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Schnefke CH, Flax VL, Ubanmhen F, Alayon S, Bose S, Daniel O, Grimes KEL, Allotey D, Seiger ER, Arije O. Attitudes, beliefs and social norms regarding infant and young child feeding among Nigerian mothers, fathers and grandmothers across time. MATERNAL & CHILD NUTRITION 2023; 19:e13524. [PMID: 37173816 PMCID: PMC10483957 DOI: 10.1111/mcn.13524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 03/27/2023] [Accepted: 04/12/2023] [Indexed: 05/15/2023]
Abstract
Infant and young child feeding (IYCF) interventions in low-resource countries mainly target pregnant women and mothers of young children; however, fathers and grandmothers also influence IYCF practices. We conducted focus group discussions with mothers, fathers and grandmothers of young children across three time points in areas where an IYCF social and behaviour change intervention was implemented in Nigeria to explore differences by participant type and shifts over time in attitudes, beliefs and social norms related to breastfeeding and dietary diversity (DD). Overall, across time points, we found more discrepancies in attitudes, beliefs and social norms for early initiation of breastfeeding (EIBF) and exclusive breastfeeding (EBF) among different participant types than for DD. Although most participants agreed EIBF and EBF are good practices, mothers believed this more strongly than fathers and grandmothers; however, at endline, a shift towards acceptance of EIBF and EBF appeared among fathers and grandmothers. Across time points, all participant types acknowledged the nutritional and health benefits of green leafy vegetables and animal-source foods but described various barriers to feeding them to children. Across time points, all participant types also highlighted the importance of health workers and antenatal visits as important sources of IYCF knowledge and facilitators to following recommended practices. Insights from this study highlight the importance of including key influencers of IYCF practices in qualitative research.
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Affiliation(s)
- Courtney H. Schnefke
- Public Health Research DivisionRTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Valerie L. Flax
- Public Health Research DivisionRTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | | | - Silvia Alayon
- Department of Global HealthSave the ChildrenWashingtonDistrict of ColumbiaUSA
| | - Sujata Bose
- FHI Solutions, MonitoringLearning and EvaluationDurhamNorth CarolinaUSA
| | - Obinna Daniel
- Public Health Research DivisionRTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | | | - Diana Allotey
- Department of NutritionUniversity of North Carolina‐Chapel HillChapel HillNorth CarolinaUSA
| | - Emily R. Seiger
- Department of NutritionUniversity of North Carolina‐Chapel HillChapel HillNorth CarolinaUSA
| | - Olujide Arije
- Institute of Public HealthObafemi Awolowo UniversityIle‐IfeOsun StateNigeria
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Kulwa KBM, Mamiro PS, Kolsteren PW. Nutrition Education Package Focusing on Infant and Young Child Feeding in Tanzania. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2023; 55:493-508. [PMID: 37245148 DOI: 10.1016/j.jneb.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of a nutrition education package on feeding practices, nutrient intakes and growth of infants in rural Tanzania. DESIGN Cluster-randomized controlled trial in 18 villages allocated to nutrition education package (n = 9) or routine health education (n = 9 villages), measured at baseline (6 months) and end of the trial (12 months). SETTING Mpwapwa district. PARTICIPANTS Infants aged 6-12 months and their mothers. INTERVENTION(S) Six months of nutrition education package (group education, counseling, cooking demonstrations) and regular home visits by village health workers. MAIN OUTCOME MEASURE(S) Primary outcome measure was the mean change in length-for-age z-scores. Secondary outcomes included mean changes in weight-for-length z-scores (WLZ), intakes of energy, fat, iron and zinc, the proportion of children consuming foods from ≥ 4 food groups (ie, dietary diversity) and consuming the recommended number of semisolid/soft meals and snacks per day (ie, meal frequency). ANALYSIS Multilevel mixed-effects regression models. RESULTS Mean change in length-for-age z-scores (β = 0.20, P = 0.02), energy (in kcal) (β = 43.8, P = 0.02), and fat (in grams) (β =2.7, P = 0.03) intakes were significant in the intervention but not in the control group. There was no effect on iron and zinc intakes. More infants in the intervention than the control group consumed meals from ≥ 4 food groups (71.8% vs 45.3%, P = 0.002). The mean increase in meal frequency (β = 0.29, P = 0.02) and dietary diversity (β = 0.40, P = 0.01) were more significant in the intervention than control. CONCLUSIONS AND IMPLICATIONS The nutrition education package is feasible and can be implemented with high coverage, demonstrating the potential to improve feeding practices, nutrient intake and growth in rural Tanzania.
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Affiliation(s)
- Kissa B M Kulwa
- Department of Human Nutrition and Consumer Sciences, Sokoine University of Agriculture, Morogoro, Tanzania.
| | - Peter S Mamiro
- Department of Human Nutrition and Consumer Sciences, Sokoine University of Agriculture, Morogoro, Tanzania
| | - Patrick W Kolsteren
- Department of Food Technology, Safety and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
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Singh A, Torres KA, Maharjan N, Shrestha J, Agbozo F, Abubakari A, Abdul-Rahman L, Mukuria-Ashe A. Learning from health system actor and caregiver experiences in Ghana and Nepal to strengthen growth monitoring and promotion. PLoS One 2023; 18:e0282807. [PMID: 36893119 PMCID: PMC9997959 DOI: 10.1371/journal.pone.0282807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/22/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Globally, growth monitoring and promotion (GMP) of infants and young children is a fundamental component of routine preventive child health care; however, programs have experienced varying degrees of quality and success with enduring challenges. The objective of this study was to describe implementation of GMP (growth monitoring, growth promotion, data use, and implementation challenges) in two countries, Ghana and Nepal, to identify key actions to strengthen GMP programs. METHODS We conducted semi-structured key informant interviews with national and sub-national government officials (n = 24), health workers and volunteers (n = 40), and caregivers (n = 34). We conducted direct structured observations at health facilities (n = 10) and outreach clinics (n = 10) to complement information from interviews. We coded and analyzed interview notes for themes related to GMP implementation. RESULTS Health workers in Ghana (e.g., community health nurses) and Nepal (e.g., auxiliary nurse midwives) had the knowledge and skills to assess and analyze growth based on weight measurement. However, health workers in Ghana centered growth promotion on the growth trend (weight-for-age over time), whereas health workers in Nepal based growth promotion on measurement from one point in time to determine whether a child was underweight. Overlapping challenges included health worker time and workload. Both countries tracked growth-monitoring data systematically; however, there was variation in growth monitoring data use. CONCLUSION This study shows that GMP programs may not always focus on the growth trend for early detection of growth faltering and preventive actions. Several factors contribute to this deviation from the intended goal of GMP. To overcome them, countries need to invest in both service delivery (e.g., decision-making algorithm) and demand generation efforts (e.g., integrate with responsive care and early learning).
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Affiliation(s)
- Akriti Singh
- USAID Advancing Nutrition, Helen Keller International, New York, New York, United States of America
| | - Kelsey A. Torres
- USAID Advancing Nutrition, JSI Research & Training Institute, Inc., Arlington, Virginia, United States of America
- * E-mail:
| | - Nashna Maharjan
- Mother and Infant Research Activities, Kathmandu, Bagmati Province, Nepal
| | - Jyoti Shrestha
- Mother and Infant Research Activities, Kathmandu, Bagmati Province, Nepal
| | - Faith Agbozo
- Department of Family and Community Health, University of Health and Allied Sciences, Hohoe, Volta Region, Ghana
| | - Abdulai Abubakari
- Department of Global and International Health, University for Development Studies, Tamale, Northern Region, Ghana
| | | | - Altrena Mukuria-Ashe
- USAID Advancing Nutrition, Save the Children, Washington, DC, United States of America
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Koyratty N, Mbuya MNN, Jones AD, Schuster RC, Kordas K, Li CS, Tavengwa NV, Majo FD, Chasekwa B, Ntozini R, Humphrey JH, Smith LE. Implementation and maintenance of infant dietary diversity in Zimbabwe: contribution of food and water insecurity. BMC Nutr 2022; 8:136. [PMCID: PMC9673371 DOI: 10.1186/s40795-022-00622-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 10/19/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background
Inadequate food and water resources negatively affect child health and the efficiency of nutrition interventions.
Methods
We used data from the SHINE trial to investigate the associations of food insecurity (FI) and water insecurity (WI) on mothers’ implementation and maintenance of minimum infant dietary diversity (MIDD). We conducted factor analysis to identify and score dimensions of FI (poor access, household shocks, low availability & quality), and WI (poor access, poor quality and low reliability). MIDD implementation (n = 636) was adequate if infants aged 12 months (M12) ate ≥ four food groups. MIDD maintenance (n = 624) was categorized into four mutually exclusive groups: A (unmet MIDD at both M12 and M18), B (unmet MIDD at M12 only), C (unmet MIDD at M18 only), and D (met MIDD at both M12 and M18). We used multivariable-adjusted binary logistic and multinomial regressions to determine likelihood of MIDD implementation, and of belonging to MIDD maintenance groups A-C (poor maintenance groups), compared to group D, respectively.
