Behaviour change communication to improve complementary feeding practices in Ethiopia: Couples' beliefs concerning paternal involvement in childcare

An important cause of stunting is limited consumption of complementary foods, in terms of both quantities and nutrients. Although existing studies show a positive association between fathers' engagement and children's diet, programmes designed to improve complementary feeding practices often only target mothers. In response to this, maternal behaviour change communication (BCC), paternal BCC and food voucher programmes were designed and implemented in Ethiopia using a clustered randomized controlled trial design. The paternal BCC programme included gender-equal messages to increase fathers' participation in childcare, household labour and decision making. The research reported in this paper is an examination of the BCC programmes, characterizing the behavioural, normative and control beliefs of both mothers and fathers in BCC households compared to those in control households. In this study, a total of 40 participants were included, with 13 mother-father pairs in the BCC + food voucher group, and seven pairs in the control group. Each participant was interviewed separately. We found that BCC mothers showed more gender-equal tendencies than the control mothers despite being more rural in location. By contrast, the beliefs of BCC and control fathers were similar overall, suggesting men are more resistant to gender-equal BCC. More work is needed to develop and test effective methods for changing fathers' beliefs and practices.

Predictors of anaemia in mothers and children in Uttar Pradesh, India

OBJECTIVE

Anaemia affects more than half of Indian women and children, but the contribution of its causes remains unquantified. We examined interrelationships between Hb and nutritional, environmental, infectious and genetic determinants of anaemia in non-pregnant mothers and children in Uttar Pradesh (UP).

DESIGN

We conducted a cross-sectional survey of households in twenty-five districts of UP between October and December 2016. We collected socio-demographic data, anthropometry and venous blood in 1238 non-pregnant mothers and their children. We analysed venous blood samples for malaria, Hb, ferritin, retinol, folate, Zn, vitamin B12, C-reactive protein, α1-acid glycoprotein (AGP) and β-thalassaemia. We used path analysis to examine pathways through which predictors of anaemia were associated with Hb concentration.

SETTING

Rural and urban households in twenty-five districts of UP.

PARTICIPANTS

Mothers 18-49 years and children 6-59 months in UP.

RESULTS

A total of 36·4 % of mothers and 56·0 % of children were anaemic, and 26·7 % of women and 44·6 % of children had Fe deficiency anaemia. Ferritin was the strongest predictor of Hb (β (95 % CI) = 1·03 (0·80, 1·27) g/dL in women and 0·90 (0·68, 1·12) g/dL in children). In children only, red blood cell folate and AGP were negatively associated with Hb and retinol was positively associated with Hb.

CONCLUSIONS

Over 70 % of mothers and children with anaemia had Fe deficiency, needing urgent attention. However, several simultaneous predictors of Hb exist, including nutrient deficiencies and inflammation. The potential of Fe interventions to address anaemia may be constrained unless coexisting determinants are jointly addressed.

The glass of milk half-empty? Dairy development and nutrition in low and middle income countries

Dairy products have an exceptionally rich nutrient profile and have long been promoted in high income countries to redress child malnutrition. But given all this potential, and the high burden of undernutrition in low- and middle-income countries (LMICs), why isn't dairy consumption more actively promoted in the developing world? In this review we focus on a broadly defined concept of "dairy development" to include production, trade, marketing, regulation, and demand stimulation. We address three key questions. First, how strong is the evidence on the importance of dairy production and consumption for improving nutrition among young children in LMICs? Second, which regions have the lowest consumption of dairy products? Third, what are the supply- and demand-side challenges that prevent LMICs from expanding dairy consumption? We argue that although more nutrition- and consumer-oriented dairy development interventions have tremendous potential to redress undernutrition in LMICs, the pathways for achieving this development are highly context-specific: LMICs with significant agroecological potential for dairy production primarily require institutional solutions for the complex marketing challenges in perishable milk value chains; lower potential LMICs require consumer-oriented trade and industrial approaches to the sector's development. And all dairy strategies require a stronger focus on cross-cutting issues of nutrition education and demand creation, food safety and quality, gender and inclusiveness, and environmental sustainability and resilience. We conclude our review by emphasizing important areas for research and policy expansion.

Household dairy production, dairy intake, and anthropometric outcomes in rural Bangladesh

We assess whether ownership of dairy cows is associated with a greater likelihood of consuming dairy products and with child anthropometric status in rural Bangladesh. Consistent with the assumption of imperfectly functioning markets for dairy products, ownership of dairy cows increases the likelihood that a child 6-59 months consumes milk by 7.7 percentage points with no difference in this association between boys and girls. This association nearly doubles in magnitude when we consider households that own a dairy cow that produced milk in the last year. This result is robust to the controls we use and the way in which we measure dairy cow ownership. Even when we saturate our model with child, maternal, household, wealth, as well as village fixed effects, we retain an association between dairy cow ownership and height-for-age z scores (HAZ) that is meaningful in magnitude - 0.13 standard deviations - and statistically significant at the one percent level. For children in the 12-23.9 month age group, ownership of a dairy cow is associated with a 0.37 SD increase in HAZ and a reduction of 11.3 percentage points in stunting. There is no statistically significant association with weight-for-height or wasting. These associations do not differ between boys and girls.

Corrigendum to "Diets of Men and Women in Rural Bangladesh are Equitable but Suboptimal" [Current Developments in Nutrition (2023), Volume 7, Issue 7]

[This corrects the article DOI: 10.1016/j.cdnut.2023.100107.].

Diets of Men and Women in Rural Bangladesh Are Equitable but Suboptimal

Background

Recent evidence suggests that diet inequities between men and women may have diminished within rural Bangladeshi households. However, this has not been directly tested with appropriate physiologic adjustments and it is unclear whether changes have occurred across socioeconomic strata. Understanding intrahousehold dietary patterns at different points on the income and food-security distribution in rural Bangladesh-particularly, within ultrapoor and farm households-is important for appropriate design of gender-sensitive and nutrition-sensitive interventions, which often target these groups.

Objective

Using 2012 and 2016 data, we aimed to examine gender differences in diet quantity and quality among ultrapoor and farm households in rural Bangladesh.

Methods

The study used baseline 24-h dietary data from 2 randomized control trials conducted in rural Bangladesh: the Transfer Modality Research Initiative (ultrapoor households) and the Agriculture, Nutrition, and Gender Linkages project (farm households). Ordinary least squares regressions with household-level fixed effects tested for gender differences among constructed diet measures, such as caloric intake, caloric adequacy ratio, dietary diversity score, global diet quality score, and probability of consuming moderate or high levels of healthy food groups.

Results

In both samples, on average, women consumed fewer calories than men in the same households but consumed near equal or more in reference to their caloric needs. Women scored <1% lower than men on diet quality indicators and showed similar probabilities to men of consuming healthy foods. Most men and women in both samples were calorically inadequate (>60%) and recorded poor diet quality scores that indicated high risk of nutrient inadequacy and chronic disease (>95%).

Conclusions

In both ultrapoor and farm households, although men record higher intake quantities and diet quality scores, the apparent male advantage disappear when energy requirements and the magnitudes of difference are considered. Diets of men and women in these rural Bangladeshi households are equitable but suboptimal.

Comparing delivery channels to promote nutrition-sensitive agriculture: A cluster-randomized controlled trial in Bangladesh

We use a randomized controlled trial in rural Bangladesh to compare two models of delivering nutrition content jointly to husbands and wives: deploying female nutrition workers versus mostly male agriculture extension workers. Both approaches increased nutrition knowledge of men and women, household and individual diet quality, and women's empowerment. Intervention effects on agriculture and nutrition knowledge, agricultural production diversity, dietary diversity, women's empowerment, and gender parity do not significantly differ between models where nutrition workers versus agriculture extension workers provide the training. The exception is in an attitudes score, where results indicate same-sex agents may affect scores differently than opposite-sex agents. Our results suggest opposite-sex agents may not necessarily be less effective in providing training. In South Asia, where agricultural extension systems and the pipeline to those systems are male-dominated, training men to deliver nutrition messages may offer a temporary solution to the shortage of female extension workers and offer opportunities to scale and promote nutrition-sensitive agriculture. However, in both models, we find evidence that the presence of mothers-in-law within households modifies the programs' effectiveness on some nutrition, empowerment, and attitude measures, suggesting that accounting for other influential household members is a potential area for future programming.

The Indian Enigma revisited

This paper re-enters the contested discussion surrounding the Indian Enigma, the high prevalence of chronic undernutrition in India relative to sub-Saharan Africa. Jayachandran & Pande (JP) argue that the key to the Indian Enigma lies in the worse treatment of higher birth order children, particularly girls. Analyzing new data, and taking into account issues relating to robustness to model specification, weighting and existing critiques of JP., we find: (1) Parameter estimates are sensitive to sampling design and model specification; (2) The gap between the heights of pre-school African and Indian children is closing; (3) The gap does not appear to be driven by differential associations by birth order and child sex; (4) The remaining gap is associated with differences in maternal heights. If Indian women had the heights of their African counterparts, pre-school Indian children would be taller than pre-school African children; and (5) Once we account for survey design, sibling size and maternal height, the coefficient associated with being an Indian girl is no longer statistically significant.

