EFFECTIVENESS OF A COMMUNITY-BASED PARTICIPATORY NUTRITION PROMOTION PROGRAM TO IMPROVE CHILD NUTRITIONAL STATUS IN EASTERN RURAL ETHIOPIA: A CLUSTER RANDOMIZED TRIAL

Background: Appropriate complementary feeding and hygiene may reduce child undernutrition. To improve child nutritional status and feeding and hygiene behaviors in rural Ethiopia, a community-based participatory nutrition promotion (CPNP) program was designed, adapting positive deviance theory and involving two-week group nutrition sessions. This program was implemented to complement the existing Essential Nutrition Action (ENA) and Community-based Management of Acute Malnutrition (CMAM) programs. The effectiveness of the CPNP program in improving child growth and caregiver feeding and hygiene practices was tested in a cluster randomized, controlled trial using the existing programs alone as the control group. To better understand how the CPNP achieved expected outcomes, we evaluated the following five key intervention components, using a program impact pathway (PIP) analysis approach: (1) quality of the CPNP implementation (2) participants’ acceptance of the program, (3) participants’ recall of delivered messages (4) child feeding practices and nutritional status at the community level, and (5) the influence of CPNP on participation in the existing ENA and CMAM programs. Methods: The CPNP program was launched on August 2012 in Habro and Melka Bello districts of Oromia region of Ethiopia. The districts were divided into 12 clusters of which the CPNP was implemented in 6, while the ongoing programs of ENA and CMAM were carried out in all 12 clusters. Out of 2,064 (1,032 per group) child and mother pairs randomly selected from the locally prepared child rosters in Habro and Melka Bello districts, 1,790 children 6 to 12 months of age and their mothers, 914 and 876 pairs in the control and intervention areas, respectively, were enrolled in the study in November 2012, four months after the CPNP program had started. Enrolled children were followed over the next 12-months and measured for length and weight every three months. At each visit the mothers were asked about the child’s diet using 24-hour-based dietary recall questionnaire, and infant and young child feeding (IYCF) practices every month, whereas hand washing practices were elicited every six months. Length-for-age (LAZ), weight-for-length (WLZ), and weight-for-age (WAZ) z scores, and stunting (LAZ<-2), wasting (WLZ<-2), and underweight (WAZ<-2) status were calculated using the WHO reference population. Child feeding scores for current breastfeeding (range 0-7), meal frequency (range 0-15), dietary diversity (DDS, range 0-10), hand washing (range 0-6), and two composite feeding scores combining different variables were constructed to represent a 12-month feeding and hygiene practice pattern. For process evaluation, we reviewed attendance records for 3,299 participants and conducted group session observation checklists of 114 sessions and extracted data to construct process indicators such as dose delivered, dose received, and fidelity. Mothers were also asked every three months whether they were involved in the ENA and CMAM programs. A small survey of individuals who directly participated in the nutrition sessions (n = 197) was conducted to examine their own acceptance of the CPNP program and recall of messages provided in the nutrition sessions. Multilevel mixed-effects linear regression models using longitudinal data and Cox regression for recurrent event models for stunting, underweight, and wasting episodes were used. Results: We conducted an intention-to-treat analysis. A total of 1,475 children—750 and 725 children in the control and intervention area who were measured at least two out of five times, respectively—were included in the analysis of child growth. After controlling for clustering effects and enrollment characteristics, children in the intervention area had a significantly greater LAZ/month of 0.021 (95% CI: 0.008, 0.034), WAZ/month of 0.015 (95% CI: 0.003, 0.026), length/month of 0.059 cm (95% CI: 0.027, 0.092), and weight/month of 0.031kg (95% CI: 0.019, 0.042) compared to children in the control area. There was no difference in the risk of recurrent incidence of stunting [Hazard Ratio (HR) 1.01, 95% CI: 0.811], underweight (HR 0.826, 95% CI: 0.643, 1.061), or wasting (HR 1.048, 95% CI: 0.812, 1.354) between intervention and control areas. Prevalence of stunting was lower in the intervention area by 7.5% at the 9 month follow-up (p = 0.037) and by 7.3% at 12 month of follow-up (not significant). Of 1,199 mothers, those in the intervention area (n = 570) showed higher scores on meal frequency (diff: 1.02, 95% CI: 0.33, 1.70), and both composite feeding scores (type 1, diff: 1.30, 95% CI: 0.41, 2.19) (type 2, diff: 1.39, 95% CI: 0.48, 2.23) than mothers in the control area (n = 629), but there were no differences in scores of current breastfeeding (diff: -0.08, 95% CI: -0.22, 0.06), dietary diversity (diff: 0.38, 95% CI: -0.21, 0.98), or hand washing (diff: 0.41, 95% CI: -0.21, 1.02) between mothers in the two areas. The CPNP sessions were delivered at 81% of the expectation level; fidelity to intervention protocols varied between 68% and 92%. Out of 197 CPNP participants, 95% had ever contributed materials to a session and 90% showed positive perceptions of the session practices. For each of the session activities (e.g., food preparation), ~70% rated their participation level as active. The participants recalled 5.0 ± 2.0 (SD) out of the 8 messages (e.g., preparing nutritious complementary foods). We also observed improvements in feeding and hygiene, i.e., minimum dietary diversity (34.0% vs. 19.9%, p < 0.05) and mother’s cleanliness (40.0% vs. 24.0%, p < 0.05) at an early stage of the CPNP, and a higher involvement of CPNP participants in the existing program (e.g., Essential Nutrition Action) over the project period compared to non-participants within the same intervention area (32.3% vs. 19.8%, p < 0.001). Conclusions: A community-based participatory nutrition program approach adapting the positive deviance model was found to be effective in improving child feeding practices among caregivers and child growth in the rural Ethiopian context. Using a PIP analysis, our results suggest that the CPNP program was adequately implemented and well-accepted among participants. Program impact was seen in the early stages of the program implementation, although a true baseline was not available, giving the additional benefit of positively influencing the ongoing ENA program, and eventually resulting in improved child nutritional status

