Effectiveness of a nutrition education package in improving feeding practices, dietary adequacy and growth of infants and young children in rural Tanzania: rationale, design and methods of a cluster randomised trial

Designing a Contextualized Food-Based Strategy to Improve the Dietary Diversity of Children in Rural Farming Households in Central Uganda

BACKGROUND

Food-based strategies have a high potential of improving the diet quality and reducing the prevalence of nutrient deficiencies in agriculture-dependent communities. Their design is however complex with trade-offs that are rarely systematically presented to allow replication and efficient contextualization.

OBJECTIVE

The systematic design of a food-based strategy to improve the dietary diversity of children in rural farming communities in Uganda.

METHODS

The intervention mapping protocol was used to provide a systematic approach to developing theory-based and evidence-based intervention methods and strategy.

RESULTS

The priority behavioral and environmental determinants identified were related to food production, consumption, and efficacy while the personal determinants focused on knowledge, skills, self-efficacy, attitude, and outcome expectations. The aim of the resulting strategy was set to improve the availability, accessibility, and consumption of diverse foods, with a particular focus on production diversity, production practices, market access, and market diversity. Behaviour change methods were selected to enhance ability and self-efficacy, strategic goal setting, and provision of feedback. The strategy focused on household groups for learning, demonstration, practice, and social support. The validation showed that the determinants and actors incorporated in the strategy were important and relevant for improving the productivity, food availability, dietary diversity, livelihoods, and health of rural farming households and communities.

CONCLUSION

Application of the protocol yielded a contextualized food-based strategy that can be adjusted for use in other smallholder contexts in developing countries by piloting implementation plans based on the strategy; reassessing the key determinants and implementing the revised strategy; or replicating the whole design process.

Household food security, child dietary diversity and coping strategies among rural households. The case of Kole District in northern Uganda

Household food security, feeding practices, dietary diversity and coping strategies to household food insecurity are largely interconnected. Using a cross sectional study approach involving 162 mothers and care givers of children 0-36 months of age in Kole district of northern Uganda, this study examined the household food security status, child dietary diversity and household coping strategies. The study revealed that a slight majority of the households (55%) were food secure although with a low level of child dietary diversity experienced (68.1% for children 6-23 months age group and 55.3% for 24-36 months age group). We found that starch-based foods derived from cereals, roots and tubers were the most predominantly used food group in child feeding (82%), with limited consumption of other essential food groups, notably fruits, vegetables, meats and dairy products (18% combined). Additionally, only 57% of children 0 to 6 months old were receiving exclusive breastfeeding, and the introduction of complementary foods is often delayed and not well planned for those above 6 months of age. Results also showed that a wide range of coping strategies are employed however the major ones were, reliance on less preferred food (54.9%), limiting portions of meals (35.2%), reducing number of meals taken in a day (29%), and gathering wild fruits and harvesting immature crops (29.6%). It was observed that household food security is a strong determinant of child dietary diversity, may influence feeding practices and the range of coping strategies applicable to households when they experience food insecurity. Furthermore, nutritional education, household size and livelihood diversity play a significant role in determining household food security status, child dietary diversity and coping with food insecurity within rural households. In conclusion, addressing household food security, and coping strategies can play an important role in improving child feeding practices and dietary diversity in rural communities.

Lay health workers in primary and community health care for maternal and child health: identification and treatment of wasting in children

BACKGROUND

Since the early 2010s, there has been a push to enhance the capacity to effectively treat wasting in children through community-based service delivery models and thus reduce morbidity and mortality.

OBJECTIVES

To assess the effectiveness of identification and treatment of moderate and severe wasting in children aged five years or under by lay health workers working in the community compared with health providers working in health facilities.