Engaging Fathers Through Nutrition Behavior Communication Change Does Not Increase Child Dietary Diversity in a Cluster Randomized Control Trial in Rural Ethiopia

BACKGROUND

Adding food vouchers or paternal nutrition behavior change communication (BCC) activities to maternal BCC may improve child diets and household food security but their effect is unknown.

OBJECTIVES

We assessed whether maternal BCC, maternal and paternal BCC, maternal BCC and a food voucher, or maternal and paternal BCC and a food voucher improved nutrition knowledge, child diet diversity scores (CDDS), and household food security.

METHODS

We implemented a cluster randomized control trial in 92 Ethiopian villages. Treatments were as follows: maternal (M) BCC only; maternal BCC and paternal BCC (M+P); maternal BCC and food vouchers (M+V); and maternal BCC, food vouchers, and paternal BCC (M+V+P). Effects were assessed using generalized estimating equations.

RESULTS

Maternal BCC and paternal BCC increased the maternal and paternal knowledge of optimal infant and young child feeding practices by 4.2-6.8 percentage points (P < 0.05) and by 8.3-8.4 percentage points (P < 0.01), respectively. Combining maternal BCC with either paternal BCC or the food voucher increased CDDS by 21.0%-23.1% (P < 0.05). The treatments M, M+V, and M+P increased the proportion of children who met minimum acceptable diet standards by 14.5, 12.8, and 20.1 percentage points, respectively (P < 0.01). Adding paternal BCC to the maternal BCC treatment or to the maternal BCC and voucher treatment did not lead to a larger increase in CDDS.

CONCLUSIONS

Increased paternal involvement does not necessarily translate into improvements in child feeding outcomes. Understanding the intrahousehold decision-making dynamics that underlie this is an important area for future research. This study was registered at clinicaltrials.gov as NCT03229629.

Respondent Fatigue Reduces Dietary Diversity Scores Reported from Mobile Phone Surveys in Ethiopia during the COVID-19 Pandemic

BACKGROUND

The computer-assisted telephone interview (CATI) has been used extensively during the COVID-19 pandemic, but the effects of respondent fatigue during these interviews on responses to questions about diet are unknown.

OBJECTIVES

We designed an experiment that randomized the placement of a survey module on the dietary diversity of rural Ethiopian women and assessed whether responses were altered by placing this module earlier or later in a phone survey.

METHODS

Two CATIs were implemented; in the second, women were randomly assigned to answer questions on diet diversity either earlier or later in the interview. Women's Dietary Diversity Scores were the primary outcome. Secondary outcomes were dichotomous measures of consumption from four or more and five or more food groups and consumption of food groups consumed frequently, often, and rarely. Impacts were assessed using a respondent fixed effects model.

RESULTS

Delaying the food consumption module by 15 min in the interview led to an 8%-17% (P < 0.01) decrease in reported Dietary Diversity Scores, a 28% (P < 0.01) decrease in the number of women who consumed a minimum of four dietary groups, and a 40% (P < 0.01) and 11% (P < 0.01) decrease in the reporting of consumption of animal source foods and fruits and vegetables, respectively. Moving the food consumption module closer to the beginning of the interview increased the number of reported food groups consumed by older women, women with a below-median education level, and women in larger households.

CONCLUSIONS

Our findings suggest that comparisons of descriptive statistics across studies and countries on metrics such as food security and dietary quality may be confounded by where these modules are placed in the interview, thus highlighting trade-offs between volume of information collected and data quality when designing CATI surveys.

Storytelling for persuasion: Insights from community health workers on how they engage family members to improve adoption of recommended maternal nutrition and breastfeeding behaviours in rural Bangladesh

Community health workers (CHWs) increasingly provide interpersonal counselling to childbearing women and their families to improve adoption of recommended maternal and child nutrition behaviours. Little is known about CHWs' first‐hand experiences garnering family support for improving maternal nutrition and breastfeeding practices in low‐resource settings. Using focused ethnography, we drew insights from the strategies that CHWs used to persuade influential family members to support recommendations on maternal diet, rest and breastfeeding in a behaviour change communication trial in rural Bangladesh. We interviewed 35 CHWs providing at‐home interpersonal counselling to pregnant women and their families in seven ‘Alive & Thrive’ intervention sites. In‐depth probing focused on how CHWs addressed lack of family support. Thematic coding based on Fisher's narrative paradigm revealed strategic use of three rhetorical principles by CHWs: ethos (credibility), pathos (emotion) and logos (logic). CHWs reported selectively targeting pregnant women, husbands and mothers‐in‐law based on their influence on behavioural adoption. Key motivators to support recommended behaviours were improved foetal growth and child intelligence. Improved maternal health was the least motivating outcome, even among mothers. Logically coherent messaging resonated well with husbands, while empathetic counselling was additionally required for mothers. Mothers‐in‐law were most intransigent, but were persuaded via emotional appeals. Persuasion on maternal rest was most effort‐intensive, resulting in contextually appealing but scientifically inaccurate messaging. Our study demonstrates that CHWs can offer important insights on context‐relevant, feasible strategies to improve family support and uptake of nutrition recommendations. It also identifies the need for focused CHW training and monitoring to address scientifically flawed counselling narratives.

Analysis of narratives of nutrition‐promoting, rural Bangladeshi community health workers (CHWs) suggest that behavior change communication (BCC) strategies to persuade husbands require logical and credible information (logos and ethos) to establish their support, while childbearing women may additionally require emotional appeals (pathos) to adopt promoted behaviors. Mothers‐in‐law, who traditionally influence multiple nutrition behaviors, can be persuaded via strategic use of ethos and pathos.

CHW communication strategies are useful in developing persuasive narratives that capture influential family members’ value beliefs and outcome expectancies and promote behavior change. However, additional programmatic efforts are needed to discourage use of unscientific narratives by CHWs.

The effect of electronic job aid assisted one‐to‐one counselling to support exclusive breastfeeding among 0–5‐month‐old infants in rural Bangladesh

Exclusive breastfeeding (EBF) for the first 6 months has established benefits, yet had slow improvements globally. Little is known about electronic job aid‐assisted counselling to support EBF. As a secondary outcome of a cluster randomized controlled trial in Bangladesh, we assessed the effect of electronic job aid‐supported nutrition counselling and practical demonstration on EBF. We randomized pregnant women to one of five study arms in the trial and followed mother–child dyads until 2 years of age. Community health workers (CHWs) provided breastfeeding counselling with or without prenatal and complementary nutrient supplements in all four intervention arms. The comparison arm continued with the usual practice where mothers could receive nutrition counselling at routine antenatal and postnatal care, and during careseeking for childhood illnesses. We assessed breastfeeding indicators at birth and monthly until the child was 6 months old, in both intervention and comparison arms. To evaluate the effect of nutrition counselling on breastfeeding, we combined all four intervention arms and compared them with the comparison arm. Intervention newborns had half the risk (relative risk [RR]: 0.54, 95% confidence interval [CI]: 0.39, 0.76) of receiving prelacteal feeds than those in the comparison arm. EBF declined steeply in the comparison arm after 3 months of age. EBF was 16% higher in the intervention than the comparison arm at 4 months (RR: 1.16, 95% CI: 1.08, 1.23) and 22% higher at 5 months of age (RR: 1.22, 95% CI: 1.12, 1.33). Maternal background and household characteristics did not modify the intervention effect, and we observed no difference in EBF among caesarean versus vaginal births. Breastfeeding counselling and practical demonstration using an electronic job aid by CHWs are promising interventions to improve EBF and are scalable into existing community‐based programmes.

Using an electronic job aid, repeated, one‐to‐one counselling and practical demonstration to mothers by locally recruited CHWs reduced prelacteal feeding and improved EBF practice by delaying the early introduction of complementary food.

The positive effect of counselling on EBF remains similar with or without nutrient supplementation.

Electronic job aid supported counselling to promote breastfeeding should be integrated into existing community‐based maternal and child health programmes.

Gender Differences in Diet Quality and Quantity in Rural Bangladesh. Are Men Still Favored?

Objectives

Studies from Bangladesh have long documented pro-male biases in intrahousehold food allocation. However, many of these earlier studies were conducted against the backdrop of caloric scarcity and since then, food availability and affordability in the country have significantly improved. This study re-examines gender differences in diet quantity and quality in rural Bangladesh with 2012 data.

Methods

The study uses 24-hour dietary recall data collected in 2012 (12,970 individuals within 5,000 households, ages 15+) from ultra-poor rural Bangladeshi households and OLS regressions to test for gender differences in constructed diet measures. Measures include caloric intake, Caloric Adequacy Ratio (CAR: intake divided by estimated requirements based on sex, occupation, and life stage), Dietary Diversity Score (DDS; range 0–10), Global Dietary Quality Score (DGQS; range 0–49), food group intakes (intake per GDQS food group, grams), and ratios of food group intake to total intake. Between-household differences are accounted for by adjusting for demographic and geographic factors.