Gender-common and gender-specific determinants of child dietary diversity in eight Asia Pacific countries

Background Optimal child feeding practices contribute to reducing child undernutrition in low- and middle-income countries. Minimum dietary diversity (MDD) is a key indicator of complementary feeding quality for children aged 6-23 months. We aimed to examine the gender-common and gender-specific factors associated with the failure to meet MDD in eight Asia Pacific countries. Methods The study used data of children aged 6-23 months from the Demographic and Health Surveys (DHS) conducted in Afghanistan (n = 8410), Bangladesh (n = 2371), Nepal (n = 1478), Pakistan (n = 3490), Cambodia (n = 2182), Indonesia (n = 5133), Myanmar (n = 1379), and Timor-Leste (n = 2115). A total of 41 household, maternal, and child-level variables were examined for association with MDD using univariate and multivariable logistic regressions. All analyses accounted for the survey design and sampling weights. Results Being aged 6-11 months, not receiving Vitamin A supplementation, low maternal education, belonging to a low wealth quintile, and having two or more young children in the household were factors related to the failure to meet MDD among both male and female children. Mothers’ not watching TV or not being exposed to media at least once a week, delivery at home, young age, and engagement to non-agricultural work were only significant risk factors among female children. Non-professional delivery assistance, unsafe disposal of children’s stool, tolerant attitudes towards domestic violence, and rural residence were significant factors only among male children. Conclusions It is possible that male and female children in the region may consume food in various ways, because the factors for meeting MDD are not the same for different genders of children. It is advised to enhance dietary diversity in child nutrition programmes through gender-specific activities

Implementation, utilization and influence of a community-based participatory nutrition promotion programme in rural Ethiopia: programme impact pathway analysis.