Results
Low food availability & quality were negatively associated with implementation (OR = 0.81; 0.69, 0.97), and maintenance (ORB = 1.29; 1.07, 1.56). Poor water quality was positively associated with implementation (OR = 1.25; 1.08, 1.44), but inconsistently associated with maintenance, with higher odds of infants being in group C (OR = 1.39; 1.08, 1.79), and lower odds of being in group B (OR = 0.80; 0.66, 0.96).
Conclusion
Food security should be prioritized for adequate implementation and maintenance of infant diets during complementary feeding. The inconsistent findings with water quality indicate the need for further research on WI and infant feeding.
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Lufumpa N, Lavis A, Caleyachetty R, Henry M, Kabombwe S, Manaseki-Holland S. Exploring attributions of causality for child undernutrition: Qualitative analysis in Lusaka, Zambia. MATERNAL AND CHILD NUTRITION 2021; 18:e13237. [PMID: 34180139 PMCID: PMC8710123 DOI: 10.1111/mcn.13237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/30/2021] [Accepted: 06/03/2021] [Indexed: 12/05/2022]
Abstract
Child undernutrition is responsible for 45% of all under‐five deaths in low‐ and middle‐income countries (LMICs) and numerous morbidities. Although progress has been made, high levels of child undernutrition persist in Zambia. Existing studies have explored primary caretakers' (PCs) explanatory models of child undernutrition in LMICs, without comparison with those of health care providers (HCPs). This paper examines and compares the perceived causes of child undernutrition among PCs and HCPs in Zambia. We conducted a qualitative study, using semistructured one‐to‐one and group interviews, with 38 PCs and 10 HCPs to explore their perceptions of child undernutrition and its perceived causes in Lusaka district, Zambia. Interview data were analysed with thematic analysis. Our findings indicate that PCs and HCPs in Lusaka district have divergent explanatory models of child undernutrition and perceive parental agency differently. In divergently framing how they conceptualise undernutrition and who is able to prevent it, these models underpin different attributions of causality and different opportunities for intervention. PCs highlighted factors such as child food preferences, child health, and household finances. Contrarily, HCPs stressed factors such as ‘improper feeding’, only highlighting factors such as wider economic conditions when these impacted specifically on health care services. One factor, identified by both groups, was ‘inadequate mothering’. To accelerate the reduction of child undernutrition, interventions must address divergences between PCs and HCPs' explanatory models. Additionally, attention needs to be paid to how wider socio‐economic and cultural contexts not only impact childhood undernutrition but shape attributions of causality.
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Affiliation(s)
- Nakawala Lufumpa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Anna Lavis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Michael Henry
- Department of Economics, University of Birmingham, Birmingham, UK
| | - Sheena Kabombwe
- Department of Historical and Archaeological Studies, University of Zambia, Lusaka, Zambia
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Mothers' perceptions on and learning from infant and young child-feeding videos displayed in Mother and Child Health Centers in Kenya: a qualitative and quantitative approach. Public Health Nutr 2021; 24:3845-3858. [PMID: 34034846 DOI: 10.1017/s1368980021002342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The objective was to explore mothers’ perceptions on educational videos on infant and young child-feeding practices, and to assess whether viewing frequencies would influence maternal knowledge, attitudes and feeding practices (KAP). DESIGN A set of forty-seven videos were displayed in health centres for 6 months. At 3 months, we conducted focus group discussions (FGD) with mothers and, at 6 months, administered KAP-questionnaire-based interviews to mothers. Using a quasi-experimental design, we compared groups according to video viewing frequencies. SETTING The study was conducted in a slum in Nairobi and a rural area in Machakos, Kenya. We installed TV screens in waiting rooms of six Mother and Child Health Centers, where mothers could choose to watch them. PARTICIPANTS Forty-three mothers with children aged 0–48 months participated in six FGD and 547 mothers of children aged 0–23 months in KAP interviews. RESULTS The mothers from the FGD found the videos acceptable and beneficial. Videos enhanced mothers’ learning and empowered them to support others in learning. The KAP data showed that after adjustments, breast-feeding (P = 0·06), complementary feeding knowledge (P = 0·01), complementary feeding attitudes (P = 0·08) and hygiene knowledge and practices (P = 0·003) were better among mothers who had seen videos three to four times, or five or more times, compared with mothers who had seen the videos once or twice. CONCLUSIONS Videos were an accepted form of education and were beneficial when watched repeatedly. The videos could be a good addition to current infant and young child-feeding education efforts in Kenya.
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Rakotomanana H, Hildebrand D, Gates GE, Thomas DG, Fawbush F, Stoecker BJ. Maternal Knowledge, Attitudes, and Practices of Complementary Feeding and Child Undernutrition in the Vakinankaratra Region of Madagascar: A Mixed-Methods Study. Curr Dev Nutr 2020; 4:nzaa162. [PMID: 33274306 PMCID: PMC7695809 DOI: 10.1093/cdn/nzaa162] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Hasina Rakotomanana
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, USA
| | - Deana Hildebrand
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, USA
| | - Gail E Gates
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, USA
| | - David G Thomas
- Department of Psychology, Oklahoma State University, Stillwater, OK, USA
| | - Fanjaniaina Fawbush
- Department of Agricultural and Food Science and Technology, University of Antananarivo, Antananarivo, Madagascar
| | - Barbara J Stoecker
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, USA
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Skiff K, deValpine M, Knopp A. Improving Breastfeeding in Rural Tanzania Using Eight-Step Policy Analysis Methodology. Policy Polit Nurs Pract 2020; 21:213-221. [PMID: 32799754 DOI: 10.1177/1527154420945306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Appropriate breastfeeding has the potential to have the broadest impact on childhood survival in children under 5 years compared with all other preventive interventions. The World Health Organization and United Nations International Children's Emergency Fund recommend that all facilities providing maternal services and newborn care have a written policy addressing breastfeeding that is routinely disseminated to staff. A Mara region hospital in rural Tanzania does not have a breastfeeding policy. Collins adapted Bardach's eightfold path for policy analysis specifically for health policies. This eight-step process was used to evaluate three promising policies to improve breastfeeding in populations in and around this hospital. These policies include exclusive breastfeeding education, complementary food education, and community health worker home visits. Analysis identified exclusive breastfeeding with adjunct complementary food education as the most feasible policies to increase breastfeeding in and around the target hospital. With improved feeding practices, chronic malnutrition rates are expected to decline in the villages that the hospital serves. This methodology can be used by nurses to develop health polices addressing a wide range of health issues in a wide variety of settings.
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Kukeba MW, Fallon D, Callery P. Child feeding in rural northern Ghana: Carer's perceptions of food and their children's diets. MATERNAL AND CHILD NUTRITION 2020; 17:e13085. [PMID: 33001571 PMCID: PMC7988845 DOI: 10.1111/mcn.13085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 08/09/2020] [Accepted: 09/03/2020] [Indexed: 11/30/2022]
Abstract
A child's diet should be composed of appropriate nutrients to achieve optimal nutritional status, and though there is a substantial evidence base for child feeding recommendations, developing countries continue to face challenges regarding optimal child feeding. This paper describes an ethnographic study undertaken in rural northern Ghana to explore community perceptions of what ‘counts’ as food for children and the impact this had on the nutrients they received. Fifteen households with children under 5 years were purposively selected. In‐depth interviews were held with 25 mothers, 7 fathers and 8 grandparents within these households as well as 2 diviners. Participant observations were also undertaken. Findings show that satiety rather than nutrition was the key consideration in adult choices about a child's diet. The community regarded carbohydrate‐based meals as food, but considered protein, vitamins and mineral‐based foods as nonessential elements of a child's diet, and important sources of these nutrients were regarded as treats.
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Affiliation(s)
- Margaret Wekem Kukeba
- Department of Paediatric Nursing, University for Development Studies, Tamale, Northern Region, Ghana.,CKT University for Technology and Applied Sciences, Navrongo, Upper East Region, Ghana
| | - Debbie Fallon
- Department of Nursing Midwifery and Social Work, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Peter Callery
- Department of Nursing Midwifery and Social Work, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
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Abstract
OBJECTIVE To explore and gain an in-depth understanding of the factors influencing child feeding practices among rural caregivers in Rwanda. DESIGN In-depth semi-structured qualitative interviews were conducted. Purposive sampling was used to recruit participants. Interviews were audio-recorded, transcribed verbatim and coded. Data were analysed inductively using thematic analysis. SETTING Rutsiro District, Western Province, Rwanda. PARTICIPANTS Participants included twenty-four mothers (median age 32 years) with children 6-23 months old. RESULTS We identified five key themes: (i) breast-feeding practices and role in food supply; (ii) family v. children's food preparations; (iii) food classification systems and their influence on child feeding decisions; (iv) child feeding during diarrhoeal episodes and (v) influence of poverty on child feeding practices and child care. CONCLUSIONS Mothers' infant and young child feeding decisions are informed by information both from health workers and from traditional/own knowledge. Navigating through this information sometimes creates conflicts which results in less than optimal child feeding. A nutrition educational approach that is cognisant of maternal perceptions should be employed to improve child feeding practices. Efforts to improve child feeding practices must be complemented by programmes that enhance household economic opportunities and access to foods.