SEARCH METHODS

We searched MEDLINE, CENTRAL, two other databases, and two ongoing trials registers to 24 September 2021. We also screened the reference lists of related systematic reviews and all included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies in children aged five years or under with moderate wasting (defined as weight-for-height Z-score (WHZ) below -2 but no lower than ≥ -3, or mid-upper-arm circumference (MUAC) below 125 mm but no lower than 115 mm, and no nutritional oedema) or severe wasting (WHZ below -3 or MUAC below 115 mm or nutritional oedema). Eligible interventions were: • identification by lay health workers (LHWs) of children with wasting (intervention 1); • identification by LHWs of children with wasting and medical complications needing referral (intervention 2); and • identification by LHWs of children with wasting without medical complications needing referral (intervention 3). Eligible comparators were: • identification and treatment of wasting by health professionals such as nurses or doctors (at health facilities); and • identification and treatment of wasting by health facility-based teams, including health professionals and LHWs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened trials, extracted data and assessed risk of bias using the Cochrane risk of bias tool (RoB 2) and Cochrane Effective Practice and Organisation of Care (EPOC) guidelines. We used a random-effects model to meta-analyse data, producing risk ratios (RRs) for dichotomous outcomes in trials with individual allocation, adjusted RRs for dichotomous outcomes in trials with cluster allocation (using the generic inverse variance method in Review Manager 5), and mean differences (MDs) for continuous outcomes. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included two RCTs and five non-RCTs. Six studies were from African countries, and one was from Pakistan. Six studies included children with severe wasting, and one included children with moderate wasting. All studies offered home-based ready-to-use therapeutic food treatment and monitoring. Children received antibiotics in three studies, vitamins or micronutrients in three studies, and deworming treatment in two studies. In three studies, the comparison arm involved LHWs screening children for malnutrition and referring them to health facilities for diagnosis and treatment. All the non-randomised studies had a high overall risk of bias. Interventions 1 and 2 Identification and referral for treatment by LHWs, compared with treatment by health professionals following self-referral, may result in little or no difference in the percentage of children who recover from moderate or severe wasting (MD 1.00%, 95% confidence interval (CI) -2.53 to 4.53; 1 RCT, 29,475 households; low certainty). Intervention 3 Compared with treatment by health professionals following identification by LHWs, identification and treatment of severe wasting in children by LHWs: • may slightly reduce improvement from severe wasting (RR 0.93, 95% CI 0.86 to 0.99; 1 RCT, 789 participants; low certainty); • may slightly increase non-response to treatment (RR 1.44, 95% CI 1.04 to 2.01; 1 RCT, 789 participants; low certainty); • may result in little or no difference in the number of children with WHZ above -2 on discharge (RR 0.94, 95% CI 0.28 to 3.18; 1 RCT, 789 participants; low certainty); • probably results in little or no difference in the number of children with WHZ between -3 and -2 on discharge (RR 1.09, 95% CI 0.87 to 1.36; 1 RCT, 789 participants; moderate certainty); • probably results in little or no difference in the number of children with WHZ below -3 (severe wasting) on discharge (RR 1.23, 95% CI 0.75 to 2.04; 1 RCT, 789 participants; moderate certainty); • probably results in little or no difference in the number of children with MUAC equal to or greater than 115 mm on discharge (RR 0.99, 95% CI 0.93 to 1.06; 1 RCT, 789 participants; moderate certainty); • results in little or no difference in weight gain per day (mean weight gain 0.50 g/kg/day higher, 95% CI 1.74 lower to 2.74 higher; 1 RCT, 571 participants; high certainty); • probably has little or no effect on relapse of severe wasting (RR 1.03, 95% CI 0.69 to 1.54; 1 RCT, 649 participants; moderate certainty); • may have little or no effect on mortality among children with severe wasting (RR 0.46, 95% CI 0.04 to 5.98; 1 RCT, 829 participants; low certainty); • probably has little or no effect on the transfer of children with severe wasting to inpatient care (RR 3.71, 95% CI 0.36 to 38.23; 1 RCT, 829 participants; moderate certainty); and • probably has little or no effect on the default of children with severe wasting (RR 1.48, 95% CI 0.65 to 3.40; 1 RCT, 829 participants; moderate certainty). The evidence was very uncertain for total MUAC gain, MUAC gain per day, total weight gain, treatment coverage, and transfer to another LHW site or health facility. No studies examined sustained recovery, deterioration to severe wasting, appropriate identification of children with wasting or oedema, appropriate referral of children with moderate or severe wasting, adherence, or adverse effects and other harms.

AUTHORS' CONCLUSIONS

Identification and treatment of severe wasting in children who do not require inpatient care by LHWs, compared with treatment by health professionals, may lead to similar or slightly poorer outcomes. We found only two RCTs, and the evidence from non-randomised studies was of very low certainty for all outcomes due to serious risks of bias and imprecision. No studies included children aged under 6 months. Future studies must address these methodological issues.

Nutrition Education Package Focusing on Infant and Young Child Feeding in Tanzania

OBJECTIVE

To evaluate the effectiveness of a nutrition education package on feeding practices, nutrient intakes and growth of infants in rural Tanzania.

DESIGN

Cluster-randomized controlled trial in 18 villages allocated to nutrition education package (n = 9) or routine health education (n = 9 villages), measured at baseline (6 months) and end of the trial (12 months).

SETTING

Mpwapwa district.

PARTICIPANTS

Infants aged 6-12 months and their mothers.

INTERVENTION(S)

Six months of nutrition education package (group education, counseling, cooking demonstrations) and regular home visits by village health workers.

MAIN OUTCOME MEASURE(S)

Primary outcome measure was the mean change in length-for-age z-scores. Secondary outcomes included mean changes in weight-for-length z-scores (WLZ), intakes of energy, fat, iron and zinc, the proportion of children consuming foods from ≥ 4 food groups (ie, dietary diversity) and consuming the recommended number of semisolid/soft meals and snacks per day (ie, meal frequency).

ANALYSIS

Multilevel mixed-effects regression models.

