Linking agriculture and nutrition education to improve infant and young child feeding: Lessons for future programmes

How Does an Artisan Cooperative Impact Food Perception and Consumer Behaviors? A Rapid Rural Appraisal of Women in East Africa

We examined the impact of artisan cooperatives on East African women related to changes in consumer perception and food choice. We sought to understand how artisan cooperatives were impacting women's food security, diet, and nutrition. To comprehend the lived experiences of women, a qualitative, phenomenological study was conducted within three purposively selected cooperatives in Rwanda and Kenya. Data was collected using Rapid Rural Appraisal (RRA) methodologies with three activities. When given a choice, women did not always eat healthier despite having more money and information about healthy diets. Diets shifted to include more sugar and fruit but less vegetables. Culture and location impacted how they cooked, what food was available to them, and what foods they chose to consume. Women explained how a higher income provided greater agency when buying food. It is crucial to comprehend how culture affects a person's diet before implementation of nutrition programs. Further research is needed to determine if cooperatives geared toward women's empowerment and economic sustainability can enhance the nutritional benefits of increased income in culturally relevant ways. This study has implications regarding sustainable development goals with international development programs that utilize locally sourced foods and are culturally viable.

Behaviour change interventions improve maternal and child nutrition in sub-Saharan Africa: A systematic review

Evidence that nutrition-specific and nutrition-sensitive interventions can improve maternal and child nutrition status in sub-Saharan Africa is inconclusive. Using behaviour change theory and techniques in intervention design may increase effectiveness and make outcomes more predictable. This systematic review aimed to determine whether interventions that included behaviour change functions were effective. Six databases were searched systematically, using MeSH and free-text terms, for articles describing nutrition-specific and nutrition-sensitive behaviour change interventions published in English until January 2022. Titles, abstracts and full-text papers were double-screened. Data extraction and quality assessments followed Centre for Reviews and Dissemination guidelines. Behaviour change functions of interventions were mapped onto the COM-B model and Behaviour Change Wheel. PROSPERO registered (135054). The search yielded 1193 articles: 79 articles met inclusion criteria, ranging from low (n = 30) to high (n = 11) risk of bias. Many that applied behaviour change theory, communication or counselling resulted in significant improvements in infant stunting and wasting, household dietary intake and maternal psychosocial measures. Interventions with >2 behaviour change functions (including persuasion, incentivisation, environmental restructuring) were the most effective. We recommend incorporating behaviour change functions in nutrition interventions to improve maternal and child outcomes, specifically drawing on the Behaviour Change Wheel, COM-B model (SORT B recommendation). To enhance the designs of these interventions, and ultimately improve the nutritional and psychosocial outcomes for mothers and infants in sub-Saharan Africa, collaborations are recommended between behaviour change and nutrition experts, intervention designers, policy makers and commissioners to fund and roll-out multicomponent behaviour change interventions.

Optimal complementary feeding practices of children aged 6–23 months in three agro-ecological rural districts of Jimma zones of southwest Ethiopia

Despite the critical importance of complementary feeding, large proportions of children in developing countries are sub-optimally fed during 6–23 months of age. In Ethiopia, even though the government has been rolling out infant and young child feeding (IYCF) guidelines, the proportion of mothers adhering to the recommended optimal practices and its associated factors have not been assessed in different agro-ecological areas. Hence, the present study aimed to determine optimal complementary feeding practices and associated factors in three agro-ecological rural districts (high, mid and lowland) of southwest Ethiopia. A community-based cross-sectional study was carried out among 845 mothers-index young children 6–23 months Jimma zone. Multistage sampling was employed to select the study participants. Structured and pretested questionnaires were used to collect data and entered into Epi Data V.1.4.4.0. The data were analysed using SPSS version 20. Binary and multivariable logistic regressions were used to identify factors associated with optimal child-feeding practices. The significance of the association was determined at P < 0⋅05. The overall proportion of optimal complementary feeding practice (OCFP) was 9⋅4 % at 95 % CI (7⋅19, 11⋅08). The timely initiation of complementary feeding, minimum meal frequency, minimum dietary diversity and minimum acceptable diet was 52⋅2, 64⋅1, 17⋅2 and 12⋅2 %. Multivariable logistic regression showed that being in the highland districts, having good maternal knowledge, and mothers having primary school education, having a family size of less than six were positively associated with optimal complementary feeding practices. The findings showed that OCFP was low, especially in the midland agro-ecological districts.