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Effects of nutritional supplementation and home visiting on growth and development in young children in Madagascar: a cluster-randomised controlled trial. LANCET GLOBAL HEALTH 2020; 7:e1257-e1268. [PMID: 31402006 DOI: 10.1016/s2214-109x(19)30317-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/21/2019] [Accepted: 06/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Evidence from efficacy trials suggests that lipid-based nutrient supplementation (LNS) and home visits can be effective approaches to preventing chronic malnutrition and promoting child development in low-income settings. We tested the integration of these approaches within an existing, large-scale, community-based nutrition programme in Madagascar. METHODS We randomly allocated 125 programme sites to five intervention groups: standard-of-care programme with monthly growth monitoring and nutrition education (T0); T0 plus home visits for intensive nutrition counselling through an added community worker (T1); T1 plus LNS for children aged 6-18 months (T2); T2 plus LNS for pregnant or lactating women (T3); or T1 plus fortnightly home visits to promote and encourage early stimulation (T4). Pregnant women (second or third trimester) and infants younger than 12 months were enrolled in the trial. Primary outcomes were child growth (length-for-age and weight-for-length Z scores) and development at age 18-30 months. Analyses were by intention to treat. The trial was registered with the ISRCTN registry, number ISRCTN14393738. FINDINGS The study enrolled 3738 mothers: 1248 pregnant women (250 women in each of the T0, T1, T2, and T4 intervention groups and 248 in the T3 intervention group) and 2490 children aged 0-11 months (497 children in T0, 500 in T1, 494 in T2, 499 in T3, and 500 in T4) at baseline who were assessed at 1-year and 2-year intervals. There were no main effects of any of the intervention groups on any measure of anthropometry or any of the child development outcomes in the full sample. However, compared with children in the T0 intervention group, the youngest children (<6 months at baseline) in the T2 and T3 intervention groups who were fully exposed to the child LNS dose had higher length-for-age Z scores (a significant effect of 0·210 SD [95% CI -0·004 to 0·424] for T2 and a borderline effect of 0·216 SD [0·043 to 0·389] for T3) and lower stunting prevalence (-9·0% [95% CI -16·7 to -1·2] for T2 and -8·2% [-15·6 to -0·7] for T3); supplementing mothers conferred no additional benefit. INTERPRETATION LNS for children for a duration of 12 months only benefited growth when it began at an early age, suggesting the need to supplement infants at age 6 months in a very low-income context. The lack of effect of the early stimulation messages and home visits might be due to little take-up of behaviour-change messages and delivery challenges facing community health workers. FUNDING Eunice Kennedy Shriver National Institutes of Child Health and Human Development, Strategic Impact Evaluation Fund, World Bank Innovation Grant, Early Learning Partnership Grant, World Bank Research Budget, Japan Nutrition Trust Fund, Power of Nutrition, and the National Nutrition Office of Madagascar.
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Using Trials of Improved Practices to identify practices to address the double burden of malnutrition among Rwandan children. Public Health Nutr 2019; 22:3175-3186. [PMID: 31221234 DOI: 10.1017/s1368980019001551] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Low- and middle-income countries (LMIC) are increasingly experiencing the double burden of malnutrition. Studies to identify 'double-duty' actions that address both undernutrition and overweight in sub-Saharan Africa are needed. We aimed to identify acceptable behaviours to achieve more optimal feeding and physical activity practices among both under- and overweight children in Rwanda, a sub-Saharan LMIC with one of the largest recent increases in child overweight. DESIGN We used the Trials of Improved Practices (TIPs) method. During three household visits over 1·5 weeks, we used structured interviews and unstructured observations to collect data on infant and young child feeding practices and caregivers' experiences with testing recommended practices. SETTING An urban district and a rural district in Rwanda. PARTICIPANTS Caregivers with an under- or overweight child from 6 to 59 months of age (n 136). RESULTS We identified twenty-five specific recommended practices that caregivers of both under- and overweight children agreed to try. The most frequently recommended practices were related to dietary diversity, food quantity, and hygiene and food handling. The most commonly cited reason for trying a new practice was its benefits to the child's health and growth. Financial constraints and limited food availability were common barriers. Nearly all caregivers said they were willing to continue the practices and recommend them to others. CONCLUSIONS These practices show potential for addressing the double burden as part of a broader intervention. Still, further research is needed to determine whether caregivers can maintain the behaviours and their direct impact on both under- and overweight.
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Schlichting D, Hashemi L, Grant C. Infant Food Security in New Zealand: A Multidimensional Index Developed from Cohort Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16020283. [PMID: 30669564 PMCID: PMC6352114 DOI: 10.3390/ijerph16020283] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/07/2019] [Accepted: 01/15/2019] [Indexed: 12/16/2022]
Abstract
Food security (FS) during infancy is associated with lifelong outcomes. New Zealand is a developed economy that reports poor childhood nutrition-related health statistics, particularly among minority children, yet has no measure of FS applicable to infancy. The objective was to develop an FS index for New Zealand infants and examine its association with demographic covariates and health outcomes. Within a large (n = 6853) nationally representative cohort, variables describing infant food consumption, breastfeeding, and maternal food-related coping methods were collected from mothers during late infancy. An FS index was derived using confirmatory factor analysis. Associations were assessed by logistic regressions and described using odds ratios (OR) and ≥95% confidence intervals (CI). Fifteen percent of the cohort was highly FS, 43% tenuously food insecure (FIS), and 16% highly food insecure (FIS). Infants from minority ethnic groups had lower odds of being food secure, as did those born to the youngest mothers, mothers who smoked, or those who lived in low-income households. FIS infants had higher odds of morbidity. Interventions to improve infant FS should focus on improving dietary quality, and should give particular consideration to minority infants. We identified that FIS shows wide ethnic and socioeconomic inequity, and is associated with poorer health. The most important driving factors of FIS included poor quality weaning diets, as well as poverty and its proxies. Any interventions to improve infant FS should focus on increasing fruit and vegetable consumption to recommended intake levels, and should give particular consideration to minority infants.
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Affiliation(s)
- Deborah Schlichting
- Department of Paediatrics: Child & Youth Health, The University of Auckland, Auckland 1142, New Zealand.
| | - Ladan Hashemi
- Department of Paediatrics: Child & Youth Health, The University of Auckland, Auckland 1142, New Zealand.
| | - Cameron Grant
- Department of Paediatrics: Child & Youth Health, The University of Auckland, Auckland 1142, New Zealand.
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Dewi Satiawati KDK, Januraga PP. Attitudes toward Supplemental Nutrition Assistance Programs in Caregivers of Children with Moderate-Acute Malnutrition Younger than 5 Years in Denpasar, Bali: A Qualitative Study. Food Nutr Bull 2018; 39:465-474. [PMID: 30037275 DOI: 10.1177/0379572118788663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Providing additional nutriment represents one strategy for overcoming moderate-acute malnutrition (MAM) in children younger than 5 years. However, it is important to examine how well received such Supplemental Nutrition Assistance Programs (SNAP) are by caregivers in order to ensure optimal results. OBJECTIVE This study explores SNAP's reception by caregivers of MAM children younger than 5 years. METHODS Qualitative research was conducted through semi-structured, in-depth interviews with 16 selected caregivers and 5 Nutritional Executives from October to November, 2016 at 4 health centers in Denpasar, Bali, Indonesia. The results are presented to highlight the underlying patterns of SNAP's acceptance. RESULTS Overall, the informants responded negatively to SNAP, reporting that it was of limited usefulness. The results show 4 main themes relating to the receipt of SNAP. The first relates to the caregiver's preferences in terms of the types of supplementary food on offer. Second, caregiver's perceptions that the child was not, in fact, in a state of illness or disease due to a medical issue. Third, that the caregiver does not require supplementary food as they maintain that they are able to buy it independently. Fourth, factors related to the lack of support for health-care workers working with malnourished children. CONCLUSION The study finds that strengthening the role of health workers in terms of enabling them to effectively communicate the benefits of supplementary food to caregivers as well as adjusting the range of foods available according to the recipient's preferences is critical in overcoming malnutrition in children younger than 5 years.
