The Oriente Study: program and policy impacts

Fathers' involvement in child care activities: Qualitative findings from the highlands of Madagascar

Few studies have investigated fathers’ roles in child care in Madagascar. This study explored the perceptions, attitudes, and practices regarding fathers’ involvement in child care using qualitative methods. Ten focus group discussions were conducted among parents of children aged 6–23 months; seven were among mothers, and three among fathers. In-depth semi-structured interviews (n = 8) were also conducted with key informants. Discussions and interviews were audio-recorded and the verbatim transcripts in Malagasy were translated into English. Data were analyzed using the thematic analysis approach. Provision of financial and material support as well as teaching and playing with the child were the main perceived roles of fathers. In practice, fathers spent their time alone with their children playing and holding them when the mother was unavailable. Busy schedules and separation due to work were major barriers to fathers’ involvement. Traditional gender roles for child care in which the mother is seen as primarily responsible for the child were salient across the data. Consequently, men involved in child care activities and their wives were often criticized by the community. Nevertheless, there was self-reported interest from both mothers and fathers in involving men more in child care. Interventions aimed to increase fathers’ involvement in child care may be more successful when they focus on shifting the community perceptions on the division of responsibilities between fathers and mothers.

Perspective: What Does Stunting Really Mean? A Critical Review of the Evidence

The past decade has seen an unprecedented increase in attention to undernutrition, and drastically reducing child stunting has become a global development objective. The strong focus on linear growth retardation and stunting has enabled successful advocacy for nutrition, but with this focus has come some confusion and misunderstanding about the meaning of linear growth retardation and stunting among researchers, donors, and agencies active in nutrition. Motivated by the belief that a sharp focus will further accelerate progress in reducing undernutrition, we critically reviewed the evidence. The global attention to stunting is based on the premise that any intervention aimed at improving linear growth will subsequently lead to improvements in the correlates of linear growth retardation and stunting. Current evidence and understanding of mechanisms does not support this causal thinking, with 2 exceptions: linear growth retardation is a cause of difficult births and poor birth outcomes. Linear growth retardation is associated with (but does not cause) delayed child development, reduced earnings in adulthood, and chronic diseases. We thus propose distinguishing 2 distinctly different meanings of linear growth retardation and stunting. First, the association between linear growth retardation (or stunting) and other outcomes makes it a useful marker. Second, the causal links with difficult births and poor birth outcomes make linear growth retardation and stunting outcomes of intrinsic value. In many cases a focus on linear growth retardation and stunting is not necessary to improve the well-being of children; in many other cases, it is not sufficient to reach that goal; and for some outcomes, promoting linear growth is not the most cost-efficient strategy. We appeal to donors, program planners, and researchers to be specific in selecting nutrition outcomes and to target those outcomes directly.

Effects of complementary feeding on attained height among lower primary school-aged children in Eastern Uganda: A nested prospective cohort study

BACKGROUND

Despite the fact that Uganda has been a signatory to the global strategy for Infant and Young Children Feeding practices (IYCF) for nearly a decade, the prevalence of stunting among children under five years of age remains tragically high at 17% in Eastern Uganda and twofold higher countrywide. Only 6% of all children aged 6-23 months feed adequately. This study aimed to establish the covariates of complementary feeding (CF) and its effect on attained height among primary school-aged children in Mbale district (Eastern Uganda).

METHODS

This was a community-based prospective cohort study using data from the PROMISE EBF trial. The main exposure variable was adequate complementary feeding (CF) measured in a parent questionnaire at 18-24 months of age. We defined adequate CF as having received animal food, cereals and fruit, juice and/or vegetables during the 24 hours preceding the interview. An adapted minimum acceptable diet was defined as having been given milk or milk products at least twice a day, an adapted meal frequency of two and solid or semi-solid food from at least four food groups on a 24-hour dietary recall based on modified IYCF criteria. The main outcome variable was attained height [(height-for-age Z score (HAZ)] measured between five and eight years of age using the WHO growth standards. Effects of CF on HAZ were estimated using linear regression analyses with cluster-robust standard errors.