OBJECTIVE: A community-based participatory nutrition promotion (CPNP) programme, involving a 2-week group nutrition session, attempted to improve child feeding and hygiene. The implementation, utilization and influence of the CPNP programme were examined by programme impact pathway (PIP) analysis. DESIGN: Five CPNP programme components were evaluated: (i) degree of implementation; (ii) participants' perception of the nutrition sessions; (iii) participants' message recall; (iv) utilization of feeding and hygiene practices at early programme stage; and (v) participants' engagement in other programmes. SETTING: Habro and Melka Bello districts, Ethiopia. SUBJECTS: Records of 372 nutrition sessions, as part of a cluster-randomized trial, among mothers (n 876 in intervention area, n 914 in control area) from a household survey and CPNP participants (n 197) from a recall survey. RESULTS: Overall, most activities related to nutrition sessions were successfully operated with high fidelity (>90 %), but a few elements of the protocol were only moderately achieved. The recall survey among participants showed a positive perception of the sessions (~90 %) and a moderate level of message recall (~65 %). The household survey found that the CPNP participants had higher minimum dietary diversity at the early stage (34·0 v. 19·9 %, P=0·01) and a higher involvement in the Essential Nutrition Action (ENA) programme over a year of follow-up (28·2 v. 18·3 %; P<0·0001) compared with non-participants within the intervention area. CONCLUSIONS: Our PIP analysis suggests that CPNP was feasibly implemented, promoted a sustained utilization of proper feeding behaviours, and enhanced participation in the existing ENA programme. These findings provide a possible explanation to understanding CPNP's effectiveness

Socio-economic disparity in food consumption among young children in eight South Asian and Southeast Asian countries

BACKGROUND/OBJECTIVES This study examined socio-economic differences in diverse food consumption among children 6–23 months of age in South Asia and Southeast Asian countries. SUBJECTS/METHODS Data from Demographic and Health Surveys in four countries in South Asia (n = 15,749) and four countries in Southeast Asia (n = 10,789) were used. Survey-design adjusted proportions were estimated for the following 10 food items: grains, legumes, dark green leafy vegetables (DGLV), vitamin A-rich fruits, vitamin A-rich vegetables, other fruits and vegetables (OFV), fish, meat, dairy, and eggs. An equity gap was defined as an arithmetic difference in the proportion of each food item consumed in the past 24-hours between the wealthiest and lowest quintiles and between rural and urban areas, denoted by percentage points (pp). RESULTS The consumption of most of the 10 food items was higher in the wealthiest quintiles and urban areas across eight countries. The size of equity gaps was greater in Southeast Asia than in South Asia, particularly for vitamin A-rich fruits (3.3–30.0 pp vs. 0.3–19.6 pp), vitamin A-rich vegetables (12.1–26.7 pp vs. 2.4–5.9 pp), meat (17.7–33.4 pp vs. 3.4–13.4 pp), and dairy (14.7–32.5 pp vs. 3.3–11.4 pp). However, the size of equity gap in egg consumption was greater in Southeast Asia than South Asia (11.2–19.8 pp vs. 11.0–26.7 pp). Relatively narrower gaps were seen in the consumption of grains (0.3–12.9 pp), DGLV (0.6–12.4 pp), and fish (0.1–16.8 pp) across all countries. CONCLUSIONS Equity gaps in food consumption differed by socio-economic status and region. Reducing equity gaps in nutrient-rich foods and utilizing regionally available food resources may increase child dietary quality

Mid-JJ CO Line Observations of Protostellar Outflows in the Orion Molecular Clouds