Results

Preliminary results show that men consume more calories than women (mean kcal: male = 2217.99, female = 2022.25, p < 0.001), but women consume more in reference to their caloric needs (CAR: m = 0.75, f = 0.90, p < 0.001). Men also score higher on diet quality measures (DDS: m = 3.43, f = 3.32, p < 0.001; GDQS: m = 8.27, f = 7.69, p < 0.001) and have greater mean intakes in 18 of the 25 GDQS food groups, but the absolute magnitude of male-female differences is small (e.g., < 10 gr. differences in all animal sourced foods). Moreover, compared to women, men did not consume significantly higher proportions of nutrient-dense foods groups.

Conclusions

Results indicate that while men's intake quantities and diet quality scores are marginally higher, the slight male advantage disappears when energy requirements and food group proportions are accounted for. Accordingly, the study results do not provide evidence of male favoritism in household food allocation.

Funding Sources

National Institutes of Health (award T32DK007158), German Ministry for Economic Cooperation and Development, UK Department for International Development, Swiss Agency for Development and Cooperation, UN Development Programme, World Food Programme.

Reliability and Validity of Physical Function Tests and ADL Survey Questions in Females Living in Rural, Highland Ethiopia

Objectives

In rural, highland Ethiopia, physical function, which is the physical ability to fulfill one's daily roles and responsibilities, may be compromised by a lack of access to nutrition, healthcare, and sanitation. Decreased physical function would be detrimental to health and income-generating activities. Unfortunately, there is a lack of validated methods to measure physical function in adult females in this region. This study aims to test the feasibility and reliability of physical tests, including the sit-to-stand (STS) and usual gait speed (UGS). These physical tests will validate context-appropriate activities of daily living (ADL) questions for use in future surveys.

Methods

Study participants consisted of 316 females between the age of 18 and 45 years living in rural Tigray, Ethiopia that had previously participated in an impact evaluation of a safety net program. Over a one-week period, participants completed the STS and UGS tests and responded to the ADL questionnaires three times. Feasibility was ascertained qualitatively. Reliability was assessed by comparing the results of the tests and questions between each visit using either Cohen's k or Pearson's r. Validity was assessed by regressing the responses to the ADL questions against the results of the STS test, controlling for relevant participant characteristics.

Results

STS was determined to be a feasible, reliable, and valid physical function test in rural, highland Ethiopia. UGS lacked feasibility and reliability. The validity of the ADLs was inconclusive.

Conclusions

STS tests can be used in future research to evaluate the physical function of females living in rural, highland Ethiopia. Future research should replicate this work to determine if STS is suitable in similar populations.

Funding Sources

NIH/NIDDK T32 Nutrition Training Program in Translational Science, the H.E. Babcock Fund, and the Bill and Melinda Gates Foundation.

Economic costs of childhood stunting to the private sector in low- and middle-income countries

BACKGROUND

Stunting during childhood has long-term consequences on human capital, including decreased physical growth, and lower educational attainment, cognition, workforce productivity and wages. Previous research has quantified the costs of stunting to national economies however beyond a few single-country datasets there has been a limited number of which have used diverse datasets and have had a dedicated focus on the private sector, which employs nearly 90% of the workforce in many low- and middle-income countries (LMICs). We aimed to examine (i) the impact of childhood stunting on income loss of private sector workforce in LMICs; (ii) to quantify losses in sales to private firms in LMICs due to childhood stunting; and (iii) to estimate potential gains (benefit-cost ratios) if stunting levels are reduced in select high prevalence countries.

METHODS

This multiple-methods study engaged multi-disciplinary technical advisers, executed several literature reviews, used innovative statistical methods, and implemented health and labor economic models. We analyzed data from seven longitudinal datasets (up to 30+ years of follow-up; 1982-2016; Peru, Ethiopia, India, Vietnam, Philippines, Tanzania, Brazil), 108 private firm datasets (spanning 2008-2020), and many global datasets including Joint Malnutrition Estimates, and World Development Indicators to produce estimates for 120+ LMICs (with estimates up to 2021). We studied the impact of childhood stunting on adult cognition, education, and height as pathways to wages/productivity in adulthood. We employed cloud-based artificial intelligence (AI) platforms, and conducted comparative analyses using three analytic approaches: traditional frequentist statistics, Bayesian inferential statistics and machine learning. We employed labour and health economic models to estimate wage losses to the private sector worker and firm revenue losses due to stunting. We also estimated benefit-cost ratios for countries investing in nutrition-specific interventions to prevent stunting.

FINDINGS

Across 95 LMICs, childhood stunting costs the private sector at least US$135.4 billion in sales annually. Firms from countries in Latin America and the Caribbean and East Asia and Pacific regions had the greatest losses. Totals sales losses to the private sector accumulated to 0.01% to 1.2% of national GDP across countries. Sectors most affected by childhood stunting were manufacturing (non-metallic mineral, fabricated metal, other), garments and food sectors. Sale losses were highest for larger sized private firms. Across regions (representing 123 LMICs), US$700 million (Middle East and North Africa) to US$16.5 billion (East Asia and Pacific) monthly income was lost among private sector workers. Investing in stunting reduction interventions yields gains from US$2 to US$81 per $1 invested annually (or 100% to 8000% across countries). Across sectors, the highest returns were in elementary occupations (US$46) and the lowest were among agricultural workers (US$8). By gender, women incurred a higher income penalty from childhood stunting and earned less than men; due to their relatively higher earnings, the returns for investing in stunting reduction were consistently higher for men across most countries studied.

INTERPRETATION

Childhood stunting costs the private sector in LMICs billions of dollars in sales and earnings for the workforce annually. Returns to nutrition interventions show that there is an economic case to be made for investing in childhood nutrition, alongside a moral one for both the public and private sector. This research could be used to motivate strong public-private sector partnerships to invest in childhood undernutrition for benefits in the short and long-term.

Designing for empowerment impact in agricultural development projects: Experimental evidence from the Agriculture, Nutrition, and Gender Linkages (ANGeL) project in Bangladesh

The importance of women's roles for nutrition-sensitive agricultural projects is increasingly recognized, yet little is known about whether such projects improve women's empowerment and gender equality. We study the Agriculture, Nutrition, and Gender Linkages (ANGeL) pilot project, which was implemented as a cluster-randomized controlled trial by the Government of Bangladesh. The project's treatment arms included agricultural training, nutrition behavior change communication (BCC), and gender sensitization trainings delivered to husbands and wives together - with these components combined additively, such that the impact of gender sensitization could be distinguished from that of agriculture and nutrition trainings. Empowerment was measured using the internationally-validated project-level Women's Empowerment in Agriculture Index (pro-WEAI), and attitudes regarding gender roles were elicited from both men and women, to explore potentially gender-transformative impacts. Our study finds that ANGeL increased both women's and men's empowerment, raised the prevalence of households achieving gender parity, and led to small improvements in the gender attitudes of both women and men. We find significant increases in women's empowerment scores and empowerment status from all treatment arms but with no significant differences across these. We find no evidence of unintended impacts on workloads and inconclusive evidence around impacts on intimate partner violence. Our results also suggest some potential benefits of bundling nutrition and gender components with an agricultural development intervention; however, many of these benefits seem to be driven by bundling nutrition with agriculture. While we cannot assess the extent to which including men and women within the same treatment arms contributed to our results, it is plausible that the positive impacts of all treatment arms on women's empowerment outcomes may have arisen from implementation modalities that provided information to both husbands and wives when they were together. The role of engaging men and women jointly in interventions is a promising area for future research.

Effect of nutrition counselling with a digital job aid on child dietary diversity: Analysis of secondary outcomes from a cluster randomised controlled trial in rural Bangladesh

Adequate dietary diversity among infants is often suboptimal in developing countries. We assessed the impact of nutrition counselling using a digital job aid on dietary diversity of children aged 6–23 months using data from a cluster randomised controlled trial in Bangladesh. The trial had five arms, each with 25 clusters. The four intervention arms provided counselling using a digital job aid and different prenatal and post‐natal combinations of lipid‐based supplements and the comparison arm with usual practice. We enrolled 1500 pregnant women and followed them until the children reached their second birthday. We developed a tablet‐based system for intervention delivery, data collection and project supervision. We combined the four intervention arms (n = 855), in which community health workers (CHWs) provided age‐appropriate complementary feeding counselling, to compare against the comparison arm (n = 403). We calculated the outcome indicators from the children's 24‐h dietary recalls. Overall, the intervention increased the mean dietary diversity score by 0.09 (95% confidence interval [CI]: 0.2–0.16) and odds of minimum dietary diversity by 18% (95% CI: 0.99–1.40). However, there was a significant interaction on the effect of the intervention on dietary diversity by age. The mean dietary diversity score was 0.24 (95% CI: 0.11–0.37) higher in the intervention than in the comparison arm at 9 months and 0.14 (95% CI: 0.01–27) at 12 months of age. The intervention effect was non‐significant at an older age. Overall, consumption of flesh food was 1.32 times higher in the intervention arm (odds ratio [OR] 1.32, 95% CI: 1.11–1.57) in 6–23 months of age. The intervention significantly improved child dietary diversity score in households with mild and moderate food insecurity by 0.27 (95% CI: 0.06–0.49) and 0.16 (0.05–27), respectively, but not with food‐secure and severely food‐insecure households. Although the study did not evaluate the impact of digital job aid alone, the findings indicate the utility of nutrition counselling by CHWs using a digital job aid to improve child feeding practices in broader programmes.

