Development and Testing of Responsive Feeding Counseling Cards to Strengthen the UNICEF Infant and Young Child Feeding Counseling Package

Diets of infants and young children in two counties of Kenya: Key drivers and barriers to improvement

Infant and young child feeding (IYCF) practices are influenced by many context-specific factors related to local food systems as well as social and cultural practices. Understanding these local contextual perspectives is essential for designing effective programs and policies. This paper uses focused ethnographic study methods to examine challenges experienced by mothers related to IYCF in two counties in Kenya, a country with considerable heterogeneity in agriculture, food systems, and cultures. A two-phase qualitative study was undertaken in each of Kilifi County and West Pokot County, entailing interviews and rating activities with mothers, health workers, and vendors. Interviews were audio-recorded, transcribed, translated into English, coded, and analysed by topic. Results show low levels of dietary diversity in both counties; in West Pokot, the level of adequate meal frequency is also low. Core foods in young child diets included maize porridge and family foods such as ugali (stiff maize porridge), vegetables, beans, fish, and plantains. Food safety, acceptability, and acquisition ease were the main drivers of food choice. Mothers generally felt that all core foods fed to young children are healthy and safe, but there was more variability regarding child acceptance, acquisition ease, cost, and convenience. Common barriers to feeding nutrient-dense foods to children included child illness, economic constraints, and limited knowledge of modification strategies, skills, or tools to make the foods suitable for young children. Potential actions to address these barriers include sharing information on child-appropriate recipes; raising awareness on local, affordable nutrient-dense foods; and improving WASH practices to reduce illness frequency.

Beneficiary and Local Stakeholder Participation in Community-Based Nutrition Interventions

Beneficiary and local stakeholder participation is an essential element to the success of community-based nutrition interventions. We sought to define active participation and review the available evidence on beneficiary and local stakeholder participation in community-based nutrition interventions in Africa. From reviewing the literature, we provide a reflective assessment on the process and findings. Participation falls on a continuum of community involvement from passive (no real involvement) to empowerment and community ownership (full active involvement). However, we found a clear gap in the research on defining active participation and identifying what constitutes active participation on behalf of beneficiaries and local stakeholders. However, progress was found; evidence included the use of participatory methods to engage beneficiaries and local stakeholders in the assessment and design phase. Beneficiary and local stakeholder participation in delivering interventions has moved forward with quantitative measures from process evaluation and implementation science. Research has started on the extent of beneficiary engagement (as recipients) and connecting this to outcomes. Evaluation has benefited from qualitative inquiry with insights from participants on engagement itself, and the barriers and facilitators to engagement. Yet questions remain in each study phase around defining and quantifying active participation and in understanding the personal, social, and motivational elements of active participation. We offer a simple framework to stimulate thought and commitment to research on participation in community-based nutrition interventions.

Strengthening Maternal, Infant, and Young Child Nutrition Training and Counseling in Ghana: A Community-Based Approach

Background

Evidence-based maternal, infant, and young child nutrition (MIYCN) counseling provides caregivers essential nutrition education to optimize infant and young child feeding practices and subsequently improve child growth and development. Effective integration of responsive feeding (RF) into current MIYCN training requires working with priority communities.

Objectives

Study objectives were to 1) assess MIYCN knowledge and practices among Ghanaian caregivers, 2) identify factors influencing RF/responsive parenting (RP) among Ghanaian caregivers, 3) identify barriers and facilitators influencing MIYCN training and counseling among Ghanaian health care providers, and 4) document recommendations for integrating an RF curriculum into the existing MIYCN training.

Methods

This was a qualitative study, conducted within the Central Region of Ghana, based on 1) 6 focus groups with caregivers of young children (<36 mo; n = 44) and 2) in-depth interviews with health care providers (n = 14). Focus group transcripts were coded independently, consensus was reached, and a final codebook developed. The same coding process and thematic analysis were applied to the in-depth interviews.

Results

Caregivers identified 3 domains influencing the primary outcome of RF/RP knowledge and practices and the secondary outcome of MIYCN: 1) health care provider counseling; 2) support from family, friends, and community members; and 3) food safety knowledge and practice. Providers identified barriers to MIYCN provider training as well as caregiver counseling which included limited access to financial and counseling resources and limited qualified staff to deliver infant and young child feeding counseling. Identified facilitators included availability of funding and counseling staff with adequate resources. Health care providers strongly endorsed integrating an RF curriculum into MIYCN training and counseling along with providing RF training and distribution of RF materials/tools to facilities.

Conclusions

Health care providers directly influenced RF/RP practices through MIYCN counseling. Strengthening MIYCN counseling through the integration of an RF curriculum into MIYCN training is desired by the community.

