An integrated microcredit, entrepreneurial training, and nutrition education intervention is associated with better growth among preschool-aged children in rural Ghana

Effect of community‐based nutritional education on dietary diversity and consumption of animal‐source foods among rural preschool‐aged children in the Ilu Abba Bor zone of southwest Ethiopia: Quasi‐experimental study

Dietary diversity (DD) is a concern for poor people in developing countries, particularly in Africa. Most people's diets consist primarily of monotonous carbohydrate staples, with little or no animal products and few fresh fruits and vegetables. The aim of this intervention was to see how nutrition education delivered by trained health professionals improved preschool‐aged children's consumption of DD and animal‐sourced foods. The study used a quasi‐experimental design with 588 preschool‐aged children. Researchers used a multistage sample technique followed by a systematic random sampling technique. A χ² test was used to determine the baseline differences in demographic and socioeconomic factors between the two groups, as well as the relationship between predictors and child DD and animal‐source foods (ASFs). The researchers used generalized estimating equations to assess the change in the difference in outcomes between the intervention and control groups, as well as the association between predictors and child DD and ASFs. The adjusted odds ratio with the corresponding 95% confidence intervals was reported to show the strength of the association. The findings of this study revealed that there was a highly significant difference in both DD scores (DDS) and ASFs between the control and intervention groups DDS (p < 0.003) and ASF (p < 0.001). According to the findings of this study, nutrition education can significantly improve DDS and ASF consumption among preschool‐aged children.

Promoting minimum dietary diversity in feeding practices is essential to improve child health and development on a global scale.

Community‐based nutritional education, delivered by trained health professionals, improved feeding practices among caregivers.

This nutrition education increased children's dietary diversity and consumption of animal‐derived foods significantly.

Our findings highlight the need for future research to investigate relevant aspects not covered in this study.

Participating in a Nutrition-Sensitive Agriculture Intervention Is Not Associated with Less Maternal Time for Care in a Rural Ghanaian District

Background

Nutrition-sensitive agriculture (NSA) interventions may increase farm-related work for mothers, with consequences for child nutrition. The Nutrition Links (NL) intervention provided mothers with poultry, gardening inputs, technical support, and education to improve livelihoods and child nutrition outcomes in rural Ghana.

Objectives

Our objective was to compare time allocated to child care by a cross-section of mothers in the intervention group of the NL intervention with the control group (NCT01985243).

Methods

A cross-section of NL mother-child pairs was included in a time allocation substudy [intervention (NL-I) n = 74 and control (NL-C) n = 69]. In-home observations of the mother-child pair were conducted for 1 min, every 5 min, for 6 h. Observations were categorized into 4 nonoverlapping binary variables as follows: 1) maternal direct care, 2) maternal supervisory care, 3) allocare, and 4) no direct supervision. Allocare was defined as care by another person in the presence or absence of the mother. Any care was defined as the observation of maternal direct care, maternal supervisory care, or allocare. Generalized linear mixed models with binomial data distribution were used to compare the child care categories by group, adjusting for known covariates.

Results

Maternal direct care (OR = 1.07; 95% CI: 0.89, 1.28) and any care (OR = 1.56; 95% CI: 0.91, 2.67) did not differ by intervention group. However, there was a higher odds of allocare (OR = 1.36; 95% CI: 1.04, 1.79) in NL-I than in NL-C women.

Conclusions

Maternal participation in an NSA intervention was not associated with a decrease in time spent directly on child care but was associated with an increase in care from other household and community members.The clinicaltrials.gov number provided is for the main NL intervention and not this current substudy.