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Affiliation(s)
| | - Pande Putu Januraga
- 1 Center for Public Health Innovation (CPHI), Faculty of Medicine, Udayana University, Bali, Indonesia.,2 Discipline of Public Health, Flinders University, Adelaide, South Australia, Australia
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Crop Upgrading Strategies and Modelling for Rainfed Cereals in a Semi-Arid Climate—A Review. WATER 2018. [DOI: 10.3390/w10040356] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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16
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Armar-Klemesu M, Osei-Menya S, Zakariah-Akoto S, Tumilowicz A, Lee J, Hotz C. Using Ethnography to Identify Barriers and Facilitators to Optimal Infant and Young Child Feeding in Rural Ghana: Implications for Programs. Food Nutr Bull 2018; 39:231-245. [PMID: 29486585 DOI: 10.1177/0379572117742298] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Understanding the context of infant and young child feeding (IYCF) is recognized as essential for designing appropriate complementary feeding interventions. OBJECTIVE Our objective was to study household IYCF behaviors in 2 districts in southern and northern Ghana to identify opportunities to improve existing nutrition programs. METHODS We interviewed 80 caregivers of children aged 6 to 23 months using ethnographic methods, including free listing, guided discussions and cognitive mapping techniques, and 24-hour dietary recall. Descriptive statistics and thematic content analysis were used to analyze quantitative and qualitative data. RESULTS In both settings, children's diets were predominantly maize based. Fish, the main animal source food, was consumed daily but in very small quantities. Milk was consumed by only a few children, in tea and porridge. Fruits were seldom consumed. Household food production did not meet requirements, and the markets were heavily relied on for staples and other key ingredients. Most caregivers demonstrated basic knowledge and understanding of key health and nutrition concepts. Barriers to optimal child feeding identified were lack of money to purchase the nutritious foods recommended for children, seasonal food insecurity, and some caregiver beliefs, practices, and nutrition knowledge gaps. Positive contextual features include caregiver recognition of the dietary needs of young children and commitment to provide foods to meet these needs. CONCLUSION Our findings suggest that complementary feeding in these rural settings can be improved through reinforcement or modification of strategic components of local health and nutrition education in light of existing barriers and enablers to optimal IYCF.
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Affiliation(s)
- Margaret Armar-Klemesu
- 1 Nutrition Department, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | - Sarah Osei-Menya
- 1 Nutrition Department, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | - Sawudatu Zakariah-Akoto
- 1 Nutrition Department, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | | | - James Lee
- 2 Global Alliance for Improved Nutrition, Geneva, Switzerland
| | - Christine Hotz
- 2 Global Alliance for Improved Nutrition, Geneva, Switzerland
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Hotz C, Pelto G, Armar-Klemesu M, Ferguson EF, Chege P, Musinguzi E. Constraints and opportunities for implementing nutrition-specific, agricultural and market-based approaches to improve nutrient intake adequacy among infants and young children in two regions of rural Kenya. MATERNAL AND CHILD NUTRITION 2016; 11 Suppl 3:39-54. [PMID: 26778801 PMCID: PMC5066664 DOI: 10.1111/mcn.12245] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 09/16/2015] [Accepted: 10/13/2015] [Indexed: 01/23/2023]
Abstract
Several types of interventions can be used to improve nutrient intake adequacy in infant and young child (IYC) diets, including fortified foods, home fortification, nutrition education and behaviour change communication (BCC) in addition to agricultural and market‐based strategies. However, the appropriate selection of interventions depends on the social, cultural, physical and economic context of the population. Derived from two rural Kenyan populations, this analysis combined information from: (1) a quantitative analysis to derive a set of food‐based recommendations (FBRs) to fill nutrient intake gaps in IYC diets and identify ‘problem nutrients’ for which intake gaps require solutions beyond currently available foods and dietary patterns, and (2) an ethnographic qualitative analysis to identify contextual factors posing opportunities or constraints to implementing the FBRs, including perceptions of cost, convenience, accessibility and appropriateness of the recommended foods for IYC diets and other social or physical factors that determine accessibility of those foods. Opportunities identified included BCC to increase the acceptability and utilisation of green leafy vegetables (GLV) and small fish and agronomic interventions to increase the productivity of GLV and millet. Value chains for millet, beans, GLV, milk and small fish should be studied for opportunities to increase their accessibility in local markets. Processor‐level interventions, such as partially cooked fortified dry porridge mixes or unfortified cereal mixes incorporating millet and beans, may increase the accessibility of foods that provide increased amounts of the problem nutrients. Multi‐sectoral actors and community stakeholders should be engaged to assess the feasibility of implementing these locally appropriate strategies.
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Affiliation(s)
| | - Gretel Pelto
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | | | | | | | - Enock Musinguzi
- Global Alliance for Improved Nutrition (GAIN), Naroibi, Kenya
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18
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Ickes SB, Heymsfield GA, Wright TW, Baguma C. "Generally the young mom suffers much:" Socio-cultural influences of maternal capabilities and nutrition care in Uganda. MATERNAL AND CHILD NUTRITION 2016; 13. [PMID: 27650794 DOI: 10.1111/mcn.12365] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/11/2016] [Accepted: 07/13/2016] [Indexed: 11/28/2022]
Abstract
We conducted 40 in-depth interviews and eight focus groups among mothers and fathers (n = 91) of diverse ages in western Uganda to define the relevant domains of maternal capabilities and their relationship to infant and young child feeding practices. This study was directed by a developing theory of maternal capabilities that posits that the impact of health-directed interventions may be limited by unmeasured and poorly understood maternal characteristics. Ugandan caregivers defined three major life events that constrain women's capabilities for childcare: early pregnancy, close child spacing, and polygamous marriage. Women describe major constraints in their decision-making capabilities generally and specifically to procuring food for young children. Future nutrition programs may improve their impact through activities that model household decision-making scenarios, and that strengthen women's social support networks. Findings suggest that efforts to transform gender norms may be one additional way to improve nutrition outcomes in communities with a generally low status of women relative to men. The willingness of younger fathers to challenge traditional gender norms suggests an opportunity in this context for continued work to strengthen resources for children's nutritional care. SIGNIFICANCE Maternal factors such as autonomy are associated with child feeding practices and nutritional status, with varying degrees depending on the definition of maternal-level constructs and context. This study describes the events and processes that constrain maternal capabilities-intrapersonal factors that shape mother's abilities to leverage resources to provide care to children-as they relate to nutrition and hygiene practices. We report community beliefs and understandings about which capabilities have meaning for child nutrition and hygiene, and develop a conceptual framework to describe how these capabilities are formed and describe implications for future nutrition programs in East Africa and similar settings.
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Affiliation(s)
- Scott B Ickes
- Department of Health Services and Program in Nutritional Sciences, University of Washington, Seattle, Washington, USA.,Department of Kinesiology and Health Sciences, The College of William and Mary, Williamsburg, Virginia, USA
| | - Grace A Heymsfield
- Department of Nutritional Sciences, The University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Timothy W Wright
- Department of Kinesiology and Health Sciences, The College of William and Mary, Williamsburg, Virginia, USA
| | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
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Osendarp SJM, Broersen B, van Liere MJ, De-Regil LM, Bahirathan L, Klassen E, Neufeld LM. Complementary Feeding Diets Made of Local Foods Can Be Optimized, but Additional Interventions Will Be Needed to Meet Iron and Zinc Requirements in 6- to 23-Month-Old Children in Low- and Middle-Income Countries. Food Nutr Bull 2016; 37:544-570. [DOI: 10.1177/0379572116655239] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The question whether diets composed of local foods can meet recommended nutrient intakes in children aged 6 to 23 months living in low- and middle-income countries is contested. Objective: To review evidence of studies evaluating whether (1) macro- and micronutrient requirements of children aged 6 to 23 months from low- and middle-income countries are met by the consumption of locally available foods (“observed intake”) and (2) nutrient requirements can be met when the use of local foods is optimized, using modeling techniques (“modeled intake”). Methods: Twenty-three articles were included after conducting a systematic literature search. To allow for comparisons between studies, findings of 15 observed intake studies were compared against their contribution to a standardized recommended nutrient intake from complementary foods. For studies with data on intake distribution, %< estimated average requirements were calculated. Results: Data from the observed intake studies indicate that children aged 6 to 23 months meet requirements of protein, while diets are inadequate in calcium, iron, and zinc. Also for energy, vitamin A, thiamin, riboflavin, niacin, folate, and vitamin C, children did not always fulfill their requirements. Very few studies reported on vitamin B6, B12, and magnesium, and no conclusions can be drawn for these nutrients. When diets are optimized using modeling techniques, most of these nutrient requirements can be met, with the exception of iron and zinc and in some settings calcium, folate, and B vitamins. Conclusion: Our findings suggest that optimizing the use of local foods in diets of children aged 6 to 23 months can improve nutrient intakes; however, additional cost-effective strategies are needed to ensure adequate intakes of iron and zinc.
