Theory-driven process evaluation of a complementary feeding trial in four countries

Junk food use and neurodevelopmental and growth outcomes in infants in low-resource settings

Introduction

Feeding infants a sub-optimal diet deprives them of critical nutrients for their physical and cognitive development. The objective of this study is to describe the intake of foods of low nutritional value (junk foods) and identify the association with growth and developmental outcomes in infants up to 18 months in low-resource settings.

Methods

This is a secondary analysis of data from an iron-rich complementary foods (meat versus fortified cereal) randomized clinical trial on nutrition conducted in low-resource settings in four low- and middle-income countries (Democratic Republic of the Congo, Guatemala, Pakistan, and Zambia). Mothers in both study arms received nutritional messages on the importance of exclusive breastfeeding up to 6 months with continued breastfeeding up to at least 12 months. This study was designed to identify the socio-demographic predictors of feeding infants' complementary foods of low nutritional value (junk foods) and to assess the associations between prevalence of junk food use with neurodevelopment (assessed with the Bayley Scales of Infant Development II) and growth at 18 months.

Results

1,231 infants were enrolled, and 1,062 (86%) completed the study. Junk food feeding was more common in Guatemala, Pakistan, and Zambia than in the Democratic Republic of Congo. 7% of the infants were fed junk foods at 6 months which increased to 70% at 12 months. Non-exclusive breastfeeding at 6 months, higher maternal body mass index, more years of maternal and paternal education, and higher socioeconomic status were associated with feeding junk food. Prevalence of junk foods use was not associated with adverse neurodevelopmental or growth outcomes.

Conclusion

The frequency of consumption of junk food was high in these low-resource settings but was not associated with adverse neurodevelopment or growth over the study period.

The impact of armed conflicts on the nutritional status of children: Evidence from Northern Nigeria

Armed conflicts often significantly exacerbate the magnitude and severity of malnutrition by increasing food insecurity. Evidence shows that malnutrition is among the leading causes of morbidity and mortality among children during conflicts. This study examines the impact of the armed conflicts in Northern Nigeria on nutritional status of children under the age of five. Three waves (2008, 2013, and 2018) of individual-level birth records data from the Nigeria Demographic and Health Survey (NDHS) dataset are spatially merged with information on conflict events drawn from the Armed Conflict Location and Events Dataset. All fatal incidents in the study region during the 5-year intervals 2004-2008, 2009-2013 and 2014-2018 are aggregated and mapped to the 2008, 2013 and 2018 NDHS clusters, respectively. A cluster is classified to be exposed to conflict if located within 5-10 km radius of an incident with at least 1 fatality. We use matching analysis in a difference-in-differences approach to estimate the effects of the conflicts on stunting, wasting, and underweight. We find that the impact of conflict exposure differs by the dimension of child nutritional status. While it significantly lowers the risk of stunting, it has no discernible significant effect on the likelihood of wasting or being underweight among under-fives. Though nutritional support/interventions in the conflict-affected areas are crucial and must be prioritised, an all-inclusive strategy for a long-term resolution of the conflict is needed to engender development, improve food security, reduce vulnerability to malnutrition, and improve the health and wellbeing of the residents of the region.

What influences child feeding in the Northern Triangle? A mixed-methods systematic review

Optimising child feeding behaviours could improve child health in Guatemala, Honduras and El Salvador, where undernutrition rates remain high. However, the design of interventions to improve child feeding behaviours is limited by piecemeal, theoretically underdeveloped evidence on factors that may influence these behaviours. Between July 2018 and January 2020, we systematically searched Cochrane, Medline, EMBASE, Global Health and LILACS databases, grey literature websites and reference lists, for evidence of region-specific causes of child feeding behaviours and the effectiveness of related interventions and policies. The Behaviour Change Wheel was used as a framework to synthesise and map the resulting literature. We identified 2,905 records and included 68 relevant studies of mixed quality, published between 1964 and 2019. Most (n = 50) were quantitative, 15 were qualitative and three used mixed methods. A total of 39 studies described causes of child feeding behaviour; 29 evaluated interventions or policies. Frequently cited barriers to breastfeeding included mothers' beliefs and perceptions of colostrum and breast milk sufficiency; fears around child illness; and familial and societal pressures, particularly from paternal grandmothers. Child diets were influenced by similar beliefs and mothers' lack of money, time and control over household finances and decisions. Interventions (n = 22) primarily provided foods or supplements with education, resulting in mixed effects on breastfeeding and child diets. Policy evaluations (n = 7) showed positive and null effects on child feeding practices. We conclude that interventions should address context-specific barriers to optimal feeding behaviours, use behaviour change theory to apply appropriate techniques and evaluate impact using robust research methods.

