Effects of engaging fathers and bundling parenting and nutrition interventions on early child development and maternal and paternal parenting in Mara, Tanzania: a factorial cluster-randomized controlled trial

BACKGROUND

Multicomponent interventions are needed to address the various co-occurring risks that compromise early child nutrition and development. We compared the independent and combined effects of engaging fathers and bundling parenting components into a nutrition intervention on early child development (ECD) and parenting outcomes.

METHODS

We conducted a 2×2 factorial cluster-randomized controlled trial across 80 villages in Mara Region, Tanzania, also known as EFFECTS (Engaging Fathers for Effective Child Nutrition and Development in Tanzania; ClinicalTrials.gov, NCT03759821). Households with children under 18 months of age residing with their mother and father were enrolled. Villages were randomly assigned to one of five groups: a nutrition intervention for mothers, a nutrition intervention for couples, a bundled nutrition and parenting intervention for mothers, a bundled intervention for couples, and a standard-of-care control. Interventions were delivered by trained community health workers through peer groups and home visits over 12 months. Mothers, fathers, and children were assessed at baseline, midline, and endline or postintervention. We used a difference-in-difference approach with intention-to-treat analysis to estimate intervention effects on ECD (Bayley Scales of Infant and Toddler Development, third edition) and maternal and paternal parenting and psychosocial well-being.

RESULTS

Between October 29, 2018, and May 24, 2019, 960 households were enrolled (n = 192 per arm). Compared to nutrition interventions, bundled interventions improved children's cognitive (β = .18 [95% CI: 0.01, 0.36]) and receptive language development (β = .23 [0.04, 0.41]). There were no differences between interventions for other ECD domains. Compared to nutrition interventions, bundled interventions achieved additional benefits on maternal stimulation (β = .21 [0.04, 0.38]) and availability of home learning materials (β = .25 [0.07-0.43]) and reduced paternal parenting distress (β = -.34 [-0.55, -0.12]). Compared to interventions with mothers only, interventions that engaged fathers improved paternal stimulation (β = .45 [0.27, 0.63]).

CONCLUSIONS

Jointly bundling parenting components into nutrition interventions while also engaging both mothers and fathers is most effective for improving maternal and paternal parenting and ECD outcomes.

Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS): study protocol for a five-arm, cluster-randomized trial

BACKGROUND

Globally, 144 million children under 5 years are undernourished and 250 million do not meet their developmental potential. Multi-input interventions, such as bundled nutrition and parenting interventions, are designed to mitigate risks for multiple child outcomes. There is limited evidence that bundled interventions have additive benefits to nutrition, growth, or development outcomes. These outcomes share common risks; therefore, designing interventions to tackle these risks using a common theory of change may optimize effectiveness. Emerging evidence suggests explicit engagement of fathers may benefit child outcomes, but few trials have tested this or included data collected from fathers.

METHODS

Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) is a community-based cluster-randomized controlled trial that will be implemented in the rural Mara Region, Tanzania. The trial aims (1) to test a bundled nutrition and parenting program delivered to mothers' groups, with or without fathers' groups, over 12 months on child and caregiving outcomes compared to a nutrition program alone, and (2) to test nutrition or bundled nutrition and parenting programs delivered to mothers' and fathers' groups over 12 months on child and caregiving outcomes compared to programs delivered to mothers alone. The trial comprises five arms: (1) mothers' groups receiving a nutrition program, (2) mothers' groups receiving a bundled nutrition and parenting program, (3) mothers' and fathers' groups receiving a nutrition program, (4) mothers' and fathers' groups receiving a bundled nutrition and parenting program, and (5) control receiving standard of care health services. The primary outcomes are child dietary diversity and early child development (mental and motor development). Parents with a child under 18 months will be enrolled in peer groups and receive twice monthly intervention by trained community health workers. Data will be collected from mothers, fathers, and children at baseline (pre-intervention), midline, and endline (post-intervention).

DISCUSSION

EFFECTS will generate evidence on the effects of bundled nutrition and parenting interventions on child nutrition, growth, and development outcomes; determine the benefits of engaging fathers on child, caregiving, and caregiver outcomes; and investigate common and unique pathways between treatments and child outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03759821. Registered on November 30, 2018.