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Affiliation(s)
- Saskia J. M. Osendarp
- The Micronutrient Initiative, Ottawa, Ontario, Canada
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Britt Broersen
- The Micronutrient Initiative, Ottawa, Ontario, Canada
- Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | | | | | | | - Eva Klassen
- The Micronutrient Initiative, Ottawa, Ontario, Canada
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Fernald LCH, Galasso E, Qamruddin J, Ranaivoson C, Ratsifandrihamanana L, Stewart CP, Weber AM. A cluster-randomized, controlled trial of nutritional supplementation and promotion of responsive parenting in Madagascar: the MAHAY study design and rationale. BMC Public Health 2016; 16:466. [PMID: 27255923 PMCID: PMC4891833 DOI: 10.1186/s12889-016-3097-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 04/29/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Over half of the world's children suffer from poor nutrition, and as a consequence they experience delays in physical and mental health, and cognitive development. There is little data evaluating the effects of delivery of lipid-based, nutrition supplementation on growth and development during pregnancy and early childhood within the context of a scaled-up program. Furthermore, there is limited evidence on effects of scaled-up, home-visiting programs that focus on the promotion of child development within the context of an existing, national nutrition program. METHODS/DESIGN The MAHAY ("smart" in Malagasy) study uses a multi-arm randomized-controlled trial (RCT) to test the effects and cost-effectiveness of combined interventions to address chronic malnutrition and poor child development. The arms of the trial are: (T0) existing program with monthly growth monitoring and nutritional/hygiene education; (T1) is T0 + home visits for intensive nutrition counseling within a behavior change framework; (T2) is T1 + lipid-based supplementation (LNS) for children 6-18 months old; (T3) is T2 + LNS supplementation of pregnant/lactating women; and (T4) is T1 + intensive home visiting program to support child development. There are anticipated to be n = 25 communities in each arm (n = 1250 pregnant women, n = 1250 children 0-6 months old, and n = 1250 children 6-18 months old). Primary outcomes include growth (length/height-for-age z-scores) and child development (mental, motor and social development). Secondary outcomes include care-giver reported child morbidity, household food security and diet diversity, micro-nutrient status, maternal knowledge of child care and feeding practices, and home stimulation practices. We will estimate unadjusted and adjusted intention-to-treat effects. Study protocols have been reviewed and approved by the Malagasy Ethics Committee at the Ministry of Health in Madagascar and by the institutional review board at the University of California, Davis. This study is funded by the Strategic Impact Evaluation Fund (SIEF), the World Bank Innovation Grant, the Early Learning Partnership Grant, the Japan Scaling-up for Nutrition Trustfund, and Grand Challenges Canada. The implementation of the study is financed by Madagascar's National Nutrition Office. TRIAL REGISTRATION Current Controlled Trials ISRCTN14393738 . Registered June 23, 2015.
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Affiliation(s)
- Lia C H Fernald
- School of Public Health, University of California, Berkeley, 50 University Hall, MC 7360, Berkeley, CA, 94720-7360, USA.
| | - Emanuela Galasso
- Development Research Group, The World Bank, Washington D.C., USA
| | - Jumana Qamruddin
- Health, Nutrition and Population Global Practice, The World Bank, Washington D.C., USA
| | | | | | - Christine P Stewart
- Program in International and Community Nutrition, University of California, Davis, Davis, CA, USA
| | - Ann M Weber
- School of Medicine, Stanford University, Stanford, CA, USA
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21
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Mokori A, Hendriks S, Oriskushaba P, Oelofse A. Changes in complementary feeding practices and nutrition status in returnee children aged 6-23 months in northern Uganda. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2016. [DOI: 10.1080/16070658.2013.11734473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Issaka AI, Agho KE, Page AN, Burns PL, Stevens GJ, Dibley MJ. Determinants of suboptimal complementary feeding practices among children aged 6-23 months in seven francophone West African countries. MATERNAL AND CHILD NUTRITION 2016; 11 Suppl 1:31-52. [PMID: 26364790 DOI: 10.1111/mcn.12193] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Suboptimal complementary feeding practices play a crucial role in the health and development of children. The objective of this research paper was to identify factors associated with suboptimal complementary feeding practices among children aged 6-23 months in seven francophone West African countries, namely, Benin, Burkina Faso, Cote d'Ivoire, Guinea, Mali, Niger and Senegal. This study covered 22 376 children aged 6-23 months from the seven countries surveyed (Benin: 3732 children; Burkina Faso: 4205 children; Cote d'Ivoire: 2109 children, Guinea: 1944 children, Mali: 3798 children, Niger: 3451 children and Senegal: 3137 children). The most recent Demographic and Health Survey datasets of the various countries were used as data sources. A set of individual-, household- and community-level factors were used to examine the four complementary feeding indicators. Multivariate analysis revealed that the youngest age bracket (6-11 months) of children, administrative/geographical region, mother's limited or non-access to the mass media, mothers' lack of contact with a health facility, rural residence, poor households and non-working mothers were the main factors associated with suboptimal complementary feeding in the countries surveyed. Our findings highlight the need to consider broader social, cultural and economic factors when designing child nutritional interventions.
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Affiliation(s)
- Abukari I Issaka
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Kingsley E Agho
- School of Science and Health, University of Western Sydney, Penrith, New South Wales, Australia
| | - Andrew N Page
- School of Science and Health, University of Western Sydney, Penrith, New South Wales, Australia
| | - Penelope L Burns
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Garry J Stevens
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Michael J Dibley
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Issaka AI, Agho KE, Page AN, Burns PL, Stevens GJ, Dibley MJ. Comparisons of complementary feeding indicators among children aged 6-23 months in Anglophone and Francophone West African countries. MATERNAL AND CHILD NUTRITION 2016; 11 Suppl 1:1-13. [PMID: 26364788 DOI: 10.1111/mcn.12196] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Stunting, a consequence of suboptimal complementary feeding practices, continues to be a significant public health problem in West Africa. This paper aimed to compare rates of complementary feeding indicators among children aged 6-23 months between four Anglophone and seven Francophone West African countries. The data used for this study were the most recent Demographic and Health Surveys of the various countries, namely Ghana, Liberia, Nigeria, Sierra Leone (Anglophone countries), Benin, Burkina Faso, Cote d'Ivoire, Guinea, Mali, Niger and Senegal (Francophone countries) conducted between 2006 and 2013. The analyses were limited to last-born children aged 6-23 months and covered 34 999 children: 12 623 in the Anglophone countries and 22 376 children in the Francophone countries. Complementary feeding indicators were examined using the method proposed by the World Health Organization (WHO) in 2008. Introduction of solid, semi-solid or soft foods among children aged 6-23 months in the Anglophone countries ranged from 55.3% (Liberia) to 72.6% (Ghana). The corresponding rates for the Francophone countries ranged from 29.7% (Mali) to 65.9% (Senegal). The average rate of minimum dietary diversity for the Anglophone countries was 32.0% while that of the Francophone countries was only 10.6%. While the minimum meal frequency rates ranged between 42.0% (Sierra Leone) and 55.3% (Nigeria) for the Anglophone countries, the corresponding rates for the Francophone countries ranged between 25.1% (Mali) and 52.4% (Niger). Both the Anglophone and the Francophone countries reported alarmingly low rates of minimum acceptable diet, with the two groups of countries averaging rates of 19.9% (Anglophone) and 5.5% (Francophone). The rates of all four complementary feeding indicators across all the 11 countries fell short of the WHO's requirement for optimal complementary feeding practices. Intervention studies using cluster-randomised controlled trials are needed in order to improve the nutritional status of young children in West Africa.
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Affiliation(s)
- Abukari I Issaka
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Kingsley E Agho
- School of Science and Health, University of Western Sydney, Penrith, New South Wales, Australia
| | - Andrew N Page
- School of Science and Health, University of Western Sydney, Penrith, New South Wales, Australia
| | - Penelope L Burns
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Garry J Stevens
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Michael J Dibley
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Robert RC, Creed-Kanashiro HM, Villasante R, Narro MR, Penny ME. Strengthening health services to deliver nutrition education to promote complementary feeding and healthy growth of infants and young children: formative research for a successful intervention in peri-urban Trujillo, Peru. MATERNAL AND CHILD NUTRITION 2016; 13. [PMID: 26931182 DOI: 10.1111/mcn.12264] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/05/2015] [Accepted: 11/17/2015] [Indexed: 11/27/2022]
Abstract
Formative research is critical for developing effective nutrition-specific interventions to improve infant and young child (IYC) feeding practices and promote healthy growth. Health workers interact with caregivers during health facility visits, yet there is limited research about how to optimize delivery of such interventions during these visits. The extensive reach of IYC health services globally calls for research to address this gap. In Trujillo, Peru, formative research was conducted to explore complementary feeding practices with caregivers as well as health worker routines and interactions with caregivers related to feeding and healthy growth; results informed the development and delivery of an educational intervention. Multiple qualitative methods were used to collect data on a purposive sample of health workers and caregivers from three health facilities and communities: household trials followed. Complementary feeding messages with doable behaviours were developed, and three were selected as key to promote based on their nutritional impact and cultural acceptability. In the health facilities, medical consultation, well-child visits and nutrition consultation all dealt with aspects of IYC nutrition/growth during their interactions with caregivers but were independent and inconsistent in approach. A nutrition education strategy was developed based on consistency, quality and coverage in the IYC health services. We conclude that formative research undertaken in the community and IYC health services was critical to developing a successful and culturally relevant intervention to promote optimal complementary feeding practices and healthy growth during interactions between health workers and caregivers at routine health facility visits. © 2016 John Wiley & Sons Ltd.