A Nutrition-Sensitive Agroecology Intervention in Rural Tanzania Increases Children's Dietary Diversity and Household Food Security But Does Not Change Child Anthropometry: Results from a Cluster-Randomized Trial

BACKGROUND

There are urgent calls for the transformation of agriculture and food systems to address human and planetary health issues. Nutrition-sensitive agriculture and agroecology promise interconnected solutions to these challenges, but evidence of their impact has been limited.

OBJECTIVES

In a cluster-randomized trial (NCT02761876), we examined whether a nutrition-sensitive agroecology intervention in rural Tanzania could improve children's dietary diversity. Secondary outcomes were food insecurity and child anthropometry. We also posited that such an intervention would improve sustainable agricultural practices (e.g., agrobiodiversity, intercropping), women's empowerment (e.g., participation in decision making, time use), and women's well-being (e.g., dietary diversity, depression).

METHODS

Food-insecure smallholder farmers with children aged <1 y from 20 villages in Singida, Tanzania, were invited to participate. Villages were paired and publicly randomized; control villages received the intervention after 2 y. One man and 1 woman "mentor farmer" were elected from each intervention village to lead their peers in agroecological learning on topics including legume intensification, nutrition, and women's empowerment. Impact was estimated using longitudinal difference-in-differences fixed-effects regression analyses.

RESULTS

A total of 591 households (intervention: n = 296; control: n = 295) were enrolled; 90.0% were retained to study end. After 2 growing seasons, the intervention improved children's dietary diversity score by 0.57 food groups (out of 7; P < 0.01), and the percentage of children achieving minimum dietary diversity (≥4 food groups) increased by 9.9 percentage points during the postharvest season. The intervention significantly reduced household food insecurity but had no significant impact on child anthropometry. The intervention also improved a range of sustainable agriculture, women's empowerment, and women's well-being outcomes.

CONCLUSIONS

The magnitude of the intervention's impacts was similar to or larger than that of other nutrition-sensitive interventions that provided more substantial inputs but were not agroecologically focused. These data suggest the untapped potential for nutrition-sensitive agroecological approaches to achieve human health while promoting sustainable agricultural practices.

What empowerment indicators are important for food consumption for women? Evidence from 5 sub-Sahara African countries

This paper draws on data from five sub-Sahara African countries; Uganda, Rwanda, Malawi, Zambia, and Mozambique consisting of 10,041 married women who were cohabitating with a male spouse. The study aim was to investigate the relationship between women's empowerment and women's dietary diversity and consumption of different food items. Women's empowerment was measured using the indicators in the five domains of Women's Empowerment in Agriculture index (WEAI) and women's dietary diversity and food consumption was examined using the women's dietary diversity score (WDDS) measure. OLS and LPM regressions were used and analyses were confirmed using marginal effects from Poisson and logistic regressions. Results suggest that three out of the 10 WEAI indicators of empowerment showed different magnitude and direction in significant associations with improved WDDS and varied associations were found in three out of the five countries examined. In addition, the three significant empowerment indicators were associated with the consumption of different food groups in three out of the five countries examined suggesting that diverse food groups account for the association between the WEAI and WDDS. Improved autonomy, and input in production were associated with improved likelihoods of consumption of dairy products, and fruits and vegetables including vitamin A-rich produce. Empowerment in public speaking was associated with improved consumption of other fruits and vegetables including vitamin A-rich produce. The varied nature of empowerment indicators towards improving women's dietary diversity and food consumption suggests that different empowerment strategies might confer different benefits towards the consumption of different food groups. Further, findings imply that interventions that seek to empower women should tailor their strategies on existing contextual factors that impact on women.

Linear Growth Trajectories in Early Childhood and Adult Cognitive and Socioemotional Functioning in a Guatemalan Cohort

BACKGROUND

Growth faltering in early childhood is associated with poor human capital attainment, but associations of linear growth in childhood with executive and socioemotional functioning in adulthood are understudied.

OBJECTIVES

In a Guatemalan cohort, we identified distinct trajectories of linear growth in early childhood, assessed their predictors, and examined associations between growth trajectories and neurodevelopmental outcomes in adulthood. We also assessed the mediating role of schooling on the association of growth trajectories with adult cognitive outcomes.

METHODS

In 2017-2019, we prospectively followed 1499 Guatemalan adults who participated in a food supplementation trial in early childhood (1969-1977). We derived height-for-age sex-specific growth trajectories from birth to 84 mo using latent class growth analysis.

RESULTS

We identified 3 growth trajectories (low, intermediate, high) with parallel slopes and intercepts already differentiated at birth in both sexes. Children of taller mothers were more likely to belong to the high and intermediate trajectories [relative risk ratio (RRR): 1.21; 95% CI: 1.15, 1.26, and RRR: 1.11; 95% CI: 1.07, 1.15, per 1-cm increase in height, respectively] compared with the low trajectory. Children in the wealthiest compared with the poorest socioeconomic tertile were more likely to belong to the high trajectory compared with the low trajectory (RRR: 2.24; 95% CI: 1.29, 3.88). In males, membership in the high compared with low trajectory was positively associated with nonverbal fluid intelligence, working memory, inhibitory control, and cognitive flexibility at ages 40-57 y. Sex-adjusted results showed that membership in the high compared with low trajectory was positively associated with meaning and purpose scores at ages 40-57 y. Associations of intermediate compared with low growth trajectories with study outcomes were also positive but of lesser magnitude. Schooling partially mediated the associations between high and intermediate growth trajectories and measures of cognitive ability in adulthood.

CONCLUSIONS

Modifiable and nonmodifiable risk factors predicted growth throughout childhood. Membership in the high and intermediate growth trajectories was positively associated with adult cognitive and socioemotional functioning.

Shonjibon cash and counselling: a community-based cluster randomised controlled trial to measure the effectiveness of unconditional cash transfers and mobile behaviour change communications to reduce child undernutrition in rural Bangladesh

Background

Undernutrition is strongly associated with poverty - levels of undernutrition are higher in poor countries than in better-off countries. Social protection especially cash transfer is increasingly recognized as an important strategy to accelerate progress in improving maternal and child nutrition. A critical method to improve nutrition knowledge and influence feeding practices is through behaviour change communication intervention. The Shonjibon Cash and Counselling study aims to assess the effectiveness of unconditional cash transfers combined with a mobile application on nutrition counselling and direct counselling through mobile phone in reducing the prevalence of stunting in children at 18 months.

Method

The study is a longitudinal cluster randomised controlled trial, with two parallel groups, and cluster assignment by groups of villages. The cohort of mother-child dyads will be followed-up over the intervention period of approximately 24 months, starting from recruitment to 18 months of the child’s age. The study will take place in north-central Bangladesh. The primary trial outcome will be the percentage of stunted children at 18 m as measured in follow up assessments starting from birth. The secondary trial outcomes will include differences between treatment arms in (1) Mean birthweight, percentage with low birthweight and small for gestational age (2) Mean child length-for age, weight for age and weight-for-length Z scores (3) Prevalence of child wasting (4) Percentage of women exclusively breastfeeding and mean duration of exclusive breastfeeding (5) Percentage of children consuming > 4 food groups (6) Mean child intake of energy, protein, carbohydrate, fat and micronutrients (7) Percentage of women at risk of inadequate nutrient intakes in all three trimesters (8) Maternal weight gain (9) Household food security (10) Number of events for child suffering from diarrhoea, acute respiratory illness and fever (11) Average costs of mobile phone BCC and cash transfer, and benefit-cost ratio for primary and secondary outcomes.

Discussion

The proposed trial will provide high-level evidence of the efficacy and cost-effectiveness of mobile phone nutrition behavior change communication, combined with unconditional cash transfers in reducing child undernutrition in rural Bangladesh.

Trial registration

The study has been registered in the Australian New Zealand Clinical Trials Registry (ACTRN12618001975280).