Education of family members to support weaning to solids and nutrition in later infancy in term-born infants

BACKGROUND

Education of family members about infant weaning practices could affect nutrition, growth, and development of children in different settings across the world.

OBJECTIVES

To compare effects of family nutrition educational interventions for infant weaning with conventional management on growth and neurodevelopment in childhood.

SEARCH METHODS

We used the standard strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5), MEDLINE via PubMed (1966 to 26 June 2018), Embase (1980 to 26 June 2018), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 26 June 2018). We searched clinical trials databases, conference proceedings, and references of retrieved articles. We ran an updated search from 1 January 2018 to 12 December 2019 in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost.

SELECTION CRITERIA

We included randomised controlled trials that examined effects of nutrition education for weaning practices delivered to families of infants born at term compared to conventional management (standard care in the population) up to one year of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified eligible trial reports from the literature search and performed data extraction and quality assessments for each included trial. We synthesised effect estimates using risk ratios (RRs), risk differences (RDs), and mean differences (MDs), with 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 21 trials, recruiting 14,241 infants. Five of the trials were conducted in high-income countries and the remaining 16 were conducted in middle- and low-income countries. Meta-analysis showed that nutrition education targeted at improving weaning-related feeding practices probably increases both weight-for-age z scores (WAZ) (MD 0.15 standard deviations, 95% CI 0.07 to 0.22; 6 studies; 2551 infants; I² = 32%; moderate-certainty evidence) and height-for-age z scores (0.12 standard deviations, 95% CI 0.05 to 0.19; 7 studies; 3620 infants; I² = 49%; moderate-certainty evidence) by 12 months of age. Meta-analysis of outcomes at 18 months of age was heterogeneous and inconsistent in the magnitude of effects of nutrition education on WAZ and weight-for-height z score across studies. One trial that assessed effects of nutrition education on growth at six years reported an uncertain effect on change in height and body mass index z score. Two studies investigated effects of nutrition education on neurodevelopment at 12 to 24 months of age with conflicting results. No trials assessed effects of nutrition education on long-term neurodevelopmental outcomes.

AUTHORS' CONCLUSIONS

Nutrition education for families of infants may reduce the risk of undernutrition in term-born infants (evidence of low to moderate certainty due to limitations in study design and substantial heterogeneity of included studies). Modest effects on growth during infancy may not be of clinical significance. However, it is unclear whether these small improvements in growth parameters in the first two years of life affect long-term childhood growth and development. Further studies are needed to resolve this question.

A Multisectoral Nutrition Program in Nepal Improves Knowledge of Dietary Diversity, Sick Child Feeding, and Handwashing, but Not All Practices: a Program Impact Pathways Mediation Analysis

BACKGROUND

Few intervention studies have focused on how inputs link with outcomes.

OBJECTIVES

This study tested whether Suaahara I program inputs translated into intended outcomes and identified gaps along the theorized program impact pathway to improved nutrition, care, and water, sanitation, and hygiene behaviors.

METHODS

We used household-level, cross-sectional survey data from a process evaluation of Suaahara I conducted in 2014. A total of 480 households with a pregnant woman or child aged <2 y were selected with an equal split between intervention and comparison arms. We used regression models to test associations between exposure to Suaahara I and 3 primary outcomes and 3 parallel knowledge mediators: child minimum dietary diversity, child feeding during illness, and proper handwashing during child care. We used generalized structural equation modeling using full information maximum likelihood to test whether knowledge mediated associations between exposure and outcomes.