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Affiliation(s)
- Rebecca C Robert
- Instituto de Investigación Nutricional, Lima, Peru.,School of Nursing, The Catholic University of America, Washington D.C., USA
| | | | | | | | - Mary E Penny
- Instituto de Investigación Nutricional, Lima, Peru
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Tumilowicz A, Neufeld LM, Pelto GH. Using ethnography in implementation research to improve nutrition interventions in populations. MATERNAL & CHILD NUTRITION 2015; 11 Suppl 3:55-72. [PMID: 26778802 PMCID: PMC5019237 DOI: 10.1111/mcn.12246] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
'Implementation research in nutrition' is an emerging area of study aimed at building evidence-based knowledge and sound theory to design and implement programs that will effectively deliver nutrition interventions. This paper describes some of the basic features of ethnography and illustrates its applications in components of the implementation process. We review the central purpose of ethnography, which is to obtain the emic view--the insider's perspective--and how ethnography has historically interfaced with nutrition. We present examples of ethnographic studies in relation to an analytic framework of the implementation process, situating them with respect to landscape analysis, formative research, process evaluation and impact evaluation. These examples, conducted in various parts of the world by different investigators, demonstrate how ethnography provided important, often essential, insights that influenced programming decisions or explained programme outcomes. Key messages Designing, implementing and evaluating interventions requires knowledge about the populations and communities in which interventions are situated, including knowledge from the 'emic' (insider's) perspective. Obtaining emic perspectives and analysing them in relation to cultural, economic and structural features of social organisation in societies is a central purpose of ethnography. Ethnography is an essential aspect of implementation research in nutrition, as it provides important insights for making decisions about appropriate interventions and delivery platforms; determining how best to fit aspects of programme design and implementation into different environmental and cultural contexts; opening the 'black box' in interventions to understand how delivery and utilisation processes affect programme outcomes or impacts; and understanding how programme impacts were achieved, or not.
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Affiliation(s)
| | | | - Gretel H. Pelto
- Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
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Flax VL. 'It was caused by the carelessness of the parents': cultural models of child malnutrition in southern Malawi. MATERNAL & CHILD NUTRITION 2015; 11:104-18. [PMID: 23941316 PMCID: PMC6667221 DOI: 10.1111/mcn.12073] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Parents' conceptions of child growth, health and malnutrition are culturally bound, making information about local understandings of malnutrition and its causes necessary for designing effective nutrition programmes. This study used ethnographic methods to elucidate cultural models of child care and malnutrition among the Yao of southern Malawi. Data were collected in six rural villages from 28 key informant interviews with village chiefs and traditional healers among others and 18 focus group discussions with parents and grandmothers of young children. For the Yao, lack of parental care is a key cause of poor child health and can lead to thinness (kunyililika) or swelling (kuimbangana). Parents are said to be careless if they are not attentive to the child's needs, are unable to provide adequate quality or quantity of food, or fail to follow sexual abstinence rules. Maintaining abstinence protects the family and failure to do so causes the transfer of 'heat' from a sexually active parent to a 'cold' child and results in child health problems, including signs and symptoms of malnutrition. These findings indicate that the Yao understanding of care is much broader than the concept of care during feeding described in the nutrition literature. In addition, the Yao note the importance of several key feeding practices supported by international agencies and understand the influence of illness on child nutritional status. These congruencies with the public health frame should be used together with information about the cultural context to design more socially and emotionally relevant care and nutrition programmes among the Yao.
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Affiliation(s)
- Valerie L. Flax
- Department of NutritionUniversity of North CarolinaChapel HillNorth CarolinaUSA
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Kavle JA, Mehanna S, Saleh G, Fouad MA, Ramzy M, Hamed D, Hassan M, Khan G, Galloway R. Exploring why junk foods are 'essential' foods and how culturally tailored recommendations improved feeding in Egyptian children. MATERNAL AND CHILD NUTRITION 2014; 11:346-70. [PMID: 25536155 PMCID: PMC6860321 DOI: 10.1111/mcn.12165] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
In Egypt, the double burden of malnutrition and rising overweight and obesity in adults mirrors the transition to westernized diets and a growing reliance on energy‐dense, low‐nutrient foods. This study utilized the trials of improved practices (TIPs) methodology to gain an understanding of the cultural beliefs and perceptions related to feeding practices of infants and young children 0–23 months of age and used this information to work in tandem with 150 mothers to implement feasible solutions to feeding problems in Lower and Upper Egypt. The study triangulated in‐depth interviews (IDIs) with mothers participating in TIPs, with IDIs with 40 health providers, 40 fathers and 40 grandmothers to gain an understanding of the influence and importance of the role of other caretakers and health providers in supporting these feeding practices. Study findings reveal high consumption of junk foods among toddlers, increasing in age and peaking at 12–23 months of age. Sponge cakes and sugary biscuits are not perceived as harmful and considered ‘ideal’ common complementary foods. Junk foods and beverages often compensate for trivial amounts of food given. Mothers are cautious about introducing nutritious foods to young children because of fears of illness and inability to digest food. Although challenges in feeding nutritious foods exist, mothers were able to substitute junk foods with locally available and affordable foods. Future programming should build upon cultural considerations learned in TIPs to address sustainable, meaningful changes in infant and young child feeding to reduce junk foods and increase dietary quality, quantity and frequency.
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Affiliation(s)
- Justine A Kavle
- PATH, Maternal and Child Health and Nutrition, Washington, District of Columbia, USA.,Maternal and Child Health Integrated Program (MCHIP), Washington, District of Columbia, USA
| | - Sohair Mehanna
- Social Research Center, American University in Cairo, Cairo, Egypt
| | - Gulsen Saleh
- SMART Project, Maternal and Child Health Integrated Program (MCHIP), Cairo, Egypt.,National Nutrition Institute of Egypt, Cairo, Egypt
| | | | - Magda Ramzy
- National Nutrition Institute of Egypt, Cairo, Egypt
| | - Doaa Hamed
- National Nutrition Institute of Egypt, Cairo, Egypt
| | - Mohamed Hassan
- Social Research Center, American University in Cairo, Cairo, Egypt
| | - Ghada Khan
- Department of Prevention and Community Health, George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - Rae Galloway
- PATH, Maternal and Child Health and Nutrition, Washington, District of Columbia, USA.,Maternal and Child Health Integrated Program (MCHIP), Washington, District of Columbia, USA
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Onyango AW, Borghi E, de Onis M, Casanovas MDC, Garza C. Complementary feeding and attained linear growth among 6-23-month-old children. Public Health Nutr 2014; 17:1975-83. [PMID: 24050753 PMCID: PMC11108726 DOI: 10.1017/s1368980013002401] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 05/24/2013] [Accepted: 07/25/2013] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To examine the association between complementary feeding indicators and attained linear growth at 6-23 months. DESIGN Secondary analysis of Phase V Demographic and Health Surveys data (2003-2008). Country-specific ANOVA models were used to estimate effects of three complementary feeding indicators (minimum meal frequency, minimum dietary diversity and minimum adequate diet) on length-for-age, adjusted for covariates and interactions of interest. SETTING Twenty-one countries (four Asian, twelve African, four from the Americas and one European). SUBJECTS Sample sizes ranging from 608 to 13 676. RESULTS Less than half the countries met minimum meal frequency and minimum dietary diversity, and only Peru had a majority of the sample receiving a minimum adequate diet. Minimum dietary diversity was the indicator most consistently associated with attained length, having significant positive effect estimates (ranging from 0·16 to 1·40 for length-for-age Z-score) in twelve out of twenty-one countries. Length-for-age declined with age in all countries, and the greatest declines in its Z-score were seen in countries (Niger, -1·9; Mali, -1·6; Democratic Republic of Congo, -1·4; Ethiopia, -1·3) where dietary diversity was persistently low or increased very little with age. CONCLUSIONS There is growing recognition that poor complementary feeding contributes to the characteristic negative growth trends observed in developing countries and therefore needs focused attention and its own tailored interventions. Dietary diversity has the potential to improve linear growth. Using four food groups to define minimum dietary diversity appears to capture enough information in a simplified, standard format for multi-country comparisons of the quality of complementary diets.