RESULTS

A total of 506 children were studied. The majority (85%) were from rural areas and the average age at the end of the study was 6.9 (standard deviation: 0.63) years. Of these, 23.9% were adequately fed and 2.3% received the adapted minimum acceptable diet. Adequate CF was not associated with HAZ (adjusted β = -0.111; 95% CI: -0.363, 0.141; p = 0.374). Factors significantly associated with attained height were baseline HAZ (0.262; 0.152, 0.374; p<0.001) and WHZ (-0.147; -0.243, -0.051; p = 0.004), child's age (0.454; -0.592, -0.315; p<0.001) and maternal education (0.030; 95% CI: 0.003, 0.057; p = 0.034).

CONCLUSION

Adequate CF at age 18-24 months was worryingly insufficient and not associated with attained HAZ at age 5-8 years. Further strategies need to be considered to improve child nutrition and linear growth in resource-constrained settings.

Water, sanitation, and hygiene practices mediate the association between women's empowerment and child length-for-age z-scores in Nepal

In Nepal, more than one-third of children are stunted. Prior studies have shown that women's empowerment in agriculture is associated with child (<2 years) length-for-age z-scores (LAZ) in Nepal. This study tests whether child dietary diversity (DD) and household water, sanitation, and hygiene (WASH) facilities and practices mediate the associations between women's empowerment and LAZ. With a cross-sectional dataset of 4,080 households from 240 rural communities across 16 districts of Nepal, we used ordinary least squares regression models to first estimate the associations between women's empowerment and LAZ for children 6 to 24 months (n = 1,402; our previous published analysis included all children <24 months of age), using the Women's Empowerment in Agriculture Index's Five Domains of Empowerment subindex. We used standardized structural equation models to test whether child DD and/or household WASH mediated the association between women's empowerment and child LAZ. Overall, women's empowerment was positively associated with child LAZ (β = 0.24, P = 0.03), as found in our previous analyses. In the mediation analysis, women's empowerment was positively associated with WASH (β = 0.78, P < 0.001), and in turn child LAZ (β = 0.09, P < 0.001). Women's empowerment was not associated with DD, but DD was associated with LAZ (β = 0.06, P = 0.05). Empowered women had better WASH practices than nonempowered women, which translated into higher child LAZ. Child DD was not a mediating factor in the association between women's empowerment and child LAZ. More research is needed to explore other pathways by which women's empowerment may affect child nutrition outcomes.

From the Field: Improving Fetal and Infant Growth in Vulnerable Populations

BACKGROUND

This article summarizes a presentation given at the 2017 Dairy for Global Nutrition Conference in Boise, Idaho.

OBJECTIVE

To give an overview of the pattern of early growth faltering in developing countries and examine the implications of the iLiNS-DYAD randomized trial in Ghana.

METHODS

The pattern of growth faltering in developing countries was outlined. In Ghana, 1320 women ≤ 20 weeks of pregnancy were assigned to 20 g/d small-quantity lipid-based nutrient supplement (SQ-LNS; LNS group) or multiple micronutrients (MMNs) containing 22 and 18 vitamins and minerals, respectively, until 6 months postpartum, or iron and folic acid (IFA) until delivery, and thereafter placebo until 6 months postpartum. Infants in the LNS group were assigned to SQ-LNS from 6 to 18 months of age.

RESULTS

Mean anthropometric z-scores for infants in developing countries start below the World Health Organization standard at 1 month of age, and generally decline until about age of 24 months. In the Ghana trial, mean (SD) birth weight (g) was greater ( P = .044) for the LNS group (3030 [414]) than the IFA group (2945 [442]) but not the MMN group (3005 [435]). Among primiparous mothers, the LNS group had significantly greater mean birth length, weight, and head circumference than the IFA or MMN group. By 18 months of age, the mean length (95% confidence interval) for the LNS group was +0.6 (0.1-1.1) cm greater than for the IFA group and +0.6 (0.1-1.2) cm greater than for the MMN group.

CONCLUSION

Pre- and post-natal SQ-LNS consumption may improve fetal and infant growth in similar populations.

Using height-for-age differences (HAD) instead of height-for-age z-scores (HAZ) for the meaningful measurement of population-level catch-up in linear growth in children less than 5 years of age

BACKGROUND

Evidence from studies conducted in nutritionally deprived children in low- and middle-income countries (LIMC) in past decades showed little or no population-level catch-up in linear growth (mostly defined as reductions in the absolute height deficit) after 2 years of age. Recent studies, however, have reported population-level catch-up growth in children, defined as positive changes in mean height-for-age z-scores (HAZ). The aim of this paper was to assess whether population-level catch-up in linear growth is found when height-for-age difference (HAD: child's height compared to standard, expressed in centimeters) is used instead of HAZ. Our premise is that HAZ is inappropriate to measure changes in linear growth over time because they are constructed using standard deviations from cross-sectional data.