RESULTS

In the adjusted regression models between maternal exposure to Suaahara I and 3 behavioral outcomes, we found a small positive association for handwashing (β: 0.21; 95% CI: 0.10, 0.31), but no association with the other 2 outcomes. In the mediation analysis, maternal exposure to Suaahara I, however, was associated with the mediator (knowledge) for all 3 outcomes: handwashing with soap and water (β: 0.05 ± 0.02), child minimum dietary diversity (logit = 0.06; P = 0.03), and child feeding during illness (logit = 0.09 ± 0.02). We found a positive, significant association for the full indirect pathway of program input to output via knowledge for child feeding during illness (logit = 0.07 ± 0.03) only.

CONCLUSIONS

Exposure to Suaahara I behavior change interventions improved knowledge, but this did not always translate into improved practices. It is important to address barriers to optimal practices beyond knowledge in future nutrition programs in Nepal.

Process Evaluation of a Large-Scale Community-Based Nutrition Program in Malawi

BACKGROUND

Global attention to the study of nutrition program implementation has been inadequate yet is critical for effective delivery and impact at scale.

OBJECTIVES

The objective of this mixed-methods process evaluation study was to measure the recruitment, fidelity, and reach of a large-scale, community-based nutrition program in Malawi.

METHODS

The nutrition program delivered a small-quantity lipid-based nutrient supplement (SQ-LNS) and social and behavior change communication (SBCC) to improve infant and young child feeding (IYCF) and water, sanitation, and hygiene (WASH) practices in households with children aged 6-23 mo. Program monitoring and evaluation data were used to measure program recruitment, reach, and fidelity. Structured direct observations and knowledge questionnaires with program volunteers measured quality aspects of program fidelity. The number of times activities were done correctly was used to tabulate proportions used to represent program functioning.

RESULTS

Half (49.5%) of eligible children redeemed program benefits by 8 mo of age during the first 4 y of program implementation. Implementation of training activities for SBCC cadres exceeded program targets (100.6%), but the completion of certain modules (breastfeeding and complementary feeding) was lower (22.9% and 18.6%, respectively). Knowledge of IYCF, WASH, and SQ-LNS messages by volunteers was >85% for most messages, except ability to list the 6 food groups (35.7%). Structured direct observations of SQ-LNS distributions indicated high fidelity to program design, whereas those of household-level counseling sessions revealed lack of age-appropriate messaging. Program reach showed participation in monthly distribution sessions of 81.0%, group counseling of 93.3%, and individual-level counseling of 36.9%.

CONCLUSIONS

This community-based nutrition program was implemented with high fidelity and quality, with specific interventions requiring further attention. The documentation of implementation contributes to our understanding about how program impacts were achieved.

Advancing child nutrition science in the scaling up nutrition era: a systematic scoping review of stunting research in Guatemala

INTRODUCTION

Ever since the 1960s, Guatemala has been a principle site for global academic research on child growth and nutrition. Nevertheless, Guatemala still has one of the highest rates of child stunting in the world. Since 2012, Guatemala has had a comprehensive national policy on stunting, calling for a renewed investment in innovative, multilevel nutrition interventions and implementation science. Our objective was to perform a systematic search and scoping review of the literature on stunting in Guatemala to identify gaps in research and opportunities for responding to this unique policy opportunity.

METHODS

We conducted a systematic search and scoping review on stunting in Guatemala, searching the PubMed, Web of Science and PsycINFO databases. Eligible articles were of any design or format, published in English and Spanish from 2000 to 2018. Articles were thematically grouped by those published before (2000-2011) and after (2012-2018) the new national policy initiatives.

RESULTS

We identified a total of 1934 articles through database searches. After full-text review, 104 were included in the synthesis. The volume of published articles on stunting increased from a mean of 3.2 to 9.4 articles/year before and after 2012. There was a shift toward articles generating new data on priority populations, including rural indigenous Maya populations (34% vs 61%, χ² test, p=0.01). However, the proportion of studies conducting implementation evaluations or testing new interventions was low and did not change significantly (34% vs 18%, χ² test, p=0.07). Among 17 identified intervention studies, only 4 tested multilevel interventions, and there were no published interventions incorporating nutrition-sensitive interventions.