Ten protostellar outflows in the Orion molecular clouds were mapped in the $^{12}$CO/$^{13}$CO ${J=6\rightarrow5}$ and $^{12}$CO ${J=7\rightarrow6}$ lines. The maps of these mid-$J$ CO lines have an angular resolution of about 10$''$ and a typical field size of about 100$''$. Physical parameters of the molecular outflows were derived, including mass transfer rates, kinetic luminosities, and outflow forces. The outflow sample was expanded by re-analyzing archival data of nearby low-luminosity protostars, to cover a wide range of bolometric luminosities. Outflow parameters derived from other transitions of CO were compared. The mid-$J$ ($J_{\rm up} \approx 6$) and low-$J$ ($J_{\rm up} \leq 3$) CO line wings trace essentially the same outflow component. By contrast, the high-$J$ (up to $J_{\rm up} \approx 50$) line-emission luminosity of CO shows little correlation with the kinetic luminosity from the ${J=6\rightarrow5}$ line, which suggests that they trace distinct components. The low/mid-$J$ CO line wings trace long-term outflow behaviors while the high-$J$ CO lines are sensitive to short-term activities. The correlations between the outflow parameters and protostellar properties are presented, which shows that the strengths of molecular outflows increase with bolometric luminosity and envelope mass.Comment: 31 pages, 16 figures, Accepted for publication in ApJ

Land access, livelihoods, and dietary diversity in a fragile setting in northern Uganda

Food systems in fragile contexts are hardly investigated. We examined the crop value chain activities, agriculture income, coping strategy, and food consumption score (FCS) among South Sudan refugees (n = 394; refugee HH) and Uganda host communities (n = 420; host HH) living on the northern border of Uganda. Secondary data analysis was conducted using baseline data collected from an NGO-supported project. Linear regression analysis was conducted to test the association between the type of crop for growing and selling, agriculture income, coping strategy, and FCS in the refugee HH and host HH, separately. The mean number of growing and selling crops was 2.7 (SD 1.7) and 0.6 (1.0) in the refugee HH and 3.6 (1.4) and 1.3 (1.1) in the host HH. Overall food insecurity and FCS was poor in both refugee and host HH. Larger land access was associated with diverse crop production and crop selling in both groups (p &lt; 0.05). The greater number of crop types grown was marginally associated with FCS in host HH only (β = 1.00; p = 0.05). Selling more types of crops was associated with agriculture income in both groups (p &lt; 0.05) and was not related to rCSI in either group, but marginally associated with FCS among only host HH (β = 0.84; p = 0.04). An inequitable food system existed between the host community and South Sudan refugees residing on the northern border of Uganda. The findings suggest that diversifying crops for selling and enhancing marketing channels could aid both host and refugee communities in establishing resilient food systems

Efficacy and Tolerability of GCSB-5 for Hand Osteoarthritis: A Randomized, Controlled Trial

AbstractPurposeThe aim of this study was to investigate the efficacy and tolerability of GCSB-5, a mixture of 6 purified herbal extracts, in treating hand osteoarthritis (OA).MethodsA randomized, double-blind, placebo-controlled trial enrolled 220 patients with hand OA who had baseline a visual analog scale joint pain score of >30 of 100 mm at 3 hospitals between September 2013 and November 2014. After randomization, patients were allocated to receive oral GCSB-5 600 mg or placebo, bid for 12 weeks. The primary end point was the change in the Australian/Canadian OA Hand Index (AUSCAN)-defined pain score at 4 weeks relative to baseline. Secondary end points included the frequency Outcome Measures in Rheumatology–OA Research Society International (OMERACT-OARSI)-defined response at 4, 8, 12, and 16 weeks after randomization.FindingsThe allocated treatment was received by 109 and 106 patients in the GCSB-5 and placebo groups, respectively. At 4 weeks, the median (interquartile range) change in AUSCAN pain score relative to baseline was significantly greater in the GCSB-5 group than in the placebo group (–9.0 [–23.8 to –0.4] vs –2.2 [–16.7 to 6.0]; P = 0.014), with sustained improvement at 8, 12, and 16 weeks (P = 0.039). The GCSB-5 group also had a significantly greater OMERACT-OARSI–defined response rate than did the placebo group at 4 weeks (44.0% vs 30.2%), 8 weeks (51.4% vs 35.9%), 12 weeks (56.9% vs 40.6%), and 16 weeks (50.5% vs 37.7%) (P = 0.0074). The 2 treatments exhibited comparable safety profiles.ImplicationsGCSB-5 was associated with improved symptoms of hand OA, with good tolerability, in these patients. GCSB-5 may be a well-tolerated alternative of, or addition to, the treatment of hand OA. ClinicalTrials.gov identifier: NCT01910116