Qualitative evidence for improved caring, feeding and food production practices after nutrition-sensitive agriculture interventions in rural Vietnam

Background

Research on nutrition-sensitive agriculture (NSA) has mostly been aimed at demonstrating its impact on nutrition and explicating underlying pathways, and more rarely at understanding processes and lessons learnt from them. This study aimed to gain insights into the processes that influence behaviour change, contributing to improved caring, feeding and food production practices, using a program theory perspective. It also investigated perceived challenges to the sustainability of interventions and potential solutions, in the context of an NSA program in rural Vietnam. Using a participatory approach, data were gathered on impact pathways and perceived outcomes, on elements of program theory that led to behavioural change, as well as barriers and facilitators. Respondents in semi-structured interviews (n = 30) and seven focus group discussions (total n = 76) were selected purposively among program participants. Data was collected and triangulated across several stakeholder groups.

Results

The impact pathways (production-consumption, caring and feeding, and home-grown school feeding) envisaged in the NSA program functioned as intended; synergies were revealed. The increased supply of locally produced nutrient-rich foods not only contributed to the emergence of a promising income sub-pathway but also reinforced synergy with the home-grown school feeding pathway. Improved diets, feeding and caring practices, and school attendance were key outcomes of the program. Successful elements were pathway-specific, such as flexibility in implementing context-appropriate agricultural models. Others, such as benefit-driven motivation and improved knowledge, triggered changes in multiple pathways. Role models, increased self-confidence, and change agents were the main process facilitators. The biggest barrier to both implementation and sustainability was the poor socio-economic conditions of the most disadvantaged households.

Conclusions

This study showed the relevance of NSA programs in addressing undernutrition in remote areas by enhancing self-reliance in local communities. The integration of behaviour change activities proved to be a key strategy in the process to enhance the impact of agriculture on nutrition outcomes. Though outcomes and influencing factors are very context-dependent, lessons on what worked and what did not work could inform the design and implementation of effective behaviour change strategies in future NSA programs in Vietnam and elsewhere.

Is Responsive Feeding Difficult? A Case Study in Teso South Sub-County, Kenya

Responsive infant and young child feeding as a reciprocal relationship between the child and his or her caregiver is recommended by the WHO but has received less attention than dietary diversity or meal frequency up to now. The current study assessed common (non)responsive child feeding practices and factors that facilitate or hinder caregivers to improve feeding practices in rural Teso South Sub-County, Western Kenya. The qualitative study used focus group discussion (n = 93) and Trials of Improved Practices (TIPs) (n = 48) to identify challenges and opportunities in household food distribution and feeding practices. Overall, the implementation of responsive feeding practices was feasible for the caregivers. Parents reported mainly positive experiences in terms of the child’s feeding behavior and effects on child health. Traditional beliefs, practices, and cultural norms hindered some households to change intrahousehold food distribution. Households who manage to implement responsive feeding even in food insecure regions should be consulted to (a) improve existing nutrition education messages that acknowledge these cultural norms, (b) to include more responsive feeding information in nutrition education material, and (c) to address gender norms to create awareness of the importance of responsive feeding practices and the need for adequate time allocation for infant and young child feeding.

Integrating Women and Girls' Nutrition Services into Health Systems in Low- and Middle-Income Countries: A Systematic Review

Women's nutrition has been highlighted as a global priority to ensure the health and well-being of both them and future generations. This systematic review summarises the available literature on the integration of nutrition services for girls and women of reproductive age (GWRA) into existing public health systems across low- and middle-income countries, as well as any barriers to integration. We searched PubMed and Cochrane Database of Systematic Reviews for articles published since 2011 according to eligibility criteria. A total of 69 articles were included. Evidence suggested that several services for GWRA are well integrated into public health systems, including antenatal care services, nutrition education and counselling, and micronutrient supplementation programmes. However, there was limited evidence on the integration of family planning, adolescent health, and reproductive health services. Barriers to integration fell into five main themes: lack of training and capacity building, poor multisectoral linkages and coordination, weak advocacy, lack of M&E systems, and inequity. We identified a lack of evidence and services for non-pregnant GWRA and for women postpartum. Addressing barriers to integration and gaps in nutrition services for GWRA would increase service coverage and contribute to improving health outcomes for GWRA and future generations.