Assessing statistical similarity in dietary intakes of women of reproductive age in Bangladesh

Women of reproductive age (WRA) need adequate nutrient intakes to sustain a healthy pregnancy, support fetal growth, and breastfeed after childbirth. However, data on women's dietary intake in low‐ and middle‐income countries (LMICs) are limited, and assessment of differences between dietary intakes of pregnant or lactating women compared with that of nonpregnant, nonlactating (NPNL) women is untested. Using single, multiple‐pass 24‐h dietary recall data from a sample of WRA residing in rural Bangladesh, we examined women's dietary intakes for energy, protein, calcium, iron, vitamin A, and dietary diversity for three groups: NPNL (n = 2,903), pregnant (n = 197), and lactating women (n = 944). We used equivalence testing to examine similarity in adjusted intakes for pregnant versus NPNL women and lactating versus NPNL women with a predetermined equivalence threshold based on recommendations specific for each reproductive stage. On average, both pregnant and lactating women had insufficient intakes for all dietary measures. Although statistically significant differences were observed between pregnant and NPNL women for energy intake and dietary diversity and between lactating and NPNL women for energy and protein intake, the magnitudes of these differences were too small to reject equivalence. Statistical similarity was also evident in all micronutrients and dietary diversity for both two‐group comparisons. Understanding statistical differences and similarities between dietary measures of women in distinct reproductive stages has important implications for the relevance, appropriateness, and evaluation of maternal diet‐enhancing interventions in LMICs, especially during pregnancy and lactation, when demand for macronutrients and micronutrients is elevated.

Nutrition, Adult Cognitive Skills, and Productivity: Results and Influence of the INCAP Longitudinal Study

This article summarizes research based on the INCAP Longitudinal Study that demonstrates the positive effects of the atole intervention on prime-age adult cognitive skills and productivities. The findings are interpreted in the context of a life-cycle stages model in which various factors and investments at each stage of life influence outcomes not only in that stage but in subsequent ones. The results point to the likely importance of improvements in adult cognitive skills due to better early-life nutrition on adult male labor market outcomes as well as on women's "home productivity" in terms of anthropometrics for the next generation. Possible mechanisms are also explored, including the impacts of early-life exposure to atole on children's height when starting school, on grades of schooling attainment, and on the extent of experience with higher-skilled jobs, as well as the impacts of improved cognitive skills on wages. Not only are investments in early-life nutrition important for immediate welfare but also they have significant productivity payoffs in adulthood.

Development and Validation of Skinfold-Thickness Equations for Predicting Body Fatness in Ethiopian Adults

Objectives

Both body fat and lean body mass have important roles in health and wellbeing. It is crucial that researchers and clinicians can accurately measure them, especially in nutritionally vulnerable populations such as people living in rural areas of Ethiopia. Skinfold thickness measurements are one of the few methods to measure % body fat outside of a clinical setting. The validity of the measurements is dependent upon age, sex, and ethnicity. The existing skinfold thickness equations are derived from populations of European descent. This study will demonstrate that existing equations are not valid for Ethiopian adults and create new, sex-specific equations for this population.

Methods

Skinfold thickness will be measured on 250 adults recruited from Jimma City, Ethiopia. Percent body fat will be calculated using several existing skinfold thickness equations. For women, the equations are the Sloan; Jackson, Pollock, & Ward; and Durnin and Wormsley. The equations for men are Sloan; Jackson and Pollock; and Durnin and Wormsley. The results of these equations will then be compared against % body fat measured by a BodPod. Pearson's correlation coefficient and Bland-Altman plots will be used to assess the validity of each calculation. Stepwise forward regression will be used to determine new sex-specific equations.

Results

In women, the Sloan equation had moderate correlation (0.59) while Jackson, Pollack, and Ward and the Durnin and Wormsley equations had near-perfect correlation (0.81 and 0.88 respectively). In men, the Sloan equation had substantial correlation (0.79) while the Jackson and Pollack and the Durnin and Wormsley had near-perfect correlation (0.89 and 0.85 respectively). Scatter and Bland Altman plots showed that all equations underestimated the % body fat measured compared to a BodPod requiring new equations. For women: body density = 1.068892 − 0.00088 x −0.0005412 y − 0.0012765 z. Where x is the skinfold thickness at the suprailiac crest, y is thigh, and x is subscapular. For men: body density = 1.08899 −0.0014585 m −0.0008318 n. Where m is abdominal skinfold thickness and n is thigh skinfold thickness.

Conclusions

The current most commonly used skinfold thickness equations are not valid for use in Ethiopian adults. The equations put forth in this analysis should be used for this population.

Funding Sources

H.E. Babcock Fund, NIDDK/NIH.

Strategies Used By Community Health Workers to Influence Adoption of Maternal Nutrition Behaviors in Rural Bangladesh: A Focused Ethnographic Study

Objectives

Efforts to integrate nutrition into antenatal health promotion in low income countries have led to increased involvement of community health workers (CHWs) in counseling on maternal nutrition. Little is known about how CHWs “package” messages in resource-poor communities to increase adoption of recommended maternal nutrition behaviors. We developed focused ethnographic techniques to explore this.

Methods

We interviewed 35 randomly selected CHWs providing monthly counseling to pregnant women and their families in 7 ‘Alive & Thrive’ intervention sites in Bangladesh. Two sorting exercises explored CHW strategies for promoting and perceptions of adoption of messages on micronutrient supplements, maternal dietary adequacy, and rest during pregnancy. In-depth probing on messages identified as “difficult” to deliver or adopt revealed how CHWs addressed barriers. Analysis of quantitative sorting data complemented thematic coding of qualitative textual data using grounded theory.

Results

CHW communication strategies involved 3 themes: feasibility (attitudes, norms, agency, poverty), audience (influence, motivators, support), and linguistic choice (emotional appeals, metaphors, logic, sellable but inaccurate arguments). CHWs viewed micronutrient messages as least difficult to adopt, requiring minimal “packaging”. Dietary messages were moderately difficult to adopt, prompting CHWs to leverage cultural congruence to target family members with different strategies. For example, messaging on diet diversity targeted husbands—the primary food-buyers—with logical arguments highlighting costs of inaction. When mothers-in-law held beliefs restricting gestational food intake, CHWs used metaphors (‘healthy tree, healthy fruit’) or faith-based appeals. Some CHWs used inaccurate messages (‘mother rests, baby rests’) to promote rest during pregnancy because it was seen as the least feasible behavior to adopt.

Conclusions

Where behavior change is viewed as feasible, CHWs use culturally resonant strategies to enhance adoption of maternal nutrition behaviors. Cultural congruence, or shared beliefs, language and cultural identity, is key to CHW effectiveness, but unhelpful for contextually infeasible behaviors. BCC programs co-designed with CHWs could improve messaging and effectiveness.

Funding Sources

Cornell AWARE Travel Grant.

Predictors of Program Participation in a Nutrition-Sensitive Agroecological Intervention in Singida, Tanzania

Objectives

Nutrition-sensitive agricultural interventions are theorized to improve child's diet through asset provision and program participation. Although some programs measure participation, predictors of participation are understudied. We therefore investigated predictors of men's and women's program participation in Singida Nutrition and Agroecology Project (SNAP-Tz; NCT02761876).

Methods

In SNAP-Tz, ‘mentor farmers’ led their peers (smallholder farmers with children &lt; 1 year at baseline) in learning about agroecology, nutrition, and gender equity through meetings and household visits. At baseline, we collected data on demographics, Household Food Insecurity Access Scale (0–27), men's involvement in 7 household tasks (0–7), and Abbreviated Women's Empowerment in Agriculture Index (AWEAI). Participating men (n = 262) and women (n = 283) were asked to recall their program participation biannually. Predictors of high participation, defined as attendance in ≥60% participant meetings and household visits, were identified using multiple logistic regressions, controlling for clustering at the village level.

Results

Only 59% and 37% of women and men, respectively, had high participation. Women's high participation was associated with their spouse's participation (OR = 4.23, P &lt; 0.01), greater food insecurity (OR = 1.03, P = 0.03), years of education (OR = 1.13, P = 0.02), and being empowered (OR = 5.88, P &lt; 0.01). Men's high participation was associated with their spouse's participation (OR = 4.22, P &lt; 0.01), greater food insecurity (OR = 2.23, P = 0.01), involvement in household tasks (OR = 1.25, P = 0.04), and age (OR = 1.03, P &lt; 0.01).

Conclusions

Associations between an individual's and their spouse's participation indicate the importance of spousal dynamics. The association between participation and baseline gender equity (i.e., women's empowerment, men's involvement in household tasks) highlights the challenges of gender programming in nutrition-sensitive interventions. Analysis of program participation was simple and revealed valuable lessons for program implementation and design; more programs should therefore analyze participation.

Funding Sources

This study was funded by the McKnight Foundation, the Borlaug Fellowship in Global Food Security Research, and NIH K01 Award.

Double Fortified Salt Delivered Through the Public Distribution System Reduced Risk of Iron Deficiency but Not of Anemia or Iron Deficiency Anemia in Uttar Pradesh, India

Objectives

Double fortified salt (DFS) with iodine and iron is efficacious in improving anemia, but evidence of effectiveness in large-scale programs is limited. We evaluated a program delivering double fortified salt (DFS) over 12 mo in five districts through the public distribution system in Uttar Pradesh, India on iron status and anemia.

Methods

Only two (Etawah and Auraiya) of the five intervention districts met the evaluability threshold of 50% DFS utilization chosen as an a priori criterion for endline inclusion. We present findings on cross-sectional survey data collected from 6388 non-pregnant women of reproductive age (WRA) in Etawah and Auraiya, and their two matched adjacent boundary comparison districts. We used generalized linear models that accounted for clustering, with log link function for risk ratio (RR) and identity link function for mean difference, adjusting for matched pairs. Models were adjusted for WRA age, education of WRA and household head, religion and housing. Ferritin levels were inflammation adjusted using the BRINDA regression equation.