Stunting in the first year of life: Pathway analysis of a birth cohort

Malnutrition among infants aged below 6 months has been largely overlooked creating gaps in our understanding of factors underlying stunting in early infancy. Recent evidence suggests that pre-natal and early childhood factors may contribute more to driving childhood stunting than previously appreciated. The study was set up to examine pathways including parental and household characteristics, birth size and gestation, and illness in infancy with stunting at birth and months 3, 6 and 12 using an a priori hypothesized framework. It was a secondary analysis of a birth cohort of 1017 infants recruited from four health facilities in Burkina Faso and followed up for one year. Structural equation models (SEM) were generated to explore pathways to stunting at birth and months 3, 6 and 12. The prevalence of being stunted at birth and months 3, 6 and 12 was 7.4%, 23%, 20% and 18% respectively. The fractions of month 12 stunting attributable to being stunted at birth, months 3 and 6 were 11% (95%CI 5.0‒16%), 32% (95%CI 22‒41%) and 40% (95%CI 31‒49%) respectively. In the structural equation model, male sex and maternal characteristics had direct effects on stunting at birth and at 3 months, but not subsequently. Premature birth, twin birth and being stunted at a previous time point were directly associated with stunting at months 3, 6 and 12. Both maternal and paternal characteristics were directly associated with preterm birth. Non-exclusive breastfeeding had borderline positive direct effect on stunting at month 6 but not at month 12. The direct and indirect pathways identified in this study highlight the complex interlinks between child, maternal, paternal and household characteristics. Interventions tackling preterm birth, in utero growth, exclusive breastfeeding and maternal wellbeing may reduce stunting in the first year of life.

Adolescent pregnancy is associated with child undernutrition: Systematic review and meta-analysis

Adolescent pregnancy is associated with poor fetal growth and development which, in turn, increases the risk of childhood wasting and underweight. However, evidence on how young maternal age affects childhood anthropometry beyond the neonatal period is limited. This systematic review and meta-analysis examined associations between adolescent pregnancy and child wasting and underweight and explored potential underlying social and biological factors. Peer-reviewed literature published in English since 1990 was systematically searched. Eligible studies presented data on wasting and/or underweight in children (≤59 months) born to adolescent mothers (10-19, or ≤24 years where applicable) from low- and middle-income countries. Data extraction used a predefined extraction sheet. Both meta-analysis and qualitative synthesis were performed. Of 92 identified studies, 57 were included in the meta-analysis. The meta-analysis showed that children born to adolescent versus adult mothers were at a higher risk of moderate (odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.00-1.26 p = 0.04) and severe underweight (OR: 1.21, 95% CI: 1.08-1.35 p < 0.01). Associated risk of wasting was not statistically significant: (OR: 1.05, 95% CI: 0.98-1.12 p = 0.17); severe wasting (OR: 1.16, 95% CI: 0.68-1.96 p = 0.59). These findings were supported by the qualitative synthesis. Evidence on the potential role of biological/social factors was limited, but suggested an intermediary role of maternal nutritional status which warrants further exploration. Particularly in contexts where adolescent pregnancy remains common, interventions to both delay adolescent pregnancy and improve adolescent nutritional status could help reduce the risk of undernutrition in children and contribute to breaking the intergenerational cycle of malnutrition.

Mapping the range of policies relevant to care of small and nutritionally at-risk infants under 6 months and their mothers in Ethiopia: a scoping review protocol

INTRODUCTION

Evidence gaps limit management of small and/or nutritionally at-risk infants under 6 months and their mothers, who are at higher risk of death, illness, malnutrition and poor growth and development. These infants may be low birth weight, wasted, stunted and/or underweight. An integrated care model to guide their management (MAMI Care Pathway) is being tested in a randomised controlled trial in Ethiopia. Evaluating the extent to which an innovation is consistent with national policies and priorities will aid evidence uptake and plan for scale.