RESULTS

Mean change in length-for-age z-scores (β = 0.20, P = 0.02), energy (in kcal) (β = 43.8, P = 0.02), and fat (in grams) (β =2.7, P = 0.03) intakes were significant in the intervention but not in the control group. There was no effect on iron and zinc intakes. More infants in the intervention than the control group consumed meals from ≥ 4 food groups (71.8% vs 45.3%, P = 0.002). The mean increase in meal frequency (β = 0.29, P = 0.02) and dietary diversity (β = 0.40, P = 0.01) were more significant in the intervention than control.

CONCLUSIONS AND IMPLICATIONS

The nutrition education package is feasible and can be implemented with high coverage, demonstrating the potential to improve feeding practices, nutrient intake and growth in rural Tanzania.

The effect of Pimpinella Anisum herbal tea on human milk volume and weight gain in the preterm infant: a randomized controlled clinical trial

BACKGROUND AND AIMS

Human milk supports pre-term infants to thrive. Yet human milk production can be inhibited when infants are born prematurely. Pimpinella Anisum has been evidenced to increase milk production and infant weight gain in previous animal studies. The present study aimed to determine the effect of Pimpinella Anisum herbal tea on human milk volume and preterm infant weight in human populations for the first time.

METHODS

Human milk supports pre-term infants to thrive. Yet human milk production can be inhibited when infants are born prematurely. Pimpinella Anisum has been evidenced to increase milk production and infant weight gain in previous animal studies. The present study aimed to determine the effect of Pimpinella Anisum herbal tea on human milk volume and preterm infant weight in human populations for the first time.

RESULTS

There was a statistically significant difference in terms of milk volume in the first, third, fourth, fifth, sixth and seventh days between the three groups of intervention, placebo, and control (p < 0.05). On the first day, the mean volume of pumped milk in the intervention group was significantly higher than the control group (p = 0.008). On the second day, there was no statistically significant difference between groups. On the third, fourth, fifth, sixth and seventh days, the mean volume of pumped milk in the intervention group was significantly higher than the placebo and control groups (p < 0.05). There was no statistically significant difference in terms of preterm infant weight on days 0, 3 and 7 between the three groups.

CONCLUSION

The use of Pimpinella Anisum or 'Anise' tea can increase the volume of human milk and since no specific side effects have been reported in its use, it may be incorporated easily, cheaply, and effectively in practice where appropriate to the benefit of preterm infant nutrition worldwide.

Educational intervention and livestock ownership successfully improved the intake of animal source foods in 6-23 months old children in rural communities of Northern Ethiopia: Quasi-experimental study

Background

Animal source foods (ASFs) are rich in high-quality proteins, including essential amino acids and highly bioavailable micronutrients vital for child growth and cognitive development. But, the daily consumption of ASFs among 6–23 months old children is very low in Tigray, Northern Ethiopia.

Objective

The study aimed to assess the effectiveness of nutrition education intervention to improve the consumption of ASFs among 6–23 months old children from rural communities with strict religious fasting traditions of avoiding intake of ASFs in Northern Ethiopia.

Methods

A quasi-experimental study was conducted in two food insecure districts namely Samre Seharti (intervention) and Tanqua Abergele (comparison). The mother-child pairs in the intervention group (n = 140) received nutrition education based on the barriers and available resources for optimal consumption of ASFs among children and followed up for nine months. The mother-child pairs in the comparison group (n = 153) received routine nutrition education. The data were collected using a pre-tested structured questionnaire. The baseline and endline data assessment included interviews on socio-demographic and socio-economic status, dietary intake, and child feeding practices. The effectiveness of the intervention was measured using the difference-in-difference (DID) analysis model.

Results

At endline, the consumption of ASFs among children was 19.5 percentage points higher in the intervention group compared with the comparison group (p = 0.008). In addition, there was a significant increase in egg consumption among children in the intervention group (DID of 16.9, p = 0.012) from the comparison group. No child was consuming meat at baseline in both the intervention and comparison arms and it was very low at endline (5.2% vs. 7.9%). Overall, the proportion of children that consumed eggs in the intervention group was higher than in the comparison group in households that owned sheep and goats (4.8% vs. 21.4%, p = 0.050) and chicken (6.3% vs. 43.8%, p = 0.002) after education interventions. However, no statistically significant difference was observed between cow ownership and milk consumption among children (p>0.05).

Conclusions

Age-appropriate educational interventions for mothers and owning small livestock in the household can improve the consumption of ASFs and eventually the minimum diet diversity of children in communities with strict religious traditions of avoiding ASFs during the fasting seasons.

Maximising the bioaccessibility of iron and zinc of a complementary food mix through multiple strategies

The investigation was undertaken to maximise the bioaccessibility of iron and zinc of a complementary food mix by multiple approaches of dephytinisation and addition of organic acids. A wheat, pulse and oilseed protein flour mix was dephytinized by phytase activation and different thermal treatments. As the mineral content of the mix was low, the spray dried mix was fortified with different iron and zinc salts to identify the salt with the highest bioaccessibility in this matrix. Based on the percent bioaccessibility, the mix with sodium iron EDTA and zinc oxide was chosen for fortification. Bioaccessibility was enhanced by the addition of fruit powders and pure organic acids. Fruit powders showed a significant increase, but citric acid at a higher dose was beneficial in enhancing bioaccessible iron. The strategy of dephytinisation followed by fortification and the addition of fruit powders or organic acids is promising in alleviating iron and zinc deficiencies.