Growing and Learning Together in Fostering Multisectoral Participation for Sustaining Interventions: Lessons from 3 Successive Integrated Multidisciplinary Interventions in Rural Ghana

Despite the recognition of nutrition as a multisectoral development issue, institutional silos persist as barriers to addressing community nutrition challenges effectively and sustainably. Over the past 2 decades, 3 integrated agriculture, livelihood, nutrition, and health interventions have been implemented in rural communities across Ghana, aimed at nurturing multisectoral collaborations to enhance institutional capacity, women's empowerment, children's diets and nutritional status, and general household well-being. Using information from published articles on the interventions, workshop reports, informal institutional engagements, and field notes, insights are presented on the efforts to garner multisectoral participation to sustain these interventions. Challenges and opportunities encountered in the process of growing and learning together relative to overcoming institutional cultures, building trust, empathizing with partners' institutional challenges, making collective decisions, and building common ownership and accountability are explored. Fostering effective multisectoral participation is a dynamic process of continuous learning.

Household Microenvironment and Under-Fives Health Outcomes in Uganda: Focusing on Multidimensional Energy Poverty and Women Empowerment Indices

Young children in low- and middle-income countries (LMICs) are vulnerable to adverse effects of household microenvironments. The UN Sustainable Development Goals (SDGs)-specifically SDG 3 through 7-urge for a comprehensive multi-sector approach to achieve the 2030 goals. This study addresses gaps in understanding the health effects of household microenvironments in resource-poor settings. It studies associations of household microenvironment variables with episodes of acute respiratory infection (ARI) and diarrhoea as well as with stunting among under-fives using logistic regression. Comprehensive data from a nationally representative, cross-sectional demographic and health survey (DHS) in Uganda were analysed. We constructed and applied the multidimensional energy poverty index (MEPI) and the three-dimensional women empowerment index in multi-variate regressions. The multidimensional energy poverty was associated with higher risk of ARI (OR = 1.32, 95% CI 1.10 to 1.58). Social independence of women was associated with lower risk of ARI (OR= 0.91, 95% CI 0.84 to 0.98), diarrhoea (OR = 0.93, 95% CI 0.88 to 0.99), and stunting (OR = 0.83, 95% CI 0.75 to 0.92). Women's attitude against domestic violence was also significantly associated with episodes of ARI (OR = 0.88, 95% CI 0.82 to 0.93) and diarrhoea (OR = 0.89, 95% CI 0.84 to 0.93) in children. Access to sanitation facilities was associated with lower risk of ARI (OR = 0.55, 95% CI 0.45 to 0.68), diarrhoea (OR = 0.83, 95% CI 0.71 to 0.96), and stunting (OR = 0.64, 95% CI 0.49 to 0.86). Investments targeting synergies in integrated energy and water, sanitation and hygiene, and women empowerment programmes are likely to contribute to the reduction of the burden from early childhood illnesses. Research and development actions in LMICs should address and include multi-sector synergies.

Improvement of Dietary Diversity and Attitude toward Recommended Feeding through Novel Community Based Nutritional Education Program in Coastal Kenya-An Intervention Study

Community-based nutritional intervention to improve the practice of dietary diversity and child nutrition by community health workers (CHWs) involving Nyumba Kumi as small neighborhood units (SNUs) in communities has not yet been explored. This study was conducted in two villages in rural Kenya between 2018 and 2019. In total, 662 participants (control vs. intervention: n = 339 vs. n = 323) were recruited. The intervention group received education on maternal and child nutrition and follow-up consultations. The custom-tailored educational guidelines were made based on Infant and Young Child Feeding and the mother and child health booklet. The educational effects on household caregivers’ feeding practice attitude and child nutritional status were analyzed using multiple linear regression. After the intervention, a total of 368 household caregivers (187 vs. 181) and 180 children (113 vs. 67) were analyzed separately. Between the groups, no significant difference was found in their background characteristics. This study successfully improved the dietary diversity score (β = 0.54; p < 0.01) and attitude score (β = 0.29; p < 0.01). The results revealed that the interventions using CHWs and SNUs were useful to improve dietary diversity and caregivers’ attitudes toward recommended feeding. This research has the potential to be successfully applied in other regions where child undernutrition remains.