Results

There was no difference in anemia and iron deficiency anemia (IDA) prevalence or in mean hemoglobin concentration between WRA in intervention and comparison districts. However, we observed a 15% lower risk of being iron deficient in intervention areas (RR = 0.85: 95% CI, 0.75–0.98). Additionally, WRA in intervention districts who reported regular use of DFS had 23% lower risk of being iron deficient (RR = 0.77: 95% CI, 0.66–0.93), and those reporting partial use had 20% lower risk (RR = 0.80: 95% CI, 0.66–0.99). There was no difference among non-users (RR = 0.98: 95% CI, 0.88–1.22).

Conclusions

DFS was effective in reducing risk of iron deficiency, but not anemia or IDA, among WRA. This modest effectiveness may have been in part due to supply chain interruptions over the course of the implementation period (slow start and earlier than planned cessation). We observed a dose responsive effect, with greater risk reductions among regular and partial users than among non-users. To maximize this potential and perhaps extend impacts to anemia or IDA, the program will require: 1) longer duration of exposure, 2) investments in addressing barriers to coverage and utilization, and 3) complementary efforts to address other causes of anemia in this context.

Funding Sources

Bill & Melinda Gates Foundation.

Combined interventions Targeting Agriculture, Gender and Nutrition Improve Agriculture Production and Diet Diversity More Than Individual interventions in Bangladesh

Objectives

Secondary data analysis in Bangladesh has found associations across agricultural production, women's empowerment, and nutrition outcomes. Less is known, though, about whether combining interventions across these areas is more effective than isolated interventions to improve agricultural diversity, diet diversity, and women's empowerment in Bangladesh.

Methods

The Agriculture, Nutrition, and Gender Linkages study used a cluster randomized controlled trial to evaluate impacts of agriculture, nutrition, and/or gender interventions on food production, diets, and empowerment. 160 blocks were randomized to control and 5 training models: (T1) nutrition by government agriculture extension agents (AEAs); (T2) nutrition by community nutrition workers; (T3) agriculture on production of nutrient-rich foods by AEAs; (T4) agriculture and nutrition by AEAs; and (T5) agriculture and nutrition by AEAs, and gender sensitization. Trainings targeted men and women together. 4000 farm households with a child under age 2 at baseline were surveyed 2 years apart. Impact estimates used endline data, adjusting for baseline characteristics using analysis of covariance.

Results

All treatments significantly improved agriculture production knowledge and adoption of improved production practices, more so in arms with agriculture training (T3, T4, T5), and for women than men. All treatments significantly improved nutrition knowledge, more so in arms with nutrition training, and for women than men. Household diet quality and child diet diversity significantly improved only in T2 and T4. Women's empowerment significantly improved in all treatments, and men's gender attitudes improved in T1, T4, T5, more so in the gender arm (T5). No impacts were expected or found on child anthropometry.

Conclusions

Joint interventions had larger impacts than isolated ones, suggesting synergies across agriculture, nutrition, and gender. Impact on food and nutrition outcomes (food production or nutrition practices) required agriculture and/or nutrition training.

Funding Sources

USAID; the Gender, Agriculture, and Assets Project, Phase 2, supported by the Bill & Melinda Gates Foundation; and the CGIAR Research Programs on Agriculture for Nutrition and Health and Policies, Institutions, and Markets.

Food transfers, electronic food vouchers and child nutritional status among Rohingya children living in Bangladesh

Objective

To examine associations between receipt of an electronic food voucher (e-voucher) compared to food rations on the nutritional status of Rohingya children living in refugee camps in Bangladesh.

Methods

This is an associational study using cross-sectional data. We measured heights and weights of 523 children aged between 6 and 23 months in households receiving either a food ration consisting of rice, pulses, vegetable oil (362 children) or an e-voucher (161 children) that could be used to purchase 19 different foods. Data were also collected on the characteristics of their mothers and the households in which they lived, including household demographics, consumption and expenditure, coping strategies, livelihoods and income profiles, and access to assistance. Associations between measures of anthropometric status (height-for-age z scores, stunting, weight-for-height z scores, wasting, weight-for-age z scores and mid-upper arm circumference) and household receipt of the e-voucher were estimated using ordinary least squares regressions. Control variables included child, maternal, household and locality characteristics. The study received ethical approval from the Institutional Review Board of the International Food Policy Research Institute, Washington DC.

Results

Household receipt of an e-voucher was associated with improved linear growth in children. This association is robust to the inclusion of maternal, household and location characteristics. The magnitude of the association is 0.38 SD (CI: 0.01, 0.74), and statistically significant at the five percent level. We cannot reject the null hypothesis that these associations differ by child sex. Receipt of an e-voucher is not associated with stunting when a full set of control variables are included. There is no association between receipt of e-vouchers and weight-for-length, weight-for-age or mid-upper arm circumference. We cannot reject the null hypothesis that these associations differ by child sex.

Conclusions

In a humanitarian assistance setting, Rohingya refugee camps in Bangladesh, household receipt of an electronic food voucher instead of a food ration is associated with improvements in the linear growth of children between 6 and 23 months but not in measures of acute undernutrition or other anthropometric outcomes. Our associational evidence indicates that transitioning from food rations to electronic food vouchers does not adversely affect child nutritional status.

Randomized controlled trials of multi-sectoral programs: Lessons from development research

Development is a multi-faceted process; achieving development goals thus requires a multi-sectoral approach. For over two decades, our research group of economists and nutritionists has designed and implemented randomized trials to assess the effectiveness of multisectoral programs in improving nutrition, food security, and other measures of well-being, largely at the request of developing country governments, development partners, and non-governmental organizations. Our approach addresses three perceived pitfalls of RCTs: the "black box" nature of RCTs, limited external validity, and challenges in translation of results to impacts at scale. We address these concerns by identifying and assessing programmatic pathways to impact with quantitative and qualitative methods; studying similar programs implemented by different organizations across various settings; and working closely with implementing partners in the design, research, and dissemination processes to inform adaptation and scale-up of programs and policies.

Setting research priorities on multiple micronutrient supplementation in pregnancy

Prenatal micronutrient deficiencies are associated with negative maternal and birth outcomes. Multiple micronutrient supplementation (MMS) during pregnancy is a cost-effective intervention to reduce these adverse outcomes. However, important knowledge gaps remain in the implementation of MMS interventions. The Child Health and Nutrition Research Initiative (CHNRI) methodology was applied to inform the direction of research and investments needed to support the implementation of MMS interventions for pregnant women in low- and middle-income countries (LMIC). Following CHNRI methodology guidelines, a group of international experts in nutrition and maternal health provided and ranked the research questions that most urgently need to be resolved for prenatal MMS interventions to be successfully implemented. Seventy-three research questions were received, analyzed, and reorganized, resulting in 35 consolidated research questions. These were scored against four criteria, yielding a priority ranking where the top 10 research options focused on strategies to increase antenatal care attendance and MMS adherence, methods needed to identify populations more likely to benefit from MMS interventions and some discovery issues (e.g., potential benefit of extending MMS through lactation). This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC.

Role of Women's Empowerment in Child Nutrition Outcomes: A Systematic Review

Women's empowerment has gained attention as critical for child nutrition during the first 1000 days of life. However, the ways in which various women's empowerment measures are applied and the evidence for how they are differentially related to child nutrition is unclear. In this systematic review, therefore, we 1) systematically parse the many ways in which women's empowerment has been quantitatively measured in the context of child nutrition through the use of a theoretically driven application of dimensions and domains of empowerment; 2) summarize evidence for each of the various pathways between women's empowerment and child nutrition, based on dimensions and domains of empowerment; and 3) offer suggestions for future research to better articulate the relationship between women's empowerment and child nutrition. A search of evidence yielded 62 quantitative studies that used 200 unique indicators of women's empowerment, tested in 1316 associations with various child nutrition outcomes. Despite the large number of unique indicators, indicators for time resource allocation and reproductive decisions and indicators for men's engagement in child care and nutrition, all pertinent to child nutrition, were missing. Overall, the findings indicated an inconclusive relationship between women's empowerment and child nutrition: 379 out of 461 (82% weighted) and 217 out of 258 (84% weighted) associations found with stunting and wasting outcomes, respectively, were not significant. The current lack of evidence is likely not due to the absence of an underlying relationship between women's empowerment and child nutrition, but rather limitations in study design. Future research should carefully select women's empowerment indicators in context-specific ways, aggregate them meaningfully, and use a longitudinal study design to conduct pathway and lifecycle analysis in appropriate populations to clarify the relationship between women's empowerment and child nutrition.