Effectiveness of a Nutrition Education Program in Improving Mothers’ Knowledge and Feeding Practices of Infants and Young Children in Sudan

Objective: To assess the effect of a designed nutrition education program (NEP) on maternal Knowledge and practices  Methods: A control two groups quasi-experimental pre- and post-experimental were adopted. Data were collected through personal interviews of two groups using a validated questionnaire. The nutrition education program was conducted in three phases. Phase one was the pre-evaluation; phase two was the program's implementation, and phase three entailed post-evaluation of the program. Results: The results supported the efficient role of the NEP intervention in raising mothers ' Knowledge and practices towards nutritional care of children under two years in Sennar Locality. No statistically significant differences were found between the two groups with the controlled variable, mother age, mother education, mother occupation, husband occupation, No of children less than five years, family size, and infant age. This indicates that the two groups were homogenous. No significant difference between the two groups in mothers' Knowledge and practices before applying the NEP. The results showed the effectiveness of the NEP in developing experimental group mother's Knowledge and practices, comparing post-test with pre-test in favor of post-test to be statistically significant. NEP has a  greater effect in developing mother's awareness post-test measuring and developing mother's Knowledge and practices comparing post-test with pre-test. Conclusions and Implications: It can be concluded that nutrition education intervention demonstrated its effectiveness in maternal Knowledge and practices. The study provided valuable baseline information to develop appropriate training courses and nutrition education programs to raise maternal Knowledge and practices towards infants and young children's nutrition.  

The role of nutrition-sensitive agriculture combined with behavioral interventions in childhood growth in Ethiopia: An adequacy evaluation study

Objective

The study aimed to investigate the role of nutrition-sensitive and specific interventions along with nutrition education on child stunting during the first 1000 days in Ethiopia.

Methods

An adequacy evaluation study was used to see changes between the baseline and end-line data after following for 1 year. A sample of 170 mother-child pairs who had a 1-year followed up was used to detect differences. We performed structural equation modeling to elucidate changes in feeding behaviors, socioeconomic status, water, sanitation and hygiene on child linear growth. Furthermore, the independent effect of covariates on child linear growth was handled using a general linear model.

Results

A total of 170 and 270 mother-child dyads were interviewed at baseline and end-line surveys, respectively. After about 1 year of intervention, the annual rate of stunting prevalence declined from 29.3% (95% confidence interval [CI] = 18.6, 42.7) to 16.4% (95% CI = 10.7, 24.2). There was a significant change in the mean of length-for-age Z-score which changed from -1.18 to -0.45 (P < .034). Adjusting for the different constructs of the health belief model, child sex, age, feeding behaviors, and dietary diversity, one egg consumption per day was responsible for the most significant variability explained (36%) for stunting reduction.

Conclusions

Sustainable access to egg consumption for children below 2 years experienced a substantial reduction in childhood stunting. A combination of nutrition-sensitive agricultural and direct nutrition interventions along with behavioral-based education is a sustainable strategy in reducing and preventing child growth from faltering in the early life stages.

Systematic review of metrics used to characterise dietary nutrient supply from household consumption and expenditure surveys

OBJECTIVE

To review existing publications using Household Consumption and Expenditure Survey (HCES) data to estimate household dietary nutrient supply to (1) describe scope of available literature, (2) identify the metrics reported and parameters used to construct these metrics, (3) summarise comparisons between estimates derived from HCES and individual dietary assessment data and (4) explore the demographic and socio-economic sub-groups used to characterise risks of nutrient inadequacy.

DESIGN

This study is a systematic review of publications identified from online databases published between 2000 to 2019 that used HCES food consumption data to estimate household dietary nutrient supply. Further publications were identified by 'snowballing' the references of included database-identified publications.

SETTING

Publications using data from low- and lower-middle income countries.

RESULTS

In total, fifty-eight publications were included. Three metrics were reported that characterised household dietary nutrient supply: apparent nutrient intake per adult-male equivalent per day (n 35), apparent nutrient intake per capita per day (n 24) and nutrient density (n 5). Nutrient intakes were generally overestimated using HCES food consumption data, with several studies finding sizeable discrepancies compared with intake estimates based on individual dietary assessment methods. Sub-group analyses predominantly focused on measuring variation in household dietary nutrient supply according to socio-economic position and geography.

CONCLUSION

HCES data are increasingly being used to assess diets across populations. More research is needed to inform the development of a framework to guide the use of and qualified interpretation of dietary assessments based on these data.

