (2010) and n = ∼500 and 1100 children of the same age, respectively, at endline (2014)]. We derived difference-in-difference impact estimates (DDEs), adjusting for geographic clustering, infant age, sex, differences in baseline characteristics, and differential change in characteristics over time. RESULTS Groups were similar at baseline. CF improvements were significantly greater in the intensive than in the nonintensive group [DDEs: 16.3, 14.7, 22.0, and 24.6 percentage points (pp) for minimum dietary diversity, minimum meal frequency, minimum acceptable diet, and consumption of iron-rich foods, respectively]. In the intensive group, CF practices were high: 50.4% for minimum acceptable diet, 63.8% for minimum diet diversity, 75.1% for minimum meal frequency, and 78.5% for consumption of iron-rich foods. Timely introduction of foods improved. Significant, nondifferential stunting declines occurred in intensive (6.2 pp) and nonintensive (5.2 pp) groups in children 24-47.9 mo. CONCLUSIONS The intensive program substantially improved CF practices compared with the nonintensive program. Large-scale program delivery was feasible and, with the use of multiple platforms, reached 1.7 million households. Nondifferential impacts on stunting were likely due to rapid positive secular trends in Bangladesh. Accelerating linear growth further could require accompanying interventions. This study establishes proof of concept for large-scale behavior change interventions to improve child feeding. This trial was registered at clinicaltrials.gov as NCT01678716.
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Affiliation(s)
- Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC;
| | - Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Kuntal Kumar Saha
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Adiba Khaled
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | | | | | | | | | | | - Marie T Ruel
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Rahul Rawat
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC
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Nguyen PH, Kim SS, Nguyen TT, Hajeebhoy N, Tran LM, Alayon S, Ruel MT, Rawat R, Frongillo EA, Menon P. Exposure to mass media and interpersonal counseling has additive effects on exclusive breastfeeding and its psychosocial determinants among Vietnamese mothers. MATERNAL AND CHILD NUTRITION 2016; 12:713-25. [PMID: 27334544 PMCID: PMC5094561 DOI: 10.1111/mcn.12330] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 03/08/2016] [Accepted: 03/31/2016] [Indexed: 11/28/2022]
Abstract
The pathways through which behavior change interventions impact breastfeeding practices have not been well studied. This study aimed to examine: (1) the effects of exposure to mass media and interpersonal counseling on exclusive breastfeeding (EBF) and hypothesized psychosocial determinants (i.e. knowledge, intention, beliefs, social norms, and self-efficacy); and (2) the pathways through which exposure to mass media and interpersonal counseling are associated with EBF. We used survey data from mothers with children < 2 year (n = 2045) from the 2013 process evaluation of Alive & Thrive's program in Viet Nam. Multiple linear regression analyses and structural equation modeling were used to estimate effects. Exposure to mass media only, interpersonal counseling only, both or neither was 51%, 5%, 19% and 25%, respectively. Exposure to both mass media and interpersonal counseling had additive effects on EBF as well as on related psychosocial factors, compared with no exposure. For example, EBF prevalence was 26.1 percentage points (pp) higher in the group that received interpersonal counseling only, 3.9 pp higher in the mass media group and 31.8 pp higher in the group that received both interventions. As hypothesized, more than 90% of the total effect of the two interventions on EBF was explained by the psychosocial factors measured. Our findings suggest that combining different behavior change interventions leads to greater changes in psychosocial factors, which in turn positively affects breastfeeding behaviors.