Suboptimal feeding practices and impaired growth among children in largely food insecure areas of north Wollo, Ethiopia

In Ethiopia, information is limited about energy and micronutrient intakes from complementary foods consumed by children in Productive Safety Net Program districts. Therefore, we assessed feeding practices and intakes of energy and selected micronutrients from complementary foods of children aged 6-23 months in a food insecure rural area of Ethiopia. Energy and micronutrient intakes were estimated from multiple-pass 24 h recall. Data were collected using a structured questionnaire. Only 1⋅9 % of children in the age range 6-8 months met recommended minimum dietary diversity of ≥5 food groups; this value slightly increased to 4 and 10⋅1 % in the older age groups (9-11 months and 12-23 months, respectively). Overwhelmingly, none of the children (9-11 months) did get the minimum acceptable diet (Children receiving minimum acceptable diet were 4 and 2⋅6 % in 6-8 months and 12-23 months, respectively). The overall prevalence of stunting was 34 % in younger children (6-8 months) and 51 % in older children aged 12-23 months. Median energy and selected micronutrient intakes from complementary foods were below corresponding WHO recommendations assuming average breast-milk amount and composition. The worst shortfalls were for vitamins A and C and for Ca. In contrast, median iron, protein and niacin intakes and densities were above the WHO recommendation. Caretakers and community leaders in the study setting need nutrition education on IYCF-related practices and on the importance of men's involvement in IYCF. Ensuring the accessibility and affordability of animal source foods (ASFs), fruits and vegetables, and feasible complementary foods is critical to address the quality of complementary feedings. This can be achieved through promoting nutrition-sensitive agriculture such as poultry and home gardening in this setting.

Influence of agriculture on child nutrition through child feeding practices in India: A district-level analysis

Malnutrition continues to be a primary concern for researchers and policymakers in India. There is limited scientific research on the effect of agriculture on child nutrition in the country using a large representative sample. To the best of our knowledge, no study has examined the spatial clustering of child malnutrition and its linkage with agricultural production at the district-level in the country. The present study aims to examine agricultural production's role in improving the nutritional status of Indian children through child feeding practices. The nutritional indicators of children from the National Family Health Survey-4 (2015-16) and the agricultural production data for all the 640 districts of India obtained from the District-Wise Crop Production Statistics (2015-16), published by the Ministry of Agriculture, Government of India were used for the analysis. The statistical analysis was undertaken in STATA (version 14.1). ArcMap (version 10.3), and GeoDa (version 1.8) were used for the spatial analysis. The study found a higher prevalence of malnutrition among children who had not received Minimum Meal Frequency (MMF), Minimum Dietary Diversity (MDD), and Minimum Acceptable Diet (MAD). Further, child feeding practices- MMF, MDD, and MAD- were positively associated with high yield rates of spices and cereals. The yield rate of cash crops, on the contrary, harmed child feeding practices. Production of pulses had a significant positive effect on MDD and MAD. Districts with high cereal yield rates ensured that children receive MMF and MAD. There is a significant spatial association between child feeding practices and malnutrition across Indian districts. The study suggests that adopting nutrient-sensitive agriculture may be the best approach to improving children's nutritional status.

A scoping review of current practices on community engagement in rural East Africa: Recommendations for snakebite envenoming

Community empowerment and engagement is one of the four strategic aims highlighted in the WHO strategy to prevent and control snakebite envenoming. Inappropriate health-seeking behaviours contribute to adverse outcomes, and community engagement is key in driving behavioural change. WHO has highlighted East Africa as a geographical area of concern for snakebite envenoming. The overall aim of the project is to develop a community engagement toolkit for snakebite envenoming and other NTDs. The objective of this scoping review was to identify current practices in recent community engagement in rural East Africa; the applicability of these results to snakebite envenoming are discussed. PubMed, Web of Science, PsycINFO and Google Scholar were searched from 1 January 2017 to 3 September 2020. Search terms were used to identify publications which related to rural communities and health or disease, for both humans and animals. After reviewing the full papers for all geographical areas, 112 publications were included, 30 of which were conducted in East Africa. Papers included nine different countries and covered a broad range of health topics; notably, water, sanitation and hygiene, nutrition, and maternal and child health. Only one publication considered animal health. The most common form of engagement was in the context of a group meeting, lecture, presentation, discussion or question and answer session (63.3%). A variety of locations within the community were used to engage with people, the most common being an individual's household (23.3%). Communication factors was the key influencer for engagement, both positively and negatively. Key barriers to engagement include local languages and health beliefs, literacy levels, mobile phone ownership and the level of mobile Internet coverage, burden of agricultural work and weather conditions. This study provides an extensive overview of recent public health community engagement in East Africa, which will serve as a useful resource for any group seeking to plan an intervention in remote and rural areas in East Africa. Furthermore, it serves as a guide to help tailor community engagement to snakebite envenoming.