Livestock ownership, household food security and childhood anaemia in rural Ghana

The mechanisms through which livestock ownership is associated with childhood anaemia are contested. Using a cross-sectional, community-based survey of 300 households in southern Ghana, we determined the associations of household livestock ownership with anaemia among children aged 2-5 years. Potential mediating effects of animal-source food (ASF) consumption, microbial infections, and household food security were investigated. Data on each child's anaemia, malaria, and intestinal infections were collected for a subset of 221 households. Anaemia was defined as a haemoglobin (Hb) concentration <110 g/L. ASF consumption was measured as a count of the number of different ASF types consumed by each child in the week prior to the interview. Household food security was measured with a 15-item, pre-tested tool adapted from the USDA Household Food Security Core Module. The number of sheep and goats in aggregate was associated with higher odds of a child being anaemic (aOR (95% CI) = 1.10 (1.03, 1.17)). Households owning more free-range poultry had greater diversity of consumed ASFs among children (Coef. (95% C) = 0.02 (0.01, 0.03)). Owning more pigs was associated with higher odds that a household was food secure (1.05 (0.99, 1.12). We found no evidence that the child's ASF consumption mediated the association of livestock ownership with child anaemia, however,household food security mediated the association between household pig ownership and child anaemia. Overall, household ownership of livestock was associated with higher ASF consumption among children and improved household-level food security, yet also a higher odd of anaemia among those young children. The mechanisms leading to these seemingly counterintuitive relationships require further investigation.

An agriculture-nutrition intervention improved children's diet and growth in a randomized trial in Ghana

Stunting in Ghana is associated with rural communities, poverty, and low education; integrated agricultural interventions can address the problem. This cluster randomized controlled trial tested the effect of a 12-month intervention (inputs and training for poultry farming and home gardening, and nutrition and health education) on child diet and nutritional status. Sixteen clusters were identified and randomly assigned to intervention or control; communities within clusters were randomly chosen, and all interested, eligible mother-child pairs were enrolled (intervention: 8 clusters, 19 communities, and 287 households; control: 8 clusters, 20 communities, and 213 households). Intention-to-treat analyses were used to estimate the effect of the intervention on endline minimum diet diversity (≥4 food groups), consumption of eggs, and length-for-age (LAZ)/height-for-age (HAZ), weight-for-age (WAZ), and weight-for-length (WLZ)/weight-for-height (WHZ) z-scores; standard errors were corrected for clustering. Children were 10.5 ± 5.2 months (range: 0-32) at baseline and 29.8 ± 5.4 months (range: 13-48) at endline. Compared with children in the control group, children in the intervention group met minimum diet diversity (adjusted odds ratio = 1.65, 95% CI [1.02, 2.69]) and a higher LAZ/HAZ (β = 0.22, 95% CI [0.09, 0.34]) and WAZ (β = 0.15, 95% CI [0.00, 0.30]). Sensitivity analyses with random-effects and mixed-effects models and as-treated analysis were consistent with the findings. There was no group difference in WLZ/WHZ. Integrated interventions that increase access to high-quality foods and nutrition education improve child nutrition.

Adaptation of a mental development assessment tool for the evaluation of the long-term effect of a successful nutrition intervention in Ghana

This study adapted a cognitive assessment tool to be used in evaluating nutrition interventions in developing countries and assessed its reliability and validity in Ghana. The tool was used to evaluate the long-term effect of the Enhancing Child Nutrition through Animal Source Food Management (ENAM) project. The former ENAM participants' children were contacted (now 13 to 15 years old). The items in the Wechsler Abbreviated Scale of Intelligence-II were adapted, pretested, refined, and pretested again. Cross-sectional data collection was conducted with former ENAM participants (60 interventions and 51 comparison families) in one of ENAM's three sites (the Guinea Savanna zone). Data on participants' socio-economic status and food insecurity were collected, along with their children's intellectual functioning, dietary intake, school attainment, anthropometry, and symptoms of depression. Alpha coefficient of the verbal subscale improved between the first and second pretest (from .34 to .80). After controlling for age, the intelligence scores of the children were associated with their grade (r = .35, p = .001) and academic performance (r = .26 to .33, p < .05). The verbal scale was associated with their anthropometry (r = .24 to .27, p < .05). The intervention children still recorded a better dietary diversity score than controls (6.8 vs 5.8, p = .0001); however, significance was lost after adjusting for confounders. There were no significant group differences in growth or intellectual functioning. The adapted Wechsler Abbreviated Scale of Intelligence-II tool performed well in evaluating adolescent intellectual functioning in rural Ghana, and there were no long-term effects of ENAM intervention on child growth and development.