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Affiliation(s)
- Adelheid W Onyango
- Department of Nutrition for Health and Development, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
| | - Elaine Borghi
- Department of Nutrition for Health and Development, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
| | - Mercedes de Onis
- Department of Nutrition for Health and Development, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
| | - Ma del Carmen Casanovas
- Department of Nutrition for Health and Development, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
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Reinhardt K, Fanzo J. Addressing Chronic Malnutrition through Multi-Sectoral, Sustainable Approaches: A Review of the Causes and Consequences. Front Nutr 2014; 1:13. [PMID: 25988116 PMCID: PMC4428483 DOI: 10.3389/fnut.2014.00013] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 07/31/2014] [Indexed: 01/11/2023] Open
Abstract
Chronic malnutrition, including stunting, is an important example of a global challenge that spans multiple sectors, specifically health, agriculture, and the environment. The objective of this paper is to review current knowledge on the causes and consequences of chronic malnutrition and their relationship with multiple sectors. Understanding the causes includes approaching chronic malnutrition from the basic, underlying, and immediate levels. The causes reach from macro-level environmental influences to specific micronutrient intake. In order to effectively address stunting, it is important to understand the timing of stunting and the ability of individuals to catch up in terms of linear growth, cognitive ability, and immune function. The consequences of chronic malnutrition are transgenerational and they have an impact at the individual, community, and national level in the short- and long-term. There are still many gaps in knowledge regarding both the causes and consequences of chronic malnutrition, particularly when it comes to the interaction with agriculture and the environment, and understanding these gaps is important to addressing the burden of chronic malnutrition through evidence-based interventions.
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Affiliation(s)
- Kristina Reinhardt
- School of International and Public Affairs, Columbia University , New York, NY , USA
| | - Jessica Fanzo
- Institute of Human Nutrition, Columbia University , New York, NY , USA ; Center for Globalization and Sustainable Development, Earth Institute, Columbia University , New York, NY , USA
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Paul A, Doocy S, Tappis H, Funna Evelyn S. Preventing malnutrition in post-conflict, food insecure settings: a case study from South Sudan. PLOS CURRENTS 2014; 6. [PMID: 25045588 PMCID: PMC4096807 DOI: 10.1371/currents.dis.54cd85fa3813b0471abc3ebef1038806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Decades of civil conflict compound the challenges of food insecurity in South Sudan and contribute to persistent, high levels of child malnutrition. As efforts to prevent child malnutrition continue, there is a critical need for strategies that effectively supplement the diets of pregnant women and young children in transitional, highly food insecure settings like South Sudan.
Methods: This mixed-methods case study of four communities in South Sudan reports on the diets of children under 2 years of age and explores household-level factors including household size, intrahousehold food allocation practices, and responses to scarcity that may have significant impact on the effectiveness of strategies relying on household ration distribution to supplement the diets of pregnant women and children under 2 years of age.
Results: Participants reported experiencing increased scarcity as a result of prolonged drought and household sizes enlarged by the high volume of returning refugees. Although communities were receiving monthly household rations through a non-emergency food assistance program, most households had exhausted rations less than 30 days after receipt. Results showed that more than one half of children 12-17 months and one third of children 18-23 months consumed diets consisting of fewer than 4 food groups in the last week. Intrahousehold food allocation patterns give children first priority at meal times even in times of scarcity, yet adult women, including pregnant women, have last priority.
Discussion: These findings suggest that distribution of supplementary household rations will likely be insufficient to effectively supplement the diets of young children and pregnant women in particular. In light of the multiple contextual challenges experienced by households in transitional, food-insecure settings, these findings support recommendations to take a context-specific approach to food assistance programming, in which considerations of intrahousehold food allocation patterns and broader cultural and environmental factors inform program design. Incorporating assessments of intrahousehold food allocation patterns as part of needs assessments for food assistance and voucher or cash transfer programs may contribute to more effective, context specific programming.
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Affiliation(s)
- Amy Paul
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Shannon Doocy
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Hannah Tappis
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Sonya Funna Evelyn
- Adventist Development and Relief Association, Silver Spring, Maryland, USA
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Sunguya BF, Poudel KC, Mlunde LB, Urassa DP, Yasuoka J, Jimba M. Poor nutrition status and associated feeding practices among HIV-positive children in a food secure region in Tanzania: a call for tailored nutrition training. PLoS One 2014; 9:e98308. [PMID: 24846016 PMCID: PMC4028312 DOI: 10.1371/journal.pone.0098308] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 05/01/2014] [Indexed: 11/18/2022] Open
Abstract
Undernutrition among HIV-positive children can be ameliorated if they are given adequate foods in the right frequency and diversity. Food insecurity is known to undermine such efforts, but even in food rich areas, people have undernutrition. As yet no study has examined feeding practices and their associations with nutrition status among as HIV-positive children in regions with high food production. We therefore examined the magnitude of undernutrition and its association with feeding practices among HIV-positive children in a high food production region in Tanzania.
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Affiliation(s)
- Bruno F. Sunguya
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Krishna C. Poudel
- Department of Public Health, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America
| | - Linda B. Mlunde
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - David P. Urassa
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Junko Yasuoka
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- * E-mail:
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Determinants of inadequate complementary feeding practices among children aged 6-23 months in Ghana. Public Health Nutr 2014; 18:669-78. [PMID: 24844532 DOI: 10.1017/s1368980014000834] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To explore complementary feeding practices and identify potential risk factors associated with inadequate complementary feeding practices in Ghana by using the newly developed WHO infant feeding indicators and data from the nationally representative 2008 Ghana Demographic and Health Survey. DESIGN The source of data for the analysis was the 2008 Ghana Demographic and Health Survey. Analysis of the factors associated with inadequate complementary feeding, using individual-, household- and community-level determinants, was done by performing multiple logistic regression modelling. SETTING Ghana. SUBJECTS Children (n 822) aged 6-23 months. RESULTS The prevalence of the introduction of solid, semi-solid or soft foods among infants aged 6-8 months was 72.6 % (95 % CI 64.6 %, 79.3 %). The proportion of children aged 6-23 months who met the minimum meal frequency and dietary diversity for breast-fed and non-breast-fed children was 46.0 % (95 % CI 42.3 %, 49.9 %) and 51.4 % (95 % CI 47.4 %, 55.3 %) respectively and the prevalence of minimum acceptable diet for breast-fed children was 29.9 % (95 % CI 26.1 %, 34.1 %). Multivariate analysis revealed that children from the other administrative regions were less likely to meet minimum dietary diversity, meal frequency and acceptable diet than those from the Volta region. Household poverty, children whose mothers perceived their size to be smaller than average and children who were delivered at home were significantly less likely to meet the minimum dietary diversity requirement; and children whose mothers did not have any postnatal check-ups were significantly less likely to meet the requirement for minimum acceptable diet. Complementary feeding was significantly lower in infants from illiterate mothers (adjusted OR=3.55; 95 % CI 1.05, 12.02). CONCLUSIONS The prevalence of complementary feeding among children in Ghana is still below the WHO-recommended standard of 90 % coverage. Non-attendance of postnatal check-up by mothers, cultural beliefs and habits, household poverty, home delivery of babies and non-Christian mothers were the most important risk factors for inadequate complementary feeding practices. Therefore, nutrition educational interventions to improve complementary feeding practices should target these factors in order to achieve the fourth Millennium Development Goal.
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Stewart CP, Iannotti L, Dewey KG, Michaelsen KF, Onyango AW. Contextualising complementary feeding in a broader framework for stunting prevention. MATERNAL AND CHILD NUTRITION 2014; 9 Suppl 2:27-45. [PMID: 24074316 DOI: 10.1111/mcn.12088] [Citation(s) in RCA: 313] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
An estimated 165 million children are stunted due to the combined effects of poor nutrition, repeated infection and inadequate psychosocial stimulation. The complementary feeding period, generally corresponding to age 6-24 months, represents an important period of sensitivity to stunting with lifelong, possibly irrevocable consequences. Interventions to improve complementary feeding practices or the nutritional quality of complementary foods must take into consideration the contextual as well as proximal determinants of stunting. This review presents a conceptual framework that highlights the role of complementary feeding within the layers of contextual and causal factors that lead to stunted growth and development and the resulting short- and long-term consequences. Contextual factors are organized into the following groups: political economy; health and health care systems; education; society and culture; agriculture and food systems; and water, sanitation and environment. We argue that these community and societal conditions underlie infant and young child feeding practices, which are a central pillar to healthy growth and development, and can serve to either impede or enable progress. Effectiveness studies with a strong process evaluation component are needed to identify transdisciplinary solutions. Programme and policy interventions aimed at preventing stunting should be informed by careful assessment of these factors at all levels.