METHODS

We compare changes in growth in populations of children between 2 and 5 years using HAD vs. HAZ using cross-sectional data from 6 Demographic and Health Surveys (DHS) and longitudinal data from the Young Lives and the Consortium on Health-Orientated Research in Transitional Societies (COHORTS) studies.

RESULTS

Using HAD, we find not only an absence of population-level catch-up in linear growth, but a continued deterioration reflected in a decrease in mean HAD between 2 and 5 years; by contrast, HAZ shows either no change (DHS surveys) or an improvement in mean HAZ (some of the longitudinal data). Population-level growth velocity was also lower than expected (based on standards) in all four Young Lives data sets, confirming the absence of catch-up growth in height.

DISCUSSION

We show no evidence of population-level catch-up in linear growth in children between 2 to 5 years of age when using HAD (a measure more appropriate than HAZ to document changes as populations of children age), but a continued deterioration reflected in a decrease in mean HAD.

CONCLUSIONS

The continued widening of the absolute height deficit after 2 years of age does not challenge the critical importance of investing in improving nutrition during the first 1000 days (i.e., from conception to 2 years of age), but raises a number of research questions including how to prevent continued deterioration and what is the potential of children to benefit from nutrition interventions after 2 years of age. Preventing, rather than reversing linear growth retardation remains the priority for reducing the global burden of malnutritionworldwide.

A 2-year integrated agriculture and nutrition and health behavior change communication program targeted to women in Burkina Faso reduces anemia, wasting, and diarrhea in children 3-12.9 months of age at baseline: a cluster-randomized controlled trial

BACKGROUND

Among young children in Burkina Faso, anemia and chronic and acute undernutrition are widespread.

OBJECTIVE

This study assessed the impact of Helen Keller International's (HKI) 2-y integrated agriculture [homestead food production (HFP)] and nutrition and health behavior change communication (BCC) program, targeted to women, on children's (3-12.9 mo old at baseline) anthropometry (stunting, wasting, and underweight), mean hemoglobin (Hb), anemia (Hb < 11 g/dL), and diarrhea prevalence.

METHODS

We used a cluster-randomized controlled trial, with 55 villages randomly assigned to a control group (n = 25) or 1 of 2 treatment groups (n = 15 each), which differed by who delivered the BCC messages [older women leaders or health committee (HC) members]. We used difference-in-difference (DID) estimates to assess impacts on child outcomes.

RESULTS

We found marginally significant (P < 0.10) impacts on Hb (DID: 0.51 g/dL; P = 0.07) and wasting [DID: -8.8 percentage point (pp); P = 0.08] and statistically significant (P < 0.05) impacts on diarrhea (-15.9 pp; P = 0.00) in HC compared with control villages among children aged 3-12.9 mo and larger impacts for anemia (DID: -14.6 pp; P = 0.03) and mean Hb (DID: 0.74 g/dL; P = 0.03) among younger children (aged 3-5.9 mo). However, we found no significant impacts on stunting or underweight prevalence. Plausibility was supported by greater improvements in women's agricultural production and maternal infant and young child feeding and care knowledge and practices in HC compared with control villages.

CONCLUSIONS

HKI's 2-y integrated HFP+BCC program (HC group) significantly improved several child outcomes, including wasting (marginal), diarrhea, Hb, and anemia, especially among the youngest children. This is the first cluster-randomized controlled trial of an HFP program that documents statistically significant positive effects on these child nutrition outcomes. This trial was registered at clinicaltrials.gov as NCT01825226.

Women's empowerment in agriculture and child nutritional status in rural Nepal

OBJECTIVE

To examine the association between women's empowerment in agriculture and nutritional status among children under 2 years of age in rural Nepal.

DESIGN

Cross-sectional survey of 4080 households conducted in 2012. Data collected included: child and maternal anthropometric measurements; child age and sex; maternal age, education, occupation and empowerment in agriculture; and household size, number of children, religion, caste and agro-ecological zone. Associations between the Women's Empowerment in Agriculture Index (WEAI)'s Five Domains of Empowerment (5DE) sub-index and its ten component indicators and child length-for-age Z-scores (LAZ) and weight-for-length Z-scores (WLZ) were estimated, using ordinary least-squares regression models, with and without adjustments for key child, maternal and household level covariates.