METHODS AND ANALYSIS

This review will evaluate the extent to which the MAMI Care Pathway is consistent with national policies that relate to the care of at-risk infants under 6 months and their mothers in Ethiopia. The objectives are to describe the range and characteristics, concepts, strategic interventions, coherence and alignment of existing policies and identify opportunities and gaps. It will be conducted in accordance with the JBI methodology for scoping reviews (PRISMA-ScR). Eligible documents include infant and maternal health, nutrition, child development, food and social welfare-related policies publicly available in English and Amharic. The protocol was registered on the Open Science Framework Registry on 20 June 2022 (https://osf.io/m4jt6).Grey literature will be identified through government and agency websites, national and subnational contacts and Google Scholar, and published policies through electronic database searches (MEDLINE, EMBASE and Global and Health Information). The searches will take place between October 2023 and March 2024. A standardised data extraction tool will be used. Descriptive analysis of data will be undertaken. Data will be mapped visually and tabulated. Results will be described in narrative form. National stakeholder discussions will inform conclusions and recommendations.

ETHICS AND DISSEMINATION

Ethical approval is not required as data consist solely of publicly available material. Findings will be used to evidence national and international policy and practice.

Engaging men in maternal, infant and young child nutrition in rural Tanzania: Outcomes from a cluster randomized control trial and qualitative study

There is growing recognition that engaging men in maternal, infant and young child nutrition (MIYCN) interventions can benefit child health and disrupt harmful gender norms. We conducted a cluster-randomized controlled trial in Tanzania, which engaged men and women in behaviour change via mobile messaging (short message service [SMS]) and traditional interpersonal communication (IPC), separately and in combination. Here, we evaluate intervention effects on individual-level men's MIYCN knowledge and discuss barriers to male engagement. Eligible clusters were dispensary catchment areas with >3000 residents. Forty clusters were stratified by population size and randomly allocated to the four study arms, with 10 clusters per arm. Data on knowledge and intervention exposure were collected from 1394 men through baseline and endline surveys (March-April 2018 and July-September 2019). A process evaluation conducted partway through the 15-18-month intervention period included focus group discussions and interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software. Male participants in the short message service + interpersonal communication (SMS + IPC) group reported higher exposure to IPC discussions than IPC-only men (43.8% and 21.9%, respectively). Knowledge scores increased significantly across all three intervention groups, with the greatest impact in the SMS + IPC group. Qualitative findings indicated that the main barriers to male participation were a lack of interest in health/nutrition and perceptions that these topics were a woman's responsibility. Other challenges included meeting logistics, prioritizing income-earning activities and insufficient efforts to engage men. The use of a combined approach fusing IPC with SMS is promising, yet countering gender norms and encouraging stronger male engagement may require additional strategies.

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.

Carers’ and health workers’ perspectives on malnutrition in infants aged under six months in rural Ethiopia: A qualitative study

Objectives

Supporting small and nutritionally at-risk (potentially malnourished) infants under six months is a global health priority, albeit with a weak evidence-base. To inform policy and research in this area, we aimed to assess the perceptions and understanding of infant malnutrition and its management among carers, communities, and healthcare workers in rural Ethiopia.

Methods

We conducted in-depth and key-informant interviews, from May-August 2020 in Jimma Zone and Deder District, Ethiopia. We used purposive sampling to recruit the participants. Interviews were transcribed into Amharic or Afaan Oromo and then translated into English. Atlas ti-7 was used to support data analysis. Findings were narrated based on the different themes arising from the interviews.

Results

Carers/community members and healthcare workers reported on five different themes: 1) Perceptions about health and well-being: an ‘ideal infant’ slept well, fed well, was active and looked ‘fat’; 2)Perceptions of feeding: overall knowledge of key recommendations like exclusive breastfeeding was good but practices were suboptimal, notably a cultural practice to give water to young infants; 3)Awareness about malnutrition: a key limitation was knowledge of exactly how to identify small and nutritionally at-risk infants; 4) Reasons for malnutrition: levels of understanding varied and included feeding problems and caregiver’s work pressures resulting in the premature introduction of complementary feeds; 5) Perceptions about identification & treatment: carers prefer treatment close to home but were concerned about the quality of community-based services.