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Affiliation(s)
- Christine P Stewart
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA
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Lutter CK, Iannotti L, Creed-Kanashiro H, Guyon A, Daelmans B, Robert R, Haider R. Key principles to improve programmes and interventions in complementary feeding. MATERNAL AND CHILD NUTRITION 2014; 9 Suppl 2:101-15. [PMID: 24074321 DOI: 10.1111/mcn.12087] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Although there are some examples of successful complementary feeding programmes to promote healthy growth and prevent stunting at the community level, to date there are few, if any, examples of successful programmes at scale. A lack of systematic process and impact evaluations on pilot projects to generate lessons learned has precluded scaling up of effective programmes. Programmes to effect positive change in nutrition rarely follow systematic planning, implementation, and evaluation (PIE) processes to enhance effectiveness over the long term. As a result a set of programme-oriented key principles to promote healthy growth remains elusive. The purpose of this paper is to fill this gap by proposing a set of principles to improve programmes and interventions to promote healthy growth and development. Identifying such principles for programme success has three requirements: rethinking traditional paradigms used to promote improved infant and young child feeding; ensuring better linkages to delivery platforms; and, improving programming. Following the PIE model for programmes and learning from experiences from four relatively large-scale programmes described in this paper, 10 key principles are identified in the areas of programme planning, programme implementation, programme evaluation, and dissemination, replication, and scaling up. Nonetheless, numerous operational research questions remain, some of which are highlighted in this paper.
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Affiliation(s)
- Chessa K Lutter
- Pan American Health Organization/World Health Organization, Washington, DC, USA
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Fenske N, Burns J, Hothorn T, Rehfuess EA. Understanding child stunting in India: a comprehensive analysis of socio-economic, nutritional and environmental determinants using additive quantile regression. PLoS One 2013; 8:e78692. [PMID: 24223839 PMCID: PMC3817074 DOI: 10.1371/journal.pone.0078692] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 09/04/2013] [Indexed: 12/19/2022] Open
Abstract
Background Most attempts to address undernutrition, responsible for one third of global child deaths, have fallen behind expectations. This suggests that the assumptions underlying current modelling and intervention practices should be revisited. Objective We undertook a comprehensive analysis of the determinants of child stunting in India, and explored whether the established focus on linear effects of single risks is appropriate. Design Using cross-sectional data for children aged 0–24 months from the Indian National Family Health Survey for 2005/2006, we populated an evidence-based diagram of immediate, intermediate and underlying determinants of stunting. We modelled linear, non-linear, spatial and age-varying effects of these determinants using additive quantile regression for four quantiles of the Z-score of standardized height-for-age and logistic regression for stunting and severe stunting. Results At least one variable within each of eleven groups of determinants was significantly associated with height-for-age in the 35% Z-score quantile regression. The non-modifiable risk factors child age and sex, and the protective factors household wealth, maternal education and BMI showed the largest effects. Being a twin or multiple birth was associated with dramatically decreased height-for-age. Maternal age, maternal BMI, birth order and number of antenatal visits influenced child stunting in non-linear ways. Findings across the four quantile and two logistic regression models were largely comparable. Conclusions Our analysis confirms the multifactorial nature of child stunting. It emphasizes the need to pursue a systems-based approach and to consider non-linear effects, and suggests that differential effects across the height-for-age distribution do not play a major role.
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Affiliation(s)
- Nora Fenske
- Institut für Statistik, Ludwig-Maximilians-Universität München, Munich, Germany
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Nair M, Ariana P, Ohuma EO, Gray R, De Stavola B, Webster P. Effect of the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) on malnutrition of infants in Rajasthan, India: a mixed methods study. PLoS One 2013; 8:e75089. [PMID: 24086447 PMCID: PMC3783470 DOI: 10.1371/journal.pone.0075089] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 08/11/2013] [Indexed: 11/18/2022] Open
Abstract
Objectives Analyse the effect of the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA), a wage-for-employment policy of the Indian Government, on infant malnutrition and delineate the pathways through which MGNREGA affects infant malnutrition. Hypothesis: MGNREGA could reduce infant malnutrition through positive effects on household food security and infant feeding. Method Mixed methods using cross-sectional study and focus group discussions conducted in Dungarpur district, Rajasthan, India. Participants: Infants aged 1 to <12 months and their mothers/caregivers. Final sample 528 households with 1056 participants, response rate 89.6%. Selected households were divided into MGNREGA-households and non-MGNREGA-households based on participation in MGNREGA between August-2010 and September-2011. Outcomes: Infant malnutrition measured using anthropometric indicators - underweight, stunting, and wasting (WHO criteria). Results We included 528 households with 1,056 participants. Out of 528, 281 households took part in MGNREGA between August’10, and September’11. Prevalence of wasting was 39%, stunting 24%, and underweight 50%. Households participating in MGNREGA were less likely to have wasted infants (OR 0·57, 95% CI 0·37–0·89, p = 0·014) and less likely to have underweight infants (OR 0·48, 95% CI 0·30–0·76, p = 0·002) than non-participating households. Stunting did not differ significantly between groups. We did 11 focus group discussions with 62 mothers. Although MGNREGA reduced starvation, it did not provide the desired benefits because of lower than standard wages and delayed payments. Results from path analysis did not support existence of an effect through household food security and infant feeding, but suggested a pathway of effect through low birth-weight. Conclusion Participation in MGNREGA was associated with reduced infant malnutrition possibly mediated indirectly via improved birth-weight rather than by improved infant feeding. Addressing factors such as lack of mothers’ knowledge and inappropriate feeding practices, over and above the social and economic policies, is key in efforts to reduce infant malnutrition.
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Affiliation(s)
- Manisha Nair
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Proochista Ariana
- Nuffield Department of Population Health, & Department of International Development, University of Oxford, Oxford, United Kingdom
| | - Eric O. Ohuma
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, United Kingdom
| | - Ron Gray
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Bianca De Stavola
- Department of Medical Statistics & Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Premila Webster
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Victor R, Baines SK, Agho KE, Dibley MJ. Factors associated with inappropriate complementary feeding practices among children aged 6-23 months in Tanzania. MATERNAL AND CHILD NUTRITION 2012; 10:545-61. [PMID: 22925557 DOI: 10.1111/j.1740-8709.2012.00435.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inappropriate complementary feeding is one of the major causes of undernutrition among young children in Tanzania. Prevalence of newly developed World Health Organization complementary feeding indicators and their associated factors were determined among 2402 children aged 6-23 months in Tanzania using data from the 2010 Tanzania Demographic and Health Survey. The survey used a multistage cluster sample of 10 300 households from the eight geographical zones in the country. The prevalence of the introduction of soft, semi-solid or solid foods among infants aged 6-8 months was 92.3%. Of all the children aged 6-23 months, the prevalence of minimum dietary diversity, meal frequency and acceptable diet were 38.2%, 38.6% and 15.9%, respectively. Results from multivariate analyses indicated that the main risk factors for inappropriate complementary feeding practices in Tanzania include young child's age (6-11 months), lower level of paternal/maternal education, limited access to mass media, lack of post-natal check-ups, and poor economic status. Overall, complementary feeding practices in Tanzania, as measured by dietary diversity, meal frequency and acceptable diet, are not adequately met, and there is a need for interventions to improve the nutritional status of young children in Tanzania.
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Affiliation(s)
- Rose Victor
- School of Health Sciences, Faculty of Health, University of Newcastle, Callaghan, New South Wales, Australia
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Jones AD, Cruz Agudo Y, Galway L, Bentley J, Pinstrup-Andersen P. Heavy agricultural workloads and low crop diversity are strong barriers to improving child feeding practices in the Bolivian Andes. Soc Sci Med 2012; 75:1673-84. [PMID: 22867863 DOI: 10.1016/j.socscimed.2012.06.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 06/23/2012] [Accepted: 06/25/2012] [Indexed: 11/15/2022]
Abstract
Most nutrition initiatives to date aimed at improving infant and young child feeding (IYCF) have emphasized addressing knowledge gaps through behavior change messaging with less focus on addressing the underlying environmental barriers that may shape these behaviors. This research integrates an analysis of longitudinal dietary data with qualitative data on barriers to improved child feeding to identify the nature and extent of the barriers caregivers face to improving IYCF practices in a farming region of the Bolivian Andes, and to determine the relative influence of these barriers on caregivers' abilities to improve IYCF practices. Sixty-nine caregivers were selected from a sample of 331 households that participated in a longitudinal survey assessing changes in IYCF practices among caregivers with children aged 0-36 months from March 2009 to March 2010. Forty-nine barriers within 12 categories of barriers were identified through semi-structured interviews with the 69 caregivers. The most frequently reported barriers were those related to women's time dedicated to agricultural labor, the limited diversity of household agricultural production, and lack of support for child feeding from spouses and mothers-in-law. In multivariate analyses controlling for several variables that could potentially influence IYCF practices, these barriers were negatively associated with changes to the diversity of child diets, child dietary energy intake, and child meal frequency. While knowledge gaps and individual-level influences affected IYCF practices, physical and social caregiving environments in this region of Bolivia were even more important. Behavior change communication alone will likely not address the social and environmental barriers to improved child feeding that often prevent translation of improved knowledge into action. Particularly in rural regions, agriculture may strongly influence child feeding, not only indirectly through household food security, but also directly by affecting women's caregiving capacity.
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Affiliation(s)
- Andrew D Jones
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA.
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