Determinants of Children's Fruit Intake in Teso South Sub-County, Kenya-A Multi-Phase Mixed Methods Study among Households with Children 0-8 Years of Age

Fruits are micronutrient-rich sources which are often underrepresented in children’s diets. More insights into the determinants of children’s fruit consumption are needed to improve nutrition education in Teso South Sub-County, Kenya. A multiphase mixed method study was applied among 48 farm households with children 0–8 years of age. A market survey together with focus group discussions were used to design a formative research approach including qualitative and quantitative data collection methods. The unavailability of fruits and the inability to plant fruit trees in the homesteads were the main challenges to improve fruit consumption behaviour, although a number of different fruit species were available on the market or in households. Perceived shortage of fruits, financial constraints to purchase fruits and taste were important barriers. Fruits as snacks given between meals was perceived as helpful to satisfy children. The mean number of fruit trees in the homesteads was positively associated with fruit consumption. Field trials are needed to test how best fruit trees within home gardens and on farms can be included, acknowledging limited space and constraints of households with young children. This should be combined with nutrition education programs addressing perceptions about the social and nutrient value of fruits for children.

Variation in the Factors Associated With Diet Quality of Children Aged 6 to 23 Months in Low and High Agroecological Zones of Rongai Subcounty, Kenya

BACKGROUND

Adequate quality complementary diets and appropriate feeding practices are important for proper growth and development of young children.

OBJECTIVE

To assess factors associated with diet diversity, meal frequency, and acceptable diet of children aged 6 to 23 months in two agroecological zones of Rongai subcounty, Kenya.

METHODS

A cross-sectional study was conducted among 384 mothers/caregivers with children aged 6 to 23 months. A structured questionnaire was used to assess sociodemographic characteristics and child feeding practices. Diet diversity, meal frequency, and acceptable diet were derived from a 24-hour recall of child's food intake. Factors associated with diet quality were determined using binary logistic regression.

RESULTS

Mean child diet diversity score was 3.54 ± 1.0 of 7 food groups, with 56.8% of the children achieving minimum dietary diversity. A majority of the children (81.8%) received minimum meal frequency (MMF), with significant (P < .05) difference between low (91.1%) and high (75.2%) agricultural potential areas. Children who received minimum acceptable diet (MAD) were only 34.1%. Mother/caregiver education level positively (P < .05) associated with minimum diet diversity in low potential area (adjusted odds ratio [AOR] = 3.79, 95% CI: 1.47-9.75) and with MAD in high potential area (AOR = 1.87, 95% CI: 1.01-3.46). Other factors associated with MDD, MMF, and MAD included household income and slow feeding in low potential area, and child gender and active feeding in high potential area.

CONCLUSION

There is a variation in factors associated with diet quality and child feeding practices in different agroecological zones. Therefore, nutrition education and behavior change communication interventions aimed at improving child nutrition should be context-specific.

Behavioural insights to support increased consumption of quality protein maize by young children: a cluster randomised trial in Ethiopia

Introduction

Biofortified crops have tremendous potential to improve child nutrition. We tested whether complementing the distribution of quality protein maize (QPM) with a package of interventions informed by behavioural insights could support greater consumption of QPM by young children and translate into improved growth.

Methods

We conducted a cluster-randomised trial in Oromia, Ethiopia. Clusters of households with a child between 6 and 35 months were randomised into an arm receiving QPM seed only (320 households, 203 clusters) or an arm receiving QPM seed and a child consumption targeting intervention (290 households, 183 clusters). The intervention package included tools to help caregivers keep QPM separate from conventional maize and to earmark QPM specifically for child consumption, as well as encouragement regarding cooking QPM specifically for young children. We analysed the impact of the intervention on food storage, cooking and consumption behaviours and on anthropometric measures (weight-for-age, height-for-age z scores).

Results

The consumption targeting intervention increased the probability of child consumption of QPM in the past week by 17.3 percentage points (pp) (95% CI 9.4 pp to 25.1 pp; p<0.01), increased the probability that QPM flour was stored separately from conventional maize by 46.5 pp (95% CI 38.3 pp to 54.7 pp; p<0.01) and increased the probability that caregivers cooked QPM specifically for young children in the past week by 14.4 pp (95% CI 7.9 pp to 20.9 pp; p<0.01). These effects persisted, but were attenuated, 10 months postintervention. No significant effects on anthropometric outcomes were found.