Improving the Performance of Children School Meal using Meal Report at Kindergarten School in Indonesia: A Quasi-Experimental Study

BACKGROUND: Kindergarten children are prone to be stunted. Currently, most kindergarten school run school meal program. AIM: The aim of the study was to assess the effect of school meal report on the meal performance. METHODS: The study was a Quasi Experiment. Four kindergarten schools were selected; two schools as intervention study and the other two schools as the control group. We enrolled 106 mothers. There were five items of food performance to be scored from 6 to 10. While children in the control group were suggested to bring meals every day without a school meal report. RESULTS: At baseline the range score of five items was not significantly different, the average score was 7.15±0.21 vs 7.09±0.18; p>.05 in the intervention group and control group respectively. However, at end-line the scores meal performance in the study group was significantly improve and made it meaningfully different than in the control group (8.94±0.31 vs 7.52±0.40; p<.05). The meal performance in both groups started at low performance. However, in study group at week four the scores gradually improved to the best performance at week eight till week twelve, while meal performance children in control group had a low performance. CONCLUSION: Meal report is effective in improving meal performance of kindergarten children. Future studies need to find the effect of school meal reports on nutritional status and frequency of sickness.

Assessment of a Nutrition Education Program designed to Enhance Mothers’ Attitudes on Infants and Young Children feeding in Sudan

Objective: To assess the effect of a designed nutrition education program (NEP) on maternal attitudes.  Methods: A control two groups quasi-experimental pre- and post-experimental were adopted. Data were collected through personal interviews of two groups using a validated questionnaire. The nutrition education program was conducted in three phases. Phase one was the pre-evaluation, phase two was the program’s implementation, and phase three entailed post evaluation of the program. Results: The results supported the efficient role of the NEP intervention in raising mothers’ attitudes towards nutritional care of under two years in Sennar Locality, Sudan. There was no significant difference between the two groups with respect to the controlled variables; mother age, mother education, mother occupation, husband occupation, number of children less than 5 years, family size, and child’s age, which indicates that the two groups were homogenous, i.e., no significant difference between mothers’ attitude of the two groups before applying the NEP. The results showed the effectiveness of the NEP in developing experimental group mother’s attitudes, comparing post-test with pre-test in favor of post-test to be statistically significant. NEP has a huge impact in developing the mother’s awareness post-test, measuring and developing the mother’s attitudes compared to post-test with pre-test. Conclusions and Implications: The nutrition education intervention demonstrated its effectiveness in maternal attitude. The study provided valuable baseline information to develop appropriate training courses and nutrition education programs to raise maternal awareness and attitudes towards infants and young children’s nutrition.                                                                                                                                          

Factors Associated With Uptake of Iron Supplement During Pregnancy Among Women of Reproductive Age in Tanzania: an Analysis of Data From the 2015 to 2016 Tanzania Demographic and Health Survey and Malaria Indicators Survey

Background: Pregnant women are vulnerable to iron deficiency due to the fact that more iron is needed primarily to supply the growing fetus and placenta and to increase the maternal red cell mass. Little is known on the factors associated with uptake of iron supplement during pregnancy.

Methods: The study used data from the 2015 to 2016 Tanzania Demographic and Health Survey and Malaria Indicators Survey. A total of 6,924 women of active reproductive age from 15 to 49 were included in the analysis. Both univariate and multiple regression analyses were used to determine factors associated with uptake of iron supplement during pregnancy.

Results: Majority of the interviewed women 5,648 (81.6%) always took iron supplement during pregnancy, while a total of 1,276 (18.4%) women never took iron supplement during pregnancy. After controlling for confounders, the predictors for uptake of iron supplement during pregnancy were early antenatal booking (adjusted odds ratio, AOR = 1.603 at 95% CI = 1.362–1.887, p < 0.001); rural residence (AOR = 0.711 at 95% CI = 0.159–0.526, p = 0.007); wealth index [rich (AOR = 1.188 at 95% CI = 0.986–1.432, p = 0.07)]—poor was the reference population; level of education [primary education (AOR = 1.187 at 95% CI = 1.013–1.391, p = 0.034)]—no formal education was the reference population; parity [para 2 to 4 (AOR = 0.807 at 95% CI = 0.668–0.974, p = 0.026), para 5 and above (AOR = 0.75 at 95% CI = 0.592–0.95, p = 0.017)], para 1 was the reference population; zones [mainland rural (AOR = 0.593 at 95% CI = 0.389–0.905, p = 0.015) and Unguja Island AOR = 0.63 at 95% CI = 0.431–0.92, p = 0.017]—mainland urban was the reference population; and current working status [working (AOR = 0.807 at 95% CI = 0.687–0.949, p = 0.009)].

Conclusion: The study revealed that, despite free access to iron supplement during pregnancy, there are women who fail to access the supplement at least once throughout the pregnancy. The likelihood to fail to access iron supplement during pregnancy was common among pregnant women who initiated antenatal visits late, were from poor families, had no formal education, reside in rural settings, had high parity, were from mainland rural, and were in working status. Interventional studies are recommended in order to come up with effective strategies to increase the uptake of iron supplement during pregnancy.