Assessing the Nurturing Care Content of UNICEF's Community Infant and Young Child Feeding Counselling Package: Gaps, Best Practices, and Lessons Learned

Background

The United Nations Children's Fund (UNICEF) Community Infant and Young Child Feeding Counselling Package (C-IYCF CP) is used globally for infant and young child feeding (IYCF) counseling. With the C-IYCF CP last updated 8 y ago, mapping existing nurturing care content, identifying gaps, and documenting current country-level changes offers a unique opportunity to guide recommendations to strengthen the nurturing care content of this package.

Objectives

The primary study aims were to: 1) identify and map existing nurturing care content within UNICEF's C-IYCF CP, 2) identify gaps related to nurturing care or feeding elements within the C-IYCF CP, 3) identify country-level nurturing care adaptations to the C-IYCF CP, and 4) identify best practices and lessons learned from country adaptations that can be recommended for inclusion in the C-IYCF CP.

Methods

The assessment included 4 phases: 1) conduct an iterative process to identify and map nurturing care elements within the C-IYCF CP using a codebook explicitly developed for this assessment; 2) identify gaps in the C-IYCF CP; 3) apply the codebook to IYCF packages from 11 countries, revise, then finalize the codebook; and 4) identify and interview key informants from 4 countries whose IYCF packages had the most comprehensive nurturing care content plus 1 country where health care professionals make routine mother-child home visits.

Results

The C-IYCF CP contained limited nurturing care content, especially around safety/security and early learning. All 5 countries interviewed had systematically identified and included priority nurturing care content in each package, yet content level varied. Two countries were also incorporating information technology into the training and delivery of the C-IYCF CP.

Conclusions

Existing country-level best practices can address nurturing care elements missing from UNICEF's C-IYCF CP. Sharing these practices can allow countries to make context-driven, evidence-informed decisions on the nurturing care content to prioritize.

Observation of Traditional Caregiver-Infant Feeding Behaviours and Porridge and Energy Intakes during One Meal to Define Key Messages for Promoting Responsive Feeding in the Amparafaravola District, Rural Madagascar

Undernutrition is highly prevalent in young children in Madagascar and insufficient intake per meal could be one of the main causes. A cross-sectional survey of infant feeding practices including video-recorded meal observations was carried out with 101 caregiver-infant pairs in the Amparafaravola district, Northeast Madagascar. The objective was to quantify the porridge/energy intake of 9-11-month-old children and assess its association with the caregiver-infant feeding behaviours. Then, key messages for promoting responsive feeding (RF) were developed and tested through focus group discussions. The mean porridge intake was 12.8 ± 7.5 g/kg body weight (BW)/meal, corresponding to hardly one-third of the 300 kcal recommended from complementary foods for 9-11-month-old children. Analysis of meal videos suggested that mothers practiced the five positive feeding behaviours (self-feeding, responsive, active, social, and distraction), and rarely the negative ones. Only 6.9% of mothers used positive RF "very frequently", although it was associated with higher intakes (p < 0.05), with mean intake reaching 21 g/kg BW. In focus groups, caregivers approved the six RF messages and related counselling cards. They suggested some modifications to improve their understanding, and counselling cards were revised accordingly. The long-term impact of RF-promoting card use on the meal intakes and the nutritional status of young children must now be assessed.

Human-centered design process and solutions to promote malaria testing and treatment seeking behavior in Guyana hinterlands

Background

Malaria is a persistent public health challenge among miners and other hard-to-reach populations in Guyana’s hinterland, specifically in Regions 1, 7, 8, and 9. Despite an overall decrease in malaria prevalence throughout Guyana, it remains common among mining populations whose work conditions both contribute toward malaria transmission and make it difficult to seek timely, Ministry of Health (MoH) approved malaria testing and treatment services. In an effort to develop innovative approaches to address this public health challenge, an interdisciplinary team of public health professionals, designers, and mining organizations collaborated using a human-centered design (HCD) process facilitated by the USAID-funded Breakthrough ACTION Guyana project in partnership with the MoH.

Methods

This paper describes two phases: [1] Define and [2] Design & Test. In the Define phase, following a literature review, we conducted 108 qualitative interviews with miners, camp managers, trained malaria testers, health workers, and other key stakeholders to understand experiences and challenges when seeking malaria testing and treatment services. These interviews were synthesized into 11 insights on issues such as risk perception, malaria knowledge, preventive behaviors, traditional and self-treatment, adherence to the correct treatment, testing, and coordination and communication gaps. From these insights, during the Design & Test phase, we developed 33 “How might we…?” questions which led to 792 ideas, of which eight emergent concepts were prototyped and refined in the field with 145 miners, camp managers, and stakeholders.

Results

The five final prototypes included: “Little Mosquito, Big Problem” social behavior change campaign; rapid counseling cards; branded malaria testing and treatment services; innovations in treatment adherence; and a participants, content, and logistics approach.