Conclusions

Enhancing the distribution of new, biofortified crop varieties with a consumption targeting campaign can change storage, cooking and consumption behaviours. However, these improved behaviours did not translate into increased growth in this setting.

Trial registration number

NCT02710760 and AEARCTR0000786.

Relationship between parents' dietary care and food diversity among preschool children in Japan

Objective:

To identify the relationship between preschool children’s dietary diversity and parents’ care behaviours related to their diet including contents of foods and snacks, mealtime practice and parent–child communication.

Design:

Cross-sectional study. Data were extracted from the National Nutrition Survey on Preschool Children in 2015 by Japan’s Ministry of Health, Labour and Welfare.

Setting:

The distribution of food diversity score (FDS) (maximum of eight points) was confirmed. The participants were divided into higher (≥4 points) and lower (≤3 points) food diversity groups. A comparison between the two groups examined parents’ socio-economic status, children’s health and living conditions, and parental care concerning children’s diets (thirteen items). A multiple regression analysis was performed relating FDS to the factors of parental socio-economic status and child health, and a logistic regression analysis was conducted to identify factors of parental care related to the higher food diversity group.

Participants:

2143 persons from households with children aged 2–6 years.

Results:

Parental care concerning children’s diets was the factor most strongly associated with children’s FDS. Those factors most strongly associated with higher food diversity were nutritional balance of foods (OR: 1·76; 95 % CI 1·44, 2·16; P < 0 0001), snack contents (OR: 1·41; 95 % CI 1·07, 1·86; P = 0·014) and regular mealtimes (OR: 1·30; 95 % CI 1·08, 1·55; P = 0·005).

Conclusions:

The findings indicate the importance of parents paying attention to the contents of children’s foods and snacks, ensuring that children eat regularly, and increasing the diversity of their diets.

An Innovative Grandmother-Inclusive Approach for Addressing Suboptimal Infant and Young Child Feeding Practices in Sierra Leone

BACKGROUND

Suboptimal infant and young child feeding (IYCF) practices contribute to child undernutrition. Sierra Leone Demographic and Health Survey data show that IYCF practices remain poor despite modest improvements. Recent studies have identified the role of grandmothers as critical to child nutrition; however, in Sierra Leone to date, the potential for grandmothers to influence IYCF practices has not been investigated.

OBJECTIVES

We examined how an innovative grandmother-inclusive approach (GMIA) can be used to address suboptimal IYCF practices.

METHODS

Using a quasi-experimental design, we compared IYCF beliefs and practices between GMIA intervention communities (receiving monthly dialogue sessions on nutrition, quarterly community praise sessions, and intergenerational forums) and comparison communities (receiving standard nutrition education) in Bum chiefdom from 2013 and 2016. The quantitative endline survey targeted 101 pregnant women, 291 women with children aged <2 y, and 219 grandmothers. Statistical analyses utilized t tests and χ2 tests to examine differences between intervention and comparison communities at endline. Multivariate regression was used to determine the intervention's effect on IYCF outcomes of interest.

RESULTS

Awareness of and participation in the GMIA was high among mothers and grandmothers in intervention communities. The percentage of infants and young children aged 0-23 mo (n = 291) exclusively breastfed during the first week of life was significantly higher in the intervention group (90.2% compared with 79.4%, P = 0.01). Among infants aged 6-23 mo (n = 219), the percentage achieving minimum dietary diversity and minimum acceptable diet was significantly higher in the intervention group (77.2% compared with 51.8%, P < 0.001; and 53.8% compared with 22.6%, P < 0.001, respectively). Differences in percentages achieving minimum meal frequency (MMF) were only significant for infants aged 9-23 mo, with the intervention group achieving a higher MMF (54.6% compared with 36.9%, P = 0.02).

CONCLUSIONS

Results suggest that a GMIA that recognizes grandmothers' roles and strengthens their knowledge can contribute to improved IYCF practices.

Facilitating factors and challenges of the implementation of multisectoral nutrition programmes at the community level to improve optimal infant and young child feeding practices: a qualitative study in Burkina Faso

OBJECTIVES

To identify the drivers and challenges of successful nutrition programme implementation in a multisectoral, community-level approach to improve infant and young child feeding (IYCF) practices in northern Burkina Faso.

DESIGN

A qualitative study was conducted in 2019 through (i) individual interviews with key informants from five different sectors (health, agriculture, environment, livestock and education) and association staff, agents and community leaders and (ii) focus groups with mothers of children under the age of 2 years.

