Exploring how and why Care Groups work to improve infant feeding practices in low- and middle-income countries: a realist review protocol

Water, Sanitation, and Hygiene for Everyone Intervention Study: Protocol for a Controlled Before-and-After Trial

BACKGROUND

Community-based behavior change interventions are a common approach to Water, Sanitation, and Hygiene (WASH). Yet, published evaluations of how these interventions work in district-wide approaches are rare.

OBJECTIVE

This study reports the baseline characteristics and study design for a trial assessing the effectiveness of a district-level Community-led Total Sanitation (CLTS) intervention compared to the additional integration of local care groups (CG) on sanitation coverage and use and hygiene behaviors in Chiradzulu District, Malawi.

METHODS

This study is a controlled before-and-after trial with 2 treatment arms and a control group. Clusters are rural villages in 3 traditional authorities (TAs). One arm will receive CLTS and the CG model (CLTS+CG group), one arm CLTS only (CLTS group), and one group will serve as the control. The trial is part of the wider WASH for Everyone (W4E) project, led by World Vision Malawi that aims to expand access to WASH services across the entire district by 2025. Study participants were selected from the 3 TAs. Systematic sampling procedures were used to select 20 households per cluster with a total of 1400 households at both baseline and end line. The primary outcome is sanitation coverage. Secondary outcome measures include sanitation use, safe disposal of child feces, observed handwashing facility, and Sanitation-related Quality of Life Index (SanQoL-5).

RESULTS

The baseline observations indicate a balanced distribution of potential demographic confounders in the trial arms with a slight variation on some WASH proxy measures. We noted the low coverage of handwashing facilities with soap and water in all 3 arms: 8% in the CLTS group, 4% in the CLTS+CG group, and 4% in the control group. There was a marginal variation in handwashing practices among the study arms with 3% of individuals handwashing with soap and water in the CLTS group, 5% in the CLTS+CG group, and 2% in the control group. Sanitation coverage also varied among the study arms at baseline as 83% of households had access to unimproved sanitation in the CLTS group, 70% in the CLTS+CG group, and 81% in the control group.

CONCLUSIONS

Results from this trial will provide evidence on whether the CLTS+CG approach is effective at improving sanitation and hygiene practices in the W4E program area compared to CLTS alone and no intervention, as well as inform implementing partners on future interventions in Chiradzulu District, Malawi. The results are expected to be published in 2025.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05808218; https://clinicaltrials.gov/study/NCT05808218.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/68280.

Participants in a peer-based nutrition and health program in Zimbabwe value dialogue, peer support, and tangible action: A qualitative exploration of peer group experiences

Peer support groups are implemented globally, and viewed as cost-effective, scalable platforms for delivering health and nutrition programming. Quality is important for participation and achieving social and behavior change goals. Little research has explored the perspectives of peer group participants on quality. This manuscript describes community-based implementation research, and associated findings, which was conducted to learn how participants of a nutrition and health program define quality peer groups and how they suggest improving peer groups. In-depth interviews on experiences, benefits, and challenges were conducted with participants of health and nutrition peer groups, including group members (n = 64) and facilitators (n = 30), in three districts in Zimbabwe. Qualitative data were analyzed thematically and preliminary results were presented in six follow-up focus group discussions with interviewees to provide input on results and interpretation. Peer groups met some of participants' needs for knowledge, social support, and visible improvements in their lives and homes. Participants described generally positive experiences that sustained participation and motivated behavior change. They highlighted group dynamics, interactive facilitation, and community recognition which support the credibility and motivation of group facilitators. Implementation could be improved by strengthening family engagement and more hands-on learning for encouraging participation. Local adaptation of group activities can address influences on behavior change and increase relevance to participants' needs. The perspectives of core stakeholders are essential to understand what aspects of peer groups are most important to implement the approach with quality across contexts. Implementation research and continued monitoring to understand participant perspectives should be an integral part of all programs to ensure the application of adult learning principles and an appropriate balance between fidelity and adaptation for local relevance and engagement.

A Peer-Led Integrated Nutrition Education Intervention through Care Groups Improved Complementary Feeding of Infants in Postemergency Settlements in the West-Nile Region in Uganda: A Cluster Randomized Trial

Background

Complementary feeding of infants in refugee settlements remains inadequate. Furthermore, there has been limited evaluation of interventions addressing these nutrition challenges.

Objective

This study examined the effects of a peer-led integrated nutrition education intervention on infant complementary feeding by South Sudanese refugee mothers in the West-Nile region in Uganda.

Methods

A community-based randomized trial enrolled 390 pregnant women (during third trimester) as the baseline. Two arms [mothers-only and parents-combined (both mothers and fathers)] comprised treatments with a control. Infant feeding was assessed using WHO and UNICEF guidelines. Data were collected at Midline-II and Endline. The medical outcomes study (MOS) social support index was used to measure social support. An overall mean score of >4 was considered optimal social support, a score of ≤2 was none or little support. Adjusted multivariable logistic regression models determined the effects of the intervention on infant complementary feeding.