Monitoring and evaluation design of Malawi's Right Foods at the Right Time nutrition program

Abstract Child stunting is a public health problem in Malawi. In 2014, the Government of Malawi launched the Right Foods at the Right Time (RFRT) program in Ntchisi district delivering nutrition social and behavior change communication, a small-quantity lipid-based nutrient supplement to children 6–23 months, and nutrition sensitive activities. Monitoring and evaluation (M&E) systems are key aspects of successful program implementation. We describe these and the methodology for an impact evaluation that was conducted for this program. Two monitoring systems using traditional and electronic platforms were established to register and track program delivery and processes including number of eligible beneficiaries, worker performance, program participation, and to monitor input, output, and outcome indicators. The impact evaluation used comparative cross-sectional and longitudinal designs to assess impact on anthropometric and infant and young child feeding outcomes. Three cross-sectional surveys (base-, mid-, and end-line) and two longitudinal cohorts of children followed in 6-month intervals from 6 to 24 months of age, were conducted in sampled households in the program and a neighboring comparison district. Additional M&E included qualitative studies, a process evaluation, and a cost-effectiveness study. The current paper describes lessons from this program's M&E, and demonstrates how multiple implementation research activities can inform course-correction and program scale-up

The cascade of care for latent tuberculosis infection in congregate settings:a national cohort 1 analysis, Korea, 2017-18

BACKGROUND: In 2017, Korea implemented a nationwide project to screen and treat latent tuberculosis infection (LTBI) in high-risk for transmission public congregate settings. We aimed to assess programme success using a cascade of care framework. MATERIALS AND METHODS: We undertook a cohort study of people from three congregate settings screened between March 2017 and December 2018: (1) first-grade high school students, (2) employees of educational institutions, (3) employees of social welfare facilities. We report percentages of participants with LTBI completing each step in the cascade of care model. Poisson regression models were used to determine factors associated with not visiting clinics, not initiating treatment, and not completing treatment. RESULTS: Among the 96,439 participants who had a positive interferon-gamma release assay result, the percentage visiting clinics for further assessment, to initiate treatment, and who then completed treatment were 50.7, 34.7, and 28.9%, respectively. Compared to those aged 20-34 years, individuals aged < 20 years and aged ≥ 65 years were less likely to visit clinics, though more likely to complete treatment once initiated. Using public health centres rather than private hospitals was associated with people "not initiating treatment" (adjusted risk ratio [aRR], 3.72; 95% confidence interval [CI], 3.95-3.86). Nine-month isoniazid monotherapy therapy was associated with "not completing treatment," compared to 3-month isoniazid and rifampin therapy (aRR, 1.28; 95% CI, 1.16-1.41). CONCLUSION: Among participants with LTBI from three congregate settings, less than one third completed treatment. Age, treatment centre, and initial regimen were important determinants of losses to care through the cascade

Immunogenicity of influenza vaccination in patients with cancer receiving immune checkpoint inhibitors

Among prospectively enrolled adult patients with cancer receiving immune checkpoint inhibitors (ICIs; n = 46) or cytotoxic agents (n = 90), seroprotection and seroconversion rates after seasonal quadrivalent influenza vaccinations were higher with ICI than with cytotoxic chemotherapy. These results support annual influenza vaccinations for cancer patients receiving ICIs.