Household food insecurity but not dietary diversity is associated with children's mean micronutrient density adequacy in rural communities across Ghana

OBJECTIVE

The aim of this study was to examine predictors of household food insecurity, dietary diversity, and children's mean micronutrient density adequacy and the relationship among these dietary measures.

METHOD

Baseline analysis of a quasi-experimental 16-mo intervention study conducted in 12 rural communities in the three main agroecological zones in Ghana. The study included 608 caregivers with their 2- to 5-y-old children. Nutrient density adequacy was estimated for a subsample of 120 children.

RESULTS

Food insecurity was more severe among farming households than their non-farming counterparts (P = 0.032). Dietary diversity score was significantly higher among non-farming households than farming households (P < 0.001). Food insecurity was negatively correlated with both household dietary diversity (r = -0.385; P < 0.001) and child mean micronutrient adequacy (r = -0.305; P < 0.001). There was no significant correlation between dietary diversity and children's mean micronutrient density adequacy. Belonging to a household that is severely food insecure and household size were significant predictors of children's mean micronutrient density adequacy (ß = -0.124, P = 0.006; ß = 0.011, P = 0.006, respectively).

CONCLUSION

Household food insecurity continues to be a good indicator of lower nutrient intake in children.

Is microfinance associated with changes in women's well-being and children's nutrition? A systematic review and meta-analysis

BACKGROUND

Microfinance is the provision of savings and small loans services, with no physical collateral. Most recipients are disadvantaged women. The social and health impacts of microfinance have not been comprehensively evaluated.

OBJECTIVE

To explore the impact of microfinance on contraceptive use, female empowerment and children's nutrition in South Asia, Sub-Saharan Africa and Latin America and the Caribbean.

DESIGN

We conducted a systematic search of published and grey literature (1990-2018), with no language restrictions. We conducted meta-analysis, where possible, to calculate pooled ORs. Where studies could not be combined, we described these qualitatively.

DATA SOURCES

EMBASE, MEDLINE, LILACS, CENTRAL and ECONLIT were searched (1990-June 2018).

ELIGIBILITY CRITERIA

We included controlled trials, observational studies and panel data analyses investigating microfinance involving women and children.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias. The methodological quality of included studies was assessed using the Cochrane risk-of-bias tool for controlled trials and quasi-experimental studies and a modified Newcastle Ottawa Scale for cross-sectional surveys and analyses of panel data. Meta-analyses were conducted using STATA V.15 (StataCorp).

RESULTS

We included 27 studies. Microfinance was associated with a 64% increase in the number of women using contraceptives (OR 1.64, 95% CI 1.45 to 1.86). We found mixed results for the association between microfinance and intimate partner violence. Some positive changes were noted in female empowerment. Improvements in children's nutrition were noted in three studies.

CONCLUSION

Microfinance has the potential to generate changes in contraceptive use, female empowerment and children's nutrition. It was not possible to compare microfinance models due to the small numbers of studies. More rigorous evidence is needed to evaluate the association between microfinance and social and health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42015026018.

The impact of poverty reduction and development interventions on non-communicable diseases and their behavioural risk factors in low and lower-middle income countries: A systematic review

INTRODUCTION

Non-communicable diseases (NCDs) disproportionately affect low- and lower-middle income countries (LLMICs) where 80% of global NCD related deaths occur. LLMICs are the primary focus of interventions to address development and poverty indicators. We aimed to synthesise the evidence of these interventions' impact on the four primary NCDs (cardiovascular disease, diabetes, chronic respiratory disease and cancer) and their common behavioural risk factors (unhealthy diets, physical inactivity, tobacco and alcohol use).