Rural Food Markets and Child Nutrition

Child dietary diversity is poor in much of rural Africa and developing Asia, prompting significant efforts to leverage agriculture to improve diets. However, growing recognition that even very poor rural households rely on markets to satisfy their demand for nutrient-rich non-staple foods warrants a much better understanding of how rural markets vary in their diversity, competitiveness, frequency and food affordability, and how such characteristics are associated with diets. This article addresses these questions using data from rural Ethiopia. Deploying a novel market survey in conjunction with an information-rich household survey, we find that children in proximity to markets that sell more non-staple food groups have more diverse diets. However, the association is small in absolute terms; moving from three non-staple food groups in the market to six is associated with an increase in the number of non-staple food groups consumed by ˜0.27 and the likelihood of consumption of any non-staple food group by 10 percentage points. These associations are similar in magnitude to those de-scribing the relationship between dietary diversity and household production diversity; moreover, for some food groups, notably dairy, we find that household and community production of that food is especially important. These modest associations may reflect several specific features of our sample which is situated in very poor, food-insecure localities where even the relatively better off are poor in absolute terms and where, by international standards, relative prices for non-staple foods are very high.

Father Engagement in Improving Infant and Young Child Feeding (IYCF) Practices: Evidence from a Clustered Randomized Controlled Trial in Ethiopia (P11-112-19)

Objectives

We identified lack of knowledge and lack of paternal support as barriers to improved IYCF practices in Ethiopia, the focus of this study. Behavior change communication (BCC) strategies are often used to improve knowledge, but BCC programs commonly target only mothers. The objective of this study is to assess the impact of both paternal and maternal BCC program on complementary feeding practices compared to maternal BCC program alone.

Methods

This study is a community-based, clustered randomized controlled trial conducted in Ejere district, Ethiopia. We randomly selected three rural kebeles (ward) and three urban kebeles within the Ejere district. 63 garees (villages) were identified and randomly assigned within selected kebeles into treatment and control groups: T1, maternal BCC only; T2, both maternal BCC and paternal BCC; and C, control. The maternal BCC program and paternal BCC program consisted of weekly one-hour long group sessions for the duration of 16 and 12 weeks, respectively. Both BCC program included messages on improved IYCF practices. In addition, paternal BCC program included messages on gender roles.

Results

Father's IYCF knowledge increased by 0.31SD when BCC was provided to mothers and by 0.62SD when provided to both mothers and fathers. Although we see spillover of knowledge from BCC from BCC-attending mothers to their partners in maternal BCC group, we see paternal BCC additionally increase father's knowledge by 0.36SD. The provision of both maternal and paternal BCC group improves child dietary diversity score (CDDS) by 0.64 food groups and increases the likelihood they meet minimum diet diversity by 18 percentage points. However, the additional impact of paternal BCC on child diets is not statistically significant at the 5% level. We see no differential impact on child anthropometry.

Conclusions

Nutrition BCC program that targets both fathers and mothers have greater impact on father's knowledge, compared to nutrition BCC program that targets mothers only. However, additional knowledge gain has limited impact on IYCF practices.

Funding Sources

Africa Future Foundation.

Supporting Tables, Images and/or Graphs

Assessing Statistical Similarity and Differences in Dietary Intakes of Women of Reproductive Age in Bangladesh (P10-058-19)

Objectives

In low-income countries, where maternal undernutrition is endemic, data on women's dietary intake is lacking. Thus, the hypothesis that intakes of pregnant or lactating women is similar to that of non-pregnant, non-lactating women remains untested. We use novel quantitative approaches to evaluate whether the hypothesized similarity is statistically significant at a population level. Our study aimed to 1) compare nutrient intakes of non-pregnant, non-lactating (NPNL) women, pregnant women (PW), and lactating women (LW) to reproductive stage- specific recommendations, 2) assess whether exposure to pregnancy and lactation alters dietary intake compared to NPNL group, 3) Test whether nutrient intakes of PW and LW are statistically similar to those of NPNL women

Methods

We used 24-hour recall data from the 2011–12 Bangladesh Integrated Household survey (n = 4044) to quantify dietary intake of energy, proteins, calcium, iron, vitamin A, and women's dietary diversity score (WDDS) for NPNL women, PW and LW. Multivariable regression models assessed the association between reproductive status and nutrient intakes. Equivalence test, that looks for proof of similarity, rather than proof of difference, assessed statistically significant similarity in nutrient intakes of PW vs. NPNL women, and LW vs. NPNL women at alpha equals 0.05 and a pre-specified equivalence margin or ‘delta’, defined as ± 60% of the additional nutrient intakes recommended for PW and LW. If the 95% CI of the difference between means lied completely within ± delta, then the null hypothesis of ‘no equivalence’ was rejected, and similarity between the two groups claimed.

Results

PW and LW had suboptimal intakes for all nutrients. Compared to NPNL group, mean energy intakes of PW and LW were greater by 100 Kcal/d and 80 Kcal/d, respectively. Mean WDDS was 3.7 ± 1 across all three groups. Significant and positive relationship was found only for lactation status and energy intake. In both group comparisons, the null of ‘no equivalence’ was rejected at alpha equals 0.05 for all nutrients.

Conclusions

Dietary intakes of PW and LW are similar to NPNL women in rural Bangladesh. There is a need to enhance women's diets, especially during pregnancy and lactation when demand for macronutrients and micronutrients is elevated.

Funding Sources

None.

The Evolution of Growth Faltering in 37 Developing Countries: A Spline-regression Approach (OR10-08-19)

Objectives

Childhood height-for-age z-scores (HAZ) have been improving in many countries over the last few decades. Most HAZ faltering in malnourished populations takes place during the first 1000 days of life, in the prenatal period and the first two years after birth, but little is known about how growth faltering evolves over time in countries witnessing significant HAZ improvement. We aimed to quantify the evolution of population-level patterns of growth faltering using a novel analytic approach.

Methods

We selected 37 low and middle-income countries with at least two Demographic and Health Surveys 7 + years apart with statistically significant increases in HAZ among children 0–59 m. For the first (T1) and second (T2) round for each country we use spline-based regressions to estimate monthly HAZ loss over the prenatal period (conception to 1 m of age) and three postnatal periods (1–6 m, 6–20 m and 20 m onwards). We tested for statistically significant changes in the speed of HAZ loss between T1 and T2. We report results by T1 HAZ, country, and region.

Results

The fastest HAZ improvements between T1 and T2 occurred in Armenia, Ethiopia, Bangladesh, Nepal and India. South Asia had the fastest HAZ improvement of any major region. In South Asia and Eastern Africa, where baseline prenatal HAZ loss was prominent, the majority of HAZ improvement occurred in the prenatal period, suggesting progress in maternal factors. Improvements in regions with less baseline growth faltering typically stemmed from gains in postnatal HAZ, in the 1–6 m or 6–24 m period, but never the 24–59 m period. Several countries in Central and Western Africa, where overall HAZ changes were modest, showed improvement in some age ranges but deterioration in others (e.g., Nigeria).

Conclusions

HAZ improvements between T1 and T2 stemmed from a mix of changes in prenatal and postnatal growth faltering, with substantial variability across countries. The timing and speed of HAZ changes varied markedly by country and region, and over time. Examining the patterns of growth faltering over time can yield important insights into the biological origins of population-level HAZ improvements and point to successes and failures of policy efforts to address the drivers of child growth, and the challenges for designing new and improved approaches.

Funding Sources

Bill & Melinda Gates Foundation through ARENA, led by International Food Policy Research Institute, Wellcome Trust grant to Federal University of Pelotas.

Supporting Tables, Images and/or Graphs

Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries

Inadequate micronutrient intakes are relatively common in low- and middle-income countries (LMICs), especially among pregnant women, who have increased micronutrient requirements. This can lead to an increase in adverse pregnancy and birth outcomes. This review presents the conclusions of a task force that set out to assess the prevalence of inadequate micronutrient intakes and adverse birth outcomes in LMICs; the data from trials comparing multiple micronutrient supplements (MMS) that contain iron and folic acid (IFA) with IFA supplements alone; the risks of reaching the upper intake levels with MMS; and the cost-effectiveness of MMS compared with IFA. Recent meta-analyses demonstrate that MMS can reduce the risks of preterm birth, low birth weight, and small for gestational age in comparison with IFA alone. An individual-participant data meta-analysis also revealed even greater benefits for anemic and underweight women and female infants. Importantly, there was no increased risk of harm for the pregnant women or their infants with MMS. These data suggest that countries with inadequate micronutrient intakes should consider supplementing pregnant women with MMS as a cost-effective method to reduce the risk of adverse birth outcomes.

Evidence to Action: Highlights From Transform Nutrition Research (2012-2017)

BACKGROUND

The Transform Nutrition ( Transform) research consortium (2012-2017), led by the International Food Policy Research Institute, sought to generate evidence to inform and inspire action to address undernutrition in 4 high-burden countries (India, Bangladesh, Kenya, and Ethiopia) and globally.

OBJECTIVE

Within the context of the literature, this synthesis article brings together core findings of Transform, highlighting priorities for future research.

METHODS

This article uses a narrative approach to synthesize diverse study findings that collectively address Transform's three primary research questions: (1) How can nutrition-specific interventions be appropriately designed, implemented, scaled, and sustained in different settings?; (2) How can the nutritional impact of social protection and agriculture be improved?; and (3) How can enabling environments be promoted so as to use existing political and economic resources more effectively?