Do Nutrition Education Approaches With Preschoolers and Their Caregivers Influence Retention of Biofortified Orange-Fleshed Sweet Potato on Farms? Evidence From Homa Bay County, Kenya

BACKGROUND

Biofortified staples have been promoted widely in sub-Saharan Africa to combat micronutrient deficiencies. Contemporary projects are increasingly using elementary schools to target households with these foods.

OBJECTIVE

This study assessed the effects of integrated nutrition education approaches, targeting preschoolers and their caregivers, on retention of orange-fleshed sweet potato (OFSP) on farms in the second season after lapse of free vine dissemination initiatives.

METHODS

Rural farming households, with preschoolers and no prior engagement with OFSP, were targeted. A multistage sample of 431 preschooler-caregiver pairs was recruited for a cluster-randomized controlled trial. After issuing routine OFSP promotion activities, 15 village-level clusters of the pairs were randomized into 1 control group (3 villages) and 3 treatment arms (4 villages each) for the interventions. Baseline and follow-up household-level survey data were collected from the caregivers. The interventions included: (1) OFSP-branded exercise books, posters, and a poem to preschoolers only; (2) OFSP-oriented mobile phone mediated text messages to caregivers only; and (3) both 1 and 2 provided to individual households concurrently. Interventions 1 and 2 were single-channeled, while 3 was multichanneled. We estimated the intention-to-treat (ITT) and treatment-on-the-treated (TOT) effects using a binary logit model and a special regressor method, respectively.

RESULTS

Only the multi-channeled nutrition education approach had significant effects (ITT = 0.167, P = .001; TOT = .243, P = .007) on the caregivers' likelihood to retain OFSP on their farms.

CONCLUSIONS

The finding implies that multi-channeled agriculture nutrition education interventions through Early Childhood Development institutions can be effective in ensuring sustainable adoption of OFSP.

Breastfeeding Rate, Food Supplementation, Dietary Diversity Among Children Aged 6-59 Months, and Associated Factors in Papua New Guinea

Background: Along the socioeconomic changes in the past decades, Papua New Guinea (PNG) has undergone significant food transition. Little is known about the influence of household and maternal socioeconomic demographic factors on dietary intake and diversity among children under 5 years of age (CU5). Objective: This study aimed to examine breastfeeding rate, food supplementation, dietary intake, and diversity among children aged 6-59 months and to identify associations with household and maternal socioeconomic demographic factors in PNG. Method: Data from 2,943 children were extracted from the Comprehensive Health and Epidemiological Surveillance System database, operated by the PNG Institute of Medical Research and used to estimate breastfeeding rate, food supplementation, and dietary intake of CU5 in a typical week. Dietary diversity score (DDS) was used as a proxy indicator to measure nutrient adequacy. Associations of DDS with household and maternal socioeconomic and demographic factors were examined using multivariate logistic regression analysis. Result: The breastfeeding rate among children aged 6-8 months was 85% (70% in urban and 90% in rural sectors), and 50% of children of this age group were fed with supplementary foods. Twenty percent of children aged 6-23 months were currently breastfed and received solid, semisolid, and soft foods three times or more per day. Forty-eight percent of children aged 6-59 months had a total DDS below the average level (23 scores). Place of residence, mother's education, and household wealth were associated with dietary diversity among studied children. Children in urban areas are 10% more likely to have a lower level of total DDS than those in rural areas (OR: 1.11 [0.79-1.56]; p-value: 0.5). Children whose mothers had a primary education level were 1.6-fold more likely to have a lower level of total DDS than children whose mothers had vocational training or college education (OR: 1.63 [0.68-3.92]; p-value: 0.28). Children from the poorest households were 1.2-fold more likely to have a lower DDS than those from the richest households (OR: 1.22 [0.79-1.87]; p-value: 0.37). Discussion: A range of factors has been identified, contributing to the eating behaviors among CU5 in PNG, in which mother's education and household wealth are among the most important determinants of childhood dietary diversity as they have a direct effect on accessibility to and affordability of a variety of foods at the household level. Conclusion: Evidence-based integrated and comprehensive approaches are needed to improve women education and household wealth, contributing to the improvement of food diversity among young children in PNG.

Anaemia and its determinants among young children aged 6-23 months in Ethiopia (2005-2016)

Anaemia in children remains a significant public health threat. Recent numbers from Ethiopia showed that more than two‐thirds of children under the age of 2 years were anaemic. This study aimed to investigate the determinants of anaemia throughout Ethiopia over 11 years, making use of the Ethiopian Demographic and Health Survey (EDHS) rounds 2005, 2011 and 2016. The EDHS made it possible to use data on blood tests and detailed questionnaires among infants and young children. Multivariable logistic regression was applied to assess the association of anaemia and different immediate and underlying determinants. A total of 7,324 children aged 6–23 months were included in the analysis, with prevalences of anaemia being 71% in 2005, 61% in 2011 and 72% in 2016. The following determinants were significantly associated with childhood anaemia throughout the entire period: children younger than 1 year, anaemic mothers and those growing up in pastoralist regions. Risk factors such as diet and infections were consistently not significantly associated with anaemia. Given the tremendous adverse health effects of anaemia in young children, urgent action is needed. Hence, this study recommends nationwide multisectoral interventions targeting pastoralist regions, maternal and child health, screening and treatment of risk groups that could reduce the prevalence of anaemia.