METHODS

We systematically searched four online databases (Medline, Embase, Web of Science and Global Health) for primary research conducted in LLMICS, published between January 1st 1990 and February 15th 2016. Studies involved development or poverty interventions which reported on outcomes relating to NCDs. We extracted summary level data on study design, population, health outcomes and potential confounders.

RESULTS

From 6383 search results, 29 studies from 24 LLMICs published between 1999 and 2015 met our inclusion criteria. The quality of included studies was limited and heterogeneity of outcome measures required narrative synthesis. One study measured impact on NCD prevalence, one physical activity and 27 dietary components. The majority of papers (23), involved agricultural interventions. Primary outcome measures tended to focus on undernutrition. Intensive agricultural interventions were associated with improved calorie, vitamin, fruit and vegetable intake. However, positive impacts were reliant on participant's land ownership, infection status and limited in generalisability. Just three studies measured adult obesity; two indicated increased income and consequential food affordability had the potential to increase obesity. Overall, there was poor alignment between included studies outcome measures and the key policy options and objectives of the Global Action Plan on NCDs.

CONCLUSIONS

Though many interventions addressing poverty and development have great potential to impact on NCD prevalence and risk, most fail to measure or report these outcomes. Current evidence is limited to behavioural risk factors, namely diet and suggests a positive impact of agricultural-based food security programmes on dietary indicators. However, studies investigating the impact of improved income on obesity tend to show an increased risk. Embedding NCD impact evaluation into development programmes is crucial in the context of the Sustainable Development Goals and the rapid epidemiological transitions facing LLMICs.

Child development in rural Ghana: Associations between cognitive/language milestones and indicators of nutrition and stimulation of children under two years of age

OBJECTIVES

Two studies aimed to assess the provision of nutrition and psychosocial stimulation in the home and to examine associations between mental development and nutrition and stimulation using a validated measure of development milestones.

METHODS

The first study consisted of secondary analyses on health and nutrition data from 1081 mother-child pairs (the children aged 0-12 months) and their households in Ghana's Eastern Region. For the second study, the Ghana Milestones Measure, consisting of items assessing cognitive and language development, was used to assess child development in a subsample (N = 330) of Study 1 participants one year later (children 10-24 months of age). This measure was mother-reported and had been validated in a separate community in Ghana. Correlation and linear regression analyses were used to analyze the data.

RESULTS

Family assets and maternal education were identified as key factors of the family context. Both variables were positively associated with preventive health practices (r = 0.08 to 0.13, p &lt; 0.0001 to 0.01), and dietary diversity (r = 0.15, p = 0.0001 to 0.0006), and negatively associated with maternal depressive symptoms (r = -0.19 to -0.12, p &lt; 0.0001). Taller children had higher receptive (standardized beta = 0.16; p = 0.04) and expressive (0.21; 0.003) language, but not cognitive (0.15; 0.07) milestone scores, and psychosocial stimulation was positively associated with all three milestones (receptive = 0.13, p = 0.01; expressive = 0.21, p &lt; 0.0001; and cognitive = 0.24, p &lt; 0.0001).

CONCLUSION

Our study provides the first validated measure of children's language and cognitive development in Ghana, finding associations with nutrition and stimulation. The Ghana Milestones Measure can be used to assess and help promote children's mental development.

Evaluating the effect of integrated microfinance and health interventions: an updated review of the evidence

BACKGROUND

Solutions delivered within firm sectoral boundaries are inadequate in achieving income security and better health for poor populations. Integrated microfinance and health interventions leverage networks of women to promote financial inclusion, build livelihoods, and safeguard against high cost illnesses. Our understanding of the effect of integrated interventions has been limited by variability in intervention, outcome, design, and methodological rigour. This systematic review synthesises the literature through 2015 to understand the effect of integrated microfinance and health programs.

METHODS

We searched PubMed, Scopus, Embase, EconLit, and Global Health databases and sourced bibliographies, identifying 964 articles exclusive of duplicates. Title, abstract, and full text review yielded 35 articles. Articles evaluated the effect of intentionally integrated microfinance and health programs on client outcomes. We rated the quality of evidence for each article.