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Affiliation(s)
- Phuong H Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, USA.
| | - Sunny S Kim
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, USA
| | | | | | | | | | - Marie T Ruel
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, USA
| | - Rahul Rawat
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, USA
| | - Edward A Frongillo
- Health Promotion, Education, Behavior, University of South Carolina, Columbia, South Carolina, USA
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, USA
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Shafique S, Sellen DW, Lou W, Jalal CS, Jolly SP, Zlotkin SH. Mineral- and vitamin-enhanced micronutrient powder reduces stunting in full-term low-birth-weight infants receiving nutrition, health, and hygiene education: a 2 × 2 factorial, cluster-randomized trial in Bangladesh. Am J Clin Nutr 2016; 103:1357-69. [PMID: 27053383 DOI: 10.3945/ajcn.115.117770] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 03/02/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The causes of stunting are complex but likely include prenatal effects, inadequate postnatal nutrient intake, and recurrent infections. Low-birth-weight (LBW) infants are at high risk of stunting. More than 25% of live births in low- and middle-income countries are at full term with low birth weight (FT-LBW). Evidence on the efficacy of specific interventions to enhance growth in this vulnerable group remains scant. OBJECTIVE We investigated the independent and combined effects of a directed use of a water-based hand sanitizer (HS) and a mineral- and vitamin-enhanced micronutrient powder (MNP) (22 minerals and vitamins) to prevent infections and improve nutrient intake to reduce stunting in FT-LBW infants. DESIGN The study was a prospective 2 × 2 factorial, cluster-randomized trial in 467 FT-LBW infants during 2 periods: from 0 to 5 mo postpartum (0-180 d postpartum) and from 6 to 12 mo postpartum (181-360 d postpartum) with the use of 48 clusters. All groups received the same general nutrition, health, and hygiene education (NHHE) at enrollment and throughout the 12 mo. Group assignments initially included the following 2 groups: no HS (control) group or HS from 0 to 5 mo postpartum. These assignments were followed by further divisions into the following 4 groups from 6 to 12 mo postpartum: 1) no HS and no MNP (control), 2) HS only, 3) MNP only, and 4) HS and MNP. RESULTS When delivered in combination with NHHE, the use of an HS showed no additional benefit in reducing indicators of infection in the first or second half of infancy or the likelihood of stunting at 12 mo postpartum. FT-LBW infants who received the MNP (with or without the HS) were significantly less likely to be stunted at 12 mo than were controls (OR: 0.35; 95% CI: 0.15, 0.84; P = 0.017). CONCLUSIONS The use of a mineral- and vitamin-enhanced MNP significantly reduced stunting in FT-LBW infants in this high-risk setting. The use of a water-based HS did not have an additive effect. This trial was registered at clinicaltrials.gov as NCT01455636.
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Affiliation(s)
- Sohana Shafique
- Departments of Nutritional Sciences and Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; and
| | - Daniel W Sellen
- Departments of Nutritional Sciences and Department of Anthropology, and Dalla Lana School of Public Health, University of Toronto, Toronto Canada; Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; and
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto Canada
| | | | - Saira P Jolly
- Research and Evaluation Division, BRAC, Dhaka, Bangladesh
| | - Stanley H Zlotkin
- Departments of Nutritional Sciences and Pediatrics, Faculty of Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto Canada; Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; and
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Nguyen PH, Kim SS, Nguyen TT, Tran LM, Hajeebhoy N, Frongillo EA, Ruel MT, Rawat R, Menon P. Supply- and Demand-Side Factors Influencing Utilization of Infant and Young Child Feeding Counselling Services in Viet Nam. PLoS One 2016; 11:e0151358. [PMID: 26962856 PMCID: PMC4786102 DOI: 10.1371/journal.pone.0151358] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/26/2016] [Indexed: 11/17/2022] Open
Abstract