Results

At the end of the study, infant complementary feeding improved significantly in both mothers-only and parents-combined arms. There was a positive effect on the introduction of solid, semisolid, and soft foods (ISSSF) in the mothers-only arm at both Midline-II {adjusted odds ratio (AOR) = 4.0]} and Endline (AOR = 3.8). Likewise, ISSSF was better for the parents-combined arm at both Midline-II (AOR = 4.5) and Endline (AOR = 3.4). Minimum dietary diversity (MDD) was significantly better at the Endline for the parents-combined arm (AOR = 3.0). Minimum acceptable diet (MAD) was significantly better at Endline for both mothers-only (AOR = 2.3) and parents-combined arms (AOR = 2.7). Infant consumption of eggs and flesh foods (EFF) was improved only in the parents-combined arm at both Midline-II (AOR = 3.3) and Endline (AOR = 2.4). Higher maternal social support was associated with better infant MDD (AOR = 3.3), MAD (AOR = 3.6), and EFF (AOR = 4.7).

Conclusion

Engaging both fathers and mothers in care groups benefited complementary feeding of infants. Overall, this peer-led integrated nutrition education intervention through care groups improved infant complementary feeding in the West-Nile postemergency settlements in Uganda.This trial was registered at clinicaltrials.gov as NCT05584969.

What are the mechanisms and contexts by which care groups achieve social and behavioural change in low- and middle-income countries? Group motivation findings from a realist synthesis

OBJECTIVE

Infant and under-five mortality rates in low- and middle-income countries (LMIC) can be reduced by encouraging behaviours such as sleeping under insecticide-treated bed nets, exclusive breast-feeding for the first 6 months, regular handwashing, etc. Community-based volunteer or peer-to-peer mechanisms are cost-effective ways of promoting these lifesaving practices. However, the sustainability and reach of community-based behaviour change promotion remains a challenge. Our inquiry focuses on the utilisation, by non-governmental organisations (NGO), of Care Groups, a peer-to-peer behaviour change intervention. We asked: What are the mechanisms and contexts by which Care Groups achieve social and behavioural change in nutrition, health and other sectors?

DESIGN

Realist synthesis reviewing forty-two texts that contained empirical evidence about Care Group interventions.

SETTING

LMIC.

PARTICIPANTS

We held consultations with a research reference group, which included Care Group and nutrition experts, and Care Group - implementing NGO staff in Malawi.

RESULTS

Different types of motivation drive the establishment and the sustainability of peer group interventions. A certain amount of motivation was derived from the resources provided by the NGO establishing the Care Groups. Subsequently, both volunteers and neighbourhood group members were motivated by the group dynamics and mutual support, as well as support from the wider community. Finally, volunteers and group members alike became self-motivated by their experience of being involved in group activities.

CONCLUSIONS

When designing and implementing community-based behaviour change interventions, awareness of the multi-directional nature of the motivating drivers that are experienced by peer- or community group members is important, to optimise these groups' reach and sustainability.

Improving breastfeeding support through the implementation of the baby friendly hospital and community initiatives: a scoping review protocol

Background: Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. Exclusively breastfeeding infants for the first six months would lead to the largest infant mortality reduction. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund (UNICEF), which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) is an extension of the BHFI's 10 th step of the Ten Steps to Successful Breastfeeding and of the BFHI overall. Its focus is on community-based breastfeeding supports for women. There have been no known attempts to synthesise the overall body of evidence on the BFHI in recent years, and no synthesis of empirical research on the BFCI. This scoping review asks the question: what is known about the implementation of the BFHI and the BFCI globally? Methods and analysis: This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria will follow the Population, Concepts, Contexts approach. A data charting form will be developed and applied to all the included articles. Qualitative and quantitative descriptive analysis will be undertaken. The PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) methodological framework will be used to analyse and report review findings. Conclusion: This review will establish gaps in current evidence which will inform areas for future research in relation to this global initiative.

Improving breastfeeding support through the implementation of the baby friendly hospital and community initiatives: a scoping review protocol

Background: Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. Exclusively breastfeeding infants for the first six months would lead to the largest infant mortality reduction. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund (UNICEF), which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) is an extension of the BHFI's 10 th step of the Ten Steps to Successful Breastfeeding and of the BFHI overall. Its focus is on community-based breastfeeding supports for women. There have been no known attempts to synthesise the overall body of evidence on the BFHI in recent years, and no synthesis of empirical research on the BFCI. This scoping review asks the question: what is known about the implementation of the BFHI and the BFCI globally? Methods and analysis: This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria will follow the Population, Concepts, Contexts approach. A data charting form will be developed and applied to all the included studies. Qualitative and quantitative descriptive analysis will be undertaken. In order to address equity of access to the BFHI/BFCI, the Levesque et al. (2013) access to health care framework will be used as a lens to analyse the charted data in relation to this aspect of the review. An already established group of stakeholders with experience of infant feeding policy and implementation in Malawi will be consulted, to obtain expert views on the findings of the scoping review. Conclusion: This review will establish gaps in current evidence which will inform areas for future research in relation to this global initiative.