RESULTS

Most interventions combined microfinance with health education, which demonstrated positive effects on health knowledge and behaviours, though not health status. Among programs that integrated microfinance with other health components ( i.e. health micro-insurance, linkages to health providers, and access to health products), results were generally positive but mixed due to the smaller number and quality of studies. Interventions combining multiple health components in a given study demonstrated positive effects, though it was unclear which component was driving the effect. Most articles (57%) were moderate in quality.

DISCUSSION

Integrated microfinance and health education programs were effective, though longer intervention periods are necessary to measure more complex pathways to health status. The effect of microfinance combined with other health components was less clear. Stronger randomized research designs with multiple study arms are required to improve evidence and disentangle the effects of multiple component microfinance and health interventions. Few studies attempted to understand changes in economic outcomes, limiting our understanding of the relationship between health and income effects.

Nutrition education improves dietary diversity of children 6-23 months at community-level: Results from a cluster randomized controlled trial in Malawi

BACKGROUND

Low dietary quality and quantity and inappropriate feeding practices can cause undernutrition. Poor nutritional status in early childhood is associated with growth faltering. The objective of the study was to assess the potential of community-based nutrition education to improve height-for-age z-scores in children 6-23 months of age.

METHODS AND FINDINGS

We carried out a cluster-randomized-controlled trial to assess the effectiveness of nutrition education. A total of 24 Extension Planning Area Sections served as clusters. The selection criteria were: the position of the extension officer was staffed and the sections had been selected by the project for activities in its first project year. The sections were randomized into intervention and control restricted on mean height for age Z-score using baseline information. In the intervention area, food security activities and community-based nutrition education was implemented. The control area received food security activities only. At baseline (2011) and endline (2014), caregivers with a child below two years of age were enrolled. Data assessment included anthropometric measurements, interviews on socio-economic status, dietary intake and feeding practices. A difference-in-differences estimator was used to calculate intervention effects. A positive impact on child dietary diversity was observed (B (SE) = 0.39 (0.15), p = 0.01; 95%CI 0.09-0.68). There was a non-significant positive intervention effect on mean height-for-age z-scores (B (SE) = 0.17 (0.12), p = 0.15; 95%CI -0.06-0.41).

LIMITATIONS

The 24h dietary recalls used to measure dietary diversity did not consider quantities of consumed foods. Unrecorded poor quality of consumed foods might have masked a potential benefit of increased child dietary diversity on growth.

CONCLUSIONS

Participatory community-based nutrition education for caregivers improved child dietary diversity even in a food insecure area. Nutrition education should be part of programs in food insecure settings aiming at ameliorating food insecurity among communities.

Caregivers’ nutrition knowledge and attitudes are associated with household food diversity and children’s animal source food intake across different agro-ecological zones in Ghana

Caregivers’ nutrition knowledge and attitudes may influence the variety of foods available in the household and the quality of children’s diets. To test the link, this study collected data on caregivers’ (n 608) nutrition knowledge and feeding attitudes as well as the diets of their household and of their 2–5-year-old children in twelve rural communities nested in the three main agro-ecological zones of Ghana. Household foods and children’s animal source foods (ASF) consumed in the past 7 d were categorised into one of fourteen and ten groups, respectively. About 28 % of caregivers believed that their children needed to be fed only 2–3 times/d. Reasons for having adult supervision during child meal times, feeding diverse foods, prioritising a child to receive ASF and the perceived child benefits of ASF differed across zones (P<0·001). Households with caregivers belonging to the highest tertile of nutrition knowledge and attitude scores consumed more diverse diets compared with those of caregivers in the lowest tertile group (11·2 (sd 2·2) v. 10·0 (sd 2·4); P<0·001). After controlling for the effect of agro-ecological zone, caregivers’ nutrition knowledge and feeding attitudes positively predicted household dietary diversity and the frequency and diversity of children’s ASF intakes (P<0·001). The number of years of formal education of caregivers also positively predicted household dietary diversity and children’s ASF diversity (P<0·001). A key component to improving child nutrition is to understand the context-specific nutrition knowledge and feeding attitudes in order to identify relevant interventions.