Adequate utilization of services is critical to maximize the impact of counselling on infant and young child feeding (IYCF), but little is known about factors affecting utilization. Our study examined supply- and demand-side factors associated with the utilization of IYCF counselling services in Viet Nam. We used survey data from mothers with children <2y (n = 1,008) and health staff (n = 60) from the evaluation of a program that embedded IYCF counseling into the existing government health system. The frequency of never users, one-time users, repeat users, and achievers of the recommended minimum number of visits at health facilities were 45.1%, 13.0%, 28.4% and 13.5%, respectively. Poisson regression showed that demand-generation strategies, especially invitation cards, were the key factors determining one-time use (Prevalence ratio, PR 3.0, 95% CI: 2.2-4.2), repeated use (PR 3.2, 95% CI: 2.4-4.2), and achievement of minimum visits (PR 5.5, 95% CI: 3.6-8.4). Higher maternal education was associated with higher utilization both for one-time and repeated use. Being a farmer, belonging to an ethnic minority, and having a wasted child were associated with greater likelihood of achieving the minimum recommended number of visits, whereas child stunting or illness were not. Distance to health center was a barrier to repeated visits. Among supply-side factors, good counselling skills (PR: 1.3-1.8) was the most important factor associated with any service use, whereas longer employment duration and greater work pressure of health center staff were associated with lower utilization. Population attributable risk estimations showed that an additional 25% of the population would have achieved the minimum number of visits if exposed to three demand-generation strategies, and further increased to 49% if the health staff had good counseling skills and low work pressure. Our study provides evidence that demand-generation strategies are essential to increase utilization of facility-based IYCF counselling services in Viet Nam, and may be relevant for increasing and sustaining use of nutrition services in similar contexts.
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Affiliation(s)
- Phuong H Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | - Sunny S Kim
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | | | | | | | - Edward A Frongillo
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, SC, United States of America
| | - Marie T Ruel
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | - Rahul Rawat
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
| | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, United States of America
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Nguyen PH, Hoang MV, Hajeebhoy N, Tran LM, Le CH, Menon P, Rawat R. Maternal willingness to pay for infant and young child nutrition counseling services in Vietnam. Glob Health Action 2015; 8:28001. [PMID: 26328947 PMCID: PMC4557091 DOI: 10.3402/gha.v8.28001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 07/18/2015] [Accepted: 07/22/2015] [Indexed: 11/14/2022] Open
Abstract
Background Alive & Thrive Vietnam, a 6-year initiative (2009–2014), has developed and incorporated elements of social franchising into government health services to provide high-quality nutrition counseling services to improve infant and young child feeding practices. One element of franchising that has not yet been implemented is fee for service, which is a potential financing mechanism for sustaining services in the long run. Objective This research aims to estimate maternal willingness to pay (WTP) for nutrition counseling services and to examine potential factors associated with their WTP. Design and methods Data were drawn from an impact evaluation survey of 2,511 women with a child <2 years old from four provinces in Vietnam. An iterative bidding technique was employed to explore individual WTP. The first bid was defined as VND 20,000 (~US$ 1), which was approximately the level of the actual service cost. Depending on the participant response, the bid increased or decreased. Finally, the respondents were asked about the highest price they would be willing to pay for the service. Results Overall, 92.6% of clients reported a need for nutrition counseling services for children <2 years. The WTP rates at bid levels of VND 5,000, 10,000, 20,000, 40,000, and 100,000 were 95.2, 94.4, 90.7, 68.9, and 33.4%, respectively. The mean and median of the maximum WTP were VND 58,500 and 50,000, respectively. In multiple regression models, WTP rates were higher among younger women, the Kinh majority group, and better educated and wealthier women. Conclusion A high demand for nutrition counseling coupled with a WTP by almost all segments of society would potentially cover costs of delivery for nutrition counseling services in Vietnam.
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Affiliation(s)
- Phuong H Nguyen
- International Food Policy Research Institute, Washington, DC, USA;
| | - Minh V Hoang
- Center for Health System Research, Hanoi Medical University, Hanoi, Vietnam
| | | | | | - Chung H Le
- Center for Health System Research, Hanoi Medical University, Hanoi, Vietnam
| | - Purnima Menon
- International Food Policy Research Institute, Washington, DC, USA
| | - Rahul Rawat
- International Food Policy Research Institute, Washington, DC, USA
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