Conclusion

To succeed, research projects that investigate programes that manage small and nutritionally at-risk infants under six months should understand and be responsive to the culture and context in which they operate. They should build on community strengths and tackle misunderstandings and barriers. Interventions beyond just focusing on knowledge and attitude of the carers and health workers are necessary to tackle the challenges around infants under 6 months of age at risk of malnutrition. Moreover, stakeholders beyond the health sector should also be involved in order to support the infants under 6 months and their mothers as some of the key reasons behind the at-risk infants are just beyond the capacity of the health sector or health system. Our list of themes could be used to inform infant nutrition work not just in Ethiopia but also in many others.

Anthropometric Criteria for Identifying Infants Under 6 Months of Age at Risk of Morbidity and Mortality: A Systematic Review

BACKGROUND

There is increasing global focus on small and nutritionally at-risk infants aged <6 months (<6 m). Current WHO guidelines recommend weight-for-length z-score (WLZ) for enrolment to malnutrition treatment programmes but acknowledge a weak evidence-base. This review aims to inform future guidelines by examining which anthropometric criteria best identify infants <6 m at high risk of mortality/morbidity.

METHODS

We searched Medline, EMBASE, CINAHL, Global Health, Cochrane Library and POPLINE for studies conducted in low- and middle-income countries and published between 1990 and October 2020. We included studies reporting anthropometric assessment of nutritional status in infants <6 m and assessed the association with subsequent morbidity or mortality.

RESULTS

A total of 19 studies were included in the final review, covering 20 countries, predominantly in sub-Saharan Africa. WLZ had poor reliability and poor prognostic ability to identify infants at risk of death. Mid-upper arm circumference (MUAC) and weight-for-age z-score (WAZ) were better at identifying infants at risk of mortality/morbidity. MUAC-for-age z-score did not perform better than using a single MUAC cut-off. Suggested MUAC cut-offs for this age group varied by context, ranging from 10.5 to 11.5 cm. The assessment for reliability showed that length was difficult to measure, making WLZ the least reliable indicator overall.

CONCLUSION

Evidence from our review suggests that a change in current practice is necessary. To better identify small and nutritionally at-risk infants <6 m WAZ and/or MUAC rather than WLZ should be used. Future research should explore possible benefits for programme coverage, impact and cost-effectiveness. Research should also examine if context-specific MUAC thresholds are needed.

Maternal-focused interventions to improve infant growth and nutritional status in low-middle income countries: A systematic review of reviews

BACKGROUND

Small and nutritionally at-risk infants under 6 months (<6m) are a vulnerable group at increased risk of mortality, morbidity, poor growth and sub-optimal development. Current national and international (World Health Organization) management guidelines focus mainly on infants' needs, yet growing evidence suggests that maternal factors also influence infant outcomes. We aimed to inform future guidelines by exploring the impacts of maternal-focused interventions on infant feeding and growth.

METHODS

We conducted a systematic review of reviews published since 2008 (PROSPERO, register number CRD 42019141724). We explored five databases and a wide variety of maternal-focused interventions based in low- and middle-income countries. Infant outcomes of interest included anthropometric status, birthweight, infant mortality, breastfeeding and complementary feeding practices. Given heterogenous interventions, we present a narrative synthesis of the extracted data.

RESULTS

We included a total of 55 systematic reviews. Numerous maternal interventions were effective in improving infant growth or feeding outcomes. These included breastfeeding promotion, education, support and counselling interventions. Maternal mental health, while under-researched, showed potential to positively impact infant growth. There was also some evidence for a positive impact of: women's empowerment, m-health technologies, conditional cash transfers, water, sanitation and hygiene and agricultural interventions. Effectiveness was increased when implemented as part of a multi-sectoral program. Antenatal supplementation with macronutrient, multiple micronutrients, Vitamin D, zinc, iron folic acid and possibly calcium, iodine and B12 in deficient women, improved birth outcomes. In contrast, evidence for postnatal supplementation was limited as was evidence directly focusing on small and nutritionally at-risk infants; most reviews focused on the prevention of growth faltering.

CONCLUSION

Our findings suggest sufficient evidence to justify greater inclusion of mothers in more holistic packages of care for small and nutritionally at-risk infants aged <6m. Context specific approaches are likely needed to support mother-infant dyads and ensure infants survive and thrive.