SETTING

Three health districts in the northern region of Burkina Faso implemented a multisectoral community nutrition programme to improve IYCF practices.

PARTICIPANTS

Forty-seven implementing actors and twenty-four beneficiary mothers.

RESULTS

Factors influencing successful implementation include community participation; sector commitment and involvement; the existence of nutrition champions; capacity building; the integration of interventions; micronutrient powder distribution; the introduction of nutrition-sensitive interventions, such as the promotion of the consumption of orange-fleshed sweet potatoes; improved food production and small livestock rearing and the effective coordination of actors and complementary funding. The main challenges of the implementation of multisectorality are low participation among nutrition-sensitive sectors, a tendency for siloed work among sectors, scheduling conflicts, high actor mobility, differences in the target population by sector, a lack of technical skills among community workers, insufficient financial resources, low geographic convergence and coverage of beneficiaries, a lack of a multisectoral monitoring mechanism and accountability and insecurity.

CONCLUSIONS

Strengthening sector participation, identifying a common targeting strategy and mobilising financial resources have the potential to significantly reduce barriers and improve the quality of implementation.

Effect of complementary feeding behavior change communication delivered through community-level actors on dietary adequacy of infants in rural communities of West Gojjam Zone, Northwest Ethiopia: A cluster-randomized controlled trial

BACKGROUND

Attaining the recommended level of adequacy of the infant's diet remains a serious challenge in most developing countries. Complementary foods, particularly in developing countries, are inadequate in quality and quantity that can result in adverse health and nutrition consequences in infants. This could be not only because of lack of food but also associated with caregiver's poor knowledge, harmful cultural norms and behaviors on infant feeding. The promotion of optimal complementary feeding through behavior change interventions is a global health priority. However, many of the interventions targeted only mothers/caregivers of infants, and studies that engaged other family members are limited worldwide. Moreover, such interventions are scarce in developing countries, including Ethiopia. This trial aimed to evaluate the effectiveness of complementary feeding behavior change communication delivered through community-level actors on the dietary adequacy of infants.

METHODS

We conducted a cluster-randomized controlled trial in rural communities of West Gojjam Zone, Northwest Ethiopia. Trial participants in the intervention clusters received complementary feeding behavior change communication for 9 months whereas those in the control clusters received only the usual care. Trained women development army leaders delivered the intervention. A pre-tested, structured interviewer-administered questionnaire was used for data collection. Generalized estimating equations regression analyses adjusted for baseline covariates and clustering were used to test the intervention effects.

RESULTS

The intervention showed positive statistically significant effects on the consumption of dairy products [RR = 1.8; 95% CI: 1.04-3.13], eggs [RR = 3; 95% CI: 1.35-6.56], vitamin A-rich fruits and vegetables [RR = 2.7; 95% CI: 1.17-6.1], other fruits and vegetables [RR = 5; 95% CI: 2.49-10.58] and animal-source foods [RR = 2; 95% CI: 1.39-2.87]. The proportions of infants who achieved minimum dietary diversity [RR = 3; 95% CI: 1.34, 7.39], minimum meal frequency [RR = 2.4; 95% CI: 1.37-4.29], and minimum acceptable diet [RR = 2.7; 95% CI: 1.13-7.23] were significantly higher in the intervention as compared to control groups.

CONCLUSIONS

Complementary feeding behavior change communication delivered through community-level actors significantly improved the dietary adequacy of infants.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03488680. Registered 5 April 2018- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03488680.

Effect of community-based nutrition on infant nutrition and associated health practices in Narok, Kenya

Background

Lack of knowledge, and poor attitudes and practices among rural women have been shown to negatively influence maternal, infant and young child nutrition outcomes as well as child health and cognitive development.

Objectives

The aim of the study was to assess the impact of community-based nutrition on infant nutrition.

Methods

A mixed method approach using a structured questionnaire to collect quantitative data (n=234) and Focus Group Discussions (FGDs) for qualitative data was used in Narok County, Kenya.

Results

About 57% of the participants received nutrition and health information from hospital trained health personnel. Whereas most women indicated having attended antenatal clinics, very few delivered in the hospital (17%). Exclusive breastfeeding knowledge was below 50%, although not statistically significant (p=0.584) across the education spectrum as opposed to identification of malnutrition signs, which was significant (p<0.05). Whereas 74% of the participants had knowledge about signs of malnutrition, only 58% could identify the causes. Rating for complementary feeding among the study participants was about 61% for introduction of complementary foods and 80% for frequency of feeding. Vitamin A supplementation knowledge, antenatal clinic attendance and type of waste disposal were statistically significant (p<0.05) in relation to education level of the study participants.