An Educational Intervention to Mothers Improved the Nutritional Status of Mexican Children Younger Than 5 Years Old With Mild to Moderate Malnutrition

Malnutrition in children younger than 5 years old has persisted in time (13.5% in 1988 to 12.3% in 2012) in Mexico City. A quasi-experimental study was performed. An educational intervention was given twice a month for 6 months to mothers of mild to moderate malnourished children 1 to 5 years old. Weight, height, and body mass index of the children were obtained at the beginning and 3 and 6 months after the intervention. Thirteen mothers and 15 children were included. The baseline mean weight/age in Z score was −1.49 ± 0.65, which improved to −1.19 ± 0.60 (P = 0.001; per protocol analysis). Linear regression analysis showed a P of 0.006 of the mothers’ adherence to improve children’s weight. The educational intervention decreased the weight deficit after 6 months with the same economic resources of the family; hence, the adherence of the mothers to the educational intervention is relevant to improve the nutritional status of their children.

A scoping review of social-behaviour change techniques applied in complementary feeding interventions

Education and other strategies to promote optimal complementary feeding can significantly improve practices, but little is known about the specific techniques successful interventions use to achieve behaviour change. We reviewed the literature for complementary feeding interventions in low‐/middle‐income countries (LMIC) published since 2000. We systematically applied a validated taxonomy mapping process to code specific behaviour change techniques (BCTs) used in each intervention; effectiveness ratios for each BCT were estimated. Sixty‐four interventions met inclusion criteria, were abstracted, BCTs identified, and coded. Dietary diversity was the most commonly assessed component of complementary feeding, and interpersonal communication, either individually or in groups, was the most commonly used delivery platform. Of the 93 BCTs available for mapping, the 64 interventions included in this review applied a total of 28 BCTs. Interventions used a median of six techniques (max = 13; min = 2). All interventions used “instruction on how to perform the behaviour.” Other commonly applied BCTs included “use of a credible source” (n = 46), “demonstration of the behaviour” (n = 35), and “providing information about health consequences” (n = 30). Forty‐three interventions reported strategies to shift the physical or social environment. Among BCTs used in >20 interventions, five had effectiveness ratios >0.8: “provision of/enabling social support”; “providing information about health consequences”; “demonstration of the behaviour”; and “adding objects to the environment” namely, food, supplements, or agricultural inputs. The limited reporting of theory‐based BCTs in complementary feeding interventions may impede efforts to improve and scale effective programs and reduce the global burden of malnutrition.

Association of food security and other socio-economic factors with dietary diversity and nutritional statuses of children aged 6-59 months in rural Bangladesh

INTRODUCTION

Dietary diversity score (DDS) is a proxy indicator for measuring nutrient adequacy. In this study, we aimed to identify the nutritional statuses and current patterns of DDS among children between 6-59 months old and their associations with different individual and household level factors in rural Bangladesh.

METHODS

The Nobokoli programme of World Vision Bangladesh was implemented in Mymensingh, Sherpur, Rangpur, Dinajpur, Thakurgaon, Panchagar, and Nilphamari districts of Bangladesh between 2014 and 2017. A cross-sectional community household survey was administered between July and October 2014 to collect baseline data to evaluate the Nobokoli programme. A total of 6,468 children between 6-59 months old were included in the final analysis. Anthropometric data was collected following WHO guidelines on using wooden height and digital weight scales. We collected food intake information for the past 24 hours of the survey. The WHO's child growth standard medians were used to identify the nutritional indices of stunting, wasting, and underweight. Food items consumed were categorized into nine food groups and the DDS was constructed by counting the consumption of food items across these groups during the preceding 24 hour period. The association of DDS and nutritional status (stunting, wasting and underweight) with sociodemographic factors and household food security status were examined using multivariable models; linear regression and logistics regression respectively.

RESULTS

The prevalence of stunting, wasting and underweight among children aged 6-59months were 36.8%, 18.2% and 37.7% respectively. Our findings revealed that almost all children ate any form of starch followed by consumption of milk or milk products (76%) and fleshy meat /fish (61%) respectively. The mean DDS among children was 3.93(sd 1.47). Forty percent of the children obtained a DDS score less than 4. Multivariable analysis suggested that children whose mothers had higher educational attainment and are skilled workers had higher DDS (15% and 48% respectively) compared to their counterparts. The DDS showed strong positive association with household wealth status. Children from food secure households had 26% higher DDS compared to children from food insecure households. Similarly, increasing maternal education and household wealth were found to be protective against childhood stunting and undernutrition.