SETTING

Two hundred and forty rural communities across sixteen districts of Nepal.

SUBJECTS

Children under 24 months of age and their mothers (n 1787).

RESULTS

The overall WEAI 5DE was positively associated with LAZ (β=0·20, P=0·04). Three component indicators were also positively associated with LAZ: satisfaction with leisure time (β=0·27, P<0·01), access to and decisions regarding credit (β=0·20, P=0·02) and autonomy in production (β=0·10, P=0·04). No indicator of women's empowerment in agriculture was associated with WLZ.

CONCLUSIONS

Women's empowerment in agriculture, as measured by the WEAI 5DE and three of its ten component indicators, was significantly associated with LAZ, highlighting the potential role of women's empowerment in improving child nutrition in Nepal. Additional studies are needed to determine whether interventions to improve women's empowerment will improve child nutrition.

Women's empowerment and child nutritional status in South Asia: a synthesis of the literature

Women's disempowerment is hypothesised to contribute to high rates of undernutrition among South Asian children. However, evidence for this relationship has not been systematically reviewed. This review of empirical studies aims to: (1) synthesise the evidence linking women's empowerment and child nutritional status in South Asia and (2) suggest directions for future research. We systematically searched Global Health, Embase (classic and Ovid), MEDLINE, Campbell Collaboration, Popline, Eldis, Web of Science, EconLit and Scopus. We generated 1661 studies for abstract and title screening. We full-text screened 44 of these, plus 10 additional studies the authors were aware of. Only 12 studies fulfilled our inclusion criteria. We included English materials published between 1990 and 2012 that examined the relationship(s) of at least one women's empowerment domain and nutritional status among South Asian children. Data were extracted and synthesised within three domains of empowerment: control of resources and autonomy, workload and time, and social support. The results showed women's empowerment to be generally associated with child anthropometry, but the findings are mixed. Inter-study differences in population characteristics, settings or methods/conceptualisations of women's empowerment, and the specific domains studied, likely contributed to these inconsistencies. This review also highlights that different women's empowerment domains may relate differently to child nutritional status. Future research should aim to harmonise definitions of women's empowerment, which key domains it should include, and how it is measured. Rigorous evaluation work is also needed to establish which policies and programmes facilitate women's empowerment and in turn, foster child nutritional well-being.

Urban-rural disparities of child health and nutritional status in China from 1989 to 2006

This paper analyzes urban-rural disparities of China's child health and nutritional status using the China Health and Nutrition Survey data from 1989 to 2006. We investigate degrees of health and nutritional disparities between urban and rural children in China as well as how such disparities have changed during the period 1989-2006. The results show that on average urban children have 0.29 higher height-for-age z-scores and 0.19 greater weight-for-age z-scores than rural children. Urban children are approximately 40% less likely to be stunted (OR=0.62; p<0.01) or underweight (OR=0.62; p<0.05) during the period 1989-2006. We also find that the urban-rural health and nutritional disparities have been declining significantly from 1989 to 2006. Both urban and rural children have increased consumption of high protein and fat foods from 1989 to 2006, but the urban-rural difference decreased over time. Moreover, the urban-rural gap in child preventive health care access was also reduced during this period.

The nutrition intervention improved adult human capital and economic productivity

This article reviews key findings about the long-term impact of a nutrition intervention carried out by the Institute of Nutrition of Central America and Panama from 1969 to 1977. Results from follow-up studies in 1988-89 and 2002-04 show substantial impact on adult human capital and economic productivity. The 1988-89 study showed that adult body size and work capacity increased for those provided improved nutrition through age 3 y, whereas the 2002-04 follow-up showed that schooling was increased for women and reading comprehension and intelligence increased in both men and women. Participants were 26-42 y of age at the time of the 2002-04 follow-up, facilitating the assessment of economic productivity. Wages of men increased by 46% in those provided with improved nutrition through age 2 y. Findings for cardiovascular disease risk factors were heterogeneous; however, they suggest that improved nutrition in early life is unlikely to increase cardiovascular disease risk later in life and may indeed lower risk. In conclusion, the substantial improvement in adult human capital and economic productivity resulting from the nutrition intervention provides a powerful argument for promoting improvements in nutrition in pregnant women and young children.