Conclusion

This study reveals the need to educate rural women for increased understanding and practice of appropriate infant and nutrition care through sustainable and effective essential nutrition actions.

Maternal depression is associated with child undernutrition: A cross-sectional study in Ethiopia

Child undernutrition is widespread in low‐ and middle‐income countries (LMIC) and is associated with health and economic losses. Undernutrition is estimated to contribute to 3.1 million deaths per year in children less than 5 years of age. A complex causal and contextual factors contributing to child undernutrition have been assessed, but maternal depression, which could contribute to child undernutrition by interfering with the mother's child caring practice and ability, has been received little attention. The objective of this study was to assess the association between maternal postpartum depression symptoms and infant (5–10 months of age) stunting in northern Ethiopia. A community‐based cross‐sectional study was conducted among mother–infant pairs (n = 232) between March and April 2018. Through interviewer‐administrated questionnaire, information on sociodemographic variables were collected, and maternal depression symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS≥13). Infants' length and weight were measured and converted to length and weight for age Z scores using the WHO growth standards. Breastfeeding was a norm, but the adequacy of complementary feeding practice was sub‐optimal. Only 25% of the infants met the minimum meal frequency (MMF), less than 10% met the minimum dietary diversity (MMD; 9%) or minimum acceptable diet (7%). Maternal depression was prevalent (22.8%) and was significantly associated with inappropriate complementary feeding and stunting (P < .05). Improving complementary feeding practices is central to preventing stunting in this and other settings. However, such efforts should integrate interventions that address maternal depression to improve child feeding and caring practices to effectively prevent stunting.

Fostering CHANGE: Lessons from implementing a multi-country, multi-sector nutrition-sensitive agriculture project

Using agriculture to improve nutrition is an approach growing in popularity, with programs becoming increasingly complex and multisectoral. While there is an active line of research assessing the impacts of such programs, little has been written about the process of successfully implementing them. As such, this paper uses a multisectoral nutrition-sensitive agriculture program implemented in four African countries as a case study to address key challenges in and lessons learned from implementation. We highlight the overall flexibility of nutrition-sensitive agriculture but also the need to adapt certain aspects to the particular context, as well as the opportunities for cross-context learning (and the limits to this). Integrating rigorous evaluation into such complex programs and forging diverse cross-sectoral partnerships offer both rewards and challenges, upon which we reflect. Main lessons learned from the program include the importance of carefully sequencing interventions, retaining flexibility in implementation, allowing for considerable time for cross-sector integration and coordination, and considering community impacts when designing research.

Association of food security and other socio-economic factors with dietary diversity and nutritional statuses of children aged 6-59 months in rural Bangladesh

Introduction

Dietary diversity score (DDS) is a proxy indicator for measuring nutrient adequacy. In this study, we aimed to identify the nutritional statuses and current patterns of DDS among children between 6–59 months old and their associations with different individual and household level factors in rural Bangladesh.

Methods

The Nobokoli programme of World Vision Bangladesh was implemented in Mymensingh, Sherpur, Rangpur, Dinajpur, Thakurgaon, Panchagar, and Nilphamari districts of Bangladesh between 2014 and 2017. A cross-sectional community household survey was administered between July and October 2014 to collect baseline data to evaluate the Nobokoli programme. A total of 6,468 children between 6–59 months old were included in the final analysis. Anthropometric data was collected following WHO guidelines on using wooden height and digital weight scales. We collected food intake information for the past 24 hours of the survey. The WHO’s child growth standard medians were used to identify the nutritional indices of stunting, wasting, and underweight. Food items consumed were categorized into nine food groups and the DDS was constructed by counting the consumption of food items across these groups during the preceding 24 hour period. The association of DDS and nutritional status (stunting, wasting and underweight) with sociodemographic factors and household food security status were examined using multivariable models; linear regression and logistics regression respectively.