DISCUSSION

Our findings reiterate the need for improving household socioeconomic factors and household food security status for improving dietary diversity practices and nutritional status of children. Evidence-based solutions are needed to be implemented and expanded at scale to ensure appropriate dietary practices and improve nutritional status of the children in local context.

Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under

BACKGROUND

Although complementary feeding is a universal practice, the methods and manner in which it is practiced vary between cultures, individuals and socioeconomic classes. The period of complementary feeding is a critical time of transition in the life of an infant, and inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. Educational interventions are widely acknowledged as effective in promoting public health strategy, and those aimed at improving complementary feeding practices provide information about proper complementary feeding practices to caregivers of infants/children. It is therefore important to summarise evidence on the effectiveness of educational interventions to improve the complementary feeding practices of caregivers of infants.

OBJECTIVES

To assess the effectiveness of educational interventions for improving the complementary feeding (weaning) practices of primary caregivers of children of complementary feeding age, and related health and growth outcomes in infants.

SEARCH METHODS

In November 2017, we searched CENTRAL, MEDLINE, Embase, 10 other databases and two trials registers. We also searched the reference lists of relevant studies and reviews to identify any additional studies. We did not limit the searches by date, language or publication status.

SELECTION CRITERIA

Randomised controlled trials (RCTs), comparing educational interventions to no intervention, usual practice, or educational interventions provided in conjunction with another intervention, so long as the educational intervention was only available in the experimental group and the adjunctive intervention was available to the control group. Study participants included caregivers of infants aged 4 to 24 months undergoing complementary feeding. Pregnant women who were expected to give birth and commence complementary feeding during the period of the study were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on participants, settings, interventions, methodology and outcomes using a specifically-developed and piloted data extraction form. We calculated risk ratios (RR) and 95% confidence intervals (CIs) for dichotomous data, and mean differences (MD) and 95% CIs for continuous data. Where data permitted, we conducted a meta-analysis using a random-effects model. We assessed the included studies for risk of bias and also assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We included 23 studies (from 35 reports) with a total of 11,170 caregiver-infant pairs who were randomly assigned to receive an educational intervention delivered to the caregiver or usual care. Nineteen of the included studies were community-based studies while four were facility-based studies. In addition, 13 of the included studies were cluster-randomised while the others were individually randomised. Generally, the interventions were focused on the introduction of complementary feeding at the appropriate time, the types and amount of complementary foods to be fed to infants, and hygiene. Using the GRADE criteria, we assessed the quality of the evidence as moderate, mostly due to inadequate allocation concealment and insufficient blinding.Educational interventions led to improvements in complementary feeding practices for age at introduction of complementary foods (average RR 0.88, 95% CI 0.83 to 0.94; 4 studies, 1738 children; moderate-quality evidence) and hygiene practices (average RR 1.38, 95% CI 1.23 to 1.55; 4 studies, 2029 participants; moderate-quality evidence). For duration of exclusive breastfeeding, pooled results were compatible with both a reduction and an increase in the outcome (average RR 1.58, 95% CI 0.77 to 3.22; 3 studies, 1544 children; very low-quality evidence). There was limited (low to very low-quality) evidence of an effect for all growth outcomes.Quality of evidenceThere is moderate to very low-quality evidence that educational interventions can improve complementary feeding practices but insufficient evidence to conclude that it impacts growth outcomes.

AUTHORS' CONCLUSIONS

Overall, we found evidence that education improves complementary feeding practices.

Effectiveness of different interventions in public nurseries based on food and nutrition education: promoting breast-feeding and healthy complementary feeding

OBJECTIVE

Food practices in the early years of life are important to form healthy eating habits; therefore, it is essential for the caregivers of infants to receive appropriate guidance. The present study aimed to investigate the effectiveness of different nutritional interventions on complementary feeding practices in municipal nurseries.

DESIGN

Non-randomized controlled intervention study with education professionals and parents of infants (<2 years). Participants were divided into: control group (CG), standard food and nutrition education in writing; and intervention group (IG), the same information as the CG and face-to-face meetings (professionals, 8 h; parents, 5 h). Changes in professionals' knowledge on the subject and alterations in parents' beliefs, attitudes and intentions were assessed using questionnaires before and after the educational activities.

SETTING

Ten public nurseries in Nova Lima, Belo Horizonte, Minas Gerais, Brazil, 2015.

SUBJECTS

Ninety professionals (fifty in CG; forty in IG) and 169 parents (ninety-seven in CG; seventy-two in IG).

RESULTS

After the intervention, there was a significant increase in the mean number of correct responses given by professionals in the IG (12·2 v. 10·7; P=0·001). In addition, there were improvements among the parents of the IG in relation to beliefs (soups and broths do not nourish my child: P=0·012), attitudes (offer meat from the sixth month: P=0·032) and intentions (do not offer soups and broths: P=0·003; offer vegetables: P=0·018; offer meat: P<0·001).

CONCLUSIONS

Face-to-face nutritional intervention had a significantly greater effect on the parameters evaluated, indicating the importance of adequate guidance in childcare services to support the introduction of complementary feeding.