Conclusion

When applying HCD to public health issues, there are both opportunities and challenges to reconcile gaps that may exist between the two disciplines. However, HCD provides additional tools and mindsets to generatively work with migrant and mobile mining communities to encourage malaria testing and treatment services.

An Integrated Enhanced Infant and Young Child Feeding (IYCF) and Micronutrient Powder Intervention Improved Select IYCF Practices Among Caregivers of Children Aged 12-23 Months in Eastern Uganda

BACKGROUND

There is little evidence of the impact of integrated programs distributing nutrition supplements with behavior change on infant and young child feeding (IYCF) practices.

OBJECTIVE

We evaluated the impact of an integrated IYCF/micronutrient powder intervention on IYCF practices among caregivers of children aged 12-23 mo in eastern Uganda.

METHODS

We used pre-post data from 2 population-based, cross-sectional surveys representative of children aged 12-23 mo in Amuria (intervention) and Soroti (nonintervention) districts (n = 2816). Caregivers were interviewed in June/July at baseline in 2015 and 12 mo after implementation in 2016. We used generalized linear mixed models with cluster as a random effect to calculate the average intervention effect on receiving IYCF counseling, ever breastfed, current breastfeeding, bottle feeding, introducing complementary feeding at age 6 mo, continued breastfeeding at ages 1 and 2 y, minimum meal frequency (MMF), minimum dietary diversity, minimum acceptable diet (MAD), and consumption of food groups the day preceding the survey.

RESULTS

Controlling for child age and sex, household wealth and food security, and caregiver schooling, the intervention was positively associated with having received IYCF counseling by village health team [adjusted prevalence difference-in-difference (APDiD): +51.6%; 95% CI: 44.0%, 59.2%]; timely introduction of complementary feeding (APDiD: +21.7%; 95% CI: 13.4%, 30.1%); having consumed organs or meats (APDiD: +9.0%; 95% CI: 1.4%, 16.6%) or vitamin A-rich fruits or vegetables (APDiD: +17.5%; 95% CI: 4.5%, 30.5%); and MMF (APDiD: +18.6%; 95% CI: 11.2%, 25.9%). The intervention was negatively associated with having consumed grains, roots, or tubers (APDiD: -4.4%; 95% CI: -7.0%, -1.7%) and legumes, nuts, or seeds (APDiD: -15.6%; 95% CI: -26.2%, -5.0%). Prevalences of some IYCF practices were low in Amuria at endline including MAD (19.1%; 95% CI :16.3%, 21.9%).

CONCLUSIONS

The intervention had a positive impact on several IYCF practices; however, endline prevalence of some indicators suggests a continued need to improve complementary feeding practices.

Maternal Knowledge, Attitudes, and Practices of Complementary Feeding and Child Undernutrition in the Vakinankaratra Region of Madagascar: A Mixed-Methods Study

BACKGROUND

Data are limited on how feeding knowledge and practices relate to child undernutrition in the highlands of Madagascar.

OBJECTIVES

This study assessed maternal knowledge and practices of complementary feeding and their associations with anthropometrics of children aged 6-23 mo in the Vakinankaratra region of Madagascar.

METHODS

Knowledge was assessed using WHO recommendations on child feeding, and WHO infant and young child feeding (IYCF) indicators were used to evaluate feeding practices. Child growth was measured as length-for-age, weight-for-age, and weight-for-length z-scores using the 2006 WHO growth standards. A z-score less than -2 was classified as child undernutrition. Logistic regression models were used to determine associations between independent variables and outcomes. Focus group discussions among mothers and in-depth interviews with key informants were conducted; barriers and facilitators of optimal feeding practices were identified using a thematic analysis approach.

RESULTS

Maternal knowledge scores regarding child feeding averaged 6.4 of 11. Better knowledge scores were associated with higher odds of appropriate complementary feeding practices before and after covariate adjustments. The proportions of children achieving the minimum dietary diversity (35.8%), minimum acceptable diet (30.2%), and consuming meat, fish, and poultry (14.1%) were low. Only consumption of iron-rich foods was associated with lower odds of underweight (adjusted OR = 0.3; 95% CI: 0.1, 0.7; P < 0.05). None of the IYCF indicators were associated significantly with stunting or wasting. Maternal attitudes about complementary foods, as well as mothers' workload and very low income, were identified as barriers to optimal feeding practices. Maternal perceived benefits of giving appropriate complementary foods as well as their positive relationship with the community health workers were the main facilitators of optimal child feeding.

CONCLUSIONS

Integrated nutrition-sensitive interventions addressing these barriers while enhancing the facilitators are critical in promoting better feeding practices in the Vakinankaratra region.