CONCLUSIONS

A systematic search and scoping review of the literature on child stunting in Guatemala identified critical opportunities for new research in multilevel interventions, nutrition-sensitive interventions and implementation science.

Implementation, utilization and influence of a community-based participatory nutrition promotion programme in rural Ethiopia: programme impact pathway analysis

OBJECTIVE

A community-based participatory nutrition promotion (CPNP) programme, involving a 2-week group nutrition session, attempted to improve child feeding and hygiene. The implementation, utilization and influence of the CPNP programme were examined by programme impact pathway (PIP) analysis.

DESIGN

Five CPNP programme components were evaluated: (i) degree of implementation; (ii) participants' perception of the nutrition sessions; (iii) participants' message recall; (iv) utilization of feeding and hygiene practices at early programme stage; and (v) participants' engagement in other programmes.

SETTING

Habro and Melka Bello districts, Ethiopia.

SUBJECTS

Records of 372 nutrition sessions, as part of a cluster-randomized trial, among mothers (n 876 in intervention area, n 914 in control area) from a household survey and CPNP participants (n 197) from a recall survey.

RESULTS

Overall, most activities related to nutrition sessions were successfully operated with high fidelity (>90 %), but a few elements of the protocol were only moderately achieved. The recall survey among participants showed a positive perception of the sessions (~90 %) and a moderate level of message recall (~65 %). The household survey found that the CPNP participants had higher minimum dietary diversity at the early stage (34·0 v. 19·9 %, P=0·01) and a higher involvement in the Essential Nutrition Action (ENA) programme over a year of follow-up (28·2 v. 18·3 %; P<0·0001) compared with non-participants within the intervention area.

CONCLUSIONS

Our PIP analysis suggests that CPNP was feasibly implemented, promoted a sustained utilization of proper feeding behaviours, and enhanced participation in the existing ENA programme. These findings provide a possible explanation to understanding CPNP's effectiveness.

Theory-Driven Process Evaluation of the SHINE Trial Using a Program Impact Pathway Approach

Two reasons for the lack of success of programs or interventions are poor alignment of interventions with the causes of the problem targeted by the intervention, leading to poor efficacy (theory failure), and failure to implement interventions as designed (program failure). These failures are important for both public health programs and randomized trials. In the Sanitation Hygiene and Infant Nutrition Efficacy (SHINE) Trial, we utilize the program impact pathway (PIP) approach to track intervention implementation and behavior uptake. In this article, we present the SHINE PIP including definitions and measurements of key mediating domains, and discuss the implications of this approach for randomized trials. Operationally, the PIP can be used for monitoring and strengthening intervention delivery, facilitating course-correction at various stages of implementation. Analytically, the PIP can facilitate a richer understanding of the mediating and modifying determinants of intervention impact than would be possible from an intention-to-treat analysis alone.

Meat as complementary food for older breastfed infants and toddlers: a randomized, controlled trial in rural China

BACKGROUND

Because of its contribution to dietary diversity and to favorable intakes of micronutrients, including iron and zinc, meat is hypothesized to be a valuable complementary food for the infant and young child. However, the evidence base remains limited.

OBJECTIVE

To compare the difference in anthropometric measurements of rural Chinese infants and toddlers 6 to 18 months of age who received a daily supplement of meat or cereal for 12 months.

METHODS

This cluster-randomized, controlled study provided a daily supplement of either meat (n = 514, 20 clusters) or cereal (n = 957, 40 clusters) starting as a first complementary food at 6 months of age. Anthropometric measurements were assessed longitudinally.

RESULTS

After 12 months of intervention, the meat group (δ13.01 ± 1.9 cm) had greater (p = .01) linear growth than the cereal group (δ12.75 ± 1.8 cm) and a smaller decrease in length-for-age z-score (LAZ) over time (-0.43 ± 0.72 in the meat group vs. -0.54 ± 0.67 in the cereal group), after adjustment for baseline length, LAZ, maternal education, work status, and maternal height and weight.

CONCLUSIONS

Linear growth was modestly greater in the meat group than in the cereal group. LAZ was substantially negative at 6 months, and the intervention did not prevent ongoing decline over the course of the study.