Results

The prevalence of stunting, wasting and underweight among children aged 6-59months were 36.8%, 18.2% and 37.7% respectively. Our findings revealed that almost all children ate any form of starch followed by consumption of milk or milk products (76%) and fleshy meat /fish (61%) respectively. The mean DDS among children was 3.93(sd 1.47). Forty percent of the children obtained a DDS score less than 4. Multivariable analysis suggested that children whose mothers had higher educational attainment and are skilled workers had higher DDS (15% and 48% respectively) compared to their counterparts. The DDS showed strong positive association with household wealth status. Children from food secure households had 26% higher DDS compared to children from food insecure households. Similarly, increasing maternal education and household wealth were found to be protective against childhood stunting and undernutrition.

Discussion

Our findings reiterate the need for improving household socioeconomic factors and household food security status for improving dietary diversity practices and nutritional status of children. Evidence-based solutions are needed to be implemented and expanded at scale to ensure appropriate dietary practices and improve nutritional status of the children in local context.

Accelerating progress for complementary feeding in Kenya: Key government actions and the way forward

Optimal complementary feeding practices, a critical component of infant and young child feeding, has been demonstrated to prevent micronutrient deficiencies, stunting, overweight, and obesity. In Kenya, while impressive gains have been made in exclusive breastfeeding, progress in complementary feeding has been slow, and the country has failed to meet targets. Recent 2014 Kenya Demographic and Health Survey reveal that only 22% of Kenyan children, 6-23 months, met criteria for a minimum acceptable diet. This case study describes key actions for complementary feeding put in place by the Kenya Ministry of Health as well as approaches for improving and monitoring complementary feeding within existing health platforms. Experience from USAID's Maternal and Child Survival Program and Ministry of Health on development of 23 complementary feeding recipes through application of a national guide for recipe development and Trials of Improved Practices is described. Challenges in how to prepare, modify, and cook foods, including meat, for young children 6-23 months of age was relayed by mothers. Addressing cultural beliefs around complementary feeding meant providing reassurance to mothers that young children are developmentally able to digest fruit and vegetables and ready to consume animal-source protein. Through the Baby Friendly Community Initiative platform, cooking demonstrations and key hygiene actions were integrated with complementary feeding messages. Future programming for complementary feeding should consider development of context specific counselling messages on consumption of animal source foods, strengthen production and use of local foods through agriculture-nutrition linkages, and include complementary indicators through routine health monitoring systems to track progress.

Linking agriculture and nutrition education to improve infant and young child feeding: Lessons for future programmes

Agriculture and food systems play a central role in nutrition by supplying nutritious, healthy and affordable foods. When integrated with nutrition education for behaviour change, agricultural interventions that supply diverse affordable foods from all food groups have great scope for improving young child and family diets. In 2014, process reviews were conducted in Cambodia and Malawi of food security projects that provided agricultural support and community-based nutrition education on improved infant and young child feeding (IYCF). In both countries, household visits were carried out with mothers/caregivers, and interviews and Focus Group Discussions (FGDs) were conducted with purposively selected project stakeholders (53 in Cambodia, 170 in Malawi), including government staff from the agriculture and health sectors. Results highlight that adoption of improved IYCF practices was facilitated by participation in nutrition education and practical cooking sessions, and supportive family and community structures. Barriers faced by families and caregivers were identified, such as women's workload and lack of access to high quality foods, namely fruits, vegetables, legumes, nuts and animal source foods. Implementation challenges regarding coordination of cross-sectoral targeting strategies and capacities of extension services to sustain community-based IYCF nutrition education need to be addressed to improve programme effectiveness and impact. The project lessons from Cambodia and Malawi are useful for integrated agriculture-IYCF nutrition education programmes to help ensure better young child nutrition outcomes.

First foods: Why improving young children's diets matter

Globally, only 52% of children aged 6-23 months meet the minimum meal frequency and a mere 29% meet the minimum dietary diversity, with large disparities across and within regions. With most of the stunting occurring during the first thousand days-from conception to age 2 years-improving complementary feeding in children 6-23 months old is an urgent priority. With this evidence in mind, UNICEF collaborated with the governments of India and Maharashtra to convene a global meeting in Mumbai, India, under the theme: First Foods: A Global Meeting to Accelerate Progress on Complementary Feeding in Young Children (November 17-18, 2015). The global meeting provided a platform that aimed to (a) synthesize the biological and implementation science on complementary feeding; (b) review the practice and experience in improving access to nutritious complementary foods and good complementary feeding practices; and (c) consolidate a strong evidence base that can inform the development of strategies and approaches to improve complementary feeding that are fit to context. This overview paper summarizes the rationale on why improving complementary foods and feeding for infants and young children matters and what it takes to improve them. It builds on the papers presented at the First Foods Global Meeting and those commissioned as a follow on to it.