RESULTS

Highlights of Transform include (1) improved understanding of the relative effectiveness of different combinations of nutrition-specific interventions and the ways in which they can be scaled for maximal impact; (2) evidence that shows that social protection and agriculture need to be explicitly linked to nutrition in order to contribute to stunting reduction; (3) identification of key components of "enabling environments" for nutrition and how they can be cultivated/sustained; (4) research that examines ways in which leaders emerge and operate to change the political and policy landscape in different settings; and (5) "stories of change" that provide in-depth contextual knowledge of how transformative change has been driven in countries that have made inroads in reducing malnutrition. The conclusion highlights the contributions of the consortium and provides recommendations for future research.

Animal Sourced Foods and Child Stunting

Stunting affects 160 million pre-school children globally with adverse life-long consequences. While work within nutritional science suggests that stunting in early childhood is associated with low intakes of animal-sourced foods (ASFs), this topic has received little attention from economists. We attempt to redress this omission through an analysis of 130,432 children aged 6-23 months from 49 countries. We document distinctive patterns of ASF consumption among children in different regions. We find evidence of strong associations between stunting and a generic ASF consumption indicator, as well as dairy, meat/fish, and egg consumption indicators, and evidence that consuming multiple ASFs is more advantageous than any single ASF. We explore why ASF consumption is low but also so variable across countries. Non-tradable ASFs (fresh milk, eggs) are a very expensive source of calories in low-income countries and caloric prices of these foods are strongly associated with children's consumption patterns. Other demand-side factors are also important, but the strong influence of prices implies an important role for agricultural policies-in production, marketing and trade-to improve the accessibility and affordability of ASFs in poorer countries.

The investment case for folic acid fortification in developing countries

There is compelling evidence that neural tube defects can be prevented through mandatory folic acid fortification. Why, then, is an investment case needed? At the core of the answer to this question is the notion that governments and individuals have limited resources for which there are many competing claims. An investment case compares the costs and benefits of folic acid fortification relative to alternative life-saving investments and informs estimates of the financing required for implementation. Our best estimate is that the cost per death averted through mandatory folic acid fortification is $957 and the cost per disability-adjusted life year is $14.90. Both compare favorably to recommended life-saving interventions, such as the rotavirus vaccine and insecticide-treated bed nets. Thus, there is a strong economic argument for mandatory folic acid fortification. Further improvements to these estimates will require better data on the costs of implementing fortification and on the costs of improving compliance where regulations are already in place.

Drivers of nutritional change in four South Asian countries: a dynamic observational analysis

This paper quantifies the factors explaining long-term improvements in child height for age z-scores in Bangladesh (1996/1997-2011), India (1992/1993-2005/2006), Nepal (1997-2011) and Pakistan (1991-2013). We apply the same statistical techniques to data from a common data source from which we have extracted a set of common explanatory variables that capture 'nutrition-sensitive' factors. Three are particularly important in explaining height for age z-score changes over these timeframes: improvements in material well-being; increases in female education; and improvements in sanitation. These factors have comparable associations across all four countries.

Nutrition behaviour change communication causes sustained effects on IYCN knowledge in two cluster-randomised trials in Bangladesh

Behaviour change communication (BCC) can improve infant and young child nutrition (IYCN) knowledge, practices, and health outcomes. However, few studies have examined whether the improved knowledge persists after BCC activities end. This paper assesses the effect of nutrition sensitive social protection interventions on IYCN knowledge in rural Bangladesh, both during and after intervention activities. We use data from two, 2‐year, cluster randomised control trials that included nutrition BCC in some treatment arms. These data were collected at intervention baseline, midline, and endline, and 6–10 months after the intervention ended. We analyse data on IYCN knowledge from the same 2,341 women over these 4 survey rounds. We construct a number correct score on 18 IYCN knowledge questions and assess whether the impact of the BCC changes over time for the different treatment groups. Effects are estimated using ordinary least squares accounting for the clustered design of the study. There are 3 main findings: First, the BCC improves IYCN knowledge substantially in the 1st year of the intervention; participants correctly answer 3.0–3.2 more questions (36% more) compared to the non‐BCC groups. Second, the increase in knowledge between the 1st and 2nd year was smaller, an additional 0.7–0.9 correct answers. Third, knowledge persists; there are no significant decreases in IYCN knowledge 6–10 months after nutrition BCC activities ended.

Behavior change communication activities improve infant and young child nutrition knowledge and practice of neighboring non-participants in a cluster-randomized trial in rural Bangladesh

Objective

To examine the impact on infant and young child nutrition knowledge and practice of mothers who were neighbors of mothers participating in a nutrition Behavior Change Communication (BCC) intervention in rural Bangladesh.

Methods

We analyzed data from 300 mothers whose neighbor participated in a nutrition BCC intervention and 600 mothers whose neighbor participated in an intervention that did not include BCC. We constructed measures capturing mothers’ knowledge of infant and young child nutrition (IYCN) and measures of food consumption by children 6-24m. The effect on these outcomes of exposure to a neighbor receiving a nutrition BCC intervention was estimated using ordinary least squares and probit regressions. The study was registered with ClinicalTrials.gov (Study ID: NCT02237144).

Results

Having a neighboring mother participate in a nutrition BCC intervention increased non-participant mothers’ IYCN knowledge by 0.17 SD (translating to 0.3 more correct answers). They were 14.1 percentage points more likely to feed their 6-24m children legumes and nuts; 11.6 percentage points more likely to feed these children vitamin A rich fruits and vegetables; and 10.0 percentage points more likely to feed these children eggs. Children of non-participant mothers who had a neighboring mother participate in a nutrition BCC intervention were 13.8 percentage points more likely to meet World Health Organization (WHO) guidelines for minimum diet diversity, 11.9 percentage points more likely to meet WHO guidelines for minimum acceptable diet, and 10.3 percentage points more likely to meet WHO guidelines for minimum meal frequency for children who continue to be breastfed after age 6m. Children aged 0-6m of non-participant mothers who are neighbors of mothers receiving BCC were 7.1 percentage points less likely to have ever consumed water-based liquids.

Conclusions

Studies of nutrition BCC that do not account for information spillovers to non-participants may underestimate its benefits in terms of IYCN knowledge and practice.

Labor Force Activities and Income among Young Guatemalan Adults

This paper considers labor force activities among adults (26 to 41 years of age in 2003) who participated as children in a nutrition supplementation trial in Guatemala. The vast majority of men are engaged in some type of income-generating activity in 2002–04. However, unlike their fathers, these men are much more likely to be engaged in wage labor, even if they remain in the original study villages. Those engaged in wage employment appear to do so steadily. Women are much more likely to be engaged in some type of income-generating activity than their mothers. For both men and women, there appears to be considerable movement in and out of own business activities. In Guatemala City, wage work is the predominant economic activity with more than half of the women interviewed working for wages; elsewhere operating non-farm businesses is the most often cited activity. For both men and women, agriculture now appears to be very much a secondary activity.

Early life height and weight production functions with endogenous energy and protein inputs

We examine effects of protein and energy intakes on height and weight growth for children between 6 and 24 months old in Guatemala and the Philippines. Using instrumental variables to control for endogeneity and estimating multiple specifications, we find that protein intake plays an important and positive role in height and weight growth in the 6-24 month period. Energy from other macronutrients, however, does not have a robust relation with these two anthropometric measures. Our estimates indicate that in contexts with substantial child undernutrition, increases in protein-rich food intake in the first 24 months can have important growth effects, which previous studies indicate are related significantly to a range of outcomes over the life cycle.

Adolescent girls' infant and young child nutrition knowledge levels and sources differ among rural and urban samples in Bangladesh

In many low‐income countries, girls marry early and have children very soon after marriage. Although conveying infant and young child nutrition (IYCN) knowledge to adolescent girls in time is important to ensure the well‐being of their children, little is known about the best ways to convey these messages. This study examines the extent of, and sources from which adolescent girls derive IYCN knowledge in order to inform the design of programmes that convey such information. Data on adolescent girls aged 12–18 was collected in 2013 in 140 clusters of villages in rural areas (n = 436), and 70 clusters of slums in urban areas (n = 345) in Bangladesh. Data were analysed using multivariable Poisson regression models. In both the urban and rural samples, girls' schooling is positively and significantly associated with IYCN knowledge (P < 0.01 and P < 0.10, respectively). IYCN knowledge of adolescent girls' mothers is also associated with adolescents' IYCN knowledge in both urban and rural samples, but the magnitude of association in the urban sample is only half that of the rural sample (P < 0.01 and P < 0.10, respectively). In Bangladesh, efforts to improve knowledge regarding IYCN are typically focused on mothers of young children. Only some of this knowledge is passed onto adolescent girls living in the same household. As other messaging efforts directed towards mothers have only small, or no association with adolescent girls' knowledge of IYCN, improving adolescent girls' IYCN knowledge may require information and messaging specifically directed towards them. © 2016 John Wiley & Sons Ltd